Structural factors (economic, social, political, environmental) can affect HIV risk. For example, gender inequality is linked to unprotected sex. That could be due to male control of finances or due to male physical violence, causing some women to submit to unprotected sex out of fear of physical violence or fear of losing financial support. Although the outcome is the same in either case, the necessary interventions differ. Financial problems could be addressed by micro-loans and changes in inheritance laws that treat men and women unequally. Male violence might be addressed by programs exploring concepts of masculinity. Monitoring and evaluating structural approaches can be difficult since such programs don’t readily lend themselves to experimental design. As such, the authors provide recommendations for undertaking program assessments.

This paper reviews four types of structural interventions: 1) community mobilization; 2) integration of HIV services; 3) contingent funding (which makes receipt of federal or state funds contingent on implementing certain laws or policies); and 4) economic and structural interventions. Social science theories about the structural dimensions of health, according to the authors, might be seen as “pie in the sky” and could be difficult to apply at a programmatic or policy level. Nonetheless, public health scholars and practitioners have taken such interventions as a starting point and created a body of literature that assesses the impact of structural interventions. This approach may also be limited, however, because of its focus on ‘tried and true’ approaches and proximate causes, which may fail to address more complex, fundamental determinants. The authors conclude that structural approaches are most effective when they occur spontaneously and emerge organically from communities (rather than being ‘implemented’ by an outside agent), and that they can have unanticipated consequences.

The authors address two fundamental types of health interventions: those that target individuals through behavioral approaches and those that address factors that are beyond individual control (structural interventions). The paper reviews four structural factors: 1) availability and accessibility of health- (or illness)-producing commodities; 2) physical structures (or the physical properties of products); 3) social structures and policies; and 4) media and cultural messages. The authors point out that increased knowledge alone (an individual or behavioral intervention) may not result in changed behavior unless such programs are accompanied by structural changes. For example, people may know that condom use reduces risk, but without a program that provides low-cost or free condoms, such knowledge may not be useful.

The authors analyze legal frameworks, human rights, and stigma and discrimination in relation to sexual diversity and gender non-conformity in low and middle-income countries. The legal systems of 153 nations are ranked as being highly or moderately repressive of sexual diversity, neutral, or protective. Despite substantial information gaps, it was clear that repressive policies were common in many parts of the world. Available data suggest that legal frameworks and State practices against sexually diverse populations may present obstacles to HIV prevention and care in many nations where epidemics are concentrated among men who have sex with men. The authors present 10 strategies that can be used to help promote more equitable legal protections for people of all sexual orientations, including using the judicial system when the legislature is unlikely to support such rights and promoting the notion that sexual rights are a part of human rights.

This participatory, community-centered project in two Vietnamese provinces addressed stigma associated with HIV, including the lack of awareness of stigma and its harmful effects; fear-driven stigma; and value-driven stigma. Among the interventions were stigma-reduction sensitization workshops for authorities and representatives of social organizations and a workshop for community members to develop their own stigma-reduction action plans. Community members led the design and implementation of the stigma-reduction activities they devised in the community workshop. The program increased awareness of stigma among the population and reduced fear-related stigma as well as active discrimination against people living with HIV in the community. However, overall levels of stigma remained high at the end of the intervention, indicating the need for ongoing stigma-reduction efforts. The authors stress the importance of community ownership and stewardship of the stigma reduction process and of ensuring that all materials are tailored to the local setting. Appendices include a list of tools and a timeline that guides program implementation.

This comprehensive report on legal issues related to HIV covers 12 broad topics, including Disclosure and Exposure, Sex Work, Clinical Research, and Access to Medicines. Subsections address topics such as Criminal Statutes and Police Harassment; International Drug Conventions: Punitive versus Public Health Approaches; Confidentiality; and Procurement of Pharmaceutical Products. A section on general discrimination related to HIV describes laws that protect against discrimination based on HIV status or health status and identifies four locations that have laws explicitly forbidding this type of discrimination (the Philippines, the Bahamas, South Africa, and New South Wales, Australia). The ways in which disability laws confer protection are explored and workplace issues, including mandatory testing, denial of employment, differential treatment and disclosure and confidentiality are addressed. Health sector and immigration issues are also examined in depth, as are issues of discrimination in public and private benefits. Specific practice examples are provided for each topic, along with an analytical discussion of legal and policy considerations and a full list of references.

