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Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010
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Richard Wolitski, Structural Interventions and the Science of HIV Prevention Texas HIV/STD Conference, May 2010

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Presentation given by Richard Wolitski at the 17th Texas HIV/STD Conference on Structural Interventons and the Science of HIV Prevention

Presentation given by Richard Wolitski at the 17th Texas HIV/STD Conference on Structural Interventons and the Science of HIV Prevention

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  • In 2006, CDC released revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. Previously, HIV testing had been considered somewhat special and different – the term coined for this situation was “exceptionalism.” The 2006 recommendations sought to return major responsibility for HIV testing to the health-care system.
  • As mass incarceration in the US has grown, more and more people have been forced to make these impossible choices(go through bullets with questions)And when people are released, the picture rarely improvesFolks are wading through decades of policies designed to limit their access to benefits, housing, employment – you name itBarred from society’s traditional means of supporting oneself, the only options that remain to people are often precisely the things that got them locked upAnd so the cycle continues2/3 of people will be rearrested within 3 years of release
  • But there we can imagine a different pictureA picture where we’re guided by the stories of the 1/3 of people who are not rearrestedThose who have set their hands to changing the systems they once found inescapableSo that the next generation might be able to imagine a future beyond mass incarcerationAnd that work has everything to do with HIV prevention
  • But by framing research questions with a structural analysis, we are able to give voice to the realities of the communities hardest hit by mass incarcerationYou know – it’s the same method that I have been trained by in theology:Who is not at the table?What is not being said?How do these same stories look when told in the voice of folks living them everyday?In community –Impact of policing on condom negotiation + NOLA (Spring 2009 American Journal of Public Health article on the impact of policing and other structural barriers on people's abilities to negotiate condom use in sex work)Prison budget eating up money for everything elseSupport kids with family in prison, keep kids homeIn prison – Condoms in prison as a campaign to address homophobiaTreatment education as critical way of not allowing community ties to be severedPrison programs that reduce the time you do behind the wallsAt reentry –All about rights taken away!!!
  • Transcript

    • 1. Structural Interventions andthe Science of HIV PreventionRichard J. Wolitski, PhDDeputy Director for Behavioral and Social SciencesDivision of HIV/AIDS PreventionNational Center for HIV/AIDS, Viral Hepatitis, STD, & TB Prevention<br />17th Texas HIV/STD Conference<br />Austin, May 27, 2010<br />The findings and conclusions in this presentation<br />are those of the author and do not necessarily represent<br />the views of the Centers for Disease Control and Prevention.<br />
    • 2. Acknowledgments<br />Linda Koenig, CDC<br />Bernie Branson, CDC<br />Laura McTighe, Institute for Community Justice<br /> Slides available at: slideshare.com<br />
    • 3. Overview<br />Putting structural interventions in context<br />How structural interventions are different from other interventions<br />Types of structural interventions<br />Examples of structural interventions<br />Resources<br />
    • 4. General population<br />Infectious<br />agent<br />Subpopulation<br />Sexual networks<br />Sexual partnerships<br />Biomedical & health<br />service interventions<br />Individual behavior<br />Socio-<br />economic<br />& cultural<br />factors<br />Adapted from Fenton & Imrie. Infect Dis Clin N Am. 2005; 19: 311-331<br />
    • 5. Highly Active HIV Prevention<br />Highly<br />Active HIV<br />Prevention<br />Community-Level Interventions<br />Biomedical<br />Interventions<br />Structural Interventions<br />HIV Testing & Linkage to Care<br />Individual & Small Group Interventions<br />Adapted from Coates, 2008.<br />
    • 6. Individual & Small Group Interventions<br />Directly influence knowledge, attitudes, and behaviors of persons who participate in intervention activities<br />Interventions delivered in one-on-one settings<br />Limited number of persons reached<br />Often provides most flexibility to meet client needs<br />
    • 7.
