1. 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

2. 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

3. 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

4. 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

5. 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?

6. 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

7. 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

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

9. 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

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

11. After 2 years, improvements in…
9 indicators of Empowerment
Intimate partner violence:
Past year physical or sexual violence reduced by 55% aRR 0.45 ( )
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

12. 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
430 households households (30,000) households (80,000)

13. 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

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