Brazil’s Ministry of Health instituted the mass media campaign “Acceptance Begins at Home” in the early 2000s to promote condom use among men who have sex with men (MSM) and combat homophobia and discrimination among the general population, and health providers in particular. The campaign included advertisements for television, movie theaters, and magazines, as well as posters and leaflets promoting respect for those from sexually diverse populations, particularly homosexual men. A key part of the project was managing the controversy sparked by the campaign. At the outset, actions were taken to deal with possible counter-campaigns (and possible increases in violence) including mobilization of key opinion leaders and institutional representatives. Community support included the homosexual movement and NGO community; civil servants, including members of the House of Representatives; and the Federal Government. Two years after the launch of the campaign, the Ministry of Justice launched “Brazil without Homophobia,” a campaign to fight discrimination and violence. This program included concrete initiatives for providing equal access to education, health care, and justice for MSM.

Mahendra, V.S., Gilborn, L., George, B., et al. Population Council, New Delhi (2006). This report and its companion report, Improving Hospital-based Quality of Care in Vietnam by Reducing HIV-related Stigma and Discrimination discuss programs for stigma reduction within health care settings in Vietnam and India. Both reports suggest that reductions in stigma and discrimination against people living with HIV in hospital settings are possible. To achieve this, interventions must be address (1) fear of occupational exposure and contagion, and (2) moral judgments and value assumptions about people living with HIV. Interventions must be developed in partnership with key stakeholders, including patients and health providers, and need to include the full range of hospital staff.

This paper presents two differing views of what drove the reduction in HIV prevalence in Uganda in the 1990s. The first viewpoint asserts that many “ABC” approaches implemented in Uganda addressed gender inequity by challenging gender norms, which ultimately contributed to their success. Other components included nationwide social mobilization, gender empowerment policies, and honest talk about AIDS and gender inequality by those at the very top of government, including President Museveni himself. The other viewpoint questions whether the “ABC” approach is responsible for the decline in HIV. The authors argue that focusing on abstinence can confuse people about the proven HIV prevention abilities of condoms. To support this claim, they cite 2005 data of young Ugandans being more concerned about pregnancy than HIV, and how condoms are seen primarily as a tool for pregnancy prevention. The authors conclude that evidence-based prevention messages, counseling, and support services are crucial in HIV prevention efforts.

This paper explores the relationship between housing and sexual and drug-related risk behavior among people living with HIV in Australia. Researchers found the odds of recent drug use, needle use, or sex exchange were higher at baseline among people who were homeless or had unstable housing than among those with stable housing. People whose housing status improved at six to nine months follow-up compared to baseline had reduced risks of drug use, needle use, needle sharing, and unprotected sex compared to those whose housing status did not change. For those whose housing situation worsened, the odds of recently exchanging sex was more than five times higher than for those whose status did not change. The authors conclude that providing housing is a promising structural intervention to reduce the spread of HIV. Furthermore, this study suggests that structural-environmental factors can be critical in HIV prevention even in a well developed economy.

Project H was designed to address HIV and other sexually transmitted infection (STI) risk among young men in Brazil and promote healthy relationships between men and women. Different interventions were used among three groups of men in three sites to identify which mix of interventions had the most impact. A curriculum included role plays, discussion sessions, and other interactive activities to reflect upon gender-equitable behaviors and understand the “costs of traditional masculinity” and was complemented by a social marketing campaign. After six months, men in intervention arms showed more support for equitable gender norms compared to baseline. At one year, the intervention sites had increases in condom use and fewer reported STI symptoms than at baseline. There was no decrease, however, in multiple partners nor were participants more likely to use condoms with casual partners. This study shows that it is possible to influence young men’s attitudes about gender roles. Program H materials have become part of national adolescent health activities in Brazil and Mexico, and have been used worldwide.

