Julia Kim School of Public Health University of the Witwatersrand &

1. New frontiers in HIV prevention science Addressing structural determinants of HIV and measuring change Julia Kim School of Public Health University of the Witwatersrand & Centre for Gender, Violence & Health London School of Hygiene & Tropical Medicine AIDS 2008, Mexico City

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

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

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

5. The IMAGE Study:A Structural Intervention for HIV in South Africa Microfinance (SEF) Poverty & economic inequalities IMAGE Gender violence HIV infection Gender/HIV Training (12 months) Gender Inequalities

6. Evaluation: Cluster- Randomized Trial 2001-2004 • 8 villages in rural Limpopo (pop 64, 000) • Matched on size and accessibility; randomly selected • Participants (Intervention + control) • Women matched by age and poverty-status • Face-to-face interviews: Baseline and 2 years later • Adjusted for baseline differences & village-level clustering • Concurrent qualitative research • 3 full-time anthropologists

7. After 2 years, improvements in… 9 indicators of Empowerment Intimate partner violence: Past year physical or sexual violence reduced by 55% aRR 0.45 (0.23-0.91) HIV risk behaviour(< 35 yrs) VCT: aRR 1.64 (1.06 – 2.56) Communication: aRR 1.46 (1.01 – 2.12) Unprotected sex: aRR0.76 (0.60 – 0.96) -Pronyk et al, Lancet 368, 2006- Pronyk et al, AIDS 22, 2008

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

9. Programme considerations… • 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 • Cross-sectoral interventions can generate synergy Microfinance: Meeting “basic needs” as part of HIV prevention • piggy-backing onto MF program: sustained participation Gender/HIV Training: Empowerment about “more than just money” • New Study: MF (without training) impacts on poverty but NOT broader benefits (empowerment, IPV, HIV risk) Strong partnerships models: each stick to what you do well

10. Research considerations: Building a body of evidence for structural interventions Strengths of using randomized trials: • Protocol registered with NIH & Lancet; pre-specified 10 and 20 outcomes • Minimized common forms bias Challenges: • N = number of clusters, not individuals (unlike clinical trials) • Wide C.I. for some indicators • Often difficult to enroll large number of clusters(e.g. incremental enrollment of MF over broad geographical area) • Complex interventions… • Take time: Limited exposure to intervention (time for diffusion effects at community level?) • Affect multiple endpoints :May be difficult to predict in advance, hard to fit within CRT ‘template’ for protocols

11. Therefore… • Growing recognition: Cannot focus exclusively on p-values to judge impact • Use trials to gain unbiased measure of effect, noting consistency, congruency & plausibility of change documented- Habicht J et al, Int J Epid 1999, 28:10-18 • Need to generate strong theoretical frameworks & measure plausible pathway variables linking structural interventions to health outcomes • Not only focus on measuring proximate risk behaviors (e.g. condom use, partner reduction) • Also measure relevant pathway variables • e.g. women’s economic empowerment, negotiating power, gender-based violence

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

13. 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 rights

14. “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 XIth International AIDS Conference Vancouver, 1996 (Mane, Aggleton, Dowsett et al)

15. Structural interventions & HIV Prevention:An unexplored frontier… • Microfinance & youth livelihoods • SHAZ (Zimbabwe) • TRY (Kenya) • Gender norms & GBV: • Stepping Stones RCT (SA) • SASA RCT (Uganda) • Promundo (Brazil, India) • Men as Partners (SA) Socio-economic conditions Individual Behaviour • Women’s property & inheritance laws • ICRW review (2004) Cultural norms Laws & Policies

16. Prevention Technology: Expanding the range of individual options • Female Condom • Male circumcision • Microbicides • PrEP • Vaccines Abstinence Partner reduction Condom use …but will this be enough? Technology only useful if one is empowered to use it

17. Structural interventions: Making prevention options realistic for individuals Socio-economic conditions • Female Condom • Male circumcision • Microbicides • PrEP • Vaccines Abstinence Partner reduction Condom use = SYNERGY Laws & Policies Cultural norms

18. 1980-90s: Prevention “burnout” Side-tracked by ideological “ABC” debates Great hopes placed in ART & new prevention technologies No “magic bullets” Is the pendulum about to swing back towards Prevention? The real cost of scaling up ART amidst ongoing infection rates Re-authorization of PEPFAR: $48B – focus shifting to prevention & women’s empowerment Structural interventions: Re-invigorating HIV prevention by learning from the past 25 years into the AIDS Pandemic… The “AIDS Pendulum” Treatment Prevention

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

20. 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