Social Drivers of HIV/STI Infections Among Young People

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Social Drivers of HIV/STI Infections Among Young
People

• Judith D. Auerbach, Ph.D.
• Independent Consultant, and
• Adjunct Professor, School of Medicine, UCSF
• SHINE Conference
• University of Chicago School of Social Service
  Administration
• November 8, 2013

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Rates of Diagnoses of HIV Infection among
Adolescents Aged 1319 Years, 2011United States
and 6 Dependent AreasN 2,316 Total Rate 7.6

• Note. Data include persons with a diagnosis of
  HIV infection regardless of stage of disease at
  diagnosis. All displayed data have been
  statistically adjusted to account for reporting
  delays, but not for incomplete reporting.

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Rates of Diagnoses of HIV Infection among Young
Adults Aged 2024 Years, 2011United States and
6 Dependent AreasN 8,140 Total Rate 36.3

• Note. Data include persons with a diagnosis of
  HIV infection regardless of stage of disease at
  diagnosis. All displayed data have been
  statistically adjusted to account for reporting
  delays, but not for incomplete reporting.

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Diagnoses of HIV Infection among Adolescents and
Young Adults Aged 1324 Years, by
Race/Ethnicity, 20082011United States and 6
Dependent Areas

• Note. Data include persons with a diagnosis of
  HIV infection regardless of stage of disease at
  diagnosis. All displayed data have been
  statistically adjusted to account for reporting
  delays, but not for incomplete reporting.
• a Hispanics/Latinos can be of any race.

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Diagnoses of HIV Infection among Adolescents and
Young Adults Aged 1324 Years, by Transmission
Category 20082011United States and 6 Dependent
Areas

• Note. Data include persons with a diagnosis of
  HIV infection regardless of stage of disease at
  diagnosis. All displayed data have been
  statistically adjusted to account for reporting
  delays and missing transmission category, but not
  for incomplete reporting.
• a Heterosexual contact with a person known to
  have, or to be at high risk for, HIV infection.
  
• b Includes hemophilia, blood transfusion,
  perinatal exposure, and risk factor not reported
  or not identified.

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Diagnoses of HIV Infection among Persons Aged 13
Years and Older, by Sex and Age Group,
2011United States and 6 Dependent Areas

• Note. Data include persons with a diagnosis of
  HIV infection regardless of stage of disease at
  diagnosis. All displayed data have been
  statistically adjusted to account for reporting
  delays, but not for incomplete reporting.

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Diagnoses of HIV Infection among Adolescent and
Young Adult Males, by Age Group and Transmission
Category 2011United States and 6 Dependent Areas
1319 years 1319 years 2024 years 2024 years
Transmission category No. No.
Male-to-male sexual contact 1,664 92.8 6,354 90.8
Injection drug use (IDU) 23 1.4 117 1.7
Male-to-male sexual contact and IDU 37 2.1 232 3.3
Heterosexual contacta 67 3.7 294 4.2
Otherb 0 0.0 0 0.0
Total 1,794 100 6,998 100

• Note. Data include persons with a diagnosis of
  HIV infection regardless of stage of disease at
  diagnosis. All displayed data have been
  statistically adjusted to account for reporting
  delays and missing transmission category, but not
  for incomplete reporting.
• a Heterosexual contact with a person known to
  have, or to be at high risk for, HIV infection.
  
• b Includes hemophilia, blood transfusion,
  perinatal exposure, and risk factor not reported
  or not identified.

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Diagnoses of HIV Infection among Adolescent and
Young Adult Females, by Age Group and
Transmission Category 2011United States and 6
Dependent Areas
1319 years 1319 years 2024 years 2024 years
Transmission category No. No.
Injection drug use 37 7.0 101 8.8
Heterosexual contacta 485 92.7 1,041 91.2
Otherb 0 0.3 0 0.0
Total 523 100 1,142 100

• Note. Data include persons with a diagnosis of
  HIV infection regardless of stage of disease at
  diagnosis. All displayed data have been
  statistically adjusted to account for reporting
  delays and missing transmission category, but not
  for incomplete reporting.
• a Heterosexual contact with a person known to
  have, or to be at high risk for, HIV infection.
  
