1. www.ias2013.org Social Determinants and Structural Interventions: Keys to turning the tide of HIV in the EECA region Barbara de Zalduondo, MSc, PhD Senior Advisor to the Deputy Executive Director for Programme, UNAIDS Chris Beyrer, MD, MPH Professor and Director, Johns Hopkins Center for Health and Human Rights, and Michel Kazatchkine, MD Professor, and UN Secretary General Special Envoy on HIV/AIDS in Eastern Europe and Central Asia

2. www.ias2013.org Overview o Basics – what are social determinants and structural interventions? o Illustration through recap of structural barriers to HIV prevention and treatment in the EECA region – and examples of positive change o Tools and strategies from the social sciences to address structural barriers – social, economic, and political o Some implications for the science agenda and the global HIV community

3. www.ias2013.org Basics “The social determinants of health are “the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness.”( WHO Commission on the Social Determinants of Health, 2008) “Structural interventions refer to public health interventions that promote health by altering the structural context within which health is produced and reproduced. (Blankenship et al. 2000 et seq; Des Jarlais, 2000; Sumartojo, 2000) Structural interventions seek to improve “the risk environment” (Barnett and Whiteside, 1999; Rhodes et al., 2005) … to create an “enabling environment” (Tawil, Verster and O’Reilly, 1997) for HIV programmes and for human development.

4. www.ias2013.org Basics (continued) “Social determinants,” “structural factors,” and the “risk environment” or “enabling environment” - focus our attention on the conditions that shape and constrain human health and behaviour. The conditions are of different types. Social and cultural Political and legal Economic Physical environment They operate at different “levels” from micro to macro (or proximate to distal). Individual Relationships, Social Groups/Networks Community, Organizations Society Inter-governmental, Regional, Global Micro, Proximal Macro, Distal The types and levels interact Intermediate - systematically.

5. www.ias2013.org Many HIV prevention and treatment strategies have focused on the individual level, assuming individuals will defy or overcome social, economic and political constraints. Individuals Social and sexual networks Community, Organizations Society Inter-governmental, Global Individuals

6. www.ias2013.org Structural interventions aim to change those powerful tides by engaging or influencing groups of people or organizations to endorse change. For example, to: Change harmful gender norms: (e.g. IMAGE; Stepping Stones) Promote community ownership and engagement of HIV (e.g. UNDP’s “Community Conversations”) Reduce stigma and discrimination (e.g. ICRW /HORIZONS; Brazil Without Homophobia programme) Remove punitive laws (e.g. Voices Against 377 coalition in India) Set rights-based inter-government policies and targets (e.g. MDGs, UN General Assembly HIV goals and targets (2001, 2006, 2011)

7. www.ias2013.org HIV prevalence in Eastern Europe and Central Asia* (UNAIDS estimates for 2012. Prevalence data NA from Russian Federation, Turkmenistan, Uzbekistan) *Selected countries. Similar to WHO/Euro’s Eastern Europe sub-region.

8. www.ias2013.org (1) Because the countries of the EECA region have the fastest growing HIV epidemics in the world.

9. www.ias2013.org (2) Enormous size and diversity of the region 9 Slide courtesy of S. Dvoryak

10. www.ias2013.org (3) HIV risks and rates are concentrated in vulnerable groups Data Sources: WHO Regional Office for Europe, 2013 Slide courtesy of Tim Rhodes HIV cases reported to WHO to date (2013) by, mode of exposure

11. www.ias2013.org Economic o Economic transformation; mobility o Poverty, income inequality o Drug trafficking routes and practices Political, legal o Punitive laws and policies re. sex work, drug use, and PLHIV o Migration policies o Legacies of vertical, specialized state services o Official corruption; abusive policing o Lack of access to services and to justice Social and cultural o Sex-Gender system; gender inequality o Low HIV knowledge and engagement o Stigma associated with HIV, drug users, sex workers, migrants, prisoners o Low awareness of human rights (4) The principal “drivers” of epidemic growth in the EECA region are structural. *For reviews see, e.g., Rhodes et al., 2005; Godhino et al. 2005; Strathdee et al., 2010; Degenhardt et al., 2010; Bridge, Lazarus and Atun, 2012; Platt et al, 2013, and MOSY03 Photo courtesy of Stephanie Strathdee

