An integrated structural intervention to reduce vulnerability to HIV and sexually transmitted infections among female sex workers in Karnataka state, south India

via BMC Public Health, by Vandana Gurnani, Tara S Beattie, Parinita Bhattacharjee , Cfar Team, H L Mohan , Srinath Maddur, Reynold Washington, Shajy Isac, B M Ramesh, Stephen Moses and James F Blanchard

Abstract

Background:

Structural factors are known to affect individual risk and vulnerability to HIV. In the context of an HIV prevention programme for over 60,000 female sex workers (FSWs) in south India, we developed structural interventions involving policy makers, secondary stakeholders (police, government officials, lawyers, media) and primary stakeholders (FSWs themselves). The purpose of the interventions was to address context-specific factors (social inequity, violence and harassment, and stigma and discrimination) contributing to HIV vulnerability. We advocated with government authorities for HIV/AIDS as an economic, social and developmental issue, and solicited political leadership to embed HIV/AIDS issues throughout governmental programmes. We mobilised FSWs and appraised them of their legal rights, and worked with FSWs and people with HIV/AIDS to implement sensitization and awareness training for more than 175 government officials, 13,500 police and 950 journalists.

Methods:

Standardised, routine programme monitoring indicators on service provision, service uptake, and community activities were collected monthly from 18 districts in Karnataka between 2007 and 2009. Daily tracking of news articles concerning HIV/AIDS and FSWs was undertaken manually in selected districts between 2005 and 2008.

Results:

The HIV prevention programme is now operating at scale, with over 60,000 FSWs regularly contacted by peer educators, and over 17,000 FSWs accessing project services for sexually transmitted infections monthly. FSW membership in community-based organisations has increased from 8,000 to 37,000, and over 46,000 FSWs have now been referred for government-sponsored social entitlements. FSWs were supported to redress >90% of the 4,600 reported incidents of violence and harassment reported between 2007-2009, and monitoring of news stories has shown a 50% increase in the number of positive media reports on HIV/AIDS and FSWs.

Conclusions:

Stigma, discrimination, violence, harassment and social equity issues are critical concerns of FSWs. This report demonstrates that it is possible to address these broader structural factors as part of large-scale HIV prevention programming. Although assessing the impact of the various components of a structural intervention on reducing HIV vulnerability is difficult, addressing the broader structural factors contributing to FSW vulnerability is critical to enable these vulnerable women to become sufficiently empowered to adopt the safer sexual behaviours which are required to respond effectively to the HIV epidemic.


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Addressing social drivers of HIV/AIDS: Q&A with Judith Auerbach

“It boggles me that I still have to make the case for understanding the relational and contextual nature of HIV transmission and the need to recognize that people and technologies are interactive and interdependent.”

Global Public Health recently published a paper titled “Addressing social drivers of HIV/AIDS for the long-term response: Conceptual and methodological considerations.” Written by Judith D. Auerbach, Justin O. Parkhurst, and Carlos F. Cáceres, this paper is generating a great deal of interest and discussion in the HIV/AIDS prevention arena.

The authors make a case for a shift in the public health community’s response to HIV/AIDS, “from an ‘emergency’ approach to a long-term response.” A key component of this shift is the need for HIV prevention efforts to adopt “a comprehensive strategy in which social/structural approaches are core elements.” The root causes, the actual drivers of HIV vulnerability, need to be addressed in order to enable individuals to protect themselves and others from HIV infection. Drivers of HIV vulnerability include factors such as poverty, gender inequality, and human rights violations. These phenomena are difficult to measure and define. More significantly perhaps, they do not operate in the same way across the world – the dynamics work differently in various countries, communities, and demographic groups.

Mapping Pathways caught up with Judith, who is not only one of the authors of this paper, but is Vice President of Research and Evaluation at the San Francisco AIDS Foundation as well. Judith, a “public sociologist,” has been working in the field of HIV prevention for 22 years. We spoke to Judith about her work, the challenges in her field, the paper, and the importance of understanding and tackling the social drivers of HIV in the context of ARV-based prevention strategies:

MP: Could you tell us a bit about your work as a public sociologist? What are some of the challenges you’ve faced?

Judith: I have a PhD in sociology, but have chosen to work outside of academia almost all of my career – in government, research, policy, advocacy, and community-based organizations – to bring the insights of sociology (and social science more broadly) to bear on medical research and health policy deliberations focused on HIV/AIDS, women’s health,and gender equity.

This has sometimes been a challenging role, as I am usually the lone social scientist in the biomedical conversation, particularly around so-called “biomedical technologies” for HIV prevention.Having to constantly educate and convince others about the existence and contributions of social science is exhausting and frustrating.It boggles me that I still have to make the case for understanding the relational and contextual nature of HIV transmission and the need to recognize that people and technologies are interactive and interdependent. But, I have seen progress in recent years, so I’m happy to keep playing the social science missionary through my publications, presentations, and inputs at meetings and conferences.

MP: Your paper talks about the need to understand and address social drivers of HIV – could you explain briefly why this is important?

Judith: We began working on the paper at the moment when there was a great deal of interest in what everyone was calling “structural interventions.” This grew out of a growing understanding that HIV epidemics would not and could not be ameliorated by individual-level behavior change or product use one-person-at-a-time, and that individual “choices” were frequently constrained by social and structural arrangements (cultural norms and institutions, laws and policies, health care infrastructures, economic systems, etc.).

The need to address these arrangements was clear but the methods for doing so were not – neither to the scientific community nor to program implementers – because, as our paper outlines, the desire to rush to interventions was not yet based on a good understanding of the fundamental social mechanisms influencing HIV epidemics in different contexts. (This is not that different from the early rush to develop HIV drugs and vaccines before understanding the basic virology and immunology of HIV.) Moreover, as our paper also notes, the standard methodology for intervention research – the randomized controlled trial – is generally not appropriate for social/structural approaches. So, our interest in writing this paper was in providing some guidance about how to move logically from conceptualizing social factors that influence HIV transmission and understanding their dynamics to designing and evaluating programs and interventions to address them.

MP: More specifically, how is this important in the context of ARV-based prevention strategies?

Judith: With the recent developments in ARV-based prevention strategies, much of the attention to social/structural approaches has vanished from the health research and policy discourse. But this is problematic, because far from obviating the need for social-level responses, these new technologies highlight it.So far, only the “efficacy” of ARV-based prevention technologies, such as PrEP and microbicides, has been established – that is, there is evidence that these products reduce HIV infections when delivered as part of a comprehensive HIV prevention package in the context of a controlled clinical trial. In order for any of them to be truly “effective” (that is, to demonstrate an impact on HIV incidence in a population when used under “real-world” circumstances), they will have to be taken up and used by people as intended.

But, as social scientists have pointed out, people are not passive recipients of technologies. They apply meanings to them, they incorporate them (or don’t) in the context of their intimate relationships – relationships that are fraught with dynamics of gender and transaction – and they modify them. Moreover, on a practical level, the new technologies have to be available and affordable for people to use. These are all social-level issues that require social science-driven understanding.My fear and my observation so far is that the excited discussions of the “treatment as prevention” strategies mostly are occurring without this understanding.

If you’d like to know more about this issue, you can read the complete paper here.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]