HIV Prevention Knowledge Base
Structural Interventions: An Overview of Structural Approaches to HIV Prevention
Effect of a Cash Transfer Programme for Schooling on Prevalence of HIV and Herpes Simplex Type 2 in Malawi: A Cluster Randomised Trial
According to the findings of this recent randomized controlled trial (RCT) in Malawi, girls and young women aged 13 to 22 who receive regular small cash payments are less than half as likely to acquire HIV than their counterparts who receive no cash payment. The study recruited approximately 1,300 never-married young women living in an area with high poverty, low school enrollment, and high HIV prevalence. The young women and their families were randomized to receive small monthly stipends for 18 months: USD$1 to $5 for the girls and USD$4 to $10 for the families (conditional on school attendance or unconditional), or nothing at all. Girls who received payments were 75 percent less likely to acquire herpes. They were also more likely to attend school, less likely to be having sex regularly, and less likely to have a partner over the age of 25. The authors did not detect a difference in age of sexual debut or condom use, and found no notable difference in HIV and HSV-2 prevalence between the conditional and unconditional cash transfer groups. According to the authors, simple cash transfer programs for unmarried schoolgirls and their families may have a significant impact on their sexual and reproductive health. They encourage policymakers to consider such programs as one component of combination prevention approaches.
Addressing the Structural Drivers of HIV/AIDS: A Luxury or Necessity for Programmes?
This article discusses a series of papers published in a recent supplement of the Journal of the International AIDS Society highlighting some of the social, economic, political, and environmental structural factors that increase susceptibility to HIV infection and undermine current prevention and treatment interventions. According to the authors, future investments in combination prevention and broader gender and development initiatives must include structural factors to ensure both clinical efficacy and effectiveness at a population level. They cite the recent trial of a cash transfer intervention in Malawi that showed that providing a small stipend to girls and their households had a significant impact on prevalence of HIV and herpes simplex virus within this population. The papers they cite address a range of issues: how structural interventions may alter social arrangements and often include value judgments; how to change behavioral dynamics among young people and address the prevention needs of the most disadvantaged youths; why inequalities in gender, power, and income lead to increased risk among women’s and men’s access to care and support services; and how to increase gender equality and livelihood security with effective combinations of structural interventions. The authors stress that future investments are needed to define the political and programmatic impact of structural interventions on reducing HIV incidence.
Combined Structural Interventions for Gender Equality and Livelihood Security: A Critical Review of the Evidence from Southern and Eastern Africa and the Implications for Young People
This study analyzes two structural drivers of HIV for young people: gender inequalities and livelihood insecurity. The authors identified nine structural interventions focusing on gender microfinance and gender empowerment, girls’ education, and gender empowerment and financial literacy targeting young people. Across all nine interventions, the authors identified three lessons learned: 1) interventions have a narrow conceptualization of livelihoods, 2) there is limited involvement of men and boys in such interventions, and 3) few studies have been done in real-world contexts. According to the authors, the interventions focused on building human and financial capital, and neglected to consider other forms of capital, systems, or institutions that often supplement and influence livelihood programs, including educational systems and state policies. The authors support including men and boys in combined interventions, but caution that further research is necessary to ensure that their participation adds value rather than detracts from the work of gender equality. They stress that successful interventions primarily carried out in rural or educational contexts must be adapted to more urban settings and to a variety of contexts.
Addressing Social Drivers of HIV/AIDS for the Long Term Response: Conceptual and Methodological Considerations
This paper provides a framework and guidance on the social and structural drivers of the HIV epidemic to move the HIV prevention field forward. There is a paucity of concrete definitions for social and structural constructs and the authors discuss some of the important terms used throughout the social science discourse. They also outline the various hypotheses and causal pathways in the social science field, and provide a logical framework for how to address the social/structural drivers through interventions. The operational structure that is provided goes through six steps: 1) identify the target populations and/or locations for intervention, 2) identify the key behavioral patterns and drivers of behavioral patterns for the target population, 3) chose level of structural intervention, 4) describe planned and potential changes and outcomes, 5) design the intervention, 6) implement, monitor, evaluate, and feedback. The authors conclude that HIV and AIDS experts should support the incorporation of social and structural approaches in the global response to improve positive health outcomes in the future. Much more work, however, also needs to be accomplished through the implementation and evaluation of programs.
Education and HIV/AIDS Prevention: Evidence from a Randomized Evaluation in Western Kenya
This randomized experimental study conducted in Kenya found a possible causal link between school attendance and reduced HIV risk factors. Three school-based HIV and AIDS programs were implemented: 1) training teachers in the Kenyan Government’s HIV and AIDS education curriculum, 2) facilitating student debates on the role of condoms and having them write essays on how to prevent themselves from acquiring HIV, and 3) decreasing the cost of education. The authors collected measures of knowledge, attitudes, and behavior related to HIV. The study’s primary outcome measure of effectiveness of the interventions was teenage childbearing, which is associated with unprotected sex. After two years, the study showed that reducing the cost of education by paying for school uniforms reduced dropout rates, teen marriage, and childbearing.
