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Expanding Global HIV Treatment

Case Studies from the Field
J.J. FURIN,a,b H.L. BEHFOROUZ,a,b S.S. SHIN,a,b J.S. MUKHERJEE,a,b,c J. BAYONA,c,d
P.E. FARMER,a,b,c J.Y. KIM,a,b,c,e AND S. KESHAVJEEa,b,c
a
Division of Social Medicine and Health Inequalities, Brigham and Women’s Hospital,
Boston, Massachusetts, USA
b
Partners In Health, Boston, Massachusetts, USA
c
Program in Infectious Disease and Social Change, Department of Social Medicine,
Harvard Medical School, Boston, Massachusetts, USA
d
Socios En Salud, Lima, Peru
e
Harvard School of Public Health, Boston, Massachusetts, USA

In the last 25 years, human immunodeficiency virus (HIV) has become the leading infectious
killer of adults globally, with an estimated 44 million people infected with the virus worldwide.
Most of these individuals live in poor regions of the world, particularly sub-Saharan Africa.
Although a great deal of work has been done in identifying and treating individuals with the dis-
ease, there has been little action to date to address the complex socioeconomic factors that lie at
the heart of this global pandemic. Understanding and responding to such factors is of paramount
importance if HIV infection is to be managed in a meaningful way. This article explores the so-
cial context of people living with HIV in three different geographic and epidemiologic settings
and highlights the social factors that shape and define an individual’s risk of acquiring HIV. It
also discusses unique programs aimed at addressing the complex realities of the world in which
HIV thrives. These programs can act as models of HIV prevention and treatment.

Key words: community-based HIV treatment; models for HIV care; social determinants of HIV;
HIV in Boston; HIV in Lesotho; HIV in Peru; Partners In Health

Introduction world, where logistical and programmatic constraints

In less than a quarter century, human immunodefi-
ciency virus (HIV) has become the leading infectious
killer of adults worldwide, with an estimated 44 million
persons infected.1 Billions of dollars have been spent
in efforts to address the AIDS pandemic, including
the development of prevention strategies, the creation
of new drugs, and the support of community-based
efforts to mitigate the effects of the disease. Yet, pre-
vention efforts—which largely target the individual—
cannot keep pace with the thousands of people who are
becoming infected each day; treatment efforts have ac-
celerated but have yet to reach the poorest areas of the
Address for correspondence: Salmaan Keshavjee, Division of Social
Medicine and Health Inequalities, Brigham and Women’s Hospital, FXB
Bldg.—7th floor, 651 Huntington Ave., Boston, MA 02115. Voice: 617-
432-3215; fax: 617-432-6958.
skeshavjee@partners.org
have led to many preventable deaths.
Although the biological understanding of HIV and
the development of new drugs has advanced rapidly,
we are losing the global battle with HIV. There are
many reasons for this: Foremost among them is that
HIV is inextricably linked with poverty. Although it is
true that “anyone can get AIDS,” a careful assessment
of this disease shows that those most likely to become
infected with and die from HIV are those who suffer
from poverty and inequality.
Although most practitioners acknowledge that so-
cial factors affect many aspects of HIV infection,
the tendency has been to focus on “behaviors” or
“lifestyles” that place some at risk for infection.2–4 Yet,
it is well documented that “risk”—here, susceptibil-
ity to infection and poor outcomes—is the product of
multiple structural forces, including poverty, racism,
and gender discrimination.5–13 Although these struc-
tural forces may not themselves be amenable to urgent

Ann. N.Y. Acad. Sci. xxxx: 1–9 (2008).

C 2008 New York Academy of Sciences.
doi: 10.1196/annals.1425.004
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2 Annals of the New York Academy of Sciences
intervention, there are strategies that can improve pa-
tient access to care.14,15
Through case studies from three sites—Peru,
Boston, and Lesotho—we will attempt to resocialize
HIV beyond the focus on behaviors and adherence
that have characterized some previous discussions. Our
aim is to demonstrate that addressing global HIV as a
complex biosocial phenomenon requires the delivery
of appropriate care in programs that ensure patient
access by ameliorating the effects of structural forces.
