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

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 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.

2. Acknowledgments Linda Koenig, CDC Bernie Branson, CDC Laura McTighe, Institute for Community Justice Slides available at: slideshare.com

3. Overview Putting structural interventions in context How structural interventions are different from other interventions Types of structural interventions Examples of structural interventions Resources

4. General population Infectious agent Subpopulation Sexual networks Sexual partnerships Biomedical & health service interventions Individual behavior Socio- economic & cultural factors Adapted from Fenton & Imrie. Infect Dis Clin N Am. 2005; 19: 311-331

5. Highly Active HIV Prevention Highly Active HIV Prevention Community-Level Interventions Biomedical Interventions Structural Interventions HIV Testing & Linkage to Care Individual & Small Group Interventions Adapted from Coates, 2008.

6. 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

8. 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 Examples Mass media and social marketing Dissemination of messages by peers Community mobilization

9. Community-Level Interventions Community-level interventions are supported by CDC Included in Updated Compendium Have been successfully adapted in diverse communities

10. 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

11. 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

12. 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.

13. 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

14. Factors that affect HIV/STD prevention Examples Smallest Impact ILI + GLI interventions to promote individual behavior change Counseling & Education Rx for viral load control, substance abuse treatment Clinical Interventions Brief intervention for alcohol, circumcision, HIV dx, vaccine (when available) Protective Interventions Readily available condoms, clean needles , + norms Changing the Context to make individuals’ default decisions healthy Largest Impact Poverty, Education, Housing, Racism, Homophobia, Stigma Socioeconomic Factors

15. Factors that affect HIV/STD prevention Counseling & Education Clinical Interventions Protective Interventions Changing the Context to make individuals’ default decisions healthy Structural Interventions Socioeconomic Factors

16. 3 Types of Structural Interventions Those that affect: Availability 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.

17. 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

18. 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.

19. 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.

20. 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.

21. Intervention Examples Distribution Methods Outreach Businesses Vending machines Online Thai condom policy in brothels Easier to get, used more Available when needed most

22. Syringe Exchange Programs SEP: 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.

23. Examples Changing pharmacy laws Changing drug paraphernalia laws Outreach distribution Fixed site distribution Increasing rates of exchange Modifying ban on use of federal funds

24. 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

25. 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%

26. 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%)

27. 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

29. 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

30. TEXAS WASAHEAD OF CDC!

31. 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.

32. 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

33. Results: Change in HIV Testing

34. 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.

35. 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

37. Incidence of HIV 1980 2000 2020 2040 Parameters for generalized epidemic, S. Africa

38. 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.

39. 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. 2

40. 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

41. 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

42. 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

43. 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.

44. 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

45. “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

46. Copyright AJPH 2000

47. Copyright AJPH 2000

48. “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)

49. 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

50. 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

51. 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

52. 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

54. Financial Instability Lack of Jobs Loss of Caregivers Broken Family Ties Fractured Communities Fractured Communities Arrest–Jail/Prison–Reentry Need for Services and Support Lack of Social Services Relationship Instability Community Health in a Time of Mass Incarceration

55. Ready Employment Financial Stability Family Reintegration Family Support Community Wholeness Community Wholeness Access to Social Services Relationship Stability A Vision for Community Healing Arrest–Jail/Prison–Reentry Need for Services and Support

57. Communitypolicing

58. Prison budget reinvestment

60. Community-led mentoring

61. Job creation and retention

63. Treatment education and advocacy

65. 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.

66. 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.

67. Racism, Sexism, Ageism, Homophobia, Transphobia, andHIV Stigma

68. Unemployment rates Poverty and income inequality Educational attainment and job advancement Biased arrests and sentencing Verbal and physical assault Social segregation

69. Simplified Health Inequities Model Mental Health SES Buffers Buffers Prejudice & Discrimination Health Behavior Physical Health Health Care Access & Quality Policies and Laws

70. 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

71. 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

72. 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

73. 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

74. 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

75. 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

76. Resources

77. Report from CDC consultation December 2008 Focus on HIV/AIDS, Viral Hepatitis, STD, and TB Available at: www.cdc.gov/socialdeterminants

78. 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 at:www.effectiveinterventions.org Completed in November 2003 Covers: Definitional issues Selection of interventions Legal/ethical/policy issues Systems integration Populations Structural interventions used in related areas

79. Conference on community advocacy in HIV treatment and prevention research. April 20-23, 2010 Slides from structural interventions session available at: hivresearchcatalystforum.org

80. 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.