    • 8. Community-Level Interventions<br />Directly and indirectly influence risk behavior of an entire community<br />Often focus on social norms<br />Large numbers of persons reached<br />Little flexibility to meet needs of individuals<br />Examples<br />Mass media and social marketing<br />Dissemination of messages by peers<br />Community mobilization<br />
    • 9. Community-Level Interventions<br />Community-level interventions are supported by CDC<br />Included in Updated Compendium<br />Have been successfully adapted in diverse communities<br />
    • 10. Structural Interventions<br />Indirectly affect risk by changing things external to the individual<br />environment and physical structures<br />social structures<br /> laws or policies<br />that affect transmission risk or availability of prevention information or tools<br />
    • 11. Structural Interventions<br />Some may require few resources, but others are expensive<br />Affect large numbers of persons<br />Do not require individuals to decide to participate<br />Not tailored to individual needs<br />
    • 12. Shifting the Curve<br />Cohen, Scribner, Farley. A structural model of health behavior: A pragmatic approach to explain and influence health behaviors at the population level. Prev Med. 2000; 30; 146-154.<br />
    • 13. Frieden’s Health Impact Pyramid<br />Published in AJPH, April 2010<br />5-tier pyramid<br />Describes impact of different types of interventions<br />Provides framework to improve public health<br />Focuses on greater impact of efforts to address socioeconomic determinants and cultural context<br />Thomas Frieden MD, MPH<br />Director, CDC<br />
    • 14. Factors that affect HIV/STD prevention<br />Examples<br />Smallest<br />Impact<br />ILI + GLI interventions to promote individual behavior change<br />Counseling <br />& Education<br />Rx for viral load control, substance abuse treatment<br />Clinical<br />Interventions<br />Brief intervention for alcohol, circumcision, HIV dx, vaccine (when available)<br />Protective <br />Interventions<br />Readily available condoms, clean needles , + norms<br />Changing the Context<br />to make individuals’ default <br />decisions healthy<br />Largest<br />Impact<br />Poverty, Education, Housing, Racism, Homophobia, Stigma<br />Socioeconomic Factors<br />
    • 15. Factors that affect HIV/STD prevention<br />Counseling <br />& Education<br />Clinical<br />Interventions<br />Protective <br />Interventions<br />Changing the Context<br />to make individuals’ default <br />decisions healthy<br />Structural<br />Interventions<br />Socioeconomic Factors<br />
    • 16. 3 Types of Structural Interventions<br />Those that affect:<br />Availability<br />Physical environment<br />Social structures and determinants<br />Cohen, Scribner, Farley. A structural model of health behavior: A pragmatic approach to explain and influence health behaviors at the population level. Prev Med. 2000; 30; 146-154.<br />
    • 17. Availability<br />Accessibility of consumer products and services that are associated with health outcomes<br />Condoms, sterile syringes, PEP, etc.<br />HIV/STD/hepatitis information, interventions, diagnosis, care, and treatment<br />Reimbursement and integration of prevention into medical care<br />Drug treatment on demand<br />Alcohol and drugs<br />
    • 18. Condom Availability<br />Multiple studies have shown condom availability to be associated with condom use (e.g., Hart, 2004; Ibanez , 2005)<br />Condom availability in high schools:<br />Increases condom use among sexually active adolescents, especially males<br />Increases condom use at initiation of sexual activity<br />Has no significant effects on sexual activity<br />Decreases use of other contraceptive methods<br />Blake et al., AJPH. 2003; 93:955-962. Guttmacher, et al., AJPH. 1997; 87:1427-1433. Schuster, et al., Fam Plan Persp. 1998; 30:67-72 & 88. Wolk & Rosenbaum. 1995; J Adolesc Health. 1995; 17:184188.<br />
