Interventions Addressing Policy Factors


  1. Definition of the Prevention Area

    Policies create frameworks for identifying objectives and setting priorities and define the roles of different stakeholders in achieving those purposes. With the encouragement of organizations such as UNAIDS and the Global Fund, national HIV programs and committees throughout the world have developed HIV/AIDS frameworks that establish national priorities in responding to the epidemic. These frameworks include goals for national prevention programs and provide the basis for coordinating the work of all partners. National HIV prevention policies are often supported by cost assessments, modeling exercises, and guidelines that assist implementers to select appropriate and evidence-based program activities and implementation strategies.

    There are many situations where additional policies affect the spread of HIV and the effectiveness of prevention activities. HIV prevention program managers and activists may advocate for supportive policies, such as policies that broaden the field of service providers authorized to perform voluntary medical male circumcision. Efforts to create a policy environment favorable to HIV prevention may enhance the impact of HIV programs.

  2. Epidemiological Justification for the Prevention Area

    While the strength of the association between policy and HIV incidence is not fully clear, reductions in HIV prevalence in Uganda and Senegal have been partially attributed to strong national policies and enabling political environments characterized by financial commitment and the endorsement of top national leadership. In Thailand, a well-implemented policy for 100 percent condom use by sex workers was associated with a significant reduction in HIV prevalence among sex workers and their clients.

    National strategies—complemented by guidelines—set priorities for target populations, approaches, and budget allocations. If policies fail to prioritize documented needs or evidence-based solutions for political or other reasons, they may fall short of their intended population effect, even with effective implementation strategies.

  3. Core Programmatic Components

    Factors affecting risk and vulnerability must be considered when developing HIV prevention policies. In evaluating policies, program planners and implementers should consider the impact on both HIV prevention and human rights.

    Policies are generally developed through careful research, application of international standards and best practices, and a lengthy consultative process with relevant constituency groups at the community, national, and international levels. HIV and AIDS policies that are adopted in response to top-down pressures may lack local political commitment and prove to be inconsistent with local realities or national priorities.

    National HIV prevention policies define and prioritize services to be provided, their recipients, and their providers. Many methods and activities can be used to inform and influence policies related to HIV prevention. Mechanisms for systematic review ensure that policies remain relevant and reflect international best practices. For example, an audit or review of an existing policy can identify both strengths and gaps, while workshops designed to provide input on service delivery problems can help advocate for policy enactment or change. Conducting assessments of the costs of HIV initiatives and building scenarios that compare the costs and impacts of different policies may also be persuasive.

    For policies to be effective, they must be disseminated and operationalized. Popular versions of policy documents may use simple language to inform constituents of possible impact on HIV prevention efforts. Operational plans move prevention policies from paper to practice.

  4. Current Status of Implementation Experience

    With the encouragement of multinational organizations, national HIV and AIDS programs and committees worldwide have been engaged in preparing national strategies that typically include guidance on prevention priorities. UNAIDS is leading the effort among multilateral organizations to create an enabling environment by providing technical and policy guidance to governments and program managers. The Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria is also supporting the formulation of national policy by requiring national monitoring and evaluation frameworks of grant applicants and by instituting policies to ensure that funded countries follow certain best practices at the policy level.

    The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has initiated the development of Partnership Frameworks with countries receiving funding. These high-level policy agreements, which address the policy reform agenda specific to each country, are designed to expand national governments’ ownership and enhance their ability to plan, develop, and implement policies. Through its POLICY project and the Health Policy Initiative the Health Policy Project, the United States Agency for International Development (USAID) has worked to strengthen national and sub-national policy, advocacy, and governance to promote strategic, equitable, and sustainable health programming in developing countries.

    Additional monitoring and evaluation is needed to illuminate the relationship between policy and HIV incidence and to identify the critical factors in effective prevention policy.

UPDATED 06/2015

What We Know

Confirming the Impact of HIV/AIDS Epidemics on Household Vulnerability in Asia: The Case of Cambodia

Alkenbrack Batteh, S.E., Forsythe, S. Martin, G. et al. AIDS (2008), 22 (1): S103–S111. doi: 10.1097/01.aids.0000327630.00469.40.

