1. Overview of Structural Interventions HIV Research Catalyst Forum Jennifer Hecht 4.21.10

2. What if we could reduce HIV transmission without focusing on behavior change? If we make changes to the environment, we might not have to change our individual behavior as much (or at all) Ex. how food arranged in cafeterias

3. Background We know that individual risk alone does not fully explain risk levels of all groups –High rates of HIV among Black MSM not explained by sexual risk or alcohol and drug use (Millett, 2006) These type of data indicate that structural and/or contextual factors play a part in HIV risk We can’t hope to reduce HIV disparities or end infections by solely addressing individual factors; need to use the full spectrum of prevention to succeed

4. Spectrum of prevention individual partnership/group network community structural

5. What are structural interventions? SUSTAINABLE changes to the environment Policy, economic, social, and physical changes Policy: removing the ban on federal funding for syringe exchange Economic: insurance companies required to cover HIV testing Social: discussion of condom use as the norm in a community Physical: sex clubs in San Francisco don’t have doors Can involve multiple areas

6. Why are structural interventions important? 1.Structural interventions can address factors of social injustice - Structural interventions can help re-adjust an imbalance of power, like legalizing gay marriage. Civil unions have been associated with a decrease in HIV/STD risk (Klausner, 2006) 2. Reach greater number of people than behavioral interventions - Including those who wouldn’t otherwise access prevention 3. Cost effectiveness: structural interventions generally affect a large population in a sustainable manner (Cohen, 2005)

7. Why are structural interventions important? (cont) 4. Reduce the burden of prevention on individuals - Behavior change difficult to achieve and costly - HIV prevention is a shared responsibility with the community as a whole rather than just the individual 5. Give a more varied response to reducing HIV transmission 6. Structural interventions can be effective –Increasing taxes by 20 cents on a six-pack of beer reduced gonorrhea rates by 8.9% (Chesson, 2000)

8. How can structural interventions reduce HIV risk? Making smart changes to the environment that result in reduced risk Ex. Fluoride in water reduces (but does not eliminate) risk of cavities

9. Understanding causal pathways Important to understand mechanisms by which structural factors affect HIV Address context in which risk occurs Male control over economic resources Unprotected sex Male physical & Social dominance Women’s economic dependence on men Inability to negotiate condom use: fear of abandonment Violence against women Inability to negotiate condom use: fear of violence Gender inequality Grupta, 2008

10. Guidelines for developing/selecting structural interventions Research support Feasibility Impact Acceptability Sustainability Consider possible unintended consequences Timing - what else is going on in the community?

11. Examples of HIV-related structural interventions Opt-out HIV testing Email reminders from websites about STD testing Housing Incarceration policies

12. Limitations Take time to formulate, implement, see results May be resource-intensive to begin Hard to evaluate and monitor Change is scary

13. Combination Prevention Suggestion to use multiple strategies to succeed in HIV prevention –Behavioral –Biomedical –Structural

14. Acknowledgments Dan Wohlfeiler Tom Kennedy Hunter Hargraves

15. Thank you! Contact info: Jen Hecht jhecht@stopaids.org 415-575-0150 x272

16. References Blankenship, K. et al, Structural Interventions in Public Health, AIDS, 2000;14 (suppl 1):S11-21 Chesson, H. et al, Sex Under the Influence: The Effect of Alcohol Policy on Sexually Transmitted Disease Rates in the United States, Journal of Law and Economics, 2000; 43: 215-238 Cohen, D. et al, Cost-Effective Allocation of Government Funds to Prevent HIV Infection, Health Affairs, 2005; 24: 915-926 Grupta, G. et al, Structural approaches to HIV Prevention, Lancet, 2008;372: 764- 775 Klausner, J.et al, Same-Sex Domestic Partnerships and Lower-Risk Behaviors for STDs, Including HIV Infection, Journal of Homosexuality, 2006;51:137-144 Millett, G., American Journal of Public Health, 2006 Wohlfeiler, D., Buying Upstream: Applying Structural and Environmental Interventions to HIV Prevention, Centers for Disease Prevention and Control Wohlfeiler, D., Ellen, J., The Limits of Behavioral Interventions, Prevention is Primary: Strategies for Community Well-Being, 2007 Nudge, Thaler and Sunstein, Yale University Press, 2008