Peter Aggleton
School of Education and Social Work, University of Sussex

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Judy Auerbach, San Francisco
Carlos Caceres, Lima
Liviana Calzavara, Toronto
Mary Crewe, Pretoria
Gary Dowsett, Melbourne
Geeta Rao Gupta, New York
Susan Kippax, Sydney
Ajay Mahal, Boston
Ted Myers, Toronto
Jessica Ogden, New York
Richard Parker, Rio de Janeiro
Justin Parkhurst, London and many others

UNAIDS Report on the Global AIDS Epidemic 2010
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In 2009, estimated 2.6 million people became newly infected with HIV -- more than one fifth (21%) fewer than the 3.2 million in 1997, when annual new infections peaked
In 33 countries, HIV incidence has fallen by more than
25% between 2001 and 2009; 22 of these countries are in sub-Saharan Africa.
Largest epidemics in sub-Saharan Africa —Ethiopia,
Nigeria, South Africa, Zambia, and Zimbabwe —either stabilised or showing signs of decline
But, between 2001 and 2009, incidence increased by more than 25% in seven countries, including five in
Eastern Europe and Central Asia (including Bangladesh,
Philippines, Uzbekistan)

UNAIDS Report on the Global AIDS Epidemic 2010
Number of annual AIDS-related deaths worldwide is steadily decreasing from the peak of 2.1 million [1.9 million –2.3 million] in 2004 to an estimated 1.8 million [1.6 million –2.1 million] in 2009 (Figure 2.3).
The decline reflects increased availability of antiretroviral therapy, as well as care and support, to people living with HIV, particularly in middle- and low-income countries; it is also a result of decreasing incidence starting in the late 1990s.

UNAIDS Report on the Global AIDS Epidemic 2010
 Dedicated efforts to promote and support combination HIV prevention are producing clear and impressive results.
 HIV prevention programmes must include a combination of behavioural, biomedical, and structural responses, and these activities should operate in synergy.

4000
3000
2000
1000
0
2000
New HIV and AIDS diagnoses in the UK, and deaths among HIV infected individuals: 2000 – 2009
9000
8000
7000
HIV diagnoses
AIDS diagnoses
Deaths
6000
5000
2001 2002 2003 2004 2005 2006
Year of HIV or AIDS diagnosis or death
2007 2008 2009

Number of new HIV diagnoses 1 by prevention group,
UK: 2000-2009
4500
4000
MSM
Heterosexual contact abroad
Heterosexual contact in the UK
IDU
Other
2
3500
3000
2500
2000
1500
1000
500
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
1 Data are adjusted for missing route of infection
2 Includes Mother to child transmission and blood product recipient

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Treatment optimism
De-prioritisation of HIV amidst other health concerns
Belief that AIDS has gone away (except in
Africa)

New diagnoses among men who have sex with men (MSM) remain high (3,080 in 2010 – highest number ever); four out of five probably acquired their infection in the UK . Over 110% increase since 1999 (1450 cases)
One in six MSM, and one in sixteen heterosexuals newly diagnosed with HIV in 2009 had acquired their infection within the previous 4-5 months before diagnosis.
Half of adults were diagnosed with HIV at a late stage of infection in 2009 (CD4 counts less than 350 per mm within three months of diagnosis), the stage at which treatment is recommended to begin.
Source: HIV in the United Kingdom: 2010 Report. Health Promotion Agency

The estimated number of people infected through heterosexual contact within the UK has increased from 540 new diagnoses in
2003 to 1,130 in 2009, and has increased, from 11% (540/4,800) in 2003 to 31% (1,130/3,560 in 2009, as a proportion of all heterosexual diagnoses during this period.
Source: HIV in the United Kingdom: 2010 Report

In the UK in 2007, there were 702 new diagnoses of HIV among young people (10 per 100,000), which is nearly three times the number reported in 1998 (258)

The annual number of new HIV diagnoses among injecting drug users fell between 1992 and 2000, but has gradually risen over the past few years. 170 HIV diagnoses, where infection was thought to have been acquired through injecting drug use, were reported in the UK for
2009
Source: HIV in the United Kingdom: 2010 Report. Health Promotion Agency

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HIV infected adults aged 50 years and over accessing care more than tripled between 2000 and 2009, from 2,432 to 12,063, representing one in five of all adults seen for HIV care in 2009
New diagnoses among older adults more than doubled between 2000 and 2009, and accounted for 13% of all diagnoses in 2009. Two-thirds (67%) were diagnosed late, with a CD4 cell count less than 350 per mm 3
Source: HIV in the United Kingdom: 2010 Report. Health Protection Agency

