What Can The HIV Epidemic Tell Us About COVID-19?
By talking to our friends and families, we can help promote a community-minded approach to COVID prevention, rather than a compliance model comprising fines and policing.
As social scientists researching how people come to understand and use HIV prevention strategies, it’s hard to avoid comparing the HIV/AIDS epidemic and the coronavirus pandemic we’re now facing globally.
At the time of writing, the second wave of coronavirus infections concentrated in areas of Melbourne has triggered a new public health response in Australia.
In addition to lockdowns and other measures, wearing a face mask in public is mandatory in Victoria.
In NSW it’s recommended to wear one where physical distancing isn’t always possible — such as public transport and grocery shopping.
These new measures have sparked controversy from both sides of the political ring. Some call them an attack on freedom, while others say not everyone is equally placed to buy and use a mask, so they should be provided to those in need. In any case, people might now face a $200 fine in Victoria if they refuse to wear a mask or face covering.
Looking back on the four decade history of the HIV epidemic, we know that prevention strategies are most effective when communities are empowered with knowledge about the virus, and can make sense of the risks they face — and crucially, are involved in the process to protect themselves and others.
Here lies our challenge.
So, what can four decades of the HIV epidemic tell us about how people will embrace or reject the coronavirus measures they’re asked to take? How do we get from resistance to feeling empowered about taking actions that look after ourselves and our communities?
How Different are HIV/AIDS and SARS-CoV-2/COVID-19?
We’d like to say there are clear lessons that can be applied to help the response to coronavirus. This is true in many cases.
For example, experts have noted similarities in the need to address disparities in access to healthcare and the need for timely testing and contact tracing, as well as the devastating effect of political denial in places like the US and Brazil.
Yet obviously HIV and SARS-CoV-2, the virus that causes coronavirus disease (COVID-19), are also vastly different in a number of ways. They have distinct routes of transmission and different prevention strategies.
HIV is now well understood as a chronic disease spread by bodily fluids mainly through sex, injecting drugs, and mother-to-child transmission.
In Australia, HIV is primarily concentrated in gay and bisexual men from sexual transmission. Along with routine testing for HIV, there are now three main strategies used (often in combination) to prevent sexual transmission of HIV: condoms; HIV treatment (because an HIV-positive person on effective treatment cannot transmit the virus); and HIV pre-exposure prophylaxis (PrEP), which involves the regular use of antiretroviral medications by HIV-negative people to prevent HIV acquisition.
On the other hand, COVID-19 is currently understood to be an acute respiratory infection spread by droplets, and potentially tiny aerosol particles from breathing and talking, that linger in the air. A person without any symptoms at all can spread COVID-19 to other people in close contact and in passing.
In Australia, the main strategies to prevent COVID-19 are testing, isolation and contact tracing for confirmed cases, practicing good hand-hygiene, physical distancing (supported in places by government imposed lockdowns), and more recently, the use of face masks.
Researchers around the world are now racing to produce safe and effective vaccines for COVID-19, with more than 90 vaccine projects underway. While some early COVID-19 vaccine trial results are promising, it is likely to take some time to get vaccines ‘from trials to clinics’.
Making face masks in public mandatory? Excellent, wise, community focused, love it ✅
Enforcing $200 fines for lack of mask, and not actually providing masks for free for the community? Terrible, classist, going to facilitate the further over policing of people based on SES 🚫
— Amy Thunig (@AmyThunig) July 19, 2020
Just as the authors of this article encourage us to manage our expectations, we have to remember that in 1984 the US Health and Human Services Secretary said they hoped to have an HIV vaccine ready for testing in two years. There’s still no vaccine for HIV, but prevention technologies have advanced significantly and people have made drastic changes to personal lives, supported by changes in many communities’ social norms toward protecting ourselves and each other.
There are unique challenges with each epidemic.
Arguably, COVID-19 is a much greater challenge because it can be so easily spread, compared to HIV and other infectious diseases. Our response is reliant on the entire population recognising the risks, understanding what they can do to minimise the risk of spreading the virus, and perhaps most importantly, for the social, political and economic climate to support people to be able to take these actions.
As others have pointed out, these sorts of structural barriers are real because some people might not be able to #StayHome, to borrow the social media rallying cry, if they need to go to work to put food on the table, particularly if they are excluded from government support programs.
Someone can’t wear a mask if they don’t have access to one or can’t make it. Similarly, someone can’t wear a mask if their social circles or colleagues don’t support them doing so. There also might be a variety of reasons (that don’t include selfishness) as to why some people don’t want to be tested for COVID-19.
We’re encouraged to see that some people in Victoria might be eligible for hardship payments if they get tested for coronavirus, they’re required to self-isolate or they test positive for coronavirus, but acknowledge that many people who might benefit from this payment may not be eligible.
While we don’t pretend to have solutions to all of these structural barriers, we know from HIV research that (physically distanced or online) dialogue, listening and empathy could help to make sense of all the information and foster social change. Like norms around condoms, talking about and actively wearing face masks is likely to promote this as a social norm.
We think that a bit less finger pointing and more community dialogue is key to the response going forward. As these researchers pointed out earlier in the COVID-19 pandemic (drawing on HIV research), stigmatising people is ineffective.
But with so much information out there, how do we make sense of the sometimes confusing and challenging messages about COVID-19 measures, and support ourselves and our communities to take action?
I think that wearing masks is a very good idea which is why I think the government should distribute them for free instead of subjecting people to arbitrary policing and fines
— Joshua Badge (@joshuabadge) July 19, 2020
Building A Community-Minded Response To COVID-19
Looking back, we have seen communities affected by HIV adapt their behaviour as new technologies were developed (like HIV antibody testing, HIV treatments, and HIV PrEP).
As we learned more about the virus, different behavioural strategies also developed. Some of these came from within communities and were not endorsed by health authorities (early on, condom usage, and later, matching HIV status before having sex). Some strategies, like matching HIV status before sex were later documented as a harm minimisation strategies despite being less effective than the other strategies promoted at the time.
Some people embraced various strategies and rejected others, but in the early years of the HIV epidemic, the most encouraging improvements from prevention efforts were driven by community involvement. Newer developments have similarly benefited from higher levels of community support.
Put another way, effective control of a pandemic needs a level of voluntary compliance, so forcible quarantine measures and financial penalties are unhelpful. It is also possible that communities will generate novel ways of dealing with COVID-19 that may reduce (but not eliminate) risk of spread, like some friends might agree to have close contact with each other or a small group of people, but continue to practice physical distancing or wearing masks around other people.
We also know that stigma and shaming undermine the community response, and that highlighting non-compliance can undermine efforts because this inadvertently creates the norm that it’s ok not to take prevention measures.
This week, many of us might be wearing a mask in public for the first time during the pandemic. Each of us will play a role in promoting new social norms for as long as they’re needed, and this might involve talking to the people around you about things like which face mask is best to wear.
By talking to our friends, families, and communities (while distancing), we can help promote a community-minded approach to COVID prevention, where people make sense of the risks they face, rather than a compliance model comprising fines and policing.
If going to a party, or dinner at a restaurant, where distancing clearly isn’t possible, let’s talk about the risks involved and acknowledge them in real time. We’re both craving time with friends, and social interactions, but knowing that even a small chance we could have asymptomatic coronavirus means we’ll be doing our bit to keep our friends and families safe. We hope you do too.
James MacGibbon and Anthony K J Smith (he/him) are PhD candidates researching HIV prevention at the Centre for Social Research in Health, UNSW Sydney.