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Interdisciplinarity and collaboration in responding to HIV and AIDS in Africa: anthropological perspectives Merrill Singer

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Department of Anthropology , University of Connecticut , 354 Mansfield Road, Unit 2176, Storrs, Connecticut, 06269-2176, United States Published online: 08 Apr 2010.

To cite this article: Merrill Singer (2009) Interdisciplinarity and collaboration in responding to HIV and AIDS in Africa: anthropological perspectives, African Journal of AIDS Research, 8:4, 379-387, DOI: 10.2989/AJAR.2009.8.4.2.1039 To link to this article: http://dx.doi.org/10.2989/AJAR.2009.8.4.2.1039

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AJAR

ISSN 1608–5906 doi: 10.2989/AJAR.2009.8.4.2.1039

— Introduction to the special issue — Interdisciplinarity and collaboration in responding to HIV and AIDS in Africa: anthropological perspectives

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Merrill Singer Department of Anthropology, University of Connecticut, 354 Mansfield Road, Unit 2176, Storrs, Connecticut 06269-2176, United States Author’s e-mail: [email protected]

Overview of anthropology and HIV/AIDS in Africa The emergence of an ‘anthropology of HIV and AIDS’ in Africa dates to the mid-1980s, a transitional period during which our basic understanding of this disease was still forming, its devastating potential was not yet fully realised, and uncertainty about the contributions that anthropologists could make in this arena was widespread within the discipline. Still, a small number of anthropologists took up HIV/AIDS-related work in Africa and other parts of the world during the 1980s, leading in the United States to the formation of the AIDS and Anthropology Research Group (AARG) in 1987. This association remains active more than 22 years after its formation and is committed to elevating a disciplinary focus on HIV and AIDS and to offering support to those already working in this field. Notably, the first AARG newsletter included a report on the dismissal of 1 000 HIV-seropositive mine workers in South Africa and their subsequent return to Zimbabwe, Malawi and other southern African countries, a move that may have hastened the geographic spread of the disease. At the suggestion of Roy Rappaport, President of the American Anthropological Association (AAA), at an AARG meeting in November 1987, the AIDS and Anthropology Task Force of the AAA was created in April 1988 with the purpose of encouraging anthropological work on HIV and AIDS. The task force was charged with building awareness of HIV and AIDS among anthropologists at a time when many had not yet recognised the relevance of the pandemic to their work, and thus with expanding anthropological impact on responses to the pandemic. The task force operated until 1993 when it was replaced (in response to questions about whether its termination signalled that the AAA was turning away from promoting HIV/AIDS awareness) by the Commission on AIDS Research and Education. The mission of this new body was to coordinate AAA educational and advocacy efforts regarding HIV and AIDS, recommend priorities for the AAA regarding HIV/ AIDS-related policies and research agendas, and evaluate

proposals by AAA members for HIV/AIDS-related initiatives. By the time the commission ended its work, the anthropology of HIV and AIDS in Africa and elsewhere was fairly well established, but the initial efforts to gain a foothold in this arena had encountered various obstacles. In 1986, the first set of anthropological papers on HIV/AIDS-related research and application appeared as a special issue of Medical Anthropology Quarterly. In a concluding essay to that set of papers (not all of which were by anthropologists), Douglas Feldman (1986, p. 38), among the earliest anthropologists to conduct research on the epidemic in Africa, observed: “It is surprising that only a dozen or so medical anthropologists have become involved in AIDS research.” This delay in the involvement of any sizeable number of anthropologists reflected a hesitation within the discipline which occurred while researchers in other fields were beginning to carry out large HIV/AIDS-related research initiatives and publish extensively on the pandemic (Bolton & Orozco, 1994). Uncertainty among anthropologists reflected the combined effects of a crisis of confidence that gripped the discipline in the wake of postmodernist critiques of theory and application, a lack of anthropological attention to the present, and a failure on the part of social and behavioural scientists in other disciplines to see the value of anthropological approaches to an infectious disease epidemic. Crafting an anthropology of HIV and AIDS Since then, much has changed in the anthropology of HIV and AIDS. HIV and AIDS has become one of the most studied infectious diseases; the devastating magnitude of the pandemic is fully recognised — although debates emerge anew about the appropriate level of resource allocation for responding to HIV and AIDS, especially in developing countries with complex health and social problems — and a large number of anthropologists have since conducted on-the-ground research, been active in HIV-prevention and intervention initiatives, or played other roles in addressing HIV epidemics in African landscapes.

