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Focus on Structural-Level Interventions Where Do We Need to Be? Use Structural-Level Interventions To Effect Change Balancing the Portfolio – How can structural interventions weigh in? Implementation Approaches How can structural-level approaches be successfully applied to HIV prevention efforts today? Conclusion Meeting and Planning Calendar

"True generosity consists precisely in fighting to destroy the causes which nourish false charity. False charity constrains the fearful and subdued, the "rejects of life", to extend their trembling hands. True generosity lies in striving so that these hands – whether of individuals or entire peoples – need to be extended less and less in supplication, so that more and more they become human hands which work and, working, transform the world."1 back to top > Where Do We Need To Be? Use Structural-Level Interventions to Effect Change The last two NASTAD Prevention Bulletins – on Power and Privilege: The Need for Social Justice in Public Health and Addressing the Complexities of Individual’s Lives – continued our ongoing conversation about structural level interventions. We know that in order to have greater overall impact on the HIV, STD and viral hepatitis epidemics in the United Sates, structural-level impediments must be removed and structural-level assets must be leveraged. We recognize efforts towards the elimination of disparities must begin to address the social, political and economic underpinnings that gird them as we know individuals’ lives are complex and not lived in isolation. HIV prevention is inextricably linked to political, legislative, economic and social forces. Any HIV prevention effort must vie for attention amidst a host of other pressing issues in a person’s life, such as mental health needs, substance use, lack of adequate housing and food, domestic violence, homophobia, racism and sexism. But what do we mean when we talk about structural-level interventions? While many HIV prevention interventions strive to impact an individual’s risk behaviors, structural level interventions seek to address or influence social, political and/or economic environments in ways that support groups of people, even entire populations. For example, structural interventions include introducing legislation which allows federal state funding to be used to support syringe and needle access programs or comprehensive sexual education curricula in public schools. Structural-level interventions also include efforts that seek to eliminate racism, income inequalities or other disparities which create a vulnerability to HIV, STD and viral hepatitis.2 back to top > Balancing the Prevention Portfolio – How can structural interventions weigh in? At a time when many of the nation’s limited HIV prevention resources are being channeled towards activities focused on case finding such as routine HIV testing and partner services, how can we prioritize structural-level interventions? Indeed, given that structural-level interventions generally address issues that may seem far beyond the scope or even, at times, seem unrelated to HIV prevention, it can be challenging for programs operating in resource constrained environments to prioritize structural level strategies in their efforts to reduce the spread of HIV. Operating in a climate where funders are compelled to require grantees to produce immediate and demonstrable results compounds these challenges. Therefore, structural-level approaches are often avoided by public health professionals and considered "too broad, too diffuse, and outside the remit of health programming."3 However, proponents recognize that a "total change of a distal structural factor might not be needed to exert its effect on HIV vulnerability."4 Structural-level interventions are operationalized as multi-stage approaches. They acknowledge that many populations, first and foremost, need community mobilization efforts to create a climate for effective HIV, STD and viral hepatitis prevention activities, and that the community building has the potential to support individuals in their attempts to reduce risk behavior while also transforming their lives and their communities.  Consider an HIV prevention intervention whose target population is black gay men. As with many behavior change programs, the first stage is outreach to introduce the men to the program and encourage their involvement. The next stage could be a dialogue among the men in which they examine underlying reasons, or "root causes", for the high rates of HIV incidence in their community. Topics such as racism, poverty, homophobia and inequities in relationships are likely to be raised, discussed and analyzed.  