Social Interventions for HIV/AIDS Intervention with Microfinance for AIDS and Gender Equity IMAGE Study

The document looks at poverty, mobility and gender inequalities as factors fuelling the growth of HIV/AIDS in South Africa. It uses South Africa as a case study in how all the three factors have fuelled the rapidly growing epidemic. It looks at how land expropriation and the forced introduction of a migrant labour system has eroded the fabric of rural communities, shaken the stability of household and community life, and exacerbated gender inequalities.

In addition, economic crisis has driven many women, either formally or informally, to exchange sex for resources as a means of survival. It is the interplay of all of these factors which have highlighted the importance of addressing such broader realities.

The paper also looks at how unequal power in sexual relationships shapes the HIV epidemic. One important manifestation of this power imbalance, gender-based violence (GBV), has been found to both directly and indirectly impact on women’s vulnerability to HIV infection. HIV transmission may be the direct result of an unwanted or forced sexual act. In addition, refusing sex, inquiring about other partners, or raising the issue of condoms have all been described as “triggers” for partner violence - yet all are intimately connected to the behavioural cornerstones of HIV prevention.

Violence against women itself represents a significant public health issue, and has been linked to a range of short- and long-term health consequences. In nearly fifty population-based surveys from around the world, between 10% and 50% of women report being hit or otherwise physically harmed by an intimate male partner at some point in their lives.

Given the importance of the contextual factors described above, a major challenge in conceptualising effective responses to both HIV and gender based violence lies in generating interventions which go beyond the concept of individual risk.

Increasingly, researchers are turning to an ecological framework to understand and describe the interplay of personal, situational, and socio-cultural factors that combine to create patterns of vulnerability or risk. Often represented as a series of concentric circles such a framework locates the individual within a larger social system comprised of interrelated and dynamic parts.

Broadening the scope of HIV/AIDS interventions requires new collaborations across multiple sectors and disciplines. For example, because the success of a poverty alleviation strategy such as microfinance depends critically on the experience of the implementing agency, health and family planning programmes would be poorly positioned to take on such an initiative alone. Yet bringing together a range of expertise extending beyond the health field can raise significant challenges for creating effective synergy. Potential difficulties range from logistical barriers such as compartmentalized institutional structures and disease-focused funding mechanisms, to less tangible factors relating to trust, ownership, and communication amongst diverse disciplines and approaches.

Moving away from individual-focused interventions shifts the emphasis towards concepts of community participation, community mobilisation and empowerment. The importance of community-led peer education and the participation of local stakeholders is emerging as a guiding principle for interventions which seek to engage the broader contextual factors relevant
to vulnerable groups.

Yet, involving communities in the conceptualisation, implementation and/or evaluation of programmes can raise significant challenges, and there is little understanding about the process of community mobilisation or the techniques that best promote sustainable community participation.

Complex interventions require complex evaluations. Policy makers need evidence of the causal links between structural determinants and prevention outcomes - yet more upstream interventions demand innovation and complex experimental methods.

Moving from studies that measures individual risk factors to those which attempt to capture dynamic and relational features raises new challenges. For example, there have been very few rigorous quantitative models specifying the link between gender-based power relations and sexual and reproductive health outcomes. Yet this has likely been constrained by the lack of a commonly accepted definition of power and the absence of useful and practical measures of power relations and gender inequalities [51-53]. Moreover, interventions which aim to move beyond concepts of individual-level risk may need to capture longitudinal changes across multiple levels of analysis, such as the individual, relationship, and community levels - yet the tools and approaches for measuring and analysing these levels of interaction are not yet well-developed.

In this light, researchers have begun to question the appropriateness of relying solely on the randomized controlled trial for assessing more complex interventions such as community intervention trials.

Finally, it is likely that interventions which attempt to address the underlying structures and social contexts influencing health behaviours will take time to manifest change in terms of population-level benefits to health. Yet there has been little systematic research investigating the impact of intervention timing or length on behaviour change outcomes - and decisions regarding program duration are typically driven by funding constraints, rather than by science.