Addressing structural factors as part of an integrated response to SRH and HIV Charlotte Watts Gender, Violence and Health Centre Department of Public Health and Policy London School of Hygiene and Tropical Medicine

Prevailing Approaches to HIV/AIDS Risk factor epidemiology & “individual risk” Psychological models of behaviour change (e.g.Theory of reasoned action) Abstinence Partner reduction Condom use Primarily technical & health sector driven

Poverty & economic inequalities Structural factors locate source of public health problems in social, economic & political environments Overlapping & mutually re-inforcing Poverty & economic inequalities Individual Behaviour Gender Inequalities Mobility & migration Impact both developed & developing countries Racism & Homophobia Health & human rights; Political economy of health

Structural interventions work by altering the contexts that support poor health Target Populations rather than individuals Laws & Policies Individual Behaviour Multiple Levels for intervention Physical environment Cultural norms Definitions & Classifications evolving Socio-economic conditions

Structural factors and SRH Poverty & gender inequalities limit sexual negotiation: Impact on STIs, unwanted pregnancy, abortions Improved education for girls: decrease in maternal & infant mortality rates Decrease in fertility rate Lower levels of violence Improved health/education prospects for next generation Structural factors, SRH & HIV: common roots of vulnerability? common points for intervention?

Structural interventions – an emerging field Despite increasing awareness of importance of structural factors, notable lack of experience with structural interventions Why is this? Traditional focus on epidemiology & disease-control models: Lack tools to conceptualise & mount broader social and economic interventions Outside traditional sphere of public health – requires new partnerships across multiple sectors & disciplines Moving away from individual-focused interventions shifts emphasis from individual change to concepts of community mobilisation & change Evidence: require innovative & complex experimental methods May challenge firmly rooted political, economic, and social interests

What do structural interventions for HIV & SRH look like? Poverty alleviation programs Eliminate school fees for girls Community mobilisation VCT Condom promotion STI treatment FP/MCH PMTCT ARVs Changing gender norms Domestic & sexual violence legislation Decriminalising homosexual activity Gender equitable school programmes

The Intervention with Microfinance for AIDS & Gender Equity (IMAGE Study)

Microfinance as a prevention tool to address social determinants of vulnerability Small Enterprise Foundation Poverty & economic inequalities IMAGE Intimate partner violence HIV infection There is some evidence to suggest that MF has the potential to address a number of the factors in the outer circle, particularly poverty and gender inequalities. In this context, it has the potential to be an important tool in the prevention of both violence and HIV. Mobility and migration Sisters for Life participatory training Gender Inequalities

Enrolment & intervention uptake 860 women enrolled Follow-up rates 90%, 84% (I,C) 1,750 loans disbursed Total value USD $ 290 000 Repayment rates 99.7%. Typical businesses: selling produce, used/new clothes, creches, food stalls

After 2 years, improvements in… 9 indicators of Empowerment Intimate partner violence: Past year physical or sexual violence reduced by 55% aRR 0.45 (0.23-0.91) HIV risk behaviour (< 35 yrs) VCT: aRR 1.64 (1.06 – 2.56) Communication: aRR 1.46 (1.01 – 2.12) Unprotected sex: aRR 0.76 (0.60 – 0.96) -Pronyk et al, Lancet 368, 2006 - Pronyk et al, AIDS 22, 2008

Additional cost = US $13/client Additional cost = US $43/client Scaling up IMAGE in South Africa Scale-up Additional cost = US $13/client Pilot Study Additional cost = US $43/client 2001-2004 2005-2007 2008-2010 430 households 4500 households (30,000) 15 000 households (80,000)

Conclusion HIV / SRH integration should be more than solely providing more services Opportunities to intervene on common risk factors & contexts that support poor SRH and HIV risk A serious response to structural factors would require: A rethinking of roles at national programmes Investment in increased working across sectors Not only between SRH &HIV Also with many other sectors Investment in research & documentation to help build an evidence base

Acknowledgements Funders: South African Department of Health DFID SIDA HIVOS Ford Foundation, AngloPlatinum & The AngloAmerican Chairman’s Educational Trust Kaiser Family Foundation