AIDS Turning the Tide Together Successes and Challenges in Implementing Structural Interventions for Prevention Presenter: Dr. Cynthia Bowa, USAID/Zambia

Presentation Overview The HIV epidemic in Zambia – What are the structural drivers of HIV transmission in Zambia? Examples of structural interventions Successes and future opportunities Challenges and potential solutions Innovations in structural programming

Zambia Background Adults 14.3% Male 12.3% Female 16.1% Urban 19.7% Rural 10.3%

HIV Transmission in Zambia Marginalized groups Mobility and migration Key drivers of the Epidemic Multiple and concurrent partnerships Low levels of male circumcision MTCT Low and inconsistent condom use

Social and Structural Drivers of Epidemic Community Level – Social and cultural norms – Age-disparate relationships – Transactional and commercial sex – Sexual and physical violence – Alcohol use Structural Level – Mobility and migration – Gender-based discrimination and inequality – Income inequality

Examples of Structural Interventions

Developing Cultural Leadership for HIV/AIDS Structural factors underpinned by social and cultural norms Traditional leaders mobilized and supported to be effective change agents Results: – Community-owned responses and priorities – Banning of childhood marriages and sexual cleansing Factors that limit/enhance effectiveness include: – Leaders commitment – Existence of complimentary programs providing HIV-related services – Support from other leaders ( e.g. political leaders) Limitation – Lack of a parallel structure in urban settings – Mobilized groups may prioritize activities other than those expected

Economic Strengthening High income inequalities contribute to HIV vulnerability Groups saving and loans provide alternatives to risky commercial interactions and increase self-sufficiency Results: – Increased savings – Access to loans for small businesses/ immediate household needs Factors that limit/enhance effectiveness – How the group is constituted – Gender representation – Linkages with other departments/Ministries Counter-effects – increased vulnerability of targeted group

Policy and Legal Support An enabling policy and legal environment is central to promotion of rights- based approach to HIV Gender-based violence (GBV) triggers include: women refusing sex, negotiating condom use, accessing HIV services Anti-GBV Act passed in 2011 Results: – Increased public awareness (increased reporting, more survivors accessing services) Factors that limit/enhance effectiveness – Community awareness of available services – Availability of legal, medical and other services for survivors – Skills of enforcing officers – Timeliness of the judicial process

Successes/Opportunities Stigma and “HIV-fatigue” negatively impact acceptance and uptake of HIV-related services The strength of structural interventions is that they: – Respond to multiple challenges faced by communities (poverty, unemployment, violence) – Respond to issues that communities themselves prioritize – Do not carry the heavy labels that lead to stigma against HIV – Are readily accepted by communities – Allow integration of prevention with broader health and socio- economic needs of the population “ I can live with HIV for many years, but hunger will kill me in a matter of days”

Challenges and Potential Solutions Fragmented response – Involve relevant sectors in all stages of design and planning – Identify lead sector/department for respective interventions – Define clear deliverables Unclear mandates for interventions spanning multiple sectors – Clearly outline roles of respective departments/Ministries – Assign authority to the coordinating body to hold implementing departments accountable Inadequate time and human resources allocated to interventions – Identify full time focal point persons with relevant skills – Define clear reporting lines within departments and with the coordinating authority

Challenges and Potential Solutions (Continued) Weak monitoring system – Define clear indicators to monitor progress – Invest in the development of tools to track interventions across sectors – Invest in research to better determine impact Inadequate financial resources for interventions – Invest in research to make case for structural interventions – Articulate clear activities that stakeholders can buy into – Strengthen collaboration and coordination across sectors Results not always transferable – Good understanding of social, political, economic factors – Clear articulation of causal pathways – Community-driven responses

Innovations at Field Level Community Compacts – Interlinks compacts with incentives to reduce HIV incidence through community-driven process – System of incentives rewards communities for reaching agreed upon benchmarks – “re-inforcers” Mainstreaming HIV Prevention - Environmental Impact Assessments (EIA) – SADC initiative – Zambia Environmental Management Authority developing guidelines to mainstream HIV, gender and human rights into EIA – Addresses vulnerability and risk associated with large construction works Land Allocation – Zambia Land Alliance works with Local Authorities to ensure access to land for the vulnerable – Addresses lack of access to property that frequently puts women in position of vulnerability

Moving Forward Utilize implementation research to better understand impact of structural interventions Develop innovative research methods to measure impact Continue to implement, but with more rigorous monitoring and evaluation