This document summarizes strategies discussed at an AIDS2031 working group meeting around addressing social and structural drivers of HIV. The group discussed (1) taking a more holistic, contextual view of social drivers that interact in complex ways, (2) shifting from individual-level to collective approaches, and (3) moving beyond short-term HIV targets to long-term social transformations. They also outlined approaches to nurturing AIDS resilience at individual and community levels and 6 strategic actions including better understanding local epidemics, community involvement, long-term funding, and multisectoral partnerships.
1. STICK IT TO THE
STRUCTURES!
New approaches to social and structural drivers
of HIV among MSM in Canada
Len Tooley, MPH
Dalla Lana School of Public Health, University of Toronto
2012 BC Gay Men’s Health Summit
Nov. 2, 2012
2. STICK IT TO THE
STRUCTURES!
Let’s get a move on to address HIV among
folks in the masculine realm of the gender
multiverse who do and/or love each other
Lenora Ramona Lovelace II
2012 BC Gay Men’s Queer Utopia
5. THE CLEAR AND PARADOXICAL
PATTERN
Black MSM were more likely than other MSM to
report any preventive behaviour against HIV infection
condom use
HIV testing
fewer sex partners
less amphetamine use
less drug use before or during sex
disclosure of HIV status to sex partners
(Millett et al., 2012)
6. BLACK MSM ALSO HAD…
…a three-fold greater odds
of testing HIV positive…
…a six-fold greater odds of
having undiagnosed HIV
infection compared with other
MSM…
(Millett et al., 2012)
7. AHA!
Disparities in HIV clinical care access and use, low
income, unemployment, incarceration, low education
access
“rather than disparities in sexual and substance-use risk
behaviours”
affect availability and choice of sex partners and localize sexual
networks to neighbourhoods with a high background HIV
prevalence and community viral load, raising infection risks
(Millett et al., 2012)
9. aids2031 is a consortium of partners who have come
together to look at what we have learned about the AIDS
response as well as consider the implications of the changing
world around AIDS.
Numerous working groups (Costs and Financing,
Leadership, Programmatic Response, and more)
Social Drivers Working Group
• Judith Auerbach, Dave Bell, Carlos Cáceres, Caitlin Chandler, Ellen
Foley, Anne Hendrixson, Kimberly Keller, Anne Murenha, Jessica
Ogden, Justin Parkhurst, Barbara Thomas-Slayter, and Ann Warner
10. THINKING BROADLY ABOUT
WHERE WE’RE AT
Behavioural interventions can work (Sullivan et al., 2012)
Biomedical interventions can work (de Wit et al., 2011)
But our efforts to date, while essential,
have not been sufficient.
11. “After 25 years of AIDS it has
become abundantly clear that
the epidemic thrives on social
inequality and marginalization,
at the root of which are
imbalances in power
relations.”
aids2031.org
15. If
GAY SEX/LOVE → DANGER
does
DANGER = SEXY?
(Carballo-Diéguez et al., 2011)
16. NEW APPROACHES
1. Re-orienting our approaches to social and
structural drivers: four key concepts
2. Nurturing AIDS Resilience
3. Strategic Actions
18. #1: RE-ORIENTING OUR
UNDERSTANDING OF SOCIAL
AND STRUCTURAL DRIVERS
• Complex
• Fluid
• Non-linear
• Contextual
• Interact with biological,
psychological, behavioural,
and other social forces
19. EXAMPLES
Links between:
• Depression and ‘risky sex’
• Gender inequality and HIV incidence (Auerbach et al., 2011)
• Criminalization of same-sex behaviour and HIV incidence
(Altman, et al, 2012)
Syndemics and resilience (Stall et al., 2008)
Positive marginality (Meyer et al., 2011)
Auerbach et al. (2011) conclude that language must shift to “discussing
how, in what circumstances, and for whom particular combinations of
factors contribute to HIV vulnerability (or, conversely, resilience)”
20. #2: FROM THE INDIVIDUAL TO
THE COLLECTIVE
“Individual capacities are intimately tied
to the enabling (or disabling) character of
social norms, practices and institutions”
(Kippax, 2012)
21. #3: RE-VISIONING GOALS FROM
SHORT-TERM HIV-FOCUSED
TARGETS TO LONG-TERM SOCIAL
TRANSFORMATIONS
• Importance vs. urgency
• Are there measures other than HIV prevalence and
incidence, community viral load, etc. that we can take
into account?
