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The IMAGE Program in South Africa: Taking a “Structural” Approach
to HIV Prevention through Cross-Sectoral NGO Partnerships
Julia Kim
School of Public HealthUniversity of the Witwatersrand
&Health Policy Unit
London School of Hygiene & Tropical Medicine
PONPO, Yale University Apr 14, 2009
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“Despite broad recognition that underlying social conditions - including poverty & gender inequalities - affect vulnerability to HIV infection, there is a serious deficiency in the design and testing of interventions to critically engage issues at this level”
Track D Summary XIth International AIDS Conference
Vancouver, 1996 (Mane, Aggleton, Dowsett et al)
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Prevailing Approaches to HIV Prevention
Abstinence
Partner reduction
Condom use
Risk factor epidemiology& “individual risk”
Psychologicalmodels ofbehaviour change(e.g.Theory of reasoned action)
Primarily technical& health sectordriven
?
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Structural determinants & HIV/AIDS
Individual Behaviour
Poverty & economic
inequalities
Mobility & migrationGender
Inequalities
“Upstream” factors that impact on individual behaviour change
Impact both developed & developing countries
Overlapping & mutually reinforcing
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Structural Interventions… Work by altering the context in which health is produced
- Blankenship et al, AIDS 2000
Individual Behaviour
Laws & Policies
Target Populations rather than individuals
MultipleLevels forintervention
Socio-economic conditions
Cultural NormsEvolving field:
little research in developing countries
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The IMAGE Study: A structural intervention to address HIV and Gender-based violence in
South Africa
Gender violence
HIV infection
Poverty & economic inequalities
Gender Inequalities
Microfinance
Gender /HIVtraining
IMAGE
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The IMAGE Study (Intervention with Microfinance for AIDS and Gender Equity)
Microfinance NGO: Small Enterprise Foundation Women’s businesses:
Selling produce, clothes, food stalls
HIV Training: RADAR 1-hr sessions during loan
repayment meetings q. 2 weeks
6 month structured curriculum
6 month community mobilization: Village Action Plans around GBV and HIV
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2001-2004 8 villages in rural Limpopo (pop 64, 000)
Matched on size and accessibility Randomly selected (Control villages receive
intervention at end of study) Intervention + control participants
Matched by age and poverty-status Face-to-face interviews: Baseline and 2 years later Analysis: Adjusted for baseline differences and
village-level clustering Parallel qualitative research
3 full-time anthropologists
Evaluation: Cluster- Randomized Trial
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Economic well-being: Improved food security,
household assets
Women’s empowerment: Greater self confidence,
autonomy, challenging gender norms, collective action: 5 public marches 40 village workshops 16 meetings with local
leaders 2 new village committees
target Crime and Rape
Results: Impacts on Poverty & Women’s Empowerment
- JC Kim et al. AJPH 97 (10), Oct 2007
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Intimate partner violenceAfter 2 years, past year risk of physical & sexual violence reduced by 55% (aRR
0.45 95% CI 0.23-0.91)
HIV Risk*Among young IMAGE participants
(age<35):
Increased HIV communication aRR=1.46 (1.01 –
2.12)
Increased VCT aRR=1.64 (1.06 – 2.56)
Reduced unprotected sex with non-spousal partner by 24%
aRR = 0.76 (0.60 – 0.96)
* Pronyk et al. AIDS 22, 2008
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Emerging Lessons… It is possible to address GBV as part of HIV
prevention, and to do so within project timeframes Challenges belief that gender norms & GBV “culturally
entrenched” and resistant to change
Cross-sectoral interventions can generate synergyMicrofinance: Meeting “basic needs” as part of HIV prevention
piggy-backing onto MF program: sustained participation
Health Training: Empowerment about “more than just money”MF Alone Study: MF (without training) improved poverty but did
NOT lead to broader impacts (empowerment, IPV, HIV risk) Importance of education, addressing social norms & community
mobilisation (Kim et al. Bulletin of WHO, 2009)
Strong partnerships models: each stick to what you do well Loan repayment rates 99%
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2001-2004 2005-2007 2008-2010430 households 4500 households (30,000) 15 000 households (80,000)
IMAGE: Scaling up in South Africa
Pilot StudyAdditional cost = US $43/client
Scale-upAdditional cost = US $13/client
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From Micro to Macro: Linking Programs to Supportive Policy
Environment Individual programs on their own, unlikely to impact
on poverty or HIV on a national scale MF a “foothold” out of poverty, but not the whole
ladder… However such programs do:
Demonstrate feasibility & suggest pathways for affecting health outcomes
Yield practical lessons & cross-sectoral partnership models
Provide “metaphor” for what might be possible by combining economic empowerment & HIV prevention on wider scale
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Scaling up “principles” as well as programs
Not just about scaling up programs (MF, Gender)
but impetus for wider policy change
Country level:National AIDS Strategic PlansRural economic development
Girls’ educationDomestic violence legislation
Customary Laws & women’s legal status
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Policy implications:At country level: How to begin addressing structural factors
as part of national HIV/AIDS strategy?
SA National HIV/AIDS Strategic Plan (2007-2011): Goal 18: Focus on the human rights of women and girls and
mobilize society to stop gender-based violence and advance equality in sexual relationships
Objective 1.2: Roll-out integrated microfinance and gender education interventions starting in the poorest and highest HIV burden areas
“Mainstreaming AIDS in Development” (UNDP/UNAIDS) Role of donors & government sectors in supporting structural
approaches to HIV (e.g. integrating Gender/HIV into economic development programs)
Private sector: Beyond “corporate social responsibility” (e.g. Anglo Platinum Mines, Goldman Sachs 10,000 Women Campaign)
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Structural interventions & HIV Prevention:
An unexplored frontier…
Individual Behaviour
Laws & Policies
Socio-economic conditions
Cultural norms
Microfinance & HIV• IMAGE (S Africa)• TRY (Kenya)• SHAZ (Zimbabwe)
Masculinities & HIV:• Promundo (Brazil, India)• Men as Partners (SA)
Women’s property & inheritance laws• ICRW review (2004)
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PreventionTreatment
The “AIDS Pendulum”
25 years into the AIDS Pandemic…
Early in epidemic Attention to structural drivers in
North as well as South Calls to address structural factors
1990s: Prevention “burnout” Side-tracked by ideological “ABC”
debates Great hopes placed in ART & new
prevention “technology” (PrEP, male circumcision, microbicides, vaccines)
No “magic bullets”
2000s: Learning from the past? Structural interventions: time to
“enrich the mix” of prevention strategies
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AIDS is a long-wave event… A “slow motion tsunami”
Requires both: Immediate, “AIDS-specific”
responses (e.g. ART) AND
Long-term commitment to addressing structural factors as part of Prevention
The challenge: Can we combine sense of urgency with long-term vision?
“Make haste slowly”
- Milarepa (12th Century, Tibet)
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AcknowledgementsLSHTM & WITS colleagues: Paul Pronyk, Charlotte Watts,
James Hargreaves, Lulu Ndhlovu, Godfrey Phetla, Linda Morison, Joanna Busza, John Porter.
Funders: South African Department of
Health, DFID, SIDA, HIVOS, Ford Foundation, AngloPlatinum & The AngloAmerican Chairman’s Educational Trust & Kaiser Family Foundation