Structural Drivers, Interventions, and Approaches for Prevention of HIV in General Populations

Definitions and an Operational Approach

The HIV prevention field has seen remarkable progress in recent years on the biomedical front, with the promise of drug- and surgery- based prevention strategies such as male circumcision, pre-exposure prophylaxis, and early initiation of widespread antiretroviral therapy (‘test and treat’) [1–5]. Unfortunately, there have been fewer clear examples of behavioural interventions which have been shown to sustainably bring about reductions in HIV incidence [6, 7]. After 30 years of the fight against the HIV/AIDS epidemic, a number of clear lessons, however, have been learned.

First, there is understanding that the patterning of human sexual behaviours is deeply embedded in, and shaped by, underlying social, economic, and legal-political structures [8–13]. Reducing HIV risk, therefore, will typically require changes in broader structural elements (be they economic opportunities, social norms and gender roles, legal freedoms, or combinations of these factors), not just information provision alone [12, 14–18]. Second, it is recognised that much HIV prevention activity has occurred without sufficient conceptualisation of why or how a particular approach should actually bring about a sustained change in behaviour in a given setting [19–21], with current calls by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and others to tailor HIV responses to the factors shaping risk and vulnerability in specific contexts [13, 18, 21–23]. Third, human behaviours are not determined by single causal factors, but rather by multiple elements in combination, which influence patterning of risk behavior. (See Heise and Watts in this series for a discussion of how multiple risk-increasing practices may often cluster together, and therefore may need to be addressed in combination—for example, 1 how violent behavior towards female partners is commonly linked with excessive alcohol consumption and frequenting of sex workers).