Jonathan Garcia

A Critical Analysis of the Brazilian Response to HIV/AIDS: Lessons Learned for Controlling and Mitigating the Epidemic in Developing Countries

The Brazilian National AIDS Program is widely recognized as the leading example of an integrated HIV/AIDS prevention, care, and treatment program in a developing country. We critically analyze the Brazilian experience, distinguishing those elements that are unique to Brazil from the programmatic and policy decisions that can aid the development of similar programs in other low- and middle-income and developing countries.Among the critical issues that are discussed are human rights and solidarity, the interface of politics and public health, sexuality and culture, the integration of prevention and treatment, the transition from an epidemic rooted among men who have sex with men to one that increasingly affects women, and special prevention and treatment programs for injection drug users.

Strange bedfellows: The Catholic Church and Brazilian National AIDS Program in the response to HIV/AIDS in Brazil

The HIV epidemic has raised important tensions in the relationship between Church and State in many parts of Latin America where government policies frequently negotiate secularity with religious belief and doctrine. Brazil represents a unique country in the region due to the presence of a national religious response to HIV/AIDS articulated through the formal structures of the Catholic Church. As part of an institutional ethnography on religion and HIV/AIDS in Brazil, we conducted an extended, multi-site ethnography from October 2005 through March of 2009 to explore the relationship between the Catholic Church and the Brazilian National AIDS Program. This case study links a national, macro-level response of governmental and religious institutions with the enactment of these politics and dogmas on a local level. Shared values in solidarity and citizenship, similar organizational structures, and complex interests in forming mutually beneficial alliances were the factors that emerged as the bases for the strong partnership between the two institutions. Dichotomies of Church and State and micro and macro forces were often blurred as social actors responded to the epidemic while also upholding the ideologies of the institutions they represented. We argue that the relationship between the Catholic Church and the National AIDS Program was formalized in networks mediated through personal relationships and political opportunity structures that provided incentives for both institutions to collaborate.

Psychosocial Implications of Homophobia and HIV Stigma in Social Support Networks Insights for High-Impact HIV Prevention Among Black Men Who Have Sex With Men

Black men who have sex with men (BMSM) bear an increasingly disproportionate burden of HIV in the United States. The Centers for Disease Control and Prevention recommends high-impact combination prevention for populations at high risk for HIV infection, such as BMSM. However, few scholars have considered the types of behavioral interventions that combined with biomedical prevention could prove effective for mitigating the epidemic among BMSM. Between June 2013 and May 2014, we conducted three in-depth interviews each with 31 BMSM, interviews with 17 community stakeholders, and participant observation in New York City to understand the sociocultural and structural factors that may affect the acceptance of and adherence to oral preexposure prophylaxis among BMSM and to inform an adherence clinical trial. BMSM and community leaders frequently described condomless sex as a consequence of psychosocial factors and economic circumstances stemming from internalized homophobia resulting from rejection by families and religious groups. BMSM revealed that internalized homophobia and HIV stigma resulted in perceived lack of self- and community efficacy in accepting and adhering to preexposure prophylaxis. Our results indicate that addressing internalized homophobia and fostering emotional social support in peer networks are key elements to improve the effectiveness of combination prevention among BMSM.

Resource mobilization for health advocacy: Afro-Brazilian religious organizations and HIV prevention and control

Brazils national response to AIDS has been tied to the ability to mobilize resources from the World Bank, the World Health Organization, and a variety of donor agencies. The combination of favorable political economic opportunities and the bottom-up demands from civil society make Brazil a particularly interesting case. Despite the stabilization of the AIDS epidemic within the general Brazilian population, it continues to grow in pockets of poverty, especially among women and blacks. We use resource mobilization theories to examine the role of Afro-Brazilian religious organizations in reaching these marginalized populations. From December 2006 through November 2008, we conducted ethnographic research, including participant observation and oral histories with religious leaders (N = 18), officials from the National AIDS Program (N = 12), public health workers from Rio de Janeiro (N = 5), and non-governmental organization (NGO) activists who have worked with Afro-Brazilian religions (N = 5). The mobilization of resources from international donors, political opportunities (i.e., decentralization of the National AIDS Program), and cultural framings enabled local Afro-Brazilian religious groups to forge a national network. On the micro-level, in Rio de Janeiro, we observed how macro-level structures led to the proliferation of capacity-building and peer educator projects among these religious groups. We found that beyond funding assistance, the interrelation of religious ideologies, leadership, and networks linked to HIV can affect mobilization.

