Keeping gay and bisexual men safe: The arena of HIV prevention science and praxis

Abstract

In this article, I draw from an ongoing ethnographic study of HIV prevention for gay, bisexual, and ‘men who have sex with men’ to develop an institutional analysis of HIV behavioral intervention science and praxis. I approach this analysis through the lens of the social worlds framework, focusing on the institutional arena in which HIV behavioral interventions are devised and executed. Toward this end, I focus on two fundamental points of contention that lie at the heart of the prevention enterprise and put its social organization in high relief: (1) conceptions of health and lifestyle practices and (2) attributions of expertise. These core contentions reveal less the steady advance of normal science than an arena of actors ensconced in boundary work and jurisdictional struggles over how to engineer behavior change and reduce the scale of the HIV epidemic. Their resolution, I argue, has occurred in a historically contingent process determined by the political economy of the US HIV prevention arena and the differential structural location of its social worlds.

Keywords

gay/bisexual HIV prevention medical sociology social worlds

In the 30 years following the first reported cases of HIV/AIDS, US public health has unfolded a range of HIV prevention initiatives.¹ Behavioral interventions, in particular, required a complex set of considerations, including an implicit theoretical choice regarding how to change behavior, the identification of a specific target population for whom the intervention is intended, and careful reflection on how and by whom the intervention is to be executed. In fact, with respect to both the science of modeling and changing behavior (i.e. HIV prevention science), and the execution of behavioral interventions (i.e. prevention praxis), HIV prevention is a complex, multi-level enterprise that brings together a wide range of actors with diverse disciplinary backgrounds, professional and organizational interests, and cultural proximity to the populations at risk. While sociologists have given extensive attention to the sociopolitical dimensions of HIV/AIDS treatment (Bayer, 1989; Epstein, 1996; Lawless et al., 1996), they have yet to provide a systematic institutional analysis of US HIV prevention.

In this article, I draw from an ongoing ethnographic study of US HIV prevention for gay, bisexual, and ‘men who have sex with men’ (MSM) to analyze the development of HIV behavioral intervention science and praxis in institutional terms. I approach this analysis through the lens of the social worlds framework (Clarke, 1998; Clarke and Star, 2008; Fujimura, 1992), directing attention away from the success or failure of prevention work itself and toward the institutional contexts in which HIV behavioral interventions are devised and executed. HIV behavioral interventions are complex, labor-intensive, and often costly public health technologies (Wilson and Moore, 2009) that enable the social worlds that create them to lay claim to and control the prevention project. I focus on two fundamental contentions that lie at the heart of the prevention enterprise and put the social construction of HIV intervention science and praxis in high relief. These include (1) polarized positions on the nature of health and lifestyle practices (e.g. does the at-risk actor make sexual and drug-using decisions on the basis of individual, rational cognitive processes or collective, relational processes?) and (2) opposing attributions of prevention expertise (i.e. is intervention expertise located within federal institutions of public health and the health sciences, or at the local community level, among community-based prevention personnel, activists, and their clients?). Such core contentions reveal an arena of social worlds ensconced in boundary work (Gieryn, 1999) and jurisdictional disputes (Abbott, 1988) over the enterprise of keeping gay and bisexual men safe from HIV/AIDS. These struggles, I argue, have been adjudicated in a historically contingent process, determined by the political economy of the US HIV prevention arena and the differential structural location of its social worlds.

To develop my analysis, I first visit the sociological literature on HIV/AIDS, and build on existing work on prevention. In a second section, I map out the key social worlds that comprise the MSM HIV prevention arena, and outline their relationships with respect to the task of producing behavioral interventions from 2001 forward – a period of time marked by the ascendance of ‘evidence-based’ HIV prevention science and praxis. A third section details the methodological procedures and plan of analysis upon which this article is based. In two subsequent data sections, I draw from original fieldwork on the HIV prevention arena in Los Angeles (LA) to highlight each core contention. In the ‘Discussion’ section, I analyze the data as a whole and show that, from 2001 forward, the political economy of the HIV prevention arena has systematically expanded the capacities of a federal public health complex, including the National Institutes of Health (NIH), the Centers of Disease Control (CDC), and associated health scientists. In this way, HIV prevention develops and controls intervention science and praxis, while eroding the capacity and impact of alternative social worlds, including community-based organizations (CBOs) and scholars outside the health sciences. I suggest that, in contrast with the historical situation of HIV/AIDS research and treatment, wherein non-scientist activists challenged and transformed the dominant, institutionalized medical practices associated with drug trials and AIDS treatment (Epstein, 1996), the HIV prevention enterprise has never been the object of a comparable social movement and has thus remained largely under the control of the CDC and its local public health affiliates.² I conclude the article by drawing out the implications of my analysis, both for the social worlds framework, and also for a broader set of case studies of contemporary prevention projects.

HIV/AIDS in sociological context

Sociological analysis of HIV/AIDS in the West comprises a broad literature.³ Sociological research on MSM HIV prevention, especially as a form of knowledge production, is, by comparison, less extensive and has yet to provide a comprehensive analysis of the institutional contexts through which prevention science and praxis have materialized in the United States. On the whole, this literature assumes a critical stance with respect to the dominant public health approaches to HIV prevention, and aims to highlight how the prevention enterprise is ill-suited to make sense of, no less change, risk-taking practices.⁴ For instance, Carrillo (2002) offers an extensive analysis of Mexican HIV prevention that focuses on the disjuncture between public health constructions of sexual decision-making and those that arise from the narratives of Mexican men and women. In the Mexican national context, Carrillo (2002) reveals how moral politics, including strong anti-gay and anti-sex sentiments, coupled with the push to modernize Mexican society, further complicated the development of effective prevention knowledge. Similarly, Bolton (1992) shows how early US HIV/AIDS prevention was (mis)anchored to a moral politics of promiscuity. Race (2007), too, captures some of the moral elements of HIV prevention discourse, indicating that discursive sorting practices in public health characterize particular acts – for example, unprotected anal intercourse – as simultaneously laudable and pathological: on the one hand, the act is effective prevention under the category of ‘sero-sorting’, or having unprotected intercourse based on shared HIV status, but, on the other hand, the act is dangerous ‘barebacking’. Dowsett (1996) and Adam (2011) criticize the positivist public health model in US HIV prevention, highlighting the distance between ‘scientific’ constructions of sexual subjectivities and the subjectivities of actual actors. Roberts and Matthews (2012) and Ayala et al. (2003) extend this methodological critique to the dominance of positivist, ‘evidence-based’ intervention models that focus on individual-level, ‘risk factorology’ (McKinlay and Marceau, 2000). Auerbach et al. (2009) and Kippax (2008), too, examine the institutionalization of ‘gold standard’ positivist evaluation measures of intervention efficacy, such as the randomized, controlled trial (RCT), showing how they contribute to reduced funding for structural HIV interventions not amenable to RCT evaluation. And from the perspective of the CBO, Gandelman et al. (2005) and Gandelman and Dolcini (2012) examine the ways in which these organizations interface with CDC intervention protocol.

