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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.
Confirming the Impact of HIV/AIDS Epidemics on Household Vulnerability in Asia: The Case of Cambodia
Alkenbrack Batteh, S.E., Forsythe, S. Martin, G. et al. AIDS (2008), Vol. 22 Suppl. 1, pp. S103-S111.
The ability of individuals and household members to reduce the risk of HIV depends, in part, on their economic and social well-being. For many households, the impact of HIV and AIDS has increased economic distress and vulnerability. HIV and AIDS household impact studies can inform policy by illuminating groups at greater risk to future HIV infections due to declining economic conditions. Similarly, impact studies point out how the epidemic can undermine national development policies and increase poverty levels.
Debate has occurred, however, about the implications of economic impacts of HIV and AIDS on households. In this study, 1,000 households living with or affected by HIV and AIDS in both urban and rural areas of Cambodia were assessed to determine the impact of the epidemic, compared to households not affected by HIV and AIDS. The study found that affected households spent more on medical care and funerals and cut other spending, such as on food. Income levels of affected households were lower, because of the loss of an income earner, than non affected comparison households. HIV and AIDS affected households sold assets, borrowed money, and children were more likely to work than comparison households.
Changing Cost of HIV Interventions in the Context of Scaling-Up in India
Dandona, L., Kumar, S.G., Ramesh, Y.K. et al. AIDS (2008), Vol. 22 Suppl. 1, pp. S43-S49.
As prevention interventions are scaled-up or new approaches are adopted, policy makers and program planners need information on the cost of such programs and the programs’ cost-effectiveness, a comparison of the expenditures (costs) and outcomes (effects) of two or more courses of action. This article examines changes in the cost of scaling-up a counseling and testing (CT) program and a sex worker program in the Andhra Pradesh state of India. The cost of serving one client for CT declined as the program expanded and served a growing number of clients. The cost of the sex worker program increased as it expanded, primarily because the program added new service components and increased staff salaries. The authors suggest that cost-effectiveness data can inform policy makers and program planners as they seek an effective combination of HIV prevention interventions.
Understanding the Politics of National HIV Policies: The Roles of Institutions, Interests and Ideas
Dickinson, C. & Buse, K. Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu Natal, South Africa (2008), Vol. 11 No. 4, pp. 418-427.
The authors argue that “politics, ideology and ignorance have proven more influential on policy than epidemiology or technical best practice.” Their analysis of the literature shows that little research has been done to understand the politics of HIV policies. The literature provides only limited insights into the ways policy change occurs. The complexity of policy change makes it difficult to predict the outcome of a given policy change intervention. Thus, informing and influencing policy development often happens without an awareness of techniques for shaping the policy process. These techniques are especially important in targeting policies that will affect HIV prevention programs for most at risk populations. The paper argues that institutions, especially those with more democratic tendencies, play a role in the nature of policy development. Likewise, ideas, arguments and evidence and their sources are important in whether policies are considered. Finally, the perceived interests of policy influencers and policy makers are critical in policy change. A set of country-specific tables provide details about countries’ respective political processes and influences on policy development.
The Terrain of Health Policy Analysis in Low and Middle Income Countries: A Review of Published Literature 1994–2007
Gilson, L. & Nika, R. Health Policy and Planning (2008), Vol. 23, pp. 294–307.
The article is the first review of literature that analyzes the health policy processes in low and middle income countries. Although not specific to HIV prevention, the article provides insights into factors for successful policy adoption in the HIV and AIDS field. Existing literature demonstrates that politics, political processes, and power are central elements in the formulation and implementation of health policies. Policymaker and bureaucratic support are critical components in both the design of policies and whether policies are effectively implemented. Follow-on regulations, guidelines, and staff engagement are also important elements in assuring policies meet their objectives.
Implementing 100% Condom Use Policies in Indonesia: A Case Study of Two Districts in Jakarta
Spratt, K. USAID/Health Policy Initiative (2007).
