Getting to 40!

There remains a lack of consensus about the extent to which pre-exposure prophylaxis (PrEP) contributed to the recent dramatic and stunning declines in HIV incidence occurring in the United Kingdom. This chapter describes the potential role of PrEP in this decline and offers insights into how this occurred despite a lack of formal, government-sponsored support for PrEP. Further, the chapter describes the development of a new PrEP movement in England as well as contributing factors, such as the leadership of a new wave of HIV activists, access to global generic markets, innovative supply chains, and the use of social media and the Internet. The “U-turn” and subsequent court cases are also described.

Enhancing Access to Safe and Secure Housing

This chapter reviews the global pervasiveness of being homeless or unstably housed as an antecedent to risk of HIV acquisition and as a barrier to global efforts directed toward treatment as prevention. Emphasis on youth is provided, as they experience a vast disparity in this regard. Subsequently, this chapter addresses key structural-level intervention designed to provide stable living environments for persons living with HIV/AIDS. Several possible public health response options are provided, with an emphasis on feasibility and sustainability. Topics covered include the multidimensional definitions of housing status and stability, the global housing crisis and how it relates to HIV, structural interventions to address the link between housing and HIV, and future directions for research.

Applying Behavioral and Social Science Theory to HIV Prevention

Set in the context of high-impact prevention, this chapter provides a brief historical account of how theory application to HIV prevention has evolved from individual-level models to structural-level approaches. The chapter describes the value and limitations of applying behavioral science and social science theories to the pandemic and describes several models and theory-based approaches. It then proceeds to identify emerging, structural-level approaches to achieving population-level HIV prevention in developing and developed countries. The chapter distinguishes structural-level interventions from multilevel interventions, and it describes strengths and weaknesses of structural-level approaches to achieving high-impact prevention. In so doing, several critical principles of structural-level approaches are identified.

Can Interventions to Increase Schooling and Incomes Reduce HIV Incidence Among Young Women in Sub-Saharan Africa?

This chapter provides insights into resolving the social issues that have led to the pre-existent disparity of young females are far more likely than young males to be infected by HIV. In this case, the structural-level problem is centered on inequitable access to education in sub-Saharan Africa. The chapter examines the impact of conditional and unconditional cash transfers on risk factors related to HIV among girls. After summarizing the existing evidence, the chapter provides a detailed description of two studies: the Schooling, Income and Health Risk study in Malawi and the Empowerment and Livelihood study in Uganda. A final section of the chapter gives recommendations for policy and future research.

Enhancing Theory of Structural-Level Interventions for HIV Prevention and Care

This chapter provides multiple insights into the theoretical basis of structural-level intervention approaches to the prevention and control of HIV/AIDS. Set within the context of social science theories applied to HIV/AIDS and the growing realization that behavioral theories are lacking in effect, the chapter suggests an expanded role of social science theory in the development of structural-level interventions. A case is presented that moving forward to prevent and control the pandemic will require improved theoretical frameworks for addressing persistent inequities. Topics covered include the emergence of “structural interventions” in HIV/AIDS and ways to move theoretically informed structural interventions. A theoretically informed agenda for a new generation of structural interventions is proposed.

Integrating Treatment for Opioid Use Disorders and HIV Services into Primary Care

The public health crisis of opiate use disorder (OUD) and HIV infection in the United States demands solutions incorporating structural-level factors to accessing and engaging in drug abuse treatment and HIV care. After providing a review of evidence-based programs that have been used in integrated approaches to treating opioid addiction for persons living with HIV, the chapter provides models of integrating treatments for OUD with services for the prevention and management of HIV infection in primary care. The chapter concludes by reviewing multiple structural barriers to integration of substance use treatment into primary care and offering structural strategies to overcoming and implementing integrated OUD-HIV services in primary care settings.

Evidence-Based Structural Interventions for HIV Prevention

Microenterprise approaches have been used in the context of both HIV prevention and treatment (e.g., adherence to antiretroviral therapy) with several highly vulnerable populations including women, female sex workers, and low-income HIV-positive individuals. This chapter defines and describes different approaches to microenterprise in the context of HIV prevention. The chapter also includes several case studies with vulnerable populations to evaluate the effectiveness of structural approaches to HIV prevention, including the IMAGE study, the Undarga study, the JEWEL study, and the Chennai study. The chapter concludes by outlining directions for future policy and research, including gaps and principles in research on HIV prevention.

Social Conditions and the AIDS Pandemic

This chapter describes the AIDS pandemic as being intimately linked with inequitable social conditions. The case is made that these social inequities must be the primary “target” of HIV prevention efforts. The five pillar model is introduced and used as guide for illustrating the inherent value of structural-level interventions to the goal of ending AIDS. The chapter further makes the case that rectifying social inequities is the basis for going beyond the goal of ending AIDS and moving toward global health for all people. The chapter describes the social drivers of the pandemic, a prevention paradigm, and a proposed framework for structural-level interventions.

Evaluating Structural Interventions

Evaluating structural interventions to understand whether they are effective, for whom, and in what context is critical to determining whether, where, and how to deliver structural interventions at scale. This chapter provides a comprehensive evaluation framework comprising three main components: impact of the intervention, process evaluation, and an economic evaluation. Featured within this chapter is the point that structural-level interventions are amenable to evaluation using adaptation of the gold-standard randomized controlled trial design. Where randomization is not feasible, however, the chapter provides alternative designs to evaluate effectiveness, including those that use the stepped-wedge cluster randomized trial, interrupted time series, and nonequivalent comparison group. Four types of economic evaluation techniques are also described.

Economic Strengthening Approaches with Female Sex Workers

This chapter examines different strategies for addressing the economic vulnerability that puts female sex workers (FSW) at increased risk of acquiring HIV. After presenting various theoretical approaches to economic interventions with FSW, the chapter provides examples of interventions employing different approaches. The focus is placed on interventions using a community empowerment approach. The authors argue that it is through this type of approach that FSW can confront their economic vulnerability at the community level, rather than through programs focused on increasing individual income alone. An applied example is provided by an in-depth look at community savings groups among FSW in Tanzania.