Jessica Ogden

Structural approaches to HIV prevention

Recognition that social, economic, political, and environmental factors directly affect HIV risk and vulnerability has stimulated interest in structural approaches to HIV prevention. Progress in the use of structural approaches has been limited for several reasons: absence of a clear definition; lack of operational guidance; and limited data on the effectiveness of structural approaches to the reduction of HIV incidence. In this paper we build on evidence and experience to address these gaps. We begin by defining structural factors and approaches. We describe the available evidence on their effectiveness and discuss methodological challenges to the assessment of these often complex efforts to reduce HIV risk and vulnerability. We identify core principles for implementing this kind of work. We also provide recommendations for ensuring the integration of structural approaches as part of combined prevention strategies.

Adherence to tuberculosis treatment: lessons from the urban setting of Delhi, India

The Revised National Tuberculosis Control Programme (RNTCP), which incorporated the WHO DOTS strategy * was introduced in India in the mid‐1990s. An operational research project was conducted between 1996 and 1998 to assess the needs and perspectives of patients and providers in two chest clinics in Delhi, Moti Nagar and Nehru Nagar, during the introduction of the new strategy. This paper reports on the findings of the project, concentrating on information collected from 40 in‐depth interviews with patient defaulters and from non‐participant observations in clinics and directly observed treatment centres. In Moti Nagar chest clinic, 117 of 1786 (6.5%) patients and 195 of 1890 (10%) patients in Nehru Nagar left care before their treatment was complete. It was argued that the reasons for default stem from a poor correlation between patient and programme needs and priorities, and from particular characteristics of the disease and its treatment. Patient needs that were not met by the health system included convenient clinic timings, arrangements for the provision for treatment in the event of a family emergency and provision for complicated cases like alcoholics. The problems facing the provider were poor interpersonal communication with the health staff, lack of attention and support at the clinic, difficulty for patients to re‐enter the system if they missed treatment and, in certain areas, long distances to the clinic. Problems related to diseases were inability of the staff to deal with drug side‐effects, and patients’ conception of equating well‐being with cure. Simple, practical measures could improve the provision of tuberculosis (TB) treatment: more flexible hours, allowances for poor patients to reach the clinics and training health care staff for respectful communication and monitoring drug side‐effects. The findings indicate a need to rethink the label of ‘defaulter’ often given to the patients. The important areas for future operational research is also highlighted.

Moving forward on women's gender-related HIV vulnerability: The good news, the bad news and what to do about it

The global response to AIDS has triggered unprecedented attention to gender inequality and the role it plays in shaping the vulnerability of women. Tragically, however, this attention has not yet led to wide-scale transformations in gender roles, or reductions in gender-related risk. This paper reviews both knowledge and action on the impact of gender inequality on women in the context of HIV prevention, and argues that, while much is known, and while effective strategies do exist, impact on a population level will not be achieved unless gender considerations are integrated into an evidence-informed comprehensive national strategy. Such a strategy must be implemented by national governments within an enabling policy and legal environment for change; be driven and owned as much as possible, by communities who are empowered with skills and resources to put their own ideas and capabilities into action; and include people living with HIV as equal partners.

Improving tuberculosis control - social science inputs.

Abstract Public health has for long been dominated by the notion of ‘control’. However, social science research on tuberculosis in the tropics indicates that policies and programmes that take ‘control’ as their primary focus may fail to meet the health needs of patients and their communities. It is proposed that research and programmes meet the public health goal of lowering the prevalence of disease in populations by forging and cementing partnerships which take the support and care of patients as their focus. These will be partnerships between researchers in the North and the South, between research and programmes/policy, between outside ‘experts’ and communities themselves and between (public) health and other social service sectors. Social science approaches to operations research in tuberculosis are outlined, and data from a recent project in New Delhi are introduced.

Identifying the determinants of tuberculosis control in resource-poor countries: insights from a qualitative study in The Gambia

Despite the availability of effective treatment, tuberculosis (TB) remains a major cause of death from an infectious disease in the world, particularly in resource-poor countries. Among the chief reasons for this are deficiencies in case tracing and in adherence to treatment. In order to investigate the contribution of non-biological factors to these deficiencies, we carried out a qualitative study in The Gambia, West Africa, from October 2000 to March 2001. The methods used were focus group discussions, interviews, participant and non-participant observation, and case histories. Four domains were distinctively investigated: the TB patients, the community, the health care providers (including programme staff), and the donors and policy makers. Analysis of the data from all these sources indicated the contribution of a wide range of socio-anthropological factors which influence the success or otherwise of the TB control programme in The Gambia, i.e. gender, urban/rural residence, recourse to traditional healers, adherence to national health policies, knowledge about TB, migration, and socio-economic factors. It is concluded that all these factors must be taken into account in formulating interventions to improve detection of TB cases and patient adherence to treatment within the framework of the national TB control programmes, and proposals have been made for targeted interventions.