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The sheer scale of the impact of the pandemic on people and places long studied by anthropologists, and recognition of the failure to fully incorporate observational methods and emic perspectives (e.g. the views of HIV-infected/affected people) within the prevailing non-anthropological research, contributed to this critical turn in anthropological work. Of equal importance have been the emergence of weariness with the postmodernist conundrum (i.e. how to do anthropology if anthropologists cannot fairly study and describe other ways of life and meaning) and a subsequent embrace of ‘good enough’ ethnographic standards that combine objective observation, reflexivity, and recognition of the responsibilities of conducting research within a health crisis. While debates continue over whether we are doing enough, doing the right things, or having the impact we hope to have — there is a general sense that anthropologists have made significant contributions to the theoretical and applied study of HIV and AIDS in Africa (Feldman, 2008). Important among these contributions is the development of ethnographically informed accounts of everyday behaviour in local contexts, which are often at odds with views from afar (or ‘above’) which are based on quantitative survey data or official health information sources (Lee & Susser, 2008). For example, ethnographic research has confirmed that structural-adjustment policies imposed by international lending institutions (on the grounds that market-based economic practices would lead to higher standards of living and better health in lesser developed countries) instead was found at times to lead to increase HIV-related risk (Lurie, Hintzen & Lowe, 2004; Susser, 2009). This was found to occur for several reasons, including: 1) these policies undermined rural economies and increased the cost of food, leading to individuals’ reduced nutritional status and weakened immunocompetence; 2) as a result of increased urban labour migration, the policies caused a separation of families and thereby contributed to the involvement of isolated urban workers and impoverished rural women as the respective customers and sellers of commercial sex; and 3) the policies supported cuts in HIV-prevention and healthcare budgets, further limiting access to care in resource-poor settings. Structural factors that interact with local cultural constructions of appropriate sexual behaviour, gender roles, and other factors have been found to underlie patterns of HIV-related risk (Rwabukwali, 2008). For example, in many parts of Africa a combination of economic and cultural factors “circumscribe the ability of women, married or single, to refuse sex with a steady partner, even if they suspect he may be [HIV-]infected, or to insist on condom protection” (Schoepf, 2004, p. 131). Another contribution of anthropological research involves investigation of “the interrelations between macro-level conditions [e.g. structural adjustment policies]…and the lived experience of individuals and social groups” (Schoepf, (2004, p. 123) — in other words, relationships between structure and agency. One product of such research is the increased awareness of an often wide gap between what people say they do and what they actually do. Asked about their own behaviour, people will often report what they intend to do under optimal conditions. However, circumstances, including the force of structural factors (such as

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structural violence or the social construction of ‘risk environments’), do not always allow people to act in accord with their intentions. An example occurs in the case of Lesotho. In the collection of papers in this issue, David Turkon and colleagues emphasize the HIV/AIDS-risk impact among Basotho who do not have control over their productive livelihoods. Issues like this are of enormous importance in HIV-prevention efforts in Africa (as everywhere); the authors define what is possible with available resources as well as bring into focus the need for changes beyond the immediate realm of HIV/ AIDS-risk behaviour to affect widespread, enduring, and profound levels of risk reduction. Ethnographic methods, because of their emphasis on long-term, locally grounded and immersion-based techniques, and their common use of understanding the insider’s experience while investigating connections between the local and the global, offer a rigorous approach for assessing the relationships between intent and action in a social context. For instance, Turkon and co-authors have been engaged in research in Lesotho for nearly two decades, an observational window that affords them understandings of aspects of life in the country that predate the development of the severest effects of the HIV epidemic there. As a result, they are able to discern the relative impacts of HIV and AIDS and other health and social challenges facing the country as well as the shortcomings of many existing responses to the epidemic. At the same time, ethnography is a productive approach for a fuller assessment of the broad range of present efforts to confront an HIV epidemic in any setting, some of which may fall beyond the usual definition of HIV/AIDS-prevention/ intervention programmes. The role of the arts in efforts to understand and address HIV and AIDS, for example, is the focus of Susan Pietrzyk’s research in Harare, Zimbabwe. Cultural activists have played important roles around the world, often helping to focus public attention on the poignant experiences of people living with HIV or AIDS. Pietrzyk has ethnographically examined the work of fiction writers and poets as they sought to articulate the impact of structural factors, such as poverty, gender disparities, uneven access to education, and authoritarian rule, on what she refers to as the entangled experiential webs that HIV and AIDS weaves in Zimbabwe. Anthropological research in Africa has influenced the shift in recent years from an exclusive focus on higher-risk behaviours to recognition of the important links between behaviour and the structural relations and processes that create vulnerability to HIV infection (as suggested by the contribution of Pietrzyk and others in this issue). As Stillwaggon (2006, p. 176) stresses, “Understanding the population dynamics of HIV transmission is trammelled by methods that examine only individual, and generally behavioural, variables.” Exemplary is Schoepf’s (1988) observation that one of the important consequences of the global economic crisis of the 1980s was the movement of women in central Africa towards commercial sex exchanges, with an attendant increase in exposure to HIV. This behaviour change is best understood not as an individual-level event nor as the consequence of individuallevel characteristics; instead, it reflects a widespread

