The 3rd

Structural Drivers of HIV Conference 5 - 6 December 2013

The 3rd

Structural Drivers of HIV Conference

Theme: Contextualising Structural Drivers of HIV and AIDS

Venue: The Cullinan Hotel, Cape Town, South Africa

Dr Kaymarlin Govender (Research Director: HEARD)

Welcome Address

Good morning delegates and welcome to the 3rd Structural Drivers of HIV Conference

In recent years there has been increasing interest in the structural drivers (SDs) of the HIV

epidemic. Broadly speaking, SDs are conceptualised as social and economic relations and

institutional practices that influence the risk and vulnerability environment, acting as barriers to,

or facilitators of HIV prevention and treatment behaviours. The first conference was held in May

2009 at University of East Anglia, UK and focused on the expanding role of antiretroviral therapy

(ART)provision in resourced constrained settings. The second conference in 2011, addressed

the issue of whether SDs of HIV should be seen as a luxury or necessity for programmes.

Building on the work of the last two conferences, this meeting is titled: ‘Contextualising

Structural Drivers of HIV’ and presents an opportunity for leading academics, international

research organisations and practitioners to explore this topical area of research and policy. The

conference aims to highlight context specific mechanisms, while at the same time, distil

common themes about structural drivers and structural interventions from the diverse settings

and experiences presented.

This meeting occurs at an important juncture in our history of the epidemic. As we progress into

the forth decade of AIDS, we have seen remarkable progress in efforts to respond to the HIV

epidemics in ESA. In every country, HIV programmes have progressively grown to scale with

increasing attention to effectiveness and impact. In 2011, the number of adults who became

newly infected with HIV in ESA was at its lowest since 1991. New HIV infections in children

have been halved since 2001. AIDS claimed fewer lives in 2011 than in any year since 1998. A

total of 6.3 million people in the region were receiving ART at end of 2012. Sub-Saharan Africa,

however continues to be most affected continent, and more particularly, southern Africa where

HIV infection has become hyper-endemic, with an overall prevalence among adults of 31%- in

Swaziland, 25% in Botswana and 17% South Africa.

While we have made significant progress to end one of the most destructive epidemics of

modern times, our effects are being curtailed by a tension that is embedded in the historical

narrative of the HIV and AIDS response and this tension is evident in our response (lack of

response) to engaging with SDs of HIV.

If one reflects on the history of HIV prevention, two narratives emerge: a biomedical and a social

narrative. These two contesting interpretations that are positioned in relation to individualistic

and collective views of diseases. The biomedical narrative is on individual members of

populations who are understood as rational neo-liberal agents, who when counseled by experts,

adopt the prevention technologies advocated/change their behaviour to reduce HIV

transmission. The social narrative is more concerned with relations between persons and on

how sexual practices that place persons at risk for HIV transmission are produced as well as

transformed to reduce risk. Here the focus is on communities and networks and the manner in

which these collectivities interact with the virus, with biomedicine, and with the state and other

institutional apparatus, and are thus enabled (or not) to respond effectively, and sometimes

creatively to the threat of HIV and AIDS.

As was pointed out in the 2009 conference, the biomedical narrative has been a dominant focus

with a particular emphasis on treatment.

The first HIV test in 1985 and the 1996 development of ART are watershed moments in the

history of HIV. Since then, we have witnessed the development of prevention of mother-to-child

transmission (PMTCT), and more recently, microbide gels based ARVs such as tenofivir,

including PreP and PEP. Most recently, we have also seen the World Health organization’s

aproach of Treatment as Prevention (Test and Treat Approach). It has therefore become

apparent that in recent years prevention has become increasingly biomedicalised (microbicide

trials; HPTN 052) and the recent scale-up of medical circumsicion as a biomedical intervention

While indeed, path breaking work, it should also be noted that the well publicised trials

(CAPRISA 004 Trial, iPrex trial, HPTN052, medical male circumsicion), heralded as watershed

moments in the fight against HIV, are emblematic of the conflation of biomedical and public

health discourses. The overreliance on biomedical technologies to solve public health problems

has significantly impeded our progress in the fight against HIV. The new prevention research

agenda requires a more comprehensive approach that leverages both biological and social

interventions as appropriate.

The motivation for structural approaches to HIV interventions is premised on a social critique of

the biomedical narrative. Firstly, there is the issue of efficacy versus effectiveness when

discussing aspects of randomised control trials (RCTs). While we define efficacy of an

intervention as the reduction in risk associated with full and complete implementation of an

intervention, effectiveness depends on the context into which an intervention is introduced. We

have lauded the success of PMTCT as being highly efficacious and effective, however the

remainder of the previously mentioned technologies have had only moderate success under

experimental conditions or their efficacy has been demonstrated only under very particular

conditions. Equally troubling has been the pre-occupation with ‘imperfect behaviour’ (adherence

variability) seen in the microbicide trials, as a key underlying reason of failure of biomedical

interventions. Ironically, it is this very perspective, that is, the focus on individualised

behaviours, that continues to privilege incomplete biomedcial solutions. Tom Coates and

colleagues have shown that even when significant behaviour changes have been demonstrated

in large RCTS prevention trials, there is a waning of interventions effects over time. This

evidence leads us to be weary of how any meaningful population level effect could be

sustained. Researchers who study behaviour change cite the importance of changing

environments in order maintain these effects.

