HIV This Week

Addressing social drivers of HIV/AIDS for the long-term response: conceptual and methodological considerations

Auerbach JD, Parkhurst JO, Cáceres CF.  Glob Public Health. 2011 Jul 11.

A key component of the shift from an emergency to a long-term response to AIDS is a change in focus from HIV prevention interventions focused on individuals to a comprehensive strategy in which social/structural approaches are core elements. Such approaches aim to modify social conditions by addressing key drivers of HIV vulnerability that affect the ability of individuals to protect themselves and others from HIV. The development and implementation of evidence-based social/structural interventions have been hampered by both scientific and political obstacles that have not been fully explored or redressed. This paper provides a framework, examples, and some guidance for how to conceptualise, operationalise, measure, and evaluate complex social/structural approaches to HIV prevention to help situate them more concretely in a long-term strategy to end AIDS.

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Editor’s note: The critical role of social determinants of health in shaping people’s decisions to act, i.e. their agency, has been recognised for a long time. These determinants include social and structural factors, such as poverty, gender inequality, and human rights violations that increase people’s vulnerability to HIV. But what are the social and structural factors that contribute to the resilience of individuals, communities, and societies against HIV? The first step in better understanding vulnerability and resilience is to assess context-specific contributing/influencing factors. These can then inform the development of a socially plausible hypothesis of causal chains linked to HIV transmission, with intervention possibilities to consider at various levels, from the most proximal to the most distal. Distal level structural interventions may institute policy-legal changes, create or reinforce environmental enablers, produce changes in harmful social norms, catalyse social and political change, and introduce economic initiatives. The challenges of evaluating the impact of structural interventions on HIV incidence are daunting but both quantitative and qualitative social science methods can start by assessing impact more generally. It is important to recall that virtually all of these social changes are important from a social justice viewpoint. UNAIDS succinct definition of combination prevention underscores the importance of integrating strategies to address social determinants: ‘ …the strategic, simultaneous use of different classes of prevention activities (biomedical, behavioural, social/structural) that operate on multiple levels (individual, relationship, community, societal) to respond to the specific needs of particular audiences…through prioritising, partnerships, and engagement of affected communities.’