Rethinking prevention: Shifting conceptualizations of evidence and intervention in South Africa's AIDS epidemic

Abstract

In recent years, statements about the 'end of AIDS' and an 'AIDS-free world' have dominated headlines about the epidemic. This contemporary moment of extraordinary optimism has been prompted in significant part by developments in the field of HIV prevention. New approaches to prevention include techniques that are markedly different from older strategies; new prevention techniques are targeted and relentlessly biomedical, and have increasingly displaced older behavior change programs and broad based social measures. HIV/AIDS, which was long called a 'social epidemic' marked by unprecedented human rights struggles and community action, has increasingly become dominated by a discourse and practice of discrete interventions and their calculable efficacy. This article aims to explain the shift in conceptualizations and practices of prevention, and the changed understanding of the epidemic. How did prevention become about access to drugs? How did the discourse around HIV/AIDS move from a concern with social determinants of disease and human rights to matters of efficiency, efficacy, and measurable impact? The article argues that a conjunction of new biomedical technologies, changing managerial logics of donors and governments, and emergent evidentiary practices have led to the ascent of new approaches to prevention. To support this argument, it traces prevention strategies over the last three decades in the context of South Africa's HIV/AIDS epidemic. The South African story, while unique and historically situated, nonetheless serves as a lens through which to understand broad based transformations underway in HIV/AIDS and in global health writ large.