INMUEBLES DE VALOR CULTURAL DE NIVEL

There has in the past decade been an increased focus on how the broader

structural environment can shape individuals HIV risk (Blankenship, Friedman et al. 2006, Coates, Richter et al. 2008, Rao Gupta, Parkhurst et al. 2008, Seeley, Watts et al. 2012). This has led to a shift in HIV prevention efforts from

interventions that focus on the individual to structural interventions that attempt to address HIV vulnerability through changing deeply entrenched social, economic, political and environmental factors such as gender or income inequality and social marginalisation.

Due to the broad nature of structural interventions, the meaning of the term remains contested. However, Blankenship, Friedman et al. (2006) definition is useful:

The term 'structural' is used to refer to interventions that work by altering the context within which health is produced or reproduced. Structural interventions locate the source of public-health problems in factors in the social, economic and political environments that shape and constrain individual, community, and societal health outcomes (Blankenship, Bray et al. 2000: 11).

Central to structural interventions is the way individual agency and autonomy is viewed. In behavioural interventions individuals are assumed to have considerable autonomy to make and act on their choices, but structural approaches view

individual agency as constrained by broader structural factors (Blankenship, Bray et al. 2000).

Rao Gupta and colleagues (2008) argue that understanding the broader structural factors that constrain individual behaviour in sexual interactions such as poverty, wealth, gender and age are vital when developing effective HIV prevention

strategies (Rao Gupta, Parkhurst et al. 2008). However, as Auerbach, Parkhurst et al. (2009) note “social drivers are complex, fluid, non-linear, and contextual, and they interact dynamically with biological, psychological, behavioural, and other social factor” (Auerbach, Parkhurst et al. 2009: 4). This can make conceptualising and operationalising structural approaches to HIV prevention challenging.

As Rao Gupta and colleagues (2008) note, the relationship of structural factors to HIV vulnerability, however, can be complex and variable (Rao Gupta, Parkhurst et al. 2008). As noted in the discussion above, the relationship between poverty and

HIV risk is complex with poverty not being a straightforward driver for HIV risk. In the earlier discussion of studies on gender and HIV vulnerability it can be seen that the exact consequences or manifestations of gender inequality can be difficult to predict, particularly because of the context specific nature of these relations. In addition, gender intersects with income, race, religion and sexuality to create complex and shifting power dynamics. The multiple ways that they can influence and counteract with one another can make it difficult to predict the consequences or exact manifestations of gender power relations in a given context (Rao Gupta 2009). Rao Gupta, Parkhurst et al. (2008) argue that progress on the use of structural

approaches has been limited due to an “absence of a clear definition; lack of

operational guidance; and limited data on the effectiveness of structural approaches to the reduction of HIV incidence” (Rao Gupta, Parkhurst et al. 2008: 764).

Rao Gupta and colleagues (2008) present a framework that draws on two models to analyse the effect of structural factors on HIV risk and vulnerability. In the first model Barnett and Whiteside (2002) incorporates structural factors on the basis of a continuum of distance from risk. The more distal factors determine risk through a longer and more variable, series of causes and effects than the proximal factors. At the macro environmental level, factors such as the national economic context or the governance are most distal. At the micro environmental, factors such as migration and urbanisation that shape the local context, are less distal and therefore influence HIV risk more directly.

The second framework that Rao Gupta and colleagues (2008) discuss is from Sweat and Denison (1995) where the superstructural factors such as economic

development as well as national cultural attitudes affect nations, with structural factors (such as laws and policies) affecting a segment of the population within these nations, and environmental factors such as living conditions and the opportunities available to the population affect the conditions and resources of individuals, and individual factors affecting how the environmental factors are experienced (Sweat and Denison 1995). In Figure 2.2 Gupta and colleagues (2008) combine these two frameworks to highlight how gender inequality might lead to women engaging in transactional sex.

Figure 2.3: Framework to understand how gender inequality might lead to transactional sex

Source: (Rao Gupta, Parkhurst et al. 2008)

Within the framework it can be seen how the broader structural factors shape behaviour and lead to women engaging in transactional sex. At the superstructural level, gender inequality shapes factors from the distal to the proximal level. At the structural level the laws restricting women’s ownership of economic assets can shape the environmental level which can lead to women becoming dependent on

men. At the individual level, this may lead to women not having sufficient money to meet their basic needs and leading them to engaging in transactional sex to meet these needs.

