1. Lesley Doyal University of Bristol Challenges and potential of intersectional analysis in context of HIV

2. Basic elements of i/s approach Subjects of research cannot be reduced to single categories (eg women) (unitary) Nor will an additive approach be sufficient eg gender + ‘race’ or ‘race’ + class as sum of independent effects (multiple) Personal identities, material lives and health are shaped by range of variables in constant interaction with each other over time and space (intersectional) These interactions take place at different levels: global, national, regional, local, family/household/intimate relationships The location of individuals at the intersections of these structures and processes plays a large part in shaping their health and wellbeing NB location can create both privilege and oppression

4. Challenges facing researchers using i/s approach Not an easy task : is it a conceptual framework, a methodology or a theory? Key problem: multitude of categories/characteristics potentially involved How to relate categories to each other…..cannot assume any one of these more significant than another in any particular context No specific methodology or mode of analysis is prescribed But currently more likely to be qualitative then quantitative

5. Problem of defining basic categories

6. Special relevance to HIV Complexity of global pandemic Differences between epidemics (eg US, Africa and Eastern Europe) Range of economic, social and cultural inequalities shape both likelihood of exposure to HIV virus and realities of living with the infection Social science increasingly complementary to medicine in making sense of these relationships And intersectional approach can provide significant value-added to soc sci Illustrate with two examples: three early studies of African migrants in London & later book taking global perpective on living with HIV

8. Overview of methods Study 1: 62 women from 11 representative countries obtained via hospital records Study 2 Heterosexual men more difficult to recruit and only 37 from 12 countries obtained through hospital sources and members of African HIV +support groups Study 3: MSM very difficult indeed to access and recruitment of eight (all from different African countries) done via personal contacts and snowballing techniques Main methods: semi-structured interviews and focus groups All three studies carried out with active participation of African HIV positive advisory groups

9. structure of sample

10. Commonalities, differences and intersectionalities NB Could not sample by intersection but did use integrated analysis to optimise understanding of these Participants in all three studies did have major features in common because all located at similar intersections of HIV, migrant status, African origins But other differences/inequities also apparent because gender and sexual identity/practices also had to be taken into account in modelling intersections (nb not class or socio-economic status)

11. What did participants have in common? HIV diagnosis always a huge shock: most expected early death and saw future ‘wiped out’ HIV/AIDS highly stigmatised among African communities both ‘at home’ and in the UK leading to great fear of disclosure and isolation Migrant status combined with illness often meant material and social deprivation relative to others in UK But also meant access to benefits and life saving health care that would not be available ‘at home’ So drugs available for survival but only if they did not return to families in Africa Hence many anxious about immigration status on top of fears about illness/death and loss of kin networks

12. What about the differences/inequalities re gender and sexual identity: overview Heterosexual women: moral and practical tensions between HIV and African models of womanhood and motherhood Heterosexual men: contradictions between illness and social construction of African masculinities in both economic and sexual contexts Gay/bisexual men (MSM) : challenges of reconciling sexuality with being an African man and coping with moral and practical implications of a stigmatised illness Look at each in turn

13. ‘My heart is loaded’: challenges of combining motherhood and HIV In most African cultures huge emphasis placed on motherhood as central defining characteristic of womanhood. Yet HIV diagnosis poses serious obstacles to the conceiving of children Mothers usually constructed as ‘moral guardians’ of society with behaviour frequently under surveillance Yet HIV diagnosis likely to ‘spoil’ their moral identity Women given major responsibility for raising children in most economic and social circumstances Yet HIV often limited their ability to achieve this because of illness, poverty or even death

14. ‘I want to survive, I want to win’ impact of HIV on masculinities HIV posed major challenges to identities of African heterosexual men Felt ‘weakness’ was destroying identities Job and money central to self image and to realising future plans but few working fulltime Failure to live up to expectations of themselves and others both in the UK and Africa Many felt loss of control in household because economically dependent on partners UK also perceived by some as unfairly advantaging women in relation to work, benefits and rights