23. Structural:
Policies that require enhanced sex ed in
high school curricula
Community:
Community activism & group-level norms
around safer sex strategies
Organizational:
Outreach works at ASOs trained to reach
out & educate specific populations &
distributing condoms
Behavioural:
Condom use and other safer sex strategies
Biomedical:
Insertive/receptive condoms and lube
24. Not
either / or
But
and / also /
all of the above
25. AIDS RESILIENCE
“a point at which individuals are effectively able to
manage the risks present in their environment”
(aids2031 Social Drivers Working Group, 2010).
26. AIDS RESILIENT INDIVIDUALS
• have the ability to increase the safety of their
practices
• can access services such as testing and
treatment
• assert their own desires and preferences
• can claim their rights without threat to
themselves, their partners or their families
28. AIDS-COMPETENT
COMMUNITIES (1 OF 2)
The knowledge and skills to prevent AIDS and a means
of translating this information into action in their own
lives;
Social spaces for dialogue and critical thinking so that
people can collectively renegotiate individual and social
norms that negatively impact the health and well-being of
the community;
A sense of agency, ownership and responsibility about
the response to the epidemic; (Campbell, 2009)
29. AIDS-COMPETENT
COMMUNITIES (2 OF 2)
A sense of solidarity and common purpose that
allows people to work together despite potentially
competing interests and to tackle the problem
collectively;
Access to bridging social capital that allows people
the ability to connect with and access resources from
outside communities or organizations that can
support them in their efforts against the epidemic.
(Campbell, 2009)
31. FOSTER INDIVIDUAL AGENCY (1
OF 2)
“the capacity of individual humans to act
independently and to make and act upon
their own decisions”
(aids2031 Social Drivers Working Group, 2010)
32. FOSTER INDIVIDUAL AGENCY (2
OF 2)
is intimately tied to the definition of enabling environments
in the sense that those environments must allow for people to
have “high levels of self-confidence, perceived self-efficacy, and
some sense of freedom and choice over one’s personal well-being
and welfare” (aids2031 Social Drivers Working Group)
it does not allow for one social goal to be placed too far above
others, it prevents the “sacrifice of broader social development
goals for the sake of HIV prevention
calls for “social valuation, which must be transparent and open
to debate”
(Parkhurst, 2012)
33. BUILD HEALTH-ENABLING
ENVIRONMENTS
Access to appropriate health and social
services
Economic empowerment
Freedom from discrimination and harassment
Gender equality
Human rights
Social capital
37. STRATEGIC ACTION #1
“Know your epidemic” by including routine
sociological assessments to identify and explore
those dimensions of social context that lead to
HIV vulnerability and risk; and as a matter of
urgency, invest in building the necessary capacity
for undertaking these assessments and analysing
the findings
(aids2031 Social Drivers Working Group, 2010)
38. STRATEGIC ACTION #1
Most of the research is focused in the three urban
centres of Canada
Introduce an MSM stream into the CIHR HIV/AIDS
Community-Based Research Program
Integrate sociologial assessments into M-track
39. STRATEGIC ACTION #2
Devolve planning and priority-setting
processes to ensure local relevance and
involvement of affected communities and civil
society organizations and networks, especially
those that include HIV positive persons and young
people.
(aids2031 Social Drivers Working Group, 2010)
40. STRATEGIC ACTION #2
Provincial gay men’s health summits & meetings
Ontario’s GMSH
Alberta Community Council on HIV
Gay men’s focused health promotion
organizations (HiM)
41. STRATEGIC ACTION #3
Link the integration of structural approaches to
budget lines that are sufficiently robust for
supporting substantial, long-term action and
project cycles of five to fifteen years or more.
(aids2031 Social Drivers Working Group, 2010)
42. STRATEGIC ACTION #3
Current funding structures are…
not conducive to an up-stream, community-based approach to gay
men’s health or HIV prevention.
limiting the types of knowledge we need to acquire
preventing us from doing upstream, structural research
not reflective of the nature of the work that is being done
not sustainable, leading to short-lived programs that need to re-invent
themselves regularly in order to continue functioning
(CATIE, 2010)
43. STRATEGIC ACTION #4
Develop a monitoring and evaluation
framework that will account for multi-
dimensional changes in the social, economic and
political environment alongside assessments of
HIV prevalence and incidence.
