Structural Approaches to HIV Prevention

Published as one of a series of six articles about HIV prevention in The Lancet (Vol. 372, pp. 764 - 775), this report builds on evidence and experience to address gaps affecting use of the structural approach to HIV prevention. The authors begin by defining structural factors and approaches; then they describe the available evidence on their effectiveness and discuss methodological challenges to the assessment of these efforts to reduce HIV risk and vulnerability. They identify core principles for implementing this kind of work and provide recommendations for ensuring the integration of structural approaches as part of combined prevention strategies.

The authors state that HIV prevention has been dominated by individual-level behavioural interventions that seek to influence knowledge, attitudes, and behaviours, such as promotion of condom use and sexual-health education. However, as stated here, "their success is substantially improved when HIV prevention addresses the broader structural factors that shape or constrain individual behaviour, such as poverty and wealth, gender, age, policy, and power." Structural approaches seek to change the root causes or structures that affect individual risk and vulnerability to HIV. Recognising the methodological challenges of assessing complex structural approaches and building upon insights from their experience implementing these approaches, the authors offer the following key messages:

• "HIV prevention efforts cannot succeed in the long term without addressing the underlying drivers of HIV risk and vulnerability in different settings. HIV prevention programmes therefore need to incorporate structural approaches."

• "...the defining characteristic of structural approaches, regardless of whether they are single policies or programmes ...or transformational processes..., is that they aim to change the social, economic, political, or environmental factors that determine HIV risk and vulnerability in specified contexts....They should be implemented in a contextually sensitive way, in recognition of both the need for situational relevance and the interaction between different levels of influence.”

• "Like all features of HIV prevention, structural approaches can be challenging to assess....Alternative methods for rigorous assessment do exist, but further developments are needed."

The document describes several projects that exemplify structural approaches, including the Sonagachi project in Calcutta, India, which, according to a project assessment, lowered HIV prevalence from the range of 50-90% to 10% among urban sex workers through creating an enabling environment for the sex worker groups to mobilise themselves. Program H in Brazil lowered the proportion of men who endorse gender inequitable norms through encouraging young men to question traditional gender norms and promoting both discussion and reflection about the costs of inequitable definitions of masculinity and the advantages of more gender-equitable behaviour. The IMAGE project of South Africa addressed gender-based vulnerabilities by partnering with a local microfinance institution to enable women to pursue microenterprises, while offering participants HIV education and creating opportunities to discuss and mobilise local action against gender-based violence. The study team for this project estimated that over 2 years, levels of intimate partner violence were reduced by 55% in the intervention group relative to the comparison; but the level of HIV incidence was not affected.

The document discusses implementation of structural approaches and gives examples of how structural approaches must be location-specific, but may be adapted to other locations. It gives examples of the effectiveness of these approaches in HIV prevention, e.g. "reviews of studies in which policy changes have allowed for needle exchange and methadone treatment programmes show substantial reductions in HIV risk in areas in which HIV is spread through injected-drug use. The inclusion of drug users in the design and implementation of these programmes can further increase their effectiveness. Stable housing is another effective structural HIV prevention approach to reduce the risks associated with injecting drug use."

Among the problems of assessing structural approaches are the following:

• When focusing on a single distal factor (a single focus, like the exposure of sex workers), there might be multiple causal pathways (e.g. poverty, gender-based violence, etc.), by which this factor affects a given HIV prevention outcome; and the mechanism by which it influences the outcome may be different in different contexts.

• Many structural approaches involve social and political mobilisation of groups, resulting in multiple and dynamic responses and activities, which makes the measurement the effectiveness of a single approach factor difficult.

• A related challenge is that the results from the assessments of structural approaches are not easily transferable when the activities involved are designed for specific local contexts, preventing easy standardisation of assessment tools.

The document recommends that assessment of projects implemented by non-research agencies - who may be well acquainted with local needs and realities -  involve researchers who are knowledgeable about measurement and analysis of structural factors. It states that assessments should document context differences and explore the mechanisms by which an intervention works for a particular group, and how those mechanisms may be different across contexts. However, applying randomised controlled trials is characterised as "not always the best way to assess the effectiveness of complex structural approaches" because they are more appropriate when the intervention being tested is proximate to the risk behaviour that it is seeking to change - generally not the case in structural approaches. The document recommends instead:

1. alternative social science methods of assessment, such as realistic evaluation, "an approach that calls for rephrasing the question of what works to what works for whom, in what situations." It includes routine process assessment of interventions.
2. a clear and well-researched causal model or framework, including a combination of qualitative and quantitative methods and analysis, as well as explorations of process.
3. prioritisation of partnerships between researchers and people implementing structural approaches.

It concludes by recommending that the Millennium Development Goals (MDGs) be used as a framework for promoting structural approaches in HIV prevention, though cautions that these approaches not be equated with the broader development agenda, or that MDG indicators be used exclusively as guides. It suggests that domestic and international aid spending be monitored to see how much is actually spent on local needs and on enabling local responses.

Note: this article is freely accessible with a complimentary registration/log-in to the Lancet. Click here for access.

Click here to access "Putting prevention at the forefront of HIV/AIDS", by Richard Horton and Pam Das. This Introductory essay to the series of which the above-summarised article is a part provides background and the rationale for this Lancet effort to provide a simplified road map for countries seeking to develop their own evidence-driven strategies to respond to AIDS. The Lancet series was launched at the International AIDS conference in Mexico City, Mexico, in August 2008.