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Charlotte Watts Ph.D. Head, Social and Mathematical Epidemiology Group

Structural economic interventions to address women’s vulnerability to HIV infection in sub-Saharan Africa. Charlotte Watts Ph.D. Head, Social and Mathematical Epidemiology Group Research Director, Structural Interventions Research Programme Consortium

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Charlotte Watts Ph.D. Head, Social and Mathematical Epidemiology Group

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  1. Structural economic interventions to address women’s vulnerability to HIV infection in sub-Saharan Africa Charlotte Watts Ph.D. Head, Social and Mathematical Epidemiology Group Research Director, Structural Interventions Research Programme Consortium Department of Global Health and Development London School of Hygiene and Tropical Medicine

  2. Challenge #1: Gender disparities in rates of heterosexual HIV transmission Source: UNAIDS Report on the Global AIDS Epidemic - 2010

  3. Challenge #2: Inequalities in relationship power & partner violence a risk factor for incident HIV infection Source: Jewkes et al The Lancet 2010

  4. Challenge #3: Benefits of HIV prevention least accessed by the poor Source: Hargreaves & Howe AIDS 2011

  5. Effective HIV prevention for women needs to address poverty, gender inequality & violence Social power Interventions that address women’s economic and social vulnerability Women controlled HIV prevention methods Effective prevention Poverty Prevention technologies Brady, Martha. Population Council, Conceptual Framework. 2005.

  6. What role could different forms of economic intervention play? • Economic development / empowerment programmes, eg micro-finance • Reduce poverty, so potentially impacting on: • Ability to negotiate sex • Ability to address violence • Need to engage in sex in exchange for resources • CCT interventions • Incentivise increased service use • HIV testing or STI treatment services • Enrolment in education – knowledge & self-efficacy, delay onset of sex, change sexual networks, increase opportunity cost of pregnancy • Reward safer sex behaviours • Reduce poverty, and on levels of sex in exchange for resources

  7. Conflicting perspectives on CCTs Marteau, Ashcroft & Oliver, 2009

  8. Population based CCTs to increase demand to learn or maintain HIV -ve status

  9. Schooling, Income, and HIV Risk (SIHR) intervention to encourage girls to stay in or return to school Baird, Chairwa, McIntost, Ozler, 2009,

  10. Alternative economic interventions: Intervention for Micro-finance And Gender Equity (IMAGE intervention) Pronyk et al The Lancet 2004, Pronyk et al AIDS 2008

  11. MF vs Control IMAGE vs MF IMAGE vs Control 0.1 1 10 0.1 1 10 0.1 1 10 0.1 1 10 0.1 1 10 0.1 1 10 1 1 10 0.1 1 10 0.1 Attitudes condoning IPV Past year experience of controlling behaviour Past year experience of violence 0.1 1 10 0.1 1 10 0.1 1 10 Household communication HIV risk behaviours Collective action Condom use with non-spousal partners Evidence that training essential to impact Microfinance vs. Control IMAGE vs. Control IMAGE vs. Microfinance Indicators of household economic wellbeing ECONOMIC INDICATORS Indicators of women’s empowerment EMPOWERMENT INDICATORS Attitudes and past year exposures to violence 0.1 10 VIOLENCE INDICATORS HIV RISK BEHAVIOURS HIV risk behaviours * All aRR for indicators represented as bar graphs on a logarithmic scale Source: Kim et al 2008 WHO Bulletin

  12. Ongoing scale-up of intervention alongside roll out of micro-finance Scale-up Additional cost = US $13/client Pilot Study Additional cost = US $43/client Expansion Additional cost = US $??/client 2001-2004 2005-2007 2008-2011 430 households 4500 households (30,000) 16000 households (80,000)

  13. Conclusions • Promising findings from both CCT and micro-finance interventions • Improved uptake of services • Reductions in reported risk behaviours • Impacts on HIV and HSV-2 • Evidence that the HIV impact of livelihood programmes enhanced by added training components • Importance of conditionality element of intervention varies between studies: • Evidence of influence on uptake of services • Less evidence of impact on rates of partner chance / maintaining HIV risk • Limited evidence on the costs of implemented conditionality

  14. How do these structural interventions fit into the new AIDS investment framework? Source: Swartlander et al Lancet 2011

  15. Investment needed to realize synergies between HIV & development programmes • School and livelihood programmes provide important infrastructures upon which HIV interventions can build • Systems of social protection that explicitly seek to achieve HIV benefits important • May be possible to achieve synergies at relatively low incremental cost • Cross-sectoral communication & collaboration essential to make prevention a reality

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