HIV Exceptionalism: Development through Disease in Sierra Leone by Adia Benton (review)

It was estimated that in 2007 official development assistance for HIV/AIDS totaled $7.4 billion, which was nearly half of all official development assistance for health and four times more than the amount devoted to the next highest funded health area (see Jennifer Kates, Eric Lief, and Jonathan Pearson, U.S. Global Health Policy: Donor Funding in Low- and Middle-Income Countries, 2001–2007, Henry J. Kaiser Foundation, 2009). Judging from data on donor spending, then, it is obvious that HIV is exceptional. Adia Benton’s new book, HIV Exceptionalism, raises important questions about this exceptionalism specifically and targeted health and development programs more generally. Her descriptive analysis of HIV programming in Sierra Leone makes clear the challenges faced by real people connected to HIV interventions, be they program implementers or people living with HIV/AIDS (PLWHA). Her book contributes to the growing scholarship critically examining HIV/AIDS interventions in Africa and highlighting the disconnect between interventions as they are designed and prioritized in corridors of power and how they are implemented and received in sub-Saharan African settings.

HIV Exceptionalism draws primarily from research and related work spanning twenty-seven months over four years (2003–2007) in Sierra Leone, a country with a relatively low HIV prevalence (1.5% of the population, according to the latest UNAIDS estimates). Benton uses ethnographic methods (e.g., attending and participating in support group meetings and HIV awareness activities), in-depth interviews, focus group discussions, and analysis of secondary materials, including reports and policy statements from UNAIDS and other HIV intervention organizations.

HIV Exceptionalism has five chapters (plus an introduction and conclusion). The introduction offers Benton’s definition for HIV exceptionalism: “the idea that HIV/AIDS is always a biologically, socially, culturally, and politically unique disease requiring an exceptional response” (8). It also presents the book’s main argument: “that the collection of HIV interventions that aim to mitigate the effects of the disease among HIV-positive people (particularly those interventions focused on modifying disclosure practices, changing sexual behavior, and encouraging visibility) entrench and reinforce HIV’s exceptional status” (9).

The first chapter vividly describes the Sierra Leonean context—not just the HIV/AIDS situation, but how HIV interventions were implemented in the aftermath of the recently ended civil war and how the postconflict moment shaped perceptions of the risk of increased HIV transmission. Chapter 1 also describes Benton’s methods of data collection. Chapter 2 raises important questions about how HIV is accounted for at the continental, national, and individual levels. One of the ironies Benton subtly presents in this chapter is the dismissal of national-level data inconsistent with expectations of high HIV risk in the postconflict moment while at the same time “vulnerable women” receiving benefits from HIV support groups were expected to have their status “verified.”

Chapters 3 and 4 provide thick description of the impact of HIV programs and policies, particularly the push for disclosure and visibility. These chapters make real the experiences PLWHA face and would be especially useful in illustrating to students the incongruity between Western norms of consent and confidentiality and Western notions of transparency and accountability in the funding of health and development interventions. Chapter 5 examines how we measure good governance in responding to HIV, highlighting how performative acts of “political will” by politicians are directed not at citizens of their states, but instead at the international community.

Benton’s book concludes with a final, biting irony: “Providing exceptional care for HIV to the exclusion of other diseases may serve to reinforce the stigma proponents of these exceptional programs claim to combat” (145). As the world reacts to the recent Ebola crisis in West Africa and witnesses the Ebola-specific, exceptional response by the international community, Benton’s book should raise caution not just about HIV/AIDS interventions in Africa, but also about exceptional interventions of all stripes.

In sum, HIV Exceptionalism will be...