(aids2031 Social Drivers Working Group, 2010)
44. STRATEGIC ACTION #4
Statistics Canada
Canadian Community Health Survey
Census
M-Track
Sex Now
Male Call Canada
45. STRATEGIC ACTION #5
Strive toward and adhere to a minimum legal
standard and introduce processes to ensure
effective implementation, enforcement and
awareness of laws that reduce stigma and
protect human rights and equity.
(aids2031 Social Drivers Working Group, 2010)
46. STRATEGIC ACTION #6
Establish inter-sectoral AIDS coalitions to
integrate HIV efforts with broader health and
development approaches.
48. THANK YOU
Community-Based Research Centre
Professor Dan Allman (University of Toronto)
Chi Chung Lau, Colleague
Uncle Danny
49. REFERENCES
aids2031 Social Drivers Working Group. (2010). Revolutionizing the AIDS Response: Building AIDS Resilient
Communities (Synthesis Paper). aids2031.
Auerbach, J. D., Parkhurst, J. O., & Cáceres, C. F. (2011). Addressing social drivers of HIV/AIDS for the
long-term response: Conceptual and methodological considerations. Global Public Health, 6(sup3), S293–S309.
doi:10.1080/17441692.2011.594451
Campbell, C. (2009). Building AIDS Competent Communities: possibilities and challenges. aids2031 meeting.
Salzburg.
Carballo-Diéguez, A., Ventuneac, A., Dowsett, G., Balan, I., Bauermeister, J., Remien, R., Dolezal, C., et al.
(2011). Sexual Pleasure and Intimacy Among Men Who Engage in “Bareback Sex.” AIDS and Behavior, 15, 57
–65.
CATIE. (2010). New Directions in Gay Men’s Health and HIV Prevention in Canada: Pan-Canadian Deliberative
Dialogue Report, 2010 (p. 32). Retrieved from http://www2.catie.ca/en/resource/new-directions-gay-mens-
health-and-hiv-prevention-canada-pan-canadian-deliberative-dialogu-0
de Wit, J. B. F., Aggleton, P., Myers, T., & Crewe, M. (2011). The rapidly changing paradigm of HIV
prevention: time to strengthen social and behavioural approaches. Health Education Research, 26(3), 381–392.
doi:10.1093/her/cyr021
50. REFERENCES
Kippax, S. (2012). Effective HIV prevention: the indispensable role of social science. Journal of the International
AIDS Society, 15(17357), 1–8. doi:10.7448/IAS.15.2.17357
Meyer, Ilan H., Ouellette, S. C., Haile, R., & McFarlane, T. A. (2011). “We’d Be Free”: Narratives of Life
Without Homophobia, Racism, or Sexism. Sexuality Research and Social Policy, 8(3), 204–214.
doi:10.1007/s13178-011-0063-0
Millett, G. A., Peterson, J. L., Flores, S. A., Hart, T. A., Jeffries 4th, W. L., Wilson, P. A., Rourke, S. B., et al.
(2012). Comparisons of disparities and risks of HIV infection in black and other men who have sex with men
in Canada, UK, and USA: a meta-analysis. The Lancet, 380(9839), 341–348. doi:10.1016/S0140-6736(12)60899-
X
Stall, R, Friedman, M., & Catania, J. A. (2008). Interacting Epidemics and Gay Men’s Health: A Theory of
Syndemic Production among Urban Gay Men. In R. Wolitski, R. Stall, & R. O. Valdiserri (Eds.), Unequal
opportunity : health disparities affecting gay and bisexual men in the United States (pp. 251–274). New York: Oxford
University Press.