The ability of individuals and household members to reduce the risk of HIV depends, in part, on their economic and social wellbeing. 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. The authors of this study assessed 1,000 households living with or affected by HIV and AIDS in both urban and rural areas of Cambodia 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 and borrowed money; and their children were more likely to work than those in comparison households.

Changing Cost of HIV Interventions in the Context of Scaling-Up in India

Dandona, L., Kumar, S.G., Ramesh, Y.K. et al. AIDS (2008), 22 (1): S43-S49.

As prevention interventions are scaled up or new approaches are adopted, policymakers and program planners need information on the cost and cost-effectiveness of such programs, and a comparison of the expenditures (costs) and outcomes (effects) of two or more courses of action. This article examined changes in the cost of scaling up a counseling and testing program and a sex worker program in the Andhra Pradesh state of India. The cost of serving one client for counseling and testing 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 suggested that cost-effectiveness data can inform policymakers 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

Dickinson, C. and Buse, K. Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu Natal, South Africa (2008), 11 (4): 418–427.

The authors of this review argued that in the development of HIV policies, the influences of politics, ideologies, and ignorance outweigh the influence of evidence. Their analysis of the literature showed 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, they said. Thus, informing and influencing policy development often happens without understanding of techniques for shaping the policy process. These techniques are especially important in targeting policies that will affect HIV prevention programs for key populations. The paper argued 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 (that is, who wields these ideas and arguments) are important in whether policies are considered. Finally, the perceived interests of policy-influencers and policymakers are critical in policy change. The paper includes a set of country-specific tables with 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

Gilson, L. and Nika, R. Health Policy and Planning (2008), 23: 294–307. doi: 10.1093/heapol/czn019.

The article was the first-ever 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, the authors said, 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 that policies meet their objectives.

Structural Approaches for Prevention of Sexually Transmitted HIV in General Populations: Definitions and an Operational Approach

Parkhurst, J.O. Journal of the International AIDS Society (2014), 17: p. 19052. doi: 10.7448/IAS.17.1.19052.

Despite global consensus around the understanding that effective HIV prevention requires measures to address the structural factors that influence HIV risk, national HIV responses continue to adhere to top-down prevention approaches, implemented in isolation and without adaptation to local conditions. Thus, the author of this article said, leaders have failed to act on lessons learned from past experiences. He suggested redefining structural approaches to HIV prevention: developing generalizable strategies that can be tailored to the local context to address the structural factors specific to the HIV risks to the target groups. HIV structural factors are commonly understood in two ways: as risk drivers that shape and influence patterns of risk behaviors; and as environmental factors that facilitate or hinder people’s ability to avoid HIV. In either case, it is critical to understand how different structural factors interrelate and how they affect the behaviors of target groups through influences at the individual, community, and national levels. Given the complexity of the risks and vulnerabilities of each target group, the author said, it makes little sense to identify a set of structural prevention interventions that works across countries or target groups. It is instead critical to adopt a structural approach that identifies a set of appropriate, context-specific activities through a diagnostic process, entirely based on the prevention needs of the targeted group.

Limits to Evidence-Based Health Policymaking

Hunsmann, M. Social Science & Medicine (2012), 74 (10): 1477–85. doi: 10.1016/j.socscimed.2012.01.023.

The study, carried out in Tanzania between 2007 and 2009, investigated the political barriers to uptake of evidence regarding non-behavioral determinants of HIV transmission in the formulation of national prevention strategies. The author compared observations of the Tanzanian policymaking process with literature on evidence-based decision-making and the politics and economics of public health. He pointed to five main reasons for neglect of structural approaches: (1) the limited weight given to the concept of cost-effectiveness in determining policies; (2) a preference for funding historically strong HIV political constituencies, paired with the absence of public advocacy for evidence-based structural approaches; (3) politically-driven preferences among policymakers for interventions seen as producing results quickly (such as behavioral approaches), versus structural interventions, seen as long-term measures; (4) the fragmented nature of the international HIV response; and (5) policymakers’ perception of structural interventions as highly complex and infeasible compared to more traditional behavioral measures. The author concluded that HIV prevention policies in Tanzania, and possibly elsewhere, are not strictly evidence-driven, but rather the result of politically mediated, competing priorities, and that the political nature of HIV policymaking must be taken into account in any efforts to promote structural change. Promoting this type of broad-based change may be more effective if programs focus on improving policymakers' ability to use evidence within the political process of the policymaking "struggle," while also taking into account the political dynamics of HIV policymaking.

