New frontiers in HIV prevention scienceNew frontiers in HIV prevention science

Addressing structural determinants of HIV Addressing structural determinants of HIV and measuring changeand measuring change

Julia KimJulia Kim

School of Public HealthSchool of Public HealthUniversity of the WitwatersrandUniversity of the Witwatersrand

&&Centre for Gender, Violence & HealthCentre for Gender, Violence & Health

London School of Hygiene & Tropical MedicineLondon School of Hygiene & Tropical MedicineAIDS 2008, Mexico CityAIDS 2008, Mexico City

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Prevailing Approaches to HIV Prevailing Approaches to HIV Prevention Prevention

AbstinencePartner

reductionCondom use

Risk factor Risk factor epidemiologyepidemiology& “individual risk& “individual risk””

PsychologicalPsychologicalmodels ofmodels ofbehaviour behaviour changechange(e.g.Theory of (e.g.Theory of reasoned action)reasoned action)

Primarily technicalPrimarily technical& health sector& health sectordrivendriven

?

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Structural factors & Structural factors & HIV/AIDSHIV/AIDS

Individual Behaviour

Poverty & economic

inequalities

Mobility & migration

Gender Inequalities

““Upstream” factors Upstream” factors that impact on that impact on individual behaviour individual behaviour changechange

Impact both Impact both developed developed & developing & developing countriescountries

Overlapping & Overlapping & mutually mutually reinforcingreinforcing

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Structural Structural Interventions… Interventions… Work by altering the Work by altering the contextcontext in which health is produced in which health is produced

- Blankenship et al, AIDS 2000- Blankenship et al, AIDS 2000

Individual Behaviour

Laws & Policies

Target Target PopulationsPopulations rather than rather than individualsindividuals

MultipleMultipleLevels forLevels forinterventionintervention

Socio-economic conditions

Cultural NormsEvolving field: Evolving field:

little research little research in developing in developing countriescountries

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The IMAGE Study:The IMAGE Study: A Structural Intervention for HIV in A Structural Intervention for HIV in

South AfricaSouth Africa

Gender violence

HIV infection

Poverty & economic inequalities

Gender Inequalities

Microfinance(SEF)

Gender/HIVTraining

(12 months)

IMAGE

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2001-20042001-2004

8 villages in rural Limpopo (pop 64, 000)8 villages in rural Limpopo (pop 64, 000) Matched on size and accessibility; randomly selectedMatched on size and accessibility; randomly selected

Participants (Intervention + control)Participants (Intervention + control) Women matched by age and poverty-status Women matched by age and poverty-status Face-to-face interviews: Baseline and 2 years laterFace-to-face interviews: Baseline and 2 years later Adjusted for baseline differences & village-level clusteringAdjusted for baseline differences & village-level clustering

Concurrent qualitative researchConcurrent qualitative research 3 full-time anthropologists3 full-time anthropologists

Evaluation: Cluster- Randomized Trial

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9 indicators of 9 indicators of EmpowermentEmpowerment

Intimate partner violence:Intimate partner violence: Past year physical or sexual violence Past year physical or sexual violence reduced by 55% reduced by 55% aRR 0.45 (0.23-0.91)

HIV risk behaviour HIV risk behaviour (< 35 yrs)(< 35 yrs)

VCT: VCT: aRR 1.64 (1.06 – 2.56)aRR 1.64 (1.06 – 2.56)

Communication: Communication: aRR 1.46 (1.01 – 2.12)aRR 1.46 (1.01 – 2.12)

Unprotected sex: Unprotected sex: aRR aRR 0.76 (0.60 – 0.96)0.76 (0.60 – 0.96)

-Pronyk et al, -Pronyk et al, LancetLancet 368, 2006 368, 2006- Pronyk et al, - Pronyk et al, AIDSAIDS 22, 2008 22, 2008

After 2 years, improvements in…After 2 years, improvements in…

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2001-2004 2005-2007 2008-2010430 households 4500 households (30,000) 15 000 households (80,000)

IMAGE: Scaling up in South Africa

Pilot Study:Additional cost = US $43/client

Scale-up:Additional cost = US $13/client

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Programme Programme considerations…considerations…

It is possible to address GBV as part of HIV prevention, It is possible to address GBV as part of HIV prevention, and to do so within project timeframesand to do so within project timeframes