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survival strategy of individuals with limited resources facing a common structural threat. Anthropologists working in Africa have helped influence the shift in the HIV/AIDS literature away from an emphasis on ‘risk groups’ to ‘risk behaviours.’ While early epidemiological publications on HIV and AIDS conceptualised the existence of groups of people who shared patterns of inherently ‘risky’ behaviour (e.g. homosexual men, injecting drug users), based on their own research anthropologists have stressed that empirically bounded ‘risk groups’ do not exist. Rather, it is various behaviours, such as unprotected sex, that put people at risk — not particular kinds of relationships, statuses or identities. Thus, some individuals involved in sex work may or may not insist on condom use depending on their structurally determined ability to exercise agency (McGrath, Rwabukwali, Schumann, Pearson-Marks, Nakayiwa, Namande et al., 1993: Schoepf, 1993). Moreover, anthropologists have helped to clarify many realities of gender relations and the ways that specific patterns of male/female interaction, as well as other gender identities, play important roles in the construction of risk behaviours and in patterned ways of living with HIV infection (Ingstad, 1990; Setel, 1996; Kornfield & Babalola, 2008). Furthermore, insights about the nature of culture as a factor in human reproductive behaviour have been used by anthropologists in Africa to help develop culturally attuned HIV-prevention and intervention models, including models that move beyond knowledge promotion to those that address structural, environmental, situational, and personal barriers to HIV-risk reduction. The challenges of HIV/AIDS and multidisciplinarity Through their effort to find a useful place in HIV/AIDS responses, as well as in other arenas of global health work, anthropologists have become strong advocates for multidisciplinary approaches. Whelehan (2009, p. 253) states: “The response to [HIV/AIDS]…needs to be comprehensive, collaborative, and continuous. A holistic, integrated, and interdisciplinary approach is necessary to address the pandemic.” While not hesitant to point out the limitations encountered in constricted biomedical paradigms of disease, top-down prevention/intervention models, a narrow epidemiological focus on individual behaviours that ignores the social embeddedness of vulnerability, and nonparticipatory research and intervention strategies — traditionally independent anthropologists have learned the value of cross-disciplinary team efforts. This has been supported in important ways by several key individuals in cognate disciplines. The late Jonathan Mann, for example, an epidemiologist, physician, and former director of the World Health Organization’s Global Programme on AIDS (WHO/GPA), argued for anthropological initiatives to clarify the cultural aspects of HIV-risk behaviour, identify effective approaches to HIV prevention, and improve clinical treatment of the disease by elucidating social factors in patients’ wellbeing. Indeed, as Kleinman (2009, p. vi) indicates: “The new global era of central concern with AIDS, other emergent infectious diseases, disability rights, tobacco-related diseases, epidemic diabetes, trauma from political and social violence, substance abuse, suicide and

