What makes a structural intervention? Reducing vulnerability to HIV in community settings, with particular reference to sex work

Abstract

Increasing emphasis is being placed on the need for ‘structural interventions’ (SIs) in HIV prevention internationally. There is great variation in how the concept of SI is defined and operationalised, however, and this has potentially problematic implications for their likely success. In this paper, we clarify and elucidate what constitutes a SI with particular reference to the structured distribution of power and to the role of communities. We summarise the background to the growing emphasis being placed on the concept of SIs in HIV prevention policy, and present ethnographic case-study material from a sex worker's HIV project in Kolkata, India, to illustrate the nature of HIV vulnerability and its implications for the design and targeting of successful SIs. The paper draws attention to the dual importance of (1) attending to local complexities in the micro and macro-level structures that produce vulnerability; and (2) clarifying the meaning and role of communities within SIs.

Keywords:

• structural intervention
• HIV
• community mobilisation
• sex work
• India
• vulnerability

Acknowledgements

We are very grateful to Durbar for supporting this research. We acknowledge the (UK) Economic and Social Research Council for a postgraduate studentship to the first author.

Notes

1. ‘Politico-legal’ refers to the political structures framed by nation states and their implementing authorities, including policies, legislation and formal rules that affect the lives of all citizens and their ability to protect their health. ‘Socio-cultural’ structures comprise the ideological constructs – expressed, for example, in social norms and cultural values – that influence and are reflected in everyday practices and social institutions but are not codified or officially expressed in legal or judicial form. ‘Economic’ refers to dominant economic systems and their related policies and procedures which determine access to and control over economic resources. In reality, however, these three broad structural domains are always entwined and mutually constitutive