Melbourne School of Population and Global Health - Theses
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ItemStudies on prevention and management of HIV/AIDS in the era of highly active antiretroviral therapy (HAART)( 2007-03)More than 25 years have passed since the first cases of HIV/AIDS were reported and a decade since highly active antiretroviral therapy (HAART) was introduced as part of the continuum of care for people living with HIV/AIDS (PLWHA). The introduction of HAART as a continuum of care for PLWHA positively changed the characteristics of HIV/AIDS epidemic, contributing for significant declines of HIV/AIDS-related morbidity and mortality rates. Thus, a new era began with HAART, often referred as the “HAART era”. However, HAART also brought with it new challenges and issues for researchers working in the field of HIV/AIDS. This thesis comprises several studies that were designed to gain understanding of some issues on prevention and management of HIV/AIDS that emerged in the current HAART era. The review of the literature points out for many emergent issues in HAART era, but only some issues were researched and presented in this thesis.
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ItemThe severed heart: dying and death among the Isaan of rural northeast Thailand( 2001)This study examines dying, death and grief among the people of Baan Yang Kham, a rural village in Northeast Thailand. Exploring its social and cultural context, I situate death as centrally important to the people of Yang Kham: despite the rapid social, economic, demographic and epidemiologic change experienced by the villagers, death, its meanings and its phenomena have changed little. I argue that death presents obligations and opportunities which are rooted in the social and cultural worlds of Baan Yang Kham. The rites of death provide opportunities both for the merit-making activities essential to auspicious transformation and rebirth, and as a means of engaging traditional constructs of community to re-emphasise the world of the living. The phenomena of death are laden with symbolism and retain a pivotal place in village life. Medical anthropology provides the disciplinary framework for this study, which focuses on the deaths of seven adults, each of whom died from cancer or AIDS. Employing the qualitative methodology of ethnography, I draw not only on the formal methods of interview and observation, but also the informal, ongoing relationships and experiences developed during a twelve-month fieldwork period when I lived in the heart of the village. Much of the data is presented in narrative form, and I employ the voices of the villagers and “thick” ethnographic description to contextualise dying and death. I acknowledge the value-laden nature of qualitative research and clearly position myself as researcher, identifying myself and my background, and my relationships within the village. I present Northeast Thailand as a region that has always experienced change, and emphasise the environment of transition which underpins social life in the village. In explaining chronic disease, its treatment and its care, the people of Yang Kham engage both traditional and modern discourses, employing biomedical and traditional treatment and situating the care of dying people in a social world of connectedness and obligation. However, death and its cosmological context, is located in traditional cultural understandings of transformation and transmigration of human consciousness. While at one level, Buddhist teachings about the impermanence of the body and the inevitability of death influence individual response and communal ritual, constructions of the unseen spirit world saturate the liminal period of death with danger and fear, affecting the experience and expression of grief. Because of its perceived contagion and offence, I present separately the issues in dying and death from AIDS. The thesis concludes with my telling of my own story of loss and grief in Baan Yang Kham.
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ItemThe applied ethics of community involvement in HIV vaccine development( 2009)Since the emergence of HIV/AIDS as a global pandemic in the 1980’s, the focus of the scientific community has been to firstly identify, then treat and ultimately find a cure for, this disease. This has proven to be challenging and far from realistically achievable by the scientific community or the communities affected by this disease. A funding allocation from the National Institutes of Health in the United States came to a consortium in Australia seeking to develop a prime-boost preventative HIV vaccine. The consortium included members of the Australian HIV/AIDS Partnership. This partnership emerged from a particular set of historical contexts and included affected community. The Australian Federation of AIDS Organisations was the affected community representative on the consortium. This thesis sets out the contextual and ethical reasons for this arrangement, and explores how this unusual partnership worked in practice, with a view to identifying its broader implications. HIV vaccine development, and AFAO’s role in that development, is complex and multifaceted. The consortium existed within a particular social context which I explore by describing the social history of HIV in Australia. The search for an HIV vaccine is difficult and complex work requiring significant effort and I describe the challenges involved in such an enterprise. Biomedical research more generally exists in the context of international and national research documents which govern the way in which researchers may conduct human experimental trialling. I discuss these documents and highlight the underlying ethical principles. This research involved 9 interviews with 7 key informants who were members of the consortium. The accounts were analysed following a grounded theory approach, utilising the sensitising concepts outlined in the discussion of the social history of HIV in Australia, the science of HIV vaccine development and the general and specific ethical principles. Following this methodological approach, I identify common themes in the data and discuss the results in greater detail, paying particular attention to the ways this particular social practice plays out in practice and the key ethical considerations arising from the accounts. I also explore the risks, costs and benefits to AFAO of its involvement in the consortium. The overall aim of this research is to understand how practicable, feasible and effective community involvement was in this consortium. Finally, I come to three major conclusions. First, that the consortium is an emerging social practice, which is the intersection of three established social practices; biomedical research, the affected community and the Australian HIV/AIDS Partnership. Using Langford’s criteria for a social practice, I demonstrate the social practice of the consortium was clearly made up of members who were aware of each other’s intentions and beliefs. It was clear from the commencement of the consortium’s project that the consortium was directed at the overall purpose of developing an efficacious preventative prime-boost HIV vaccine. The unique history and tradition of the social practice of the consortium is slightly less clear but what the accounts of the informants demonstrated is that the histories and traditions of the Australian HIV/AIDS Partnership approach and biomedical research, in particular, were a significant influence on most of the consortium members. So much so, that the consortium adopted that unique history and tradition and it was this factor, perhaps above all others, that facilitated AFAO becoming a full partner in the vaccine development enterprise in the first place. Importantly, my research theoretically extends the notion of shared ways of seeing and doing within a social practice. The socialisation aspects are highlighted very strongly within the accounts. Second, AFAO’s involvement was highly concordant with the core principles of the Good Participatory Practice Guidelines for biomedical HIV prevention trials document, and it influenced important protocols within the consortium, but there were also conflict of interest issues for AFAO to manage. Third, the different approaches for community involvement in biomedical HIV prevention trialling (the partnership approach and the Community Advisory Board approach) each has strengths and weaknesses and should be carefully considered in light of the context of the trialling to be conducted. This thesis concludes with a series of recommendations for future biomedical HIV prevention trials.