If you remember the 1980s, you will likely summon up the image of the Grim Reaper or a black tombstone when asked to think about AIDS. Those images, embedded in our collective memory by two iconic Australian and British public health campaigns of that decade, reveal how AIDS has been both a medical and a cultural epidemic since it was first clinically observed in the US in 1981. In the words of American scholar Paula Treichler, AIDS has always partly been an “epidemic of meanings”.

As we commemorate another World AIDS Day and remember all those who have died, we must remind ourselves of all that is still left to do to eradicate HIV. We must also remember the role culture plays in shaping our understanding of the virus and those living with it.

If we take into account the highly homophobic social context in which news of the condition first started circulating, then its cultural dimensions become all the more important. We must consider what AIDS meant to people in the 1980s and 1990s, and what HIV still means today, at a time when antiretroviral therapies are being used successfully to manage existing infections and prevent new ones.

Take, for instance, these 1987 public service announcements, produced in the US for the State Health Division of Oregon:

These videos highlight some of the key features of the publically-funded AIDS awareness campaigns of the 1980s and early 1990s. Even if we ignore the fact that governments only publicly acknowledged AIDS years after the first known patients (homosexual men) started dying, these and other films of the time are evidence of the impact a homophobic mainstream culture had on the ways AIDS was dealt with in public.

Despite the fact that homosexual men had been one of the demographics most affected by the condition, these campaigns still refused to address homosexuals directly and communicate clearly to them ways in which homosexual sex could be made safer. Instead, they preferred to deal in visual metaphors and allusions aimed at an abstract general public.

Marked by a fear, on the part of the Thatcher and Reagan governments, that speaking directly to homosexuals could be seen as endorsing “deviant” homosexual behaviour, the often moralistic – and publicly-funded – health campaigns released during the peak of the Western AIDS crisis ignored the specific realities of those most affected by the epidemic.

Not only that, but health campaigns and news stories often played with metaphors that were not only deeply sexist and homophobic, but also inspired by the language of warfare. They also mostly chose to endorse celibacy or monogamy rather than educate people about risk-management and safer sex.

A fatal price

In Oregon’s “Revolver” video, for example, promiscuity is posited as the ultimate cause of AIDS. Further, the penis is represented by a gun and the (infected) semen by killer bullets, associating HIV transmission, in most cases unintentional, with murder.

Or consider the image below. Published in the popular science magazine Discover, in December 1985, medical illustrations and considerations about human anatomy are used to portray the rectum as “vulnerable” and the vagina as “rugged … designated to withstand the trauma of intercourse”. As a result, the article concluded “AIDS … is now – and is likely to remain – largely the fatal price one can pay for anal intercourse.”

Even in the realm of art, the earliest representations of HIV and AIDS weren’t any less problematic. When, in 1988, American photographer Nicholas Nixon included portraits of men living with AIDS in his show Photographs of People at the Museum of Modern Art (MoMA) in New York, activists were quick to respond with anger.

In the photos, which led activist group ACT UP New York to protest against the show, emaciated bodies of sick men are portrayed in a way that could be seen as objectifying them. In one image included in the show, the subject – Donald Perham – is depicted as an “AIDS body”, deprived of individuality or agency, his whole existence violently reduced by the camera to the syndrome that would eventually kill him. The photograph tells us nothing about him apart from his name and the health condition that will eventually destroy him. He is portrayed as a living corpse.

A new visual vocabulary

Despite the many counter-narratives of HIV and AIDS that artists and activists have been producing since the 1980s, this mainstream visual imaginary still informs how we picture HIV today and sustains the stigma that remains associated with the virus. While many recent films and TV productions such as How To Survive a Plague (2012), Dallas Buyers Club (2013), The Normal Heart (2014), or 120 BPM (2017), have been revisiting the early years of the AIDS crisis and looking at it from afar, we need a new visual vocabulary to make sense of the virus today, at a time when treatment has made HIV a manageable and untransmittable condition.

Further, if AIDS became such a defining spectre haunting gay men during the 1980s and the early 1990s, we need to think about the ways in which gay masculinities and sexual practices are today being shaped and represented in the age of antiretroviral therapies.

That is, in part, the aim of my new research project, funded by a fellowship of the Arts and Humanities Research Council, which will look at contemporary representations of masculinity in “post-AIDS” gay pornography. The hope is that it will help us to understand the ways in which the AIDS crisis and its aftermath have impacted the lives, identities, and sexual practices of gay men, rather than just see it in terms of tombstones and grim reapers.

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Cape Town – A new UN report shows that while important progress has been made in addressing the Aids epidemic for children and adolescents, countries failed to meet the goals set for 2018.

South Africa represents 9% of children acquiring HIV through vertical transmission across the world, only topped by Nigeria and Mozambique.

While this seems like a bad indication of how HIV/Aids is being handled, Scott McQuade from the South African branch of UNAids said otherwise.

“South Africa has the largest population of people living with HIV, about 20% of the global burden. Having only 9% of the global burden of vertical transmission indicates the relative success of South Africa in moving towards elimination of mother-to-child transmission.”

