An Overview of Structural Approaches to HIV Prevention
I. Definition of the Prevention Area
Structural approaches reduce an individual's HIV-related vulnerability by creating the conditions in which people can adopt safer behaviors. For example, making micro-finance loans available to poor women can reduce their need to engage in transactional sex, which may reduce their vulnerability to HIV infection.
Structural approaches include social, economic, and political interventions that can improve public health outcomes by increasing the willingness and ability of individuals to practice prevention.
Auerbach and colleagues (2009) categorize structural interventions that focus on three areas of change:
- Social change: These approaches focus on factors affecting multiple groups (e.g., a region or country as a whole), such as legal reform, stigma reduction, and efforts to cultivate strong leadership on AIDS.
- Change within specific groups: These approaches address social structures that create vulnerability among specific populations, such as men who have sex with men, mine workers, young women, or poor women. Examples include efforts to organize and mobilize sex workers, micro-finance programs for poor women, and interventions to change harmful male norms.
- Harm reduction or health-seeking behavior change: These approaches work to make harm-reduction technologies available to those in need and to change rules, services, and attitudes about these technologies. Examples include efforts to provide safe housing for drug users and 100 percent condom use campaigns.
II. Epidemiological Justification for the Prevention Area
Structural approaches to HIV prevention represent an evolving area of prevention. There is less consensus about this area, yet many agree that structural factors may in part help explain the existence of hyper-epidemics, such as those seen in Southern Africa. The most effective structural approaches will use a combination of strategies that are tailored to a given social, political, economic, and epidemic context.
View Combination Approaches to HIV Prevention
III. Core Programmatic Components
The nature of an epidemic may necessitate different types of interventions. For example, concentrated epidemics may best be addressed through legal and policy approaches, such as legalizing needle and syringe exchange, facilitating and enforcing condom use by brothel clients, and legalizing same-sex practices.
In more generalized epidemics and hyper-endemic areas, interventions may be broadened to include cultural, social, and economic approaches, such as interventions to reduce the economic dependency of women on men and/or to reduce violence against women. Other approaches might address the social norms that affect sexual risk-taking or enact social protections for poor and/or affected people.
An example of a group that uses a broad range of innovative approaches for prevention is the aids2031 initiative. The organization promotes enforcement of a minimum legislative standard, which includes the following provisions: 1) decriminalize HIV status, transmission, and exposure; 2) decriminalize same-sex practices and sexual diversity; 3) decriminalize sex work; 4) ensure access to harm reduction services for drug users; 5) guarantee equal rights of people living with AIDS; and 6) equalize men's and women's legal rights.
IV. Current Status of Implementation Experience
Structural approaches to HIV prevention have been employed throughout the epidemic, but such strategies have only recently emerged as an internationally recognized, distinct area of HIV prevention. Although there is a growing literature describing and categorizing structural approaches, few programs have been rigorously evaluated. This remains an emerging programmatic area, and work is needed to reach consensus on how to integrate structural approaches into comprehensive HIV prevention.
Quantifying the effectiveness of structural intervention programs can be difficult for several reasons: there is no direct, one-to-one relationship between structural interventions and HIV incidence; structural interventions are not generally amenable to randomization; and causal pathways from intervention to AIDS outcome are usually indirect and complex. It will be necessary to develop evaluation methodologies not classically used within public health, and to engage more social scientists in program design and evaluation.
Updated: March 2011
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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 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.
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
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.
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.
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.
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."
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The authors of this study of sexually active women in two provinces of the Dominican Republic sought to examine factors related to a woman's ability to negotiate her partner's behavior and to avoid HIV. Nearly half of the women had received loans and nearly half relied completely on their partner or others for financial support. While the majority of women (62 percent) reported that they did negotiate with their partner to avoid HIV, there was no observed difference between those who received loans and those who did not. However, obtaining a loan did not guarantee that women remained in control of the money. However, women who retained control of their money were significantly more likely to enter HIV-related negotiation than those who did not maintain control over the money.
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 study examined the hypothesis that school attendance among a rural South African population would be associated with lower HIV prevalence and less sexual risk-taking. The investigators also explored the mechanisms through which HIV risk and education might be mediated. The findings were encouraging. The researchers found that school attendance was indeed associated with lower-risk sexual behaviors. For example, school attendees of both sexes had fewer sex partners than their non-attending counterparts and were more likely to use condoms during sex. School-attending young women were less likely to have sex partners greater than three years their senior, and young, male, school attendees had a lower prevalence of HIV. The authors conclude that "[s]econdary school attendance may influence the structure of sexual networks and reduce HIV risk. Maximizing school attendance may reduce HIV transmission among young people."
