This week marks the 30th anniversary of the announcements that HIV causes AIDS and a blood test to identify HIV had been developed. As part of these announcements, hope was expressed that the next scientific development would come within two years: the testing of an HIV vaccine. Yet, after 30 years a vaccine remains elusive. Nevertheless, enthusiasm for and confidence in biomedical science to achieve an "AIDS free" world is as strong today as it was 30 years ago, and as overly optimistic. Though the bulk of research dollars is spent in support of biomedical science, AIDS is as much a social disease as it is one determined by a virus. It is simply not possible to prevent, treat or cure it without understanding and addressing its social dimensions. For this, we need the tools of the social sciences.
Consider prevention. With the discovery of the HIV virus came the understanding that it could be transmitted and acquired through sex. But that knowledge alone does not prevent HIV. To prevent HIV, people must have sex in ways that protect them from transmitting or acquiring it. One of the most effective tools for this is the condom (especially when combined with water-based lubricants). But, as social scientists make clear, condom use is fundamentally a social activity that occurs in the context of a sexual encounter. Whether that encounter takes place with a complete stranger or a lover of 50 years, it involves a relationship, one that also, not insignificantly, occurs in a larger social context. It is this that gives meaning to condoms and their use.
Introducing condoms in the context of a longstanding relationship, for example, may raise questions about partner trust that are more difficult to face than the possibility of HIV. Or in contexts like India, where I do some of my research, there are impoverished women who exchange sex for money and clients who offer them more money for condomless sex. For these women, condoms can mean the difference between feeding their children and letting them go hungry. And, in the context of heterosexual encounters, women do not themselves use condoms; they must rely on or convince their male partners to do so. This can be challenging in an equal partnership, and nearly impossible in one that is less so.
Consider treatment and care. No matter how efficacious they may be in the laboratory, treatments can have no impact on the epidemic unless they are taken up and adhered to appropriately. In the United States, this is demonstrated by what we call the "treatment cascade." In theory, those who are HIV infected and receiving treatment should be able to maintain undetectable viral loads, meaning both that they are relatively symptom free and that they have a very low likelihood of transmitting the virus to others. But data from the Centers for Disease Control indicate that large numbers of individuals in the U.S. are not receiving these benefits. Of those who are HIV infected, about 80 percent are aware of their infection, 62 percent have been linked to care, 41 percent are retained in care, 36 percent get antiretroviral therapies, and 28 percent adhere to treatment and maintain undetectable viral loads. The treatment cascade implicates a complex array of factors in the domain of the social sciences, including the organization of health care, the vulnerabilities that make it difficult for people to access or remain in care, and the varied understandings of the value and consequences of treatment.
By identifying how social relations, processes and structures affect HIV transmission, acquisition, treatment and care, the social sciences have also helped inspire structural interventions that have moved us closer to an "AIDS free" world. We now have much greater availability of syringes and drug treatment to address HIV risk in drug users; universal precautions that virtually eliminate transmission in health care facilities, greater access to housing among the HIV-infected, which has been shown to improve treatment outcomes, and support for the collective mobilization of marginalized populations like drug users and sex workers in various parts of the world, so they can change the conditions that put them at risk.
Finally, the social sciences remind us that not everyone has benefited from scientific advances over the last 30 years. This is as clear in the nation's capital, where I live, as it is anywhere in the world: At the end of 2011, 2.4 percent of D.C.'s population over the age of 13 was living with HIV, well above the national average. The rate of HIV among black men in the city is 3.5 times that of white men; rates among black women are 24.4 times those among white women. Globally, the burden of HIV/AIDS is borne disproportionately by countries in Sub Saharan Africa.
In remembering the discovery 30 years ago of the HIV virus, let's remember, too, the critical contributions of the social sciences. Without them, we would not be where we are today, closer (but still much further than we should be) to an AIDS free world.