HIV This Week

Gupta GR, Parkhurst JO, Ogden JA, Aggleton P, Mahal A. Structural approaches to HIV prevention. Lancet. 2008 Aug 30;372(9640):764-75. Epub 2008 Aug 5.

Recognition that social, economic, political, and environmental factors directly affect HIV risk and vulnerability has stimulated interest in structural approaches to HIV prevention. Progress in the use of structural approaches has been limited for several reasons: absence of a clear definition; lack of operational guidance; and limited data on the effectiveness of structural approaches to the reduction of HIV incidence. In this paper Gupta et al build on evidence and experience to address these gaps. They begin by defining structural factors and approaches. Structural factors include the physical, social, cultural, organisational, community, economic, legal, or policy features of the environment that affect HIV infection. These factors operate at different societal levels and different distances to influence individual risk and to shape social vulnerability to infection. Structural approaches to HIV prevention seek to change social, economic, political, or environmental factors determining HIV risk and vulnerability. They should be implemented in a contextually sensitive way, in recognition of both the need for situational relevance and the interaction between diff erent levels of influence. Gupta et al describe the available evidence on their effectiveness and discuss methodological challenges to the assessment of these often complex efforts to reduce HIV risk and vulnerability. They identify core principles for implementing this kind of work. They also provide recommendations for ensuring the integration of structural approaches as part of combined prevention strategies.

Editors’ notes: Broad structural factors such as poverty and wealth, gender inequality, age, social marginalisation, laws and policies, and power both shape and constrain individual behaviour. They can be distal (further way from risk–taking, e.g. the economy) or proximal (more directly influencing risk, e.g. personal unemployment). They can undermine HIV prevention programmes that are narrowly focused on individuals. Combining structural approaches that aim to change the social, economic, or environmental factors that determine HIV risk and vulnerability in specified contexts with behavioural or biomedical prevention programmes not only increases programme effectiveness, it can transform social norms to support sustained behaviour change.