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dementia was the time for medical anthropology.” As the work presented in this special issue suggests, anthropologists have been responding enthusiastically to this interdisciplinary opportunity to reshape approaches to public health around the world. More remains to be done, however. As we move further into the 21st century, “More AIDS research needs to cross disciplinary boundaries so that biomedical research might explore…the way that HIV behaves in different human ecological settings,” while social science “needs to incorporate the physiological characteristics of the human population in its analysis of the dynamics of disease spread” (Stillwagon, 2006, p. 32). Yet the triumph of multidisciplinarity — involving successful collaboration that transcends not only defended disciplinary boundaries but inherent conceptual worlds and jargon-filled disciplinary languages, and, perhaps more challenging, our ability to see through the historic blinders imposed by disciplinary bias and discipline-centrism — is far from guaranteed. Notes Ramin (2007, p. 127), even now “it is exceedingly rare for medical doctors and anthropologists to sit down and exchange ideas, even about an issue as important as the global HIV/AIDS epidemic.” Speaking of their respective disciplines, Cone & Martin (2003, p. 232) inquire: “Is collaboration between a biologist and a cultural anthropologist possible today? Would bringing insights from biological science and cultural studies together produce a synergy that scholars on both sides would find enlightening?” Anthropological perspectives demonstrating the value of cross-disciplinary synergy in addressing the HIV epidemic in Africa — using the perspectives of anthropologists who have worked in various locales and among diverse peoples on the continent — is the theme uniting the papers in this special issue of AJAR. Framing the approach of these contributors, moreover, is recognition of the fundamental importance of collaboration, including forging partnerships with indigenous colleagues who have first-hand knowledge of specific expressions of the epidemic in local sociocultural contexts, and who are committed to strengthening the capacity of their national healthcare systems to respond to HIV and AIDS. Central to the newfound importance of multidisciplinarity is an understanding that not only is the HIV pandemic a biosocial complex that involves multiple intersections among global political economy, local environments, cultural patterns, local social structures (including class, ethnic and gender inequalities), war, human evolutionary biology and viral pathogenesis, but also that the pandemic did not emerge in a disease vacuum (Armelagos, Ryan & Leatherman, 1990). As many authors in this collection emphasize, HIV and AIDS in Africa are entwined with a wide range of other diseases and threats to health and wellbeing. Critical among these are malnutrition, malaria, tuberculosis, and a group of afflictions associated with poverty that have come to be called ‘neglected tropical diseases’ (Hotez, Ottesen, Fenwick & Molyneux, 2006). As a result, many countries of Africa face a daunting constellation of interacting and mutually exacerbating epidemics, epidemicenhancing social conditions, and socially adverse disease syndemics (Singer, 2008). The syndemic concept of disease

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developed within anthropology during the early 1990s to denote the adverse interactions that transpire among diseases and other health conditions as they are clustered within populations, brought into interacting co-morbidities in human bodies, and, as a result, add to the disease burdens of disparate populations by the force of encompassing social structures (Singer, 2009). For example, Molyneux, Hotez & Fenwick (2005) note that analyses of poverty-promoting and often stigmatising “endemic neglected tropical diseases in Africa…exhibit considerable geographical overlap, and…in many cases are syndemic.” Older syndemics in Africa (e.g. the synergistic interaction between helminthic infection and malaria) have been significantly complicated by the emergence of HIV and AIDS. Research in several Africa nations (particularly in areas where helminth infections are endemic) has shown that individuals suffering from worm infestation are more susceptible to malaria and have more adverse clinical outcomes if infected by Plasmodium, probably because some infectious worm species diminish the body’s ability to develop immunity to the malaria-causing parasite (Druilhe, Tall & Sokhna, 2005). Adding HIV and AIDS to this syndemic cluster significantly magnifies the threat to a sufferer’s health. Diseases caused by parasitic worms have been found to interact with HIV infection, both increasing susceptibility and exacerbating HIV-infection progression. Similarly, it is known that “HIV fuels malaria and malaria fuels HIV” (Abu-Raddad, 2007). Moreover, HIV and AIDS adversely interact with many of the other major health problems in sub-Saharan Africa. Syndemic interaction between HIV or AIDS and malnutrition, for example, involves degradation of the body’s complex and multi-layered immune system. In fact, malnutrition and HIV infection are the two most common causes of acquired immune dysfunction, and the patterning of immune system suppression caused by malnutrition in several ways mirrors the immune effects of HIV infection. When these two disruptive conditions are concurrent, their impact on the immune system is both synergistic and severe. The result is the kinds of intense and costly HIV/AIDS syndemics seen in parts of sub-Saharan Africa (Singer, 2009). Likewise, with reference to HIV and tuberculosis, Laserson & Wells (2007, p. 379) observe: Approximately 38% of African TB patients are estimated to be HIV-infected. This TB/HIV syndemic has seriously compromised even historically strong national TB programmes in many countries…. Furthermore, TB is the leading cause of death among HIV-infected persons, and HIV is the strongest predictor of progression from latent TB infection to active disease…. The TB/HIV syndemic has also had a tremendous impact on human resources. Additionally, the “TB/HIV syndemic has also increased the clinical complexity of managing patients” (Sirinak, Kittikraisak, Pinjeesekikul, Charusuntonsri, Luanloed, Srisuwanvilai et al., 2008, p. 245) because of the hepatotoxic effects of some of the medications used to treat HIV or opportunistic infections that are common in HIV/AIDS patients in local settings.

