1. The IMAGE Program in South Africa: Taking a “Structural” Approach to HIV Prevention through Cross-Sectoral NGO Partnerships Julia Kim School of Public Health University of the Witwatersrand & Health Policy Unit London School of Hygiene & Tropical Medicine PONPO, Yale University Apr 14, 2009

2. “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 XI th International AIDS Conference Vancouver, 1996 (Mane, Aggleton, Dowsett et al)

3. 3 Prevailing Approaches to HIV Prevention Abstinence Partner reduction Condom use Risk factor epidemiology & “individual risk ” Psychological models of behaviour change (e.g.Theory of reasoned action) Primarily technical & health sector driven ?

4. 4 Structural determinants & HIV/AIDS Individual Behaviour Poverty & economic inequalities Mobility & migration Gender Inequalities “Upstream” factors that impact on individual behaviour change Impact both developed & developing countries Overlapping & mutually reinforcing

5. 5 Structural Interventions… Work by altering the context in which health is produced - Blankenship et al, AIDS 2000 Individual Behaviour Laws & Policies Target Populations rather than individuals Multiple Levels for intervention Socio-economic conditions Cultural Norms Evolving field: little research in developing countries

6. 6 The IMAGE Study: A structural intervention to address HIV and Gender-based violence in South Africa Gender violence HIV infection Poverty & economic inequalities Gender Inequalities Microfinance Gender /HIV training IMAGE

7. 7 The IMAGE Study (Intervention with Microfinance for AIDS and Gender Equity)  Microfinance NGO: Small Enterprise Foundation  Women’s businesses: Selling produce, clothes, food stalls  HIV Training: RADAR  1-hr sessions during loan repayment meetings q. 2 weeks  6 month structured curriculum  6 month community mobilization: Village Action Plans around GBV and HIV

8. 8 2001-2004 8 villages in rural Limpopo (pop 64, 000) 8 villages in rural Limpopo (pop 64, 000) Matched on size and accessibility Matched on size and accessibility Randomly selected (Control villages receive intervention at end of study) Randomly selected (Control villages receive intervention at end of study) Intervention + control participants Intervention + control participants Matched by age and poverty-status Matched by age and poverty-status Face-to-face interviews: Baseline and 2 years later Face-to-face interviews: Baseline and 2 years later Analysis: Adjusted for baseline differences and village-level clustering Analysis: Adjusted for baseline differences and village-level clustering Parallel qualitative research Parallel qualitative research 3 full-time anthropologists 3 full-time anthropologists Evaluation: Cluster- Randomized Trial

9. 9 Economic well-being:  Improved food security, household assets Women’s empowerment: Greater self confidence, autonomy, challenging gender norms, collective action: Greater self confidence, autonomy, challenging gender norms, collective action: 5 public marches 5 public marches 40 village workshops 40 village workshops 16 meetings with local leaders 16 meetings with local leaders 2 new village committees target Crime and Rape 2 new village committees target Crime and Rape Results: Impacts on Poverty & Women’s Empowerment - JC Kim et al. AJPH 97 (10), Oct 2007

10. 10 Intimate partner violence After 2 years, past year risk of physical & sexual violence reduced by 55% (aRR 0.45 95% CI 0.23-0.91) HIV Risk * Among young IMAGE participants (age<35): aRR=1.46 (1.01 – 2.12)  Increased HIV communication aRR=1.46 (1.01 – 2.12) aRR=1.64 (1.06 – 2.56)  Increased VCT aRR=1.64 (1.06 – 2.56)  Reduced unprotected sex with non-spousal partner by 24% aRR = 0.76 (0.60 – 0.96) aRR = 0.76 (0.60 – 0.96) * Pronyk et al. AIDS 22, 2008

11. 11 Emerging Lessons…  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 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 piggy-backing onto MF program: sustained participation Health Training: Empowerment about “more than just money” MF Alone Study: MF (without training) improved poverty but did NOT lead to broader impacts (empowerment, IPV, HIV risk) Importance of education, addressing social norms & community mobilisation (Kim et al. Bulletin of WHO, 2009) Importance of education, addressing social norms & community mobilisation (Kim et al. Bulletin of WHO, 2009) Strong partnerships models: each stick to what you do well Loan repayment rates 99% Loan repayment rates 99%

