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Overview of Structural Interventions

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)

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Overview of Structural Interventions

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  1. Overview of Structural Interventions HIV Research Catalyst Forum Jennifer Hecht 4.21.10

  2. 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

  3. 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

  4. Spectrum of prevention • individual • partnership/group • network • community • structural

  5. 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

  6. Why are structural interventions important? • 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)

  7. 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)

  8. 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

  9. Understanding causal pathways • Important to understand mechanisms by which structural factors affect HIV • Address context in which risk occurs Male physical & Social dominance Inability to negotiate condom use: fear of violence Violence against women Gender inequality Unprotected sex Women’s economic dependence on men Male control over economic resources Inability to negotiate condom use: fear of abandonment Grupta, 2008

  10. Guidelines for developing/selecting structural interventions • Research support • Feasibility • Impact • Acceptability • Sustainability • Consider possible unintended consequences • Timing - what else is going on in the community?

  11. Examples of HIV-related structural interventions • Opt-out HIV testing • Email reminders from websites about STD testing • Housing • Incarceration policies

  12. Limitations • Take time to formulate, implement, see results • May be resource-intensive to begin • Hard to evaluate and monitor • Change is scary

  13. Combination Prevention • Suggestion to use multiple strategies to succeed in HIV prevention • Behavioral • Biomedical • Structural

  14. Acknowledgments • Dan Wohlfeiler • Tom Kennedy • Hunter Hargraves

  15. Thank you! Contact info: Jen Hecht jhecht@stopaids.org 415-575-0150 x272

  16. References • 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: 764-775 • 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

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