Environmental–Structural Interventions to Reduce HIV/STI Risk among Female Sex Workers in the Dominican Republic

Kerrigan, D., Moreno, L. Rosario, S. et al. American Journal of Public Health (2006), 96 (1): 120–125.

The article reported the findings of two environmental/structural approaches to HIV prevention among female sex workers. The first approach was to mobilize community initiatives; the second 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 sex workers rejected clients’ unsafe sex requests. Also, there were larger decreases in sexually transmitted infections in the policy site than occurred in the community sites. The authors concluded that combining two or more structural interventions can have a significant impact on prevention outcomes among targeted groups.

Realigning Government Action with Public Health Evidence: The Legal and Policy Environment Affecting Sex Work and HIV in Asia

Gruskin, S., Pierce G.W., and Ferguson, L. Culture, Health & Sexuality (2014). 16 (1): 14–29. doi: 10.2105/AJPH.2004.042200.

This article examined the public health and human rights implications of laws governing sex work, focusing on Asia. Using reports from 21 Asian countries to the United Nations General Assembly Special Session on AIDS (UNGASS), the authors compared legislation on sex work and looked for trends linking national-level laws and policies on sex work with HIV-related outcomes. They identified four regulatory approaches across countries: (1) criminalization, (2) decriminalization, (3) regulation and/or legislation, and (4) absence of meaningful regulation or legislation. Among the four approaches, criminalization of sex work (by prohibiting all forms of sex work, or activities related to sex work) was most often associated with higher levels of stigma and discrimination and decreased access to health care and other social services. Moreover, sex workers who operate in a criminalized context are less able to take safety measures—especially negotiation of condom use—and are thus more vulnerable to sexually transmitted infections, including HIV. The study findings confirmed that HIV-related outcomes are poorer where the legal and policy environment is not supportive. These findings, the authors said, suggest that legally punitive environments threaten both the rights and the health of sex workers, and have the potential to further exacerbate the HIV epidemics in Asia and the rest of the world.

A History of State Action: The Politics of AIDS in Uganda and Senegal

Putzel, J. The HIV/AIDS Epidemic in Sub-Saharan Africa in a Historical Perspective: Part IV, Facing the Challenges of HIV, London School of Economics (2006), pp. 171–184.

Both Senegal and Uganda are frequently cited for their proactive responses to the HIV epidemic. The article examined 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 to learn from a wider community and 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 to reach people across the country.

Strengthening the Enabling Environment for Women and Girls: What is the Evidence in Social and Structural Approaches in the HIV Response?

Hardee, K., Gay, J., Croce-Galis M., Peltz, A. Journal of the International AIDS Society (2014), 17 (1): p. 18619. doi: 10.7448/IAS.17.1.18619.

The authors of this review analyzed structural prevention interventions in sub-Saharan Africa that targeted the drivers of HIV infection among women and girls (who are eight times more likely than men to be living with HIV) and reviewed effective approaches. The paper identifies six social and structural factors that influence women’s and girls’ willingness and ability to practice HIV prevention and defines them as (1) transforming gender norms, (2) addressing violence, (3) transforming legal norms, (4) promoting employment, (5) advancing education, and (6) reducing stigma and discrimination. Evidence showed that structural interventions that created an enabling environment by addressing these factors had beneficial HIV-related outcomes for women and girls. The activities normally carried out in these successful interventions included (1) training individuals, communities, and providers ; (2) providing community-based participatory learning and education for males and females; (3) providing peer support; (4) conducting mass media campaigns;(5) offering financial service and social protection programs linked with training on gender; (6) implementing programs to reduce HIV-related violence; (7) promoting law enforcement and greater legal literacy; and (8) increasing girls' school attendance (including abolishing school fees).

