Social Drivers of HIV/STI Infections Among Young People

1. Social Drivers of HIV/STI Infections Among Young People Judith D. Auerbach, Ph.D. Independent Consultant, and Adjunct Professor, School of Medicine, UCSF SHINE Conference University of Chicago School of Social Service Administration November 8, 2013

2. Rates of Diagnoses of HIV Infection among Adolescents Aged 13–19 Years, 2011—United States and 6 Dependent AreasN = 2,316 Total Rate = 7.6 Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting.

3. Rates of Diagnoses of HIV Infection among Young Adults Aged 20–24 Years, 2011—United States and 6 Dependent AreasN = 8,140 Total Rate = 36.3 Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting.

4. Diagnoses of HIV Infection among Adolescents and Young Adults Aged 13–24 Years, by Race/Ethnicity, 2008–2011United States and 6 Dependent Areas Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. a Hispanics/Latinos can be of any race.

5. Diagnoses of HIV Infection among Adolescents and Young Adults Aged 13–24 Years, by Transmission Category 2008–2011—United States and 6 Dependent Areas Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting. a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.

6. Diagnoses of HIV Infection among Persons Aged 13 Years and Older, by Sex and Age Group, 2011—United States and 6 Dependent Areas Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting.

7. Diagnoses of HIV Infection among Adolescent and Young Adult Males, by Age Group and Transmission Category 2011—United States and 6 Dependent Areas Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting. a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.

8. Diagnoses of HIV Infection among Adolescent and Young Adult Females, by Age Group and Transmission Category 2011—United States and 6 Dependent Areas Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting. a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. b Includes blood transfusion, perinatal exposure, and risk factor not reported or not identified.

9. Global Epidemic • About 6,300 new HIV infections occurred each day in 2012: • About 95% were in low- and middle-income countries • About 700 were in children under 15 years of age • About 5,500 were in adults aged 15 years and older, of whom: • Almost 47% were among women • About 39% were among young people aged 15-24 (Source: WHO/UNAIDS 2013)

10. Disparate HIV/STI Rates Among Young Women • Of all young people(15-24) living with HIV (about 5 million), 75% are in sub-Saharan Africa • 71% of these are female, and they average only 2.3 sex partner in their lifetime • Yet they are 2 to 8 times more likely than male counterparts to be HIV positive • In the US, young people acquire nearly ½ of new STIs • In 2010, women 15-19 were 3 times more likely than male counterparts to have chlamydia

11. Conceptualization • HIV and STIs are pathogens that are transmitted between individuals in the course of certain practices (and behaviors) that occur in social contexts. • These practices are both influenced by, and themselves shape core elements of social organization, such as norms, values, networks, and institutions. • As such, risk of and resilience to HIV/STI among young people (or anyone) is a function of dynamic social processes.

12. Bronfenbrenner’s Ecological Systems Theory (1979)

13. Ecological Framework

14. Social Drivers of HIV UNAIDS (2007) Definition: “The social and structural factors, such as poverty, gender inequality, and human rights violations that are not easily measured that increase people’s vulnerability to HIV infection.” Auerbach, et al. (2011) Definition: “The core social process and arrangements—reflective of social and cultural norms, values, networks, structures and institutions—that operate around and in concert with individual behaviors and practices to influence HIV epidemics in particular settings.”

15. Social Determinants of Health (WHO & Public Health Reports) “The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries.” (Emphasis added).

16. The HIV Risk Environment • Levels: • Macro • Micro • Types: • Physical • Social • Economic • Policy Adapted by Strathdee et al., 2010, from Rhodes 1999 and Glass and McAttee 2006

17. Key Features of Social Determinants/Drivers/Factors • Not unilateral variables with causal, one-to-one linkages • Interactive phenomena reflective of social processes • Complex, fluid, non-linear, contextual • Interact dynamically with biological, psychological, behavioral, and other social factors • Must be characterized situationally and contextually

18. Examples • Gender Inequality • E.g. Gupta et al. 2008; Krishnan et al. 2008; UNAIDS 2007; Obermeyer 2006; Phillips 2011 • Poverty/Wealth • E.g. Gilles et al 1996; Hallman 2005; Weiser et al 2007; Shelton et al 2005; Chin 2007; Mishra et al. 2007; Fox 2010; Fox 2011

19. World Health Organization’s Commission on Social Determinants of Health Conceptual Framework Source: Solar O, and Irwin A (2010)

20. Framework for Analysis of Determinants of Child Wellbeing Macro actions Micro actions Systems Health Education Public admin Child protecn Social protection Public - Private Community - Family - Individual Institutions Religious Media Markets Human Rights Child Well being Material - Relational - Subjective Policy processes Legislation Taxation Public Policy Gender equality

21. Gender inequality & social norms condoning some use of violence Poverty & economic stresses Social constructions of masculinity Problematic alcohol use Reduced access to Info & HIV services Low or inconsistent condom use Increased probability partner has HIV and/or STI Increased likelihood that woman is HIV infected Pathways of association between IPV and women’s risk of HIV infection (from C. Watts 2012) PROXIMATE DETERMINANTS OF PERPETRATION OF INTIMATE PARTNER VIOLENCE BY PARTNER Early experiences or witnessing of violence Partner physical and/or sexual intimate partner violence Physical Sexual Woman has concurrent sexual partners Partner has concurrent sexual partners PROXIMATE DETERMINANTS OF HIV RISK FROM PARTNER Genital trauma

22. Where to Enter the Causal Chain: Most “Macro”? Colonialism Sex Work STI/HIV Transmission Labor Migration STI/HIV Transmission Colonialism

