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

3. SPECIAL EDITION
HIV in Men who have Sex with Men
July 20, 2012

4. AWESOME ARTICLE
7 13
174
(Millett et al., 2012)

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)

8. THEY STUCK IT TO THE
STRUCTURES

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

13. TWO MAJOR ISSUES

14. TWO MAJOR ISSUES

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

17. Re-orienting our
approaches to social
and structural
drivers:
FOUR KEY
CONCEPTS

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?

22. #4: COMBINATION APPROACHES:
BIOMEDICAL AS BEHAVIOURAL AS
STRUCTURAL

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

27. 3 GUIDING OBJECTIVES

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)

30. SEROADAPTATION STRATEGIES

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

35. SO WHAT CAN WE ACTUALLY DO?

36. SIX STRATEGIC ACTIONS
(aids2031 Social Drivers Working Group, 2010)

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.

47. LOVE EACH OTHER

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