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The full extent of the adverse effects of HIV/AIDS syndemics on health and healthcare in Africa is daunting. An analogous phenomenon is found in meteorology where the concept of the ‘perfect storm’ refers to a combination of factors that significantly aggravate climatic conditions, resulting in the worst possible storm-related damage. From a public health perspective, in the African context, HIV/ AIDS syndemics constitute a perfect epidemiological storm (Singer, 2008). Notes Bastos (2008, p. 1721): In addition to devastating the health of the African population, a major catastrophe by itself, HIV has exacerbated many other medical and social horrors, such as endemic tuberculosis, persistent malaria, civil wars, droughts and famines. The resulting multifarious syndemic…with AIDS as one of its main components, has compromised the frail local economies of the sub-Saharan countries, disrupted the social fabric of these communities, and contributed to an unexpected reversal of much of the hard-won social and health progress of the 1970s. In short, it is not possible to understand the African HIV/ AIDS epidemic without appreciating the syndemic aspect of this disease and its multiple adverse interactions with other diseases, health adversities and social disparities. As reflected in the paper by David Himmelgreen and colleagues, anthropologists have begun to examine the impact of HIV/AIDS syndemics on everyday life in affected populations in Africa. The ability of biological and cultural anthropologists to collaborate in this type of work underlines the value of the range of specialties incorporated within the discipline. Not surprisingly, over the last 25 years, anthropologists with a special interest in HIV and AIDS in Africa have pursued a wide range of topics and issues (characteristic of the discipline), from patterns of male condom use and female condom acceptability, to the benefits (and unintended risk consequences) of circumcision; from the roles of ethno-medical practices and practitioners in HIV/ AIDS treatment, to the consequences of the stigmatisation of people living with HIV or AIDS; and from the role of gender relations in the structuring of HIV/AIDS vulnerability, to the health and social impacts on children orphaned by AIDS. This is only a short list of the many relevant concerns investigated by anthropologists working on the continent. Indeed, inventories like this are always partial because not only have anthropologists participated in HIV/AIDS work in diverse African countries, regions and local contexts, but also because HIV and AIDS remains an ever-changing domain with a continuous array of emergent issues. The specific set of HIV/AIDS-related problems addressed by the anthropologists writing in this issue is further discussed below. The mosaic of HIV/AIDS-related anthropological work in Africa From the start, anthropological efforts in the field of HIV/ AIDS research in Africa, as elsewhere, have had a noticeably applied dimension. While such work has contributed to theory development and addressed issues in method-

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ology and research ethics, a core issue in most HIV/AIDS research projects conducted by or involving anthropologists has been disease prevention or improving access to quality care among infected or affected populations. This attribute characterises the papers in this collection as well. The work reported by Edward Green and colleagues in four nations in southern Africa (Botswana, Lesotho, South Africa and Swaziland) was designed to identify aspects of indigenous leadership and cultural resources that could be used to influence alterations in individuals’ behaviour as well as in community norms, values, and social controls related to sexual practices. One of the ‘levers for change’ they discovered was the mobilisation of traditional leaders, a group that has largely felt bypassed by HIV/ AIDS-intervention efforts. Building collaborative relations with traditional leaders, they argue, offers an important culturally sensitive approach to limiting the epidemic in southern Africa. Similarly, Alexander Rödlach describes the need for significant shifts in Zimbabwe in the way government bodies collaborate with home-based voluntary caregivers of people living with AIDS. Overburdened by the ever-increasing number of AIDS patients being made their responsibility due to hospitals’ incapacitation, he found that caregivers have become bitter and are at high risk for burnout. Unless increased government support of caregivers is implemented, Rödlach argues, AIDS patients from poorer families will be left without any support, a situation known to increase disease progress (Leserman, Jackson, Petitto, Golden, Silva, Perkins et al., 1999; Galvan, Davis, Banks & Bing, 2008). Enhancing intersectoral and interpersonal collaborations As the forgoing examples suggest, the contributors to this special issue recognise the fundamental importance of collaboration across national boundaries and societal levels, and between disciplines, institutions and service sectors. Accordingly, Gisele Maynard-Tucker elucidates the advantages of a comprehensive approach to HIV/AIDS and family planning services, because such an approach would assist HIV-positive women to avoid unintended pregnancies and reduce the number of children born with HIV infection. Based on recent field research in Malawi, Maynard-Tucker suggests the merits of training and involving barbers, hair dressers, seamstresses, pharmacists, and rural communitybased distribution workers to function as a network of lay counsellors and HIV/AIDS educators who are able to promote family planning, HIV-prevention information and referrals to their everyday clients. The collaborations championed by anthropologists working on HIV/AIDS topics in Africa vary depending on the local context and the needs of the affected populations. Thus, David Himmelgreen and co-workers suggest a reassessment of policy priorities. In light of the food insecurity-HIV/AIDS syndemic in Lesotho, they advocate collaboration between various government bodies and NGOs concerned with food-security-related services and those that address HIV and AIDS. Such an approach, they observe, would maximise the effectiveness of existing strategies and

