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Policy and Programme Responses for Addressing the Structural Determinants of HIV

The last decade has witnessed remarkable progress in addressing the consequences of the HIV pandemic. In 2011, some 8 million people in low- and middle-income countries were on antiretroviral therapy (ART), marking the first time in which a majority of people eligible for treatment were receiving it [1]. Efforts to address the causes of the epidemic, however, have not yet matched the combined speed, scale, and successes of treatment programmes. While new infections globally have steadily declined by 20 percent since peaking in 1997, HIV prevalence and incidence remains stubbornly high. In 2011, 34 million people were living with HIV and 2.5 million new infections occurred. Moreover, the epidemic’s march continues to outpace treatment efforts, with five new infections for every two people placed on therapy [2]. Global progress also masks underlying disparities, and even reversals. While there has been remarkable behaviour change in some settings, countries in Central and South Asia, for example, have seen significant increases in new infections.

One reason that prevention efforts have not kept pace has been insufficient attention to HIV’s “structural factors”—those areas beyond individual knowledge or awareness that shape risk and vulnerability to infection [3]. Examples are often context-specific but can include economic inequality and livelihood insecurity, as well as hunger, gender inequality, and lack of education. These factors, many of which are rooted in various formal and informal types of marginalisation, underpin the diversity of HIV epidemics, helping to explain why some countries have a higher HIV burden than others. In addition, structural factors have been demonstrated to influence treatment access and retention.