The report examines factors that determined willingness to implement policies in two districts in Jakarta, Indonesia. The focus was on implementing the 100% Condom Use Program (CUP) endorsed in the Indonesia National HIV and AIDS Strategy. Data were collected primarily through key informant interviews. One district had adopted legislation to implement the national policy; the other one had not. Among the reasons for non-implementation of the CUP were stigma and discrimination against most-at-risk groups by local policy makers; the frequent transfer of staff involved with HIV and AIDS issues; and limited interest in those issues among some members of the District AIDS committees. A fourth reason was the differing beliefs and values of legislators and program staff on the meaning of “condom promotion” with groups involved in high risk sex. The researchers found that opponents to the CUP felt that the policy would “encourage pre- or extra-marital sex, which are considered `immoral.” Even supporters of the program were reluctant to support the national policy too openly, worrying that their support would be seen as “admitting sex work exists and thereby endorsing infidelity.” Such negative views of and trepidation about the consequences of local implementation of the national policy prevented the development of guidelines for policy implementation. Finally, there were no strong constituencies at district levels to advocate for implementation of the CUP. The study concludes with suggestions for building an advocacy strategy to inform and influence policy implementation.
Making the Money Work for the People: An Analysis of 2006 Budget Allocations and Debt Relief Gains to Fund HIV and AIDS Interventions in Nigeria
Adewumi, B. Journalists Against AIDS (2006).
In 2005, Nigeria achieved major debt relief, with the understanding that savings on the cancelled debt repayments would be applied to poverty, health and related programs. This study monitors the efficient and effective use of resources arising from debt relief repayment toward programming for HIV and AIDS. The analysis found that 4.5 percent of total debt relief allocations went to HIV and AIDS programs, with the remaining being spread out over nine others target programs. Other sources of funding for HIV and AIDS programs were tapped by various line ministries, but these nine remained modest. The report argues: “Many African countries have been observed to reduce local spending on HIV and AIDS once there are new in-coming funds. With the new money coming from [debt relief], Nigeria seems to be towing the line by reducing its annual health spending from its core budget.”
Environmental–Structural Interventions to Reduce HIV/STI Risk among Female Sex Workers in the Dominican Republic
Kerrigan, D., Moreno, L. Rosario, S. et al. American Journal of Public Health (2006), Vol. 96 No. 1, pp. 120-125.
The article reports the findings of two environmental–structural approaches to HIV prevention among female sex workers (SW). The first approach was to mobilize community initiatives; the second approach combined community mobilization and government policy initiatives. Rates of condom use increased In both study sites, but in the policy/community site a much higher percentage of SW rejected clients’ unsafe sex requests. Also, there were larger decreases in sexually transmitted infections (STI) in the policy site than occurred in the community sites. The authors conclude that combining two or more structural interventions can have a significant impact on prevention outcomes among targeted groups.
A History of State Action: The Politics of AIDS in Uganda and Senegal
Putzel, J. The HIV/AIDS Epidemic in Sub-Saharan Africa in a Historical Perspective: Part IV, Facing the Challenges of HIV, London School of Economics (2006), pp. 171-184.
Both Senegal and Uganda are frequently cited for their proactive responses to the HIV and AIDS epidemic. The article examines some of the state-led political and policy factors that contributed to those effective national responses. The factors include early adoption of sentinel surveillance systems that provided evidence of increases in HIV rates. Both countries aligned themselves with international agencies in order to learn from a wider community and to access financial resources. Early on, both countries encouraged civil society and religious leaders to mobilize and develop prevention and care programs. Finally, each country had a relatively liberal policy toward the media, which enabled messages about HIV and AIDS to reach people across the country.
How Uganda Reversed Its HIV Epidemic
Slutkin, G., Okware, S., Naamara, W., et al. AIDS Behavior (2006), Vol. 10, pp. 351-361.
