‘Upstream/downstream’ – locating the ‘social’ in health promotion and HIV/AIDS in south africa?

ABSTRACT Strengthening HIV prevention remains an urgent global health priority. The problem is that ‘advancement’ in HIV prevention often stands for the development of biomedical technologies or interventions. Theories and practices of health promotion have been advocating a shift from a biological/medical preventive focus to a more social one; from the level of individuals to organisations, communities and broader social policy. It seems, however, that in practice a real shift in the desired direction remains an elusive goal. This article explores HIV/AIDS health promotion efforts in South Africa, focusing on the traditional dichotomies of bio–social; individual–society and downstream–upstream, in order to draw attention to associated complexities that should be taken on board. Relying on evidence from South Africa (past and present), the main thesis in the article demonstrates the limitation of these efforts, and argues for a more comprehensive approach along a flexible continuum of options, with a focus on the ‘social’. The main argument advanced here, rests on the premise that there is a lack of fit between the forces that shaped the epidemic and efforts to prevent its rapid spread, despite the existence of an adequate sociological understanding of these forces. A model based on the critique developed in the article is presented as a ‘way forward’, suggesting solutions along a flexible ‘continuum of options’ that take the ‘social’ on board. While the focus of the article is on HIV/AIDS, the insights offered in the final thesis and the way forward should prove useful for health promotion efforts in dealing with other health problems as well.