Covid 19: Lessons from the sociology of AIDS

By Catherine van de Ruit

HIV/AIDs is a chronic infectious disease transmitted by sexual intercourse or intravenous drug use. Thanks to antiretroviral therapy (ART), AIDS is now a manageable chronic condition. Whereas COVID 19, an acute airborne disease, has thus far limited treatment options. While these distinct infectious diseases do not have biological commonalities, shared social factors including structural, institutional, cultural, and environmental conditions shape the biological trajectory of both diseases.

Sociological research on AIDS offers critical lessons for understanding the public health response to the COVID 19 pandemic thus far. In particular, this review examines limitations of dominant epidemiological models of individual risk and the concomitant disease mitigation interventions emerging from this risk model that underpinned the global AIDS response. This risk model underpinning AIDS biomedical innovation may have saved countless lives, but the resulting health disparities are extensive and have ultimately undermined efforts to contain and eradicate the HIV virus. 

The dominant policy response to AIDS focussed on individual behavioral interventions influenced by epidemiological and biomedical conceptions of disease as a biological pathology. The emphasis on “risk groups” is a foundational approach within epidemiology and used as a tool to prevent and mitigate infectious disease by targeting groups within populations most likely to contract and transmit the disease. AIDS public health programs identified high risk groups to include gay and bisexual men, transgender people, sex workers, and intravenous drug users. By contrast, high risk COVID 19 groups are identified as older age adults and, people with pre-existing conditions who are immunocompromised.

There are several critiques of this individual risk approach: first, it obscures differences within groups, and thus public health interventions were unlikely to develop nuanced programming relevant to specific groups (Mojola 2011); second, it affirmed narrow individual risk reduction strategies that ignored the social and cultural characteristics of AIDS transmission (Swidler 2009; Auerbach, Parkhurst, and Cáceres 2011). 

Third, narrow risk group models concealed how social marginalization intersects with AIDS risk. People with multiple minority identities are at higher risk of contracting AIDS and less likely to receive sustained access to treatment (Watkins-Hayes 2014). In the context of COVID 19 patterns of transmission inside the United States, minorities are at high risk of contracting COVID 19 and greater mortality relative to the general population (Johnson and Buford 2020).

In the COVID 19 crisis the UK and US initially targeted high risk groups such as seniors and people with multiple morbidities rather than issue universal stay-at-home orders as the economic costs of social isolation were deemed too high.  As a result of these initial narrow targeted risk group strategies, the US currently leads the world in infections and mortality. The UK radically changed course after epidemiological models suggested that unchecked COVID 19 related morbidity would overwhelm the health system (Booth 2020). 

Prior to the introduction of standard antiretroviral  therapy (ART), global health’s reliance on individual behavior change prevention programs were largely unsuccessful and prompted sociologists to argue that the global AIDS response imported standardized AIDS prevention programs ill-suited to local contexts (Tawfik and Watkins 2007; Watkins-Hayes 2014). Similar concerns have been raised about standardized social distancing guidelines to mitigate COVID 19 that may not be appropriate for all country contexts particularly for countries in the Global South with large informal sectors. This suggests that most necessary are tailored social and public health programs in addition to social isolation orders while taking into account food insecurity and the improvement of sanitation (Corburn et al. 2020).  Similarly, in the United States low income workers performing roles in the meat packing industry, supermarket and delivery services are at higher risk of contracting COVID 19. These workers cannot afford to follow social distancing guidelines and work place protections against the virus are inadequate.

Inequities in both AIDs and COVID 19 patient prevention and treatment in turn translated into underinvestment in health care workers. The burden of care falls primarily on people who face forms of social exclusion based on their gender, race, class, and age, thus reproducing and exacerbating social inequality. For example, community health workers on the frontlines of the AIDS epidemic are predominantly women of color who do not receive formal wages, benefits, or work place protection insurance (van de Ruit 2019).  In the case of the treatment response for COVID 19 in the US, frontline health care-workers are predominantly women and racialized minorities performing low paid work roles, with inadequate safety equipment and who face high occupational exposure risks (Robertson and Gebeloff 2020).

In closing sociologists of AIDS identified how health disparities produced by misaligned prevention programming, inequities in patient access to AIDs treatment programs, and deficits in AIDS care contributed to the continued spread of the disease. In the absence of clinical treatments to effectively prevent and treat COVID 19, the inability of marginalized populations to practice social distancing, and stark health inequities in testing and available treatment in the Global North and South must be addressed if this virus is to be managed and ultimately contained.  

Catherine van de Ruit is an Assistant Professor at Ursinus College. Her research areas focus on medicine, health policy, and global health.

References

Auerbach, Judith D., Justin O. Parkhurst, and Carlos F. Cáceres. (2011). “Addressing Social Drivers of HIV/AIDS for the Long-Term Response: Conceptual and Methodological Considerations.” Global Public Health 6 (sup3): S293-S309.

Booth, William. (2020). “A Chilling Scientific Paper Helped Upend U.S and U.K Coronavirus Strategies.” Washington Post, March 17, 2020

Corburn, J., D. Vlahov, B. Mberu, and Lee Riley. (2020). “Slum Health: Arresting COVID-19 and Improving Well-being in Urban Informal Settlements. J Urban Health (2020). In press.  Journal of Urban Health.

Johnson, Akilah and Talia Buford. (2020). “Early Data shows African Americans have Contracted and Died of Coronovirus at an Alarming Rate.” ProPublica, April 3, 2020.

Mojola, Sanyu A. (2011). “Fishing in Dangerous Waters: Ecology, Gender and Economy in HIV Risk.” Social Science & Medicine 72 (2): 149-156.

Robertson, Campbell and Robert Gebeloff. (2020). “How Millions of Women Became the most Essential Workers in America.” The New York Times, April 18, 2020.

Swidler, Ann. (2009). “Responding to AIDS in Sub-Saharan Africa: Culture, Institutions, and Health.” Successful Societies: How Institutions and Culture Affect Health: 128-150.

Tawfik, Linda and Susan Cotts Watkins. (2007). “Sex in Geneva, Sex in Lilongwe, and Sex in Balaka ” Social Science & Medicine, 64 (5): 1090-1101.

van de Ruit, Catherine. (2019). “Unintended Consequences of Community Health Worker Programs in South Africa.” Qual Health Res 29 (11): 1535-1548.

Watkins-Hayes, Celeste. (2014). “Intersectionality as Theory, Method, and Praxis in the Sociology of HIV/AIDS.” Annual Review of Sociology 40 (1).