The social worlds framework (Clarke, 1998; Clarke and Star, 2008; Garrety, 1997) situates the formation of scientific and technological development at the interface of scientific and non-scientific actors. To the extent that such actors operate within their own particular ‘universes of discourse’, they are conceived as occupying distinct social worlds (Clarke and Star, 2008: 118), each world distinguished by particular sites, technologies, discursive forms, and organizational structures. When a given problem attracts the mutual interest and commitments of multiple social worlds, there is an arena (Fujimura, 1988, 1992) characterized by crisscrossing and sometimes competing discourses, problem-solving perspectives, funding sources, and infrastructures. Nevertheless, in any given instance, science and technology can be configured in standardized packages that traverse social worlds, reducing ‘the amount of tacit knowledge, discretionary decision-making, or trial-and-error procedures needed to solve problems’ (Fujimura, 1988: 278). To the extent that a wide range of social worlds adopt and invest in a given standardized package, a scientific bandwagon can occur, representing a more or less uniform collective approach to a given scientific problem (Fujimura, 1988: 261). Thus, the social worlds framework puts in high relief the institutional contexts and discursive practices whereby scientific programs, theories, and technologies arise in a process of ‘negotiation, articulation, translation, triangulation, debating, and sometimes even coercion’ (Star and Greisemer, 1989: 171).

The US HIV prevention enterprise is precisely such an arena, comprising both scientific and non-scientific social worlds that span federal, state, county, and local levels. The target populations of prevention mobilize somewhat distinct configurations of social worlds. I focus in this article on that part of the prevention arena that targets MSM, a group that comprises about 2 percent of the population but accounts for the majority of new infections (CDC, 2011). I distill seven key social worlds and provide a representation of their relationships, in relation to the creation of behavioral interventions (see Figure 1, below) from 2001 forward, a period characterized by the ascendance of ‘evidence-based’ HIV prevention science and the dominance of the ‘Diffusion of Evidence-Based Interventions’ (DEBIs) bandwagon. I highlight these particular social worlds (and their relationships) not to offer a historically fixed or exhaustive schema of the gay/bi/MSM HIV prevention arena but, instead, to provide an orienting map of what is an enormously complex, multidimensional arena.

Figure 1.

The influence structure of the US GAY/BI/MSM HIV prevention arena.

The rise of the DEBI bandwagon

Historically, the CDC has funded a wide range of CBO activities, the bulk of which include condom education and distribution and, until 2000, ‘homegrown’ HIV interventions developed by CBO personnel in close concert with their particular client base (Gandelman, 2005). However, in the years leading up to 2000, funding streams for homegrown interventions came under fire from the US Congress, due to perceived lack of connection between NIH supported intervention research and CDC-funded prevention programs on the ground. As a result, by the end of the 1990s, the CDC formally adopted the Institute of Medicine’s (IOM) protocol of ‘evidence-based medicine’ (EBM) (Lyles et al., 2007) as a way to assuage the concerns of Congress and at the same time standardize the prevention programs they funded. It did so by striking a committee to comb through the extant HIV literature and develop a list of ‘scientifically rigorous’, ‘science-based HIV-prevention interventions’ (Sutton et al., 2009: 253) that demonstrated the most effective results in reducing rates of unprotected vaginal or anal intercourse (Gandelman and Reitmeijer, 2004), among other outcomes. Here, ‘rigorous evaluation methods’ such as RCTs were established as the ‘gold standard’ upon which the efficacy of ‘Evidence-Based Interventions’ (EBIs) were to be judged (Auerbach et al., 2009: 12). By 2001, a subset of behavioral interventions culled from this prevention science was consecrated by the CDC in the Compendium – a meta-analytic compilation of the most successful and rigorously tested EBIs (Lyles et al., 2007). CBOs in 38 states were then mandated by the CDC to adopt and execute one or more EBIs when applying for federal prevention dollars (Dworkin et al., 2008).

In order to facilitate CBO adoption of the EBIs, the CDC packaged these interventions in ‘user-friendly’ kits, called DEBIs (Dworkin et al., 2008), and disseminated them downward to CBOs in a process of ‘technology transfer’ (Gandelman and Rietmeijer, 2004). The DEBI standardized package – what providers call ‘out-of-the-box prevention’ (Ayala et al., 2003: 10) – includes 33 EBIs comprising protocol based largely on cognitive behavioral theories of behavior change (Coates et al., 2008). CBOs seeking federal and state or county public health funds apply by selecting one of the DEBIs for implementation based on the needs of their particular at-risk clientele. Successful CBOs are then awarded funding to hire DEBI staffing, and provided with organizational resources for DEBI training, infrastructure, support, and adaptation (Collins and Tomlinson, 2014). In addition, each DEBI kit comes with an array of CDC-prepared, standardized materials for CBO providers to mount the intervention:

In the DEBI project, evidence-based interventions are packaged with well-articulated implementation steps, instructions and resources. Many intervention products such as risk assessments, job descriptions, camera-ready promotional materials, evaluation tools, sample budgets, and logic models are included to provide those implementing an intervention as many concrete tools for successful implementation as possible. (Collins and Tomlinson, 2014: 252)

Each DEBI typically consists of a pre-set number of sessions with trained intervention personnel, designed to modify individual perceptions, skills, and behaviors, including ‘perceived personal vulnerability, self-efficacy, intention, assertiveness and communication skills, condom use, (and) reduction in the number of sex partners’ (Ayala, 2008: 3).

By anchoring federal prevention dollars to DEBI adoption and producing DEBI kits as a standardized package of highly transposable technologies and operating procedures, the CDC incentivized a bandwagon of intervention science and praxis throughout the US HIV prevention arena. In effect, the DEBI bandwagon permitted the CDC to maintain financial support of CBO behavioral interventions, appease Congress, and at the same time centralize control of HIV prevention praxis.

Figure 1 offers a rough scheme of this top-down influence structure whereby the CDC has sought to standardize HIV behavioral interventions at the state, county, and community levels. Here, the double-headed arrows represent reciprocal and alternative pathways by which intervention programming has developed in this period.⁵

At the top of the influence structure, Congress funds a three-pronged, mutually reinforcing federal public health complex, comprising the NIH, the CDC, and associated health scientists. The NIH funds little social scientific HIV intervention research (Green and Kolar, 2015; Kippax and Race, 2003; Roberts and Matthews, 2012),6 thereby consecrating individualistic, cognitive behavioral approaches as gold standard prevention science (Kippax, 2008). At the same time, as I note above, the CDC mandates that the majority of CBOs applying for federal, state, and county public health dollars do so on the condition that the CBO will use the CDC-approved, health science, EBIs (Dworkin et al., 2008; Wilson and Moore 2009), of which 75–80 percent are developed and tested under the auspices of NIH funding.

