An Overview of Structural Prevention

Introduction

  1. Definition of the Prevention Area

    A "structural approach” to HIV prevention is the process of selecting a set of interventions that use structural factors to reduce HIV risk at the individual and/or group level. Structural factors are elements outside individual knowledge or awareness that have the potential to influence people’s vulnerability to HIV infection. They include social (e.g., stigma, gender inequality); legal-political (e.g., laws and regulations); cultural (e.g., religious beliefs); and economic (e.g., lack of livelihood opportunity) factors.

    Structural factors fall into two conceptual categories:

    1. Risk drivers: Factors that have been empirically shown to shape patterns of risk behavior in particular populations.
    2. Environmental mediators: Increase people’s resilience to HIV (PDF, 1.23 KB) or hinder their ability to avoid HIV in a particular context (e.g., laws that criminalize and drive underground men who have sex with men, limiting their ability to seek HIV-prevention services.)
  2. Epidemiological Justification for the Prevention Area

    There is a growing body of quantitative and qualitative evidence linking structural factors to HIV risk and its proximate determinants (e.g., multiple sexual partnering and lack of condom use). Given the complex and numerous pathways between structural factors and HIV transmission, however, few structural programs have been evaluated for their impact on HIV incidence.

    Most of the emerging evidence centers on a few factors, including gender inequality, stigma and discrimination, economic empowerment and livelihood opportunities, education, and alcohol. For each of these factors, there is evidence on the impact of interventions that target them, although the relative importance of particular structural factors varies across settings.

    One randomized controlled trial (RCT) that linked structural factors with HIV biomarkers found significantly lower levels of HIV and HSV-2 among Malawian schoolgirls who received monthly cash payments than among those who did not receive the payments. In Kenya, a study showed that reducing the cost of primary education by paying for school uniforms reduced dropout rates, teen marriage, and childbearing—all factors closely related to HIV risk. Other HIV-prevention programs have addressed structural factors by changing gender and violence against women norms, supporting micro-credit programs, and strengthening the legal rights of underserved populations. A recent Journal of the International AIDS Society supplement discusses the necessity of addressing these and other structural factors in future HIV investments. Service models should be adapted to the economic and social environments of clients, and HIV programming incorporated into wider gender and development efforts.

  3. Core Programmatic Components

    There is now widespread agreement that structural approaches are a critical part of a “combination HIV-prevention” strategy. In addition to the positive outcomes that structural interventions can achieve on their own, they are important to the success of biomedical and behavioral interventions. For example, voluntary medical male circumcision provision programs may not realize potential impact without including activities that address structural factors, such as socio-cultural norms that influence men and women’s circumcision (PDF, 1.18 MB) preferences and mobility-constraining poverty that may limit certain populations’ access to services.

    There is no “one size fits all” structural approach that is appropriate for all epidemics, settings, or target populations. A defining component of a structural approach to HIV prevention is choosing a set of interventions according to evidence-informed analysis of the particular characteristics of the target population, the context, and the risk drivers and environmental mediators of HIV in a specific setting. For example, in a setting where migratory labor is common and laborers have high levels of HIV, a structural approach might include workplace HIV-prevention (PDF, 444 KB) or an intervention to create alternative economic opportunities. In an epidemic where HIV is transmitted primarily through sex work, a priority intervention could focus on persuading local authorities to enforce condom use in brothels.

    Although there is no single approach for all settings, the following considerations and features are characteristic of good structural programming and should be addressed in the development and implementation of structural approaches in any setting:

    • Clear articulation of the causal pathway between the structural factor and HIV risk, and where along the pathway the intervention aims to have impact.
    • Understanding of the intervention’s possible unintended effects.
    • Definition of the macro (national/regional), meso (community), and/or micro (individual/family) levels that the intervention expects to influence.
    • Attention to the needs of marginalized and/or hard-to-reach groups.

    These considerations are delineated in the AIDSTAR-One Structural Resource tool.

