Social Exclusion, Citizenship and Rights: Grappling with Vulnerability in the Epidemic of HIV

• Author: Robert Carr
• Pages: 71-92

71

SOCIAL EXCLUSION, CITIZENSHIP AND RIGHTS

Almost universally…the epidemic has disproportionately affected

individuals and communities who are marginalized or discriminated

against for reasons of sex, age, ethnicity, race, sexuality, economic status,

and cultural, religious or political affiliation.

UNAIDS

[Across the globe] hundreds of millions of new urbanites must subdivide

the peripheral economic niches of personal service, casual labour, street

vending, rag picking, begging and crime. This outcast proletariat … is a

mass of humanity structurally and biologically redundant to global

accumulation and the corporate matrix.

Mike Davis

The need [for recognition] is one of the driving forces behind nationalist

movements in politics. … Due recognition is not just a courtesy we owe

people. It is a vital human need.

Charles Taylor

A nation’s greatness is measured by how it treats its weakest members.

Mahatma Ghandi

PARAMETERS AND BEGINNINGS

As in most countries of the world where HIV and AIDS are concerns,

the initial response in the Caribbean was managed by doctors and

institutionalized in ministries of health, which focussed on risk reduction

(prevention) and impact mediation (treatment). Further, what became

Social Exclusion, Citizenship and

Rights

Robert Carr

Chapter 4

Grappling with Vulnerability in the Epidemic of HIV

72

SEXUALITY, SOCIAL EXCLUSION AND HUMAN RIGHTS

increasingly clear and important, if still controversial, were the distinctions

between AIDS as a medical condition requiring antiretroviral treatment,

and HIV as an as yet incurable and panic-inducing sexually transmitted

infection. Nevertheless, research shows that after more than 20 years of

responding to HIV and AIDS, the Caribbean remains the region with

the second highest infection rates among the general population (UNAIDS

2007).1 While countries, such as Haiti, have experienced a decline in

average prevalence rates, for most, progress has been measured only in

terms of rates that have stabilized over time (CAREC 2007).2 This means

that success in HIV prevention is marked by increases in condom sales,

and other proxy measures for changes in behaviour. Some countries have

also relied on the results from Knowledge, Attitudes and Practices surveys

(KAPs) both of the general population, but also among groups considered

‘high risk’ such as taxi drivers, informal commercial importers, and

adolescents or, more infrequently, sex workers or men who have sex with

men (CAREC 2004).3 Notwithstanding the use of these markers, the

general picture is worrying. Even where KAPs show high levels of

knowledge, and where qualitative research shows that people know HIV

is a risk, infection rates have not been brought down. To understand why

this is so requires digging deeper into issues of human interaction and

sexual exchanges, which points to the limits of disciplines such as

psychology, particularly in relation to the psychology of behaviour change,

which had hitherto made strong claims to truth, for example behaviour

predictability based on increased knowledge.

In recognition of the fact that many traditional approaches and theories

have proven inadequate to the task, the Joint United Nations Programme

on HIV/AIDS (UNAIDS), the intergovernmental agency charged with

guiding the global response, began looking more deeply into the

complexity of country and population dynamics. A critical objective was

to understand why certain groups who were already cast out as society’s

pariahs –– whether in Eastern Europe, the Caribbean, Asia, or more

controversially, Africa4 –– demonstrated higher than average infection

rates. The analysis was made against the backdrop of famous if unevenly

documented success stories, such as those of Uganda, Kenya, Zimbabwe,