“There’s always going to be that political filtering”: the emergence of Second Generation Surveillance for HIV/AIDS, data from Uganda, and the relationship between evidence and global health policy
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05/07/2017Author
Richards, Douglas Alexander
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Abstract
Background: It is widely acknowledged that Uganda was the first country in
sub-Saharan Africa to experience a significant decline in HIV seroprevalence
in the 1990s. Framed as the initial ‘success story’ in the history of the global
HIV/AIDS pandemic, the behavioural mechanisms and policies accounting
for the Ugandan HIV decline have been extensively debated over the past 25
years. With reference to broader debates about the role of evidence in policy,
this thesis aims to examine contested explanations for the decline in HIV
prevalence in Uganda and the role of evidence in the development of global
HIV prevention policy in the 1990s.
The thesis examines diverse explanations for Uganda’s HIV decline and how
these came to be framed in the context of the emergence of Second
Generation Surveillance (SGS), a global HIV/AIDS surveillance framework
introduced by UNAIDS/WHO in 2000. Official accounts describe SGS as
having been developed on the basis of Ugandan behavioural evidence
presented during a key meeting of HIV/AIDS policymakers which took
place in Nairobi in 1997. This meeting provides a focal point for examining
the role of evidence in global HIV prevention policy and the relationship
between evidence and policy pertaining to low income countries in the
1990s.
Methods: A review of UNAIDS/WHO documents and 29 in-depth
interviews with HIV/AIDS experts from Uganda and international
organisations were analysed.
Results: UNAIDS documents present SGS as a technocratic, problem-solving
response to limitations in established HIV surveillance approaches,
developed at a UNAIDS-sponsored workshop in Nairobi, Kenya, in 1997.
These official accounts present the emergence of SGS as evidence-based and
reflecting a clear consensus that developed during the Nairobi workshop.
While interview data suggest agreement around the need for improved HIV
surveillance systems, they indicate a more complex picture in terms of the
extent to which SGS was evidence-based and highlight contested
interpretations of this evidence among HIV experts.
Findings from interviews suggest that the introduction of SGS by
UNAIDS/WHO may be understood as serving both technical and broader
strategic purposes. As indicated in UNAIDS/WHO policy documentation,
SGS was intended to improve older global HIV surveillance methodologies
via the triangulation of multiple data sources. The introduction of SGS also
appears to have served two broader purposes, functioning as something akin
to a marketing tool to help promote the institutional identity of UNAIDS,
while also signalling a shift towards a ‘multisectoral’ approach that aimed to
unify epidemiological and social scientific disciplinary approaches.
While interviewees’ accounts coincide in describing a decline in HIV
prevalence during the 1990s, they present divergent interpretations of this
evidence which became significant in the development of SGS. One
interpretation focused on a reduction in multiple partnerships within the
Ugandan population as the key change driving the decline in HIV
prevalence, while a contrasting explanation focused on increased use of
condoms as the primary cause of this decline. Interviewees’ accounts suggest
a process of competition, whereby different actors sought to secure the
primacy of their interpretation in institutional understandings of Uganda’s
HIV decline and in the development of SGS. Claims of disciplinary bias and
institutional marginalisation appear to have contributed to the subordination
of explanations focused on a decline in multiple sexual partners, while the
policy entrepreneurship of one key actor appears influential in explaining
the ascendency of explanations focused on increased condom use. Despite
these contestations around the evidence used to inform the development of
SGS, UNAIDS documents and peer-reviewed publications from this period
emphasise one interpretation (that of increased condom uptake) which thus
appears as the official explanation for the success of HIV control in Uganda.
The transition from the WHO’s Global Programme on AIDS (GPA) to
UNAIDS, and the initiation of a multisectoral HIV prevention approach,
appear as important contextual and institutional influences in the
interpretation of evidence for Uganda’s HIV decline. The failure of the
partnership reduction explanation to align with the evolving institutional
and political orthodoxy, and the potential for this explanation to challenge
UNAIDS’ new focus on multisectoral HIV prevention, may help to explain
why it did not inform subsequent HIV/AIDS policy and does not appear in
official accounts of SGS’s development. In contrast, explanations focused on
increased condom use were consistent with UNAIDS’ HIV prevention policy
agenda (including its emphasis on multisectoral approaches) and appeared
to reinforce the organisation’s need for increased financial resources to
mitigate HIV/AIDS via the distribution and promotion of condoms.
Discussion: This study demonstrates that the development of SGS, and the
politics of evidence supporting its introduction, are more complex than
existing UNAIDS/WHO accounts describe. Official explanations of the
development of SGS provide a simplistic account of how evidence informed
policy in a linear and rational way. In contrast, findings from this thesis
suggest that SGS served multiple policy functions (i.e. marketing, promotion
of institutional credibility, and a demonstration of disciplinary integration) in
the context of the recently-formed UNAIDS, and that the role and
interpretation of evidence in this context were highly contested. Consistent
with the work of Kingdon (1995) and more recently Stevens (2007), this study
suggests that personal, political and institutional factors play important roles
in shaping how evidence is presented and linked with policy. These findings
suggest that more nuanced understandings of the relationship between
evidence and policy are needed to explain HIV/AIDS policy development
within both sub-Saharan African and at a global level.