Transcript HIV prevention – beyond the biomedical

Conceptualising and
operationalising a structural
approach to HIV prevention
Justin Parkhurst
LSHTM / LIDC
Calls not new

The importance of structural factors, or strategies for
prevention dealing with underlying causes seen before



2000 special issue of AIDS dedicated to structural
approaches
1990s – articles identifying and calling for greater
inclusion of structures or ‘enabling environments’.
Yet little progress in policies/plans dealing with
structures


Focus has remained on individual interventions, or
searches for ‘magic bullets’
Language has remained simple – e.g. Science 2008 ‘what
works’ – ‘reducing multiple sexual partnerships’


Little though about how to achieve this.
“few demonstrated replicable approaches to reducing multiple
sexual partnerships” (Potts et al 2008)
Structural factors, structural drivers?

Many factors are associated with risk
behaviour



Macro/Statistical correlations
Descriptive works have highlighted
potential causal drivers of risk behaviour
Complexity involved with any determinant
of behaviour

Multiple structures will influence patterns of
behaviour. Often no single ‘start point’ per se,
or direct cause.
Can classify structural factors

By risk group:






IDUs
OVCs
Females/girls
MSM
Etc.
By sector:





Legal
Economic
Education
Socio-cultural
Etc.
Other models/classifications

Structures affecting interventions:



Availability
Acceptability
Accessibility
(Blankenship et al, 2000)
Cohen and Scribner (2000)

Causal Levels




Superstructural
Structural
Environmental
Individual
(Sweat and Denison, 1995)

Distal-Proximal determinants of HIV
infection
(Barnett and Whiteside, 2002)
Useful for planners?

Key issues appears to be identifying to
planers:




What they can (practically) do
Where they can act (what levels, what
issues)
How to act in a ‘structural’ way
Key needs are therefore:


A conceptual model which identifies points of
potential action
A strategy to guide planning
Points of potential action

Most useful/applicable elements of
past models appear to be:


Level of activities – local, mid-level,
national/international
Proximity of factor to ultimate risk
behaviour of interest
Strategy for planning

Structural approaches effectively call for
targeting activities to community needs.
2 ways to do so:
1.
2.
Enabling approach

Set up structures so that local (target)
communities can identify needs and act on
them
‘Diagnostic’ approach

Approach intervention by first researching
your target population and identifying
drivers of risk behaviour.
Distal
P
O
V
E
R
T
Y
Proximal
Inability to
meet key
needs
Unable to meet
education costs
Sugar daddy to
support school fees
Food
insecurity
Pull child out of
school to work on
farm
No spending
on health
care
Transactional sex
Diseases
untreated
- More indirect impact
- Longer causal chain
- Difficult to monitor and measure
impact
- Typically affects larger
population group
- Typically longer duration of
impact
Suits:
– National planners addressing large populations;
- Programme officers with broader development remit;
- International donors.
- More direct causal impact
- Easier to monitor and
measure impact
- Typically affects smaller
population group
- Typically shorter duration of
impact
Suits:
– Local planners addressing a specific community (e.g. young
women in a village);
- Programme officers with specific HIV remit;
- Planners with concern for specific target groups (e.g. IDUs)
Challenges/Issues

How to move forward our conceptions of
structural factors?


Can we make guides for different types of
actors?


A clear framework that is understood and
useful to planners
A set of guidelines for planning?
How to make useful recommendations?



When can we generalise?
How to assess if contexts are similar enough,
etc.
How to evaluate and determine causality?

How to shift thinking away from
sets of ‘magic bullet’ interventions?

What can be learned from other
disciplines on similar issues?


Do other social policy fields face similar
challenges in conceptualising, and
addressing complex drivers of
behaviour?
How are they conceptualised? How do
policy makers think in other areas?