    • 19. Condom Availability<br />Distribution of 33 million free condoms in Louisiana from 1994 to 1996 resulted in:<br />Increased condom use at last sex:<br />28% to 36% African American women<br />30% to 48% African American women with 2+ partners<br />40% to 54% African American men<br />No change in number of sex partners<br />Cohen, Farley, Bedimo-Etame, et al. Implemetnation of condom social marketing in Lousiana, 1993 to 1996. AJPH. 1999; 89: 204-208.<br />
    • 20. Condom Availability<br />Estimated to have prevented 170 HIV infections<br />Estimated to have averted $33 million in medical costs<br />Cost saving (would be cost saving even with increase in condom use of 2.7%)<br />When nominal cost introduced ($0.25)<br />Distribution fell 98%<br />Condom use at last sex decreased from 77% to 64% among persons with 2+ partners<br />Condom use increased when cost eliminated<br />Bedimo et al., Int J STD AIDS. 2002; 13:384-392. Cohen et al., AJPH. 1999; 89:567-568. Cohen & Farley. Lancet. 2004. 364: 13-14.<br />
    • 21. Intervention Examples<br />Distribution Methods<br />Outreach<br />Businesses<br />Vending machines<br />Online<br />Thai condom policy in brothels<br />Easier to get, used more<br />Available when needed most<br />
    • 22. Syringe Exchange Programs<br />SEP:<br />Reduce use of non-sterile syringes<br />Reduce needle sharing<br />Reduce rates of HIV, hepatitis B and C infection<br />Do not increase drug use or drug injection<br />Promote entry into drug treatment<br />DesJarlais et al., AJPH. 2006; 96 : 1354-1358. Fisher et al., JAIDS. 2003; 33:199-205. Ksobiech. AIDS Educ Prev. 2003; 15:257-268. Latkin et al., Substance Use and Misuse. 2006; 41:1991-2001.<br />
    • 23. Examples<br />Changing pharmacy laws<br />Changing drug paraphernalia laws<br />Outreach distribution<br />Fixed site distribution<br />Increasing rates of exchange<br />Modifying ban on use of federal funds<br />
    • 24. Syringe Exchange Programs---United States, 2005<br />November 9, 2007 / 56(44);1164-1167<br />Survey of syringe exchange programs<br />118 SEPs in US<br />91 cities<br />28 states, territories, and DC<br />Budgets: $645 to $1.5 million per yer<br />74% state, county, local funding<br />Distributed 22+ million syringes<br />
    • 25. Syringe Exchange Programs---United States, 2005<br />November 9, 2007 / 56(44);1164-1167<br />Almost all provided other services<br />Condoms 97%<br />Drug treatment referrals 86%<br />HIV testing 81%<br />STD screening 49%<br />Hep A/B vaccination 37-39%<br />On-site medical care 29%<br />
    • 26. Greater Drug Injecting Risk for HIV, HBV, and HCV Infection in a City Where Syringe Exchange and Pharmacy Syringe Distribution are Illegal<br />Neagius et al. 2000;85: 309-322<br />Compared IDUs (N = 566) from Newark and New York City from 2004-2006—when syringe distribution illegal in Newark<br />IDUs in Newark were more likely to:<br />Inject with used syringe & obtain syringe on street<br />Have HIV (26% vs. 5%)<br />Have HBV (70% vs. 27%)<br />Have HCV (82% vs. 53%)<br />
    • 27. HIV Testing<br />HIV testing is an individual-level intervention<br />Significantly reduces risk among HIV+<br />Necessary step in linking HIV+ to care, treatment, and partner services<br />Increasing availability and use of testing is a structural intervention<br />More places and options for testing<br />Reducing barriers to offering or accepting testing<br />Cost, written consent, risk screening<br />
    • 28.