Challenges belief that gender norms & GBV “culturally Challenges belief that gender norms & GBV “culturally entrenched” and resistant to changeentrenched” and resistant to change

Cross-sectoral interventions can generate Cross-sectoral interventions can generate synergysynergyMicrofinance:Microfinance: Meeting “basic needs” as part of HIV prevention Meeting “basic needs” as part of HIV prevention

piggy-backing onto MF program: sustained participationpiggy-backing onto MF program: sustained participation

Gender/HIV Training:Gender/HIV Training: Empowerment about “more than just money” Empowerment about “more than just money” New Study: MF (without training) impacts on poverty but NOT New Study: MF (without training) impacts on poverty but NOT

broader benefits (empowerment, IPV, HIV risk)broader benefits (empowerment, IPV, HIV risk)

Strong partnerships models:Strong partnerships models: each stick to what you do well each stick to what you do well

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Research considerations: Research considerations: Building a body of evidence for Building a body of evidence for

structural interventionsstructural interventionsStrengthsStrengths of using randomized trials: of using randomized trials: Protocol registered with NIH & Lancet; pre-specified 1Protocol registered with NIH & Lancet; pre-specified 100 and 2 and 200

outcomesoutcomes Minimized common forms biasMinimized common forms bias

ChallengesChallenges:: N = number of clusters, not individuals (unlike clinical trials)N = number of clusters, not individuals (unlike clinical trials)

Wide C.I. for some indicatorsWide C.I. for some indicators Often difficult to enroll large number of clustersOften difficult to enroll large number of clusters (e.g. incremental (e.g. incremental

enrollment of MF over broad geographical area)enrollment of MF over broad geographical area)

Complex interventions…Complex interventions… Take time: Limited exposure to intervention (time for diffusion Take time: Limited exposure to intervention (time for diffusion

effects at community level?)effects at community level?) Affect multiple endpointsAffect multiple endpoints : : May be difficult to predict in advance, May be difficult to predict in advance,

hard to fit within CRT ‘template’ for protocols hard to fit within CRT ‘template’ for protocols

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Therefore…Therefore… Growing recognition: Cannot focus exclusively on p-values Growing recognition: Cannot focus exclusively on p-values

to judge impactto judge impact Use trials to gain unbiased measure of effect, noting consistency, Use trials to gain unbiased measure of effect, noting consistency,

congruency & plausibility of change documentedcongruency & plausibility of change documented - - Habicht J et al, Int J Epid 1999, 28:10-18Habicht J et al, Int J Epid 1999, 28:10-18

Need to generate strong theoretical frameworks & measure Need to generate strong theoretical frameworks & measure plausible pathway variables linking structural interventions plausible pathway variables linking structural interventions to health outcomesto health outcomes

Not only focus on measuring proximate risk behaviors Not only focus on measuring proximate risk behaviors (e.g. condom use, partner reduction)(e.g. condom use, partner reduction)

Also measure relevant pathway variables Also measure relevant pathway variables e.g. women’s economic empowerment, negotiating power, gender-e.g. women’s economic empowerment, negotiating power, gender-

based violencebased violence

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From Micro to Macro: Linking From Micro to Macro: Linking Programs to Supportive Policy Programs to Supportive Policy

EnvironmentEnvironment Individual programs Individual programs on their ownon their own, unlikely to impact , unlikely to impact

on poverty or HIV on a national scaleon poverty or HIV on a national scale MF a “foothold” out of poverty, but not the whole ladder… MF a “foothold” out of poverty, but not the whole ladder…

However such programs do:However such programs do: Demonstrate feasibility & suggest pathways for affecting Demonstrate feasibility & suggest pathways for affecting

health outcomes health outcomes Yield practical lessons & cross-sectoral partnership modelsYield practical lessons & cross-sectoral partnership models Provide “metaphor” for what might be possible by combining Provide “metaphor” for what might be possible by combining

economic empowerment & HIV prevention on economic empowerment & HIV prevention on widerwider scale scale

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Scaling up “principles” as well Scaling up “principles” as well as programsas programs

