Elsevier

The Lancet

Volume 372, Issue 9640, 30 August–5 September 2008, Pages 764-775
The Lancet

Series
Structural approaches to HIV prevention

https://doi.org/10.1016/S0140-6736(08)60887-9Get rights and content

Summary

Recognition that social, economic, political, and environmental factors directly affect HIV risk and vulnerability has stimulated interest in structural approaches to HIV prevention. Progress in the use of structural approaches has been limited for several reasons: absence of a clear definition; lack of operational guidance; and limited data on the effectiveness of structural approaches to the reduction of HIV incidence. In this paper we build on evidence and experience to address these gaps. We begin by defining structural factors and approaches. We describe the available evidence on their effectiveness and discuss methodological challenges to the assessment of these often complex efforts to reduce HIV risk and vulnerability. We identify core principles for implementing this kind of work. We also provide recommendations for ensuring the integration of structural approaches as part of combined prevention strategies.

Introduction

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

  • 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

  • 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

  • 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

  • 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

Section snippets

What are structural factors?

Several attempts have been made to define, identify, and categorise structural factors in HIV epidemics. In 2000, the journal AIDS dedicated an entire issue to structural factors, defined as physical, social, cultural, organisational, community, economic, legal, or policy aspects of the environment that impede or facilitate efforts to avoid HIV infection.4 Because of the wide range of factors that can be defined as structural, there have been several attempts to classify them. These frameworks

Evidence linking structural factors and HIV

For many people, the simple fact that 90% of the world's HIV infections occur in developing countries is evidence that social, economic, and political structures drive risk behaviours and shape vulnerability. However, there are many types of evidence showing the importance of structural factors in HIV epidemics.

Some studies show an association between structural factors and HIV risk without establishing direct causality. These include studies of the macrolevel correlates of infection, such as

What are structural approaches?

Structural approaches include structural actions implemented as single policies or programmes that aim to change the conditions in which people live, multiple structural actions of this type implemented simultaneously, or community processes that catalyse social and political change. These approaches can be applied in combination with behavioural or medical interventions targeted at individuals. When a structural approach is taken, it can result in activities or services being delivered to

Implementation of structural approaches

Structural factors and, by inference, approaches, are sometimes passed over by the health sector as being too broad, too diffuse, and outside the remit of health programming. Often this is a reaction to the fact that risk and vulnerability can be, and often are, linked to distal, society-level factors, such as gender inequality or social marginalisation, that are beyond the control of individual health-service providers or clients. However, total change of a distal structural factor might not

Are structural approaches effective?

A growing number of studies have assessed the outcomes and effects of structural approaches for HIV prevention. Since structural approaches involve different activities in different settings, there will not be a single level of effectiveness in reducing HIV incidence for all approaches any more than there is for approaches that promoted behaviour change at the individual level.

Conclusion

Sustained progress in HIV prevention requires structural approaches rather than continuing to address individual-level factors. Structural factors can be influenced but until they are, individuals in many settings will find it difficult to reduce their risk and vulnerability.

Moving forward will entail better assessment of structural approaches and interventions, and a better understanding of how these can be implemented. There is enormous scope for building an evidence base, but doing so will

Search strategy and selection criteria

Information for this paper was obtained from various sources, which included initial searches of databases including Medline and PubMed, Embase, Psychological Abstracts, and Social Sciences Citation Index. The emerging nature of the subject does not lend itself to the systematic literature review methods. Most cited literature does not yet appear on searches using key words such as “structural approach” or “structural intervention”, as these terms are not mainstream. Instead, work with

References (76)

  • United Nations Millennium Declaration, 55th session, agenda item 60(b)

  • E Sumartojo et al.

    Enriching the mix: incorporating structural factors into HIV prevention

    AIDS

    (2000)
  • Expanding the global response to HIV/AIDS through focused action, in UNAIDS Best Practive Collection

    (1998)
  • T Barnett et al.

    AIDS in the twenty-first century: disease and globalisation

    (2002)
  • MD Sweat et al.

    Reducing HIV incidence in developing countries with structural and environmental interventions

    AIDS

    (1995)
  • MN Lurie et al.

    The impact of migration on HIV-1 transmission in South Africa

    Sex Transm Dis

    (2003)
  • D Serwadda et al.

    HIV risk factors in three geographic strata of rural Rakai District, Uganda

    AIDS

    (1992)
  • P Gould

    The slow plague: a geography of the AIDS pandemic

    (1993)
  • JW Carswell et al.

    Prevalence of HIV-1 in east African lorry drivers

    AIDS

    (1989)
  • F Kane et al.

    Temporary expatriation is related to HIV-1 infection in rural Senegal

    AIDS

    (1993)
  • K Hallman

    HIV vulnerability of non-enrolled and urban poor girls in Kwa-Zulu Natal, South Africa

    (2006)
  • K Hallman

    Gendered socioeconomic conditions and HIV risk behaviours among young people in South Africa

    Afr J AIDS Res

    (2005)
  • Hallman K. The effects of orphaning and poverty on sexual debut in KwaZulu-Natal, South Arica. IUSSP Seminar on...
  • JR Hargreaves et al.

    Socioeconomic status and risk of HIV infection in an urban population in Kenya

    Trop Med Int Health

    (2002)
  • MJR Rwenge

    Poverty and sexual risk behaviour among young people in Bamenda, Cameroon

    Afr Pop Stud

    (2003)
  • K Dunkle et al.

    Perpetration of partner violence and HIV risk behavior among young men in the rural Eastern Cape, South Africa

    AIDS

    (2006)
  • C Campbell

    ‘Letting them die’: why HIV/AIDS prevention programmes fail (African issues)

    (2003)
  • SC Kalichman et al.

    HIV testing attitudes, AIDS stigma, and voluntary HIV counselling and testing in a black township in Cape Town, South Africa

    Sex Transm Infect

    (2003)
  • S Maman et al.

    HIV status disclosure to sexual partners: Rates, barriers and outcomes for women

    (2007)
  • R Jewkes et al.

    Factors Associated with HIV sero-status in Young rural South African women: connections between intimate partner violence and HIV

    Int J Epidemiol

    (2006)
  • D Bloom et al.

    Asia's economies and the challenge of AIDS

    (2004)
  • M Over

    The effect of societal variables on urban rates of HIV infection in developing countries: an exploratory analysis

  • S Preston

    The changing relation between mortality and level of economic development

    Popul Stud

    (1975)
  • I Kawachi et al.

    The health of the nations: why inequality is harmful to your health

    (2002)
  • A Whiteside

    Poverty and HIV/AIDS in Africa

    Third World Quarterly

    (2002)
  • V Mishra et al.

    HIV infection does not disproportionately affect the poorer in sub-Saharan Africa

    AIDS

    (2007)
  • Report on the global AIDS epidemic

    (2006)
  • S Gillespie et al.

    Is poverty or wealth driving HIV transmission?

    AIDS

    (2007)
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