12. 12 2001-2004 2005-2007 2008-2010 430 households 4500 households (30,000) 15 000 households (80,000) IMAGE: Scaling up in South Africa Pilot Study Additional cost = US $43/client Scale-up Additional cost = US $13/client

13. 13 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 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… MF a “foothold” out of poverty, but not the whole ladder… However such programs do: However such programs do: Demonstrate feasibility & suggest pathways for affecting health outcomes Demonstrate feasibility & suggest pathways for affecting health outcomes Yield practical lessons & cross-sectoral partnership models Yield practical lessons & cross-sectoral partnership models Provide “metaphor” for what might be possible by combining economic empowerment & HIV prevention on wider scale Provide “metaphor” for what might be possible by combining economic empowerment & HIV prevention on wider scale

14. 14 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 legal status

15. 15 Policy implications: At country level: How to begin addressing structural factors as part of national HIV/AIDS strategy? SA National HIV/AIDS Strategic Plan (2007-2011): Goal 18: Focus on the human rights of women and girls and mobilize society to stop gender-based violence and advance equality in sexual relationships Goal 18: Focus on the human rights of women and girls and mobilize society to stop gender-based violence and advance equality in sexual relationships Objective 1.2: Roll-out integrated microfinance and gender education interventions starting in the poorest and highest HIV burden areas Objective 1.2: Roll-out integrated microfinance and gender education interventions starting in the poorest and highest HIV burden areas “Mainstreaming AIDS in Development” (UNDP/UNAIDS) Role of donors & government sectors in supporting structural approaches to HIV (e.g. integrating Gender/HIV into economic development programs) Role of donors & government sectors in supporting structural approaches to HIV (e.g. integrating Gender/HIV into economic development programs) Private sector: Beyond “corporate social responsibility” (e.g. Anglo Platinum Mines, Goldman Sachs 10,000 Women Campaign) Private sector: Beyond “corporate social responsibility” (e.g. Anglo Platinum Mines, Goldman Sachs 10,000 Women Campaign)

16. 16 Structural interventions & HIV Prevention: An unexplored frontier… Individual Behaviour Laws & Policies Socio-economic conditions Cultural norms Microfinance & HIV IMAGE (S Africa) TRY (Kenya) SHAZ (Zimbabwe) Masculinities & HIV: Promundo (Brazil, India) Men as Partners (SA) Women’s property & inheritance laws ICRW review (2004)

17. 17 PreventionTreatment The “AIDS Pendulum” 25 years into the AIDS Pandemic… Early in epidemic Early in epidemic Attention to structural drivers in North as well as South Attention to structural drivers in North as well as South Calls to address structural factors Calls to address structural factors 1990s: Prevention “burnout” 1990s: Prevention “burnout” Side-tracked by ideological “ABC” debates Side-tracked by ideological “ABC” debates Great hopes placed in ART & new prevention “technology” (PrEP, male circumcision, microbicides, vaccines) Great hopes placed in ART & new prevention “technology” (PrEP, male circumcision, microbicides, vaccines) No “magic bullets” No “magic bullets” 2000s: Learning from the past? 2000s: Learning from the past? Structural interventions: time to “enrich the mix” of prevention strategies Structural interventions: time to “enrich the mix” of prevention strategies

18. 18 AIDS is a long-wave event… A “slow motion tsunami” A “slow motion tsunami” Requires both : Requires both : Immediate, “AIDS-specific” responses (e.g. ART) AND Immediate, “AIDS-specific” responses (e.g. ART) AND Long-term commitment to addressing structural factors as part of Prevention Long-term commitment to addressing structural factors as part of Prevention The challenge: Can we combine sense of urgency with long-term vision? The challenge: Can we combine sense of urgency with long-term vision? “Make haste slowly” - Milarepa (12th Century, Tibet)

19. 19 Acknowledgements LSHTM & WITS colleagues: 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