Aids, Abuse, and Alcohol in Peru:
Miguel’s Case
Peru is one of the poorest countries in Latin Amer-
ica, with a per capita gross domestic product of
US$6,600,16 and suffers from some of the highest
rates of infectious diseases in the region.17,18 Com-
pared with other countries, Peru has a relatively low
HIV prevalence, with an estimated 93,000 individ-
uals (0.6%) living with HIV,19 of whom 65% reside
in Lima.20 Published reports on HIV transmission in
Peru cite primary risk factors of men having sex with
men, early sexual activity, and number of past part-
ners among women.19,21–23 However, among recently
diagnosed patients in Lima, heterosexual sex among
impoverished individuals is a prevalent mode of trans-
mission.24 The case of Miguel, a young man from the
capital city, Lima, is emblematic of this.
Even when Miguel was diagnosed with HIV, he did
not consider it the worst of his problems. Miguel had
spent his entire life struggling to survive from one day
to the next. His parents lived in an invasión, a group
of homeless squatters who invaded a privately owned
land and, by Peruvian law, gained ownership by man-
aging to stay there for a requisite number of years. He
grew up in a one-room shack made from bits of trash
collected from the streets, meagerly supported by the
periods when his father was sober enough to work.
Because of his father’s abusive behavior, his mother
eventually fled the house, and the children were left in
the care of his father. Miguel dropped out of primary
school, his main concern being his next meal. Work
was scarce: The most reliable way to eat was to steal.
As he grew up, he began to join the family drinking.
Occasionally, he found himself propositioned by both
men and women; if he was drunk enough, he would
agree as another way to make ends meet. When his fa-
ther died, he inherited the shack and ultimately started
his own family.
To provide for his family, Miguel worked seasonal
and temporary jobs as a painter and in kitchens. As
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with many Peruvians, the sporadic nature of his work
made making ends meet nearly impossible. Things be-
came worse when Miguel began to get ill. His symp-
toms were insidious: fatigue, weight loss, and poor ap-
petite. Miguel knew he was unwell, but he couldn’t
afford the time and money required to go to a doc-
tor. He started to have painful sores in his mouth. The
sicker Miguel became, the more focused he became on
trying to work. If he were to die, his family would be
left with nothing. His only wish was to work as much
as possible, while he was still able. A year later, he had
lost 8 kg.
Miguel knew that he was dying. Only on the insis-
tence of his wife did he agree to see the doctor. When
he went to the local health center, his physician advised
him to be tested for HIV. In October 2005, Miguel’s
test for HIV returned positive; his doctor informed him
that, fortunately, HIV treatment was available for free
in Peru and that he should start treatment as soon as
possible. There was one catch: Before he could start
treatment he would need to be seen at the referral hos-
pital and obtain a series of tests, for which he would
have to pay. With no health insurance, steady job, or
assets, this was not an option.
Three months after his diagnosis, Miguel developed
a lump on his neck, and his fever, previously intermit-
tent, became constant. His family decided that they
could not afford to wait any longer. Miguel’s brother-
in law, Christian, had to carry Miguel on his back down
the rocky slanted hill that led to the road to take a taxi
to the hospital. At the hospital, Christian helped to pay
for the services and tests that ultimately revealed the
presence of tuberculosis (TB) adenitis. However, the
family did not have money to go back to the hospital
to learn the results.
Later that month, the community health promoter
who had previously met Miguel—an employee of
a nongovernmental organization, Socios En Salud
(SES)—came to see him. Miguel’s situation was so
grave that the promoter brought him to the local health
center, where Miguel began TB treatment. Soon there-
after, unable to keep down any food, he was hospital-
ized (with financial assistance from SES). His condition
improved with medical attention, TB treatment, and
nutritional supplements. Once Miguel was discharged,
the SES promoters provided food and transportation
support to Miguel and his family. On April 21, 2006,
more than 6 months after diagnosis, Miguel finally
started antiretroviral therapy (ART).