The authors, describing the prevention programs and activities implemented between 1987 and 1994 in Uganda, advocate for increased funding for multi-layered in-depth HIV prevention campaigns. In 1986, the national government of Uganda formed the National Committee for the Prevention of AIDS (NCPA) and the National AIDS Control Program (NACP) while entering into an emergency mode of accelerated program development. Some of the first strategies of the National AIDS control plan involved an aggressive educational HIV prevention campaign (subsequently becoming the center piece of activities), safety regulations on blood transfusions, health worker safety campaigns and in-depth case surveillance and seroprevalence studies. Following a comprehensive program review, the Government of Uganda implemented ten main recommendations and increased its annual expenditures of $1 to 4 million to $18 million over the first three years. The authors stress that the intensity and decentralization of the educational HIV prevention campaign, encompassing all modes of transmission, the level of involvement of all sectors as well as extensive financial and political support led to extensive behavior change at both the individual and public health level.
Using Incentives to Encourage AIDS Programs and Policies in the Workplace: A Study of Feasibility and Impact in Thailand
Baker, S., Srisuman, S. Rumakom, P. et al. Population Council, Horizons Final Report (2004)
Workplaces are frequently cited as targets for expanding HIV prevention initiatives. However, relatively few companies in most countries have adopted HIV and AIDS workplace policies or instituted HIV prevention programs. A study was undertaken in Thailand to assess whether companies would respond to financial incentives for adopting such policies and programs. Companies were offered a 5 to 10 percent reduction in insurance rates and public recognition for social responsibility if they adopted a workplace HIV policy and prevention program. Only one percent of all the companies originally invited to participate actually did so. The others felt the incentive was too small to compensate for the costs of developing and implementing a prevention program. For most companies that did join the initiative, the study found that the financial incentive made little difference. Rather, the companies that joined in the initiative did so more because of the increased awareness and peer momentum associated with the project. The study also found that while the number of company workplace policies increased, employees of the companies showed little change in knowledge of HIV or in their risk behaviors. Thus, without a concerted effort toward implementation, HIV workplace policies remained primarily paper exercises.
An Audit of HIV/AIDS Policies
Zungu-Dirwayi, N., Shisana, O., Udjo, E. et al. (eds.) Human Sciences Research Council (2004).
The audit covers policy responses and gaps in Botswana, Lesotho, Mozambique, South Africa, Swaziland, and Zimbabwe. For each country, a short overview of elements of the national HIV and AIDS policy, and other related policies, are provided. Given the date of the audit, prevention was a strong focus of most national policies, although one chapter of the report deals with national drug policies. A very useful chapter examines programmatic implementation of policies, identifies gaps and suggests initiatives to correct the gaps. The analysis includes some discussion of the roles of various actors in designing policies.
Structural Interventions to Reduce HIV Transmission among Injecting Drug Users
Des Jarlais, D.C. AIDS (2000), Vol. 14 Suppl. 1, pp. 541-546.
This article distinguishes structural-level interventions from individual- and social-level interventions. The article provides evidence that structural-level interventions, such as increasing legal access to sterile needles and syringes, are associated with “large effects” in decreasing HIV risk behavior among injecting drug users (IDUs). While individual and social-level interventions attempt to affect a person’s knowledge, attitudes, motivations, and social interactions; structural-level interventions seek to modify the environment that facilitates HIV risk behavior. Over-the-counter sales of sterile injection equipment at pharmacies have resulted in higher usage of sterile injection equipment among IDU populations in France; Glasgow, Scotland; and the state of Connecticut in the United States. The review also cites national studies in the United States and Australia that associate syringe-exchange programs with a reduction in HIV transmission among IDUs without increasing drug use in the general population. To maintain the effectiveness of these interventions, the review advocates for programs that do not limit the allowable number of syringes exchanged, and for including drug users in the design and implementation of risk reduction programs. Government programs that aim to reduce the distribution and usage of illicit drugs should not oppose structural-level HIV prevention programs such as needle exchange, but instead should work in tandem with interventions that reduce HIV transmission.