CBOs engage gay/bi/MSM participants directly in counseling, interventionist and/or testing capacities, in local condom distribution outreach, in homegrown workshops and focus groups, using social media and neighborhood campaigns designed to promote safe sex and personal responsibility. In this sense, CBOs can function as both clinical settings for HIV treatment and prevention and also as centers of community development and outreach. Some CBOs are generalist organizations that serve the entire local community, while others specialize in the needs of gay/bi/MSM clients or, even more specifically, a particular racial or ethnic subpopulation therein.

CBOs conduct prevention in relation to activists and community partners. Depending on the particular period in question, activists may include any number of community stakeholders, ethnic leaders, scholars, and health advocates, along with ‘lay’ gay and bisexual men who organize to contest or promote a given prevention policy. In the 1980s, for instance, prevention activism included protest around issues of sexual liberty – most notably, the closure of bathhouses by public health officials (Fitzgerald, 1986). Since the late 1990s, with few exceptions, this kind of activism has all but disappeared, though pointed criticisms of the dominant approaches to prevention have persisted in published opinion pieces and various organizational, scholarly, and commercial publications and conferences. Community partners may also be involved in CBO prevention programming, and can include representatives of racial and ethnic community groups, along with various community bodies that bring together local stakeholders. Such bodies may include city and county public health officers, along with local businesses that have a stake in prevention policy, such as the owners of sex clubs who may be obligated by local health department to provide HIV testing onsite.

Social scientists and humanist psychologists conducting research on gay/bi/MSM health become actors in the prevention arena, too, through published scholarship, conference presentations, and organizational affiliations that inform existing ideas about the determinants of HIV risk behaviors or the effectiveness of a given intervention regime. These scholarly contributions have, on a few occasions, been incorporated into CBO praxis, either through direct transmission from literature to CBO prevention personnel or by working their way ‘up’ the professional networks of the prevention arena to the NIH, the CDC, and then back ‘down’ again in the form of new CDC funding priorities, changing prevention target groups, or new emphases in CDC approved EBIs.

And finally, gay/bi/MSM actors constitute a social world in their own right insofar as they receive and make sense of HIV prevention programming. But their role in the prevention arena is not simply to be passive targets of prevention: they may also engage in prevention practices that later become codified as an institutionalized prevention method (e.g. negotiated safety) or, as in the case of the bathhouse closures, act against local public health administrations and rally for their own conception of prevention, health, and well-being.

Method

The present analysis draws from an ongoing study of LA gay/bi/MSM HIV prevention. LA is home to a large and ethnically diverse gay and bisexual male population, a highly developed prevention infrastructure (including long-standing CBOs), established institutionalized mechanisms for acquiring resources and executing prevention outreach, and rates of HIV infection which, over the decades, are roughly comparable to those in other large North American cities.

To make sense of the HIV prevention arena, I use a multi-method strategy that includes extensive archival research and in-depth interviews with: key past and present prevention service providers, organizational leaders, policy makers, public health officials at the city, county, state and federal levels, and nationally recognized HIV activists.

In-depth interviews

The core of the gay/bi/MSM HIV prevention arena in LA is configured by a handful of CBOs, each of which works alongside the LA County Department of Public Health in a variety of capacities. In this article, I focus on (semi-structured) interview and archival data from four major CBOs: (1) AIDS Project Los Angeles (APLA), (2) AIDS Health Care Foundation (AHF), (3) the Los Angeles Gay and Lesbian Center, and (4) Bienestar – a CBO that services the city’s Hispanic community. These CBOs have multi-million dollar annual budgets, extensive histories of doing gay/bi/MSM HIV prevention work, and represent the most developed HIV prevention organizations in LA. I conducted additional interviews with senior officials of the division of HIV/STD (sexually transmitted disease) programming at the LA County Department of Public Health. I also interviewed the co-trustee and president of the largest corporation running sex-on-premise venues in LA. This actor worked directly with the LA Department of Public Health, negotiating the terms of bathhouse licensure and serving as a member of the LA Prevention Planning Committee – a critical community entity for LA HIV prevention strategy.

Outside the core of the LA HIV prevention arena are a range of actors that play an important role in shaping gay/bi/MSM HIV prevention, including prevention activists, gay-related business establishments, and CDC funded, state-level intervention training centers. I interviewed two nationally recognized, high-profile prevention activists/writers housed in California – each of whom published articles, op-ed pieces, and commercial books on MSM HIV prevention that had direct effects on CBO prevention programming and discourse. Additionally, I conducted two rounds of interviews with the director and three full-time prevention staff members of a federally funded training and capacity-building center in California, which has over 20 years of experience translating CDC intervention protocol at the level of California CBOs. To further investigate the federal side of prevention, in 2012–2013 I conducted multiple interviews with two long-standing senior-level officials associated with the CDC Division of HIV/AIDS Prevention (DHAP), including recorded phone interviews and a series of substantive email correspondences.⁷

Archival research

Archival materials include print and digital matter pertaining to CBO gay/bi/MSM HIV prevention work, organizational minutes, prevention plans dating back to the mid-1980s, prevention pamphlets and assorted literature pertaining to outreach, social media campaigns, fundraisers, and retrospectives of organizational activity. These documents were located within CBO archives and the One Archive at University of Southern California. Additionally, I obtained 9 years of meeting minutes from the LA County Commission on HIV Health Services, 12 years of minutes from the LA county HIV Prevention Planning Committee, copies of LA County Comprehensive HIV Plans, and the LA County annual HIV Surveillance Reports.

Key digital data came from online, publicly available, CDC prevention materials including statements regarding organizational goals, strategies, policy initiatives, and public health mandates. I also reviewed the latest volume of the Compendium – the CDC publication that contains a master list of approved EBIs, and the online CDC website for EBI diffusion.⁸ Other important digital and printed materials included daily posts on an international HIV prevention and treatment listserv (Rectal/Micro IRMA), HIV MSM prevention-related newspaper and journal articles, Op Ed pieces and published commercial books from two nationally recognized HIV activists.