Global Transformations and Intimate Relations in the 21st Century: Social Science Research on Sexuality and the Emergence of Sexual Health and Sexual Rights Frameworks

Abstract This article tracks the conjunction between the social, cultural, political, and economic changes taking place on a global level and the shift in sexuality research from primarily biomedical and behavioral concerns to those of rights and social justice. Particular attention is paid to how transnational public health and human rights discourses, and social movements concerned with gender inequality and the oppression of sexual minorities, have influenced the field of sexuality research. This influence is especially clear in the emergence of the concepts of sexual health and sexual rights, which have enabled researchers to draw clear connections between highly localized phenomena and transnational systems. The importance of rights-based approaches, in particular, has supported an explicit politicization of research and the engagement of researchers in social justice causes. To illustrate the interests and approach of contemporary sexuality research, the article includes a review of recent literature on sex trafficking and same-sex marriage. These cases are used to outline the negative and positive use of rights—the former a means to control harm and the latter a means to advance freedoms. Addressing the tension between these two strategies is a core challenge for the field of sexuality research.

Religious communities and HIV prevention: An intervention study using a human rights-based approach

Abstract Religious communities have been a challenge to HIV prevention globally. Focusing on the acceptability component of the right to health, this intervention study examined how local Catholic, Evangelical and Afro-Brazilian religious communities can collaborate to foster young peoples sexual health and ensure their access to comprehensive HIV prevention in their communities in Brazil. This article describes the process of a three-stage sexual health promotion and HIV prevention initiative that used a multicultural human rights approach to intervention. Methods included 27 in-depth interviews with religious authorities on sexuality, AIDS prevention and human rights training of 18 young people as research-agents, who surveyed 177 youth on the same issues using self-administered questionnaires. The results, analysed using a rights-based perspective on health and the vulnerability framework, were discussed in daylong interfaith workshops. Emblematic of the collaborative process, workshops are the focus of the analysis. Our findings suggest that this human rights framework is effective in increasing inter-religious tolerance and in providing a collective understanding of the sexuality and prevention needs of youth from different religious communities, and also serves as a platform for the expansion of state AIDS programmes based on laical principles.

“You're Really Gonna Kick Us All Out?” Sustaining Safe Spaces for Community-Based HIV Prevention and Control among Black Men Who Have Sex with Men

Black men who have sex with men (BMSM) experience among the highest rates of HIV infection in the United States. We conducted a community-based ethnography in New York City to identify the structural and environmental factors that influence BMSMs vulnerability to HIV and their engagement with HIV prevention services. Methods included participant observation at community-based organizations (CBOs) in New York City, in-depth interviews with 31 BMSM, and 17 key informant interviews. Our conceptual framework shows how creating and sustaining safe spaces could be a critical environmental approach to reduce vulnerability to HIV among BMSM. Participant observation, in-depth and key informant interviews revealed that fear and mistrust characterized men’s relation to social and public institutions, such as churches, schools, and the police. This fear and mistrust created HIV vulnerability among the BMSM in our sample by challenging engagement with services. Our findings suggest that to be successful, HIV prevention efforts must address these structural and environmental vulnerabilities. Among the CBOs that we studied, “safe spaces” emerged as an important tool for addressing these environmental vulnerabilities. CBOs used safe spaces to provide social support, to address stigma, to prepare men for the workforce, and to foster a sense of community among BMSM. In addition, safe spaces were used for HIV and STI testing and treatment campaigns. Our ethnographic findings suggest that safe spaces represent a promising but so far under-utilized part of HIV prevention infrastructure. Safe spaces seem integral to high impact comprehensive HIV prevention efforts, and may be considered more appropriately as part of HIV capacity-building rather than being nested within program-specific funding structures.

Religious responses to HIV and AIDS: understanding the role of religious cultures and institutions in confronting the epidemic.

