HIV Prevention Knowledge Base
Structural Interventions: Interventions Addressing Policy Factors
Confirming the Impact of HIV/AIDS Epidemics on Household Vulnerability in Asia: The Case of Cambodia
The ability of individuals and household members to reduce the risk of HIV depends, in part, on their economic and social well-being. For many households, the impact of HIV and AIDS has increased economic distress and vulnerability. HIV and AIDS household impact studies can inform policy by illuminating groups at greater risk to future HIV infections due to declining economic conditions. Similarly, impact studies point out how the epidemic can undermine national development policies and increase poverty levels.
Debate has occurred, however, about the implications of economic impacts of HIV and AIDS on households. In this study, 1,000 households living with or affected by HIV and AIDS in both urban and rural areas of Cambodia were assessed to determine the impact of the epidemic, compared to households not affected by HIV and AIDS. The study found that affected households spent more on medical care and funerals and cut other spending, such as on food. Income levels of affected households were lower, because of the loss of an income earner, than non affected comparison households. HIV and AIDS affected households sold assets, borrowed money, and children were more likely to work than comparison households.
Changing Cost of HIV Interventions in the Context of Scaling-Up in India
As prevention interventions are scaled-up or new approaches are adopted, policy makers and program planners need information on the cost of such programs and the programs’ cost-effectiveness, a comparison of the expenditures (costs) and outcomes (effects) of two or more courses of action. This article examines changes in the cost of scaling-up a counseling and testing (CT) program and a sex worker program in the Andhra Pradesh state of India. The cost of serving one client for CT declined as the program expanded and served a growing number of clients. The cost of the sex worker program increased as it expanded, primarily because the program added new service components and increased staff salaries. The authors suggest that cost-effectiveness data can inform policy makers and program planners as they seek an effective combination of HIV prevention interventions.
Understanding the Politics of National HIV Policies: The Roles of Institutions, Interests and Ideas
The authors argue that “politics, ideology and ignorance have proven more influential on policy than epidemiology or technical best practice.” Their analysis of the literature shows that little research has been done to understand the politics of HIV policies. The literature provides only limited insights into the ways policy change occurs. The complexity of policy change makes it difficult to predict the outcome of a given policy change intervention. Thus, informing and influencing policy development often happens without an awareness of techniques for shaping the policy process. These techniques are especially important in targeting policies that will affect HIV prevention programs for most at risk populations. The paper argues that institutions, especially those with more democratic tendencies, play a role in the nature of policy development. Likewise, ideas, arguments and evidence and their sources are important in whether policies are considered. Finally, the perceived interests of policy influencers and policy makers are critical in policy change. A set of country-specific tables provide details about countries’ respective political processes and influences on policy development.
The Terrain of Health Policy Analysis in Low and Middle Income Countries: A Review of Published Literature 1994–2007
The article is the first review of literature that analyzes the health policy processes in low and middle income countries. Although not specific to HIV prevention, the article provides insights into factors for successful policy adoption in the HIV and AIDS field. Existing literature demonstrates that politics, political processes, and power are central elements in the formulation and implementation of health policies. Policymaker and bureaucratic support are critical components in both the design of policies and whether policies are effectively implemented. Follow-on regulations, guidelines, and staff engagement are also important elements in assuring policies meet their objectives.
Implementing 100% Condom Use Policies in Indonesia: A Case Study of Two Districts in Jakarta
The report examines factors that determined willingness to implement policies in two districts in Jakarta, Indonesia. The focus was on implementing the 100% Condom Use Program (CUP) endorsed in the Indonesia National HIV and AIDS Strategy. Data were collected primarily through key informant interviews. One district had adopted legislation to implement the national policy; the other one had not. Among the reasons for non-implementation of the CUP were stigma and discrimination against most-at-risk groups by local policy makers; the frequent transfer of staff involved with HIV and AIDS issues; and limited interest in those issues among some members of the District AIDS committees. A fourth reason was the differing beliefs and values of legislators and program staff on the meaning of “condom promotion” with groups involved in high risk sex. The researchers found that opponents to the CUP felt that the policy would “encourage pre- or extra-marital sex, which are considered `immoral.” Even supporters of the program were reluctant to support the national policy too openly, worrying that their support would be seen as “admitting sex work exists and thereby endorsing infidelity.” Such negative views of and trepidation about the consequences of local implementation of the national policy prevented the development of guidelines for policy implementation. Finally, there were no strong constituencies at district levels to advocate for implementation of the CUP. The study concludes with suggestions for building an advocacy strategy to inform and influence policy implementation.
