Operationalising Structural Interventions for Hiv Prevention Lessons from Zambia

Structural interventions are key components of a combination approach to HIV prevention. While global guidance for HIV prevention recognises this key role, evidence for the effectiveness of structural interventions, and their implementation, are lagging behind other areas of prevention. Over the past several years, ‘structural prevention’ has received significant academic and intellectual attention. However, the challenges to implementation at the community and national levels are less well understood. This paper examines the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)/U.S. Agency for International Development (USAID) experience with implementing structural interventions in Zambia. We propose several ways forward to speed the implementation process for structural interventions. Acknowledgements Thanks are extended to Helen Cornman (JSI), Amelia Rock (JSI), Molly Fitzgerald (Futures Group, formerly JSI), Shanti Conly (USAID), Michael Grillo (Department of Defense), Katherine Fritz (ICRW), Linda Wright-De Aguero (Centers for Disease Control and Prevention),Tisha Wheeler (USAID), Kristin Bork (USAID), Nina Hasen (Office of the U.S. Global AIDS Coordinator), Diana Prieto (USAID), Monique Widyono (USAID), and Amelia Peltz (USAID). Corresponding Authors Cynthia Bowa, United States Agency for International Development (USAID)/Zambia, Stand 100 Ibex Hill Road, P.O. Box 32481, Lusaka, Zambia; Email: [email protected]. Phone: +260-211-357192 Timothy L. Mah, USAID, 1201 Pennsylvania Ave NW, Suite 200, Washington D.C. 20004, USA; Email: [email protected]. Tel: +1-571-218-2808 Disclaimer The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. The study was supported by UKaid from the Department for International Development. However, the views expressed do not necessarily reflect the department’s official policies. AIDSTAR-One John Snow, Inc. 1616 Fort Myer Drive, 16th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 E-mail: [email protected] Internet: aidstar-one.com STRIVE STRIVE Research Programme Consortium London School of Hygiene & Tropical Medicine Room 329 15–17 Tavistock Place London WC1H 9SH UK http://strive.lshtm.ac.uk/ INTRODUCTION In recent years, as combination prevention approaches have become the mainstay of HIV prevention responses globally, significant gaps in implementing structural interventions have been recognised [1, 2]. The discussion around structural HIV prevention has been largely informed by academic literature, but, increasingly, programmatic data are available [3-5]. Consensus on the specific definitions of structural barriers, factors, and interventions is lacking, which often causes confusion in identifying specific and appropriate interventions at the programme level, though other authors in this series attempt to address this gap [6]. Parkhurst defines structural interventions as activities that address structural drivers (both risk drivers and environmental mediators) in a given setting [6]. Despite challenges, HIV prevention programmers have successfully utilised existing knowledge to implement context-specific structural interventions, recognising that removing or alleviating structural barriers is likely to have long-term impact not only on HIV incidence, but also on broader development goals. In the present paper, the authors describe the experience of programming structural interventions in Zambia, beginning with a brief description of the HIV and AIDS situation and responses in the country, followed by an overview of structural interventions being implemented. We conclude with several overarching and cross-cutting challenges and opportunities in implementing structural interventions, alongside recommendations for a way forward for other countries. 1 STRUCTURAL FACTORS CONTRIBUTING TO HIV TRANSMISSION IN ZAMBIA HIV and AIDS impose a large burden on the health system in Zambia, and remain a significant threat to the country’s development [7]. While significant decreases have been recorded among some populations in Zambia, HIV incidence and prevalence have stabilised at very high levels (estimated 1.6 percent incidence; prevalence: 14.3 percent) [8-10]. Six key drivers of the HIV epidemic in Zambia have been identified in the National AIDS Strategic Framework (NASF) 2011–15: 1) high rates of multiple concurrent partnerships, 2) low and inconsistent condom use, 3) low rates of medical male circumcision, 4) mobility and labour migration, 5) vulnerable groups with high-risk behaviours, and 6) mother-to-child transmission [11]. Importantly, the NASF recognises the role of structural factors, stating that “HIV is further compounded by other structural factors that are underpinned by social and cultural norms, and limitations in service delivery. Among them are stigma and discrimination, gender inequalities, low levels of education, rural-urban dichotomy in accessing services, and inadequate focus on key populations, vulnerable groups including women and girls, and people with disabilities” [11]. A 2009 Modes of Transmission (MOT) Analysis highlights several structural risk drivers and environmental mediators thought to impact HIV transmission—including Operationalising Structural Interventions for HIV Prevention: Lessons from Zambia 2 marriage patterns and polygyny, social and cultural norms, and sexual and physical violence and alcohol use, among others [9]. Age-disparate or intergenerational partnerships and transactional partnerships have often been cited in southern Africa and in Zambia as important contributing factors to high HIV incidence, particularly among young women [10, 12-15]. Inequality in gender roles and gender-based violence (GBV) are structural risk drivers and environmental mediators resulting in increased vulnerability, particularly for young girls and women in Zambia [10, 12]. In 2009, approximately 26 percent of urban women and 20 percent of rural women reported ever being forced to have sex against their will [12]. While few data from Zambia establish a causal