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Structural risk reduction-- tools to integrate into HIV prevention?

By Claire Cole | 17 May, 2010

A new joint report by the UN Development Programme and the Asia Pacific Coalition on Male Sexual Health finds that 90% of homosexual and bisexual men are denied HIV/AIDS related care due to hostility and discrimination in Asian countries towards these groups. The report was released to coincide with May 17th as the International Day Against Homophobia, and coverage of the report has largely highlighted the role of stigmatization in law and society as a major player in the skewed (higher) HIV prevalence within MSM communities-- particularly in countries where homosexual sex is illegal. In countries without actual criminalization however, stigma and targeted police hostility still create barriers to access. Of course, this won't be new information for many. But what I did find interesting was this quote from Mandeep Dhaliwal of the UNDP: "The effectiveness of the HIV response will depend not just on the sustained scale up of HIV prevention, treatment and care, but on whether the legal and social environment support or hinder programs for those who are most vulnerable."

At the same time, PEPFAR has made gender-based violence a priority for HIV prevention, and has allocated additional funding (USD 30 million) for scale up of responses to gender-based violence with particular focus on the Democratic Republic of Congo, Mozambique, and Tanzania.

Together, these amount to a recognition of the need for a holistic approach to HIV prevention that includes the risk environments in which vulnerable communities live, work, and access (or don't) health services. But at the same time, there seems ample room left to pursue a more integrated means of addressing these risk environments in programming and policy.

My colleagues and I have been discussing structural risk reduction in HIV prevention programs-- particularly in large-scale programs, where understanding of the diverse locally-specific contexts can be so important to efficacy and yet so elusive precisely because of a program’s large-scale. To address this challenge, we have been contemplating practical tools that can help programs considering scale to plan and implement activities that integrate locally-appropriate responses to diverse risk environments even as they take on the myriad other components necessary to keep a large-scale program running. --Does anyone have practical tools they have used to help map out how to integrate structural risk reduction activities into their HIV prevention programs? --Or how to figure out what "appropriate" risk reduction activities would look like for a diverse pool of local community contexts?

Links to relevant news coverage:



Claire Cole Replied at 6:26 PM, 20 May 2010

I found this "Evidence and Rights-based Planning and Support Tool" online from the World Population Fund. It's an attempt at the sort of tool I am interested in knowing more about (re: structural risk environments, and integrated programs. This one focuses on youth & sexual and reproductive health & rights (SRHR).

What do folks think? Is a tool like this useful or additive to your work? Would planners out there find this instructive? Is it sufficient to move us to a more integrated approach to HIV prevention? If not, what's missing?

Alexander Irwin Replied at 10:20 AM, 25 May 2010

A new resource that people may also find useful has recently come out from WHO. It builds on the effort by the WHO Commission on Social Determinants of Health to analyze how major public health programs can incorporate a structural approach to the social factors that shape health risks. There's no specific discussion of HIV prevention, but I believe lessons from these cases could well be extrapolated to the design and implementation of prevention work addressing structural risk.

New book:
Equity, social determinants and public health programmes

Edited by Erik Blas and Anand Sivasankara Kurup 2010, 300 pages
ISBN 978 92 4 156397 0
World Health Organization 2010

PDF [300p] Available online at:

“…This book is a collection of analyses of the social determinants of health that impact on specific health conditions. Stemming from the recommendations of the Commission on Social Determinants of Health, promising interventions to improve health equity are presented for the areas of: alcohol-related disorders, cardiovascular diseases, child health and nutrition, diabetes, food safety, maternal health, mental health, neglected tropical diseases, oral health, pregnancy outcomes, tobacco and health, tuberculosis, and violence and injuries.

The book was commissioned by the Department of Ethics, Equity, Trade and Human Rights as part of the work undertaken by the Priority Public Health Conditions Knowledge Network of the Commission on Social Determinants of Health, in collaboration with 16 of the major public health programmes of WHO. In addition to this, through collaboration with the Special Programme of Research, Development and Research Training in Human Reproduction, the Special Programme for Research and Training in Tropical Diseases, and the Alliance for Health Policy and Systems Research, 13 case studies were commissioned to examine the implementation challenges in addressing social determinants of health in low-and middle-income settings….”

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