In this video Lori Heise, the CEO of the DFID funded STRIVE research consortium, gives a brief summary of their work on the drivers of HIV. She describes how the group is working with partners from India, Tanzania and South Africa to gain a better understanding of how environments can help people to make healthier choices. Making healthy choices is not always easy for people for a range of reasons including poverty, gender inequality as well as other social and structural issues. STRIVE focuses on the structural drivers of HIV. The main aim is to intervene upstream to create the kind of environment that is more supportive to those who are pursuing HIV protection. STRIVE focuses on four main areas, which are: 1) Gender inequality and violence against women; 2) Stigma and criminalisation; 3) Secure livelihoods; 4) Alcohol and drinking norms.
Lori Heise is widely credited with getting gender violence onto the international health agenda. As founding director of the Global Campaign for Microbicides, she focused global attention on women’s options for HIV protection. At the London School of Hygiene and Tropical Medicine she teaches Ethics, Global Justice and Health. Among other research, she leads a team of epidemiologists investigating partner violence.
Lori is the Chief Executive to STRIVE, a research consortium investigating the social norms and inequalities that drive HIV. Thirty years into the AIDS epidemic, science shows that certain methods work to prevent and treat the virus. And yet this has not stopped the spread of HIV. More and better evidence is needed on how structural forces increase vulnerability to HIV and on the interventions that work, in practice, to address them.
STRIVE have produced a series of five case studies based on research to adapt and test a global HIV stigma reduction framework in India. STRIVE partner The International Centre for Research on Women (ICRW), led the research with funding from UNDP. Each case study focuses on the implementation of stigma-reduction activities in partnership with local organisations and populations. The case studies focus on local government, industry, sex worker collectives, education and health worker providers.
A summary report produced by ICRW, UNDP and STRIVE presents key findings from ICRW’s evaluation study in five settings. India’s National AIDS Control Programme (NACO) recognises stigma as a key driver of HIV infection and a barrier to treatment. The paper lists activities conducted to implement and test the framework in the settings of education, sex-workers, local governments, industry and health services. Findings show that:
- fear of infection and social judgement – two key actionable drivers of stigma in the framework – are prevalent among the different populations and need to be the focus of intervention and measurement efforts
- it is important to work with multiple target populations in interrupting the actionable drivers of stigma
- the framework’s inclusion of ‘intersecting stigmas’ is critical, given the nature of the epidemic in India and its focus on targeted interventions
- two additions are important for the Indian context: the inclusion of family and peers as a distinct target population and the addition of ‘occupation’ and ‘caste’ as examples of intersecting stigma
- using a range of activities concurrently enables a multi-level approach and maximises stigma reduction efforts
- contact strategies are a key component for stigma reduction
The report includes recommendations for programmers, policy-makers and practitioners on scaling up interventions for national implementation.
In 2012 a report, titled ‘Know me: Understanding the vulnerabilities of adolescent girls’ was published to illustrate the findings of a qualitative study carried out among young people in Karnataka State, in India. The Karnataka Health Promotion Trust (KHPT) published the document, which explores girls’ attitudes and aspirations with respect to education and attending school, with support from STRIVE. It documents girls’ experiences and explores a range of issues related to structural factors such as gender and social norms, traditional cultural practices, nutrition, healthcare, education and poverty. The report also considers the importance of school as a social space, providing a peer-based support system, representing an alternative to household work and early marriage, and for the significance of teachers as role models.
A general overview of the HIV epidemic’s evolution can be accessed from a presentation given by STRIVE Research Director Charlotte Watts, which was presented at a workshop hosted by DFID with the AIDS Consortium, to review the UK government Position Paper on AIDS, ‘Towards Zero Infections’. The presentation addresses several key issues, including the implications for HIV of the global economic context, how HIV financing has been affected by shifting global priorities and importantly, the existence of structural barriers that continue to limit HIV prevention efforts and service uptake. The presentation offers examples of programmes that achieve value for money by producing multiple outcomes with a single investment.
A report titled ‘Impact of two vulnerability reduction strategies on HIV risk reduction among female sex workers’ by Pillai et al. (2012) focuses on the impact of training of female sex workers (FSW) in alternative income generation as an innovative HIV/AIDS prevention strategy. It gives more information on a range of interlinking community mobilisation strategies. The report argues that FSWs participating in group organising and savings activities are more likely to adopt safer sex practices. The intervention was carried out in three districts of Karnakata state, south India. The results offer comparative insights on community mobilisation in all three settings.
In an editorial by Seeley et al. (2012) titled ‘Addressing the structural drivers of HIV: a luxury or necessity for programmes?’, the social, economic, political and environmental structural factors that increase susceptibility to HIV infection and undermine prevention and treatment efforts are discussed as continuing challenges. It highlights the need to integrate responses to the structural drivers of HIV/AIDS into future HIV investments, with both initiatives to integrate HIV into broader gender and development initiatives, as well as adaptations of current service models, to ensure that they are sensitive to and able to respond to the broader economic and social responsibilities that their clients face.
Women and girls between the ages of 15 to 24 are the population most vulnerable to HIV. STRIVE and ICRW have collaborated on an infographic, which can be viewed below, to explain structural factors that contribute to this vulnerability.
Violence against women
In 2011, STRIVE published an empirical evidence of what works in low- and middle-income countries to prevent violence against women by their husbands and other male partners, which was written by Lori Heise. The review focuses on prevention programmes rather than responses or services, and on research-based evaluations rather than insights from practice.
SASA! means ‘now!’ in Kiswahili. This comprehensive approach combines tools and a systematic process for community mobilisation to prevent violence against women and HIV. SASA! was developed by Raising Voices and is being implemented in Kampala, Uganda by the Centre for Domestic Violence Prevention (CEDOVIP). SASA! and the SASA! study are part of a broader portfolio of research being undertake by STRIVE and the Gender, Violence and Health Centre at LSHTM. A short video documenting SASA’s systematic phases for organising communities to take on the prevention of violence against women and HIV is available through their website. At its core, SASA! is a way to discuss and transform power. Community activists engage at many levels – from individuals to families to leaders and institutions – to infuse a community with new ways of thinking and behaving.