Engaging with HIV care systems: why space, time and social relations matter

Care trajectories of people living with HIV (PLHIV) in Southern and Eastern Africa have drastically changed over the past two decades as a result of significant funding to support health systems’ responses to HIV. Global expansion of access to diagnostic procedures and treatment has extended and improved the health and well-being of PLHIV, and modified the scope of HIV care. In the absence of treatment, testing for HIV once represented a critical, yet stand-alone, moment in an uncertain and fragmented care pathway. Early emphasis on voluntary testing acted as a kind of ‘ confessional technology ’:1 a means to ‘know your status’ and to contribute to the management of collective risk. As antiretroviral therapy (ART) became more widely available, HIV testing came to be seen as the gateway for timely access to treatment, with the weight of responsibility for ensuring the care continuum falling to health providers. Global strategies to meet specific HIV-related targets, often described in the bureaucratic language of service delivery—roll-out, scale-up, decentralisation and integration—entailed reconfigurations of the health workforce implementing HIV programmes. At the same time, securing commitment to lifelong adherence to ART from PLHIV translated the promise of universal test-and-treat programmes in many high-burden countries into renewed emphasis on responsibilisation of patients and their families.2 The special issue brings together a series of papers that provide critical and timely inquiry into a specific moment in the historical trajectory of HIV care. As such, it is worthwhile recalling how spatial, temporal and relational parameters of the current drive towards universal test-and-treat models have evolved. In the course of the past two decades, HIV testing and counselling procedures have undergone substantial revision. Tests are rapid and routinised, and take place outside of the clinic: new sites for testing represent a continuum of social spaces, spanning the intimacy of homes and domestic …