• b Includes blood transfusion, perinatal exposure,
  and risk factor not reported or not identified.

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Global Epidemic

• About 6,300 new HIV infections occurred each day
  in 2012
• About 95 were in low- and middle-income
  countries
• About 700 were in children under 15 years of age
• About 5,500 were in adults aged 15 years and
  older, of whom
• Almost 47 were among women
• About 39 were among young people aged 15-24
• (Source WHO/UNAIDS 2013)

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Disparate HIV/STI Rates Among Young Women

• Of all young people(15-24) living with HIV (about
  5 million), 75 are in sub-Saharan Africa
• 71 of these are female, and they average only
  2.3 sex partner in their lifetime
• Yet they are 2 to 8 times more likely than male
  counterparts to be HIV positive
• In the US, young people acquire nearly ½ of new
  STIs
• In 2010, women 15-19 were 3 times more likely
  than male counterparts to have chlamydia

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Conceptualization

• HIV and STIs are pathogens that are transmitted
  between individuals in the course of certain
  practices (and behaviors) that occur in social
  contexts.
• These practices are both influenced by, and
  themselves shape core elements of social
  organization, such as norms, values, networks,
  and institutions.
• As such, risk of and resilience to HIV/STI among
  young people (or anyone) is a function of dynamic
  social processes.

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Bronfenbrenners Ecological Systems Theory (1979)
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Ecological Framework

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Social Drivers of HIV

• UNAIDS (2007) Definition The social and
  structural factors, such as poverty, gender
  inequality, and human rights violations that are
  not easily measured that increase peoples
  vulnerability to HIV infection.
• Auerbach, et al. (2011) Definition The core
  social process and arrangementsreflective of
  social and cultural norms, values, networks,
  structures and institutionsthat operate around
  and in concert with individual behaviors and
  practices to influence HIV epidemics in
  particular settings.

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Social Determinants of Health (WHO Public
Health Reports)
The social determinants of health are the
conditions in which people are born, grow, live,
work and age, including the health system. These
circumstances are shaped by the distribution of
money, power and resources at global, national
and local levels, which are themselves influenced
by policy choices. The social determinants of
health are mostly responsible for health
inequities - the unfair and avoidable differences
in health status seen within and between
countries. (Emphasis added).
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The HIV Risk Environment

• Levels
• Macro
• Micro
• Types
• Physical
• Social
• Economic
• Policy

Adapted by Strathdee et al., 2010, from Rhodes
1999 and Glass and McAttee 2006
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Key Features of Social Determinants/Drivers/Factor
s

• Not unilateral variables with causal, one-to-one
  linkages
• Interactive phenomena reflective of social
  processes
• Complex, fluid, non-linear, contextual
• Interact dynamically with biological,
  psychological, behavioral, and other social
  factors
• Must be characterized situationally and
  contextually

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Examples

• Gender Inequality
• E.g. Gupta et al. 2008 Krishnan et al. 2008
  UNAIDS 2007 Obermeyer 2006 Phillips 2011
• Poverty/Wealth
• E.g. Gilles et al 1996 Hallman 2005 Weiser et
  al 2007 Shelton et al 2005 Chin 2007 Mishra et
  al. 2007 Fox 2010 Fox 2011