link between violence and HIV infection, evidence from the southern Africa region suggests that violence may increase women’s susceptibility to HIV infection [16-19]. According to the MOT Analysis, “Local data show that there is a certain level of tolerance or acceptance towards gender-based discrimination and inequality...and that school education and women’s cash income reduces gender-discriminatory attitudes” [9]. Other key structural drivers include alcohol use and abuse, which are associated with increased sexual risk taking, including lower condom use and multiple partnerships [20-24]. As in other countries of southern Africa, migration and mobility impact numerous aspects of the HIV response, from accessibility of services to changes in community ‘fabric’ and social networks. A significant portion of the formal and informal Zambian economy relies on migrant labour on agricultural estates, in mining communities, and along transit corridors (e.g. truck drivers and cross-border traders), which has led to the formation of sexual networks that facilitate HIV transmission [9]. Cultural practices such as ‘sexual cleansing’* or widow inheritance, dry sex, traditional circumcision, and traditional treatment of infertility are also thought to contribute to HIV transmission, though few data exist to conclusively implicate their roles [25-27]. IMPLEMENTING STRUCTURAL INTERVENTIONS With broad recognition of the importance of structural factors in facilitating or hampering an effective HIV and AIDS response, and despite challenges in establishing the effectiveness of structural interventions on reducing HIV incidence directly or indirectly, PEPFAR/USAID is using several such approaches in Zambia. The following are selected examples of structural interventions for addressing structural factors in Zambia, utilising the broad categories of domains identified by Pronyz and Lutz (i.e. economic well-being, education, gender, mobility/migration, social capital, and stigma/discrimination) [28]. * A ritual involving a woman who has sex with a member of her deceased husband’s family to purge the spirit of her deceased husband. Operationalising Structural Interventions for HIV Prevention: Lessons from Zambia 3 Operationalising Structural Interventions for HIV Prevention: Lessons from Zambia BUILDING SOCIAL CAPITAL WITH TRADITIONAL LEADERS The Support to the HIV/AIDS Response in Zambia (SHARe and SHARe II) Program, funded by PEPFAR through USAID, works with traditional leaders to mobilise and equip them with the necessary skills to be effective change agents and to lead their communities in identifying problems and developing solutions [29]. The project is premised on an impact pathway that assumes that sustained changes to cultural norms to reduce sexual risk will be attainable, in part, by involving traditional leaders. The project aims to identify and address community-owned priorities; therefore, specific objectives vary by community. For instance, in several communities, local chiefs have led efforts to ban childhood marriages in a bid to protect vulnerable young girls and address issues of intergenerational partnerships. Other local chiefs have begun to include discussions about HIV in traditional ceremonial gatherings, utilising long-established methods of communication. IMPLEMENTATION SUCCESSES AND CHALLENGES Several factors enhanced the effectiveness of the traditional leaders programme, including ensuring the leaders’ commitment and ability to understand the programme; collaboration with other programmes that were able to provide services identified as needed by the community and traditional leaders; and support and buy-in from political and other leaders able to mobilise resources and provide links to other sectors not easily accessible to the traditional leaders. Several factors have limited the success of the programme in some communities, including relying on external donor support for service provision; having limited scale and reach because of the small populations within certain chiefdoms; and the lack of a similar traditional leadership structure to effectively implement the programme in urban settings, where the population is larger and HIV prevalence higher. BUILDING SOCIAL CAPITAL USING COMMUNITY INCENTIVES In recent years, several interventions in sub-Saharan Africa have examined the impact of conditional cash transfers on changing school-attending and sexual risk behaviours, particularly among young women [30-32]. Building broadly on the promising outcomes and impact of these programmes and other incentive-based interventions and recognising the important role of social capital and community-led responses to address HIV and AIDS, PEPFAR has begun funding an intervention through USAID called the Community Mobilization for Preventive Action (COMPACT) project. The intervention, which is led by the Population Council, aims to reduce HIV incidence in four communities in Zambia using a communitydriven process of social norms change [33]. A system of incentives has been designed to reward communities for reaching agreed-upon benchmarks, to act as reinforcement for healthy behaviours of community members related to HIV prevention, and to make the “reward” of risk reduction more immediate. After undergoing a process to identify local risk behaviours and social norms, the selected communities identified benchmarks to which they would be held accountable, including targets related to GBV, alcohol, and safe spaces for adolescents. IMPLEMENTATION SUCCESSES AND CHALLENGES Although the intervention is fairly new, initial data suggest that participation is high, given the potential for community reward. However, it is likely that the impact on HIV incidence may be too diffuse to measure over a short period of time. Although the communities have set and achieved numerous benchmarks, complex pathways between intervention and outcomes pose a measurement challenge, which exists for other structural interventions as well. Additional challenges have been experienced, including determining how to provide incentives and to