Missed opportunities? Coercion or commitment: policies of prevention.

Abstract: The DOTS strategy (directly observed therapy, short course) has been the cornerstone of international TB control policy since the early 1990s. This strategy has provided the international community with an advocacy tool to harness funds for TB as well as a method for helping country programs to achieve high cure rates for TB. But as much as the strategy is seen as successful by some, it is perceived as unsuccessful by others. This paper looks at the results of the introduction of DOTS into control programs and discusses research relating to direct observation of treatment. It asks how policies like DOTS are created, and how they are administered and transferred from the international to the national and finally to the local level. The discipline of public health policy is used to interrogate the creation and history of the DOTS strategy in order to find ways of aiding the transfer of the policy to national and local levels. Finally, the paper asks whether the concepts of “control” and “elimination” continue to be useful in the management of infectious diseases. We ask whether it is time to change the perspective to policies that focus more on the context of implementation and the importance of the development of care, integration, and flexibility rather than cure, targets, and short‐term solutions.

Health systems and the implementation of disease programmes: Case studies from South Africa.

Abstract This paper analyses the transfer and implementation of two internationally formulated infectious disease strategies in South Africa, namely, directly observed therapy (DOTS) for TB and syndromic management (SM) for sexually transmitted infections (STIs). Using the tools of policy analysis, this paper seeks to draw conclusions from contrasting experiences with the two strategies. DOTS and SM differ with respect to styles of engagement by World Health Organization (WHO), the international agency promoting the ideas, in the following ways: continuity and networking between policy makers, practitioners and researchers nationally; and approaches to sub-national implementation. We show how these factors may have been important to national uptake, and conclude on the need for a context sensitive approach to policy transfer and a balance between bottom-up and top-down implementation strategies. These insights may have relevance for the current global wave of treatment programmes for HIV and other infectious diseases.

Revolutionising the AIDS response

Individual behaviour change interventions and technological approaches to HIV prevention can only be effective over time if the broader social environment in which health-related decisions are made facilitate their uptake. People need to be not only willing but also able to take up and maintain preventive behaviours, seek testing, treatment and care for HIV. This paper presents findings and recommendations of the Social Drivers Working Group of the aids2031 initiative, which focus on how to ensure that efforts to address the root causes of HIV vulnerability are integrated into AIDS responses at the national level. Specific guidance is given on how to operationalise a structural approach.

Looking back, moving forward: Towards a game-changing response to AIDS

The aids2031 consortium was initiated by UNAIDS in 2007 to consider lessons from the AIDS response of the prior three decades and to make recommendations for the subsequent two. The aids2031 consortium was not about what we should do in 2031 but what we should do differently now to change the face of the pandemic by 2031 -- 50 years from the discovery of the first cases of AIDS. The initiative convened nine multi-disciplinary working groups to ‘question conventional wisdom stimulate new research and spark public debate. This Special Supplement synthesises findings of the group concerned with understanding the key political social and economic ‘drivers’ -- or determinants -- of HIV and AIDS. The aim of the Social Drivers Group was to illustrate how HIV epidemics interact with social (cultural political and economic) factors and to advise policy-makers and planners on how to address these factors to achieve their HIV prevention care and treatment objectives. The Social Drivers Group undertook this work between 2007 and 2009 through white papers workshops and public conversations each of which addressed social determinants from a unique standpoint. A key message emerging from these activities is that a successful shift in emphasis from individualised approaches to prevention care and treatment to approaches that take key structural determinants of vulnerability (and resilience) into account will be the critical ‘game changer’ that the AIDS response has been seeking. Such a shift must occur in local- and national-level action not just in international discourse and policy. (Excerpts)

Commentary on 'the resurgence of disease: social and historical perspectives on the 'new' tuberculosis'

Gandy and Zumla offer a contribution to a burgeoning debate within the tuberculosis (TB) community and public health more generally around the need for interdisciplinarity in research and intervention. Their paper provides further evidence of an apparent consensus among those working in TB which is based on the understanding that research and intervention efforts would become more effective by using the whole range of perspectives and approaches available within the academy. The key issue in TB control is not whether researchers should become more inter-disciplinary or whether social science is important or even whether the directly observed treatment short course strategy is the answer. The real issue is how care is delivered to patients. Much can be gained through thoughtful application of care communication and social justice. There should be a shift in perspective from a focus on the microbe to a focus on the terrain; from standardized short term interventions with an emphasis on outputs to an approach that is responsive to context with longer term objectives and a focus on process. This will assist in the integration of technical advances with the truly old fashioned human aspects of disease control that emphasize relationship community partnership and care.