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World Health Organizations Commission on Social
Determinants of Health Conceptual Framework
Source Solar O, and Irwin A (2010)
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Framework for Analysis of Determinants of Child
Wellbeing
Macro actions
Micro actions
Domains Systems, institutions policy processes Actions actors Actions actors
Political, historical economic e.g. Reproductive choice Parental choice Sex discrimination Gender equality Implementation of human rights frameworks Violence and conflict Early marriage Education access for girls Advertising to children
Demographic, geographic environment e.g. Reproductive choice Parental choice Sex discrimination Gender equality Implementation of human rights frameworks Violence and conflict Early marriage Education access for girls Advertising to children
Governance human rights e.g. Reproductive choice Parental choice Sex discrimination Gender equality Implementation of human rights frameworks Violence and conflict Early marriage Education access for girls Advertising to children
Social, cultural norms e.g. Reproductive choice Parental choice Sex discrimination Gender equality Implementation of human rights frameworks Violence and conflict Early marriage Education access for girls Advertising to children
Social, cultural norms gtgt Direct effect gtgt Direct effect
Approaches - Life course, Interdisciplinary, Inter-sectoral Approaches - Life course, Interdisciplinary, Inter-sectoral Approaches - Life course, Interdisciplinary, Inter-sectoral Approaches - Life course, Interdisciplinary, Inter-sectoral
Mechanisms - Research, evidence, policy and programs Mechanisms - Research, evidence, policy and programs Mechanisms - Research, evidence, policy and programs Mechanisms - Research, evidence, policy and programs
Systems Health Education Public admin Child
protecn Social protection
Public - Private
Community - Family - Individual
Institutions Religious Media Markets Human Rights
Child Well being
Material - Relational - Subjective
Policy processes Legislation Taxation Public
Policy Gender equality
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Pathways of association between IPV and womens
risk of HIV infection (from C. Watts 2012)
PROXIMATE DETERMINANTS OF PERPETRATION OF
INTIMATE PARTNER VIOLENCE BY PARTNER
Early experiences or witnessing of violence

Partner physical and/or sexual intimate
partner violence
Physical
Sexual
Woman has concurrent sexual partners
Partner has concurrent sexual partners
PROXIMATE DETERMINANTS OF HIV RISK FROM PARTNER
Genital trauma
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Where to Enter the Causal Chain Most Macro?
Labor Migration
STI/HIV Transmission
Colonialism
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Operationalization

• Structural approaches must begin with
  understanding of
• Level targetedspecific group of individuals or
  broader social, legal, economic environment.
• Extent to which fundamental behavioral patterns
  are seen as fixed or changeable.
• Interventions may be ameliorative or
  fundamental, targeting proximal or distal risk
  factors, respectively
• (See, e.g., Gupta et al. 2008 Blankenship et al.
  2006 Cohen 2000 Coates et al. 2008)

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Fundamental vs. Ameliorative

• Health policymakers concerned with broad social
  conditions as causes of disease should regard
  with skepticism interventions that focus only on
  intervening variables but claim to address the
  broader social condition. Even an effective
  intervention that addresses the identified risk
  factor will, in the long run, fail to eliminate
  the effect of a fundamental social condition. In
  a changing state of affairs, the resources that
  accrue to the more advantaged allow them to
  regain the health advantage that may have been
  dented temporarily by the intervention. . . . If
  one wishes to address fundamental social causes,
  the intervention must address inequality in the
  resources that fundamental causes entail.
• Bruce G. Link and Jo Phelan, Social conditions as
  fundamental causes of disease. Journal of Health
  and Social Behavior 1995 (Extra Issue)80-94.

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Proximal and Distal Determinants
Source Robert Black, UNICEF Office of Research
Meeting, Florence, July 2012
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School Determinants

• Physical and Structural Environment
• activity space, physical safety, air quality,
  hazardous environments, rural/urban location
• Health Policies
• Policies for health education and school safety
• Health Programs
• Nutrition, physical education, prevention/interven
  tion, health services
• Health Resources
• Availability of nurses, mental health
  professionals and physical specialists, links
  between school and community health resources
• School Climate
• Violence/bullying, school norms, academic values,
  teacher-student relationships, family-school
  connections
• School Composition
• Average pupils SES, student and staff gender and
  racial/ethnic composition, school size
• (Huang, Cheng, Theise, PHR Vol 128 Suppl 3,
  2013)

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Proximal Influences Relevant to Adolescents
(DiClemente, Salazar, and Crosby 2007)
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Recent Publications on Social/Structural
Approaches Interventions

• Addressing social determinants of health in the
  prevention and control of HIV/AIDS, viral
  hepatitis, sexually transmitted infections, and
  tuberculosis.
• Dean HD, Fenton KA. Public Health Reports 2010
  Jul-Aug 125 Suppl 41-5.

