In order to successfully prevent as many HIV infections as possible, attention must be given to structural factors that affect vulnerability and risk, as well as focusing on individual level behaviours. These are the conclusions of Dr Geeta Rao Gupta and Dr Jessica Ogden, International Center for Research on Women (ICRW), Washington, DC, USA, and colleagues, authors of the fourth paper in The Lancet Series on HIV Prevention.
Structural factors are defined as physical, social, cultural, organisational, community, economic, or legal aspects of the environment that impede or facilitate efforts to avoid HIV infection. Studies have shown a meaningful association between structural factors and HIV risk. Examples of such factors include income and relative wealth, gender inequality, exposure to domestic violence, school enrolment, and being orphaned. All of these things provide a guide to the vulnerability of an individual that increases their risk of HIV exposure or limits their ability to protect themselves from infection. Structural approaches can include policies and/or programmes that aim to change the conditions in which and under which people live.
There are several examples of HIV and AIDS initiatives that have taken a structural approach. The Sonagachi project – a community oriented project addressing the needs of Indian sex workers – reduced HIV prevalence to 10%, compared with 50-90% in many Indian cities. An essential component of its success was that the sex workers themselves were empowered to decide what they needed to do and to take action. Condom use rose from 3% to 90% during the programme's implementation in the 1990s. Needle exchange programmes for injecting drug users are also examples of structural approaches, as they require a shift in policy in the contexts where such possession or use of such drugs is illegal. Such policy shifts remain a challenge for many nations, yet evidence shows that needle exchange programmes reduce HIV infection in injecting drug users without adverse effects.
Gender inequality is another structural factor that affects vulnerability to HIV. For example, women's unequal access to paid work can contribute to their economic dependence on men, which can make it difficult for a woman to negotiate condom use. Structural approaches to lessen gender inequality and vulnerability to HIV could include increasing women's access to credit and other financial services that make them more economically independent.
The authors stress the importance of understanding the social and epidemiological context in which a structural approach is to be taken, and argue that: "When implementing a structural approach, there is no single blueprint that will work everywhere." They add, however, that structural programmes applied in one setting can be implemented in another through careful adaptation based on critical features of the new setting. The authors also acknowledge the difficulties in assessing structural approaches due to their indirect effect on HIV transmission, and the fact that they can often involve multiple activities. They emphasise that the randomised trial is not always the best method for assessment of structural approaches, due to the complexity and often layered nature of structural approaches. They call for closer collaboration between groups implementing the structural changes, eg, community groups, and social science experts who have the skills to effectively monitor effects of the intervention.
The authors conclude: "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."
Dr Geeta Rao Gupta, International Center for Research on Women (ICRW), Washington, DC, USA T) +1 202 797 0007 ext. 166 E) geeta@icrw.org
Dr Jessica Ogden, International Center for Research on Women (ICRW), Washington, DC, USA (attending conference) (cell) T) +1 571 271 9749 E) jogden-consultant@icrw.org
Please note: a press conference to launch this series will take place at the International AIDS conference on Tuesday 5 August, 1500-1545 (Mexico City time) in Room 1 (Aztecas), Media Centre, Hall A, Level 1, Centro Banamex, Mexico City
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Journal
The Lancet