An Audit of HIV/AIDS Policies

Zungu-Dirwayi, N., Shisana, O., Udjo, E. et al. Human Sciences Research Council (2004).

This audit covered policy responses and gaps in Botswana, Lesotho, Mozambique, South Africa, Swaziland, and Zimbabwe, providing a short overview of elements of the national HIV and AIDS policy, and other related policies for each country. 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.

Putting it Into Practice

Breaking Barriers to HIV Prevention, Treatment, and Care for Women

Croce-Galis, M. Open Society Institute (2008).

This set of case studies described interventions and activism by women to influence and shape policies, laws, HIV and AIDS programs, and access to HIV and AIDS services. One case example focused on how activists use Internet technology to disseminate information, organize, and gain support for and deliver message on policies and policy implementation. Another case study summarized the activities of the Malawi Health Equity Network. Among other things, the network analyzes the national budget before it is finalized and publishes the findings of the analysis in newspapers, to illuminate how funding is allocated. The public dissemination of the draft budget and related analysis allows other organizations to argue for changes before final adoption of the budget.

South Africa’s Treatment Action Campaign (TAC): An Example of a Successful Human Rights Campaign for Health. Chapter 3 in Introduction: Politics, Human Rights and Poor Global Health

Heywood, M. Treatment Action Campaign (2008).

The article summarized the efforts of the Treatment Action Campaign (TAC) in South Africa to mobilize public opinion and pressure the national government to provide for the needs of people living with HIV and to expand resources for prevention initiatives. Heywood, an AIDS activist, argued that to be successful, initiatives promoting the right to health must be conducted within the context of law, politics, or governance. The author related that TAC's strategy for creating a social movement, rather than a top-down advocacy campaign, was to become the first AIDS organization to introduce HIV "treatment literacy" in a developing country. TAC's treatment literacy program provided health education and communication for poor and HIV-vulnerable people, focused on the science of HIV, health, and the benefits of HIV treatment. TAC continues to engage with the South African government to achieve policy reforms and expand HIV and AIDS services.

Swaziland Antiretroviral Therapy Policy Dialogue (APD) Report

Southern Africa HIV and AIDS Information Dissemination Service (SAfAIDS) (2007)

The paper reported on a workshop designed to provide community input to the policy and programmatic provision of antiretroviral treatment (ART) in Swaziland. Representatives from a national organization of people living with HIV (PLHIV), an organization of women living with HIV and AIDS, the national ART coordinator’s office, and a clinician from a health facility initiated the dialogue about progress toward full implementation of the national policy. These participants' perspectives on the implications for service delivery of ART balanced the policy focus of the workshop. PLHIV felt that far more was needed to meet their constituents’ needs. Each speaker included prevention topics in their presentations. One participant noted that the workshop was a “good starting point in forwarding the ART agenda and as a mode of diversifying the means and source of information sharing and subsequent translation into action.”

HIV and AIDS Prevention and Control Act

Government of Kenya (2006), Act No. 14.

This legislation established measures for preventing and managing HIV and AIDS in Kenya, and for protecting public health. It includes language prohibiting discrimination against people living with HIV and AIDS, promotes HIV prevention, and guarantees the full human rights of all citizens suspected or known to be HIV positive. It established a tribunal which is tasked to hear and judge complaints about any violations of the act. The law has faced criticism from groups representing people living with HIV and AIDS and human rights advocates, especially regarding a provision specifying that knowingly transmitting HIV may subject all people living with HIV and AIDS to criminal law.

The Role of Public Policy in Prevention and Control of Sexually Transmitted Infections: A Guide to Laws, Regulations and Technical Guidelines

World Health Organization (1999).

The guide provides a standard outline of key elements in developing a policy. Especially useful is the chapter dealing with operational factors to consider, not only when implementing a policy but also in considering the legal and regulatory factors during the drafting of a policy. An example of a national sexually transmitted infection policy is offered in an annex to the guidelines. As in this instance, international agencies will develop such guidelines as a way to inform and influence country policy development.