The STRIVE consortium, a DfID funded research programme based at the London School of Hygiene and Tropical Medicine is investigating how structural factors shape vulnerability to HIV also presents a useful framework for conceptualising structural drivers and HIV (LSHTM 2012).

Figure 2.4: STRIVE conceptual framework on understanding structural drivers of HIV vulnerability

Source: (LSHTM 2012)

Within the framework, macro level factors such as the criminal justice system, GDP, media culture and religion can shape the structural drivers such as stigma, gender norms, economic opportunities and mobility which in turn shape the proximate determinants of risk such as access to information and services, partner selection,

partner change and unprotected sex that lead to HIV transmission. This framework highlights both the breadth of factors that make up structural drivers but also the specific areas that led to HIV transmission.

There have been a number of interventions in the past five years that have aimed to change the broader structures that influence vulnerability to HIV. Three of these interventions, which have reported positive results, are discussed below. Two of these interventions were based in South Africa and one in Malawi.

The Stepping Stones programme, that is a participatory HIV prevention programme aims to improve sexual health through building stronger, more gender-equitable relationships (Jewkes, Nduna et al. 2008). The programme was developed more than a decade ago and has been used in over 40 countries (Wallace 2006). The intervention has been evaluated with rural youth in South Africa in a

randomised controlled trial. The trial used a 50 hour programme, which aimed to improve sexual health by using participatory learning approaches to build

knowledge, risk awareness, and communication skills and to stimulate critical reflection (Jewkes, Nduna et al. 2008). Villages were randomised to receive either this or a three hour intervention on HIV and safer sex. After 2 years follow-up, Stepping Stones lowered the incidence of herpes simplex virus 2 in men and women by approximately 33%, and men reported less perpetration of intimate partner violence across 2 years of follow-up, as well as changes in several other HIV risk behaviours (Jewkes, Nduna et al. 2008). However, there was no evidence that Stepping Stones lowered the incidence of HIV (Jewkes, Nduna et al. 2008).

The second study based in South Africa, the IMAGE study, sought to reduce HIV risk by intervening structurally at community and individual levels (Hargreaves, Atsbeha et al. 2002). Based on evidence that the rising prevalence of HIV in that country was a product of prevalent migrant labour, widespread poverty, and entrenched gender inequalities, the study combined microfinance initiative with a participatory learning and action curriculum on gender and HIV education (Pronyk, Hargreaves et al. 2006).

IMAGE sought to determine whether the involvement of women in the programme would improve household economic wellbeing, social capital, and empowerment and thus reduce vulnerability to intimate partner violence a known risk factor for HIV (Pronyk, Hargreaves et al. 2006). The project also sought to assess “whether such measures could raise levels of communication and collective action on HIV and gender issues within communities and reduce the vulnerability of 14–35-year old household and village residents to HIV infection” (Pronyk, Hargreaves et al. 2006: 1973). The study was evaluated using a cluster randomised trial methodology. The study team estimated that over two years, levels of intimate partner violence were reduced by 55% in the intervention group (who had access to microfinance services and the gender training programme) relative to the control group (Pronyk, Hargreaves et al. 2006). There was evidence that the intervention improved

household wellbeing, social capital, and empowerment however, there appeared to be no effect on HIV incidence (Pronyk, Hargreaves et al. 2006).

The lack of education and economic dependence on men has often been seen as important drivers of HIV infection in women. In the Zomba district of Malawi,

Baird and colleagues (2012) assessed the efficacy of giving young women money to reduce their risk of sexually transmitted infections (Baird, Garfein et al. 2012). Using a cluster randomised trial, the study team provided a payment of between $4 and $10 a month to never-married women aged 13-22 (Baird et al. 2012). There were two groups: one where the payment was conditional on attending school and one where there were no conditions to receive the money. Behavioural risk

assessments were done at baseline and 12 months; serology was tested at 18 months. The study found a reduction in new HIV and HSV-2 infections in the schoolgirls irrespective of whether the money was given conditionally or not (Baird, Garfein et al. 2012).