HIV: know your epidemic, act on its politics
Authors: Kent Buse, Clare Dickinson, Michel Sidibé
Journal: Journal of the Royal Society of Medicine (2008)

The ‘know your epidemic, know your response’ is an increasingly well-known rallying cry to put evidence at the heart of national AIDS programmes. While this is welcome, it is unlikely to be sufficient to deliver evidence-informed responses. In our view, it is equally important that national programmes routinely seek to understand and address the political determinants of whether and how evidence is used to guide policies and national programmes. We make this case because politics, ideology and ignorance have, in many countries, proved far more influential on HIV policy than evidence and best practice guidance. Partly as a result of this, we can expect another 7000 persons to be infected with the virus today, just as they were on World AIDS Day, earlier this month. Prevention policies and their messages are still not targeting people most at risk and laws and regulations continue to stand in the way of effective policies in too many countries.1

Policy emerges through interactions among institutions (the structures and rules which shape how decisions are made), ideas (which include not only evidence but also the way that problems and solutions are framed – often based on underlying values and training) and interests (groups and individuals who stand to win or lose from change).2 Understanding these interactions can provide insights into the process of policy change and can identify and address political barriers and opportunities that undermine evidence-informed policy. Lack of routine screening for congenial syphilis3 and the limited use of magnesium sulphate to prevent eclamptic seizures4 illustrate the limits of technical evidence and analysis in the health policy arena in low-income countries.

Despite the role played by politics in the response to HIV, a search of the peer-reviewed literature dealing with HIV policy change in low- and middle-income countries identified only 28 papers reporting empirical case studies concerning HIV/AIDS.5 Scrutiny of those papers reveal that high-profile success stories and highly contested issues in a very small number of countries receive the bulk of attention while the de facto policy-making addressing the HIV pandemic in the rest of the world remains largely ignored.6 Other under-explored areas in this set of literature include the extent to which political dynamics at the global level interact with national politics, and the role and influence of domestic parliamentary processes in challenging and demanding greater accountability from institutions responsible for determining the national AIDS response. The apparent neglect of a political analysis of HIV policy is surprising not just because politics is central to policy-making in health generally, but because HIV has acted as a lightning rod in the health sector – generating considerable public attention, resources, research and controversy.

The HIV policy literature acknowledges that institutional context plays a defining role in explaining policy outcomes but there is little predictive power in the limited findings. Some areas that have received attention include the impact of regime type, degree of centralization of power, and location of the government agency tasked with leading and coordinating HIV policy dialogue with, for example, the inclusion of the scientific community and civil society in policy formulation.7 Political, professional, religious, organizational as well as social institutions (e.g. governing gender norms, sexuality) are powerful determinants of HIV policy and represent longer-term targets in terms of policy change. If we are to bring about changed norms, there is a need to conduct more transparent public policy dialogue with these institutions, to understand how their values and mores affect HIV risks and HIV responses and how to address them.

The literature reveals the tremendous impact of ideas on HIV policy. The social construction of who is thought to be at risk plays into the perceived political acceptability of action on HIV.8 Similarly, moral values concerning sexuality and drug (mis)use shape decisions on whether or not to act and the nature of action. Policy entrepreneurs have used ideas to frame issues. For example, that ARV provision can break the cycle of denial, stigma and silence of HIV.9 Some have framed routine HIV testing as a proven public health intervention while others have portrayed it as a threat to human rights which has led to quite different policy outcomes. Similarly, framing the need for an ‘African’ as opposed to ‘Western’ response to AIDS has led to fundamentally different policy prescriptions.10

While it is intuitive that interests and political incentives facing stakeholders help explain why specific HIV policies emerge, the literature typically fails to reveal what these interests constitute. Analysis of the incentives facing political leaders suggests that electoral calculations, international standing and risks to the workforce, economy or the uniformed services have triggered action and inaction. Similarly, there has been some analysis of the financial interests of the research and development pharmaceutical industry in relation to intellectual property protection as interests driving policy ends.

Although limited, the literature confirms a commonsense understanding that politics are important determinants of HIV policy and offers a number of lessons for those wishing to influence such policy. The most important among these is that a failure to appreciate the political dimensions of HIV can frustrate efforts to promote and implement evidence informed policy. We suggest that prospective policy analysis11 that examines the interactions among institutions, ideas and interests in specific priority, evidence-informed interventions and approaches ought to become a routine component of national HIV programmes. In our view, the know-your-epidemic analysis coupled with a programmatic gap analysis should inform the development of evidence-based policies whose prospects for implementation are buttressed by forward-looking policy analysis.