Cash Transfers for HIV Prevention: Considering Their Potential

Heise, L., Lutz, B., Ranganathan, M., Watts, C. Journal of the International AIDS Society (2013), 23 (16) 18615.

The authors reviewed evidence on the impact of cash transfers on HIV-related outcomes, outlined the theory underpinning this approach, and identified areas for future research. They discussed two main theories behind cash transfers. In the first, cash transfers serve as a means to address structural factors (such as socioeconomic distress among vulnerable groups), or to promote social goods (such as school attendance). The second theory views cash transfers as a form of contingency management meant to directly motivate people to avoid high-risk behaviors (for example, to remain free of sexually transmitted infections). The authors concluded by stating that cash transfers are an important addition to HIV prevention efforts, but if they are to have an impact on the epidemic, these programs should be implemented within an environment of combination prevention, rather than in isolation. They also underscored the need for additional research on the multiple impacts of cash transfers within different settings, as a way of addressing critical questions around sustainability and the possible negative consequences that cash transfers scheme might generate.

Tools and Curricula

PolicyMaker 4 Software: Computer Assisted Political Analysis

Polimap (2015).

PolicyMaker is a software package that uses a rapid assessment method for analyzing and managing the political aspects of public policy. PolicyMaker is a logical and formal procedure to provide practical advice and to help decision-makers improve the political feasibility of their policy.

Health Policy Initiative Tools

Health Policy Initiative (2015).

The Health Policy Initiative developed a set of computer-based models to assist planners and inform policy makers around the world. Many models have express relevance to HIV prevention, including the “Spectrum” models to project service needs, a number of workplace policy models, and the “Male Circumcision Decisionmakers Tool.”

View Resources:

UNAIDS Prevention Toolkit

Joint United Nations Programme on HIV/AIDS (2015).

This toolkit, created for project managers implementing HIV prevention programs, offers practical information on current prevention interventions alongside approaches for validating prevention strategies. An especially relevant section provides valuable information for managers at national and subnational level on how to select prevention interventions tailored to the country context and for different epidemic scenarios.

Additional Resources

10 Reasons to Oppose the Criminalization of HIV Exposure or Transmission

Open Society Institute (2008).

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 set out 10 arguments describing why criminalizing HIV exposure undermines prevention work; presented a cogent set of arguments against criminalizing transmission; and offered alternatives to ensure that prevention activities will be far more effective and successful in protecting people from transmission.

Evolution of Thailand’s Strategy to Cope with the HIV/AIDS Epidemic

Phoolchareon, W. Food, Nutrition and Agriculture (2005), 34: 1–8.

The author of this article describes how Thailand responded to HIV and AIDS and looked at the influences and some of the decision-making processes that informed the country’s HIV and AIDS policies and programs. The author described three phases in the evolution of Thailand's HIV policy: confronting the epidemic; creating multisectoral alliances for policy development and public outreach; and addressing the consequences of HIV and AIDS. This article, however, omitted many details about the political and socioeconomic context, 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.

Health Policy Initiative

Health Policy Initiative (2015).

A USAID-funded follow-on project to the POLICY Project. The HIV and AIDS section contains several publications covering various HIV policy themes.

Medical Advocates

A website devoted to articles and reports on numerous aspects of HIV and AIDS. Documents dealing with policy, legal and regulatory aspects of HIV and AIDS prevention can be found in the Human Rights/Violence/Infectious Diseases section and the Marginalized People section.

The POLICY Project

This USAID-funded 11-year, two-phase project focused on raising awareness of reproductive health and HIV issues, and supporting the development of sound policies related to those issues. The project has ended, but many papers and reports are available online.

UNAIDS Policies and Briefs

This web page houses a comprehensive set of briefs and practical guidelines promoting the principles and standards that UNAIDS recommends to policymakers and programmers. Many areas of HIV prevention are covered, including male circumcision, condoms, and post-exposure prophylaxis. Populations such as men who have sex with men, prisoners, people who inject drugs, women and girls, and others are addressed as well.