Sullivan, P. S., Carballo-Diéguez, A., Coates, T., Goodreau, S. M., McGowan, I., Sanders, E. J., Smith, A., et
al. (2012). Successes and challenges of HIV prevention in men who have sex with men. The Lancet, 380(9839),
388–399. doi:10.1016/S0140-6736(12)60955-6
Notes de l'éditeur
Wow, Sarah! That was amazing. Thank you so much for that work – it’s something our movement really needs and good to start looking for consensus. My name is Len Tooley and I come to this conference wearing a few different hats. I work at a national HIV organization called CATIE doing capacity building and knowledge translation, I do HIV testing and STI counselling with guys who love/do guys through Hassle Free Clinic in Toronto, and I just finished a degree in public health at the University of Toronto. Fortunately for me, I submitted a very academic abstract to the community-based research centre and – yay! – they accepted it. This presentation is actually baed on a paper I wrote to complete my degree. Unfortunately for the CBRC…
I’m also known as Lenora Ramona Lovelace the Second. To be honest, I think I’m actually the first, but I always like to hedge my bets and I figure if someone else says they claimed the title first second is still OK with me. My real presentation is called Stick it to the Structures! Let’s get a move on to address HIV among folks in the masculine realm of the gender multiverse who do and/or love each other. And while I’m being a bit facetious, I wanted to re-name my title because, well, I have a big, catholic, confession to make. That’s that I don’t actually identify as gay or as a man. I’m queer. And to me that means the sexual possibilities are so much more endless and for me that really works. I also don’t really like how the things I do are often either considered manly or feminine – because I think they’re actually just sorta gay. Or queer. So I really prefer the term genderqueer. That being said, I have a lot of sex with gay men. I work with gay men, I work for gay men. I even have had the words “gay men” in my job title. But I wanted to reflect the diversity of sexuality and gender orientations that sometimes we don’t really get to explore all that much, particularly in professional settings.
Now on to business…. So a few months ago, around the time of the international AIDS conference, there was this special edition of the lancet that specifically focused on HIV in Men who have sex with men. If you haven’t seen it, I highly suggest reading through it. It’s online so you can GOOGLE it.
In the issue, there was this awesome article called “ Comparisons of disparities and risks of HIV infection in black and other men who have sex with men in Canada, UK, and the USA: a meta-analysis” So a meta-analysis is basically where you take a bunch of studies, combine and compare them, and by looking at them all together come to new conclusions. Basically, they wanted to ask the question – why, in many parts of the world, are we seeing higher rates of HIV in black MSM than in other MSM? They basically looked at articles that had words relevant to race like black, african, caribbean, afro-, african-american. <Click> So they looked at Canada, the UK, and the USA and ended up including 174 studies from the US, 13 from the UK and…..7 from Canada. Waawaa. So, the funny thing is that Canada was actually different from the US and UK. They actually didn’t find much interesting stuff in Canada, so the data I’m going to be talking about is actually focused on the US and UK. But I promise, it’s worth looking at.
<CLICK> for CHECK MARK
So despite all their preventive behaviours, why do black MSM seem to be at higher risk of HIV?
Social Drivers Working Group: A number of leading social scientists who have been collaborating to revise and enhance our understanding of how social and structural drivers impact our experience of HIV as well as think about how we can address those drivers BASICALLY WHAT I AM GOING TO DO IS PRESENT THE KEY CONCEPTS THAT HAVE BEEN DEVELOPED THROUGH THIS INITIATIVE AND TALK ABOUT HOW THEY ALIGN WITH GAY MEN’S HEALTH.
But we know that some things DO WORK. But why haven’t they been sufficient? We’ve been exploring many different answers at this summit. <click> Is it that we just don’t have enough funding to make it work? <click> Is it that these things work but we just haven’t brought them up to the required scale? <click> Is it that they work but only for a period of time, and then they lose their effectiveness? <click> Is it that they work but just not well enough? We know that it’s actually probably a combination of all of these things.
OK, so we have to do better. But Lenora, you say, we *know* this already – we have already been talking about all these structural issues!
