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The Role of Social Research in the Fight Against HIV/AIDS in Brazil and South Africa, 1990s-2010s. An Assessment of the Socio-Political Context of Knowledge Production and Use

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Universitat de Barcelona. Departament de Teoria Sociològica, Filosofia del Dret i Metodologia de les Ciències Socials

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[eng] The core argument of the present work is articulated in four points. First, social- science knowledge is crucial to understand and combat HIV/AIDS; second, integrated and engaged social-science is especially vital for such endeavor; third, integrated and engaged scholarship of HIV/AIDS has been prominent in Brazil (since 1990s) and South Africa (since 2000s); Fourth, Brazil’s earlier use of social- science knowledge in HIV/AIDS policy accounts for its success in tackling the epidemic, and South Africa has only recently started making effort in this direction. The theoretical background of the present discussion consists in social-science approaches to problem-solving and policy-making within the debates about the role of social-science in modern states formation. It is about history and epidemiology of the social sciences, but the discussion goes beyond these instances and maintains a normative approach to academics social responsibility to contribute more directly and consciously to national development. In this sense, this is a matter of both cameral social-science (linked to public policy design and evaluation: John Goldthorpe) and public social-science (in support of to civil society for social justice: Alain Touraine, Michael Burawoy). The rationale and main objective of the thesis substantiates in three questions: first, why HIV/AIDS? second, why social-science? and, third, why Brazil and South Africa? In this regard, it is argued that: HIV/AIDS is a complex social problem that needs and allows comprehensive analysis; the role of social-science knowledge in HIV/AIDS interventions, as well as the impact of the epidemic on social-science, are understudied; and, finally, Brazil and South Africa are good examples to demonstrate how the use of social-science knowledge accounts for the success of health policy oriented to HIV/AIDS. Indeed, Brazil was far superior to South Africa until a decade ago (it is still the case, to some extent) in responding effectively to the HIV/AIDS epidemic by implementing a nation-wide comprehensive program of prevention, treatment and care. It is then suggested that this was partly due to a consistent use of social- science knowledge that helped the state to go beyond the concept of risk-groups. Based on these premises, it is here suggested that social scientists played a significant role in Brazil’s National AIDS Program by infusing politics with the concept of social vulnerability to HIV/AIDS. This means that interventions need to go beyond risk-groups and information-based strategies (that characterized the initial HIV/AIDS studies and programs), as demonstrated by the global debate on the locus of behavioral change in HIV/AIDS studies and interventions. Following the shift of approaches from individual and information-based strategies to structural factors and holistic approaches (the latter being in vogue since the 1990s globally), social scientists in Brazil suggested that it was necessary to improve people’s social, cultural and economic circumstances in order to create healthy supporting contexts. This was associated with Brazil state’s political will to prioritize HIV/AIDS and to act collectively, which implied alliances between administrative levels (federal state, local states, and municipalities), civil society and academics. So, social scientists were great protagonists in the battle against the HIV/AIDS in Brazil within this climate of political will and collective action against the epidemic. The same cannot be said in the case of South Africa. This particularly explains the divergent policy outcomes: Brazil’s low and concentrated HIV incidence rate (0.5%), and South Africa’s generalized epidemic and high incidence rate of HIV infection (18%). This is despite the fact that by the HIV emergence the two countries were rather similar societies in terms of general state capacity, civil society involvement, Human Development Index, and epidemiological profile. The former point means that by the HIV outburst the initial risk-group in both countries was constituted by male middle-class homosexuals – as situation that radically and rapidly reversed more in South Africa than in Brazil, although pauperization, feminization and heterosexualization of HIV infection are aspects that characterize both countries today. Brazil’s major political will and cohesiveness, with social scientists’ participation, falsifies arguments according to which Brazil’s superiority – compared to South Africa - in tackling HIV/AIDS is due to the countries’ earlier democratization (1986 vs 1994), the role of World Bank’s loans throughout the 1990s, and Brazilian elites’ tradition of investment in public health. Indeed, first, Brazil’s National AIDS Plan was already well established by the end of 1980s had already made progress towards a comprehensive program of prevention, treatment and care. Brazil’s National AIDS Plan created early on an