Fragmented families, unemployment, and heavy al-
cohol use characterize many households in the squatter
settlements. These communities in the urban periph-
ery of Lima arose as a result of waves of migration
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from rural provinces forced by political violence dur-
ing the Shining Path, and in later years, economic
hardship in the wake of “Fujishock.”25,26 Thus, al-
though the proximal risk factor for Miguel’s acquisi-
tion of HIV was bisexual sex in exchange for money,
the motivations behind his actions were fundamentally
rooted in a common distal risk factor for acquiring
HIV: poverty resulting in substance abuse, depression,
and food insecurity. For Miguel, sexual exchanges were
not a choice but rather a necessary sacrifice for sur-
vival. These structural factors not only placed Miguel
at risk for contracting HIV but also contributed to
life-threatening barriers to starting ART.
As tragically illustrated in Miguel’s case, given the
many complexities associated with the AIDS pan-
demic, it is unlikely that simple solutions—such as
simply offering free HIV testing and free ART—will
be adequate. For this reason SES, a pioneer in the
treatment of drug-resistant TB in the urban slums of
Lima, began working on the HIV problem. As with
its previous TB work, SES realized that financial and
logistical barriers prevented patients from accessing
the health system. In response, SES provided finan-
cial assistance to impoverished HIV patients, as well
as community-based support to help patients navigate
the health system and understand their diagnosis.27
However, the task for SES was not complete once
patients successfully began treatment. Once on ART,
impoverished patients were again at risk of poor out-
comes: The greatest risk factors for nonadherence to
ART among HIV-positive patients in Peru are low
social support, depression, and substance abuse—all
products of poverty.28 SES started a project for paid
community health workers to accompany patients.
These are workers who deliver directly observed ART,
nutritional and transportation assistance, and psy-
chosocial support. SES’s team works with health pro-
fessionals to maximize HIV treatment adherence and
address psychosocial stressors during the 18 months
of ART. To date, the SES program has helped more
than 2,500 patients initiate Ministry-sponsored HIV
therapy and accompanies more than 100 patients on
ART.29
HIV and Inequality in the United
States: The Case of Bernadette
For HIV providers in the United States, the associ-
ation of AIDS and poverty is an all too familiar one.
Although the largest number of individuals living with
HIV in the United States still comprises white men
who have sex with men, they are not the population
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3
progressing to AIDS or HIV death.30 In fact, black
men and women (who constitute only 13% of the U.S.
population) account for more than 50% of AIDS cases
and more than 50% of AIDS deaths in the United
States.31 An increasing number of individuals living
with and dying from AIDS are female, reside in the
South, and acquired their HIV through heterosexual
transmission.32 In Boston, a black woman infected with
HIV who lives in Roxbury (a poor and predominantly
black neighborhood) is 15 times more likely to die
from AIDS than is a white man from Boston.33 Why
do black women in the United States bear a dispropor-
tionate burden of HIV-related disease and death? The
reasons are not biological; the virus itself is not prone
to behave more aggressively in black women. As the
story of Bernadette illustrates, the reasons are related
to social factors—marginalization at multiple levels—
that negatively affect access to and use of available
resources and medical technology.
Bernadette is a 37-year-old African American
woman living in Boston’s inner city. She was diagnosed
HIV-positive more than 10 years ago and believes that
she contracted the virus from her ex-husband, who has
since died. She relies primarily on a meager disability
check from Social Security to support herself and her
two children. Although intermittently homeless in the
past, she now lives in subsidized housing in Matta-
pan, a community whose residents are primarily poor
and black. Bernadette’s family moved to Boston from
Virginia four generations ago. She has a sixth grade
education and has never been gainfully employed. She
has been in a string of bad relationships and has of-
ten been the victim of domestic violence; her current
partner (who supplements the family income) is physi-
cally abusive. She has a long history of depression and
alcohol and cocaine use. She recently learned that her
15-year-old daughter is pregnant.
Bernadette’s HIV disease is not well controlled de-
spite medical insurance with full prescription coverage,
two case managers, a primary care doctor, an HIV spe-
cialist, and having been prescribed ART over the past
8 years. She continues to struggle to make her medical
appointments and take her medications. Consequently,
her immune system is weak (CD4 count is 4 cells/µL,)
she weighs 84 pounds, she is frequently hospitalized
for opportunistic illnesses, and her viral load is exceeds
750,000 copies/mL, suggesting that she is not respond-
ing to her salvage ART regimen. Her doctors state that
she is “dying” from depression and denial.