‘The UK is a relatively low prevalence country for
HIV infections as a result of sustained public education and health promotion campaigns’ http://www.dh.gov.uk/en/Publichealth/Healthimprovement/Sexualhealth/HIV/index.htm

 Increasing normalisation
 Increasing biomedicalisation
 Simplified view of drivers (e.g. lack of knowledge of
HIV status)
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Overly simple remedies (e.g. better health services)
Limited understanding of valid knowledge (e.g. RCTs)
 Lack of memory of what has been learned in the past

 Social solidarity
 Sense of inequity and injustice
 Generalised reciprocity
 Dense and overlapping networks of communication
 Community trust
 Cultural templates for success
 Properly comprehensive response

 Need to
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 move beyond the search for ‘magic bullets’ move beyond simplistic ‘interventions’
 value the importance of a programmatic approach
 combine actions to maximise the likelihood of success

…… involves all the strategies required to prevent transmission of
HIV. These include AIDS education; behaviour change programmes for young people and vulnerable populations; promotion of male and female condoms, along with abstinence, being safer through fidelity and reducing the number of partners; voluntary counseling and testing; prevention of mother-to-child HIV transmission; preventing and treating sexually transmitted infections; blood safety, prevention of transmission in health care settings; community education and changes in laws and policies to counter stigma; vulnerability reduction through social, legal and economic change; and harm reduction programs for injecting drug users.
Adapted from http://data.unaids.org/Publications/Fact-
Sheets04/FS_Prevention_en.pdf

 Social vulnerability
 Individual risk
 Impact of HIV on communities
 Generational continuity and change

 Single policy or programmatic actions
 Multiple structural actions to catalyse change
 Regardless of type, structural approaches
 Address factors that influence individual behaviour
 Change social, economic, political and environmental factors affecting HIV-related vulnerability and risk in specific contexts

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Syringe and needle exchange worldwide
Socalled ‘100%’ condom use programmes in Dominican Republic,
Thailand and other countries
 Program H, working with young men in
Brazil
 IMAGE Project in South Africa

 Recognizing the importance of context cautions against
 assuming there is any one ‘blueprint’ for success
 assuming effects of a programme will be same in different settings
 Context (time, place, group) really does matter

Neither poverty nor wealth is a social driver per se; rather, it is the context in which some people are wealthy and some people are poor that can lead to relational patterns resulting in forms of sexual networking that can spread HIV.
Poor people in some settings may be more likely to engage in particular practices —perhaps earlier onset of sexual activity, or occasional transactional sex —which may increase risk of infection.
Wealthy people in some settings may find that their wealth permits greater social and sexual networking, or allows them to have a higher number of regular sex partners —a pattern that may place them at risk, as well.
Context determines the nature of social/sexual arrangements, which interact with both poverty and wealth to contribute to greater or lesser vulnerability.
J. Auerbach, J. Parkhurst, C. Caceres and K. Keller (2009) Aids2031 Social Drivers paper

 Causes of social vulnerability
 Distal (national policies and laws)
 Proximal (being in prison or being in football/rugby/cricket team)
 Focus of programmatic action
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Individual
Group
 Community as a whole

Intervention focus
• Shorter causal chains
• Easier to control for other elements
• Less potential for unforeseen outcomes
• Limited impact to specific issues
• Less potential for sustained change
Causal process
• Potential to affect larger groups or numbers
• Increasing challenge to measure and control
Society Community
Proximal
Legal reforms affecting the whole population
National leadership for social change
Provision of prevention technologies
Traditional IEC activities (not social/structural)
Legal reforms affecting particular groups
Community mobilisation activities
• More limited to specific groups
• Easier to measure and control
Group Individual
Programmes to shape immediate drivers of specific group behaviour
(e.g. microcredit)
• Longer causal chains
• Multiple interacting elements need to be followed
• Increased potential for unforeseen outcomes
• Increased potential for larger scale impact
• Increased potential for sustained change
Distal
Efforts to change gender norms in communities or groups
Popular movements for social change
Color Key
Strategies aiming to reshape desired behaviour patterns
Strategies aiming to enable existing behaviours

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Important to address social structure in HIV prevention
Changing political economy of HIV
Value of an inclusive and comprehensive approach to HIV prevention
New conceptual tools at our disposal
Importance of partnership for success