Fillieule, Olivier

Horat, Simone

Voegtli, Michael

Serveur académique lausannois

The Structuring of HIV/AIDS Policy in Switzerland: A Socio-Historical Analysis (1985-2005)  Background: The historical phases of HIV/AIDS policy in Switzerland since the beginning of the epidemic to the present were explored. For each of the five phases, an analysis is provided of the social properties of members involved in local AIDS groups within the Swiss Aids Federation (SAF), which are linked with transformations in HIV/AIDS policy.   Methods: A quantitative analysis via a self-administered questionnaire was sent to volunteers and ex-volunteers of eight associations during the Summer of 2005 (n=363, answer rate 20.2%). Semi-structured interviews were arranged with activists of the SAF, local AIDS groups, and members of the Federal Office of Public Health (FOPH) (n=41), and a study of the records of the SAF and of local AIDS groups was conducted.    Results: Five phases were distinguished, according to the general trend shown by Rosenbrock et al. in Western European countries  (See R. Rosenbrock, F. Dubois-Arber, M. Moers, P. Pinell, D. Schaeffer, & M. Setbon (2000), “The Normalization of AIDS in Western European Countries”, Social Science & Medicine, 50, 1607-1629).  The first phase (1982-1986) refers to the emergence of exceptionalism – that is the major commitment of gay activists to create the Swiss Aids Federation in June of 1985 with the support of the FOPH. The FOPH became a member of this association. Prevention was first targeted toward “men who have sex with men” (MSM) and activists promoted Safer Sex and the use of condoms by creating a new brand specifically dedicated to gay men (“Hot Rubber”). Local groups began cropping up in Zurich, Basel, Bern, and Geneva at the end of the year. These local AIDS groups were mostly created by gay activists who were already committed to various gay associations, and who utilized the infrastructure of gay associations to ease the creation of such groups. In 1986, heterosexual women and a few heterosexual men began to join these groups. Nevertheless, gay male volunteers remained the most numerous in the fight against the epidemic (See Figure 1).  During this phase, the majority of those who committed themselves to the fight against HIV/AIDS were volunteers. When we examined the sociodemographic characteristics of volunteers actively involved during this first phase, several tendencies were observable. Due to the small number of cases in this first generation, we should not draw a hasty conclusion about this data, even if the sample gathers around 20 percent of the total amount of volunteers for 1985 and 1986 (in Zurich, Bern, and Basel). Compared with generations in subsequent phases, this first generation of activists exhibited a higher rate of previous involvement in other associations (mainly gay organizations) and a higher rate regarding their proximity to the disease (i.e., these volunteers were either HIV-positive themselves or had personal relationships – as lovers, family members, friends, etc. – with those affected by the disease). Activists mainly worked in the socio-medical sector (see Table 1).     The second phase (1987-1990) refers to the consolidation of exceptionalism. During this phase, the investment of Swiss authorities, both financially and politically, became more clearly visible (see Figure 2). The set up of ELISA screening tests contributed to improving the public image of the epidemic, showing its dramatic extension (see Figure 3).  In collaboration with the Swiss Aids Federation, the FOPH launched the STOP AIDS campaign in 1987. The campaign symbolized the moment HIV/AIDS became politicized in Switzerland, with clear opposition in the Swiss Parliament by conservative groups against condom use and in support of fidelity. A special division (AIDS division) was also created inside the FOPH.  