    • 29. Revised Recommendations - 2006 <br />Routine, voluntary HIV screening for all persons 13-64 in health care settings, not based on risk<br />Repeat HIV screening of persons with known risk at least annually<br />Separate, signed consent should not be required<br />Prevention counseling in conjunction with HIV screening in health care settings should not be required<br />
    • 30. TEXAS WASAHEAD OF CDC!<br />
    • 31. Texas Informed Consent Law<br />Sec. 81.105. Informed Consent.<br /> (a) Except as otherwise provided by law, a person may not perform a test designed to identify HIV antibody without first obtaining the informed consent of the person to be tested.<br />Sec. 81.106. General Consent.<br />(a) A person who has signed a general consent form for the performance of medical tests is not required to also sign a specific consent form relating to medical tests to determine HIV infection that will be performed on the person during the time in which the general consent form is in effect.<br />
    • 32. Texas Opt-Out Evaluation 1996-97<br />50% of HIV-positive patients in STD clinic were not being tested.<br />6-month evaluation periods before and after phased implementation at 6 STD programs:<br />Amarillo, Austin, Dallas, Fort Worth, Houston, Lubbock<br />Each site recorded data on:<br />Utilization of HIV testing, prevention counseling<br />Number of new HIV infections identified<br />
    • 33. Results: Change in HIV Testing<br />
    • 34. Availability of Medical andSupportive Services for HIV+ People<br />Study of 526 HIV+ patients in care in southeastern US found (AL, NC, SC):<br />40% reported 1+ unmet service needs<br />Those with a greater number of unmet needs and specific needs for benefits (e.g., SSI, insurance) and support groups were less likely to be taking HIV medications<br />Those with unmet mental health counseling needs and recent substance use reported poorer medication adherence<br />Reif, Whetten, Lowe, & Ostermann. Association of unmet needs for support services with medication use and adherence among HIV-infected individuals in the southeastern United States. AIDS Care. 2006; 18:277-283.<br />
    • 35. Intervention Examples<br />Policies, performance standards, and/or incentives that require all people who are diagnosed to be linked to medical care<br />Changing treatment guidelines to allow for earlier treatment<br />Eliminating ADAP waiting lists<br />Expanding ADAP eligibility<br />Co-locating medical and supportive services<br />
    • 36. <ul><li> Based on observational studies, effective antiretorviral therapy can reduce infectiousness as much as 92%.</li></li></ul><li>Conceptual Framework for Test and Treat Strategy<br />GOAL: Decrease in HIV transmission from persons with undiagnosed or inadequately controlled HIV infection<br />Identify HIV+ persons unaware of their HIV status<br />Active bridge to HIV care for ART <br />Earlier ART eligibility to reduce infectiousness<br />Achieve & maintain high ART adherence rates<br />
    • 37. Incidence of HIV<br />1980<br />2000<br />2020<br />2040<br />Parameters for generalized epidemic, S. Africa<br />
    • 38. Availability of Alcohol<br />Density of liquor stores and bars has been linked to:<br />Traffic crashes and deaths<br />Drunk driving offenses<br />Cirrhosis mortality<br />Violent assaults and homicides<br />STD rates<br />Cohen et al. Social Science and Medicine 2006; 62:3062-3071. LaVeist & Wallace. Social Science and Medicine 2000; 51:613-617. Theall et al. Alcohol & Alcoholism 2009; 44:491-499.<br />
    • 39. A Geographic Relation Between Alcohol Availability and Gonorrhea Rates<br />SCRIBNER, COHEN, & FARLEY. STD. 25:544-548, November 1998.<br />1995 census tract density of licensed off-sale alcohol outlets overlaid with the reported cases of gonorrhea during 1995 in New Orleans.<br />© Copyright 1998 American Sexually Transmitted Diseases Association. Published by Lippincott Williams & Wilkins, Inc.<br />2<br />