15. I count myself as being in a different world’: MSM living with HIV Being African, gay/bisexual and HIV positive meant location at an intersection that is very difficult to ‘manage’ Homosexuality in most African communities seen as ‘unnatural’ and un-African’ with addition of HIV diagnosis exacerbating stigmatisation Some reported having to choose between mixing with heterosexual African men OR gay (usually white) men ‘Liberated’ in London in terms of legal status and ability to live as ‘out’ gay/bisexual men But very few told families about sexual identity OR diagnosis: fragmented lives

16. Moving forward Three studies gave starting point for understanding some of key intersectionalities shaping life with HIV But had obvious limitations being in just one setting with limited range of participants Raised many questions that could only be answered with much wider analysis Most important issue: identification of inequalities/inequities between HIV positive people to provide evidence as basis for more justice in resource allocation, policy making and service provision

17. Introduction to global analysis

18. Problems with most current studies Focus only on one group: usually heterosexual women or gay (white) men or (less often) heterosexual men or injecting drug users Very few studies designed to compare experiences of these different groups in same setting Most studies of HIV/AIDS focus either on developed or developing countries And very few take intersectional approach Therefore needed to build this up from critical analysis of existing studies

19. ‘the way we develop, grow, age, ail and die necessarily reflects a constant interplay within our bodies, of our intertwined and inseparable social and biological history’ (Krieger 2001)

20. Shaping the framework Different epidemics involve different groups of people and shaped by different dynamics Need to explore how specific (but interrelated) characteristics and circumstances shape lives and deaths of those individuals (already) infected Key characteristics shaping intersections: socio-economic status, sex/gender and ‘race/ethnicity BUT in case of HIV crucial to add sexual identities and practices and also injecting drug use Need to explore these in different settings and at different stages of life

21. Deconstructing categories: SES No standard measurement : needs to be context specific Most measurements need to be multi-dimensional including income, wealth, education Cannot assume one –way relationship in context of HIV: bi- directional causality Also some (African)settings associate HIV prevalence with greater wealth (more sexual activity?) while other settings associate it with poverty (partly due to greater biological vulnerability?) Period after infection, the relationship between socio-economic status and the effects of HIV more consistent with poor doing worse

22. Deconstructing categories: gender Sex/gender often used interchangeably: both important in context of HIV Women biologically more vulnerable than men to infection during heterosex Biological vulnerability interacts with gender inequalities in diverse ways Patriarchal values limit women’s access to a wide range of resources necessary for health as well as limiting their autonomy to make sexual choices Vital to include impact of gender on men/masculinity

23. Deconstructing categories: ‘race’ Categories of race and ethnicity frequently used in both medical and social research but what do they mean? ‘Race’ has traditionally been used with reference to the notion of a group biological ‘heritage’ that may affect health but this view now discredited Increasingly replaced by ‘ethnicity’ or what appears to be common culture but this problematic too in diverse societies Preferred alternative: people from range of subordinated racialised groups share common experiences of oppression which can damage health. BUT…. ‘Race and ethnicity are poorly defined terms that serve as flawed surrogates for multiple environmental and genetic factors in disease causation(Collins 2004)

24. Deconstructing categories: sexuality Thus far, linked sex to gender identifying risks for heterosexual women Also need to look at MSM: particular risks of anal sex but also stigmatised/concelaed identity Especially diverse group: may be gay/bisexual/or transgender in social and/or sexual lives In some countries, sex between men (or between women) remains illegal ‘Invisibilization’ of African MSM major source or risk NB women much less likely than men to acquire HIV infection as a result of same-sex relationships so not key in this context

25. paying attention to IDU Accurate figures of this illegal and highly stigmatised behaviour are difficult to collect But very important to include in some settings around 3 million: 30% of positive people outside Africa Despite these large numbers, IDUs have been left behind in the provision of preventive services and in access to therapies Need to link closely with gender as female IDUs have much worse prognosis

26. Framing life with HIV /AIDS: how do intersectionalities operate? Changing identities and narratives across the life cycle: stigma, discrimination and activism Depending on health care for survival Changing livelihoods: HIV and work Sex after diagnosis Reshaping reproductive futures: contraception, abortion, pregnancy, motherhood

27. How to use this intersectional analysis to help achieve an equitable strategy for meeting the human needs of the millions of positive people still striving for an improved quality of life (and death)? Ultimate Question