  4. Current Status of Implementation Experience

    Structural interventions are not new to public health prevention strategies. Well-known and successful examples include increasing taxes to reduce or prevent smoking and national programs to put fluoride into drinking water to prevent tooth decay. In the HIV arena, however, the importance of structural interventions has only recently garnered significant attention. There is no consensus on key concepts, definitions, what works, or the causal pathways that help programs succeed. This is in part due to gaps in the evidence base, many of which result from the technical challenges of measuring the impact of structural programming. The position paper series developed by AIDSTAR-One and STRIVE makes progress, providing definitions for key structural HIV-prevention concepts, analysis of the current evidence base and gaps, frameworks for approaching structural prevention, and lessons from field-based implementation experience.

    Measuring the effectiveness of structural intervention programs can be difficult for several reasons:

    • There is no direct, one-to-one relationship between structural interventions and HIV incidence.
    • Structural interventions are not often amenable to randomization.
    • Causal pathways from intervention to end point outcomes are usually indirect and complex.
    • Funding to study these questions at scale is not proportionate with funding for research on biomedical and behavioral interventions.

    Existing evaluations of the effect of structural interventions on HIV and proximal behavioral outcomes use multiple, diverse methodologies to allow triangulation of data. Methodologies include RCTs (PDF, 104 KB), quasi-experimental studies, and qualitative studies (PDF, 377 KB). Retrospective studies of broad national responses to the epidemic have combined sources and methods typically used in public health (e.g., HIV prevalence and incidence modeling, behavioral and demographic health survey data, interview and focus group data, and condom shipment data), with infrequently used (PDF, 78 KB) (i.e., newspaper reports of behavior change) methods. Limitation to conventional methods may undercut the development of new and effective HIV-prevention approaches. Researchers have called for further engagement with social science methods and the use of combinations of data from different types of evaluations, as well as careful inclusion of less rigorous sources to make progress in generating an evidence base.

UPDATED 06/2015

What We Know

Effect of a Cash Transfer Programme for Schooling on Prevalence of HIV and Herpes Simplex Type 2 in Malawi: A Cluster Randomised Trial

Baird, S.J., Garfein, R.S, McIntosh, C.T., et al. The Lancet (April 2012), 379 (9823): pp. 1320–1329, doi: 10.1016/S0140-6736(11)61709-1.

According to the findings of this randomized controlled trial in Malawi, girls and young women ages 13–22 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: between US$1 and $5 for the girls and US$4 and $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 simplex virus 2 (HSV-2). They were also more likely to attend school, less likely to have sex regularly and a partner older than 25 years. The authors did not detect a difference in age at sexual debut or condom use, and found no notable difference in HIV or HSV-2 prevalence between the conditional and unconditional cash transfer groups. They concluded that simple cash transfer programs for unmarried schoolgirls and their families may have a significant effect on girls’ sexual and reproductive health, and encouraged policymakers to consider such programs as a component of combination prevention approaches.

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

Gibbs, A., Willan, S., Misselhorn, A., Mangoma, J. Journal of the International AIDS Society (June 2012), 15, doi: 10.7448/IAS.15.3.17362.

This study analyzed two structural drivers of HIV for young people: gender inequalities and livelihood insecurity. The authors identified nine structural interventions focusing on gender, microfinance, girls’ education, gender empowerment, and financial literacy targeting young people. Across all nine interventions, the authors identified three lessons: 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 implemented in real-world contexts. The authors said that the interventions focused on building human and financial capital but neglected to consider other forms of capital, systems, or institutions that often supplement and influence livelihood programs, including educational systems and state policies. They supported including men and boys in combined interventions, but cautioned that further research is necessary to ensure that their participation adds value rather than detract from the work of gender equality. They stressed that successful interventions conducted primarily in rural or educational contexts must be adapted to urban settings and a variety of contexts.

Addressing Social Drivers of HIV/AIDS for the Long Term Response: Conceptual and Methodological Considerations

Auerbach, J.D., Parkhurst, J.O., and Cáceres, C.F. Global Public Health (January 2011), doi: 10.1080/17441692.2011.594451.