12. www.ias2013.org ) More Intermediate Level, Social, Economic and Political Factors for key populations For People who Inject Drugs (PID) o Registration o Risk of incarceration or deportation o Unsafe injecting sites o Homelessness o No/low access to OST o No/low of access to NSE o Lack of integrated health and SRH services For female, male and trans sex workers (SW) o Legal restrictions o Unsafe workplaces o Mandatory HIV testing o Drug use, partner’s drug use o Threats to children o Gender-based violence (GBV) o Police exploitation/abuse o No/poor quality SRH & social services Similar lists emerge from studies with men who have sex with men, migrants, and prisoners. (4) (continued) Photo courtesy of Tim Sladden and Stephanie Strathdee

13. www.ias2013.org Barriers within the health care system ↑ vulnerability Source: Medelevich and Zohrabian, 2012. Barriers to health care services for women who inject illegal drugs. IAS 2012 In a 2011 study of women who inject drugs in 4 cities in Tatarstan province, Russian Federation, over half (66.1%) encountered barriers accessing health care “sometimes” or “often.”

14. www.ias2013.org (5) Overlapping epidemics; overlapping vulnerabilities Especially vulnerable: o Young people in key populations (UNICEF; UNESCO) o Women (El Bassel, 2012) For example: o 20-50% of women who use or inject drugs also sell sex (Platt et al. 2013) o Prevalence of HIV among FSW in Central Asia who inject drugs is 40- 50%

15. www.ias2013.org (6) Insufficient investment in EECA in services for key populations Data source, UNAIDS 2010. Graph from D. Wilson, 2012

16. www.ias2013.org Social determinants require social solutions. Political challenges require political responses.

17. www.ias2013.org Russian Police arresting LGBT rights protestors in Moscow. The protest was in response to Moscow’s then mayor, Yuri M. Luzhkov, calling gay protests “satanic acts.” (Photo credit: Chris Beyrer) Stigma (meanings) Discrimination (behaviour) “Hard to reach” Low knowledge, access and use of HIV services

18. www.ias2013.org Vicious cycle of neglect, exclusion, avoidance of health services, and continued risk and vulnerability PUD experience and/or fear poor treatment Low uptake of services; health, economic and social difficulties Increased risk of HIV; High rate of HIV among PUD Values shame and blame PUD, especially when poor, female, and/or young Policies neglect or exclude PUD, and ignore special needs of women and young people Service providers exclude or shame PUD

19. www.ias2013.org Myths about PWID perpetuate ineffective treatment 19 Slide courtesy of S. Dvoryak Opinions of Most Effective Strategies for Treating Addiction (N=239)

20. www.ias2013.org Source: J. Auerbach, 2012

21. www.ias2013.org Individuals Knowledge, attitudes, beliefs, experiences, biological characteristics Adapted with permission from S. Baral et al., 2013. Investigating context systematically, to identify dependencies and opportunities

22. www.ias2013.org Recent growth in use of methods appropriate for evaluating complex interventions & programmes Complementary to the tarnished* “gold standard” o Highest Available Standard of Evidence method (Baral et al. Beyrer, Wirtz, Walker et al. 2011): “HASTE not waste” o Modeling combined impact of national responses (e.g. Garnett et al, 2008 on Zimbabwe) o Modeling prospective impact of adding structural interventions to basic programmes (e.g. Watts et al. – stigma and PMTCT; Strathdee et al (2010) on reducing police violence against PID in Ukraine (* e.g. Habicht, et al., 1989; West et al, 2007; Auerbach et al., 2009; MERG, 2009; Laga et al. 2010; Atun et al. etc.) Strathdee, Hallett, Bobrova et al., Lancet 2010

23. www.ias2013.org Steady work has produced improved measures of complex social constructs, such as Gender Based Violence, Stigma, and Community response, etc.

24. www.ias2013.org Increasing use of political strategies

25. www.ias2013.org More experimental, quasi-experimental and natural experimental intervention studies are welcome, and needed BUT are we doing the right things?