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programming, and specifically (in light of the negative effects of HIV/AIDS stigma on wellbeing and healthcare-seeking) increase participation among those who are reluctant to take part in programmes exclusively focused on HIV and AIDS. Multidimensional programming, combined with improved monitoring and evaluation to support a programme’s efficacy, can ultimately provide HIV/AIDS-related assistance to those who might otherwise avoid seeking HIV testing, counselling and treatment, as they serve to identify individuals in need of HIV/AIDS services who were not aware they were infected. Britta Thege stresses the need for interpersonal collaboration. She observes that among rural women in South Africa, risk of exposure to HIV is high because of gender inequality and socio-economic hardship. As a result of traditional patriarchal structures, negotiating safer sex both with husbands and other intimate partners, as well as with customers among women who engage in commercial sex, may be very difficult. Also, despite facing patterns of gender inequality, Thege found that the women tended to hold negative perceptions of other women and their solidarity was limited (a reflection of a common ‘blame the victim’ sentiment among subordinate groups, which hegemonically expresses the divisive effects of dominant ideologies). In Thege’s view, the HIV epidemic, despite its heavy toll, nonetheless provides an opportunity for enhancing women’s agency and solidarity among those in a community facing common challenges and barriers. ‘Translating’ research Despite an applied orientation in most sectors of the anthropology of HIV and AIDS, an important challenge facing anthropologists is the need to publish their findings or present them at professional conferences. While these are important activities, they frequently occur in academic and research institutions located in developed countries — venues that may not be readily available to scholars in some African settings. Moreover, anthropologists and others studying HIV/AIDS-related issues must take steps to ensure that their research is readily accessible, relevant, and understood among those who work in diverse HIV-prevention programmes, offer care to people living with HIV or AIDS and their families, or who are involved in health policy decision-making. As Sloboda (1998, p. 203) emphasizes, a “key issue that faces the field of intervention in general is how to translate the research findings for more widespread practice.” Easily accessible and usable information is a vital component of increasing the efficacy of intervention efforts and is particularly important in HIV/ AIDS-intervention programmes that target harder-to-reach populations. But the need exists among all population sectors in developing countries, including all countries of Africa. At the same time, intervention models that are proven effective at the local level must be scaled up beyond pilot programmes if they are to have a significant impact on the epidemic within a country. For example, Binswanger (2000, p. 2173) observes: “In most of Africa, there are examples of excellent HIV/AIDS-prevention, mitigation, and care projects. These projects reach only a small fraction of the

