The Technocratic Turn in the Phases of International AIDS Politics

Since 1981, when HIV was formally identified as the cause of AIDS, a cure for both the virus and the syndrome has occupied scientists, philanthropists, activists, bureaucrats and politicians alike. Methods of preventing the spread of HIV were always on the surface quite straightforward: adopt the ABC approach—abstain from sex, be faithful to one partner, use a condom, and know your status. However, prevention has always been contentious. People, especially politicians, do not like to talk about sex. Sex often makes people and their behaviour irrational. Many people around the world, particularly women, are unable to negotiate safe sex or say no to sex both with their partners and non-partners. Providing clean needles to prevent HIV transmission from intravenous drug use (particularly in prisons) provokes contentious reactions. The tricky nature of prevention has led to a growth in focus of international HIV/AIDS policymakers towards treatment and cure and technocratic, rather than political, solutions.

The current preoccupation with technocratic treatment and cure is being led by a group of state and non-state actors ranging from the ‘Bill and Melinda Gates Foundation’ that invests heavily in vaccine research, to the US government’s ‘President’s Emergency Plan for AIDS Relief’ (PEPFAR) and the ‘Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria’ that combined provide the majority of free life-saving and sustaining anti-retroviral drugs for half of those living with HIV in low and middle income countries. This focus on treatment and cure is not only evident in how money is spent; it is also clear from some of the policy directives and discussions of the last five years, particularly in the areas of treatment such as cure, vaccine discovery, and ‘the Berlin patient.’  Towards the end of 2011 the lead UN agency for HIV/AIDS—UNAIDS—highlighted in its annual report research findings that demonstrated the efficacy of anti-retroviral treatment as a method of HIV prevention. Excitement as to the potential of treatment as a method of cure was heightened, particularly in the media, around ‘the Berlin patient’ Timothy Brown who was presented as the first man to have been cured of HIV after receiving a bone marrow transplant as part of his treatment for Leukaemia. The 2012 International AIDS Conference saw the coming together of emphasis on vaccines, scaled up anti-retroviral treatment, and other medical interventions towards the halting and reversing of HIV/AIDS. Combined, such emphases signified a technocratic turn within the governance of HIV/AIDS that places scientists, medical practitioners and technical solutions at the centre of articulating future agendas and policy for AIDS.

For some this may be no bad thing — science saw the delivery of anti-retroviral drugs that sustain millions of lives and medical practitioners are at the forefront of treatment and care. However HIV/AIDS is seen by many as an exceptional disease both in that it is different to other global health concerns in its deeply political nature, requires a combination of actors, and that it has received significant funds towards its containment. To understand such exceptionalism, the political nature of the disease, and the technocratic turn it is useful to map and identify the three previous phases of the international politics of HIV/AIDS.

The first phase can be characterised by denial, stigma and community activism. When gay men started dying at an accelerated rate in North America and Europe in the early 1980s politicians remained silent, scientists frantically searched to identify what was causing these deaths, and self-help support groups and community activists formed to demand care, educate, break stigma, and care for the sick. [i] In parts of Africa people were dying of ‘slim’—so labelled because of the wasting effect of the disease—and communities of neighbours and friends organised to care for or stigmatise and ostracise the sick. The international politics of such a phase focused on co-ordinated research between laboratories (that resulted in a dispute over who first identified HIV), government silence, and the growth of transnational support and activism on the need to break the stigmatisation of people living with HIV.

The second phase of HIV/AIDS can be characterised as the development period.  From the late 1980s and throughout the 1990s safe sex campaigns proliferated, the World Health Organisation developed its Global Programme on AIDS, the red ribbon became synonymous with the 1st December World AIDS Day, and the prevalence rate in sub-Saharan Africa continued to grow. Explanations as to high prevalence in sub-Saharan Africa fell into two camps: behavioural and poverty. Towards the late 1980s (and still ongoing) experts began to hypothesise that the spread of AIDS in sub-Saharan Africa was due to behaviour and sexual practice involving multiple partners and concurrent relationships.[ii] However for some such explanations were replete with sexual metaphors and ignored the socio-economic context in which the disease spread.[iii] For many, the spread of HIV/AIDS could not be separated from poverty; hence HIV/AIDS was not a behavioural problem but one of development.[iv] The framing of HIV/AIDS as a development concern piqued the interest of the World Bank and put the disease at the heart of the World Trade Organisation’s view on intellectual property. It also chimed with the work of non-governmental organisations working with community groups on prevention, treatment and care as well as a host of United Nations (UN) agencies, working towards the end of the 1990s under the umbrella of UNAIDS.