    • 40. Alcohol Outlets, Gonorrhea, and the Los Angeles Civil Unrests:<br />A Longitudinal Analysis<br />Cohen et al. 2006;62: 3062-3071<br />Compared changes density of alcohol outlets before and after 1992 civil unrest in Los Angeles County<br />270 alcohol outlets surrendered licenses due to arson or vandalism<br />Compared areas affected by the civil unrest with unaffected areas<br />Adjusting for other factors, unit decrease in number of alcohol outlets per mile associated with 21 fewer gonorrhea cases per 100,000 people<br />
    • 41. Physical Environment<br />Physical characteristics of structures/products that inherently either reduce or increase opportunities for healthy behaviors or outcomes<br />Well-lit streets<br />Childproof medicine containers<br />Airbags in cars<br />Removing doors from private rooms in sex clubs and bathhouses<br />Improving availability and quality of housing<br />
    • 42. Homelessness in the United States<br />Up to 3.5 million persons experience homelessness each year<br />Homelessness & HIV risk co-occur:<br />HIV/AIDS is 3-9 times higher in homeless/unstably housed<br />Higher rates of risk behavior including:<br />Injection drug and other substance use<br />Multiple partners<br />Sex exchange<br />Unprotected sex with non-main partners<br />
    • 43. Homelessness & Living with HIV<br />Homeless/unstably housed persons living with HIV:<br />Have poorer access to regular HIV care<br />Less likely to receive optimal antiretroviral therapy<br />Less likely to adhere to therapy<br />Have lower CD4 counts and higher viral loads<br />Wolitski, Kidder, & Fenton. HIV, homelessness, and public health: Critical issues and a call for increased action. AIDS and Behavior. 2007;11(Supl 2): S167-S171.<br />
    • 44. Housing Status and HIV Risk Behaviors:<br />Implications for Policy and Prevention<br />Aidala et al. 2005;9: 251-265<br />Multisite study of 2,149 clients at medical and social service agencies followed for 6-9 months<br />Improvement in housing status associated with:<br />Reduced drug use<br />Reduced needle sharing<br />Reduced unprotected sex<br />Worsening housing status associated with:<br />5x increase in sex exchange<br />
    • 45. “Broken Windows” and the Risk of Gonorrhea<br />Cohen et al. 2000;90: 230-2236<br />Assessed gonorrhea rates and neighborhood conditions in 55 blocks in New Orleans<br />Used “broken window” index<br />Housing quality, abandoned cars<br />Graffiti, trash, public school deterioration<br />Controlled for poverty, unemployment, education level<br />
    • 46. Copyright AJPH 2000<br />
    • 47. Copyright AJPH 2000<br />
    • 48. “Broken Windows” and the Risk of Gonorrhea<br />Cohen et al. 2000;90: 230-2236<br />In high-poverty neighborhoods, blocks with high broken windows score had higher gonorrhea rates<br />46.6 per 1,000 vs. 25.8 per 1,000 (p < .001)<br />
    • 49. Neighborhood Physical Conditions and Health<br />Cohen et al. 2003;93: 467-471<br />2003 follow-up study in 107 cities <br />Controlled for race, poverty, education, population change, and health insurance<br />Boarded-up housing associated with:<br />Higher gonorrhea rates<br />Premature death, Cancer, Diabetes<br />Homicide, Suicide<br />
    • 50. Why Might NeighborhoodConditions Matter?<br />If considered dangerous, promote social isolation<br />Indicates that there are no rules and no one cares<br />May lead to break down of pro-social norms, reduce self and collective efficacy<br />May contribute to hopelessness and fatalism<br />
    • 51. What Might Be Done?<br />Increased local, state, and federal investment to improve neighborhood and housing quality<br />Community action and mobilization to monitor and improve neighborhoods<br />Benefit of increasing community cohesion, collective and self efficacy, and social capital<br />
    • 52. Social Structures and Determinants<br />Social conditions, laws, policies that affect social structures and social determinants of health that increase or decrease healthy behaviors or outcomes<br />Seat belt laws<br />Biased arrest rates and sentencing<br />Laws barring discrimination based on race, gender, religion, disability, age, sexual orientation<br />Laws supporting stable partnerships and families<br />
    • 53.
