AIDS: Questions for Development

This Institute of Development Studies (IDS) Policy Briefing aims to assess past and current efforts to understand AIDS in relation to development and to identify key policy and research gaps for development. One of the central questions being addressed here is what the role of partnership can be in combating AIDS, globally: What are the best ways of harnessing the capacity of governments, civil society, the private sector, researchers and communities to enhance coordination, transparency and accountability in the response to HIV? To that end, in June 2005 IDS hosted a workshop in partnership with UNAIDS and the International HIV/AIDS Alliance to examine the linkages between HIV and vulnerability; the strategies that emerged are highlighted in this paper.

To begin, the authors explore various frameworks for understanding and addressing the drivers of HIV transmission. Some have been less effective than others. For instance, in the early years of the pandemic, a risk framework was developed that centred on the conception that the behaviour of high-risk groups was at the core of HIV transmission. The information campaigns developed to change this high-risk behaviour rarely succeeded in sustaining long-term change, particularly when standardised messages were directed at broad, general groups. Similarly, the efforts of those who picked up on these themes by arguing that marginalised groups were suffering a lack of human rights which contributed to lapses in public health support were often criticised by focusing on abstract rights of the individual. In contrast to this risk framework, a vulnerability framework emerged. Influenced by participatory methodologies, this approach moved beyond a focus on individual behaviour to address community-level factors such as culture, gender, economic status, and mobility (population movement). Some critics have argued that this approach is too open-ended and lacks a clear focus on public health. Recently, popular "security discourse" has emerged focusing on issues of conflict and insecurity in relation to HIV; arguing from a rights perspective, some have worried that the aspect of this discourse characterising migrants and refugees as "external threats", for instance, reinforces stigma and discrimination.

In this context, IDS suggests that a framework that integrates a rights approach, public health evidence, and issues of structural vulnerability and inequality at global and local levels is needed. Partnership here is key: "social scientists and development thinkers must work together, engaging with epidemiologists and using public health evidence to understand what drives the epidemic in different contexts..." This is particularly true, IDS contends, in the research context, where development researchers can help policymakers and practitioners analyse in a context-specific way how the disease complicates and exacerbates the existing challenges of disease, poverty, conflict, and injustice by contributing to a complex set of interlocking vulnerabilities.

Communicators and development personnel also have a role to play in the medical arena, such as by strategising together about how to deliver affordable essential drugs like antiretrovirals (ARVs) to those in need. "With the appearance of more affordable HIV drugs in local open markets and the chronic shortage of highly skilled health workers, it is crucial to look for new ways to enable informed access to treatment and support for adherence." Collaboration is also in order in the area of testing, where "Policymakers and practitioners need to consider new approaches to testing and counselling to overcome cost constraints and skills shortages, without compromising confidentiality and principles of informed consent." Crucially, though, researchers, policymakers, and practitioners need to link up not just with one another but with people living with HIV, who "are coalescing as political constituencies to influence policy and practice". Though they have powerful potential as agents in HIV prevention and care, they are "still largely an untapped resource."

The concluding sections of the paper share insights on politics and policy process, and look at what lies ahead in the HIV/AIDS response. One theme to emerge in these sections is, again, that of the importance of a collaborative and interdisciplinary approach. For instance, the authors stress that "Policymakers and governments cannot adequately address the challenges alone. The corporate sector is lobbying to influence policy and civil society organisations are increasingly shaping the agenda. Development and HIV researchers need to investigate and communicate better about how the advocacy of people living with HIV, civil society, and networks is facilitating change at national level and foster learning between local, national and international initiatives." Engaging with those from other disciplines - as well as with affected communities (using participatory approaches to development, citizenship, and power) - is thought to be crucial for health and social change researchers and communicators who are seeking to reap the full potential of a development approach to AIDS.

Click here to access a related key issues guide, "Vulnerability, HIV and AIDS: What Role for Development, Rights and Community?, which emerged from the same workshop on which the policy briefing summarised above was based.