Re-articulating treatment and/as prevention: a complex systems perspective

In the discourse of treatment as prevention (TasP) we’re seeing an initiative to rearticulate the historically separate traditions of HIV treatment and prevention as a single system.

Its starting point is the research finding that people with HIV who have suppressed viral load and no STI co-infection are ‘virtually uninfectious’ to HIV-negative partners, even when condoms are not used.

The word ‘virtual’ is interesting here.  The finding itself is virtual; at first, it was just a fact that can be repeated in discourse.  It didn’t change anything; it describes a situation that already existed.

It will take a concerted effort to bring about changes that will make this fact material, in other words, to see it concretely reflected in the work of prevention and the everyday lives of people living with and at risk of HIV infection.

My current work looks at prevention as an emergent effect of patterns among all those everyday encounters and interactions: in other words, a complex systems perspective.

The systems perspective suggests there are many different paths the rearticulation of systems for treatment and/as prevention could take.  Some of them lead in quite problematic directions, while others may reveal productive and generative possibilities.

Of course, this being a blog about stigma and public health strategy, the primary axis I’m thinking of is HIV stigma and the ‘serodivide’ between positive and negative people in different populations.

Articulation is a useful perspective for thinking through apparent dichotomies.

At the AIDS2014 conference I took part in a video interview by Rex Pilgrim from ACT UP Queensland, offering a critical public health slant on the potentially coercive application of public health power, which many see as a preferable and gentler alternative to crimino-legal responses to HIV transmission.  I don’t actually see that as a choice between alternatives; I see the threat of criminal prosecution as articulated with public health power, as an intensifier of its implied coercive potential.

However, in one of its many different formulations, articulation was seen as the way people and institutions with power take up the concerns of the working class and use them to re-express the agenda of the powerful.

That portrait of power is a bit crude, though.  I did a workshop last week on the systems perspective in which I argued that change ‘management’ is challenging because the status quo is actively and continually being produced by social systems, and this resonated for one stakeholder as a ‘conspiracy theory’ about a powerful Them.

On a complex adaptive systems (Holland 1995; Ostrom 1999) perspective, however, agency itself might be an emergent property of aggregate patterns among interactions on lower levels of social organisation.

That’s an exciting possibility; for instance, it provides an empirically plausible account of the ‘microfoundations‘ (Dan Little’s term) of the Ottawa Charter philosophy of engaging with communities as having agency as communities.

Research by Holland, Kingdon (1984) and more recently the European social theorist Klaus Eder (1999) has examined the way more or less random and recombinatory events in social systems can contribute to social learning at a local level and, when the lessons learned are picked up and transmitted by the nature of those systems, to wide-scale social transformation.

Exactly these processes have been observed in the work of Stephen Lansing on the Subak system for water allocation on the fragile farming ecosystem of Mount Agung in Bali, which originated the world’s oldest and longest functioning democratic culture to facilitate that learning process.

Elinor Ostrom won the Nobel Prize in Economics for developing these findings into a general model of how self-organising human collectives manage to avoid ‘tragedies of the commons’, the bogeyman of classical economics that underpins so many of its arguments in favour of market based ‘cap and trade’ or quota systems.

A key idea in this work is that social units within complex adaptive systems observe the outcomes of new rule combinations in neighbouring terrain and ‘borrow’ the ones that are seen to work.

I’d argue this model applies to policy innovation(s) as well, generally and specifically.  So I was deeply concerned this morning to read this article from St Louis Today, titled ‘2,000 St Louisans are HIV Positive but not taking their medications‘.  It recombines or in other words weaves together strands from an astonishing variety of different memes about HIV prevention.

In particular, it takes the ‘treatment cascade’ concept, created as a complex matrix of targets on the path towards population-level treatment as prevention, and it translates it into an object of media concern, a well-worn step on the pathway towards legislative responses that seek to coerce compliance among people reconfigured as a risk to public health.

Along the way, it treats medical doctors as experts in the social science of prevention.  Many are, but they generally don’t repeat stereotyped ideas such as ‘young people aren’t scared enough’ and ‘African-American men have an element of denial in their sexuality’ (as opposed to the white middle-class ‘masc gay btm’ who just hit on me on Grindr).

The really key problem is the way it translates treatment as prevention into an idea with primarily individual behavioural implications, setting up concern in the community about whether PLHIV are compliant or ‘a risk to others’.

That’s a deeply concerning pathway for the rearticulation of treatment and/as prevention to take.

The countries with the most successful HIV prevention responses are those that enabled communities to educate, resource and support their own people to protect themselves and their partners — what I called community-based prevention responses in my contribution to a 2012 NAPWHA Monograph on criminalisation.

The countries with the least successful HIV prevention responses are those that created punitive laws as ‘incentives’ within that model of classical individual rational choice theory economics that can’t place any trust in altruism.

So far, this discussion has been pretty theoretical, so I want to finish by highlighting two recent attempts to make this stuff concrete and practical.  One was posted today by a friend of mine, Ted Kerr, former convenor of Visual AIDS in New York.  It shows the educational approach that is necessary when public policy does not enable community-based responses.

how to have sex in a police stateThe title bookends the early resource produced by Callen and Berkowitz for gay men, ‘How to have sex in an epidemic: one approach‘, a resource which got some things wrong but most things right, and effectively invented condoms as safe sex, long before researchers were ready to say with confidence that HIV was a virus and sexually transmitted.

It was an act of recombination whose fitness was selected for by reality.  As a colleague of mine, Garrett Prestage, has said, people in the gay community tried it out and they knew it worked when they got tested.

A second highlight is a new resource for people living with HIV published by Living Positive Victoria in partnership with the Victorian AIDS Council, called ‘Talking with your negative friends and partners about PrEP‘.

Screenshot 2015-03-30 15.55.57Full disclosure and/as humblebrag: my new business, DNM Strategic Consulting, developed and focus tested the resource.

It would be problematic if PrEP were only ever marketed to HIV-negative men as a strategy to protect them from PLHIV, so the resource encourages people using or considering PrEP to learn from people living with HIV about taking meds, trusting their GP, dealing with stigma.

Importantly, the resource reflects a different path for the articulation of treatment and/as prevention — integrating new knowledge about the efficacy of HIV medications while strengthening and adding value to the ongoing encounters, interactions and relationships that constitute community among people living with and at risk of HIV in the absence of a vaccine or cure.