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

“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