When it comes to dining out, most of us are familiar with the practice of ‘going Dutch’. Everyone partakes in the food, and everyone foots part of the bill. Researchers at the London School of Hygiene & Tropical Medicine are now proposing that such an approach could be used to pay for HIV prevention interventions.
In a recent seminar at the School, Professor Charlotte Watts and health economist Michelle Remme discussed the emerging field of ‘structural interventions’ for HIV prevention, and addressed the all too important question of who should pay for them.
What is structural HIV prevention?
Recent years have seen major biomedical advances in the field of HIV prevention, with innovations such as pre-exposure prophylaxis and early use of antiretrovirals to reduce the infectiousness of new patients. However, the number of people newly infected with HIV continues to grow, and there are clear limits to how far we can fight the virus on a purely biomedical front.
Individual behaviour change interventions also have their limitations. Potentially efficacious interventions, such as those promoting condom use, are all too often undermined by the wider social forces that shape people’s behaviours, such as:
• gender inequitable norms that condone violence against women and limit the extent to which women can refuse sex or insist on condom use
• social norms that define a man’s masculinity by his sexual conquests
• poverty that influences patterns of sexual mixing and engenders fatalistic attitudes towards treatment and prevention efforts
“HIV prevention must engage with these social, legal and economic factors that shape HIV risk”, says Watts, co-research director of STRIVE, a research consortium tackling the so-called ‘structural drivers’ of HIV. Structural interventions do this by addressing the broader risk environment in which HIV occurs. They might, for example, focus on community-level poverty alleviation, social norm change or the empowerment of women and girls.
From theory to practice
The motivations behind structural interventions are clear, but what might a structural intervention look like in practice?
A cash transfer programme in the Zomba district of Malawi provides a good example. The programme, designed to keep adolescent girls in school, comprised monthly cash payments to be split between the girls and their guardians. The payments were conditional on the girls attending school. A cluster randomised trial found that the transfers reduced school drop-out rates and early marriages by over a third. Furthermore, 18 months after enrolling in the programme, school girls receiving the transfers were:
• 76% less likely than controls to be infected with HSV-2
• 30% less likely to have become pregnant
• 64% less likely to be HIV positive
The researchers leading the study concluded that, “Structural interventions that do not directly target sexual behaviour change can be important components of HIV prevention strategies.”
Big aims, shrinking budgets
As the Zomba example nicely illustrates, structural interventions often impact on multiple outcomes spread across different sectors – in this case, HIV, sexual and reproductive health, education and mental health. On one level, this is good news for the HIV sector, as it provides opportunities to piggy back HIV components onto existing development programmes, or simply reap benefits from development programmes already underway. Indeed, the UNAIDS HIV investment framework highlights structural factors as ‘critical enablers’ of HIV prevention and recognises the potential for synergies between development sectors.
However, the broad scope of structural interventions also proves a sticking point. Cost-effectiveness analyses, conventionally used to help inform investment decisions for HIV programming, typically compare the total costs of a programme with their direct HIV outcomes only, such as number of HIV infections averted. In this so-called ‘silo approach’, benefits to other sectors do not form part of the equation. Structural interventions, where benefits are spread across different sectors, are thus undervalued and less likely to be prioritised, financed and taken to scale.
This disjunction between the cost-effectiveness of an intervention when cross-sectoral benefits are considered, versus the cost-effectiveness when a sector-specific silo mentality is adopted, led Remme and others in the STRIVE consortium to consider alternative approaches to funding for structural interventions. They compared different approaches for deciding whether to finance the Zomba cash transfer programme, and found ‘cross-sectoral cofinancing’ to be one approach that could increase the cost-effectiveness of structural interventions from an HIV perspective, and make it more likely that such interventions are funded. In this approach, each sector that benefits from the intervention contributes to the total cost, with each using cost-effectiveness analysis to determine how much they would be willing to contribute to the intervention, based on their sector -specific benefits. Remme concludes that “Co-financing provides an opportunity for multiple HIV, health and development objectives to be achieved simultaneously.”
It’s an idea that has intuitive appeal. If several sectors benefit from a programme, it makes sense to split the bill. Now it’s time to iron out the details and develop the cross-sectoral coordination and negotiation mechanisms that will allow co-financing to become the new status-quo.
Tanya Abramsky is a researcher and writer in the Social and Mathematical Epidemiology group (SaME) at the London School of Hygiene & Tropical Medicine, partners in the STRIVE research consortium, tackling the structural drivers of HIV, with support from UKaid from the Department for International Development. However, the views expressed do not necessarily reflect the department’s official policies.