Familiar Failures: The HIV and COVID-19 pandemics

What COVID-19 analogies to HIV get right and wrong

Esther Moon

By: Abigail Cartus and William Goedel

COVID-19 is the most severe and widespread pandemic to reach the United States in over 100 years. However, to make sense of COVID-19, many scientists, health officials, communicators, and laypeople have looked to the more recent past — specifically to the HIV pandemic, which emerged in the early 1980s and quickly spread across the globe, devastating communities worldwide. In the four decades since HIV emerged, over 34 million people have died of the disease, including over 700,000 Americans. We can learn a lot from the collective experience of HIV, but learning those lessons requires an honest discussion of the similarities and differences between the two viruses and the pandemics they unleashed.

Both viruses — HIV and SARS-CoV-2 — spread through human to human contact, but they do so very differently. HIV spreads when an uninfected person comes into direct contact with an infected person’s body fluids like blood or semen (commonly via sexual contact or via sharing syringes used to inject drugs). COVID-19, on the other hand, is airborne, and spreads when an uninfected person inhales an infected person’s respiratory droplets (by talking, singing, shouting, coughing, or simply breathing in close proximity).

These differences have important implications for public health. For example, contact tracing is a common public health tool used to track (and ultimately stop) outbreaks of infectious diseases. We define who is a “close contact” differently with both diseases. A “close contact” of someone who has tested positive for HIV is likely to have been a sexual or drug-using partner — a very close or even intimate contact, which has both emotional and public health implications. In contrast, COVID-19 spreads through less direct and intimate contact; a “close contact” of someone who tests positive for COVID-19 could be anyone that person encountered at home, at work, at school, at a party or social gathering, on public transportation, or in a variety of other settings. When COVID-19 is so prevalent that contact tracing capacity of local public health departments becomes overwhelmed, it can become essentially impossible to pinpoint where or how a person contracted COVID-19. Because of the different routes by which the two viruses spread, everyone is at risk for COVID-19 in a way that not everyone was/is at risk for HIV.

“ Because of the different routes by which the two viruses spread, everyone is at risk for COVID-19 in a way that not everyone was/is at risk for HIV.”

There are also many strategies for risk reduction for both viruses. Barrier methods exist for both HIV (e.g., condoms) and COVID-19 (e.g., face masks). Effective treatments (antiretroviral therapies) and prophylaxis (pre-exposure prophylaxis or PrEP) now exist for HIV, just as effective treatments and vaccines now exist for COVID-19. The concept of “harm reduction,” with a long and complex history in the USA, also has relevance for both pandemics. In the early 1980s, as the HIV pandemic accelerated, harm reduction began to take on the meaning it has today as harm reduction practitioners advocated for safer ways to inject and use drugs and have sex (rather than focusing on total abstinence). Harm reduction has been a critical framework for orienting public health responses to the HIV pandemic; in addition to the risk reduction strategies already mentioned, harm reduction approaches to HIV center strategies for safer drug use (e.g., syringe exchange programs), safer sex, and above all, the perspectives and needs of the people most affected by or at risk for infection.

Harm reduction has also been repeatedly invoked in relation to COVID-19: for example here, here, and here. It is worth asking, however, in what sense “harm reduction” is applicable to COVID-19 transmission, and whether invocations of harm reduction in relation to COVID-19 remain true to the spirit and purpose of harm reduction first espoused by activists in the 1980s.