The Western Cape further beats the odds. In its 2018 report, the Health Department reported a 0.2% mother-to-child HIV transmission rate at 10 weeks. The most recent data indicate that 12.6% of adults in the Western Cape have HIV, the lowest rate of all provinces. The city and NGOs continue to urge people to get tested and educated about HIV prevention.

The Joint UN Programme on HIV/Aids (UNAids) in partnership with the US President’s Emergency Plan for Aids Relief introduced the Start Free Stay Free Aids Free framework and goals in 2016. The programme sought to end Aids as a public health threat for children and adolescents by focusing on 23 countries (mainly in Africa and Asia) with high numbers of children, adolescents and young women with HIV.

The programme had three main goals. To ensure 95% of pregnant women living with HIV knew their status and were on antiretroviral therapy (ART), to reduce the number of women aged 10-24 acquiring HIV to fewer than 100000 annually by 2020, and to make sure that 95% of all adolescents 10-19 years of age with HIV are receiving ART by 2020. They missed the mark in 2018 and indicators for 2020 are not looking too optimistic.

The 23 countries in the focus group for the programme represent 86% of pregnant women with HIV, 80% of children ages 0-14 acquiring HIV, 85% of girls and women ages 10-25 acquiring HIV, and 85% of young people ages 0-19 living with HIV.

South Africa was one of the countries included in the programme.

The new UNAids report shows that many of the countries studied made significant strides in reducing HIV among young people, but overall their efforts fell short. Children are a difficult group to target with these efforts. Vertical transmission of HIV is still a major problem and according to the study, only 63% of infants exposed to HIV during birth were tested before two months of age. South Africa tested more than 85% of babies exposed to HIV in the first two months.

But the fight to eradicate HIV and Aids in South Africa needs to be increased. According to the UNAids study, less than 30% of men and women ages 15-24 have a comprehensive understanding of HIV prevention.

This problem is exacerbated by an intense lack of funding to combat Aids – global numbers indicate that funding decreased by $1billion (R14bn) last year.

According to the report, the geographic concentration of where children are most acquiring HIV is so substantial that changes in only a few countries could improve global trends.

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Significantly better health outcomes are reported for both infants and mothers living with HIV when male partners are co-enrolled in antenatal care with the mother. In this clinic-randomised control trial, infants were 4.55 times less likely to become infected with HIV when male partners were actively involved in prevention of mother-to-child transmission (PMTCT) programmes during pregnancy.

The study took place across 12 randomly selected community health centres in Gert Sibande and Nkangala districts in Mpumalanga province, South Africa.

Researchers compared standard of care PMTCT programs with a new intervention which used group sessions and individual counselling to encourage adherence to treatment, HIV testing of family members, disclosure and partner communication alongside other outcomes.

In the first phase women were enrolled in the intervention or the standard of care alone, while in the second phase they were invited to enrol with their male partners.

The primary outcomes of the trial were infant HIV status, assessed at 12 months by DNA polymerase chain reaction (PCR) test, and infant survival, defined as miscarriage or death by 12 months postpartum. They also collected data on socioeconomic status, knowledge of HIV status, depressive symptoms, HIV stigma, family planning knowledge and intimate partner violence.

A total of 1,399 participants were included in the analysis at baseline. The average (mean) age of the women in the study was 28 and 48% had completed 10 to 11 years of education. Just over half (54%) of the women were unmarried and living separately from their partner and 64% had a monthly income of at least 1,000 ZAR (~70USD). Just over half (55%) of the women had been diagnosed with HIV in this present pregnancy and 50% reported that their pregnancy was unplanned.

The analysis found that more infants became HIV-positive in Phase 1 over Phase 2, and infants whose mothers were enrolled alone had a 1.98% increased likelihood of death or becoming infected with HIV. Moreover, rates of attrition and loss to follow-up were much lower when male partners were involved.

Researchers found that on average, across both phases, women had been diagnosed with HIV 24 months prior to baseline and had been on treatment for 15 months. Male involvement and family planning knowledge were moderate, and HIV-related stigma was low. Depression rates were high, with 45% of women showing clinically significant symptoms of depression. In addition to this, approximately 15% of women reported having more than two alcoholic drinks in the past month, and 61% reported having disclosed their HIV status to their partner. However, of these demographic findings, only depressive symptoms were significantly associated with infant HIV infection at 12 months.

The study found male participation was by far the most significant factor in determining health outcomes of both mother and child, outperforming the ‘protect your family intervention’, which had no significant impact on health outcomes of mother and child compared to standard of care, when women were enrolled alone.

In discussing these findings researchers comment that “male participation in the intervention may have promoted greater male partner involvement overall, including in PMTCT and child nurturing, leading to decreased risk of infant HIV infection and mortality. Male involvement, therefore, should be emphasized in areas with high rates of HIV transmission during or after pregnancy to enhance infant outcomes among HIV-exposed infants.”

Previous programmes primarily focus on mother and child, with little emphasis on the role of the father in pre- and postpartum care. These study results support the shift in thinking and programming that looks at male partner involvement as a critical component of PMTCT.

In this study, depressive symptoms are highlighted as high-risk poor HIV-related outcomes, and interventions should focus on screening for depression in order to improve treatment adherence and decrease infant HIV infection and mortality.

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