Rethink HIV: Social Policy Assessment, Watts Remme Vassall
Given these challenges discussed, this paper presents an analysis of the costs and benefits of interventions that seek to address some of underlying social drivers of HIV vulnerability, and the social barriers to achieving a high coverage to proven HIV interventions. Specifically, we consider interventions to address the following four social drivers of HIV vulnerability:
1. Widespread problematic alcohol use that helps fuel men’s and women’ s engagement in risky sexual behaviours, and undermines core HIV prevention messaging. A systematic review of 20 African studies finds that alcohol drinkers had 57% to 70% greater risk of HIV infection than non-drinkers (Fisher et al., 2007).
2. Transactional sex between young girls and older men, that provides one of the main bridges of HIV infection from older sexually active cohorts into uninfected newly sexually active adolescent cohorts. Current HIV prevalence data, for example, shows that eight fold more girls than boys are HIV infected before age 24 in some sub-Saharan African settings (UNAIDS, 2010).
3. Established social norms about gender roles and behaviours, including norms about masculinity that condone multiple sexual partnerships amongst men and permit some forms of domestic violence. These limit women’s ability to negotiate or influence the circumstances of sex or address violence in their lives. For example, in South Africa women in violent relationships are at 34% higher risk of incident HIV infection than other women (Jewkes et al., 2010).
4. Stigma and discrimination towards people infected with or affected by HIV, limiting their ability to access or benefit from HIV services, or ensuring that HIV programmes and policies are responsive to their needs (Nyblade, 2004; Schwartländer et al. 2011). The active involvement of those most vulnerable to HIV is central to an effective HIV response, with a study in Kenya finding four times higher levels of condom use in communities with strong community mobilization and involvement (Schwartländer et al. 2011).
The Assessment Paper on the topic of Social Policy is authored by Charlotte Watts, Professor of Social and Mathematical Epidemiology at the London School of Hygiene and Tropical Medicine, Michelle Remme, Health Finance Specialist at the London School of Hygiene and Tropical Medicine and Anna Vassall, Lecturer Economics of HIV at the London School of Hygiene and Tropical Medicine.
The working paper used by the Expert Panel is available for download here, the finalized paper has been published in the Rethink HIV book by Cambridge University Press.