The authors of this paper assert that the rapid HIV decline in Uganda was a result of behavior change and communication about HIV on the community level—responses that preceded formal HIV prevention programs. Personal communication about HIV in Uganda was prevalent, and was mobilized by multiple players: political, cultural, faith-based organizations, non-governmental organizations, military, and community figures. The authors support their claim by presenting data showing a substantial reduction in casual sex partners over time. The government also significantly invested in clear HIV messages, AIDS case surveillance, and care for those with HIV, which supported the community response. Although they claim that Uganda is unique in that it found its own response to the epidemic, the authors show evidence of decline in HIV prevalence among white gay men in the United States, sex workers in Thailand, and certain groups in Brazil, Senegal, and Zambia driven by population-based behavior change. The authors conclude that if translated to other settings, this African HIV prevention success can “provide a social vaccine more powerful than any of the programs or biomedical approaches proposed from outside.”

This paper presents the relationship between women’s property rights and HIV prevention and mitigation. Women are frequently prevented from owning or controlling property in developing nations, which can result in a widow losing her deceased husband’s property to his family. Despite laws designed to protect women from forced removal from their land or home, social norms and local customs can override the law. The authors discuss the gap between the law and social reality in Kenya, Lesotho, Malawi, Namibia and Zambia. Other barriers to women’s tenure over land, housing, and other property include lack of awareness of the law; cumbersome and costly legal systems; corruption; threats of domestic violence; and natural and human-made disasters. To combat these barriers, programs can promote gender-sensitive legislation, protect women’s rights, increase the judicial sector’s capacity to uphold women’s rights and provide effective litigation; and promote awareness of women’s rights. Recommendations for next steps include a special focus on legislation and reform; judicial capacity and litigation; education and awareness; creation of networks; and research and evaluation.

The authors provide an in-depth overview of the mining industry in South Africa, how it has (and has not) responded to HIV, and how a complex chain of factors can make mineworkers vulnerable to HIV. Many of these issues, the authors argue, are not addressed by the HIV prevention programs offered by mine management, which focus only on information-based education, and testing and treatment of sexually transmitted infections. The authors contend that the most important factors shaping HIV vulnerability in this population include economic inequality, unequal gender norms, and the dangerous conditions in the mines, which leads to a sense powerlessness and fatalism among the miners. The paper describes an intervention that addresses HIV vulnerability in this population in a more comprehensive manner.

This toolkit is a revision of a 2003 report written by AIDS activists from over 50 NGOs in Ethiopia, Tanzania, and Zambia. The activists participated in workshops in which they explored the implications of stigma and designed exercises on different aspects of stigma reduction. This toolkit has modules and exercises to challenge stigma and discrimination among people at all levels. In addition to addressing stigma among heterosexual adults with HIV, there are modules addressing stigma among children, youth, and men who have sex with men. Readers can download the entire manual, individual modules, or a booklet containing images juxtaposing scenarios of stigma with scenarios in which human rights that have not been violated.

This two-volume training course guides health workers through an investigation of the root causes of HIV stigma and discrimination. At the same time, it helps them understand their own attitudes about HIV and AIDS and how these attitudes may affect the people they care for. Available in French and English, the curriculum consists of a 75-page participant's handbook and an 85-page trainer's manual. The training uses role-playing, small- and large-group discussions, and brainstorming activities. Curriculum topics include clients’ rights to receive health care services; the use of standard precautions and proper infection prevention techniques to minimize the risk of occupational exposure to HIV; and developing action plans to help participants put what they have learned into practice at their service delivery sites.

International Community of Women Living with HIV (ICW), International Planned Parenthood Federation (IPPF), Global Network of People Living with HIV (GNP+), UNAIDS, South Africa. It can be difficult to quantify the notion of stigma or discrimination. However, it is important to understand to what degree these issues exist in a country to be able to effectively combat them. Thus this tool not only measures stigma and discrimination that people living with HIV experience but also provides ways that stigma can be addressed. This website provides readers with the methodology, key steps for implementation, and guidance on communicating the results. The data collected can be used to influence national policies and program design. The use of the tool over time, in conjunction with surveys, can enhance collective understanding and detect changes and trends.Over 20 countries used this index in 2009-2010.