Making the Money Work for the People: An Analysis of 2006 Budget Allocations and Debt Relief Gains to Fund HIV and AIDS Interventions in Nigeria
In 2005, Nigeria achieved major debt relief, with the understanding that savings on the cancelled debt repayments would be applied to poverty, health and related programs. This study monitors the efficient and effective use of resources arising from debt relief repayment toward programming for HIV and AIDS. The analysis found that 4.5 percent of total debt relief allocations went to HIV and AIDS programs, with the remaining being spread out over nine others target programs. Other sources of funding for HIV and AIDS programs were tapped by various line ministries, but these nine remained modest. The report argues: “Many African countries have been observed to reduce local spending on HIV and AIDS once there are new in-coming funds. With the new money coming from [debt relief], Nigeria seems to be towing the line by reducing its annual health spending from its core budget.”
Environmental–Structural Interventions to Reduce HIV/STI Risk among Female Sex Workers in the Dominican Republic
The article reports the findings of two environmental–structural approaches to HIV prevention among female sex workers (SW). The first approach was to mobilize community initiatives; the second approach combined community mobilization and government policy initiatives. Rates of condom use increased In both study sites, but in the policy/community site a much higher percentage of SW rejected clients’ unsafe sex requests. Also, there were larger decreases in sexually transmitted infections (STI) in the policy site than occurred in the community sites. The authors conclude that combining two or more structural interventions can have a significant impact on prevention outcomes among targeted groups.
A History of State Action: The Politics of AIDS in Uganda and Senegal
Both Senegal and Uganda are frequently cited for their proactive responses to the HIV and AIDS epidemic. The article examines some of the state-led political and policy factors that contributed to those effective national responses. The factors include early adoption of sentinel surveillance systems that provided evidence of increases in HIV rates. Both countries aligned themselves with international agencies in order to learn from a wider community and to access financial resources. Early on, both countries encouraged civil society and religious leaders to mobilize and develop prevention and care programs. Finally, each country had a relatively liberal policy toward the media, which enabled messages about HIV and AIDS to reach people across the country.
How Uganda Reversed Its HIV Epidemic
The authors, describing the prevention programs and activities implemented between 1987 and 1994 in Uganda, advocate for increased funding for multi-layered in-depth HIV prevention campaigns. In 1986, the national government of Uganda formed the National Committee for the Prevention of AIDS (NCPA) and the National AIDS Control Program (NACP) while entering into an emergency mode of accelerated program development. Some of the first strategies of the National AIDS control plan involved an aggressive educational HIV prevention campaign (subsequently becoming the center piece of activities), safety regulations on blood transfusions, health worker safety campaigns and in-depth case surveillance and seroprevalence studies. Following a comprehensive program review, the Government of Uganda implemented ten main recommendations and increased its annual expenditures of $1 to 4 million to $18 million over the first three years. The authors stress that the intensity and decentralization of the educational HIV prevention campaign, encompassing all modes of transmission, the level of involvement of all sectors as well as extensive financial and political support led to extensive behavior change at both the individual and public health level.