Within the Swiss Aids Federation and within its local groups, this period was characterized by instability. On the one hand, test results showed the diversity of patient groups (IV drug users, sex workers, heterosexuals, young people), affected by the epidemic, provoking an expansion of preventive actions as well as actions against HIV/AIDS-related stigma. On the other hand, the increasing number of people concerned about HIV/AIDS stimulated the diversification of actions (in particular, the support and accompaniment of People Living With AIDS (PLWA). Consequently, a greater number of people began to join AIDS associations. New entrants shared common assumptions and goals with their predecessors, but they also differed in important ways. Broadly, two main conflicts were observed. First, heterosexual women raised objections to the emphasis placed on HSH prevention and requested specific actions for women. Second, professional workers began making more of a commitment to the HIV/AIDS cause (coming from socio-medical sector, see Table 1, professional sector). Consequently, the first wave of formerly committed activists begin to roll back, mainly gay men (see Figure 1).  Local AIDS groups were created in other federated States (cantons), such as, concerning our sample, in Geneva (Groupe sida Genève, founded by Dialogai activists and by members of Aspasie, a sex workers association) and in the canton Jura (Groupe sida Jura). All of the local AIDS groups began to secure funds from the federated States. At the same time, the first specific self-support groups were created in Lausanne (Sid’action, 1989), and then at the federal level (PWA Switzerland).     During the third phase (1991-1996), known as exceptionalism crumbling, the fight against HIV/AIDS became more specialized and even more professionalized. After several crises in phase two, the SAF began with a new team to develop a long-term AIDS program (called “Vision”, 1994). Prevention for migrants through peer educators came to be one of the central focuses of the fight against HIV/AIDS, including prevention for MSM and IV drug users. Positive HIV test results, at their highest rate in 1991, began to decrease during this phase. Social workers replaced volunteers and long-term committed activists in the leading of local associations and in the heading of the SAF. In 1996, an important internal crisis dividing professional workers and remaining long-term committed activists provoked the rolling back of the last ones. Nevertheless, new volunteers continued to join AIDS groups and fight against HIV/AIDS, acting under the supervision of professional workers. In 1996, the SAF and its local groups contended for access to HAART, which was postponed by official registration before its authorization and refunded by medical insurers.      The fourth phase (1997-2001), called normalization, followed the introduction of HAART. It was characterized by the intent of some public authorities in the FOPH to promote a new strategy (called the “transfer strategy”) that aimed to integrate HIV/AIDS associations into other general socio-medical structures. This strategy relied on the downward trend of positive HIV test results, on the transformation of the public image of HIV/AIDS, and on the decrease in State funding to the AIDS division of the FOPH. After much opposition, members of the SAF agreed to maintain the autonomy of the organization, even if the SAF could not avoid a drop in its funding (see Figure 2). During this phase, members of the SAF and of the local AIDS groups attempted to adapt prevention messages to the new situation following the introduction of HAART.    The fifth phase (until 2002) was characterized by the failure of the transfer strategy, and by a trend toward political remobilization in the fight against HIV/AIDS. In 2001, the SAF adjusted to the drop in State funding by modifying its strategy in order to include preventive actions for all sexually transmitted diseases (STDs). At the same time, this association attempted to become increasingly financially independent from the State (see Figure 2).  In 2001, positive HIV test results began to increase again, with a growth of 25% between 2001 and 2002. More precisely, the increase among MSM was particularly strong (148 positive HIV test results in 2001, 191 in 2002 and 236 in 2005). The FOPH and the SAF strengthened preventative measures for this group. In the same way, local AIDS groups began developing new strategies for MSM. In Zurich (ZAH, Checkpoint) and Geneva (Dialogai, Checkpoint) attempts were made to integrate HIV prevention in a more global way, and to offer voluntary counselling and testing. The main idea behind these projects (in Geneva, Dialogai, Projet Santé Gaie) was to adopt a more complete view of gay health-related topics, with HIV/AIDS issues being part of a broader endeavour to improve gay men’s health. Among volunteers, some ex-volunteers began to join AIDS groups again, and to act in these new programs. According to sociodemographic characteristics of volunteers, the particularity in this phase is the fact, still being studied, that the number of young people involved in the fight against HIV/AIDS increased compared to the previous phases.   