23. Operationalization • Structural approaches must begin with understanding of: • Level targeted—specific group of individuals or broader social, legal, economic environment. • Extent to which fundamental behavioral patterns are seen as fixed or changeable. • Interventions may be “ameliorative” or “fundamental”, targeting proximal or distal risk factors, respectively (See, e.g., Gupta et al. 2008; Blankenship et al. 2006; Cohen 2000; Coates et al. 2008)

24. Fundamental vs. Ameliorative “Health policymakers concerned with broad social conditions as causes of disease should regard with skepticism interventions that focus only on intervening variables but claim to address the broader social condition. Even an “effective” intervention that addresses the identified risk factor will, in the long run, fail to eliminate the effect of a fundamental social condition. In a changing state of affairs, the resources that accrue to the more advantaged allow them to regain the health advantage that may have been dented temporarily by the intervention. . . . If one wishes to address fundamental social causes, the intervention must address inequality in the resources that fundamental causes entail.” Bruce G. Link and Jo Phelan, Social conditions as fundamental causes of disease. Journal of Health and Social Behavior 1995 (Extra Issue):80-94.

25. Proximal and Distal Determinants Source: Robert Black, UNICEF Office of Research Meeting, Florence, July 2012

26. School Determinants • Physical and Structural Environment • activity space, physical safety, air quality, hazardous environments, rural/urban location • Health Policies • Policies for health education and school safety • Health Programs • Nutrition, physical education, prevention/intervention, health services • Health Resources • Availability of nurses, mental health professionals and physical specialists, links between school and community health resources • School Climate • Violence/bullying, school norms, academic values, teacher-student relationships, family-school connections • School Composition • Average pupils’ SES, student and staff gender and racial/ethnic composition, school size (Huang, Cheng, Theise, PHRVol 128 Suppl 3, 2013)

27. Proximal Influences Relevant to Adolescents (DiClemente, Salazar, and Crosby 2007)

28. Structural approaches to HIV prevention. Gupta GR, Parkhurst JO, Ogden JA, Aggleton P, Mahal A. Lancet 2008; 372: 764–75 Recent Publications on Social/Structural Approaches & Interventions Addressing social determinants of health in the prevention and control of HIV/AIDS, viral hepatitis, sexually transmitted infections, and tuberculosis. Dean HD, Fenton KA. Public Health Reports 2010 Jul-Aug; 125 Suppl 4:1-5. Transforming social structures and environments to help in HIV prevention. Auerbach J. Health Affairs 2009 Nov-Dec;28(6):1655-65. Structural interventions for HIV prevention in the United States. Adimora AA, Auerbach JD. JAIDS. 2010 Dec 15;55 Suppl 2:S132-5. Addressing social drivers of HIV/AIDS for the long-term response: Conceptual and methodological consideration Auerbach JD, Cáceres CF, and. Parkhurst JO , Global Public Health 2011 (Sppl 3):S293-S309.

29. Aims of Social/Structural Interventions • Policy-Legal Changes • Criminalization of homosexuality • Criminalization of drug user/users • Marriage, property & inheritance rights • Sex trafficking • Environmental Enablers • Access to and affordability of services • Educational & economic opportunities • Shifting Harmful Social Norms • Gender/sexuality discrimination & violence • Catalysis of Social & Political Change • Adopting human(including child) rights frame; building civil society capacity • Empowerment of Communities • Advocacy among PLWHA • Community engagement in research (Auerbach, 2009; Vincent, 2009)

30. Examples of Structural Interventions • Policy: • Expanding syringe access, e.g., by removing the ban on federal funding for syringe exchange • Legalizing same-sex marriage • Economic: • Requiring insurance companies to cover HIV testing • Providing conditional/other cash transfers • Social: • Normalizing comprehensive sex education in schools • Implementing anti-stigma and anti-bullying programs • Physical: • Removing doors in sex clubs

31. Appropriate Methods for Social-Level Approaches • Experimental & Quasi-Experimental • Observational • cohort, case-control, cross-sectional, ecologic • Qualitative & Quantitative Social Science Methods • survey, interview, focus group, participant observation, life histories or narratives, case studies, policy or content analysis, network mapping, mathematical modeling • Program Monitoring & Evaluation • process, outcome, indicators • Operations Research/Implementation Science

32. Steps in Designing Social/Structural Interventions for HIV Prevention • Assess social and structural factors that may shape risk behaviors in target population; • Identify/hypothesize sociologically plausible causal chains; • Identify levels of possible influence in line with scope and aim; • Make explicit any assumptions about social influences; • Build in rigorous and appropriate evaluation mechanisms.

33. Program, Practice, Policy: Applying Social Determinants of Health to Public Health Practice • PHR Vol 128 Supplement 3, Nov/Dec 2013

34. Key Points • Efforts to combat HIV need to engage underlying socio-cultural drivers/determinants. • Upstream factors veer apparently far from HIV infection and are historically intractable problems (e.g., gender and sexual violence, economic inequities, stigma and discrimination, colonialism, etc.). • Where does one enter in the causal chain? • Drawing causal linkages between drivers/determinants and HIV/STI is complicated by: • Complex, nonlinear and interactive relationships between drivers/determinants and HIV • Importance of specific local contexts. • Non-traditional methods/approaches required • Start from place of “sociological plausibility” • Draw from epidemiological as well as social science data. • Observational, modeling, triangulated methods tell stories of what worked and can work • Social change—including in research—is inherently political.

35. THANK YOU!