Transcript Overview of Structural Interventions HIV Research Catalyst Forum Jennifer Hecht 4.21.10 What if we could reduce HIV transmission without focusing on behavior change? • If we.

Overview of Structural
Interventions
HIV Research Catalyst Forum
Jennifer Hecht
4.21.10
What if we could reduce HIV transmission
without focusing on behavior change?
• If we make changes
to the environment,
we might not have
to change our
individual behavior
as much (or at all)
• Ex. how food
arranged in
cafeterias
Background
• We know that individual risk alone does not fully
explain risk levels of all groups
– High rates of HIV among Black MSM not explained by
sexual risk or alcohol and drug use (Millett, 2006)
• These type of data indicate that structural and/or
contextual factors play a part in HIV risk
• We can’t hope to reduce HIV disparities or end
infections by solely addressing individual factors;
need to use the full spectrum of prevention to
succeed
Spectrum of prevention
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individual
partnership/group
network
community
structural
What are structural
interventions?
• SUSTAINABLE changes to the environment
• Policy, economic, social, and physical
changes
• Policy: removing the ban on federal funding for syringe
exchange
• Economic: insurance companies required to cover HIV
testing
• Social: discussion of condom use as the norm in a
community
• Physical: sex clubs in San Francisco don’t have doors
• Can involve multiple areas
Why are structural
interventions important?
1.
Structural interventions can address factors of social
injustice
- Structural interventions can help re-adjust an
imbalance of power, like legalizing gay marriage. Civil
unions have been associated with a decrease in
HIV/STD risk (Klausner, 2006)
2. Reach greater number of people than behavioral
interventions
- Including those who wouldn’t otherwise access
prevention
3. Cost effectiveness: structural interventions generally affect
a large population in a sustainable manner (Cohen, 2005)
Why are structural
interventions important? (cont)
4. Reduce the burden of prevention on individuals
- Behavior change difficult to achieve and costly
- HIV prevention is a shared responsibility with the
community as a whole rather than just the individual
5. Give a more varied response to reducing HIV transmission
6. Structural interventions can be effective
– Increasing taxes by 20 cents on a six-pack of beer
reduced gonorrhea rates by 8.9% (Chesson, 2000)
How can structural
interventions reduce HIV risk?
• Making smart
changes to the
environment that
result in reduced
risk
• Ex. Fluoride in water
reduces (but does
not eliminate) risk of
cavities
Understanding causal
pathways
• Important to understand mechanisms by
which structural factors affect HIV
• Address context in which risk occurs
Male physical &
Social dominance
Violence against
women
Inability to negotiate
condom use: fear
of violence
Gender inequality
Unprotected sex
Male control over
economic
resources
Women’s economic
dependence
on men
Inability to negotiate
condom use: fear of
abandonment
Grupta, 2008
Guidelines for developing/selecting
structural interventions
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Research support
Feasibility
Impact
Acceptability
Sustainability
Consider possible unintended
consequences
• Timing - what else is going on in the
community?
Examples of HIV-related
structural interventions
• Opt-out HIV testing
• Email reminders
from websites about
STD testing
• Housing
• Incarceration
policies
Limitations
• Take time to formulate, implement, see
results
• May be resource-intensive to begin
• Hard to evaluate and monitor
• Change is scary
Combination Prevention
• Suggestion to use multiple strategies to
succeed in HIV prevention
– Behavioral
– Biomedical
– Structural
Acknowledgments
• Dan Wohlfeiler
• Tom Kennedy
• Hunter Hargraves
Thank you!
Contact info:
Jen Hecht
[email protected]
415-575-0150 x272
References
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Blankenship, K. et al, Structural Interventions in Public Health, AIDS, 2000;14
(suppl 1):S11-21
Chesson, H. et al, Sex Under the Influence: The Effect of Alcohol Policy on Sexually
Transmitted Disease Rates in the United States, Journal of Law and Economics,
2000; 43: 215-238
Cohen, D. et al, Cost-Effective Allocation of Government Funds to Prevent HIV
Infection, Health Affairs, 2005; 24: 915-926
Grupta, G. et al, Structural approaches to HIV Prevention, Lancet, 2008;372: 764775
Klausner, J.et al, Same-Sex Domestic Partnerships and Lower-Risk Behaviors for
STDs, Including HIV Infection, Journal of Homosexuality, 2006;51:137-144
Millett, G., American Journal of Public Health, 2006
Wohlfeiler, D., Buying Upstream: Applying Structural and Environmental
Interventions to HIV Prevention, Centers for Disease Prevention and Control
Wohlfeiler, D., Ellen, J., The Limits of Behavioral Interventions, Prevention is
Primary: Strategies for Community Well-Being, 2007
Nudge, Thaler and Sunstein, Yale University Press, 2008