Using Incentives to Encourage AIDS Programs and Policies in the Workplace: A Study of Feasibility and Impact in Thailand
Workplaces are frequently cited as targets for expanding HIV prevention initiatives. However, relatively few companies in most countries have adopted HIV and AIDS workplace policies or instituted HIV prevention programs. A study was undertaken in Thailand to assess whether companies would respond to financial incentives for adopting such policies and programs. Companies were offered a 5 to 10 percent reduction in insurance rates and public recognition for social responsibility if they adopted a workplace HIV policy and prevention program. Only one percent of all the companies originally invited to participate actually did so. The others felt the incentive was too small to compensate for the costs of developing and implementing a prevention program. For most companies that did join the initiative, the study found that the financial incentive made little difference. Rather, the companies that joined in the initiative did so more because of the increased awareness and peer momentum associated with the project. The study also found that while the number of company workplace policies increased, employees of the companies showed little change in knowledge of HIV or in their risk behaviors. Thus, without a concerted effort toward implementation, HIV workplace policies remained primarily paper exercises.
An Audit of HIV/AIDS Policies
The audit covers policy responses and gaps in Botswana, Lesotho, Mozambique, South Africa, Swaziland, and Zimbabwe. For each country, a short overview of elements of the national HIV and AIDS policy, and other related policies, are provided. Given the date of the audit, prevention was a strong focus of most national policies, although one chapter of the report deals with national drug policies. A very useful chapter examines programmatic implementation of policies, identifies gaps and suggests initiatives to correct the gaps. The analysis includes some discussion of the roles of various actors in designing policies.
Structural Interventions to Reduce HIV Transmission among Injecting Drug Users
This article distinguishes structural-level interventions from individual- and social-level interventions. The article provides evidence that structural-level interventions, such as increasing legal access to sterile needles and syringes, are associated with “large effects” in decreasing HIV risk behavior among injecting drug users (IDUs). While individual and social-level interventions attempt to affect a person’s knowledge, attitudes, motivations, and social interactions; structural-level interventions seek to modify the environment that facilitates HIV risk behavior. Over-the-counter sales of sterile injection equipment at pharmacies have resulted in higher usage of sterile injection equipment among IDU populations in France; Glasgow, Scotland; and the state of Connecticut in the United States. The review also cites national studies in the United States and Australia that associate syringe-exchange programs with a reduction in HIV transmission among IDUs without increasing drug use in the general population. To maintain the effectiveness of these interventions, the review advocates for programs that do not limit the allowable number of syringes exchanged, and for including drug users in the design and implementation of risk reduction programs. Government programs that aim to reduce the distribution and usage of illicit drugs should not oppose structural-level HIV prevention programs such as needle exchange, but instead should work in tandem with interventions that reduce HIV transmission.
Ten Reasons to Oppose the Criminalization of HIV Exposure or Transmission
The criminalization of sex work and HIV transmission has appealed to lawmakers in many countries. Specific laws criminalizing forms of HIV transmission have been adopted in recent years. Initially intended to protect people, especially women, from willful transmission, such laws are often vague and ambiguous. Also, in many countries, sex work and injecting drug use linked with sex work are illegal. This document sets out ten arguments why criminalizing HIV exposure undermines prevention work; presents a cogent set of arguments against criminalizing transmission; and offers alternatives to strengthen prevention efforts that will be far more effective and successful in protecting people from transmission.
Evolution of Thailand’s Strategy to Cope with the HIV/AIDS Epidemic
The article describes how Thailand responded to HIV and AIDS and looks at the influences and some of the decision-making processes that informed the country’s HIV and AIDS policies and programs. The author notes, “the evolution of the policy may be categorized into three main phases–confrontation with the new epidemic; creation of unified alliances; and alleviation of the consequences of HIV and AIDS.” Each stage is described, although many of the details of the political and socioeconomic context are not included, giving the impression of a very centralized and top-down response by Thai authorities.
A similar but more general article by Phoolchareon entitled “Thailand” can be found in Fighting a Rising Tide: The Response to AIDS in East Asia. Tadashi Yamamoto and Satoko Itoh (eds). Center for International Exchange, Tokyo, (2006), pp. 247-265.