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 report and its companion report, Reducing AIDS-related Stigma and Discrimination in Indian Hospitals 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 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 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.
This brief describes Stepping Stones, an HIV prevention project that focuses on developing more gender-equitable relationships. Data from project efforts on the Eastern Cape of South Africa found decreases in HIV and herpes (HSV-2) infections among men and women participating in the project, although decreases were not statistically significant. While transactional sex behaviors generally remained unchanged, men participating in the project reported a statistically significant decrease in sex partners at one and two years of follow up. Qualitative research indicates that profound changes in communication took place among partners, particularly among men and how they related to others. Changes in individual attitudes as a result of the project intervention can ultimately impact HIV rates through providing participants with knowledge about HIV risks, raising awareness of personal risks, and fostering a culture of openness about HIV in the intervention communities.
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.
Forty South Asian organizations working on the intersection between property rights and HIV formed the basis for this research through qualitative interviews. Program implementers, key informants, and women living with HIV described their experiences of property dispossession--including eviction and household asset liquidation--stigma and discrimination, and challenges in resolving their children's inheritance claims. Activities that reduce the economic vulnerabilities of women living with HIV include providing legal aid to support formal legal recourse for securing property; using informal community-based dispute resolution rooted in tradition; and mediation involving the use of groups that negotiate on a woman's behalf, which facilitate negotiation of property between a woman and her family. The authors recommend using an integrated, collaborative approach addressing underlying norms that may influence women's property rights along and other immediate needs.
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 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.
Because intimate partner violence has been tied to HIV risk (women may be physically or financially pressured to submit to unsafe sexual relations) some researchers have recommended interventions to empower women in order to reduce their vulnerability to violence and the attendant risk of HIV. The authors of this interventional study examined how microfinance loans to poor women affected intimate partner violence, their use of condoms, and the incidence of HIV. To do this, they combined loans with a "gender and HIV training curriculum" in pair-matched communities of South Africa, in which one community served as a control for the active intervention. Over the two-year study period, intimate partner violence decreased by 55% in women in the intervention group relative to the comparison group. Positive effects on women's economic well-being, social capital, and empowerment were observed. However, there was no change in condom use or the incidence of HIV.
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.
This intervention focused on increasing condom use among sex workers in Calcutta, India to reduce HIV transmission. The study was conducted in two small urban communities and involved 100 sex workers at each site. One site served as the control arm. The project reached women in the intervention arm using community organizing and advocacy, peer education, and condom social marketing. In addition, sex workers in this intervention arm were able to access free reproductive and sexual health services through a health clinic established in their community. After 15 months of follow up, condom use was 39% among sex workers in the intervention group and only 11% in the control arm. The authors conclude that this intervention, modeled after the Sonagachi project, is effective in increasing condom use, thus helping reduce HIV prevalence among sex workers.
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.
This paper evaluates the impact of two structural intervention models promoting 100% condom use in 34 sex establishments in Santo Domingo (basic intervention) and 34 in Puerta Plata (enhanced intervention). The basic intervention focused on building solidarity among sex workers, sex establishment owners, and other members of sex work community. The enhanced intervention included the above, plus regional government policy requiring condom use in all participating sex establishments. An increase in consistent condom use (CCU) with new clients occurred in both sites, but a significant increase in CCU with regular partners during the last month only took place in the enhanced intervention group. This group also saw a significant increase in verbal rejection of unsafe sex. The prevalence of sexually transmitted infections decreased significantly in both groups, with a stronger effect in Puerta Plata. Participants with high levels of exposure to the intervention were almost twice as likely to use condoms consistently. The researchers concluded that the enhanced intervention model was more cost-effective than the basic intervention.
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."
Data and focus group discussions from the Kagera AIDS Research Project from 1987 through 2002 informed behavior changes in Bukoba, Tanzania that may explain declines in HIV. The authors identify four changes in the social-structural environment: 1) a perceived threat due to seeing many people sick and dying; 2) increased social incentives for change; 3) evolving community consensus for need to change to low-risk behaviors; and 4) increased social sanction against those who break the new rules. Individual behavior changes included increased use of condoms, reduced concurrent partnering, an increase in voluntary HIV testing and counseling, a decline in practicing widow inheritance, less alcohol use, and a decline in polygamy. However, there were also higher separation and divorce rates and increased violence against women stemming from increased HIV-related stigma. The researchers state that individuals "are more likely to be influenced by group or community dynamics… than by their mere personal knowledge and awareness" and they conclude that the "agony of AIDS" together with increased health education, a strong National AIDS Control Program, and the presence of an ongoing AIDS research project all contributed to the positive outcomes.