So let’s back up and look at one of the more commonly used models to think about HIV risk. This is called the socio-cultural model. Basically the model starts with Individual behaviour. But then it acknowledges that behaviours occur in a context. <Click> Relationships <Click> Community <Click> Social/Structural <Click> But the problem that some have levelled at this model is that, in the end, it all comes back to the individual. And that can have to major consequences. <click>
The first is shame. <CLICK> So as I mentioned I’m an HIV tester, and I do testing in a bathhouse in Toronto. I actually do the rapid test with the client sitting beside me, so we see the results together. And more often than not, when we move to exploring their feelings, a common theme of shame emerges. In other words, I should have known better and this is what I get for doing what I did. They say you only have 30 seconds to get information in to someone before they blank after getting a positive diagnosis. The one message I always try to convey is that HIV IS NOT YOUR FAULT. But there are many people who might not agree with me. <<MOVING ON>>
A second concern is the consequence of focusing on individual, RISKY behaviours. In a society where heterosexual unions are really priveleged and idealized <CLICK> When we have sexual or romantic thoughts for other men, often that is <CLICK> DANGEROUS. Socially dangerous. And so a few academics have picked up on the idea that…. <click>
<CLICK> for BB
So I’m going to talk about ways of moving forward in three sections. <READ SECTIONS>
First, how can we re-think or re-orient our approachs to social and structural drivers?
Note that I mentioned DRIVERS and I am not using the word DETERMINANTS any more.
Condoms are a great example of a biomedical tool that has seen interventiosn at all levels.
Condoms are a biomedical, behavioural, and structural intervention all at the same time Obviously condoms have not been the solution to HIV among gay/bi/MSM men – so it is probably arguable that even when all three are combined they are not sufficient That doesn’t mean things are hopeless, it just means we need more options at every level – biomedical, behavioural, and structural You can choose where you want to act and how you want to spend you time – but I would challenge everyone to question how they can support one another rather than rip each other’s approaches to shreds.
A further implication, and requirement of, structural interventions is how they “[highlight] the need for more prevention options” (de Wit et al., 2011, p. 3) both within and across different epidemic scenarios. Disrupting the distinctions between biomedical, behavioural and structural interventions is an important conceptual shift that provides the flexibility to tailor multi-faceted interventions that address the complex nature of different HIV epidemics. In order to do this effectively Hayes et al. (2010) emphasize that it is social sciences and community experience which are integral to tailoring programmes to local epidemics, such that interventions “be attuned to people’s life conditions, address all the interacting barriers to prevention and be delivered with the intensity and quality necessary to achieve intended effects” (p. S85). ny options open to me as possible when I think about managing HIV risk in my daily life.
Rather than a quality, a point.
AIDS resilience is cultivated by attempting to achieve three guiding objectives.
Compare last point to idea of syndemics and multi-sectoral collaboration
Ever since the introduction of HIV/AIDS, communities of GBMSM have picked up on the science of HIV and its transmission and utilized this to modify their sexual behaviours (translating information into action). Sullivan (2012) argues that historic examples of group-level behaviour change, such as the adoption of condoms by GBMSM in the 1980s, “…show that community-initiated strategies can have an important role in shaping of epidemics” (p. 390). Increasing amounts of research are beginning to acknowledge and study the practices that gay men are adopting with the hope that these practices will reduce their HIV risk (Mao et al., 2011; Philip, Yu, Donnell, Vittinghoff, & Buchbinder, 2010; Zablotska et al., 2009). These practices are generally called seroadaptation strategies, and an increasing number of them revolve around condomless sex.
GASP – Is Lenora talking about INDIVIDUALS in a SOCIAL STRUCTURAL DRIVERS presentation??
GASP – Is Lenora talking about INDIVIDUALS in a SOCIAL STRUCTURAL DRIVERS presentation??