Although depression is probably an important factor
in Bernadette’s course, her lot is similar to that of many
African Americans interacting with the health system.
For some the problem is underinsurance,34–37 but even
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for those with insurance, access to a host of required
medical interventions—from renal transplants to treat-
ment for congestive heart failure and pneumonia—
is linked to their race.38–42 The geographical ar-
eas in which people live and the nature of their
clinics—for example, location and flexibility vis-à-vis
appointments—all affect patient care and disease out-
come.43–48 Pharmaceutical costs are lowest and hos-
pital costs are highest among underserved groups, in-
cluding blacks, women, those who have not completed
high school, and patients without private insurance.49
Patients with the lowest CD4 counts (< 50 cells/µL)
accrue medical costs of $2,344/month, as opposed to
those with the highest CD4 counts (> 500 cells/µL),
who accrue costs of only $532/month.50 For patients
with low CD4 counts, the bulk of expenditure is for
non-ART medications and hospitalization.51
One solution to the problems faced by disadvan-
taged and underserved groups in the United States
is the Prevention and Access to Care and Treatment
(PACT) Project, an existing community-based HIV
health promotion program affiliated with Partners In
Health (PIH) and the Division of Social Medicine and
Health Inequalities at the Brigham and Women’s Hos-
pital. For more than 5 years, PACT has used the con-
cept of peer health promotion to address the needs
of impoverished, minority individuals with advanced
AIDS in Boston who have had difficulties with adher-
ence. These patients are referred to the program as
having “failed” standard care. Most have lived with
HIV for more than 12 years, have viruses with signif-
icant ART resistance, and have a long history of poor
adherence.
Similar to the Peru intervention, PACT pairs each
patient with HIV health promoters, lay community res-
idents who develop their knowledge and skill through
module-based and field-based training. Patients receive
monthly, weekly, or daily home-based support services
(a three-tiered model) to help them adhere to their
medication regimens and medical appointments, prac-
tice harm reduction, and increase self-efficacy. Over
6 months, health promoters administer an educational
and counseling curriculum that addresses such topics
as psychological adjustment to life with HIV, medica-
tion side-effect management, effective communication
with providers, and pharmacy management. Health
promoters also provide patients and their families with
social support and collaborate with other agencies to
make sure that patients have adequate food, housing,
mental health care, and substance abuse counseling.
They particularly focus on helping patients adhere to
their medication and treatment recommendations with
the aim of reducing rates of opportunistic illness, costly
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hospitalizations, and death. Some patients “graduate”
from the program but can return at any time.
The findings from PACT have been heartening. To
date, 220 patients have been enrolled; after 12 months
of participation, patients had a clinically significant
increase in median CD4 count from 145 cells/µL
to 220 cells/µL. Patients experienced an average de-
crease in median viral load from 30,641 copies/mL
to 421 copies/mL; 48% of patients achieved a sus-
tained undetectable viral load at 1 year. An analy-
sis of the hospital billing records of 40 PACT pa-
tients in 2006 showed a 35% decrease of inpatient
hospital day use and a 50% decrease in hospital-
ization costs, from an average of $22,443/patient to
$12,926/patient—important savings compared with
the $3,600/patient/year that PACT support costs.
Bernadette was referred to PACT in 2005. She did
not join the program until spring 2006, when she
was hospitalized for pneumonia. Upon discharge, she
called her PACT health promoter and said that she was
ready for services. Three months later, even though her
adherence was still not at goal, she started directly ob-
served ART. Within 9 months of engaging with PACT,
she had gained almost 60 pounds. Her CD4 count was
289 cells/µL and her viral load was undetectable on
two successive readings. She was more than 90% ad-
herent to her medical and social service appointments
and received support regarding her daughter’s preg-
nancy, her abusive relationship, and her drug abuse.
She continues to thrive in the PACT program.