Finally, I conducted a systematic content analysis of all NIH HIV-related behavioral and social scientific grant awards between 1989 and 2012, in order to identify epistemological and disciplinary patterns in funded prevention research.⁹

Two fundamental contentions in the gay/bi/MSM HIV prevention field

When HIV/AIDS emerged in the early 1980s, both the CDC and the NIH were already combating the spread of other sexually transmitted infections from within a biomedical public health paradigm that remains dominant to date (Kazanjian, 2012). Premised on ‘biomedical individualism’ (Fee and Krieger, 1993), this approach to disease prevention couples a narrow emphasis on individual behavioral mechanisms with a health science model of human motivation that presumes a rational (as opposed to relational) actor (Auerbach et al., 2009; Fee and Krieger, 1993). In the United States, HIV prevention inherited the framework of biomedical individualism that, in turn, shaped how the gay/bi/MSM subject was conceptualized as an object of intervention: the framework motivates issues, including: why the individual gay/bi/MSM subject has sex, what outreach efforts are required to change his sexual behaviors and, by extension, which entities should be put in charge of developing programming to produce this change. Against this backdrop, fundamental contentions in the MSM HIV arena have taken form, which include: oppositional stances on whom interventions should target (e.g. ‘gay’ men or ‘MSM’, HIV negative men or HIV positive men, biological men alone or transgender women, too); the proper balance of sexual freedom, health and social responsibility; polarized positions on the nature of sexual decision-making; and divergent attributions of expertise, among still others. Due to limits in space, I focus here on the latter two contentions as they have emerged in the LA prevention arena. These struggles put into question core elements of MSM HIV prevention and, as I will show, imply fundamentally divergent configurations of power and control of the prevention enterprise. While gay/bi/MSM HIV prevention programming varies across US cities and states, the contentions highlighted in this article are not unique to LA, but are issues in US HIV prevention more broadly.

Contention 1: Polarized positions on the subject at-risk

As I note above, the dominant public health approach to prevention is anchored in the health sciences, and thus incorporates the principles of cognitive behavioral theory developed first in US Behavioral Science Departments during the 1950s (Rosenstock et al., 1994). In this framework, human behavior is understood from within value expectancy theory, which claims that actors act toward a valued outcome when they have the expectation that a given behavior will achieve it (Rosenstock et al., 1994). Following this logic, HIV prevention developed under the assumption that actors make sexual decisions in a more or less individualistic, rational fashion, weighing their options in terms of cost–benefit analyses (Adam, 2006; Adam et al., 2000; Davis, 2002; Gastaldo et al., 2009). Accordingly, sexual actors could be trained to make positive, health-affirming sexual choices (Bandura, 1994; Fishbein et al., 1994; Rosenstock et al., 1994).

From the 1990s forward, the construction of the individualistic, rational sexual actor was institutionalized via models like the ‘Health Belief Model’ and the ‘Theory of Reasoned Action’. According to these approaches, individuals use condoms if they understand the seriousness of contracting HIV, the effectiveness of condoms at preventing transmission, the benefits of remaining uninfected, and the perception that they are capable of using condoms (Bandura, 1994). Summarizing the Health Belief Model and, implicitly, the cognitive behavioral, rational actor model more generally, Rosenstock et al. (1994) conclude,

In general, it is now believed that individuals will take action to ward off, to screen for, or to control ill-health conditions if they regard themselves as susceptible to the condition. They will also take action if they believe the health condition to have potentially serious consequences; if they believe that a course of action available to them would be beneficial in reducing either their susceptibility to or the severity of the condition; and if they believe that the anticipated barriers to taking the action are outweighed by its benefits. (p. 8)

Within the prevention arena, such models reflect a family of highly related cognitive behavioral theories from which actors named ‘health experts’ developed HIV prevention science. As I note above, in 1999, the CDC configured this prevention science in the form of a standardized package (Fujimura, 1988) of evidence-based HIV behavioral interventions or EBIs (Lyles et al., 2007), and mandated their use in 38 states, creating a bandwagon of HIV intervention science and praxis that became known as the DEBIs. Examination of this highly select list of ‘best-evidence’ interventions reveals an overwhelming emphasis on cognitive behavioral models that promote HIV education and skills-building around condom use, with limited content addressing the emotional, cultural or social determinants of risk practices (Coates et al., 2008).¹⁰ From the perspective of a former Executive Director of one of the largest CBOs in LA, the uniformity of these interventions is not surprising, given the relationships between the NIH, the CDC, and associated health scientists, wherein strong scientific and professional insularity advanced a paradigmatic approach to the epidemic underwritten by federal dollars. In a 2012 interview, he said,

[T]he CDC was very, very heavily influenced by the NIH … [T]he NIH got locked into a certain way of thinking about behavioral prevention research for a long, long time and kept funding the same kind of research over and over with a small circle of researchers as result of the way that reviews and funding decisions get made at the NIH. So, you know, how the review panels are populated and who knows who and it became very insular.

As these HIV behavioral interventions grew in number and popularity over the course of the 1990s, a contingent of actors from distinct social worlds – including sociologists, humanist-oriented psychologists, CBO service providers, and activists – began to voice their opposition.¹¹ They argued that the Health Belief Model and similar cognitive behavioral approaches incorporate only the barest concept of the cultural, contextual, and psychological bases of sexual decision-making. One of the most vocal of these critics – nationally recognized psychoanalyst and activist Walt Odets – articulated an especially scathing critique of the reigning cognitive behavioral model in the mid-1990s, which would eventually become the basis of the DEBI standardized package. Odets’ (1994, 1995) critique targeted social media campaigns with slogans that presumed an audience of rational actors readily marshaled to the project of health promotion, and prevention programming that incorporated too little of the psychology of sexual life:

We have also told gay men that if they do what we say, they can ‘Be Here for the Cure’ or that they can ‘Play it Safe’ by ‘Making a Plan’ and ‘seeing it through’ … In truth … sexual life in the epidemic is considerably more complicated than making a plan and seeing it through. The slogans are more appropriate proposals for losing ten pounds and are an offense to the man dealing with the kinds of complex feelings that arise in the radical form of life the gay community is now conducting. (Odets, 1994: 3)

Conceiving of the sexual actor from a psychologically nuanced philosophy of the sexual subject – a subject who pursues sexual relations on the basis of deep emotional needs for physical intimacy – Odets’ approach pressed for an entirely different intervention science that highlighted the psychological and symbolic content of sexual relations. On the topic of intercourse and fluid exchange – an obvious target for prevention work – Odets argued that a simple message urging the importance of condom use did nothing to address why gay men have sex in the first place. Rather, he argued that the act of intercourse is about building intimate connection, one for which semen exchange had great symbolic import, and the condom was easily perceived as a barrier: ‘What AIDS education has come to call the “exchange of body fluids” was once acknowledged as an important aspect of intimacy for many men’ (Odets, 1994: 9). In effect, Odets called for the dismantling of the dominant cognitive behavioral intervention model in favor of a humanist, interpretive approach to behavior change that incorporated at its core the psychological meanings of sexual life.