Paying to Prevent HIV Infection in Young Women?
The authors comment on the findings of a cluster randomized controlled trial of a cash transfer program for schoolgirls in Zomba, Malawi, which showed that schoolgirls who received monthly cash payments were significantly less likely than girls who did not receive payments to be infected with HIV and HSV-2, have an older male partner, and have sexual intercourse once per week at follow-up (Baird 2012). The study compared the impacts of providing cash transfers conditional on school attendance, providing cash transfers unconditionally, and providing no cash transfers. In this commentary, the authors discuss the importance of the study in providing evidence that an intervention to change the structural environment through provision of cash payments can impact young women’s HIV risk. They also cited the study’s limitations, including the fact that HIV incidence was not used as an outcome measure and that few HIV infections were detected. The study was not powered to detect different effects on biological outcomes between the conditional cash transfer and unconditional cash transfer interventions. More research is needed to understand the casual pathways through which the program achieved impact.
Evaluating HIV Prevention Effectiveness: The Perfect as the Enemy of the Good
“Magic bullet thinking”—that is, prioritizing only the well-defined and measurable biomedical interventions—may inhibit understanding of what works in HIV prevention by leaving out the less easily measurable social and contextual approaches. According to the authors, measuring the impact of combination prevention remains an elusive goal for the HIV prevention community due to the methodological challenges of applying the gold standard of randomized controlled trials for prevention programming. The authors contend that the use of costly randomized designs with the community as unit of intervention may not produce valid data. This is due to a number of challenges in measuring change in HIV incidence, including a lack of reliable, easy-to-use tools to measure HIV incidence at a population level, the need for unrealistically large sample sizes, and the unreliability of intermediate indicators, such as reported behavior change. Plausibility designs—which do not include randomly selected control groups but instead triangulate data sources—may provide important evidence of impact and help explain program effectiveness. The authors encourage the use of a clear description of program components and their potential causal pathways, intermediate outputs, and outcomes leading to HIV incidence reduction. They also encourage the use of mixed methods and modeling as an alternative to probability evidence.
Policy and Programme Responses for Addressing the Structural Determinants of HIV
Over the past decade, there have been increasing numbers of successful, practical interventions that address HIV’s structural factors, from policy measures that remove user fees for schools in Africa, to sex worker peer-prevention programs in India, to economic safety nets such as cash transfers to adolescent girls in Malawi. This paper examines the relatively recent evidence to produce insights that can strengthen the global response to HIV. The paper profiles: 1) efforts that address structural factors and measure effects on HIV-related behavioral and biological outcomes and 2) interventions that have been demonstrated to affect known HIV-related structural factors, whether or not clinical or behavioral endpoints were assessed, to stimulate thinking on the importance of cross-sectoral approaches. The authors identify several lessons: 1) action on structural factors is a necessary component of the global HIV response, even in the context of the re-medicalization of HIV prevention, 2) action on structural factors is possible, can be highly effective, and is likely context-specific, 3) action on structural factors can benefit other health, development, and human rights objectives in addition to HIV, 4) a range of disciplinary perspectives outside the health sector will be required to implement structural approaches, and 5) cross-sector governance and financing are critical for structural approaches to work.
Intervening Upstream: A Good Investment for HIV Prevention
Today’s HIV prevention, care, and treatment strategies are based largely on the science and insights of biomedicine and epidemiology, two disciplines that have traditionally emphasized biological interventions and individual behavior change over measures addressing social or structural sources of risk. Most research has focused on the biological co-factors that affect transmission dynamics, such as the presence of concomitant sexually transmitted infections or the use of prevention methods that reduce transmission likelihood. However, non-biological factors that influence behavior and the likelihood of transmission—such as alcohol use, internalized stigma, economic and consumer pressures that encourage transactional sex, exposure to violence, or the impact of gender norms—also affect HIV transmission. They operate earlier in the causal chain through more varied and complex pathways. Increasingly, scientists and policymakers have begun calling for more attention to the structural forces that create environments of risk, arguing that the touchstone of future programming must be “combination prevention.” This paper examines some of the evidence linking structural factors to HIV risk, as well as the research gaps, including the pathways through which factors interact and affect HIV vulnerability. It explores the advantages of taking a “structurally informed” approach to HIV planning and implementation, namely, the value of influencing clustered risk factors, the potential to influence multiple outcomes, and opportunities for co-financing.