HIV Prevention Knowledge Base
Structural Interventions: An Overview of Structural Approaches to HIV Prevention
Addressing Social Drivers of HIV/AIDS: Some Conceptual, Methodological, and Evidentiary Considerations
This paper examines the nature of HIV social drivers and how interventions to modify social factors are evaluated. Although there is no standard definition of social drivers, UNAIDS refers to them as the “social and structural factors, such as poverty, gender inequality, and human rights violations, that are not easily measured that increase people’s vulnerability to HIV infection.” Despite the difficulties inherent in measuring these factors and programs, the authors call for an improved evidence base in order to fully understand and distinguish social factors from behavioral approaches. They emphasize the need for consistent methods, measurement, and evaluation. Three case studies illustrate failed and successful social interventions, providing insight into the unexpected consequences of certain approaches and the complexity of evaluating programs. The authors conclude that despite the complexity of social drivers, it is possible to identify individual components of social factors in ways that allow program planners to devise clear and actionable steps.
Structural Approaches to HIV Prevention
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.
Understanding and Integrating the Structural and Biomedical Determinants of HIV Infection: A Way Forward for Prevention
According to the author, the two main pathways for HIV infection, sexual behavior and injection practices, are often classified and addressed as if they were primarily biological events. However, these pathways are related to behaviors and practices that are determined by socio-cultural, economic, cultural, and political forces that affect social norms. The author asserts that the ongoing epidemic in South Africa is in part due to the treatment of HIV as an individual health issue rather than a social health issue. The author provides comparisons of successful and unsuccessful prevention programs that address structural determinants of risk. For HIV-prevention programs to be effective, the author states, the focus must shift from behaviors such as vaginal intercourse, to the contexts in which sexual activity occurs, that is, to marriage, concurrent partnerships, sex work, and so forth
Structural Interventions: Concepts, Challenges and Opportunities for Research
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.
Structural Interventions in Public Health
This paper describes three categories of structural interventions: those that target availability, acceptability, or accessibility of health-related products or activities. Each of these approaches can, in turn, be targeted at the individual, organizational or social/legal/physical environmental level. An example of an availability approach is legislation prohibiting the sale of alcohol or tobacco to underage persons. An example of an acceptability intervention might include “shaming” initiatives, such as boycotts of risky products. Accessibility interventions address unequal access to products, such as condoms, due to unequal distribution of wealth and resources. Implications for HIV programs are discussed and a number of useful examples are provided, including provision of condom vending machines in bars, laws permitting pharmacy sale of syringes, and 100 percent condom policies.
A Structural Model of Health Behavior: A Pragmatic Approach to Explain and Influence Health Behaviors at the Population Level
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.
Structural Barriers and Facilitators in HIV Prevention: A Review of International Research
This literature review is among the first to assess how structural factors affect HIV risk and vulnerability. To date, most structural research has been conducted around poverty, population movement (including migration, wars, seasonal work), gender inequality, and HIV/AIDS reduction policies. The authors find evidence of these structural factors fueling the HIV epidemic worldwide, in both developed and developing countries. Less research, however, is available on interventions that attempt to address these structural factors. Where such interventions have been tried, they are primarily implemented among sex workers, truck drivers, men who have sex with men, and heterosexual women. The authors conclude that a shift is taking place from focusing on individual, behavioral factors in HIV prevention efforts to examine structural forces that affect HIV risk. They present research questions to help guide future research, and hopefully spur innovative approaches to “achieve more broad-based social and structural change.”