From a sociological perspective, critics of the cognitive behavioral intervention model pointed out that unprotected intercourse occurs regularly among men who are both already educated on the mechanisms of HIV transmission and also well aware of the consequences of infection (Collins et al., 2008; Davis, 2002; Kippax, 2008). Rather than rely on the model of an individualistic sexual decision maker, sociologically oriented scholars argued that sexual decision-making is less rational than relational, both in the sense of occurring in relation to another partner and in concert with cultural and contextual factors (Adam, 2006, 2011, 2015; Coates et al., 2008; Kippax and Race, 2003; Wilson and Moore, 2009). And from within a social determinants of health perspective, scholars conceived of the sexual actor as structurally situated in ways that bear on his or her ability to enact safe sex, including broad structures associated with racialization, homophobia, and poverty (Auerbach et al., 2009; Roberts and Matthews, 2012). From a sociological perspective, HIV prevention falters from the outset when it assumes actors are liberal health consumers (Lupton, 1999), each similarly situated, engaging in health promotion free from structures of inequality and the psychological and social contexts in which sexual decision-making arises (Coates et al., 2008; Wilson and Moore, 2009).

In LA, CBOs articulated a parallel line of objections upon engagement with gay/bi/MSM clientele. Thus, in their 2003 HIV prevention policy publication, APLA concluded:

The risk for HIV infection is often understood as being connected to some individual trait, characteristic or deficit. Another way to understand the risk for HIV infection is as a function of interpersonal and socio-cultural contexts. In other words, risk behavior does not happen in a social vacuum. At present, interventions that are endorsed by public health institutions in the U.S. largely focus on modifying individual risk behavior without taking into account the situational, interpersonal, social or cultural contexts in which risk occurs. (Ayala et al., 2003: 9–10)

Drawing instead on an interpretive and structuralist view of the subject-at-risk, humanist psychologists, sociologists and CBO personnel constitute social worlds that formulate HIV intervention science and praxis in contrasting terms from the dominant federal public health complex. Through scholarly and organizational publications, conference presentations, and congressional testimony, these actors argue that the psychological and social underpinnings of sexual decision-making provide the key starting point for the development of intervention programming. As I show in the next section, the implication is that HIV intervention science needs to move out of the jurisdiction of the health sciences and into the control of those with the capacity to make sense of, engage with, and direct human practice. Such a shift would reconfigure the making of prevention science, redirecting federal and state resources away from the social worlds of health scientists and the DEBI standardized package, toward alternative, humanist, and social scientific social worlds that are better suited to the challenge of engineering behavior change.

Contention 2: The location of epistemic authority

Between 2000 and 2012, the CDC trained well over 10,000 service providers to implement the DEBI bandwagon (Owczarzak and Dickson-Gomez, 2011). Some CBOs welcomed the DEBI bandwagon as a powerful prevention tool, while others adopted the DEBI standardized package on account of economic necessity, forgoing the development of their own, ‘homegrown’ interventions (Dworkin et al., 2008). At the core of disputes over the CDC’s top-down control of intervention science and praxis is the question of epistemic authority, the issue of who has ‘[t]he legitimate power to define, describe and explain bounded domains of reality’ (Gieryn, 1999: 1).

From within the social worlds of federal public health and their state and local affiliates, the tethering of DEBI adoption to CBO funding is warranted, given the fundamental role of science in the development of HIV behavioral interventions. In an explicit process of boundary work, senior officials at the CDC’s National Center for HIV/AIDS contrast the DEBI program with CBO homegrown interventions. Here, the task of creating systematic behavior change requires scientific expertise generally not available to nor understood by ‘community members’.

Delivery of public health services requires some specialized knowledge of empirical ways to define the problem – using surveillance and epidemiologically derived data – and of practical ways to address the problem with innovations or technology strategies. In general, community members by themselves may lack expertise in the use of public health practitioners’ tools for problem identification as well as state-of-the-art programs to address those problems (Collins and Tomlinson, 2014: 244).

The fact that so few interventions have met the rigorous standards of evidence required for inclusion within the Compendium is itself testament both to the challenge of engineering behavior change and the crucial role of scientific expertise in the HIV prevention enterprise. In 2012, one of the senior-level CDC HIV prevention personnel said,

The desire and belief among CBOs that they have the ability to create efficacious interventions and the problem with that is that since 1988 … there have only been 74 interventions in the published literature that met our criteria of working. So you’re telling me that the best minds in the scientific community for the last 25 years have come up with 74-75 intervention and you’re telling me that all these 1500 CBOs are going to make up efficacious interventions.

Thus from the position of federal public health, the critics of the DEBI bandwagon overestimate the ability of non-expert, non-scientist CBO staff to effect systematic behavior change, and underestimate the necessity of expert behavioral science toward that end – what the agent above refers to as ‘the best minds in the scientific community’.

In addition, whereas the DEBI standardized package comes in kit-form with a program officer and written materials that highlight and maintain the core logic of the intervention, CBO providers of homegrown interventions typically receive informal, haphazard training, with the consequence that even sound interventions ‘migrate’ over time. In 2012, one of the senior-level CDC HIV Prevention Personnel said,

What we informally observed was that there was a tendency for locally developed interventions to migrate, depending on the interest, skills and training of their newly hired employee … [I]f they hired a social worker, the intervention started taking on case management characteristics. So the staff would bring their perspective into the agency and frequently that would bring about a migration of the intervention.

One of the primary consequences of this hierarchical distinction between expert and community knowledge and praxis is materialized in the process of DEBI adaptation to local settings. While the CDC trains DEBI implementation teams to ‘translate’ the science of any given intervention downward, adapting it to local communities while preserving its core ‘scientific principles’, CBO personnel in LA and abroad maintain that the process of ‘adaptation’ is riddled with problems (Wilson and Moore, 2009). Specifically, strict emphasis on ‘fidelity’ to the core principles of the intervention puts into question the degree to which CBOs have input into DEBI implementation (Owczarzak and Dickenson-Gomez, 2011). Thus, in a 2013 interview, a senior member of a California, CDC-funded DEBI training center recites the CDC policy on CBO adaptation like a mantra:

Implement with fidelity based on the internal logic of the intervention and you had to follow all of the core elements because if you don’t you cannot be guaranteed that the intervention is going to be effective and that still holds true …

Perhaps it is not surprising, then, that CBOs widely refer to the DEBI standardized package as ‘out-of-the-box’ interventions. The colloquialism highlights at least two problematic ‘one-size-fits-all’ features of the DEBI standardized package, both of which arise because of conflicting attributions of expertise within the prevention arena. First, DEBIs are interventions originally conducted on a study sample that may not reflect diverse CBO clientele, including their differences of race, class, and ethnicity (Gandelman, 2005; Wilson and Moore, 2009). And second, university studies upon which the DEBIs are based typically occur within highly controlled conditions – conditions that may not at all compare with those within which non-study sexual actors live (Ayala et al., 2003; McKleroy et al., 2006). In a 2012 interview with one of the senior personnel of an LA CBO, these problems are brought together in the real-world terms of on-the-ground prevention – in this case, a mismatch between the race of the experimental sample and the men of color for whom the DEBI was being mounted:

Because basically what happened was … ‘I’m a researcher, and … (I say) this will work perfectly with gay men!’; But I’m like, ‘well, I’m sorta a black gay man’. ‘Well … just tweak it a little bit, but don’t change it too much, ‘cause then it’s not my intervention!’

