In the fourth of six papers in The Lancet Series on HIV Prevention, Dr Geeta Rao Gupta and Dr Jessica Ogden (International Center for Research on Women (ICRW), Washington, DC, USA) and colleagues call for policy makers to give more attention to structural factors known to affect vulnerability and risk of HIV infections. They maintain that successful prevention of HIV infections requires structural reform and policies that focus on individual level behaviors.
Structural factors include physical, social, cultural, organizational, community, economic, or legal considerations that can both help and harm efforts to prevent HIV infections. Previous research has shown significant relationships between HIV risk and specific structural factors. For example, income and wealth, gender treatment, domestic violence exposure, ability to enroll in school, and being orphaned are all factors that are positively correlated with an individual’s risk of HIV exposure and that manage to dampen an individual’s ability to prevent HIV infections. Policies and programs that address structural issues attempt to alter the conditions under which people live.
One example of an HIV/AIDS policy that focused on structural reform is the Sonagachi project, which involved the community to focus on needs of Indian sex workers. The program resulted in a reduction in HIV prevalence to 10% – compared with a prevalence of 50 to 90% among sex workers in other Indian cities. The authors specify that one key element contributing to the program’s success was that it empowered the sex workers to decide for themselves what they needed to do and when to take action. During the program’s implementation in the 1990s, condom use increased substantially from 3% to 90%.
A second type of structural approach is that of needle exchange programs for users injecting drugs. These are often political challenges since possession or use of these drugs is usually illegal. However, there is evidence suggesting that needle exchange programs can reduce HIV infections in these drug users without adverse effects. The structural factor of gender inequality can also affect HIV prevention efforts. It is difficult, for example, for women to negotiate condom use in many parts of the world because they do not have equal access to paid work and are economically dependent on men. Policies such as increasing women’s access to credit or other implementing programs that lead to their economic independence are structural approaches that may reduce gender inequality as well as vulnerability to HIV.
Realizing that social and epidemiological factors will cause structural approaches to have varying outcomes, the authors note that, “When implementing a structural approach, there is no single blueprint that will work everywhere.” However, structural programs can be adapted or modified to fit other settings through careful analysis of the critical features of the new setting. Structural approaches often use multiple activities and they affect HIV in an indirect way, which means the success or failure of such programs is difficult to monitor. Since these approaches are so complicated, the authors suggest that randomized trials may not always be the most suitable assessment method. In order for structural approaches to be successfully assessed, community groups, social scientists, and all other involved must closely collaborate.
“Sustained progress in HIV prevention requires structural approaches rather than continuing to address individual-level factors. Structural factors can be influenced but until they are, individuals in many settings will find it difficult to reduce their risk and vulnerability…Structural approaches represent a largely untapped, yet crucial, part of combination HIV prevention advocated for in this Series. Serious attention must be given to defining and building capacity to make that happen,” conclude the authors.
Understanding and addressing structural factors in HIV prevention
Jessica Ogden et al.
The Lancet (2008).
Written by: Peter M Crosta