The culmination of the development phase of the international politics of HIV/AIDS was the inclusion of the disease as Goal 6 of UN Millennium Development Goals and an upsurge in funds towards tackling the disease. However the turn of the millennium saw a slight shift in how the disease was viewed in the international community. UN Security Council Resolution 1308 stated that HIV/AIDS ‘if unchecked, may pose a risk to stability and security.’[v] From this point in 2000 a plethora of academic research concentrated on the nature of the threat of HIV/AIDS to national and international security and what that meant for how we understand security, risk, and the impact of such a frame on stigma, policy and funding.[vi] Arguably it was during this phase that HIV/AIDS came onto the agenda of international relations. However for many such a framing was disconcerting, distorting, and did not reflect experiences on the ground.[vii] Moreover such a phase intersected with that of the on-going development phase that generated an ‘AIDS biz’[viii] of actors, money, policy and programmes.

These three phases and the new technocratic turn reveal several important points for the study of international relations and the role of HIV/AIDS within it. First, the international politics of HIV/AIDS is about more than security: it is about community organising, racial and homophobic stigma and metaphors about people living with and affected by HIV, and the changing nature of how HIV/AIDS is somehow exceptional in international affairs. Second, the number of actors, policies, and initiatives developed over the last thirty years demonstrate an intricate, and growing, form of global governance that involve public and private actors operating at various levels within the international system. How these actors interact, their interests, the sources of their finance, and their views on HIV/AIDS and behaviour all reveal expressions of power in the international system. Finally, the increased technocratic emphasis on managing HIV/AIDS within a frame of science and technology reflects a wider tendency to depoliticise international relations and provide technical solutions for some of the most complex of problems. The initial three phases of the international politics of HIV/AIDS – stigma and activism, development, and security – all reveal the deeply political nature of identifying the spread and demanding a cure for HIV/AIDS. Instead of overcoming problems of politics, the technocratic turn may sideline politics in a way that ignores the tensions between actors, individuals, and structures of power that are vital to making the science both work and available to those who need it most.

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Sophie Harman is a Senior Lecturer in the School of Politics and International Relations, Queen Mary, University of London. Her research focuses on the political economy of governance with particular reference to the World Bank, health, gender, and agency in international politics. She has published several books with Routledge, most recently Global Health Governance (2012) and The World Bank and HIV/AIDS (2010).

[i] For excellent accounts of this period see Shilts, R. (1987). And the Band Played On, New York: St Martin’s Griffin and the film We Were Here (2011).

[ii] Caldwell, J.C. et al. (1992). ‘Under-reaction to AIDS in sub-Saharan Africa’ Social Science and Medicine 34: 1169-1182; Epstein, H. (2007). The Invisible Cure: Africa, the West and the fight against HIV/AIDS London: Penguin

[iii] Stillwaggon, E. (2003). ‘Racial Metaphors: Interpreting sex and AIDS in Africa’ Development and Change 34: 809-832

[iv] Poku, N.K. (2002) ‘Poverty, debt, and Africa’s HIV/AIDS crisis’ International Affairs 78(3): 531-546; Barnett, T. and Whiteside, A. (2002). AIDS in the twenty-first Century: Disease and Globalization London: Palgrave

[vi] McInnes, C. (2006) ‘HIV/AIDS and Security’ International Affairs 82(2):315-326; Elbe, S. (2006). ‘Should HIV/AIDS be securitized? The ethical dilemmas of linking HIV/AIDS and security’ International Studies Quarterly 50 (2006): 121-146.

[vii] Seckinelgin, H. (2012). International security, conflict and Gender: ‘HIV/AIDS is another war’ Abingdon: Routledge

[viii] Pisani, E. (2008). The wisdom of whores London: Granta Books

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