Structural Interventions and the Prevention of HIV/AIDS Robert Fullilove, EdD Columbia University

Some guiding principles “HIV/AIDS is a social epidemic with medical outcomes” Monica Sweeney, MD, MPH Assistant Commissioner for HIV Prevention, NYC Department of Health and Mental Hygiene

And… Plus ca change, plus c’est la meme chose. The more things change, the more they stay the same

Foundations Structural interventions [also described as ‘social drivers’ and/or social determinants] are not new as public health strategies to improve health and prevent disease The foundations of public health in the 19th century did not come about via successful efforts to change behavior. They were result of successful changes in the physical and social environment

A little history cholera is an infectious disease that was a major cause of mortality 200 years ago. As Farley and Cohen point out in Prescription for a Healthy Nation, there were two major approaches for reducing cholera mortality:

Approach #1 Individual behavior change response: teach urban dwellers to wash their hands and boil water before each use….

Approach #2 What actually worked: changing the urban environment. Creating a system of clean water supply, sanitary disposal of human wastes,developing systems for trash removal, and improved housing quality. The roots of public health were in structural change, not strategies to change risk behavors

What about now? What constitutes the greatest opportunity for transforming the social environment and the social drivers of HIV/AIDS at this point in the 21st century? Answer: Seeking legislative reforms that reduce the impact of mass incarceration of those at risk for HIV/AIDS

Why now? Because many states are planning to close prisons/jails and release large numbers of non-violent offenders back into the community as cost-saving measures. These steps are bound to suffer significant “blowback”

Where should we concentrate our efforts? See: One in 31 from the Pew Center on the States This report argues that shifting our focus from prisons to parole will dramatically alter the negative social impact of mass incarceration

A modest Proposal A significant number of presenters at this conference are deeply engaged in the link between corrections and HIV Prediction: the provision of services for large numbers of newly released prisoners will be the new “HIV prevention frontier”

A Modest Proposal [continued] All of the populations with which prevention workers currently work are represented in this flood of folks coming out of prison Partnering with service providers who will be mandated to manage this challenge may provide the resources that we currently lack to do our jobs