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population, however. Like expensive boutiques, they are only available to a lucky few.” Yet as Maynard-Tucker argues, in most African contexts this is especially difficult to achieve because of the lack of sustainable funding for large-scale programmes. As a result, international funders must bear the responsibility of working with ministries of health and related government bodies as well as both local and international NGOs and HIV/AIDS activists in moving effective programmes to a national scale. Advocacy in support of such moves is also a responsibility of anthropological researchers as the discipline seeks an approach that reconnects academia with the practical concerns and pressing needs of everyday life (Basch, Saunders, Sharp & Peacock, 1999; Sanford & Angel-Ajani, 2006). Revealing culture Anthropologists are trained to pay keen attention to local patterns of culture and the intricacies of social organisation; in the course of work on HIV and AIDS as well as other applied health and social issues, anthropologists have repeatedly seen programmes that treat indigenous culture as either irrelevant or as an obstacle to be overcome to achieve planned change. Gausset (2001, p. 509) remarks: “The fight against AIDS in Africa is often presented as a fight against ‘cultural barriers’ that are seen as promoting the spread of HIV. This attitude is based on a long history of Western prejudices about sexuality in Africa which focus on its exotic aspects only (polygamy, adultery, wife-exchange, circumcision, dry sex, levirate, sexual pollution, sexual cleansing, various beliefs and taboos, etc.).” Anthropologists are well aware that cultural beliefs and practices at times contradict HIV/AIDS-intervention agendas — although often the problem is simply a failure by interventionists to learn about and fully appreciate the cultural logics that underlie behaviour in target communities. Consequently, anthropologists commonly play an active role as ‘revealers’ of culture — by stressing its structure and meaningfulness and that culture should not be ignored by interventionists. Moreover, anthropologists have sought to demonstrate that including sincere attention to local culture, and (more challengingly) its incorporation in some (locally appropriate) fashion into intervention design, can contribute significantly to improving programmes’ appeal and efficacy. Often, anthropologists stress, full community participation at all levels in a programme is the most productive approach (Schensul, Weeks & Singer, 1999). As Bennett (2007) comments: An education in applied anthropology requires training in engaged scholarship, which mandates community participation from the beginning of a research project as opposed to the community’s having a more passive role, simply receiving research results. The more students are involved in engaged scholarship, the more successful they will be as applied or practicing anthropologists. Even in cases where specific cultural practices appear to increase HIV risk, as Gausset (2001, p. 517) points out, “Prevention campaigns in Africa [should] try to make cultural practices safer, rather than to eradicate them,” for the sake of both ethics and efficacy.

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This perspective on culture is clearly evident in the papers in this collection. In Zambia, Emily Frank observes that getting tested for HIV infection is not a simple or straightforward health-seeking behaviour, as might be assumed by interventionists who know the health benefits of learning one’s HIV status. Rather, getting tested for HIV often is enmeshed in layers of cultural meaning and significance, which may be beyond the recognition of public health or biomedical providers seeking to address the HIV epidemic. Ethnography, which has long served as the core methodology of anthropological research, has proven to be an adroit approach for allowing cultural outsiders to grasp and appreciate the inner logics that inform people’s behaviour and attitudes. Additionally, ethnography has contributed to our understanding that, in addition to reflecting webs of meaning, behaviour is shaped by networks of power and the history of power relations as locally experienced. Frank, for example, suggests that Zambian’s fear of and resistance to HIV testing and treatment does not reflect a lack of desire for healthier lifestyles and improved wellbeing. But rather that these emotions, attitudes, and behaviours express resistance to a system that prioritises individual and scientific outcomes over locally valued goals, such as protecting community identity and assuring community sustainability in a globalising world. Frank argues that resistance to HIV testing and treatment is part of a communal effort to defend against an international system that hurtfully depicts Zambia as a nation characterised by economic failure and a devastating HIV epidemic. From the cultural logic that informs the Zambian perspective, HIV/ AIDS-intervention programmes are not impartial players in a world of international social relations and economic development. Instead these programmes may be experienced as one of the adverse ways in which international powers impact on the most personal domains of everyday life and identity. Of importance are not only the beliefs that contextualise popular responses to specific interventions but the emotions that are no less significant in channelling human behaviour and attitudes. With these insights, it is possible to begin to address resistance to HIV testing, for example, through a sensitive handling of this issue. In South Africa, Robert Thornton similarly identifies an overlap between known patterns of risk for sexual transmission of HIV and prevalent behavioural patterns in communities. Thornton examines underlying culturally meaningful reasons for maintaining multiple concurrent sexual partners even though this is an identified HIV-risk pattern among public health experts and educators. He found that rather than being irrational or obstructionist this behaviour could be a realistic response to limitations in access to social and economic goods because it enables people to increase both the size and the diversity of their social networks. In a world in which social networks are critical in accessing needed resources, enhancing one’s ties to others through any available means may be key to immediate survival, even though this may increase one’s health risks in the long run. Identifying and trouble-shooting situational barriers As noted above, one task of anthropologists in applied research is the ethnographic identification of local barriers

