Social/environmental change

The final model assumes that there are broad structural factors which shape or constrain the behaviour of individuals. Without seeking to change the root causes or structures that affect individual risk and vulnerability to HIV, individually focused interventions will be unable to achieve real change.

The model suggests that influencing social policy, the legal environment, economic structures and the medical infrastructure are some of the key routes to achieving change. This model proposes the necessity of working with social groups, not individuals, and is the theoretical underpinning for activism, advocacy and political lobbying.

Friedman and Des Jarlais,¹ amongst many others, have argued that it is only by reference to social factors that we can understand differences in HIV prevalence amongst different ethnic groups of injecting drug users in the US.

Numerous studies have found that various environmental factors are associated both with high levels of risk behaviour and high levels of HIV infection.

These range from:

• factors that could be influenced by economic improvement, such as the poverty that drives some women and men into sex work
• factors that could be influenced by legislative change, such as laws which criminalise needle exchange, sex work or sex between men
• factors that can be influenced by cultural change or education programmes, such as stigma against people with HIV in the general population or in bodies like the police.

Gupta and colleagues suggest² that an analysis of how social, political, economic and environmental factors relate to risk is the starting point for planning interventions. For example, gender inequality may be theorised to increase unprotected sex through more than one causal chain - women are economically dependent on men, so feel unable to negotiate condom use because they fear being abandoned by their partner. In addition, fear of violence by men leads to women being unable to negotiate condom use.

Interventions need not aim to achieve total change with regard to gender inequality, but can identify points in a causal pathway where change may be achieved. For example, interventions may aim to help women be more economically independent, uphold women’s property rights in cases of domestic abuse, prosecute men who inflict violence or provide havens for women who have experienced violence.  

It is beyond the remit of this book to investigate the social drivers of HIV in detail or action that has shown evidence of producing, as at least one of its outcomes, a reduction in HIV infections. Moreover, one of the problems with investigating social change as a driver of changes in HIV incidence, and devising studies to measure the efficacy of specific measures, is that there is a very long chain of causation between social changes being made and health outcomes, with many intervening links.

The social-change model is influential in setting the agenda for HIV prevention and social change is regarded as essential as a prerequisite for tackling epidemics in certain populations. However, social change may not be sufficient in itself to produce a reduction in HIV incidence and may sometimes have paradoxical effects. For example, decriminalising drug users or MSM may lead to more people adopting behaviours that risk HIV infection. Taking account of individual vulnerabilities and skills deficits will also continue to be an essential part of HIV prevention.