26. www.ias2013.org Who has the power to effect the needed change? Stakeholder analysis Strategic partnerships Political action

27. www.ias2013.org Doctors and scientists can’t solve every problem, but can encourage or discourage decision-makers to take hard decisions “I’m a doctor, Jim, not a miracle worker!!”

28. www.ias2013.org Structural change in Moldova – transforming the risk environment for PWID in Prisons Harm reduction legalized in 1997 Harm reduction for PWID legalized in 2001, and NSE and OST provided Major decline in HIV prevalence in PWID (14.4% in 2004; 7.9% in 2010, from IBBS studies) Major decline of HIV prevalence in prisons (3.4% in 2010, 1.9% in 2013, from IBBS studies) Slides presented by Dr. Doltu at the IHRC in Vilnius, June 2013

29. www.ias2013.org Prevention programs among vulnerable groups have led to a decrease in HIV cases registered among PID and general population in Ukraine Source: International HIV/AIDS Alliance in Ukraine based on the data from Ukrainian Center for Socially Dangerous Disease Control of the Ministry of Health of Ukraine

30. www.ias2013.org Modeling suggests that reducing unmet need of OST, NSP and ART by 60% could prevent 41% of incident HIV infections (Strathdee et al, 2010) Slide courtesy of S. Strathdee

31. www.ias2013.org Over all, miniscule investment in creating enabling environments EECA countries invested 0.64% of HIV programme spending in enabling environment in 2012 (UNAIDS 2012 GARPR data). Activities categorized as “enabling environment” include: o Advocacy o Human rights programmes o AIDS-specific institutional development o AIDS-specific programmes focused on women o Programmes to reduce GBV o And other Enabling Environment and Community Development UNAIDS. 2012. Investing for results. Results for people. A people-centred investment tool towards ending AIDS. Geneva.

32. www.ias2013.org Critical to pursue scientific breakthroughs in the sciences that deal with power and passion

33. www.ias2013.org “Fostering social structural change is the critical next stage in the global fight against AIDS.” Tim Rhodes, Merrill Singer, Philippe Bourgois, Sam Friedman and Steffanie Strathdee, (Soc Sci Med, 2005)

34. www.ias2013.org Concluding Summary o Groups vulnerable to HIV are being left behind o Structural factors – especially socio-cultural, economic and political factors including stigma and punitive laws – largely account for and perpetuate these shortcomings o Social and political barriers require social and political solutions. o While EECA countries face low or concentrated HIV epidemics, they are extremely diverse; This demands local diagnosis, local leadership, and tailored and dynamic responses. o National AIDS programmes and partners around the world need political allies beyond the health sector. In the EECA region, achieving MDG6 and post-2015 development goals depends on this. o More investment will bring more advances in the social dimensions of the epidemic.

35. www.ias2013.org Acknowledgements JudithAuerbach StephanBaral RichardBurzynski KentBuse CarlosCaceres AlisonCrocket PatrickEba TaaviErkkola PeterGhys RomanHailevich CatherineHankins LoriHeise GabrielaIonascu LuizLoures Jean-ElieMalkin ChrisMallouris TimRhodes ErnaRibar AidaSemaga AniShakarashvili TimSladden StephanieStrathdee OussamaTawil SusanTimberlake LevZohrabyan

36. www.ias2013.org René Sabatier, - 1989 Carol Jenkins, 1945 - 2008 Robert Carr, 1963 - 2011 Mary Haour-Knippe, 1945 - 2013 Dedication In memoriam Moment of Silence Let us continue to light a candle, to honour all those we have lost, those who are vulnerable, and those who are working for health justice today

37. www.ias2013.org

38. 15 Structural Intervention strategies, from micro to macro scale and effects Source: UNAIDS. 2010. Discussion Paper: Combination Prevention.

39. www.ias2013.org “…Engaging with social drivers requires methods and approaches beyond traditional conceptualizations that seek to identify and intervene on single, causal determinants or universal mechanisms of influence.” Source: (Auerbach, Parkhurst, Cáceres et al., aids2031 Working Paper 24)

40. www.ias2013.org Modified Ecological Model for HIV Risk in People who inject drugs Adapted with permission from S. Baral et al., 2013. The varied factors influence each other; each contributes to the “context” of the others