AIDSTAR-One is funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development (USAID), and provides rapid technical assistance to USAID and U.S. Government country teams to build effective, well-managed, and sustainable HIV and AIDS programs, and promotes new leadership in the global campaign against HIV.

During the recent International AIDS Society Conference in Washington, DC, exciting breakthroughs in HIV prevention, treatment, and care—even a possible cure—took center stage. But despite recent advances, many men and women remain at risk of HIV as a result of structural issues that fuel and have an impact on the epidemic. Structural Interventions reduce individual HIV-related vulnerability by creating conditions that enable people to adopt safer behaviors. Addressing gender inequality, poverty, stigma, and other social, economic, cultural, and legal factors is necessary to create an “enabling environment” for these promising biomedical and behavioral interventions.

There is increasing agreement worldwide that structural issues are too often overlooked where HIV prevalence remains high. Women who are not empowered to take charge of their sexual lives cannot practice HIV prevention, be it in the form of condoms or pre-exposure prophylaxis. Most-at-risk populations, such as men who have sex with men, will not seek out prevention and care services if they fear stigma or prosecution. Countries that cannot afford an extensive public health network cannot offer voluntary medical male circumcision or antiretroviral therapy to its rural citizens.

Unfortunately, specific operational guidelines, definitions, and evidence to clearly guide implementation of scalable structural approaches remain inadequate. To fill this gap, the U.S. Government and the global HIV community are working toward achieving consensus on how to prioritize which structural interventions. Addressing structural drivers can have a tremendous impact on the epidemic, but bringing promising approaches to scale requires sustained investment, a significant challenge in the face of competing priorities and tightening budgets.

Recent PEPFAR guidance recognizes the importance of addressing structural drivers as part of a comprehensive combination prevention package of services. At the International AIDS Conference, USAID – along with other U.S. Government agency staff, implementers, researchers, and policymakers – discussed the structural issues that impede progress, with the goal of building consensus to move forward.

The challenge is figuring out which structural approaches will achieve the maximum impact within different contexts. Implementers at the community level know that addressing structural drivers—which are deeply entrenched in social, economic, and political systems—requires sustained investments with strategies tailored to local contexts. Identifying what works is also difficult. Although there is increasing evidence that supports the links between these factors and HIV, measuring change can often be hard in relatively short-term project lifecycles. Experts also disagree on which types of evaluation methods are adequate to demonstrate change, and balancing the need to address these factors while also scaling up other proven interventions continues to be a challenge. Because structural drivers are linked to the very fabric of social, economic, and political systems, they often require a broader sector response, unlike more narrow biomedical and behavioral approaches.

Nonetheless, and despite the existence of clear guidance, some countries are making great progress in this area. For example, Zambia is integrating structural approaches into its national HIV framework through a multisectoral response. Key successes in Zambia’s national strategy have been strengthening collaboration and coordination across sectors and investing in a community-driven process. Panelists at a satellite session on the topic at the International AIDS Conference discussed some of these initiatives. For example, the Zambia Land Alliance is working with local authorities to ensure the availability of land for vulnerable populations, which helps address the lack of access to property that increases women’s vulnerability.

The best strategies for lifting structural barriers will be context specific, and will ultimately come from local communities. But to achieve widespread success, the response will also have to be coordinated with and supported  by national and international strategies and—given limited resources—strategically integrated into other combination prevention program areas. Easier said than done, but acknowledging the challenges and building consensus are two positive steps in moving one stubborn gorilla.

Learn more about structural approaches to HIV prevention at AIDSTAR-One.