Associate Professor of Behavioral and Social Sciences
Tell us about your early training and how you found your way to public health.
I was a history and anthropology major but I got interested in public health through a women’s health class I took my senior year of college. It was life changing. I knew I was interested in women’s issues but I didn’t know there was a field like public health that I could go into.
After I graduated, I was in Pakistan for a year volunteering in an urban community health program. That was my first experience doing public health in a community—seeing how people live in a community and what that’s like, what it’s like to be in a clinic. That experience had a big influence on how I thought about public health, and about communities and global health in particular.
And then you got an MPH.
When I finished my MPH in 1993 I worked in D.C. for John Snow, Inc., a big public health consulting group. I worked on a maternal mortality reduction project with a focus on delivering health services to women in remote places. I travelled and did training workshops in India, Pakistan, and Egypt. This was when I first became interested in adolescent health. It was relatively new at the time, but people were starting focus more on poor reproductive health outcomes among younger women and adolescents.
You didn’t start your Ph.D. right away. You went to South Africa.
I first went to South Africa in 1996 to work with the South African Medical Research Council. I worked with Mark Lurie on a team of HIV researchers. (Professor Harrison is married to Mark Lurie, a native South African and associate professor in the Department of Epidemiology) It was a very interesting time to be there, in both the immediate post-Apartheid period and at the start of the AIDS epidemic. We worked at a rural hospital and research site where some of the early work was being conducted to understand the patterns and causes of the HIV epidemic. This was a good five years before drugs [antiretroviral therapy] were available anywhere. The epidemic was exploding and there was a lot of denial and a lot of stigma, for women in particular. HIV was wreaking havoc in people’s lives and in communities, but treatment was not available until 2001. Even when drugs for HIV did become available in South Africa they were contested and fought and argued about. It took several years for policy to catch up with science the needs of the country.
Why was it especially difficult for women?
It’s so hard for younger women to advocate for themselves. They can’t stand up and say, ‘Give me those drugs’ or ‘Give me access to those resources’ or ‘Make my community safer’ or ‘Help me reduce gender-based violence.’
HIV works like any other infectious disease. The fact that people are disadvantaged in terms of access to resources, that they are living in communities without good access to health care, that gender inequalities are so profound, all of those pieces are so important, and yet people tend to point the finger and say actually, it’s about behaviors. It’s about how people are behaving and who they’re having sex with and how many partners they’re having. All of those things matter, but what really matters is the bigger picture of social determinants.
Of all those factors, you focused your work on gender inequality.
I was interested in writing about and working on the gender inequality piece, and then the flip side of that, which is empowerment. We worked to put frameworks in place for what is now standard practice in global HIV research—positive things like resilience and access to care. There is a USAID/PEPFAR initiative called D.R.E.A.M.S., Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe. That’s the paradigm now for working with adolescent women and girls, but it’s taken a long time to turn around the focus on risk to being more positively focused on helping women help themselves, on helping them to be safe and protected.
You have worked in South Africa from the very beginning of the HIV disaster all the way through today. You’ve witnessed huge changes.
There have been huge changes in South Africa. The most important part of that has been bringing in drugs for treatment. There’s no question about that. That’s affected women in two ways. First, like anyone else, if they’re living with HIV they have access to treatment for free, which is an amazing thing. But women also have access to treatment to prevent mother to child transmission. That was where we first really saw improvement in the epidemic, in the reduction in the rates of mother to child transmission.
Despite these advances, South Africa still has the world’s worst HIV epidemic, with 19% of the adult population living with HIV and 40% prevalence among women in some areas.
Many of the adolescents you work with today have always lived with HIV.
They’re the first generation to come of age living with HIV and it’s a hugely important population. Younger people who will be adolescents in 15 years will be much less likely to be infected in the same way. There is now treatment, and success of treatment, but we still have failure of prevention. I tell students all the time, that’s why I’m still doing this. [PULL QUOTE] The questions are still the same. We’re looking for better answers, but the big picture research questions remain. How do you prevent HIV in this super important population of adolescents and young women?
How are you looking at these questions in your research currently?
I’m involved in two big areas of research at the moment in collaboration with investigators at the University of Cape Town. One is women’s reproductive health and contraceptive use patterns specifically. Why are women are shifting methods? What methods do they prefer and how does that possibly relate to developing better HIV prevention methods? That work is more nascent and I’m very passionate about it.
The second is with adolescents and young women living with HIV. A series of four interlinked studies in Cape Town is investigating how adolescents are living successfully, or not successfully, with HIV as teenagers. These young people were mostly infected from their moms, who were among the group of women denied treatment in the early 2000s. We’ve been conducting qualitative interviews to learn what young people themselves think they need to live successfully with HIV. We also interview parents or caregivers, clinicians, peer supporters, and counselors and then we bring those different perspectives together. We’re looking for strategies, in the form of interventions and programs, to help these adolescents transition into a more successful young adulthood.
What are you finding?
Many young people don’t live a fully disclosed life. Their families know they are living with HIV but people at school might not. Teachers might know, or they might not. This makes treatment adherence, for example, very complicated because even to seem to be on treatment can be stigmatizing. It’s amazing that that’s still the case, but for young people and women especially, it really is. Some of the adolescents in our studies are old enough to have peers who were infected through sexual transmission, so it’s complicated. A lot of them don’t have clear answers about whether they can have safe relationships. Can they have families? Can they have children? It’s a very rewarding project with the potential to have real impact on these young lives.