HIV Prevention Knowledge Base
Structural Interventions: An Overview of Structural Approaches to HIV Prevention
Personal, Interpersonal & Structural Challenges To Accessing HIV Testing, Treatment & Care Services Among Female Sex Workers, Men Who Have Sex With Men & Transgenders in Karnataka State, South India
The number of government-funded HIV and AIDS services in India’s Karnataka state has increased greatly from 2006 to 2010. However, only a minority of key populations access these services. A qualitative study was conducted to understand the barriers to accessing HIV and AIDS care, treatment, and support services. The authors conducted 26 focus group discussions (FGD) with a total of 302 individuals in March and April 2008. Participants include female sex workers, men who have sex with men, and transgendered individuals. They found that participants were knowledgeable about how HIV was transmitted and acquired, and were accurate in measuring their own risk level. There was a large degree of fear surrounding an HIV-positive test result. There was also little knowledge about care, support, and treatment services, which hindered them getting tested. A motivator to getting tested, however, was wanting to live a longer and healthier life. Stigma and discrimination from family, friends, and healthcare providers were barriers to accessing HIV and AIDS services, as were fears of breaches of confidentiality. Additional structural barriers to using services included long travel distances, cost for “free” services, and needing an ID card that they did not have. Much needs to be accomplished in terms of educating communities and health workers to reduce the stigma and discrimination reported in the study. The authors recommend that HIV testing services should be integrated into existing clinics for female sex workers and men who have sex with men and trans populations to increase their HIV status knowledge as well as improving the quality of government services.
Can Money Prevent the Spread of HIV? A Review of Cash Payments for HIV Prevention
This systematic review of 16 studies using cash for prevention of sexual transmission of HIV found that the majority of cash transfer programs have targeted adolescents and address such structural risk factors as poverty. According to the authors, cash transfer programs—both unconditional and conditional, which are tied to behaviors deemed beneficial to the individual—are reaching over 1 billion people in developing countries. The majority of studies on these programs have found positive impacts on sexual behaviors, although, due to a lack of biological endpoints in data collection, only one study has been able to make a direct correlation between a decrease in HIV prevalence and cash payments. According to the authors, cash programs either address upstream drivers of risk, such as poverty and education, or downstream behavior change, such as receiving cash for negative results on a test for a sexually transmitted infection. The authors caution that the downstream approach may have unintended consequences, such as violence or coercion, although they also note that to date there is no evidence of social harm to individuals participating in cash transfer programs. The authors note that the amount of payment will likely affect results and that clear and transparent selection criteria are critical. They encourage the use of formative and ethnographic research and pilot studies to determine the most effective structure for cash transfers to reduce risk. The authors hypothesize that cash transfer interventions may also be used to encourage HIV testing, HIV-related health visits, and adherence to antiretroviral drugs. A presentation at the 2012 International AIDS Conference provided evidence that cash transfers helped increase birth registration and school attendance in eastern Zimbabwe.
Property Rights Violations as a Structural Driver of Women's HIV Risks: A Qualitative Study in Nyanza and Western Provinces, Kenya
Fifty in-depth interviews were conducted to gain perspectives on how property rights influence primary and secondary HIV transmission. Participants were recruited through a community-led land and property rights development project in rural Kenya, where HIV prevalence is high and property right violations are prevalent. Interview themes consisted of questions on what happened to women when their husbands died, the reasons for property rights violations, and the perceived links between property rights violations and HIV transmission. Outside interviewers unknown to the participants conducted the interviews in the local language, for about 1.25 to 2.25 hours. They found that women would often “disappear” shortly after their husband died. Oftentimes, the husband’s family blamed the wife for giving HIV to their son/brother so felt that she did not deserve the property or assets. The interviewees clearly saw the link between property rights violations and increasing HIV prevalence rates in the community. Women left their homes in search of shelter, food, and a livelihood. If she were HIV-positive, this made the continuation of care and treatment almost impossible. If she were HIV-negative, she would be vulnerable to infection from partners whom she would not otherwise have had if she were able to keep her property. The authors conclude that securing women’s property rights could decrease her, and the community’s, vulnerability to HIV infection and transmission.