This paper provided a framework and guidance on the social and structural drivers of the HIV epidemic as a way to move the HIV-prevention field forward. Addressing the paucity of concrete definitions for social and structural constructs, the authors discussed some of the important terms used throughout the social science discourse. They also outlined various hypotheses and causal pathways in the social science field, and provided a logical framework for addressing social and structural drivers through interventions. The operational structure they described entails six steps: 1) identify the target populations and/or locations for the intervention; 2) identify the key behavioral patterns and drivers of behavioral patterns for the target population; 3) chose the level of the structural intervention; 4) describe planned and potential changes and outcomes; 5) design the intervention; and 6) implement, monitor, evaluate, and solicit feedback. The authors concluded 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.

Education and HIV/AIDS Prevention: Evidence from a Randomized Evaluation in Western Kenya

Duflo, E., Dupas, P., Kremer, M., et al. World Bank Policy Research Working Paper No. 4024 (2006).

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 primary outcome measure of the intervention's effectiveness 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?

Pettifor, A., McCoy, S.I., and Padian, N. The Lancet (April 2012), doi: 10.1016/S0140-6736(12)60036-1.

The authors of this commentary discussed the findings of a cluster randomized controlled trial of a cash transfer program for schoolgirls in Zomba, Malawi (Baird, Garfein, McIntosh, and Osler 2012; see earlier entry). The study examined the effect of cash transfers on risky sexual behavior among schoolgirls by providing cash transfers conditional on school attendance; providing transfers unconditionally; and providing no cash transfers. The findings showed that at follow-up, 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. In this commentary, the authors discussed the study's importance in providing evidence that an intervention to change the structural environment by providing cash payments can lessen young women’s HIV risk. They also noted 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 capable of detecting effects on biological outcomes between conditional and unconditional cash transfer interventions. They called for more research to understand the causal pathways through which cash transfer programs achieve impact.

The Cost and Cost-Effectiveness of Gender-Responsive Interventions for HIV: A Systematic Review

Remme, M., Siapka, M., Vassall, A., et al. Journal of the International AIDS Society (November 2014), doi: 10.7448/IAS.17.1.19228, eCollection 2014.

This paper examined the cost-effectiveness of 22 gender-responsive interventions that had been shown to be effective against HIV transmission. Most of the 36 studies reviewed were implemented in settings with generalized epidemics; had different designs including randomization; and assessed impacts on HIV or other biological outcomes using mostly proxies of HIV risk (behavior change). Despite the mixed quality of the studies, the authors identified several gender-sensitive interventions as cost-effective. These included the invitation of male partners for couples counseling on prevention of mother-to-child transmission; gender empowerment and violence prevention through community mobilization; female condom promotion for female sex workers; female condom distribution for general population; conditional and unconditional cash transfer for schoolgirls; school support (including fees, uniforms, and supplies for girls); and HIV post-exposure prophylaxis within a post-rape health service package. The authors concluded that given the multiple benefits of these interventions on communities, the HIV sector should share funding with other sectors to implement gender-sensitive interventions that address structural drivers of HIV, specifically harmful gender norms, inequalities in access to education, and poor livelihood.

Policy and Programme Responses for Addressing the Structural Determinants of HIV

Pronyk, P. and Lutz, B. Structural Approaches to HIV Prevention Position Paper Series (2013). Arlington, VA: USAID’s AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1, and London: UKaid’s STRIVE research consortium.

Over the past decade, increasing numbers of successful, practical interventions have been implemented to 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 examined relatively recent evidence for strengthening the global response to HIV. The paper profiled: 1) approaches for addressing structural factors and measuring effects on HIV-related behavioral and biological outcomes; and 2) interventions proven 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 identified 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) such action can benefit other health, development, and human rights objectives; 4) implementation of structural approaches will require a range of disciplinary perspectives outside the health sector; and 5) cross-sector governance and financing are critical for structural approaches to work.

Intervening Upstream: A Good Investment for HIV Prevention

Heise, L. and Watts, C. Structural Approaches to HIV Prevention Position Paper Series (2013), Arlington, VA: USAID’s AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1, and London: UKaid’s STRIVE research consortium.