Poverty, Mine Work, and the HIV
Pandemic in Lesotho: The Case of
Matsepo and Kolobe
Lesotho is a mountainous nation, home to almost
2 million people, and it is surrounded by the Republic
of South Africa. It has the third-highest HIV sero-
prevalence rate in the world, with an estimated 25%–
30% of the population living with HIV.52 The isolated
mountain regions are as affected as urban centers, with
seroprevalence in some villages reported at 70%. One-
quarter of Lesotho’s children have lost one or both
parents to HIV, and Lesotho has the highest popula-
tion density of orphans in the world. The economic
consequences of losing the most active segment of the
population have put Lesotho in further peril; the coun-
try is facing its worst food crisis in 30 years. Although
the ravages of HIV have manifested themselves in the
postapartheid period, as the story of Matsepo and
Kolobe suggests, the roots lie at the nexus of a long
history of social, economic, and political deprivation.
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Matsepo was only 27 years old when she died of
AIDS-related complications in a small village on a
mountain in the remote village of Ha Ramojane in
Lesotho. Her story, sadly, is not unique. Matsepo was
born in rural Lesotho, the fifth of seven children. Al-
though school was free, she left after the primary level
because her parents could not afford the uniforms and
books. Despite being able to read and write, Matsepo
could not find employment. Her older brother and sis-
ter were working in South Africa and sending money
home for the family, but this was not enough to keep the
family warm and fed through Lesotho’s harsh winters.
Matsepo’s mother became ill with a chronic cough,
eventually requiring hospitalization. To pay for this,
Matsepo found temporary employment dying denim
fabric in a garment factory. She worked 16 hours a day,
6 days a week and earned less than US$10 a month.
Her hands became stained permanently blue from the
chemical dye.
Unfortunately, her employment did not last long
because the factory closed and Matsepo returned to
her village. By that time her mother had died and the
household work fell to Matsepo and her older sister,
who herself was ill and often covered in rashes and
sores. Although Matsepo and her father sought help
for this sister, the effort was to no avail. Her sister was
not strong enough to make the long and arduous 5-
hour journey over mountains and valleys to the nearest
clinic, and the family could scarcely afford the user fee.
Several months later, Matsepo’s sister died, leaving two
small children, one of whom was also ill.
One day a young man from the village came to speak
with Matsepo’s father. His name was Kolobe and he
was looking for a wife to help care for his young son,
whose mother had died the year before. He proposed
marriage to Matsepo as a way to help her family and
his. Matsepo’s father readily accepted: Kolobe would
be going to work illegally in a diamond mine in South
Africa as a blaster, and although there would be risks
to him, the pay was high and in cash. A week later,
Kolobe and Matsepo were married, and he returned
to South Africa.
In the mine Kolobe worked 12 hours a day, 7 days
a week, often crouched in a tunnel 4 feet high. He
rarely saw daylight and shared sleeping quarters with
50 other men, usually from other poor countries. Al-
though he dutifully sent money home to Matsepo and
his son, he occasionally would blot out the pain of his
daily existence with alcohol and was known to indulge
himself with one of the commercial sex workers at the
mining camp.
At Christmas, Kolobe returned to Lesotho. He and
Matsepo were overjoyed to see one another. Kolobe’s
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5
son had grown, and although one of Matsepo’s sis-
ter’s children had died, the other was doing well. With
the monies that Kolobe was sending home, the fam-
ily’s economic situation was stable. They spent 3 weeks
together, after which he had to return to the mine.
When Kolobe returned in April, Matsepo shared the
news that she was expecting their first child. Although
Kolobe was excited for this, he was worried about
a constant cough that he had developed. He even
coughed blood sometimes and was plagued by a per-
sistent fever.
Despite his weakening physical condition, Kolobe
returned to the mines. In Kolobe’s absence, Matsepo
gave birth to a baby boy who died after 2 weeks. Kolobe
was unable to return home and heard about this family
tragedy only from another villager who had come to
South Africa. Kolobe returned home again at Christ-
mas and Matsepo was shocked at how thin and frail
looking he had become. She urged him to see a doctor,
and although they walked 6 hours through the rains
to reach the health center, they found it locked and
unattended. They had to spend the night in a hut on
the roadside without heat and food. Although Kolobe
returned to the mine, he was unable to work prop-
erly and was sent home. He found that Matsepo was
pregnant again, but he was too weak to rejoice and
constantly worried about the family’s survival. Kolobe
lost so much weight that Matsepo barely recognized
him. He coughed large quantities of blood daily and
could not walk for longer than 10–15 minutes at a time.
