Transcript Structural Interventions and the Prevention of HIV/AIDS

Structural Interventions and
the Prevention of HIV/AIDS
Robert Fullilove, EdD
Columbia University
Some guiding principles
• “HIV/AIDS is a social epidemic with
medical outcomes”
• Monica Sweeney, MD, MPH
Assistant Commissioner for HIV
Prevention, NYC Department of Health
and Mental Hygiene
And…
• Plus ca change, plus c’est la meme chose.
• The more things change, the more they stay
the same
Foundations
• Structural interventions [also described as ‘social
drivers’ and/or social determinants] are not new as
public health strategies to improve health and
prevent disease
• The foundations of public health in the 19th
century did not come about via successful efforts
to change behavior. They were result of successful
changes in the physical and social environment
A little history
• cholera is an infectious disease that was a
major cause of mortality 200 years ago.
• As Farley and Cohen point out in
Prescription for a Healthy Nation, there
were two major approaches for reducing
cholera mortality:
Approach #1
• Individual behavior change response: teach
urban dwellers to wash their hands and boil
water before each use….
Approach #2
• What actually worked: changing the urban
environment.
• Creating a system of clean water supply, sanitary
disposal of human wastes,developing systems for
trash removal, and improved housing quality.
• The roots of public health were in structural
change, not strategies to change risk
behavors
What about now?
• What constitutes the greatest opportunity
for transforming the social environment and
the social drivers of HIV/AIDS at this point
in the 21st century?
• Answer: Seeking legislative reforms that
reduce the impact of mass incarceration of
those at risk for HIV/AIDS
Why now?
• Because many states are planning to close
prisons/jails and release large numbers of
non-violent offenders back into the
community as cost-saving measures.
• These steps are bound to suffer significant
“blowback”
Where should we concentrate
our efforts?
• See: One in 31 from the Pew Center on
the States
• This report argues that shifting our
focus from prisons to parole will
dramatically alter the negative social
impact of mass incarceration
A modest Proposal
• A significant number of presenters at
this conference are deeply engaged in
the link between corrections and HIV
• Prediction: the provision of services for
large numbers of newly released
prisoners will be the new “HIV
prevention frontier”
A Modest Proposal
[continued]
• All of the populations with which
prevention workers currently work are
represented in this flood of folks coming
out of prison
• Partnering with service providers who
will be mandated to manage this
challenge may provide the resources
that we currently lack to do our jobs