What%do%we%know%and%where% are%we%going?% · Violence Problematic alcohol use Physical Sexual Partner has concurrent sexual partners Woman has concurrent sexual partners Poverty &

Structural Factors & HIV What%do%we%know%and%where%

are%we%going?%

%Lori%Heise,%LSHTM%

September%11,%2013%

STRIVE'partners'&'affiliates'

!   ICRW,%Asia%regional%office%

!   Karnataka%Health%PromoGon%Trust,%India%

!   NaGonal%InsGtute%for%Medical%Research%(NIMR)/Mwanza%IntervenGon%Trials%Unit%,%Tanzania%

! WiQs%ReproducGve%Health%and%HIV%InsGtute,%SA%

!   ICRW,%Washington%DC%

!   LSHTM%

•  %Soul%City%InsGtute,%SA%•  IMAGE,%SA%

•  SASA!%–%Raising%Voices%,%Uganda%•  UNDP/HIV%unit%

Affiliates%

STRIVE'Priority'Research'Topics'

HIV%%

Gender%Norms%&%Violence%

Insecure%livelihoods%

MigraGon%

Alcohol%&%drinking%norms%

SGgma%and%CriminalizaZ

Gon%

STRIVE:(Tackling)the)factors)that)create)vulnerability)and)undermine)HIV)prevention)

and)treatment)

%%%Conceptual'framework'

Culture'&'''Religion GDP'

Economics'Media Politics Corporate'&'Tax'policy Criminal'

JusEce Laws'Rights

Alcohol'Availability Economic'

Opportunity Gender'Norms CriminalizaEon'

of'behaviours Mobility SEgma

Partner'change Partner'

selecEon UnprotectedSex

Alcohol'Use

Access'to'Info'&'Services

Violence

Structural'Factors

MACRO''''LEVEL

Proximate'Determinants'

of'Risk

HIV'transmission'

Structural Interventions

Deepen%understanding%%of%links%&%pathways%%

Add%value%to%onZgoing%iniGaGves%

Assess%impact%

Research Theme Groups Reducing%Adolescent%Vulnerability%

Addressing%alcoholZrelated%

risk%

Addressing%norms,%gender%inequality%&%violence%

Understanding%structural%factors%&%biomedical%prevenGon%

Realising%Development%synergies%&%coZ

financing%

%HIV%

Why'Focus'on'Adolescents?'

Reducing%Adolescent%Vulnerability%

Addressing%alcoholZ

related%risk%

Addressing%gender%

inequality%&%violence%

Effect%of%structural%factors%on%biomedical%prevenGon%

Realising%Development%synergies%&%coZfinancing%

%HIV%

%%

%%

%

%Young%women%

have%up%to%8%Gmes%more%HIV%

than%men%

Source:(Adapted(from(UNAIDS(2012(

%%%%%%Zimbabwe%

Almost%one%quarter%

of%the%world�s%populaGon%are%aged%

10Z24%years,%yet%they%

account%for%nearly%

half%of%all%new%HIV%

infecGons.%%

Finding'from'ecological'analyses:'

'

Ecological'analyses:'

!   NaEonal'wealth,'income'inequality'and'access'to'educaEon'associated%with%poor%adolescent%health%outcomes%worldwide%

!   Countries%with%a%greater%proporGon%of%school'enrolment'had%beQer%health%outcomes,%including%lower%HIV%prevalence%

!   Countries%with%greater%sex'inequaliEes'had%poorer%health%outcomes%for%both%sexes%

% 9%Viner,%Lancet%2012%

Adolescent'health'is'socially'determined'

Investments'in'adolescent'health'more'generally'will'have'benefits'for'HIV,'and'for'development'more'generally''

TransacEonal'Sex'

Modeling%

the%potenGal%

importance%

of%

transacGonal%

sex%in%

Nigeria%

%

%Prudden%et%al%

2013,%in%press%

AIDS%

Addressing'girl’s'risk'in'Karnataka'

!   CRT%of%mulGZcomponent%intervenGon%to%keep%girls%in%school,%increase%age%

of%marriage%and%delay%entry%into%sex%

work%

–  Gender%training%of%teachers;%tracking%of%drop%outs%

–  Work%with%parents;%assist%with%accessing%enGtlements%

–  Sport’s%based%programmes%for%boys%and%

girls%%(Parivatan%Plus)%

Assess%Impact%


Addressing%alcoholZ

related%risk%

Addressing%norms,%gender%




%HIV%

HIV%infecGon%

Alcohol'consumpEon'

Unprotected'sex'

Partner'selecEon''

Partner'turnover'

Access'to''info'&'services%

Biologic%

suscepGbility%Sexual'

frequency'

Immune%

funcGon%

CogniEve'impairment'

Drinking'norms'

Partner%violence%

Drinking%venue%

Alcohol'myopia'

Risk%taking%

personality%

HIV'AcquisiEon'

!   Synthesis%of%evidence%!   MulGZcountry%study%on%role%of%

drinking%norms,%alcohol%

promoGon%and%packaging%on%drinking%behaviour%among%

young%people%

!   QualitaGve%and%quanGtaGve%study%of%drinking%and%HIVZrelated%behaviours%among%

young%people%in%Mwanza%and%

Kilimanjaro,%Tanzania%



Addressing%alcoholZ

related%risk%

Addressing%gender%




%HIV%

Why gender inequality & violence?:30% women globally experience partner violence

Addressing%gender%


*Strongest'data'comes'from'South'Africa'&'Uganda'%Cross%secGonal%data%more%mixed;%methodological%limitaGons%Consistent%associaGon%found%between%more%severe%IPV%and%HIV%risk%

Devries%et%al,%submiQed%2013%

3%prospecGve%studies%link%IPV%with%Incident%HIV%or%STI%


Addressing%gender%



Increased likelihood that woman is HIV

infected

Partner Violence

Problematic alcohol use

Physical Sexual

Partner has concurrent

sexual partners

Woman has concurrent

sexual partners

Poverty & economic stresses

Gender inequality & social norms

condoning use of violence

Social constructions of masculinity

Early experiences or witnessing of

violence

PROXIMATE DETERMINANTS OF PERPETRATION OF INTIMATE PARTNER

VIOLENCE BY PARTNER

Unprotected sex

Increased probability

partner has HIV and/or STI

Reduced access to Info

& HIV services

PROXIMATE DETERMINANTS

OF HIV RISK FROM PARTNER

Genital trauma

Addressing%gender%


IMAGE Replication Trial in Tanzania

Addressing%gender%


Assess%Impact%


Addressing%alcoholZ

related%risk%

Addressing%gender%




%HIV%

!   Embedded%quesGons%on%

alcohol%use,%sGgma,%and%partner%violence%into%onZ

going%POPART%trial%

!   Ancillary%study%to%specifically%explore%role%of%sGgma%among%health%

workers%as%barrier%to%uptake%

and%use%of%TasP%

Structural%factors%and%biomedical%prevenGon%



Assess%Impact%

!   Study%to%increase%effecGveness%of%PMTCT%

by%addressing%community%and%health%

worker%sGgma%in%Tabora%

Tanzania%

!   Invited%to%reZsubmit%to%%

NIMH%with%high%marks%


Addressing%alcoholZ

related%risk%

Addressing%gender%




%HIV%

Visit'us'at'strive.lshtm.ac.uk'%

STRIVE%Digest%

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STRIVE%TV%

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What%do%we%know%and%where% are%we%going?% · Violence Problematic alcohol use Physical Sexual Partner has concurrent sexual partners Woman has concurrent sexual partners Poverty &