Specifically, due to its mode of transmission and due to state and government failure to take measures to control the spread of the virus, COVID-19 is, as much as anything else, an occupational disease — it spreads at work in addition to private settings. We know that Black, Latinx and Indigenous people are disproportionately impacted by this. The “harm reduction” conversation around COVID-19, however, has focused on the desires of individual people to engage in specific consumer or leisure activities, such as socializing or choosing not to wear face masks in public settings. In doing so, it has sidestepped real questions of power and accountability. Why did COVID-19 rip through meatpacking plants (in one case, Tyson managers organized a betting pool to wager on how many employees would be infected)? Who is responsible for the shortages of personal protective equipment in US hospitals that contributed to over 3,000 deaths among health care workers? What is proper accountability for the industry groups that lobbied for reopening indoor dining even as line cooks absorbed the highest COVID mortality of any occupational group in California? Or for the many industry groups that lobbied against an Occupational Health and Safety Association (OSHA) Emergency Temporary Standard for COVID-19 — which, when finally issued weeks behind schedule, covered only health care workers? Does using the language of behavioral harm reduction focus attention on the institutional failures that created the COVID-19 crisis, or distract from them? Since working is a risk factor for COVID-19, and since most people in the United States do not have a choice as to whether to continue working in the absence of a strong social safety net, removing masks or encouraging vacation (especially during the peak of the pandemic when vaccines were not widely available) is not an appropriate use of “harm reduction” and does not account for how this kind of “harm reduction” is not a choice available for huge numbers of US workers.

“Does using the language of behavioral harm reduction focus attention on the institutional failures that created the COVID-19 crisis, or distract from them?”

This brings us to a deeper and more disconcerting parallel between COVID-19 and HIV: state failure and official indifference resulting in what Friedrich Engels called “social murder”, when the holders of social and political power place working people “in such a position that they inevitably meet a too early and an unnatural death.” The unstated official policy of social murder was evident during the AIDS emergency, which then-President Reagan did not even publicly acknowledge until 1985, several years into the crisis in the US. The unstated official policy of social murder is also evident during COVID-19: in the Trump administration’s denial and minimization of the threat, in state- and national-level “herd immunity via natural infection” approaches, and in the discussions which treated risk of severe COVID-19 as a problem only for older or medically complex individuals. The Biden administration has continued the Trump administration’s approach to COVID-19 in effect if not in rhetorical approach. The narrow focus on health care workers in the Occupational Safety and Health Administration’s (OSHA) recently issued emergency temporary standard is one such example — which, again, came late, after substantial revision and intense lobbying. These new regulations — implyies that the only occupational risk for COVID-19 worth considering is among those directly caring for patients with the disease, while ignoring and normalizing the occupational risks that put these individuals in need of care in the first place.

“Social murder”: when the holders of social and political power place working people “in such a position that they inevitably meet a too early and an unnatural death.”

Narrowly applying the principles of harm reduction to minimize individual-level discomfort during the COVID-19 pandemic is both reductive and inappropriate. The harm reduction praxis developed in response to the HIV pandemic is two-pronged — first, providing the tools needed to make safer, less harmful choices in the moment and second, working to demolish the structures that create the conditions of harm in the first place. This is a harm reduction is that providing a sex worker with a condom while fighting for their right to earn a living wage without fear of violence or criminalization. It is a harm reduction that provides a person who injects drugs with new syringes while advocating for a safe, decriminalized drug supply. It is not a harm reduction that tells members of the public to get comfortable with a “new normal” of sustained viral transmission, illness, and death — whether from HIV or from COVID-19. As the COVID-19 pandemic continues, our harm reduction work must not only provide a mask and a vaccine to every worker, but also strengthen their union and give them the power to demand working conditions where COVID-19 cannot spread, establish strong workplace standards for COVID-19 protection, disburse unemployment insurance and other forms of financial relief, and advocate for appropriate non-pharmaceutical interventions to control spread. While we reduce individual harms, we need to turn our attention to the structures that establish and perpetuate these harms in the first place. These components of harm reduction praxis are not separable.

Hopefully, promising developments globally and coordinated efforts at home will prevent COVID-19 from following the same trajectory of HIV: many years into the pandemic, prophylaxis and treatment are available only to the rich and privileged, while the disease remains endemic for everyone else and particularly for intensely marginalized, criminalized, and socially vulnerable communities. What harms we do (or don’t) reduce now — from the individual to the structural level — will make the difference.

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Public health research that is people centered, place oriented, & data driven. We study drugs, infectious diseases + intersecting epidemics.

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