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—alcohol use, internalized stigma, economic and consumer pressures that encourage transactional sex, exposure to violence, and the effect 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 called 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 examined evidence linking structural factors to HIV risk, as well as research gaps, including the pathways through which factors interact and affect HIV vulnerability. It explored the advantages of taking a “structurally informed” approach to HIV planning and implementation, specifically the value of influencing clustered risk factors, the potential to influence multiple outcomes, and opportunities for co-financing.

Putting it Into Practice

Findings from the SASA! Study: A Cluster Randomized Controlled Trial to Assess the Impact of a Community Mobilization Intervention to Prevent Violence Against Women and Reduce HIV Risk in Kampala, Uganda

Abramsky, T., Devries, K., Kiss, L., et al. BMC Medicine (July 2014), doi: 10.1186/s12916-014-0122-5.

The SASA! study in Uganda (2007–2012) was the first community randomized controlled trial in sub-Saharan Africa to assess a gender-focused community mobilization intervention to reduce intimate partner violence (IPV) and prevent HIV. The SASA! approach includes four phases (Start– Awareness– Support– Action) implemented by community activists and law enforcement and health care professionals. Cross-sectional surveys of community members at baseline (n = 1,583) and four years post-intervention (n = 2,532) showed that in intervention communities, social acceptance of a man’s use of violence against his partner was lower among men (adjusted risk ratio [ARR] = 0.13) and significantly lower among women (ARR = 0.54). More men (ARR =1.31) and women (ARR = 1.28) in intervention than control communities accepted women's right to refuse sex. Significantly fewer women in the intervention areas reported experiencing physical IPV over the past year (ARR = 0.48), and the likelihood of community support for women experiencing physical IPV in the past year was 100 percent higher in intervention than control communities. The investigators concluded that the study demonstrated the value of engaging women and men to effect community-level changes in social norms.

Can Money Prevent the Spread of HIV? A Review of Cash Payments for HIV Prevention

Pettifor, A., Macphail, C., Nguyen, N., et al. AIDS and Behavior (October 2014), 16 (6): pp. 1729–38, doi: 10.1007/s10461-012-0240-z

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 structural risk factors. The authors say that conditional and unconditional cash transfer programs reach over 1 billion people in developing countries. Most studies on these programs have found positive impacts on sexual behaviors, although because data on biological endpoints are rarely collected, only one study has shown a direct correlation between a decrease in HIV prevalence and cash payments. Cash programs 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 cautioned that the downstream approach may have unintended consequences, such as violence or coercion, although they also noted that there is no evidence of social harm to individuals participating in cash transfer programs. The amount of payment likely affects results, so clear and transparent selection criteria are critical. They encouraged the use of formative and ethnographic research and pilot studies to determine the best structure for cash transfers to reduce risk. The authors hypothesized that cash transfer interventions might be used to encourage HIV testing and adherence to antiretroviral drugs.

What Community-Level Strategies Are Needed to Secure Women’s Property Rights in Western Kenya? Laying the Groundwork for a Future Structural HIV Prevention Intervention

Dworkin, S.L., Lu, T., Grabe, S., et al. AIDS Care (October 2014), 26 (6): pp. 754–757, doi: 10.1080/09540121.2013.845286.

Research has shown that ownership and control over land and assets reduce the likelihood of domestic violence, an important risk factor for HIV infection in settings hard hit by the HIV epidemic. This qualitative study identified strategies used to prevent and resolve land and property rights violations in two rural areas in Kenya where HIV prevalence was high and property disputes were common. Through in-depth interviews with local watchdog group members (20 leaders and 30 women and men who mediated property rights disputes), the authors discerned four main themes as key strategies to secure women’s land ownership: 1) education of individuals and communities about women’s land rights and ways of preventing property rights violations; 2) formation of a funeral committee to intervene on land disputes; 3) capacity building on property rights and mediation at community level; and 4) referral of unresolved cases to the formal legal system. This study, the authors concluded, provided groundwork for future research on the relationship between property rights, violence, and HIV infection.