Is Food Insecurity Associated with HIV Risk? Cross-sectional Evidence from Sexually Active Women in Brazil
Studying how food insecurity contributes to increased HIV risk among 12,684 sexually active Brazilian women, the authors conclude that severe food insecurity with hunger is associated with lower levels of condom use. Using a multi-variable logistic regression model, the study examined the associations between food insecurity, condom use, and symptoms of sexually transmitted infection. The research revealed that severe food insecurity with hunger is associated with statistically significant reduced odds of consistent condom use and condom use at last sexual intercourse, and with self-reported itchy vaginal discharge, most likely indicating the presence of a sexually transmitted infection. The study employed a culturally adapted 18-item food insecurity scale measuring a wide range of human experience with food insecurity, from food security to severe food insecurity with hunger. According to the authors, the findings add to the abundance of new data that highlight the importance of food insecurity in relation to women’s risk of sexual violence and exposure to HIV. They recommend that HIV prevention programs target high-risk women through food supplementation or livelihood interventions to help equalize gender-based bargaining power within households. They stress that to be consistently effective in reducing HIV risk, biomedical, individual-level cognitive, and behavioral interventions for HIV prevention must also address structural factors, such as food insecurity.
Effectiveness of Interventions for the Prevention of HIV and Other Sexually Transmitted Infections in Female Sex Workers in Resource Poor Settings: A Systematic Review
The review presents the evidence base for HIV and sexually transmitted infection (STI) prevention interventions among female sex workers in resource-poor settings. The review only included randomized controlled trials or studies that included a control group. The authors identified 1,272 articles and abstracts across the various databases, and 28 of these met the selection criteria. Twenty-five interventions were focused at the individual level and three targeted structural interventions. Half of the studies evaluated a combination of behavioral interventions and STI treatment, seven studies focused on increasing condom use, four evaluated a vaginal microbicide, and three evaluated structural interventions. Almost all of the studies (93 percent) reported on changes of STI/HIV incidence or prevalence. Those with positive findings included interventions that focused either on a combination of behavioral interventions and STI treatment or on increasing condom use. There was either no effect or an increased risk of HIV in the microbicide studies. The three structural interventions were highly successful. The authors discuss the limitations of the review and recommend next steps for future evaluations.
Tap and Reposition Youth (TRY) Program: Providing Social Support, Savings, and Microcredit Opportunities to Adolescent Girls at Risk for HIV/AIDS in Kenya
The Tap and Reposition Youth (TRY) Program was implemented by the Population Council and K-Rep Development Agency, a microfinance organization, in low-income areas in Nairobi, Kenya from 1998 to 2004. The program targeted out-of-school females aged 16 to 22 years old. The goal of the program was to reduce female adolescent’s vulnerability to negative social and reproductive health outcomes by involving them in a microfinance project. The project went through three stages. The first phase organized a group of 25 young women, who were trained, contributed to a group savings plan, and were offered microloans to start small businesses. Participation was high in the beginning of phase one, but the young women eventually started dropping out of the program. Based on lessons learned from the first phase, the second phase strengthened the social components to provide more support to the young women. However, it was found that they continued to exit the program because they were concerned for the safely of their savings, since members defaulted on their loans, or needed it for emergencies. The third phase offered women access to safe and secure savings as well as the necessary social support, but did not have the loan and repayment portion of the original program. It was found that the initial program’s focus on loans and repayments was only successful for the most stable and least vulnerable young women. Social support interventions and safe loans were more immediate needs for the majority of women in this setting. The authors suggest having different types of economic development interventions based on the level of stability and vulnerability of the young women targeted for the project.