In a 2012 interview, the Director of Programs and Public Affairs of the largest LA CBO devoted to servicing a minority clientele discussed a similar problem of racial/ethnic translation from the experimental context to the real world:

If you were directly funded from the CDC … you have to apply only with that DEBI. But guess what? There was not one DEBI that was developed for Latinos, so we have to adapt what was done for African Americans, and what was for Caucasians or whites.

In this sense, DEBI critics perceive a faulty attribution of expertise and, consequently, a system-wide mismatch between the logic of the DEBIs and the actual target communities for whom they are mounted. Thus, in a 2012 interview, an Executive Director of an LA CBO recounts an instance of this mismatch with respect to a specific DEBI called ‘Popular Opinion Leader’ or ‘POL’:

The problem is if you take something like … oh the Popular Opinion Leader Model, right, POL was done in Denver. And what they did, roughly speaking, was they went into the gay bars in Denver and they identified who the POLs were. And they found the men … who were looked up to by the other men … And they enlisted those men to become peer educators and they trained them on … risk reduction behaviors and all those things … The problem is, you get it into LA and the bars don’t work that way. And it’s such a big town compared to Denver, and there’s so many bars and there’s so many POLs and they come from so many different communities and POLs in our black communities are very different than who might be a POL in bars in West Hollywood. And then we have our Asian bars and then we have bars where people go because they wanna be with lots of other different races and yet you couldn’t vary the curriculum. And so it was, it was built for white upper middle-class gay men in Denver and we’re trying to adapt it for lower and middle-class Latinos in Los Angeles.¹²

Contentions in the HIV prevention arena regarding who is best situated to design and execute effective interventions reflect jurisdictional struggles (Abbott, 1988) over fundamental elements of the prevention enterprise. Expertise is presumed to emanate from the health sciences and a centralized staff of public health administrators at the CDC, so the work of devising prevention is hierarchically organized, ‘abstracted’ (Abbott, 1988) from the jurisdiction of community personnel and ‘translated’ (or dictated) downward from the expert scientist to CBO service providers. Hence, Gandelman (2005) observes a one-way process of technology transfer that reserves epistemic authority for university- and federal-level health scientists while restricting the potential contributions of local service providers:

The path from research to practice is quickly becoming a well-paved road, however, for the most part, that road is still a one-way street … For the most part, theories are taught to prevention providers, and there have been few attempts to elicit information from prevention providers that reflects their intuitive knowledge of theories concerning factors that influence risk-taking behaviors among their priority populations. (p. 300)

From the vantage point of the CDC, however, there is a crucial division of labor in HIV prevention science and praxis. In a 2013 interview, a senior CDC officer suggested that CBOs still bear the responsibility for the local, cultural, and linguistic work of DEBI adaptation – a kind of contextual management not suited for federal public health:

I can’t tell somebody in Montgomery, Alabama, what is driving their epidemic so the agency needs to know their community … They need to know language, they need to know slang, they need to know key stakeholders, they need to know who the gatekeepers in the community are that you have to communicate with when you start to implement an intervention. They need to know what incentives are needed to get someone to come to an intervention or stay in an intervention. They need to know what music people are listening to. We can’t package that! … So people say that we don’t take account of local culture/local language and we’re saying that’s not our job! That’s your job! Why are we paying you all this money to do this intervention? You’re supposed to know your community!

But critics of the DEBI system, including CBO staff and scholars in the prevention arena, take issue with the division of labor articulated by the senior CDC official above, rejecting the notion that behavioral scientists and public health administrators have a monopoly on the development of effective interventions. These critics rally for a more bottom-up, community-based approach, grounded in the experiences of those the intervention aims to target (Dworkin et al., 2008; Kippax and Race, 2003; Wilson and Moore, 2009). Thus, the very definition of what constitutes expertise is put into question. In this challenge lies a critique of the institutionalization of epistemic authority through alternative boundary work (Gieryn, 1999) that privileges indigenous, ‘subjugated knowledges’ (Adam, 2011: 2) over the distant knowledge of the health sciences:

[I]t is not only essential to step back and consider the definition of what is ‘the best’ intervention for organizations to adopt, but to also ask the question as to whether the process of EBI embraces and bolsters local knowledge and histories or effectively erases them. (Dworkin et al., 2008: 54)

In this sense, the DEBI program represents less a bandwagon of consensus across social worlds than an arena of uneasy compliance, wherein CBO personnel engage in discursive jurisdictional struggles that place the HIV prevention enterprise under their own control. Thus, in a CBO position paper that explicitly criticizes the DEBI bandwagon, APLA argues,

HIV prevention advocates must therefore question the policy of promoting pre-packaged, science-based HIV prevention interventions over supporting and researching more localized, indigenous and collaborative HIV prevention strategies … It is important that HIV prevention advocates honor local knowledges by protecting local control over how HIV prevention strategies are developed and prioritized. (Ayala et al., 2003: 10–11)

‘Out-of-the-box’ prevention has played a central role in the US HIV prevention arena since the ascendance of EBM in HIV intervention science and praxis. In recent years, however, ‘… after much debate and dissatisfaction with original DEBI implementation requirements …’, says one CBO Director, CBOs have been given greater latitude to shape the substance of an intervention. For example, today, the LA County Public Health allows CBOs to borrow from other intervention models around the country that are compatible with their particular target populations. Or, should a CBO prefer to develop its own intervention, LA County provides the theoretical rationale upon which it may do so via ‘Community/Intuitive Theory’ (Gandelman, 2005) – a theory that shifts epistemic authority to CBO staff to whom are attributed ‘common sense’ and ‘intuitive knowledge’ of the community of clients they serve. However, as elsewhere in the United States, LA County funding for non-DEBI prevention requires that CBOs first establish the effectiveness of these alternative interventions, including standards of evidence that CBOs are not always able to meet, because of limited organizational resources and assessment expertise (Auerbach et al., 2009; Dworkin et al., 2008). In addition, in a highly competitive funding environment, CBOs take a marked risk when proposing their own homegrown interventions, whereas DEBIs are already granted the CDC seal of approval. And finally, the DEBI bandwagon has the unintended consequence of diminishing the capacity of CBOs to create homegrown interventions (Owczarzak and Dickenson-Gomez, 2011), as CBO infrastructure and personnel are retooled to meet the demands of the DEBIs. In summary, while there appears to be increasing latitude over time for CBOs to adapt the DEBIs or develop their own homegrown variants, the institutionalization of the DEBI bandwagon itself has been built on a CDC policy of ‘technology transfer’ that creates a strong, top-down hierarchy of intervention science development, from so-called expert scientists, downward to CBO service providers. The sheer scale of the DEBI bandwagon and its concomitant political economy have meant that social worlds outside the federal public health complex have had limited organizational capacity to challenge the epistemic authority of the health sciences and recapture the prevention project on their own terms.