Again, like other behavioral change models, participants could then be encouraged to educate and engage in further discussions about HIV and its root causes with their peers and other community members while simultaneously encouraging them to learn their HIV status and linking them with venues to do this. At this meso-level many HIV prevention interventions hover or terminate. But, what if instead, participants of the program are encouraged and supported, based on their interests and desires, to continue the program to influence some of the root causes of HIV risk among friends and in their communities? What if the next step prepared these individuals to educate legislators about the need for comprehensive sexuality education, or engage leaders in the faith community in a dialogue about homophobia, or organize local bar and club owners to increase the availability of free condoms to their patrons? It can be argued that offering and promoting a next step in HIV prevention efforts, like those mentioned above, is, in and of itself, empowering on an individual level by increasing protective factors that make it less likely individuals will engage in risk taking behaviors. It can simultaneously be argued that these individuals can support and/or lead long term structural changes in their communities through their activism. back to top > Implementation Approaches "And those who recognize or begin to recognize themselves as oppressed must be among the developers of the pedagogy. No pedagogy which is truly liberating can remain distant from the oppressed by treating them as unfortunates and by presenting for the emulation models from among the oppressors. The oppressed must be their own example in the struggle for their redemption."5 The process to implement a structural approach to HIV prevention should begin with analyses of how social, political, economic and environmental factors operate in the lives of at risk populations and how these factors act as pathways to risk behavior within a given community (see figure).6 It is essential that program implementers understand the causal pathways so they can identify the opportunities to maximize the effect for any given intervention. 7 To begin this contextual analysis, Gupta, et. al., suggests two possible approaches. One option is to approach this as "an orthodox health planning exercise – with skilled personnel gathering data, identifying which structures are creating the problem and then deciding how to intervene."8 A second possibility takes a more participatory tack and actually engages communities themselves "in the process of problem-solving, building on local knowledge to generate an indigenous organic response."9 A UNAIDS assessment of the AIDS Competence Programme has illustrated that community ownership and local knowledge can achieve effective HIV prevention and can lead to long term sustainability.10 The concept is analogous to population education. Population education has been defined as educational techniques designed to raise the consciousness of its participants and allow them to become more aware of how an individual’s personal experiences are connected to larger societal problems. Participants are empowered to act to effect change on the problems that affect them.11 As Freire discusses in writings about his literacy work with Brazilian peasant farmers in the 1960s, this process of genuine dialogue and engagement of marginalized, disenfranchised people has the potential, in and of itself, to initiate social, political and environmental structural change. "The insistence that the oppressed engage in reflection on their concrete situation is not a call to armchair revolution. On the contrary, reflection – true reflection – leads to action. On the other hand, when the situation calls for action, that action will constitute an authentic praxis only if its consequences become the object of critical reflection. In this sense, the praxis is the new raison d’etre of the oppressed; and the revolution which inaugurates the historical moment of the raison d’etre, is not viable apart from their concomitant conscious involvement."12 back to top > How can structural-level concepts be successfully applied to HIV prevention efforts today? One area we find this in action is in harm reduction based work with people who use injection drugs. One of the core principles of harm reduction is to affirm drugs users themselves as the primary agents of reducing the harms of their drug use and seeks to empower users to share information and support each other in strategies that meet their actual conditions of use.13 An excellent application of the  harm reduction approach is demonstrated in the document "Nothing About Us Without Us: A manifesto by people who use illegal drugs" published by the Canadian HIV/AIDS Legal Network, the International HIV/AIDS Alliance, the International Network of People who Use Drugs and Open Society Institute Public Health Program.14 The statements articulated in this manifesto, as well as the process of developing it, are examples of transforming and rethinking oppressive structures. The incorporation of overdose prevention curricula and the distribution of naloxone at syringe access sites are structural level interventions that offer an example of a win in the "fight for the health and human rights of people who use illegal drugs."15 How could an approach like this be replicated with other populations at risk for HIV, STD and viral hepatitis infection, like gay men?  