Enriching the mix: incorporating structural factors into HIV prevention

Structural factors associated with HIV risk and prevention may be broadly defined to include physical, social, cultural, organizational, community, economic, legal or policy aspects of the environment that impede or facilitate persons' efforts to avoid HIV infection 1. These factors have been understudied and underutilized, as much of public health has emphasized individual-level behavioral and biomedical prevention approaches. However, experts in HIV policy, research, and service implementation are now beginning to describe the ways that structural barriers create vulnerable populations and sustain high-risk behaviors, or that structural facilitators support safe behaviors 2-12. As part of this emerging effort, in February 1999, the Division of HIV/AIDS Prevention at the National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention sponsored an interdisciplinary meeting of researchers and policy-makers to identify structural factors associated with HIV, and to assist the Centers for Disease Control and Prevention in identifying priority areas for research and implementation 13. The discussion primarily focused on structural issues in the United States, but it was informed by and relevant to structural issues internationally. Participants differentiated between two levels of structural factors. At the broadest level, economics, race, gender, or societal attitudes confound HIV risk and prevention. For example, stigmatization may diminish recognition of the need for specialized prevention programs targeting high-risk groups, or lead to legal barriers to the availability of clean injection equipment. At a proximal level, structural factors impact prevention more directly, such as when procedures are put in place to make prevention services accessible and acceptable. Proposed interventions to reduce structural barriers included changes in laws and policies, increased services for populations at risk, changes in provider practices, changes in funding priorities, increased participation by the private sector, and increased community participation. Proposed research to inform these efforts would identify how to engage community leaders in encouraging structural level prevention efforts, and how to reduce stigmatization and other social forces that make populations particularly susceptible to HIV risk behaviors. Evaluations of naturally occurring structural interventions as well as projects to develop research methodologies would also be needed. The papers in this special issue provide definitions and frameworks for structural factors in HIV, and examples showing how these factors operate within the major high-risk populations. They point to several broad conclusions. First, structural barriers or facilitators may be put in place by governments, service organizations, businesses, workforce organizations, faith communities, justice systems, media organizations, educational systems or healthcare systems. They are expressed through economics, policies, social norms and values, and organizational structures and functions 1. Second, initiatives to prevent health risks other than HIV have focused on structural supports or constraints that influence the availability, acceptability, and accessibility of the materials or environments needed by individuals to maintain safe behaviors 14. Third, political and economic factors that help to foster HIV in developing countries are equally pertinent among disadvantaged populations in developed countries 15. Finally, the populations at highest risk for HIV - men who have sex with men, communities of color, intravenous drug users, and vulnerable women and youth - are particularly affected by structural barriers to prevention 16-22. Studying and addressing structural barriers poses many different challenges for HIV workers. For researchers, the conditions demand innovations and complex experimental methods that incorporate multiple levels of effects as well as community participation. Some interventions will be outside the traditional sphere of public health and will require collaborations across multiple sectors of society. Policy-makers will need evidence of causal links between structural determinants and prevention outcomes in order to support research or intervention programs. This work will demand new methods and coalitions. HIV compels public-health officials to enrich the mix of strategies so that the structural and social environment can support rather than impede new and existing prevention approaches. We hope that the papers in this special issue will help further that effort.