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to an intervention’s efficacy, be it shortcomings in the approach adopted by the interventionists, conflicts that splinter targeted communities into hostile factions, contradictions between interventionist and target community understandings, or opposed expectations, values, and other points of tension or miscommunication in planned interventions. A number of these shortcomings are discussed by David Turkon and colleagues based on their meetings with representatives of international nongovernmental organisations (INGOs) engaged in HIV/AIDS mitigation and related development programming in Lesotho. Commonly, the representatives voiced frustrations about the culture within which their organisations must function, accompanied by complaints that the central offices, which set funding priorities, did not fully grasp the scale of HIV/AIDS-related problems at the local level or the underlying forces driving the epidemic, including poverty and inadequate livelihoods. Rather than developing programmes that enable interventionists to get ahead of the epidemic, HIV-prevention efforts could become focused on crisis management. As a result, funding for HIV prevention may be wasted on programme models already shown to have fallen well short of their intended goals. Similarly, John Mazzeo and Loveness Makonese, working in rural Zimbabwe, observed that flawed partnerships between government, international NGOs, and community providers of home-based care led to fragmented outcomes for HIV/AIDS programming, with immediate adverse consequences for the intended beneficiaries. Anthropologists are trained and positioned to help communicate the concerns and attitudes of local communities to programme stakeholders, such as foreign-based aid organisations. While anthropologists recognise the importance of people directly articulating their own concerns and attitudes, in some settings this may be difficult because of beneficiaries’ fear that any criticism could result in the loss of needed programmes or other retribution. Another useful approach to intervention troubleshooting is presented by Sophie Kotanyi and Brigitte Krings-Ney. In Mozambique, they found that biologically oriented HIV-prevention campaigns have not had the behavioural impact expected by the programme’s originators. Despite the biological dimensions of HIV transmission, the authors observed conflicts with cultural understandings about health and disease. Consequently, they underscore the critical importance of paying attention to local cultural paradigms, metaphors, and values in the development of HIV-prevention messages. Furthermore, the authors came to recognise the usefulness of particular, culturally validated approaches and opportunities for effectively communicating this information to target audiences. Importantly, they note that cognitive HIV-prevention messages have not proven adequate to motivate enduring behavioural change. Incorporation of HIV-prevention education into traditional initiative rites — because of their long-term emotional impact on participants — offers an alternative, untapped culturally sensitive opportunity to enhance preventative behaviour. Roos Willems offers another example of the misuse of generalised messaging in HIV/AIDS education. While HIV prevalence is comparatively low in Senegal (in part, as a

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result of an early national response), Willems found that gains in HIV/AIDS knowledge in the urban context are not replicated in rural areas. Willems explains this regional disparity by way of HIV-prevention messages that lack the flexible, cultural sensitivity needed for addressing the multi-ethnic rural population. Highlighting several common themes that unify this set of papers, Willems stresses the need for an evidence-based approach through interdisciplinary collaboration in the development of appropriate messages for vulnerable subgroups. The need for culturally targeted HIV-prevention programmes is also reflected in the paper by Jeremiah Chikovore and co-workers. Their qualitative examination of HIV-risk knowledge and concerns among youths in rural Zimbabwe used a self-directed question-writing process and revealed notable gaps and uncertainties about HIV transmission and prevention. The study participants raised questions demonstrating that young people inhabit complex and often hybrid social worlds with multiple and sometimes contradictory sources of health information. Qualitative methods, like the use of self-directed questions, allow insights about the experiential worlds of target populations which are critical to effective intervention designs yet are not likely to be developed using the findings of standard survey methods. Conclusions Anthropological research on HIV and AIDS in Africa has yielded insights of both theoretical and practical utility. In regard to social and behavioural theory, this work has helped expand our understanding of how culture shapes behaviour (in sometimes unexpected ways), even in the midst of a life-threatening epidemic, as well the role of political and economic history in shaping community responses to planned interventions. In a world where inequality constitutes a threat to life and wellbeing, anthropological research helps to clarify how this complex aspect of human social life reverberates through and impacts on human endeavours. Furthermore, this work has informed analyses of the intricate biosocial nature of epidemics and other social disruptions that threaten health. The intersection of social, health, and ecological crises amplifies the challenges that communities face; it is in Africa that we are first seeing patterns that may well define the global publichealth landscape of the 21 century. In a practical sense, anthropological research in Africa has improved our understandings of local HIV-related beliefs, behaviours, attitudes and emotions — knowledge that is of critical importance in making changes that matter in responding to HIV and AIDS. Key contributions include the identification of local barriers to HIV-risk reduction, the causes of intervention programme resistance, and the reasons individuals choose behaviours that appear to enhance vulnerability to HIV infection. These contributions validate the locally grounded and ethnographically informed approach that guides much anthropological research. Moreover, the benefits of multidisciplinary/multisectoral programmes and authentic cooperation that transcends national boundaries, social sectors, and other social divisions are affirmed by anthropological research.

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Interdisciplinarity and collaboration in responding to HIV and AIDS in Africa: anthropological perspectives.

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