Discussion

Despite representing only about 2 percent of the US population, by 2012, an estimated 300,000 US gay and bisexual men had died because of HIV/AIDS – nearly four times the number of heterosexuals (CDC, 2012). Moreover, gay/bi/MSM continue to be vastly overrepresented among the newly infected, comprising upward of 60 percent of new HIV infections in the United States (CDC, 2011), with approximately 50 times the likelihood of being infected of the general US population (CDC, 2009). In response, CBOs have sprung up from the bedrock of former gay community institutions to provide care for the ill and mitigate the waves of illness and death (Rofes, 1997). With increasing resources from the health sector, coupled with private donations, HIV prevention moved from condom distribution on the streets to formal organizations with full-time paid staff and, in large urban areas, multi-million dollar annual budgets. In this process, HIV prevention evolved into a complex, multi-stakeholder enterprise.

In this article, I conceptualize the HIV prevention enterprise from the perspective of the social worlds framework (Clarke and Star, 2008; Star and Griesemer, 1989), and draw attention to two fundamental contentions that divide the arena and lay bare its architecture. This architecture comprises scientific and non-scientific social worlds, each defined by distinct ‘universes of discourse’, disciplinary/occupational training, organizational forms and professional interests (Clarke and Star, 2008). Brought together by the shared goal of ending the epidemic, the social worlds of the prevention arena are committed to disease containment, and at the same time aim to establish distinct prevention regimes that both align with their particular vantage points and also consolidate their interests. That is, mediating between the goal of containing the epidemic and the actual practice of prevention work is the HIV prevention arena, at once a multi-stakeholder enterprise and a contested domain of knowledge production.

One of the most critical practices of the HIV prevention arena is the formulation and execution of the behavioral intervention. In the contemporary context of evidence-based prevention, CDC accounts of prevention science articulate a narrative of ‘normal science’ (Kuhn, 1962), according to which intervention research is developed, tested, adjudicated, and refined in university settings, the domain of peer reviewed publications and NIH funded intervention studies (Collins and Tomlinson, 2014; Lyles et al., 2007; Sutton et al., 2009). Here, scientific knowledge is framed as the engine of prevention, and progress in containing the epidemic is understood as a function of advances in behavioral research, coupled with the dissemination of user-friendly behavioral interventions in the form of the DEBI bandwagon.

The two core contentions outlined in this article, however, reveal less the steady advance of normal science than an arena of diverse social worlds characterized by competing positions on the subject at-risk and the location of expertise. These positions, in turn, differentially construct the behavioral intervention and put into question its most basic elements, including what it should consist of, who should decide, and why. Focus on behavioral interventions highlights professional and epistemological tensions between disparate social worlds, as actors work to impose their ‘definitions of the situation’ (Hughes, 1971) onto the development and execution of the science or technology in question. With respect to HIV prevention, any given behavioral intervention represents the crystallization of a position regarding both the nature of sexual and drug-using decision-making and also an implicit stance on which social worlds are to be put in charge of its execution. Here, claims of epistemic authority function as boundary work (Gieryn, 1999) – an assertion of a ‘privileged position in the accepted practice of knowing’ (Friedland, 2009: 901) – that reveal jurisdictional struggles over the ‘true’ nature of the risk-taker and the rightful owners of the prevention enterprise.

In the United States, during the late 1990s and early 2000s, the political economy of the HIV prevention arena was transformed as congressional pressure mounted on the CDC to standardize prevention programming in light of the ascendance of the IOM’s EBM protocol. Then, the CDC institutionalized a scientific-behaviorist approach to HIV prevention in the form of a standardized package which, via the DEBI technology, was transferred downward from health scientists to on-the-ground prevention service providers. The DEBI standardized package carries the symbolic capital of the health sciences that created it, along with the credibility that comes with NIH funded research. More importantly, the DEBI program achieved the status of a prevention bandwagon throughout the prevention arena on account of the fact that CBOs across 38 states were mandated to implement a DEBI in order to qualify for federal prevention dollars (Dworkin et al., 2008). Accordingly, to the extent that CBOs have been beholden to the CDC and to state and county public health departments for their economic survival, they have exercised limited power to resist the DEBI standardized package. Put differently, in the words of senior personnel at the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD and Tuberculosis Prevention, DEBI uptake was contingent upon ‘some degree of manipulation or exertion from external authority’:

Before the launch of the DEBI project, many in the HIV prevention workforce would not have sought to implement evidence-based practices. It is precisely the ability of funders to influence the policy and resource environments that has been used to advance public health in HIV prevention and in other areas. In all such cases, where diffusion requires some degree of manipulation or exertion of external authority, resistance to change is expected. (Collins and Tomlinson, 2014: 257)

Thus, from 2001 onward, the political economy of the prevention arena became crucial in shaping the prevention enterprise, as health scientists and public health administrators within the federal public health complex engaged in a process of professional abstraction (Abbott, 1988). They attributed to themselves epistemic authority and argued for a dominant role in the making of prevention science and praxis on account of their unique expert status in understanding and executing so-called evidence-based practices. Here, with the power of the purse in hand, the federal public health complex established a fundamental division of labor, whereby the specific social and cultural features of any given target population are contextual details to be handled by local CBOs, separate from the science upon which effective interventions depend:

The broad and overarching strategies used for diffusion of HIV prevention technologies to community-based settings – whether directly from the CDC or through state and local health departments – are distinct from implementation of those technologies by partners on the ground. We contend that in a modern public health environment the former necessitates a high degree of centralized planning, decision-making, and coordination – about both resources and science – whereas the latter takes maximum advantage of local knowledge, experience and wisdom. (Collins and Tomlinson, 2014: 256)

The impact of the political economy in shaping CBO programming was echoed in the accounts of CBO service providers. In a 2012 interview, one provider described why the DEBIs have remained so prevalent, even among CBOs for whom homegrown interventions were more valued:

As the funding switched (to the DEBI system) … not everyone jumped right after. People tried to hold out … but all the money was dependent on donations. So, as time has gone on and donations have stopped being at the levels they were at, it has become important for agencies like APLA, AHF, GMHC, to be sustainable, so you have to go through the government. So it wasn’t like, ‘Oh you want us to do this? Everyone jump, let’s do this!’ I think that there was a strong belief that the community approach in these agencies was the way we wanted to go … but unfortunately people that did the Tunnel of Love workshop (a homegrown intervention) lost their job and the people that did Popular-Opinion Leader (a DEBI) continue on to this day.

