1. New frontiers in HIV prevention science Addressing structural determinants of HIV and measuring change
Julia Kim
School of Public Health
University of the Witwatersrand
&
Centre for Gender, Violence & Health
London School of Hygiene & Tropical Medicine
AIDS 2008, Mexico City
Thank the organizers for allowing me the opportunity to you be with you today, at the end of what has been an exciting and energizing conference.

2. Prevailing Approaches to HIV Prevention
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. Structural factors & HIV/AIDS
“Upstream” factors that impact on individual behaviour change
Poverty & economic inequalities
Overlapping & mutually reinforcing
Individual
Behaviour
Gender Inequalities
Mobility & migration
Impact both
developed
& developing
countries

4. Structural Interventions… Work by altering the context in which health is produced - Blankenship et al, AIDS 2000
Target Populations rather than individuals
Socio-economic
conditions
Individual
Behaviour
Multiple
Levels for
intervention
Cultural
Norms
Laws & Policies
Evolving field: little research in developing countries

5. The IMAGE Study: A Structural Intervention for HIV in South Africa
Microfinance
(SEF)
Poverty & economic inequalities
IMAGE
Gender 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.
Gender/HIV
Training
(12 months)
Gender Inequalities 5

6. Evaluation: Cluster- Randomized Trial
8 villages in rural Limpopo (pop 64, 000)
Matched on size and accessibility; randomly selected
Participants (Intervention + control)
Women matched by age and poverty-status
Face-to-face interviews: Baseline and 2 years later
Adjusted for baseline differences & village-level clustering
Concurrent qualitative research
3 full-time anthropologists

7. -Pronyk et al, Lancet 368, 2006 - Pronyk et al, AIDS 22, 2008
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, Pronyk et al, AIDS 22, 2008

8. Additional cost = US $43/client Additional cost = US $13/client
IMAGE: Scaling up in South Africa
Pilot Study:
Additional cost = US $43/client
Scale-up:
Additional cost = US $13/client
430 households households (30,000) households (80,000)

9. Programme considerations…
It is possible to address GBV as part of HIV prevention, and to do so within project timeframes
Challenges belief that gender norms & GBV “culturally entrenched” and resistant to change
Cross-sectoral interventions can generate synergy
Microfinance: Meeting “basic needs” as part of HIV prevention
piggy-backing onto MF program: sustained participation
Gender/HIV Training: Empowerment about “more than just money”
New Study: MF (without training) impacts on poverty but NOT broader benefits (empowerment, IPV, HIV risk)
Strong partnerships models: each stick to what you do well

10. Research considerations: Building a body of evidence for structural interventions
Strengths of using randomized trials:
Protocol registered with NIH & Lancet; pre-specified 10 and 20 outcomes
Minimized common forms bias
Challenges:
N = number of clusters, not individuals (unlike clinical trials)
Wide C.I. for some indicators
Often difficult to enroll large number of clusters (e.g. incremental enrollment of MF over broad geographical area)
Complex interventions…
Take time: Limited exposure to intervention (time for diffusion effects at community level?)
Affect multiple endpoints : May be difficult to predict in advance, hard to fit within CRT ‘template’ for protocols

11. Therefore…
Growing recognition: Cannot focus exclusively on p-values to judge impact
Use trials to gain unbiased measure of effect, noting consistency, congruency & plausibility of change documented Habicht J et al, Int J Epid 1999, 28:10-18
Need to generate strong theoretical frameworks & measure plausible pathway variables linking structural interventions to health outcomes
Not only focus on measuring proximate risk behaviors (e.g. condom use, partner reduction)
Also measure relevant pathway variables
e.g. women’s economic empowerment, negotiating power, gender-based violence

12. From Micro to Macro: Linking Programs to Supportive Policy Environment
Individual programs on their own, unlikely to impact on poverty or HIV on a national scale
MF a “foothold” out of poverty, but not the whole ladder…
However such programs do:
Demonstrate feasibility & suggest pathways for affecting health outcomes
Yield practical lessons & cross-sectoral partnership models
Provide “metaphor” for what might be possible by combining economic empowerment & HIV prevention on wider scale

13. Scaling up “principles” as well as programs
Not just about scaling up programs (MF, Gender)
but impetus for wider
policy change
Country level:
National AIDS Strategic Plans
Rural economic development
Girls’ education
Domestic violence legislation
Customary laws & women’s rights

14. “Despite broad recognition that underlying social conditions - including poverty & gender inequalities - affect vulnerability to HIV infection, there is a serious deficiency in the design and testing of interventions to critically engage issues at this level”
Track D Summary XIth International AIDS Conference Vancouver, (Mane, Aggleton, Dowsett et al)

15. Structural interventions & HIV Prevention: An unexplored frontier…
Microfinance & youth livelihoods
SHAZ (Zimbabwe)
TRY (Kenya)
Gender norms & GBV:
Stepping Stones RCT (SA)
SASA RCT (Uganda)
Promundo (Brazil, India)
Men as Partners (SA)
Socio-economic
conditions
Individual
Behaviour
Women’s property & inheritance laws
ICRW review (2004)
Cultural
norms
Laws & Policies

16. Prevention Technology: Expanding the range of individual options
Female Condom
Male circumcision
Microbicides
PrEP
Vaccines
Abstinence
Partner reduction
Condom use
…but will this be enough?
Technology only useful if one is empowered
to use it

17. Structural interventions: Making prevention options realistic for individuals
Socio-economic
conditions
Female Condom
Male circumcision
Microbicides
PrEP
Vaccines
Abstinence
Partner reduction
Condom use
= SYNERGY
Laws & Policies
Cultural
norms

18. 25 years into the AIDS Pandemic…
s: Prevention “burnout”
Side-tracked by ideological “ABC” debates
Great hopes placed in ART & new prevention technologies
No “magic bullets”
Is the pendulum about to swing back towards Prevention?
The real cost of scaling up ART amidst ongoing infection rates
Re-authorization of PEPFAR: $48B – focus shifting to prevention & women’s empowerment
Structural interventions: Re-invigorating HIV prevention by learning from the past
The “AIDS Pendulum”
Treatment
Prevention

19. AIDS is a long-wave event…
A “slow motion tsunami”
Requires both:
Immediate, “AIDS-specific” technological responses AND
Long-term commitment to addressing structural factors as essential part of HIV prevention
The challenge: Can we combine sense of urgency with long-term vision?
“Make haste slowly”
- Milarepa
(12th Century Tibetan yogi)

20. Acknowledgements LSHTM & WITS colleagues: Funders:
Paul Pronyk, Charlotte Watts, James Hargreaves, Lulu Ndhlovu, Godfrey Phetla, Linda Morison, Joanna Busza, John Porter
Funders:
South African Department of Health, DFID, SIDA, HIVOS, Ford Foundation, AngloPlatinum & The AngloAmerican Chairman’s Educational Trust & Kaiser Family Foundation