If we are to advocate for scaling up of combined bio and behavioural interventions as a means

to maximise HIV intervention efforts, we cannot continue to neglect fundamental questions on

agency and structure that governs human behaviour.

This 3rd Structural Drivers of HIV Conference is premised on the limits to what individually

focused interventions, including what chemo-prophylaxis and behavioural modification can

achieve, precisely because of the difficulty of implementing individually based interventions.

Individual agency refers to an individual’s freewill and decision making capacity. We refer to

structures, on the other hand, to describe patterned social relationships (group affiliations),

resources (capital accumulation) and institutions (governments). Accordingly, we use the term

structural interventions to refer to efforts to target the aforementioned entities in order to

influence health, usually by facilitating health promoting behaviours or hindering health-harming

behaviours. While individual interventions target behaviours or target biological pathways of HIV

infection, structural interventions are more difficult to categorise, but include targets such as

gender, poverty, cultural and social norms, and discriminatory laws and policies that interact at

multiple levels to influence individual choice and behaviours, including the type and number of

sexual partners, use of condoms and demand and uptake of biomedical prevention services

such as voluntary male circumcision and HIV counseling and testing. So while we recognise

that health behaviours are ultimately determined by individual choice, these choices are a

function of very real structural constraints. In addition to modifying those structures that

influence health outcomes, structural interventions also promotes the possibility of increased

individual agency. Structural change should not be seen at odds with individual autonomy, but it

may facilitate it!

However structural considerations go beyond to the biomedical and social response. There is a

third narrative. We now more than ever in need of undertaking economics analyses of

prevention and treatment programmes. Post the global financial crisis in 2008, when the

sustainability of International Development Assistance (IDA) was being questioned, issues

related to how should we finance the AIDS response in the medium to long term has taken

centre stage. Debates here include the cost effectives of ART, MC and Treatment as

Prevention, including debates on innovative financing mechanisms to sustained funding to

priority health areas. (David Willson will talk extensively on Economics of TasP).

Structural interventions are hardly the magic bullet to public health problems, but they represent

an important step forward. For example, the importance of structural interventions that explicitly

address the social and economic forces can be seen in recent cash transfer studies in Malawi

and Tanzania. The Malawi study showed that providing a stipend to girls and their households

reduced HIV prevalence among girls who stayed in school. The reductions in prevalence were

most likely due to less transactional sex with much older men. While this research is promising,

we are still left with many answered questions: What are the probabilistic pathways through

which cash transfers affect HIV related outcomes and how this is affected by context? Should

cash transfers be conditional? What are human rights implications of conditional cash transfers

(CCTs)? What are the longer term impacts of CCTs?

The effectiveness of ARV-based interventions have also been undermined by social issues. For

example, investigators from FEM-PrEP trail which used ART as a HIV prevention method in

mixed status heterosexual couples concluded that poor adherence was the cause of the failure

to demonstrate an effect of PrEP. In this regard, evidence from the roll-out of ART in different

countries indicate that structural factors such as stigma, alcohol use, gender dynamics and lack

of access to functioning health systems contribute to poor adherence.

As we move into the 4th decade of the HIV epidemic and review key changes for AIDS

governance post 2015, we acknowledge that research needs to unearth the complexity of

structures producing health behaviours. The new era of HIV prevention research is being

expanded from biomedical research to include implementation, effectiveness and economic

efficiencies - to impact at a population level. The epidemiologies of the HIV epidemic are

complex, diverse and dynamic. So we need a de-essentialisation of the term ‘structural’.

Structural approaches to HIV do not work the same way or have the same effect in all

populations and settings. Structural approaches are complex, fluid, non-linear and contextual,

and they interact dynamically with biological, psychological, behavioural and other social

factors. We cannot have a one size fits all approach.

Accordingly, then the aim of this conference is to consider these complexities in implementation

and research. More specifically, this conference will explore how these structural drivers of HIV

are conceptualised and researched. What are some of the challenges for implementation and

effectiveness in different populations? This meeting is a platform for leading international

researchers, programme funders and policy makers to debate these issues and further the

programmatic agenda on ‘Structural Drivers of HIV’.

This two day meeting has four keynote speakers, with 31 oral presentations and 10 sessions

(including three panels) covering issues on HIV prevention, treatment, children, youth, key

populations and community issues/health care provider issues. The conference will end with a

World Bank/HEARD cocktail party.