September 28, 2016

As ART becomes more available in Sub-Saharan African countries with high HIV burden, an unexpected effect has emerged: since people living with HIV who are on treatment tend to look healthier and more sexually appealing, community members are concerned that ART recipients will be able to spread their HIV infection more than when they appeared ill, even when transmission while on ART is almost impossible.

Before the widespread availability of ART in these communities, visual cues and local biographic knowledge exchanged in social networks helped people believe that they could distinguish “safe” women from those who were considered “risky”. These strategies, the authors write, are confounded by ART. Ambivalence about ART is based on one feature of the treatment regime: its capacity to restore an appearance of good health, replacing the wasting and weakness associated with AIDS.

Researchers evaluated a scale-up of treatment in rural Malawi by analyzing content from a unique dataset of diaries documenting life in communities during the time of AIDS which were composed by Malawian authors as part of the Malawi Journals Project. The study team analyzed 150 diaries, from 2010-2013 across three locations, to detect emerging themes about treatment.

The study was co-authored by Drexel University’s Astha Ramaiya, DrPH Community Health and Prevention ’18, and published in Social Science and Medicine.

Through thematic content analysis, researchers explored the emerging perception that the widespread availability of ART constitutes a form of social danger, as treatment makes it difficult to tell who does or does not have AIDS. This ambiguity introduced through ART is interpreted as putting individuals at risk, because it is no longer possible to tell who might be infected - indeed, the sick now look healthier than the well. Authors note that “this ambivalence over the social impact of ART co-exists with individual demand for and appreciation of the benefits of treatment.”

The researchers conclude that attention to this perceived ‘social danger’ is very timely, as the global push for ‘treatment as prevention’ - providing antiretroviral drugs to everyone who tests positive for HIV - accelerates, regardless of whether they have symptomatic or clinical signs of AIDS itself.

“In reality, effective treatment reduces viral loads to the point where transmission is almost impossible. However, the belief that people on treatment can be dangerous persists,” the authors conclude, “and any scale-up of treatment programs beyond the current reach should take this into consideration.”

“They are looking just the same”: Antiretroviral treatment as social danger in rural Malawi