Is Food Insecurity Associated with HIV Risk? Cross-Sectional Evidence from Sexually Active Women in Brazil

Tsai, A.C., Hung, K.J., Weiser, S. PLoS Medicine (April 2012), 9 (4): pp. 1–10, doi: 10.1371/journal.pmed.1001203.

In this study of how food insecurity contributes to increased HIV risk among 12,684 sexually active Brazilian women, the authors found that severe food insecurity with hunger was associated with lower levels of condom use. Using a multivariable 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 was 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 range of human experience from food security to severe food insecurity with hunger. The authors said that these findings added to the abundance of new data highlighting the importance of food security in relation to women’s risk of sexual violence and exposure to HIV. They recommended that HIV-prevention programs target high-risk women through food supplementation or livelihood interventions to help equalize gender-based bargaining power within households. They stressed that to be consistently effective in reducing HIV risk, biomedical, individual-level cognitive, and behavioral interventions must address structural factors, such as food insecurity.

Global Epidemiology of HIV among Female Sex Workers: Influence of Structural Determinants

Shannon, K., Strathdee, S. A., Goldenberg, S. M., et al. The Lancet (January 2015), 385 (9962): pp. 55–71, doi: 10.1016/S0140-6736(14)60931-4.

In this study of how food insecurity contributes to increased HIV risk among 12,684 sexually active Brazilian women, the authors found that severe food insecurity with hunger was associated with lower levels of condom use. Using a multivariable 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 was 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 range of human experience from food security to severe food insecurity with hunger. The authors said that these findings added to the abundance of new data highlighting the importance of food security in relation to women’s risk of sexual violence and exposure to HIV. They recommended that HIV-prevention programs target high-risk women through food supplementation or livelihood interventions to help equalize gender-based bargaining power within households. They stressed that to be consistently effective in reducing HIV risk, biomedical, individual-level cognitive, and behavioral interventions must address structural factors, such as food insecurity.

Global Epidemiology of HIV among Female Sex Workers: Influence of Structural Determinants

Shannon, K., Strathdee, S. A., Goldenberg, S. M., et al. The Lancet (January 2015), 385 (9962): pp. 55–71, doi: 10.1016/S0140-6736(14)60931-4.

This review investigated the role of structural determinants on HIV epidemics and access to care among female sex workers (FSWs) in settings with concentrated and generalized epidemics (Canada/India and Kenya, respectively). The authors also used modeling to determine the number of infections that could be averted through structural changes in two different epidemic contexts, represented by Canada and Kenya. Only 43 percent of the 204 studies reviewed were designed to assess one or more structural determinants, and most of them (93 percent) were from limited-resource countries in Asia. The majority of studies reported associations between structural determinants and condom use rather than HIV and sexually transmitted infections. Modeling showed that eliminating sexual violence alone could avert 20 percent of HIV infections among FSWs and their clients in Canada over the next decade. In Kenya, the highest impact on infections averted (34 percent) over the next decade was achieved by the scale up of antiretroviral treatment (ART) for both FSWs and their clients, which underscored the important role of ART as prevention in generalized epidemics. Predictions from modeling showed that in both concentrated and generalized epidemics, decriminalization of sex work would have the greatest effect on the course of the HIV epidemic (33–46 percent of HIV infections averted) over the next decade.

A Systematic Review of Income-Generation Interventions, Including Microfinance and Vocational Skills Training, for HIV Prevention

Kennedy, C.E., Fonner, V.A., O'Reilly, K.R., et al. AIDS Care (October 2014), 26 (6): pp. 659–73, doi: 10.1080/09540121.2013.845287.

