HIV Prevention Knowledge Base
Structural Interventions: Interventions Addressing Policy Factors
I. 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 programs' impact.
II. 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.
III. 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.
In order 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.
IV. 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 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 are needed to identify critical factors in effective prevention policy and their potential role in lessening HIV transmission.