Ten Reasons to Oppose the Criminalization of HIV Exposure or Transmission
Open Society Institute (2008).
The criminalization of sex work and HIV transmission has appealed to lawmakers in many countries. Specific laws criminalizing forms of HIV transmission have been adopted in recent years. Initially intended to protect people, especially women, from willful transmission, such laws are often vague and ambiguous. Also, in many countries, sex work and injecting drug use linked with sex work are illegal. This document sets out ten arguments why criminalizing HIV exposure undermines prevention work; presents a cogent set of arguments against criminalizing transmission; and offers alternatives to strengthen prevention efforts that will be far more effective and successful in protecting people from transmission.
Evolution of Thailand’s Strategy to Cope with the HIV/AIDS Epidemic
Phoolchareon, W. Food, Nutrition and Agriculture (2005), No. 34, pp. 1-8.
The article describes how Thailand responded to HIV and AIDS and looks at the influences and some of the decision-making processes that informed the country’s HIV and AIDS policies and programs. The author notes, “the evolution of the policy may be categorized into three main phases–confrontation with the new epidemic; creation of unified alliances; and alleviation of the consequences of HIV and AIDS.” Each stage is described, although many of the details of the political and socioeconomic context are not included, giving the impression of a very centralized and top-down response by Thai authorities.
A similar but more general article by Phoolchareon entitled “Thailand” can be found in Fighting a Rising Tide: The Response to AIDS in East Asia. Tadashi Yamamoto and Satoko Itoh (eds). Center for International Exchange, Tokyo, (2006), pp. 247-265.
Breaking Barriers to HIV Prevention, Treatment, and Care for Women
Croce-Galis, M. Open Society Institute (2008).
This set of case studies describes interventions and activism by women to influence and shape policies, laws, HIV and AIDS programs, and access to HIV and AIDS services. One case example focuses on how Internet technology is used by activists to disseminate information, to organize and gain support for and deliver message on policies and policy implementation. Another case study summarizes the activities of the Malawi Health Equity Network. Among other things, the network analyzes the national budget before it is finalized and publishes the findings of the analysis in newspapers, to illuminate how funding is allocated. The public dissemination of the draft budget and related analysis allows other organizations to argue for changes before final adoption of the budget.
South Africa’s Treatment Action Campaign (TAC): An Example of a Successful Human Rights Campaign for Health. Chapter 3 in Introduction: Politics, Human Rights and Poor Global Health
Heywood, M. Treatment Action Campaign (2008).
The article summarizes the efforts of the Treatment Action Campaign (TAC) in South Africa to mobilize public opinion and pressure the national government to provide for the needs of people living with HIV and to expand resources for prevention initiatives. Heywood, an AIDS activist, argues that “the right to health [cannot] be pursued outside of law, politics or issues of governance.” In order to create a social movement, not just a top-down advocacy campaign, “TAC became the first AIDS organization to pioneer HIV ‘treatment literacy’ in a developing country. Treatment literacy is a program of health education and communication that aims to educate HIV-vulnerable and poor people about the science of HIV, health and the benefits of treatment.” TAC actively engaged with the South African government to achieve policy reforms and expand HIV and AIDS services.
Swaziland Antiretroviral Therapy Policy Dialogue (APD) Report
Southern Africa HIV and AIDS Information Dissemination Service (SAfAIDS) (2007)
The paper is a report of a workshop designed to provide community input to the policy and programmatic provision of ART in Swaziland. Representatives from a national organization of people living with HIV (PLWH), an organization of women living with HIV and AIDS, the national ART coordinator’s office, and a clinician from a health facility initiated the dialogue about the progress toward full implementation of the national policy. These representatives’ perspectives on the implications for service delivery of ART balanced the policy focus of the workshop. From the perspective of PLWH, far more was needed to meet their constituents’ needs. Each speaker included issues of prevention in their presentations. One participant noted that the workshop was a “good starting point in forwarding the ART agenda and as a mode of diversifying the means and source of information sharing and subsequent translation into action.”
