A fundamental goal of HIV prevention is to change the behaviour that puts individuals at risk of infection. For the past two and a half decades, HIV prevention has been dominated by individual-level behavioural interventions that seek to influence knowledge, attitudes, and behaviours, such as promotion of condom use, or sexual-health education, and education of injecting drug users about the dangers of sharing equipment.
Coates and colleagues1 show in their review of individual behaviour change strategies in this Series that, although some individually oriented interventions have shown results in reducing risk behaviour 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.
Causal pathways link so-called structural factors—social, economic, political, and environmental factors—and risk of HIV. Efforts to address these underlying factors are commonly referred to as structural approaches and seek to change the root causes or structures that affect individual risk and vulnerability to HIV. However, as Merson and co-workers2 point out in this Series, structural approaches are just part of an overall HIV prevention strategy and must be complemented by other prevention options and HIV treatment to achieve maximum reductions in HIV risk and vulnerability.
Progress in incorporating structural approaches into HIV prevention has been limited because of a lack of conceptual and technical consensus on definition and implementation, and because of methodological challenges in their assessment. Because many structural approaches address deeply entrenched social, economic, and political factors—such as gender or income inequality and social marginalisation—that are difficult to change, they are commonly viewed as long-term initiatives that belong within the purview of broader economic and social development as measured through development achievements, such as the UN Millennium Development Goals (MDGs),3 rather than within the scope of HIV prevention.
We review existing theoretical frameworks and use evidence and examples to define structural factors and structural approaches. We discuss the limited evidence available on the effectiveness of such approaches and the methodological challenges to the assessment of complex, multilayered social, economic, and political efforts to reduce HIV risk and vulnerability. Crucially, we build on insights gained through experience implementing these approaches in different settings to identify some core principles and guidelines, making a structural approach to HIV prevention more feasible. We conclude with recommendations on directions for research and action to integrate a structural approach into combination prevention.
Key messages
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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
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Structural factors include the physical, social, cultural, organisational, community, economic, legal, or policy features of the environment that affect HIV infection. These factors operate at different societal levels and different distances to influence individual risk and to shape social vulnerability to infection
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Structural approaches to HIV prevention seek to change social, economic, political, or environmental factors determining HIV risk and vulnerability. 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
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Like all features of HIV prevention, structural approaches can be challenging to assess. They are not always amenable to assessment with comparative experimental designs because of their situational specificity and the need to address multiple interacting elements. Alternative methods for rigorous assessment do exist, but further developments are needed