A key component of the shift from an emergency to a long-term response to AIDS is a change in focus from HIV prevention interventions focused on individuals to a comprehensive strategy in which social/structural approaches are core elements. Such approaches aim to modify social conditions by addressing key drivers of HIV vulnerability that affect the ability of individuals to protect themselves and others from HIV. The development and implementation of evidence-based social/structural interventions have been hampered by both scientific and political obstacles that have not been fully explored or redressed. This paper provides a framework, examples, and some guidance for how to conceptualise, operationalise, measure, and evaluate complex social/structural approaches to HIV prevention to help situate them more concretely in a long-term strategy to end AIDS.
After nearly 30 years of the HIV/AIDS pandemic, there have been woefully few examples of truly successful HIV prevention initiatives conceived and implemented by national policy makers and programme planners. To ensure measurable HIV prevention success by 2031, the 50th anniversary of the epidemic, it will be necessary to move beyond the limited, individualistic, urgency-based approaches of the past. Shifting from an emergency framework and mounting a long-term response to AIDS requires new approaches that engage with underlying social-structural drivers of patterns of practices that influence vulnerability and facilitate the spread of HIV, as part of comprehensive, strategic programming (or ‘combination prevention’).

Patterns of behaviour and practices arise from combinations of drivers, operating in specific social, economic, and political contexts. As such, no single causal pathway can be drawn from a social driver to a set of practices or behaviours; rather, a range of potential outcomes may arise. Making causal inference about correlations between social drivers and HIV burden involves identifying ‘sociologically plausible’ pathways drawn from extant social science and epidemiological data. Engaging with social drivers requires methods and approaches beyond traditional conceptualisations that seek to identify and intervene on single, causal determinants or universal mechanisms of influence. HIV prevention researchers and advocates should reject and resist over-simplified language for social drivers. Statements that particular social-structural factors ‘do’ or ‘do not’ lead to HIV transmission are almost always too simplistic; language should shift to discussing how, in what circumstances, and for whom particular combinations of factors contribute to HIV vulnerability (or, conversely, resilience). In order to be rigorous, design of HIV prevention programmes and interventions aiming to address social-structural factors should:

  • Begin with an assessment of the social and structural factors that may be
  • increasing HIV vulnerability in targeted populations and settings.
  • Identify (hypothesise) sociologically plausible causal chains between distal structural factors and specific individual or group practices.
  • Identify levels of possible influence, in line with the HIV prevention programme’s or intervention’s scope and aim.
  • Articulate any assumptions about such influences and aims including potential expected and unexpected consequences of the programme or intervention (including other social impacts).
  • Build in evaluation mechanisms that are both feasible and appropriate to the aim, level, scope and method of the programme or intervention as a way to enable validation of assumptions, investigation of the mechanisms by which structures affect risk and vulnerability, and appropriate assessment of outcomes and impact.
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