Not just about scaling up programs (MF, Gender)

but impetus for wider policy change

Country level:National AIDS Strategic PlansRural economic development

Girls’ educationDomestic violence legislation

Customary laws & women’s rights

““Despite broad recognition that Despite broad recognition that underlying social underlying social conditionsconditions - including poverty & gender inequalities - - including poverty & gender inequalities - affect vulnerability to HIV infection, there is a affect vulnerability to HIV infection, there is a serious serious deficiencydeficiency in the design and testing of interventions to in the design and testing of interventions to critically engage issues at this levelcritically engage issues at this level””

Track D Summary Track D Summary XIXIthth International AIDS Conference International AIDS Conference

Vancouver, 1996 Vancouver, 1996 (Mane, Aggleton, Dowsett et al)(Mane, Aggleton, Dowsett et al)

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Structural interventions & HIV Structural interventions & HIV Prevention:Prevention:

An unexplored frontier…An unexplored frontier…

Individual Behaviour

Laws & Policies

Socio-economic conditions

Cultural norms

Microfinance & youth livelihoods• SHAZ (Zimbabwe)• TRY (Kenya)

Gender norms & GBV:• Stepping Stones RCT (SA)• SASA RCT (Uganda)• Promundo (Brazil, India)• Men as Partners (SA)

Women’s property & inheritance laws• ICRW review (2004)

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Prevention Technology: Prevention Technology: Expanding the Expanding the rangerange of of

individual optionsindividual options

AbstinencePartner

reductionCondom use

• Female Condom• Male circumcision• Microbicides• PrEP• Vaccines

…but will this be enough?

Technology only useful if one is empowered

to use it

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Structural interventions: Structural interventions: Making prevention options Making prevention options realisticrealistic for individuals for individuals

AbstinencePartner

reductionCondom use

• Female Condom• Male circumcision• Microbicides• PrEP• Vaccines

= SYNERGY Laws & Policies

Cultural norms

Socio-economic conditions

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PreventionTreatment

The “AIDS Pendulum”

25 years into the AIDS Pandemic…25 years into the AIDS Pandemic… 1980-90s: 1980-90s: Prevention Prevention

“burnout”“burnout” Side-tracked by ideological “ABC” Side-tracked by ideological “ABC”

debatesdebates Great hopes placed in ART & new Great hopes placed in ART & new

prevention technologiesprevention technologies No “magic bullets”No “magic bullets”

Is the pendulum about to swing back Is the pendulum about to swing back towards towards Prevention?Prevention? The real cost of scaling up ART The real cost of scaling up ART

amidst ongoing infection ratesamidst ongoing infection rates

Re-authorization of PEPFAR: $48B – Re-authorization of PEPFAR: $48B – focus shifting to prevention & women’s focus shifting to prevention & women’s empowermentempowerment

Structural interventions: Re-Structural interventions: Re-invigorating HIV prevention by invigorating HIV prevention by learning from the pastlearning from the past

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AIDS is a long-wave AIDS is a long-wave event…event…

A “slow motion tsunami”A “slow motion tsunami” Requires Requires bothboth::

Immediate, “AIDS-specific” Immediate, “AIDS-specific” technological responses technological responses ANDAND

Long-term commitment to Long-term commitment to addressing structural addressing structural factors as essential part of factors as essential part of HIV preventionHIV prevention

The challenge: The challenge: Can we combine sense of Can we combine sense of urgencyurgency with with long-term long-term visionvision? ?

“Make haste slowly” - Milarepa

(12th Century Tibetan yogi)

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AcknowledgementsAcknowledgementsLSHTM & WITS colleagues:LSHTM & WITS colleagues: Paul Pronyk, Charlotte Watts, Paul Pronyk, Charlotte Watts,

James Hargreaves, Lulu James Hargreaves, Lulu Ndhlovu, Godfrey Phetla, Linda Ndhlovu, Godfrey Phetla, Linda Morison, Joanna Busza, John Morison, Joanna Busza, John PorterPorter

Funders:Funders: South African Department of South African Department of

Health, DFID, SIDA, HIVOS, Ford Health, DFID, SIDA, HIVOS, Ford Foundation, AngloPlatinum & Foundation, AngloPlatinum & The AngloAmerican Chairman’s The AngloAmerican Chairman’s Educational Trust & Kaiser Educational Trust & Kaiser Family FoundationFamily Foundation