Matsepo cared for him as best she could, but within
2 months Kolobe died. Six weeks later, Matsepo give
birth to a baby girl.
Sadly, Matsepo herself had begun to feel ill, wracked
with nightly fevers. Concerned about the welfare of her
children and her father, she unsuccessfully sought work.
When a mine worker who had returned to the village
offered to give her food for her family if she would
agree to sexual intercourse, she agreed. As the months
wore on, Matsepo’s health status became worse and she
also began to cough blood. Fearing for her children’s
welfare should she die, Matsepo decided to undertake
the long journey to the health center, where she had
heard that there were new doctors and nurses working.
When the doctors from Partners In Health Lesotho
(PIH Lesotho) saw this 35-kg woman covered in open
sores and coughing, they immediately obtained a spu-
tum specimen, and Matsepo underwent HIV counsel-
ing and testing. Her test was positive for HIV and she
began TB therapy. Her sister’s child and her own child
also underwent HIV testing; both came back HIV-
positive and began ART. The physician sent Matsepo
home with nutritional support and planned to make a
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home visit to her village in 2 weeks to start Matsepo on
ART. Unfortunately, Matsepo began coughing large
amounts of blood one night and perished. Upon ar-
rival in the village, the doctor found the two children
living with their elderly grandfather, cold and without
shoes. The family was given support. Outreach and
education was done in the village regarding HIV and
TB, and through intensive efforts, most of the villagers
agreed to undergo HIV counseling and testing. Of the
72 inhabitants in the village, 47 tested positive for HIV.
Stories such as Matsepo’s and Kolobe’s are com-
monplace in Lesotho. Since the first diamonds were
discovered in South Africa in 1867, a significant por-
tion of southern Africa’s income has come from the
mining of diamonds and precious elements. By some
estimates, remittances from mine workers account for
nearly 60% of Lesotho’s gross domestic product. En-
tire communities depend on migrant mine work to
survive. At the mines, workers live in overcrowded bar-
racks, away from their families and communities for
long periods, with easy access to alcohol and commer-
cial sex workers.53–56 As part of the legislation that
became known as apartheid in the 1940s, black men
were forbidden to bring their families and settle in
the communities where they worked. Moreover, men
from neighboring countries like Lesotho are forced to
work illegally, without benefit of even the small safety
net afforded to poor South Africans. This situation is
particularly dangerous given the risk of becoming ill:
In addition to exposure to occupational illnesses and
TB,57,58 the mines have become a locus of transmis-
sion for HIV.59 As men return home from the mines
for short holidays, they bring HIV and other diseases
with them, entrenching the disease in their communi-
ties. One survey performed in a clinic in rural Lesotho
showed that 90% of HIV-positive men had a history
of working in a South African mine.60
Although some care is available at the mines, work-
ers fear seeking medical attention for fear of deporta-
tion and loss of income.61 When they return home, they
are usually faced with a dearth of health care resources
and user fees that they can ill afford. Recently, the Min-
istry of Health and Social Welfare joined forces with
several foreign nongovernmental organizations to pro-
vide HIV testing and preventive services and care to the
entire population, even those living in remote moun-
tain areas. PIH Lesotho is leading these efforts and has
launched a rural initiative in the mountains to provide
HIV treatment and preventive services, in addition to
primary care; maternal and child health care; and the
management and treatment of TB, sexually transmit-
ted infections, and malnutrition. The backbone of this
effort is a staff of trained and paid village health work-
10-16-2007 :1114
ers who visit patients daily in their homes and number
more than 400 in three mountain regions alone. To
date, more than 2,000 HIV-infected individuals have
been identified and more than 600 are receiving ART.
The program provides a model of high-quality and
sustainable care that can be undertaken even in the
most remote settings.