This review assessed 12 mixed-design studies on income-generation interventions in resource-limited countries, and provided comparative outcomes on behavioral, psychological, social, treatment, and biological outcomes related to HIV prevention. The 12 studies selected were mainly from sub-Saharan Africa and targeted a range of populations including female sex workers, youth or orphans, and adult women. The majority of interventions included microfinance schemes alone or combined with vocational training and health education. Studies on conditional or unconditional cash transfer interventions with no expectations of repayment were excluded from the analysis. Microfinance alone or combined with other interventions did not lead to significant changes in HIV-related sexual risk behaviors, but exerted important effects on knowledge, attitudes, and intimate partner violence. In some cases, income-generation interventions were associated with greater risk for HIV, gender-based violence, or safety concerns. The authors said that their findings should be interpreted with caution, because the review had several limitations despite rigorous study selection criteria. The outcomes of the studies included were subject to self-reporting bias, did not include HIV biomarkers, and did not measure HIV incidence or prevalence among participants. The authors concluded that more well-designed studies are needed to examine causal pathways between income-generation interventions and HIV-related outcomes.

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., et al. Journal of the International AIDS Society (January 2014), doi: 10.7448/IAS.17.1.18619, eCollection 2014.

This paper reviewed evidence supporting interventions that address six social and structural drivers of HIV for women: changing gender norms; tackling violence against women; changing legal norms to empower women; fostering women’s employment; providing income and livelihood opportunities; increasing educational attainment for girls; and reducing stigma and discrimination. The review included 64 studies and evaluations on 19 intervention activities implemented between 2005 and 2011. The authors labeled interventions showing strong evidence of effectiveness as “working,” and those with limited evidence as "promising." Effective interventions to transform gender norms included training; and discussions and education among peers, between couples, and within communities. Community-based participation and learning for women and men were successful approaches for discussing violence against women. Employment, micro-financing, and small-scale income-generating activities fostered women’s employment and income and livelihood opportunities. Interventions to increase educational attainment and abolish school fees advanced education, especially for girls. Community-based interventions that provided accurate information about HIV transmission and training on universal precautions for care providers reduced stigma and discrimination. The authors concluded that additional research to expand the evidence base on social and structural factors is needed. They added that educating girls along with income-generating opportunities will lead to beneficial HIV-related outcomes for women and girls.

Effectiveness of an Integrated Intimate Partner Violence and HIV Prevention Intervention in Rakai, Uganda: Analysis of an Intervention in an Existing Cluster Randomised Cohort

Wagman, J.A., Gray, R.H., Campbell, J.C., et al. The Lancet (January 2015), 3 (1): pp. 23–33, doi: 10.1016/S2214-109X(14)70344-4.

This study assessed whether a combination of intimate partner violence (IPV) prevention and HIV services would reduce IPV and HIV incidence among participants in the Rakai Community Cohort Study in Uganda. Intervention participants (n = 5,337) received standard HIV services plus services through the Safe Homes and Respect for Everyone project, a community-based intervention to change social norms and behaviors in IPV that offers IPV screening and an intervention for safe HIV disclosure and risk reduction among women seeking counseling and testing services. Control participants (n = 6,111) received standard HIV services only. At the 35-month follow-up, the intervention was associated with reduction in HIV incidence (1.15 cases/100 person years in control versus .87 cases/100 person years in intervention group) and fewer women in the intervention group had experienced physical IPV compared to the control group. Men's reports of IPV decreased over the course of the trial in both groups, but reported IPV incidence at follow-up did not differ significantly. Both women and men in the intervention group reported higher HIV status disclosure rates. The authors concluded that the SHARE approach could reduce IPV against women and overall HIV incidence, and could be used within other HIV-prevention programs in sub-Saharan Africa.

Promoting More Gender-Equitable Norms and Behaviors among Young Men as an HIV/AIDS Prevention Strategy

Pulerwitz, J., Barker, G., Segundo, M., et al. Horizons Final Report. (2006), Washington, DC: Population Council.

This report describes a quasi-experimental evaluation of Programa H, a program implemented in Brazil to change young men’s attitudes on 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 through gender-equitable messages that echoed those used in the group sessions. The researchers developed and used the Gender-Equitable Men scale to measure attitudes toward gender norms related to topics such 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 symptoms of sexually transmitted infections (STIs). 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

Kirby, D. Sexually Transmitted Infections (2008), 84 (S2): ii35–ii41, doi: 10.1136/sti.2008.029892.