    • 54. Financial Instability<br />Lack of <br />Jobs<br />Loss of <br />Caregivers<br />Broken Family Ties <br />Fractured Communities <br />Fractured Communities <br />Arrest–Jail/Prison–Reentry<br />Need for Services and Support<br />Lack of <br />Social Services<br />Relationship Instability<br />Community Health in a Time of Mass Incarceration<br />
    • 55. Ready Employment<br />Financial Stability<br />Family Reintegration<br />Family Support<br />Community <br />Wholeness<br />Community <br />Wholeness<br />Access to <br />Social Services<br />Relationship Stability<br />A Vision for Community Healing <br />Arrest–Jail/Prison–Reentry<br />Need for Services and Support<br />
    • 56. Structural Interventions forPreventing HIV and Incarceration<br />In Communities:<br /><ul><li>Sentencing reform
    • 57. Communitypolicing
    • 58. Prison budget reinvestment
    • 59. Youth empowerment</li></ul>At Reentry:<br /><ul><li>Civic participation
    • 60. Community-led mentoring
    • 61. Job creation and retention
    • 62. Housing expansion</li></ul>In Jail/Prison:<br /><ul><li>Harm reduction programs
    • 63. Treatment education and advocacy
    • 64. Good time earned time</li></li></ul><li>Economic Interventions<br />Unemployment and disability insurance<br />Social security<br />Aid to families with dependent children<br />Food stamps<br />Microfinance and microenterprise interventions<br />Small loans to help with short-term financial crisis or to encourage small business development<br />Long history in developing countries, but relatively little attention in US<br />Job training<br />
    • 65. JEWEL Project<br />Pilot of HIV prevention and jewelry making intervention<br />Drug-using women (n=50) in Baltimore (62% African American)<br />6 two-hour sessions<br />HIV intervention based on Social Cognitive Theory<br />Jewelry making skills<br />Also aimed to increase job-related self-efficacy<br />Sherman, et al., The evaluation of the JEWEL project: An innovative economic enhancement and HIV prevention intervention . . . AIDS Care. 2006; 18:1-11.<br />
    • 66. JEWEL Project<br />Significant changes from pretest to 3- month posttest:<br />Receiving drugs/money for sex<br />Median number of sex trade partners<br />Amount of money spent on drugs<br />Daily drug use and crack use<br />Sold $7000+ of jewelry<br />Income from jewelry sales associated with reduction in number of sex trade partners in multivariable model<br />Sherman, et al., The evaluation of the JEWEL project: An innovative economic enhancement and HIV prevention intervention . . . AIDS Care. 2006; 18:1-11.<br />
    • 67. Racism, Sexism, Ageism, Homophobia, Transphobia, andHIV Stigma<br />
    • 68. Unemployment rates<br />Poverty and income inequality<br />Educational attainment and job advancement<br />Biased arrests and sentencing<br />Verbal and physical assault<br />Social segregation<br />
    • 69. Simplified Health Inequities Model<br />Mental<br />Health<br />SES<br />Buffers<br />Buffers<br />Prejudice &<br />Discrimination<br />Health<br />Behavior<br />Physical<br />Health<br />Health<br />Care Access<br />& Quality<br />Policies<br />and Laws<br />
    • 70. The Impact of Institutional Discrimination on Psychiatric Disorders in Lesbian, Gay, and Bisexual Populations<br />Hatzenbuehler et al. 2010;100: 452-459<br />Assessed relation between living in states with bans on same-sex marriage with changes in psychiatric disorders<br />Compared nationally representative data from 2001-2002 with data from 2004-2005<br />
    • 71. The Impact of Institutional Discrimination on Psychiatric Disorders in Lesbian, Gay, and Bisexual Populations<br />Hatzenbuehler et al. 2010;100: 452-459<br />LGB respondents in states passing ban has significant increases in:<br />Any mood disorder (37% increase)<br />Generalized anxiety disorder (248% increase)<br />Alcohol use disorder (42% increase)<br />Psychiatric comorbidity (36% increase)<br />No significant increases in LGB respondents in other states or among heterosexuals<br />