Since the very beginning of the HIV epidemic, few social institutions have been as important as religion in shaping the ways in which individuals, communities and societies have responded to HIV and AIDS. In societies around the world, what are sometimes described as religious belief systems or religious cultures have been fundamental to the interpretation of AIDS to the ways in which a newly emerging infectious disease was incorporated into existing understandings of the world. Over the course of more than three decades now, religious meaning systems have mediated the attitudes and policies related to the epidemic and public health programmes, and religious organisations have been central to the response to HIV and AIDS in countries and cultures around the world (Lagarde et al. 2000, Agadjanian 2005, Global Health Council 2005, McGirk 2008, Garcia et al. 2009, Akintola 2010, Murray et al. 2011, Trinitapoli 2011). This impact has been profoundly complex and often contradictory. At the same time, religious organisations play a key role globally in providing front-line access to primary and terminal care, advocating for health and social welfare resources and influencing public health and social policies (Sanders 1997, Chatter 2000, DeHaven et al. 2004, Pargament et al. 2004). This has been especially visible in relation to the global HIV epidemic, and has expanded significantly over the past decade as part of the global scale-up of HIV programmes (Shelp and Sunderland 1992, Global Health Council 2005). Agencies such as the World Health Organisation, Joint United Nations Programme on HIV/AIDS (UNAIDS), the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the US President’s Emergency Plan for AIDS Relief (PEPFAR) programme have all called for increased involvement of and partnerships with community-based organisations (CBOs) and faith-based organisations (FBOs) as part of the expanded global response to AIDS (Global Health Council 2005, United Nations Population Fund [UNFPA] 2008a, 2008b, UNAIDS 2009). With the assistance of international donor agencies, millions of dollars are now spent annually to support interventions by religious institutions and FBOs for HIV prevention and treatment in the developing world, and the WHO estimates that at least one in five organisations involved in HIV/AIDS programming is now faith-based (WHO 2004, Agadjanian 2005, Global Health Council 2005, Agadjanian and Sen 2007, Akintola 2010). However, concerns have been raised that

Sex Markets and Sexual Opportunity Structures of Behaviorally Bisexual Latino Men in the Urban Metropolis of New York City

Sex markets (the spatially and culturally bounded arenas) that shape bisexual behavior among Latino men have been utilized as a deterministic concept without a sufficient focus on the ability of individuals to make autonomous decisions within such arenas. We nuance the theory of sex markets using the concept of sexual opportunity structures to investigate the ways in which behaviorally bisexual Latino men in the urban metropolis of New York City navigate sexual geographies, cultural meaning systems, sexual scripts, and social institutions to configure their bisexual behaviors. Drawing on 60 in-depth interviews with bisexual Latino men in New York City, we first describe and analyze venues that constitute sexual geographies that facilitate and impede sexual interaction. These also allow for a degree of autonomy in decision-making, as men travel throughout the urban sexual landscape and sometimes even manage to reject norms, such as those imposed by Christian religion. We explore some of the cultural meaning systems and social institutions that regulate sex markets and influence individual decision-making. Secrecy and discretion—regulated by the family, masculinity, migration, and religion—only partially shaped sexual behavior and relationships. These factors create a flux in “equilibrium” in bisexual sex markets in which sociocultural–economic structures constantly interplay with human agency. This article contributes to the literature in identifying dynamic spaces for sexual health interventions that draw on individual agency and empowerment.

Beyond faith-based organizations: using comparative institutional ethnography to understand religious responses to HIV and AIDS in Brazil.

Religious institutions, which contribute to understanding of and mobilization in response to illness, play a major role in structuring social, political, and cultural responses to HIV and AIDS. We used institutional ethnography to explore how religious traditions--Catholic, Evangelical, and Afro-Brazilian--in Brazil have influenced HIV prevention, treatment, and care at the local and national levels over time. We present a typology of Brazils division of labor and uncover overlapping foci grounded in religious ideology and tradition: care of people living with HIV among Catholics and Afro-Brazilians, abstinence education among Catholics and Evangelicals, prevention within marginalized communities among Evangelicals and Afro-Brazilians, and access to treatment among all traditions. We conclude that institutional ethnography, which allows for multilevel and interlevel analysis, is a useful methodology.