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 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

Parkhurst, J.O. Structural Approaches to HIV Prevention Position Paper Series (2013), Arlington, VA: USAID’s AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1, and London: UKaid's STRIVE research consortium.

The lessons of the past 30 years of the response to the HIV epidemic point to three key objectives for future behavior change-based HIV-prevention activities: 1) addressing broader structures shaping behavioral risk and vulnerability; 2) tailoring responses to factors known to influence risk and vulnerability within the target population; and 3) ensuring that multiple factors are addressed when needed. This paper defined key terms and concepts that may help to operationalize 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 multiple elements that might shape risk and vulnerability for different populations. Structural drivers encompass a set of factors empirically shown to influence risk for a given target group. The paper also discussed other key operational terms (causal pathways, levels of influence) and additional considerations, such as unforeseen and undesirable consequences to changing structural factors.

Incorporating a Structural Approach within Combination HIV Prevention: an Organising Framework

Hargreaves, J.R. Structural Approaches to HIV Prevention Position Paper Series (2013), Arlington, VA: USAID’s AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1, and London: UKaid’s STRIVE research consortium.

“Structural factors” are characteristics of the social, economic, legal, and cultural environment that determine 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 set broad social policy or research agendas, but respond to and seek to influence them. Programmers are often motivated to adopt a structural approach within combination HIV prevention. This paper proposes a three-pronged structural approach: 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, and recognizes that multiple factors shape risk patterns. It overlaps with the investment framework proposed by the Joint United Nations Programme on HIV/AIDS 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

Bowa, C., Mah, T.L. Structural Approaches to HIV Prevention Position Paper Series (2013), Arlington, VA: USAID’s AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1, and London: UKaid’s STRIVE research consortium.

Evidence of the effectiveness of structural interventions for HIV prevention is scant 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/U.S. Agency for International Development 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

Padian, N.S., McCoy, S.I., Balkus, J.E. AIDS (March 2010), 24 (5): pp. 621–635, doi: 10.1097/QAD.0b013e328337798a.

A systematic review of late-phase randomized controlled trials (RCTs) for preventing sexual transmission of HIV found that only six, all evaluating biomedical interventions, demonstrated definitive effects on HIV. Three male circumcision trials, one trial of sexually transmitted infection treatment and care, and one vaccine trial significantly reduced HIV. One trial of nonoxynol-9 gel produced adverse results. The authors said that 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 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.

Tools and Curricula

Review of the Evidence: Linkages between Livelihood, Food Security, Economic Strengthening, and HIV-Related Outcomes

Xiong, K. MEASURE Evaluation. 2012.

This literature review explored the links between poverty, livelihood, food security, economic strengthening, and HIV- and AIDS-related outcomes. It found that the links between poverty and HIV and AIDS were mostly based on qualitative research and were unclear. Quantitatively, there were conflicting results between poverty and HIV and AIDS. The literature is stronger in providing links between food insecurity and HIV and AIDS outcomes, with food security positively affecting antiretroviral adherence and mortality. While most studies were qualitative, they generally agreed that improved economic standing improved HIV and AIDS outcomes. The authors concluded that there is strong evidence linking food insecurity, hunger, and the need to earn money to access to and use of HIV and AIDS care, treatment, and support services.

Integrating Gender into HIV/AIDS Programmes in the Health Sector: Tool to Improve Responsiveness to Women’s Needs

World Health Organization. 2009.

This tool was developed for program managers and providers who develop, implement, manage, or evaluate HIV and AIDS programs. It enables them to increase awareness on how gender can affect an individual’s access to and experience with HIV and AIDS programs and services. The tool provides guidance to make programs more gender-friendly, and identifies four HIV or AIDS services and gives details on how to address key gender issues. These services include HIV testing and counseling; prevention of mother-to-child transmission; and HIV and AIDS care and support. The tool was field-tested in five countries and can be used in a number of different settings such as trainings, development of curricula, and integration of gender issues within strategies to address HIV.