HIV and AIDS Prevention and Control Act
Government of Kenya (2006), Act No. 14.
This legislation enacted in Kenya includes, among other things, language prohibiting discrimination against people living with HIV and AIDS. The law promotes HIV prevention and guarantees the full human rights of all citizens suspected or known to be infected with HIV and AIDS. It established a tribunal which is tasked “to hear and determine complaints arising out of any breach of the provisions of this Act.” The law has faced criticism from groups representing people living with HIV and AIDS and human rights advocates. They worry that one provision about knowingly transmitting HIV may subject all people living with HIV and AIDS to criminal law. Kenya is still working out details for implementation of the law.
The Role of Public Policy in Prevention and Control of Sexually Transmitted Infections: A Guide to Laws, Regulations And Technical Guidelines
World Health Organization (1999).
The guide provides a standard outline of key elements in developing a policy. Especially useful therein is the chapter dealing with operational factors to consider, not only when implementing a policy but also in considering the legal and regulatory factors during the drafting of a policy. An example of a national STI policy is offered in an annex to the guidelines. As in this instance, international agencies will develop such guidelines as a way to inform and influence country policy development.
Legal Aspects of HIV/AIDS: A Guide for Policy and Law Reform
Gable, L., et al. World Bank (2007)
A practical guide for assessing the need for legal reform to support effective action related to HIV and AIDS, the book covers 65 prevention, treatment, care and support and related topics. Each topic outlines the rationale for conducting a review of the policy and legal context and provides specific country and international agency examples of appropriate policy and legal responses.
Positive Dialogue Newsletter
The Lawyers Collective (India)
The Lawyers Collective is an Indian NGO that provides legal services and advocacy on HIV and AIDS, among other issues. Positive Dialogue is the collective’s newsletter for its HIV and AIDS-related activities. The newsletter has not been published since 2005, but the issues published up to that date provide critiques and analyses of national laws; on-going legal cases to protect the rights of people living with HIV; the rights of sex workers; and access to services. The newsletter is a useful tool for informing policy influencers and building support for policy and legal changes.
PolicyMaker 4 Software: Computer Assisted Political Analysis
Polimap, Brookline, MA
PolicyMaker is a software package that uses a rapid assessment method for analyzing and managing the political aspects of public policy. PolicyMaker is a logical and formal procedure to provide practical advice and to help decision-makers improve the political feasibility of their policy.
Health Policy Initiative
Health Policy Initiative
The Health Policy Initiative developed a set of computer-based models to assist planners and inform policy makers around the world. Many models have express relevance to HIV prevention, including the “Spectrum” models to project service needs, a number of workplace policy models, and the “Male Circumcision Decisionmakers Tool”.
Health Policy Initiative
A USAID-funded follow-on project to the Policy Project. The section headed Technical Briefs contains some useful case study materials.
A website devoted to articles and reports on numerous aspects of HIV and AIDS. Documents dealing with policy, legal and regulatory aspects of HIV and AIDS prevention can be found in the Human Rights/Violence/Infectious Diseases section and the Marginalized People section.
The Policy Project
The project has ended, but many papers and reports are available online.
UNAIDS Policies and Briefs
This web page houses a comprehensive set of briefs and practical guidelines promoting the "broad principles and standards" UNAIDS recommends to policy makers and programmers. Many areas of HIV prevention are covered, including male circumcision, condoms and post-exposure prophylaxis. Populations such as men who have sex with men, prisoners, injecting drug users, women and girls and others are addressed as well.
- An Overview of Structural Approaches to HIV Prevention
- Workplace Interventions to Prevent HIV
- Injection Safety
- Blood Safety and Availability
- Harm Reduction for Injecting Drug Users
- Prevention of Alcohol-related HIV Risk Behavior
- Multiple and Concurrent Sexual Partnerships
- Transactional and Age-disparate Sex in Hyperendemic Countries
- Male Circumcision
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