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
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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
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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.
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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).
Inter-governmental,
Regional, Global
Macro,
Distal
Society
The types and levels
interact
- systematically.
Community, Organizations
Relationships, Social
Groups/Networks
Individual
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Intermediate
Micro,
Proximal
Many HIV prevention and treatment strategies have
focused on the individual level, assuming individuals will
defy or overcome social, economic and political
constraints.
Inter-governmental, Global
Society
Community, Organizations
Social and sexual networks
Individuals
Individuals
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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)
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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.
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(1) Because the countries of the EECA region have the
fastest growing HIV epidemics in the world.
Number of people newly infected with HIV, 2001–2011, by region
Latin America
Middle East and North Africa
150
Thousands
3
Thousands
Millions
Sub-Saharan Africa
50
250
0
0
2001
2011
800
0
2011
2011
Oceania
30
5
0
0
2001
2001
Thousands
2001
2011
Caribbean
Thousands
0
0
2001
2011
Asia
Thousands
Thousands
Eastern Europe
and Central Asia
2001
Dotted lines represent ranges, solid lines represent the best estimate.
Source: UNAIDS estimates.
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2011
2001
2011
(2) Enormous size and diversity of the region
Slide courtesy of S. Dvoryak
9
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(3) HIV risks and rates are concentrated in vulnerable
groups
HIV cases reported to WHO to date (2013) by, mode of exposure
Data Sources: WHO Regional Office for Europe, 2013
Slide courtesy of Tim Rhodes
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(4) The principal “drivers” of epidemic growth in the
EECA region are structural.
•
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
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Photo courtesy of Stephanie Strathdee
*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
(4) (continued)
More Intermediate Level, Social, Economic and Political
Factors for key populations
)
•
For People who Inject Drugs (PID)
o
o
o
o
o
o
o
•
Registration
Risk of incarceration or deportation
Unsafe injecting sites
Homelessness
No/low access to OST
No/low of access to NSE
Lack of integrated health and SRH services
For female, male and trans sex workers (SW)
o
o
o
o
o
o
o
o
Legal restrictions
Unsafe workplaces
Mandatory HIV testing
Drug use, partner’s drug use
Threats to children
Gender-based violence (GBV)
Police exploitation/abuse
No/poor quality SRH & social services
Similar lists emerge from studies with men who have sex with
men, migrants, and prisoners.
Photo courtesy of Tim Sladden and
Stephanie Strathdee
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Barriers within the health care system ↑ vulnerability
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.”
11.6%
Required to officially register as drug user
34.8%
Breach of confidentiality
5.1%
Refusal of treatment services
11.1%
Refusal of hospital admission
22.7%
Addiction-related abuse/humiliation
11.6%
Waiting times/ waiting lists
16.7%
Fee for services
22.7%
Maltreatment
0%
5%
10%
15%
20%
25%
30%
35%
Source: Medelevich and Zohrabian, 2012. Barriers to health care services for women who inject illegal drugs.
IAS 2012
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(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 4050%
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(6) Insufficient investment in EECA in services for key populations
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
HIV newly diagnosed in IDUs as share of total new reported cases in ECA*
Spending for high risk group as % of prevention spending
Data source, UNAIDS 2010. Graph from D. Wilson, 2012
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Social determinants require social solutions.
Political challenges require political responses.
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Stigma
(meanings)
Discrimination
(behaviour)
“Hard to reach”
Low knowledge,
access and use of
HIV services
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)
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Vicious cycle of neglect, exclusion, avoidance of health services,
and continued risk and vulnerability
PUD
experience
and/or fear
poor
treatment
Service
providers
exclude or
shame PUD
Policies neglect or
exclude PUD, and ignore
special needs of women
and young people
Low uptake of services;
health, economic and
social difficulties
Values shame
and blame
PUD,
especially
when poor,
female,
and/or young
Increased risk
of HIV; High
rate of HIV
among PUD
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Myths about PWID perpetuate ineffective treatment
Opinions of Most Effective Strategies for Treating Addiction (N=239)
Folk Medicine
New environment
Detox
Substitution Therapy
Employment
Rehabilitation
Family support
Medication
Religion
Incarceration
0.8
4.1
4.5
7.4
8.2
10.7
11.9
14.0
17.7
18.9
0.0
5.0
Slide courtesy of S. Dvoryak
10.0
15.0
Percent (%) Responding.
F.Altice et al. 2013
20.0
19
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Source: J. Auerbach, 2012
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Investigating context systematically, to identify dependencies
and opportunities
Individuals
Knowledge, attitudes, beliefs, experiences, biological characteristics
Adapted with permission from S. Baral et al., 2013.
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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
HIV Infections Averted By Structural Changes
1000
 4 - 19%
800
600
 3 - 9%
400
 2 - 5%
200
0
(* e.g. Habicht, et al., 1989; West et al, 2007; Auerbach
et al., 2009; MERG, 2009; Laga et al. 2010; Atun et al.
etc.)
662
343
209
Est for Odessa
Est for Makeevka
Est for Kiev
Elimination of police beatings
Strathdee, Hallett, Bobrova et al., Lancet 2010
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Steady work has produced improved measures of complex
social constructs, such as Gender Based Violence, Stigma, and
Community response, etc.
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Increasing use of political strategies
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More experimental, quasi-experimental and natural
experimental intervention studies are welcome, and
needed
BUT
are we doing the right things?
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Who has the power to effect the needed change?
Stakeholder analysis
Strategic partnerships
Political action
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“I’m a doctor, Jim,
not a miracle worker!!”
Doctors and scientists can’t solve every
problem, but can encourage or discourage
decision-makers to take hard decisions
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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
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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
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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
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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:
UNAIDS. 2012. Investing for results. Results for people. A
people-centred investment tool towards ending AIDS.
Geneva.
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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
Critical to pursue scientific breakthroughs in the
sciences that deal with power and passion
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“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)
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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.
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Acknowledgements
Judith
Auerbach
Stephan
Baral
Richard
Burzynski
Kent
Buse
Carlos
Caceres
Alison
Crocket
Patrick
Eba
Taavi
Erkkola
Peter
Ghys
Roman
Hailevich
Catherine
Hankins
Lori
Heise
Gabriela
Ionascu
Luiz
Loures
Jean-Elie
Malkin
Chris
Mallouris
Tim
Rhodes
Erna
Ribar
Aida
Semaga
Ani
Shakarashvili
Tim
Sladden
Stephanie
Strathdee
Oussama
Tawil
Susan
Timberlake
Lev
Zohrabyan
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Dedication
In memoriam
René Sabatier,
- 1989
Carol Jenkins, 1945 - 2008
Robert Carr, 1963 - 2011
Mary Haour-Knippe, 1945 - 2013
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
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15 Structural Intervention strategies, from micro to
macro scale and effects
Source: UNAIDS. 2010. Discussion Paper: Combination Prevention.
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“…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)
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The varied factors influence each other;
each contributes to the “context” of the others
Modified Ecological Model for HIV Risk in People who inject drugs
Adapted with permission from S. Baral et al., 2013.
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