Revolutionising The AIDS Response
According to the authors, structural approaches that address social, economic, and political factors beyond the control of individuals are still lacking in both the global and national responses to HIV. This synthesis paper outlines six key recommendations and provides specific guidance from the Social Drivers Working Group of the aids2031 initiative. These actions are designed to operationalize structural approaches that will increase uptake and sustainability of behavioral and biomedical prevention approaches. The authors argue that addressing the root causes of vulnerability, such as gender inequity, may have the greatest effect in reducing vulnerability to HIV. The six actions identified by the working group include:
• Integration of HIV efforts with broader health and develoliment should be suliliorted through inter-sectoral AIDS coalitions.
• Governments and donors should invest in sociological assessments to identify the social context as liart of routine efforts to “know your eliidemic.”
• Civil society and affected communities—including women living with HIV, networks of affected liersons, and young lieolile—must be fully engaged in lilanning and liriority-setting activities.
• Substantial and long-term structural aliliroaches should be funded for liroject cycles of 5 to 15 years or more.
• Monitoring and evaluation frameworks must account for multidimensional changes in the social, economic, and liolitical environments.
• Laws that reduce stigma and lirotect human rights and equity must be effectively imlilemented and monitored.
• Integration of HIV efforts with broader health and develoliment should be suliliorted through inter-sectoral AIDS coalitions.
The 100% Condom Use Programme in Asia
Sex work is a major route of HIV transmission in many Asian countries and effective interventions that address the HIV risk of sex workers and their clients are greatly needed. This paper describes the 100% Condom Use Programme, which was conceived in 1989 and has been implemented in Thailand, Cambodia, Philippines, Vietnam, China, Myanmar, Mongolia, and Laos PDR. It achieved success in many cases. In each country, program components have been adapted to fit the local context. However, the program universally aims to empower sex workers to refuse sex without a condom. Key strategies applied in all contexts have been to promote "No condom - No sex" in all types of sex work and collaboration among local authorities, sex business owners, and sex workers. In some contexts, program components include formation of sex workers' self-help groups, peer education, and issuance of membership cards by local authorities. The nationally-implemented 100% Condom Use Programmes in Thailand and Cambodia have been credited as the main factor contributing to the decline in those countries’ HIV epidemics.
Promoting More Gender-Equitable Norms and Behaviors among Young Men as an HIV/AIDS Prevention Strategy
This report describes a quasi-experimental evaluation of Programa H, a program implemented in Brazil to change young men’s attitudes towards traditional gender roles and sexual relations and to reduce HIV risk behaviors and intimate partner violence. The evaluation used a survey and qualitative interviews to compare different combinations of the program components. Components included interactive group education sessions for young men led by adult male facilitators and a community-wide “lifestyle” social marketing campaign to promote condom use, using gender-equitable messages that echoed those used in the group education sessions. The researchers developed and used the Gender-Equitable Men (GEM) Scale to measure attitudes toward gender norms related to such topics as HIV prevention, intimate partner violence, and sexual relationships. Evaluation results showed significant behavioral and biological changes among 15- to 25-year-olds at intervention sites, including an increase in condom use with primary partners and reduction in reported sexually transmitted infections (STI) symptoms. Further, young men’s decreased support for inequitable gender norms over one year was significantly associated with decreased reports of STI symptoms.
Changes in Sexual Behaviour Leading to the Decline in the Prevalence of HIV in Uganda: Confirmation from Multiple Sources of Evidence
This study combined analysis of several different types of evidence—some traditionally used in public health and some not—to identify the changes in sexual behavior that led to the marked reduction in the prevalence of HIV in Uganda in the early 1990s. Seven types of evidence were used, including models of HIV prevalence and incidence in Kampala and other sentinel sites in Uganda; reports of behavior change in the primary newspaper in Uganda; surveys with questions about perceptions of personal behavior change; large demographic and health surveys and large Global Program on AIDS surveys with questions about sexual behavior; smaller surveys of reported sexual behavior; reports of numbers of condoms shipped to Uganda; and historical documentation of the implementation of HIV prevention programs in Uganda. The study found consistency among the findings from the different types of evidence examined, concluding that people in Uganda first reduced their number of sexual partners prior to or outside of long-term marital or cohabiting relationships and subsequently increased condom use with non-marital and non-cohabiting partners.