But the rise and hegemony of the DEBI bandwagon has been facilitated by a second, perhaps unintended consequence of the changing political economy of the HIV prevention arena: diminished CBO capacity to develop and support homegrown interventions. Thus, Owczarzak and Dickenson-Gomez (2011) note,

Prior to adopting a DEBI, most agencies had existing programs that they had been conducting, with anecdotal success, for many years. Therefore the adoption of new programs often required agencies to make decisions regarding resource allocation, use of staff time, and agency-level priorities. The time intensive nature of the DEBI interventions meant that agencies would have to cut back on existing programs to dedicate sufficient staff time to DEBI implementation. (p. 175)

This diminished capacity occurred over time as CBO infrastructure was retooled to meet the demands of the DEBIs, thus redirecting the energies of service providers away from critical and innovative intervention programming and toward technical expertise associated with DEBI implementation. Thus, in a 2012 interview, one former CBO Executive Director said,

I noticed that as health departments and CDC officials began packaging and promoting boxed interventions that CBO capacities in the area of prevention began to wither … The problem, however, is that this approach resulted in the redirection of capacity-building and technical support resources to ensuring that front-line preventionists were trained to deliver a prescribed set of interventions. Organizations began hiring and retaining technicians … With weakened organizational capacity for reflexivity and a labor force trained for a narrowly defined set of rote tasks, fewer and fewer folks on the front-lines were thinking critically and more comprehensively about prevention – nor being paid to do so. In this environment, it is difficult to be creative, to listen to the communities we serve, and to enact more iterative, engaged prevention strategies since there is no incentive to do so.

Finally, the hegemony of the DEBI bandwagon must be understood in the political context in which it has emerged. Unlike HIV/AIDS treatment, for which a powerful, and wide-ranging contingent of patient-activists, advocacy groups, health educators, journalists, and public health officials were mobilized in the face of a medical and drug treatment system ill-suited to handle the AIDS crisis (Epstein, 1996), evidence-based HIV prevention has never elicited an oppositional social movement on the scale of HIV/AIDS treatment and has thus remained largely under the control of the CDC and its state and county public health affiliates. This is not to suggest that there has been no challenge to evidence-based HIV prevention and the DEBI bandwagon more broadly. To the contrary, while the prevention arena exhibits structural capacity to reproduce itself amid long-standing dissension, there have been recent changes in intervention design and execution that reveal signs of a democratized HIV intervention science and praxis. For example, regarding behavioral intervention science, social drivers of the epidemic have become increasingly acknowledged in federal public health discourse on HIV intervention science and praxis (Auerbach et al., 2009). In addition, CDC insistence on so-called fidelity to the core principles of the DEBIs has relaxed in recent years, as CBOs are afforded greater latitude to adapt intervention protocols as necessary. These shifts occurred as actors articulated their criticisms of the reigning prevention regime in professional conferences, in published work, and through prevention networks that traverse the boundaries of individual social worlds and include leading federal public health actors. They have also occurred in a historical period in which behavioral interventions have been shown to be largely ineffective (Sullivan et al., 2012), and HIV transmission rates have held steady or increased among MSM (CDC, 2011). In short, alternative social worlds – including the social sciences and CBOs – have gained some traction in the prevention arena on account of mounting discursive resistance to the DEBI bandwagon. Nevertheless, challenges to evidence-based prevention and the concomitant epistemic divide have been slow in coming and have been accompanied by the failure of the federal public health complex to successfully contain the epidemic among at-risk populations.

Conclusion

By bringing together the social worlds framework with a political economic analysis of the HIV prevention arena, I move beyond an account of the multiple ways in which social worlds construct the behavioral intervention and toward an explanation of how power operates to make particular ‘definitions of the situation’ (Hughes, 1971) more consequential than others in the making of HIV prevention science and praxis. Regarding social worlds as ‘structural units’ (Clarke, 1990: 20) in a negotiated social order (Clarke, 1990: 20), the present analysis brings to the forefront the structural conditions that ‘shape the outcomes of the power struggles which characterize controversies’ (Garrety, 1997: 756).

While this article focuses on the development of HIV interventions, the approach is surely applicable to a broader set of prevention projects. Indeed, prevention projects associated with prostate cancer, breast cancer, and diabetes, to name only a few, command hundreds of millions of dollars annually, have enormous impact on the lay public and appear to be even more common with the medicalization of everyday life (Szasz, 2007). The contemporary ‘war’ against obesity is precisely such a disease prevention enterprise (Saguy, 2013). From policies that legislate hours of physical activity among children (Budd and Volpe, 2006) to banning the sale of large, sugary soft drinks (Grynbaum, 2012), obesity prevention has reached a fever pitch in contemporary America. Yet, to be sure, obesity prevention does not follow in a simple way from the principles of weight gain itself. Rather, differentially positioned actors within the obesity prevention industry – from public health experts at the CDC to talk show hosts to health practitioners at weight loss clinics – promote diverse lines of action that privilege certain knowledges and practices while discounting others. Recommended prevention protocols are those that often locate their advocates at the center of the prevention effort while rendering superfluous prevention alternatives (Tesh, 1996). Here, the most basic questions of who is determined to be obese (a historically moving target on the Body Mass Index), who obesity interventions should target (e.g. children, diabetics, African Americans, soda drinkers, those with familial predispositions to obesity or heart disease), which prevention agents/experts should lay claims to commanding the prevention project (e.g. the CDC, endocrinologists, general practitioners, city governments, dieticians, school boards), and by what means obesity should be prevented (e.g. pharmaceuticals, lifestyle regimes related to diet and exercise, herbs, psychotherapy, gastric surgery), are all unclear and contested matters.

What is true of obesity prevention is no less so of other major disease prevention enterprises. Accordingly, sociologists would do well to sustain a critical analysis of the social forces that underpin prevention science and praxis, including an analysis of the scientific and non-scientific social worlds that develop and adjudicate what counts as effective intervention protocol. Much more than simply codified techniques to keep people safe from illness, disease interventions are crucial crystallizations of the epistemic, institutional, and political economic structures of the social worlds from which they spring.

Footnotes

Acknowledgements

The author would like to thank Zaheer Baber and the reviewers at Social Studies of Science for their most helpful comments.

Funding

This research was supported by a standard operating grant from the Canadian Institutes of Health Research.

Notes

Author biography

Adam Isaiah Green is Associate Professor of sociology at University of Toronto. He is currently writing a book-length manuscript on MSM HIV prevention in Toronto and Los Angeles.

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