1985-1986 (n=21)1987-1990 (n=48)1991-1996 (n=110)1997-2001 (n=78)2002-2005 (n=78)All (n=363)Heterosexual women 19 56 53 55 51 49Homo- or bisexual women 5 15 5 5 6 6Heterosexual men 24 13 19 13 22 17Homo- or bisexual men 43 17 23 23 21 26Don't know 10 0 1 4 0 2<18 year olds 5 0 4 1 3 218-25 year olds 19 10 15 10 23 1526-35 year olds 33 40 39 35 27 3436-45 year olds 24 31 20 27 28 2446-55 year olds 14 8 18 17 14 1556-65 year olds 0 6 2 6 5 4>65 year olds 0 0 1 3 0 1No answer 5 4 1 1 0 5Primary School 0 0 2 1 4 2Secondary School 5 2 1 0 1 1Apprenticeship 14 19 30 32 21 26General and technical high school 5 4 6 6 13 8University of Applied Sciences 14 27 27 28 24 26University Degree (BA and MA) 10 27 7 10 12 13University Post-MA 0 0 5 4 4 3PhD 33 10 8 5 6 9Ongoing Studies, Secondary School 0 0 1 0 1 1Ongoing Studies, Tertiary Education 5 0 5 4 6 4No answer 14 10 8 9 8 9HIV-negative 67 67 77 71 74 71HIV-positive 24 6 15 19 13 15Don't know 5 13 6 5 10 7Don't want to answer 5 4 0 1 3 2No answer 0 10 2 4 0 5None 33 29 33 38 37 33Weak 24 44 45 37 42 40Intermediate 29 23 20 17 14 21Strong 14 4 3 8 6 6None 43 71 73 56 58 58Weak 33 15 18 23 27 20Strong 14 13 7 14 15 11No answer 10 2 2 6 0 10Student/Apprenticeship 5 4 9 7 20 9Medical/social 20 38 37 32 26 31Doctor 25 4 2 1 0 3Liberal profession 0 2 2 1 1 1Media 0 0 2 1 3 1Bank/finance 0 0 4 4 7 4Arts 0 0 2 0 0 1Employee third sector 0 9 5 11 9 7Transports 0 4 0 1 0 1Worker 5 4 7 5 3 5Middle management 10 4 4 1 4 4Private third sector 0 0 4 3 1 2Public service 0 0 1 1 1 1Invalidity Insurance 0 0 2 3 5 2Unemployed 0 2 0 1 0 1Retired 0 2 0 3 0 1Homemaker (M + F) 0 11 4 3 4 4Self-employed 0 2 0 1 0 1Religious 0 0 1 1 0 1Teacher (Primary and Secondary School 0 2 1 5 1 2Teacher (High School and University) 0 0 1 0 1 1Researcher 0 0 0 0 3 1No answer 35 11 14 13 9 17Table 1: Sociodemografic Properties of the Members of eight local AIDS Groups of The Swiss Aids Federation (1985-2005)(In percent for each phase)Education level at the time of joiningSerological status at the time of joiningProfessional sectorLevel of associational committment at the time of joiningSocio-sexual orientation X sexAge at the time of joiningGlobal incidence of HIV/AIDS among acquaintancesFigure 1: Sex and socio-sexual orientation of local AIDS groups volunteers (in percent for each phase)01020304050601982-1986 1987-1990 1991-1996 1997-2001 2002-2005Heterosexual womenHomo- or bisexual womenHeterosexual menHomo- or bisexual menNo answerFigure 2: Financial Resources of the Swiss Aids Federation per year (in Swiss Franks)01'000'0002'000'0003'000'0004'000'0005'000'0006'000'0007'000'0008'000'0009'000'00019851987198919911993199519971999200120032005YearSAF's own funding (donations,membership fees…)Funding from FOPH (State)Figure 3: Number of positive HIV tests results reported by the confirmatory laboratories0500100015002000250030003500198519861987198819891990199119921993199419951996199719981999200020012002200320042005Year of testUnknownFemaleMaleConclusions: This socio-historical approach helps us to understand the changes in policy since the beginning of the HIV/AIDS epidemic in Switzerland. It also allows us to observe the variation of several social properties of people involved in associations fighting HIV/AIDS. To some extent, the fight against HIV/AIDS has become very professionalized, especially since the mid 1990s. Nevertheless, volunteers remain important in the struggle against the HIV/AIDS epidemic. In this vein, the fact that younger people have begun joining volunteer AIDS organizations since 2002 is encouraging. However, the question to know if they will be long-term committed people still remains.  M. Voegtli, S. Horat & O. Fillieule Institute of Political and International Studies, University of Lausanne, Switzerland  E-mail: Michael.Voegtli@unil.ch 

The structuring of HIV/AIDS Policy in Switzerland. A Socio-Historical Analysis (1985-2005)

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The structuring of HIV/AIDS Policy in Switzerland. A Socio-Historical Analysis (1985-2005)

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