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.
This paper begins with presenting the rationale behind developing socialization interventions for young men in the fight against HIV. It then describes Project H, designed to reduce HIV risk behaviors by questioning traditional "macho" norms among men ages 15-24. The researchers developed a Gender Equitable Attitudes in Men (GEM) scale to measure changes in attitudes and social norms around manhood as a result of the project. The author details the GEM development process and presents preliminary results of Project H in Rio de Janeiro, Brazil. These data indicate that Project H did indeed have an impact, and that the GEM scale is a valid model for measuring changes in gender attitudes. (For more results from this project, see Promoting Healthy Relationships and HIV/STI Prevention for Young Men: Positive Findings from an Intervention Study in Brazil.)
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 project seeks to end the acceptance of cross-generational sexual relationships in Tanzania. The program consists of a radio show and posters depicting a pathetic and lecherous older man named Fataki, who is repeatedly thwarted by community members and young women who reject his unwanted advances. The program targets the families and friends of young women, and is intended to reduce acceptance of cross-generational sex and to provide family and community members with a language for protecting their loved ones from being lured into such relationships. The program is broadcast six times a day on 15 radio stations nationwide. The messages conveyed in these programs are reinforced with 1,000 banners and posters shown in 10 regions of the country. The project is showing striking success - community members surveyed are more aware of the problem of cross-generational sex and are more likely to reject it in their communities. An increasing number of people report having intervened in an effort to protect a loved one. The word "Fataki" has also entered the mainstream lexicon as a new moniker for a predatory older man.
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This training manual was developed to help hospital workers feel safe while providing care for HIV positive individuals and simultaneously creating an environment where HIV-positive clients feel safe and welcome. The training targets all hospital workers, including administrative and support staff. The curriculum provides recommendations on how to plan and organize the training in a way that actively engages the administration. The curriculum includes content on basic information about HIV/AIDS, how staff can follow universal precautions for protection, and HIV stigma and discrimination. It ends with exercises that participants use to develop policy guidelines and a code of practice ensuring a safe and friendly health facility.
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.
Available in English, Spanish, French, and Portuguese, this 17-page report based on a Global Survey on HIV and AIDS and Disability provides guidelines for a range of "no-cost" and higher cost approaches that can be used by program implementers, policymakers, advocates, and educators to ensure that individuals with disabilities are included in HIV prevention efforts.
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.
Developed for use by Men As Partners educators, trainers can use this manual to design workshops that best fit their needs: A one-day HIV/AIDS workshop, for example, or a five-day life skills workshop. It can also be used for different groups, such as men only, adolescents, or men and women together. Interactive exercises, case studies, and icebreakers are used to highlight key points about life skills. Training activities include topics on gender and sexuality (such as gender stereotypes, sexual orientation), male and female sexual health (anatomy and physiology, myths and facts about family planning), HIV and other sexually transmitted infections, relationships (fatherhood, unhealthy relationships), and violence, including examining and defining sexual and domestic violence.
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.
Five manuals, available in Spanish, English, and Portuguese, support work with young men in order to explore their concepts of masculinity. The program uses interactive activities and theoretical content. Each manual contains an introduction on a specific theme; a description of the group activities; and a list of references for further research, including videos, websites, and organizations that work in the area. The five manuals are:
Volume 1: Sexuality and Reproductive Health
Volume 2: Fatherhood and Care-giving
Volume 3: From Violence to Peaceful Coexistence
Volume 4: Reasons and Emotions Volume
5: Preventing and Living with HIV/AIDS
This manual outlines a participatory, human rights-based approach for working with communities that are affected by HIV. The process engages all community members ages 11 years and older in a series of meetings. The process employs a "bottom-up" response to the epidemic and has been used with a wide range of communities to address sensitive issues including violence, stigma, gender inequalities, homophobia, and coping with grief.
Men As Partners Program
EngenderHealth, New York.
The Men As Partners Program works to address the imbalance between reproductive health programs focusing on women and the degree of decision-making power that women often have about their health-seeking behaviors. As such, the program focuses on educating men about the importance of good reproductive health--both their partner's and their own. The program also works to increase men's access to reproductive health services and catalyze men to "take an active stand for gender equity and against gender-based violence." This website contains technical publications related to the Men As Partners program, including a program manual and men's reproductive health curriculum, as well as multimedia resources.
View Men As Partners Website