How do "health and human rights" concerns – like opposition to domestic partnerships and/or gay marriage – ultimately influence the HIV risk? Another application of structural-level HIV prevention is microfinance and economic enhancement interventions. Programs such as these seek to reduce women’s vulnerability to HIV by bolstering their economic prospects. The JEWEL (Jewelry Education for Women Empowering Their Lives), a pilot study in Baltimore, Maryland, studied the efficacy of economic empowerment and HIV prevention among women who used drugs and were involved in prostitution. The 50 women in the project sold over $7000 in jewelry that they made. The study demonstrated significant reductions in receiving drugs or money for sex, the median number of sex trade partners per month, daily drug use and the amount of money spent on drugs each day.16 back to top > Conclusion If we are truly to turn the tide on the U.S. epidemics, we must recognize that issues not directly related to HIV, STD and viral hepatitis often create the conditions that increase risk, thus making structural level interventions an essential component of robust prevention portfolios. "All social and political problems are interwoven – that energy, for example, affects economics, which in turn affects health, which in turn affects education, work, family life, and a thousand other things. The attempt to deal with neatly defined problems in isolation from one another … creates only confusion and disaster."(Alvin Toffler – The Third Wave) The November Prevention Bulletin will focus on the need to continuously educate the mass public about HIV/AIDS. References 1. Freire, P. Pedagogy of the Oppressed. New York: Continuum. 1970. 2. Center for AIDS Prevention Studies. What is the Role of Structural Interventions in HIV Prevention?. 2003. 3. Gupta, GR, Parkhurst, JO, Ogden, JA, Aggleton, P, Mahah, A. Structural Approaches to HIV Prevention. The Lancet Vol. 372., No. 9640., 764-775. August 2008. 4. Ibid. 5. Freire, P. Pedagogy of the Oppressed. New York: Continuum. 1970. 6. Gupta, GR, Parkhurst, JO, Ogden, JA, Aggleton, P, Mahal, A. Structural Approaches to HIV Prevention. The Lancet Vol. 372., No. 9640., 764-775. August 2008. 7. Ibid. 8. Ibid 9. Ibid. 10. Ibid. 11.  Wikipedia, the free encyclopedia. http://en.wikipedia.org/wiki/Popular_education. Downloaded September 2008. 12. Freire, P. Pedagogy of the Oppressed. New York: Continuum. 1970. 13. The Harm Reduction Coalition. http://www.harmreduction.org/article.php?list=type&type=62. Downloaded September 2008. 14. The International AIDS Alliance. Nothing About Us Without US Manifesto. May 2008. http://www.aidsalliance.org/graphics/secretariat/publications/Nothing_About_Us_MANIFESTO_English.pdf. Downloaded September 2008. 15.  Ibid. 16.  Johns Hopkins Bloomberg School of Public Health. Public Health News Center. Jewelry-Making Program Empowers Participants, Reduces HIV Risk. December 1, 2005. http://www.jhsph.edu/publichealthnews/press_releases/2005/sherman_JEWEL.html. Downloaded August 2008. back to top > Meeting and Planning Calendar Capacity Building Opportunities: For a searchable database of CDC-supported capacity building trainings and events, please visit: the Capacity Building Branch’s Group Events Management System site. October 3, 2008 2008 Summit on Oral Health Care and HIV/AIDS, New York City, NY. Focused on: oral lesions, implementing counseling and testing in the dental setting, post-exposure prophylaxis, infection control in the dental setting, HIV co-morbidities, as well as confidentiality and human rights, the summit is being sponsored by the New York State Dental Foundation and the New York State Dental Association in partnership with the NY/NJ AIDS Education and Training Center, Delta Dental, New York University College of Dentistry, and PennWell Publishing. For more information, visit the conference website. October 15, 2008 National Latino AIDS Awareness Day October 20–22, 2008 Management of Hepatitis B: An NIH Consensus Development Conference December 1, 2008 World AIDS Day February 7, 2009 National Black HIV/AIDS Awareness Day March 10, 2009 National Women and Girls HIV/AIDS Awareness Day March 20, 2009 National Native HIV/AIDS Awareness Day April 5-7, 2009 4th International Conference on HIV Treatment Adherence, Miami, FL. Sponsored by the International Association of Physicians in AIDS Care (IAPAC). For more information, visit the conference website. May 18, 2009 HIV Vaccine Awareness Day May 19, 2009 National Asian and Pacific Islander HIV/AIDS Awareness Day June 8, 2009 Caribbean American HIV/AIDS Awareness Day June 27, 2009 National HIV Testing Day August 23-26, 2009 National HIV Prevention Conference, Atlanta, GA. Additional information, including a call for abstracts, forthcoming.

	Credits, Feedback and Input The NASTAD Prevention Bulletin is edited by NASTAD staff and is written by staff and prevention experts from around the country. This publication was supported by Cooperative Agreement Number 5U62PS323958-05 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. If you have an idea or program that you would like to include in the Bulletin, please contact Dave Kern or Lynne Greabell (202/434-8090). NASTAD welcomes feedback to issues presented in Bulletin. To submit commentary, please e-mail us at NASTAD@NASTAD.org. Electronic versions of the Bulletin are available on our webpage.
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