Addressing structural factors in HIV prevention and treatment

Addressing structural factors in HIV prevention and treatment

A series of papers, drawn from the 3rd Structural Drivers of HIV Conference, address the importance of understanding how broader social, cultural, economic and environmental factors shape HIV transmission.

The authors argue that the current implementation challenge for HIV prevention is the need to shift the AIDS response from an emergency mode to a programmatic long-term reaction. In every setting, interventions are entangled with local community dynamics and realities, therefore understanding, so adapting to a changing context is crucial.

The main factors that shape risk behaviour and the environmental factors that mediate the degree to which people can avoid HIV or access treatment vary according to:

  • location
  • age
  • social network

The first two papers provide a broad perspective of both the trajectory of the epidemic and the present pre-occupation with treatment scale up and the potential use of ‘treatment as prevention’.

The authors propose three transition points:

  1. Economic transition: the number of newly infected people falls below the number of deaths of people living with HIV
  2. Epidemiological: treatment programme scale-up is increasing coverage and reducing treatment needs
  3. Programmatic: the number of people newly initiated onto treatment exceeds the number who need it

They also stress the importance of understanding and considering the economic feasibility of the scale-up of Treatment as Prevention (TasP).

 The next papers look at the structural factors that shape individual risk behaviour, with a particular focus upon:

  • sexuality
  • intimacy and love
  • first sex
  • alcohol use

The authors use different sexual history narratives to contribute to the evidence needed to develop effective intervention for young people at risk of HIV infection.

Other papers in the series explore the challenge associated with implementing HIV prevention programmes that attempt to address issues of gender and poverty.

Through a cost simulation exercise it is concluded that scaling up cash-transfer programmes may be more expensive and less effective than other HIV interventions. The authors suggest that cash-transfer programmes are a short-term intervention, and to increase effectiveness should be linked to increasing girls’ educational attainment in order to promote lasting change. It is also argued that it may be most appropriate to co-finance cash transfer programmes across education and health sectors budgets.

Another focus within the series is upon intimate partner violence (IPV) and HIV risk among young people in urban informal settlements. Using the Stepping Stones and Creating Futures case study, the authors assess how implementation of interventions is hindered by structural factors such as:

  • poverty
  • gender inequality
  • dense social networks

The final papers focus upon adolescents. Parent-child connectedness is explored as a potential protective mechanism against undesirable sexual and reproductive health outcomes among young people in Tanzania.

Connectedness is influenced by:

  • economic circumstances
  • gender
  • social status
  • state education
  • globalisation

The papers in this volume stress the need to recognise that human behaviour is not determined by a single causal factor. Further, a sustained change in human behaviour is extremely difficult to achieve through discrete or generic ‘one size fits all’ interventions. 

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