inter-ministerial body (compressing the ministries of health, education, labor and justice) and defined clear authorities responsible for HIV/AIDS policies. Second, South African elites’ were equally prone to invest in public health, for Brazil was not superior in this field. Hence, the present work suggests that it was political will and collective action that permitted Brazil to act more promptly and aggressively against the HIV/AIDS epidemic until a decade ago. In turn, here’s the core argument – this positive atmosphere facilitated the production and inclusion of massive use- inspired research that informed HIV/AIDS policy about the complexity of the epidemic and the most appropriate measures to reverse it. For example, social research helped Brazil to enlighten Brazilians’ openness towards sex, sexuality and sexual diversity, whereby not only did prevention social actors find it easy to discuss those issues for the sake of prevention initiatives, but also permitted the government to involve gay groups, rather than stigmatizing them. Importantly, Brazil state’s openness towards social-science was part of a general positive attitude towards science, whereby the use of biomedical measures (explanation of HIV-AIDS link and provision of antiretroviral drugs to infected persons) was an essential element in the response to the epidemic. By contrast, holistic and large-scale inquiries and, above all, their use in policy were late to emerge in South Africa (between the end 1990s and early 2000s). This contributed to HIV/AIDS policy being poorly informed by social-science until a decade ago. HIV/AIDS policy in South Africa was consequently characterized by negligence and inaction (in the initial phase), simplistic explanations (like the negative impact of poverty on vulnerability to HIV infection without the exploration of its link with cultural factors), and denial. The state had a hostile attitude towards orthodox biomedical professionals and civil society organizations who sought to combat the epidemic through mainstream science. Therefore, the state went through controversial policies that ultimately prohibited the provision of antiretroviral therapy in the public sector and was hostile to mainstream social theory of HIV/AIDS. This negative political scenario hampered the contribution of social scientists in the battle against the epidemic in South Africa. Contrary to Brazil, HIV/AIDS use-inspired research was not fomented and academics activism was not welcomed by South African state. The situation would only improve in mid-2000s when the state commenced providing public antiretroviral therapies and making progress in prevention programs. Relatedly, the state started then to work in concert with civil society and academics. This was partly a result of a series of high court instructions for the state to accomplish its constitutional duty to provide health services, following a case law-suited by Treatment Action Campaign, the leading civil society AIDS organization. More importantly, HIV/AIDS social-science which was carried out in South Africa until a decade ago relevant, nevertheless. The unfortunate story is that it was not used for policy design and evaluation. Social scientists in South Africa did seek to stress the concept of social vulnerability, warning against the impact of poverty and inequalities, misogyny, magical thinking and traditional healers, just to mention a few. But these insights found no support of the state. It is this early South African scholarship of HIV/AIDS that constitutes the basis for today’s vibrant comprehensive and engaged social-science in the country, whereby South Africa is making-up with its delay. Besides reflection on the complexity of HIV/AIDS and the need for integrated interventions, we can single out some fields of research-action in which the history of HIV/AIDS scholarship materializes: public policy (cameral social-science), peer educators and teachers training, and harm reduction programs for injecting drug users (the latter characterizing especially Brazil). Both in Brazil and South Africa, integrated and engaged scholarship has boosted cross-disciplinarity and multidimensional approaches, as well as debates about academics social responsibility in terms of use-inspired research and research- action. Such debate is largely shaped by reflections on the timing of Brazil’s and South Africa’s responses to the epidemic - early in the former and late in the latter – and the related outcomes with regard to HIV incidence rates. It is to this debate that the present dissertation seeks to contribute by suggesting that the use of social-science knowledge made a difference in Brazil’s success and South Africa’s failure in tackling the HIV/AIDS epidemic until a decade ago. Furthermore, the thesis goes on, social-science engagement with HIV/AIDS, theoretically and practically, will continue to shape the way in which we conceive of the position and the role of social-science knowledge in society.

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Tesis Doctorals - Departament - Teoria Sociològica, Filosofia del Dret i Metodologia de les Ciencies Socials

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The Role of Social Research in the Fight Against HIV/AIDS in Brazil and South Africa, 1990s-2010s. An Assessment of the Socio-Political Context of Knowledge Production and Use