Structural Drivers, Interventions, and Approaches for Prevention of Sexually Transmitted HIV in General Populations: Definitions and an Operational Approach
The lessons of the past 30 years of the response to the HIV epidemic have pointed to three key objectives that future behaviour change based HIV prevention efforts must work to achieve: 1) address broader structures shaping behavioral risk and vulnerability, 2) tailor responses to the factors influencing risk and vulnerability understood to affect the target population, and 3) ensure multiple factors can be addressed when needed. This paper provides definitions of key terms and concepts that may help in the operationalization of an approach that meets these objectives. A “structural approach” is defined as process undertaken to decide upon an appropriate set of structural HIV prevention interventions. It is a “process” because it is impossible to define in advance what activities to undertake, “appropriate” because HIV prevention must be tailored to local realities, and a “set” of activities because risk is typically shaped by multiple factors. Structural factors can be broad, encompassing the multitude of potential elements that might shape risk and vulnerability for different populations. Structural drivers encompass an identified set of factors empirically shown to influence risk for a given target group. Other key operational terms (e.g., causal pathways, levels of influence) and additional considerations, such as unforeseen and undesirable consequences to changing structural factors, are discussed.
Incorporating a Structural Approach within Combination HIV Prevention: An Organising Framework
“Structural factors” are characteristics of the social, economic, legal, and cultural environment that act as determinants of HIV risk for whole populations and influence how this risk is distributed within populations. To date, “structural approaches” that engage these factors remain poorly developed. HIV-prevention programmers deploy limited resources over set timeframes with the primary goal of reducing HIV infection rates and disparities. They do not themselves set broad social policy or research agendas, but both respond and seek to influence these. They are often motivated to adopt a structural approach within combination HIV prevention. This paper proposes a three-pronged structural approach to be used by HIV-prevention programmers: 1) social epidemiology targeting to enhance equity of HIV prevention, 2) interrupting the causal pathway from social determinants to risk through critical enabler interventions, and 3) addressing structural factors directly through HIV-sensitive, cross-sectoral development. This approach can be tailored to populations, considers factors beyond provision of information alone, and recognizes that multiple factors shape risk patterns. It overlaps with the investment framework proposed by UNAIDS in 2011, which proposes three categories of investment required for a comprehensive response: basic programmatic activities, addressing critical enablers, and achieving development synergies. The author describes how a structural approach can inform action in all three categories.
Operationalizing Structural Interventions for HIV Prevention: Lessons from Zambia
The evidence of the effectiveness of structural interventions for HIV prevention is lacking in comparison to the evidence for interventions in other prevention areas, despite the key role of structural interventions in combination prevention approaches. This role is recognized in global guidance. While “structural prevention” has received significant attention in the academic community in recent years, the challenges to program implementation at the community and national levels are not well understood. This paper discusses the experience of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)/U.S. Agency for International Development (USAID) in implementing structural interventions in Zambia. The authors propose several ways to expedite the implementation process.
Weighing the Gold in the Gold Standard: Challenges in HIV Prevention Research
A systematic review of late phase randomized controlled trials (RCTs) for prevention of sexual transmission of HIV found that only six, all evaluating biomedical interventions, demonstrated definitive effects on HIV (five reduced transmission; one had adverse effects). The authors conducted a review of RCTs for prevention of sexual transmission, identifying 37 trials (reporting on 39 interventions) from over the last 30 years. Three male circumcision trials, one trial of sexually transmitted infection treatment and care, and one vaccine trial significantly reduced HIV. One microbicide trial of nonoxynol-9 gel produced adverse results. The authors cite problems in design and implementation that impeded the studies. According to the authors, while well-designed and executed RCTs should remain the gold standard in defining the evidence base for prevention programs, public health researchers and practitioners must also employ complementary lines of evidence and observational studies. The HIV prevention science community must also examine trials that failed to demonstrate results to learn how to improve study design and implementation.