Revolutionising the AIDS response

Abstract

Individual behaviour change interventions and technological approaches to HIV prevention can only be effective over time if the broader social environment in which health-related decisions are made facilitate their uptake. People need to be not only willing but also able to take up and maintain preventive behaviours, seek testing, treatment and care for HIV. This paper presents findings and recommendations of the Social Drivers Working Group of the aids2031 initiative, which focus on how to ensure that efforts to address the root causes of HIV vulnerability are integrated into AIDS responses at the national level. Specific guidance is given on how to operationalise a structural approach.

Keywords:

• structural approaches
• social determinants
• HIV prevention
• resilience
• vulnerability

Notes

1. Findings from the work of the aids2031 Social Drivers Group indicate that the potential benefit of taking up a structural approach to AIDS is great. However, the benefit is not in the application of structural approaches per se, but in the thoughtful assessment of context, appropriate consultation and engagement of affected individuals and civil society and the development of a response that includes efforts to address social and structural, as well as epidemiological and behavioural, determinants of risk and vulnerability. We caution strongly against the use of structural approaches to curtail individual freedom, discriminate against or criminalise those affected. In the choice of structural approaches, therefore, we encourage programmers to consider whether the approaches selected promote health in its fullest sense (‘A state of complete physical, mental and social well-being – not merely the absence of disease or infirmity’) and foster resilience by ‘ensuring the conditions in which people are healthy’.

2. Buse et al. 2008 argue similarly that it is critical to also understand the political determinants of AIDS policy-making. They note, on page 572, that ‘[p]olitical, professional, religious, organisational as well as social institutions (e.g. governing gender norms, sexuality) are powerful determinants of HIV policy and represent longer-term targets in terms of policy change’.

3. The Social Drivers Group defines resilience as a proactive quality of individuals who are able to manage the risks in their environment. When individuals are AIDS-resilient, they are able to make choices that increase the safety of their individual practices, access appropriate testing and treatment services, assert their own desires and preferences and claim their rights without threat to themselves, their partners or families. AIDS competent communities are made up of AIDS resilient individuals living in a common geographic area or sharing a common set of activities, identities or interests. AIDS competent communities exist where there are effective HIV-related information and services, and where individuals within the community are connected to each other and to external organisations, which can provide additional resources and support.

4. Methods identified by Auerbach et al. (2011) include classical or quasi-experimental designs, observational data, social science methods – such as surveys, interviews and focus groups, behavioural and participant observation, life histories or narratives, case studies, policy and content analysis, network mapping and mathematical modelling, as well as programme monitoring, evaluation and operations research.

5. The paucity of rigorous evidence proving that structural approaches can impact incidence should not be used as an excuse to avoid adopting structural approaches; rather it should spur greater investment.