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



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!!!

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 Presentation Transcript

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