    • 72. Same-Sex Domestic Partnerships and Lower-Risk Behaviors for STDs, Including HIV Infection<br />Klausner et al. 2006;51: 137-144<br />Phone survey of 2,881 gay men living in large urban areas from 1996-1998<br />Compared men in legal domestic partnerships with those in steady relationships and single men<br />Men in domestic partnerships were:<br />Less likely to have multiple partners and “one night stands”<br />Less likely to have unprotected anal intercourse with non-primary partner<br />
    • 73. Intervention Examples<br />Reduce prejudice and discrimination<br />Educating general public about HIV transmission<br />Change laws and policies<br />Repeal laws that promote discriminatory practices, enact laws promote equality and punish discrimination<br />Encourage equal opportunity<br />Strengthen community and individual resilience<br />Community mobilization<br />Promoting individual coping skills and social support<br />
    • 74. Issues and Challenges<br />Research and evaluation is difficult<br />Theory and evidence-base are not well developed<br />Some structural change is a long-term process<br />Funding may be directed to specific issues and have short time to demonstrate effects<br />May require new partnerships and skills<br />Political will may be lacking<br />Some of these issues are really hard<br />
    • 75. Conclusions<br />Structural interventions can be effective and have the potential to impact HIV, STD, and viral hepatitis epidemics<br />There’s still a lot to learn about developing, implementing, and evaluating structural interventions<br />But that shouldn’t stop us from acting now--structural interventions should be part of comprehensive efforts to stop HIV, STD, and viral hepatitis transmission<br />
    • 76. Resources<br />
    • 77. Report from CDC consultation<br />December 2008<br />Focus on HIV/AIDS, Viral Hepatitis, STD, and TB<br />Available at: <br />www.cdc.gov/socialdeterminants<br />
    • 78. Bibliography<br />Structural Interventions<br />HIV Prevention and Public Health:<br />Descriptive summary of selected literature<br />Academy for Educational Development <br />Center on AIDS and Community Health <br />funding provided by <br />The Centers for Disease Control and Prevention <br />November 2003<br />Summary of literature at:www.effectiveinterventions.org<br />Completed in November 2003<br />Covers:<br />Definitional issues<br />Selection of interventions<br />Legal/ethical/policy issues<br />Systems integration<br />Populations<br />Structural interventions used in related areas<br />
    • 79. Conference on community advocacy in HIV treatment and prevention research.<br />April 20-23, 2010<br />Slides from structural interventions session available at: <br />hivresearchcatalystforum.org<br />
    • 80. Selected Papers<br />Blankenship, K.M., Friedman, S.R., Dworkin, S., & Mantell, J.E. (2006). Structural interventions: Concepts, challenges, and opportunities for research. Journal of Urban Health, 83, 59-72.<br />Cohen, D. A., & Scribner, R. (2000). An STD/HIV prevention intervention framework. AIDS Patient Care and STDs, 14, 37-45.<br />Cohen, D.A., Scribner, R., & Farley, T.A. (2000). A structural model of health behavior: A pragmatic approach to explain and influence health behaviors at the population level. Preventive Medicine, 30, 146-154.<br />Frieden, T.R. (2010). A framework for public health action: The health impact pyramid. AJPH, 100, 590-595.<br />Gupta, G.R., Parkhurst, J.O., Ogden, J.A., Aggleton, P., & Mahal, A. (2008). Structural approaches to HIV prevention. Lancet, 372, 764-775.<br />Sumartojo, E. (2000). Structural factors in HIV prevention: Concepts, examples, and implications for research. AIDS, 14(Suppl 1), S3-S10.<br />

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