• Structural approaches to HIV prevention.
• Gupta GR, Parkhurst JO, Ogden JA, Aggleton P,
  Mahal A. Lancet 2008 372 76475

• Transforming social structures and environments
  to help in HIV prevention. Auerbach J. Health
  Affairs 2009 Nov-Dec28(6)1655-65.

• Structural interventions for HIV prevention in
  the United States.
• Adimora AA, Auerbach JD. JAIDS. 2010 Dec 1555
  Suppl 2S132-5.

Addressing social drivers of HIV/AIDS for the
long-term response Conceptual and methodological
consideration Auerbach JD, Cáceres CF, and.
Parkhurst JO , Global Public Health 2011 (Sppl
3)S293-S309.
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Aims of Social/Structural Interventions

• Policy-Legal Changes
• Criminalization of homosexuality
• Criminalization of drug user/users
• Marriage, property inheritance rights
• Sex trafficking
• Environmental Enablers
• Access to and affordability of services
• Educational economic opportunities
• Shifting Harmful Social Norms
• Gender/sexuality discrimination violence
• Catalysis of Social Political Change
• Adopting human(including child) rights frame
  building civil society capacity
• Empowerment of Communities
• Advocacy among PLWHA
• Community engagement in research
• (Auerbach, 2009 Vincent, 2009)

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Examples of Structural Interventions

• Policy
• Expanding syringe access, e.g., by removing the
  ban on federal funding for syringe exchange
• Legalizing same-sex marriage
• Economic
• Requiring insurance companies to cover HIV
  testing
• Providing conditional/other cash transfers
• Social
• Normalizing comprehensive sex education in
  schools
• Implementing anti-stigma and anti-bullying
  programs
• Physical
• Removing doors in sex clubs

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Appropriate Methods for Social-Level Approaches

• Experimental Quasi-Experimental
• Observational
• cohort, case-control, cross-sectional, ecologic
• Qualitative Quantitative Social Science Methods
• survey, interview, focus group, participant
  observation, life histories or narratives, case
  studies, policy or content analysis, network
  mapping, mathematical modeling
• Program Monitoring Evaluation
• process, outcome, indicators
• Operations Research/Implementation Science

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Steps in Designing Social/Structural
Interventions for HIV Prevention

• Assess social and structural factors that may
  shape risk behaviors in target population
• Identify/hypothesize sociologically plausible
  causal chains
• Identify levels of possible influence in line
  with scope and aim
• Make explicit any assumptions about social
  influences
• Build in rigorous and appropriate evaluation
  mechanisms.

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Program, Practice, Policy Applying Social
Determinants of Health to Public Health Practice

• PHR Vol 128 Supplement 3, Nov/Dec 2013

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Key Points

• Efforts to combat HIV need to engage underlying
  socio-cultural drivers/determinants.
• Upstream factors veer apparently far from HIV
  infection and are historically intractable
  problems (e.g., gender and sexual violence,
  economic inequities, stigma and discrimination,
  colonialism, etc.).
• Where does one enter in the causal chain?
• Drawing causal linkages between
  drivers/determinants and HIV/STI is complicated
  by
• Complex, nonlinear and interactive relationships
  between drivers/determinants and HIV
• Importance of specific local contexts.
• Non-traditional methods/approaches required
• Start from place of sociological plausibility
• Draw from epidemiological as well as social
  science data.
• Observational, modeling, triangulated methods
  tell stories of what worked and can work
• Social changeincluding in researchis inherently
  political.

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