The AAA's Commission on AIDS Research and Education seeks to expand intervention research and programs that include examination of risk within its social, economic, and cultural context. We endorse recent calls for a focus on "vulnerability" to risk and support efforts to address "structural and enabling approaches" to HIV prevention. HIV intervention programs have traditionally focused on individuals, and research and evaluations of individual level intervention programs have continued for more than a decade. We call for a shift in focus from the individual to the community to understand the broader setting within which individual risk occurs. This change in focus will enable us to identify social and contextual risk factors that predispose individuals and communities to HIV and to develop more effective intervention programs.
It is clear that individual-level risk reduction programs can only have limited effect without fundamental changes in the social and economic conditions of vulnerable persons and populations. With the AIDS epidemic increasingly focused in the poorest countries in the world and in the poorest communities in developed nations, there is increased urgency to address the broader social and economic factors that create vulnerability for persons and communities. Paramount among these factors is poverty and inequality which impact on exposure to risk and on the capacity for risk reduction as well as access and utilization of health care.
While many public health advocates acknowledge the importance of social and economic factors, including poverty and inequality, to health, most feel understandably frustrated and powerless to act on this knowledge. Because of the public health emergency posed by the AIDS epidemic, the focus has been on programmatic solutions to decrease individual risk. We believe that it is time to overcome our institutional paralysis and proceed to conduct research and implement interventions that will address the contextual factors that impede further progress in HIV risk reduction.
The value of community level approaches is recognized in biomedicine as evidenced from interventions such as vaccines. It is the value of vaccines in controlling infection at the community level that drives the success of vaccine programs. Indeed, immunization programs are generally designed to maximize indirect effects on transmission. With respect to HIV, consider the community study of STD treatment in Mwanza, Tanzania. Although not directed at HIV control per se, the attention to STD control at the community level resulted in a decline in HIV rates. Population structure, social networks, and community linkages have all been successfully included as parameters in such studies.
To this end we make the following specific recommendations:
2. Current funding and research systems must be altered to accommodate research within the three emergent N's of AIDS risk reduction: networks, neighborhoods, and natural groups. This will require rethinking standards for research design, including appropriate outcome measures and ways of evaluating success at the community level. We argue, however, that situating research and intervention programs in communities will move us forward in addressing the contextual factors in the epidemic.
3. There must be expansion of research on the role of structural factors, including economic and social inequities in creating vulnerability to risk. The goal should be to move beyond "one size fits all" interventions to tailor interventions to specific situations. For example, structural factors that may impede risk reduction can range from relatively simple factors, such as access to affordable condoms, to more sweeping goals, such as social justice.
4. Current HIV/AIDS research methodology focuses on experimental designs. Although experimental designs provide higher reliability, this comes at the expense of validity. It is important to integrate ethnographic methods into experimental designs to test validity of the designs' outcome. Ethnography is a methodology for studying human behavior of individuals and groups of individuals in natural contexts. Ethnography, combined with epidemiology, has been successfully used to test the validity of experimental designs. It is important, also, that we develop evaluations on the impact of prevention and HIV care service on hard to reach populations or populations not served by current interventions.
5. It will be important to rethink how outcomes are measured. Community-level interventions may not permit specification of a single outcome in advance but may require delineation of a range of possible outcomes. Therefore we need to be prepared to respond to new and unexpected opportunities for intervention.
6. A disadvantage that such structural and enabling approaches face in the funding domain is that evaluation of outcome is often indirect. Research is urgently needed to devise ways to evaluate community level interventions so that decisions can be made regarding which interventions have the most significant and lasting effects both at the level of the individual and the community.
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