In an analysis of representation of MSM over five years of annual Canadian Association for HIV/AIDS Research conferences (the largest HIV/AIDS research conference in Canada), Tooley (2012a) found that only 12% of abstracts made any mention of MSM, with 7% exclusively addressing MSM . Further, only 1.2% of all abstracts exclusively addressed HIV positive MSM (Tooley, 2012a) , who have accounted for 55.4% of all HIV positive test reports in Canada since 1985 (Public Health Agency of Canada, 2012a). MOST OF THE RESEARCH IS FOCUSED IN THE THREE URBAN CENTRES OF CANADA INTRODUCE AN MSM STREAM INTO THE CIHR HIV/AIDS COMMUNITY-BASED RESEARCH PROGRAM INTEGRATE SOCIOLOGIAL ASSESSMENTS INTO M-TRACK
iN an analysis of representation of MSM over five years of annual Canadian Association for HIV/AIDS Research conferences (the largest HIV/AIDS research conference in Canada), Tooley (2012a) found that only 12% of abstracts made any mention of MSM, with 7% exclusively addressing MSM . Further, only 1.2% of all abstracts exclusively addressed HIV positive MSM (Tooley, 2012a) , who have accounted for 55.4% of all HIV positive test reports in Canada since 1985 (Public Health Agency of Canada, 2012a). MOST OF THE RESEARCH IS FOCUSED IN THE THREE URBAN CENTRES OF CANADA INTRODUCE AN MSM STREAM INTO THE CIHR HIV/AIDS COMMUNITY-BASED RESEARCH PROGRAM INTEGRATE SOCIOLOGIAL ASSESSMENTS INTO M-TRACK
MOST OF THE RESEARCH IS FOCUSED IN THE THREE URBAN CENTRES OF CANADA INTRODUCE AN MSM STREAM INTO THE CIHR HIV/AIDS COMMUNITY-BASED RESEARCH PROGRAM INTEGRATE SOCIOLOGIAL ASSESSMENTS INTO M-TRACK
iN an analysis of representation of MSM over five years of annual Canadian Association for HIV/AIDS Research conferences (the largest HIV/AIDS research conference in Canada), Tooley (2012a) found that only 12% of abstracts made any mention of MSM, with 7% exclusively addressing MSM . Further, only 1.2% of all abstracts exclusively addressed HIV positive MSM (Tooley, 2012a) , who have accounted for 55.4% of all HIV positive test reports in Canada since 1985 (Public Health Agency of Canada, 2012a). MOST OF THE RESEARCH IS FOCUSED IN THE THREE URBAN CENTRES OF CANADA INTRODUCE AN MSM STREAM INTO THE CIHR HIV/AIDS COMMUNITY-BASED RESEARCH PROGRAM INTEGRATE SOCIOLOGIAL ASSESSMENTS INTO M-TRACK
iN an analysis of representation of MSM over five years of annual Canadian Association for HIV/AIDS Research conferences (the largest HIV/AIDS research conference in Canada), Tooley (2012a) found that only 12% of abstracts made any mention of MSM, with 7% exclusively addressing MSM . Further, only 1.2% of all abstracts exclusively addressed HIV positive MSM (Tooley, 2012a) , who have accounted for 55.4% of all HIV positive test reports in Canada since 1985 (Public Health Agency of Canada, 2012a). MOST OF THE RESEARCH IS FOCUSED IN THE THREE URBAN CENTRES OF CANADA INTRODUCE AN MSM STREAM INTO THE CIHR HIV/AIDS COMMUNITY-BASED RESEARCH PROGRAM INTEGRATE SOCIOLOGIAL ASSESSMENTS INTO M-TRACK
MOST OF THE RESEARCH IS FOCUSED IN THE THREE URBAN CENTRES OF CANADA INTRODUCE AN MSM STREAM INTO THE CIHR HIV/AIDS COMMUNITY-BASED RESEARCH PROGRAM INTEGRATE SOCIOLOGIAL ASSESSMENTS INTO M-TRACK
There’s not much I can say about this, other than, as always, we need to get creative. And we need to be honest about a number of things: • First, we need to be honest about what the law now clearly requires for consent • Second, we need to be honest about the fact that HIV transmission has a HUGE grey zone and that it’s almost impossible to say for any particular sexual encounter whether HIV has been transmitted or not, although we do have a very good idea of what the most likely outcome is • Thirdly I would suggest that we as individuals need to practice something different: if you want to know, ASK. If you don’t ask, don’t blame.
iN an analysis of representation of MSM over five years of annual Canadian Association for HIV/AIDS Research conferences (the largest HIV/AIDS research conference in Canada), Tooley (2012a) found that only 12% of abstracts made any mention of MSM, with 7% exclusively addressing MSM . Further, only 1.2% of all abstracts exclusively addressed HIV positive MSM (Tooley, 2012a) , who have accounted for 55.4% of all HIV positive test reports in Canada since 1985 (Public Health Agency of Canada, 2012a). MOST OF THE RESEARCH IS FOCUSED IN THE THREE URBAN CENTRES OF CANADA INTRODUCE AN MSM STREAM INTO THE CIHR HIV/AIDS COMMUNITY-BASED RESEARCH PROGRAM INTEGRATE SOCIOLOGIAL ASSESSMENTS INTO M-TRACK