AIDS and Poverty: Conclusions
Analyses in the scientific literature of the varied
spread of HIV globally often rely on biological ex-
planations; the extent of many social analyses is often
limited to “patient barriers,” such as low health literacy,
mental illness, and cultural difference.62 An example of
this concept is the recent debates over the lack of male
circumcision as a driving force in the HIV pandemic
in Africa.63 Although there are good data indicating
that male circumcision may decrease the likelihood of
HIV transmission, there have been no studies, oper-
ational or otherwise, that have demonstrated that in-
creasing male circumcision will lead to decreased HIV
rates in settings that are rocked by poverty, hunger,
racism, and inequality. In many ways, this approach
is reminiscent of scholarly writing in the early 1990s
that blamed preference for “dry and tight vaginas” as
the force driving the HIV pandemic in Africa.64,65 Al-
though certain social practices can affect transmission,
given the profound effect of poverty and inequality on
an individual’s susceptibility to HIV infection, accept-
ing that they are the principal forces behind the high
prevalence of HIV noted in sub-Saharan Africa is diffi-
cult. Rather, a variety of social determinants—serious
societal and health care system problems often rooted
in poverty and poor programs—play a significant role
in making some communities more susceptible to in-
fection with HIV and less likely to receive appropriate
care.
What are the lessons from the case examples of Peru,
Boston, and Lesotho? The first is that properly under-
standing and addressing the HIV pandemic requires
a biosocial approach where biology, phenomenology,
and the social and historical roots of the disease are
taken into account. It would be dishonest to view
Bernadette’s case without, at some level, consider-
ing the history of slavery, genocide, and patriarchy
that placed her in a specific societal locus; to not ac-
knowledge that Miguel’s poverty and abusive child-
hood of deprivation, the product of a state system
that disregarded the urban poor, did not contribute
to his condition; to ignore the role of centuries of
colonialism, apartheid, and economic deprivation in
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determining the devastating circumstances faced by
Matsepo, Kolobe, and the people of Lesotho. Rather,
these factors are the roots of the epidemic, which policy
makers and program planners must address.
Second, biosocial analyses must go beyond the aca-
demic, to become part of a programmatic approach to
overcoming barriers to care. For example, in each case
study, the programs reconfigured “patient factors” into
“programmatic factors” that called for programmatic
solutions. By moving away from a limited view of HIV
as a biological entity shaped by patients’ personal and
psychological problems, the programs could address
specific barriers—such as lack of food, housing, trans-
portation, childcare, and economic opportunity—and
deliver appropriate biomedical care to patients. As we
and others have demonstrated elsewhere, the impor-
tance of removing clinical, economic, and community
barriers to care is paramount to the success of HIV
treatment and prevention programs.14,66,67
Third, providing care to patients in villages and
communities where they live can help improve access
to care. Especially for chronic diseases, such as HIV,
this strategy decreases the effects of structural barriers
to care (and often has the collateral benefit of creating
jobs in communities that need them).13,68,69 It does not
mean that clinics and hospitals are not required; rather,
community-based delivery of care for chronic illnesses
should be viewed as logical and necessary extensions
of the activities of larger, specialized health facilities.
Such interventions are not only cost-effective but, as
we have described, can also positively affect patient
adherence to treatment.
The linkage is well known between social, economic,
and political conditions and epidemics, disease, and
poor health outcomes.70,71 Yet, there has been a gap
between this knowledge and large-scale implementa-
tion of programs that can support and sustain patients
undergoing treatment for HIV and other chronic con-
ditions. The cases reveal the need for interventions that
address the social roots of this pandemic by eliminating
barriers to effective care. The next challenge will be to
replicate such programs on a larger scale.
Source of funding and conflict of interest: Furin, Shin,
Mukherjee, and Keshavjee received partial salary sup-
port and/or travel support from the Bill and Melinda
Gates Foundation, the Eli Lilly Foundation, and the
Frank Hatch Fellowships in Global Health Equity at
the Brigham and Women’s Hospital. Shin, Mukher-
jee, and Behforouz received additional salary support
from the United States National Institutes of Health.
Keshavjee received additional research and travel sup-
port from the John D. and Catherine T. MacArthur
Foundation. Shin received additional salary support
10-16-2007 :1114
7
from the Infectious Disease Society of America, the
Eleanor Miles Shore Fellowship, the Rockefeller Foun-
dation, and the Heiser Foundation.
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