Economic interventions affect women's poverty can decrease their vulnerability to HIV infection in important ways. Such interventions, for example, may mitigate their need to stay in violent relationships or to engage in transactional sex. Although these strategies may facilitate change in prevailing inequitable gender norms, evidence suggests that these norms are more intransigent and require more direct focus. That is, economic strategies alone may be insufficient to address the structural pathways that result from the combined effects of poverty and gender-power inequities. Thus, approaches that work to reduce poverty while promoting gender equity, and vice versa, are more likely to have an enduring success. An integrated approach can profoundly alter the structural pathways to HIV, affecting the underlying risk environment, and thereby enhancing HIV prevention in ways not achieved by traditional methods of prevention.
Effective approaches to transform the structural pathways are likely to have two critical components: (1) an economic strategy to improve women's access to education, training, and employment; enhance HIV/STI prevention information and tools; and/or minimize the necessity for migration and (2) gender transformation efforts, that is, strategies that challenge women and girls as well as men, families, and the broader community to question and rethink gender socialization and norms. Below we describe a few promising examples of these strategies.
Economic Interventions for Poverty Reduction
Three economic interventions stand out as having significant potential to address the structural pathways that derive from women's experience of poverty: conditional cash transfers (CCTs), microcredit, and economic livelihoods. These strategies may not only address pathways, such as girls' and women's access to income, education, and health information and services, but also can reduce the necessity for migration prompted by economic insecurity, even within politically and economically unstable environments.62 Finally, these strategies can enhance decision-making abilities and even reduce IPV63 by empowering women and instilling optimism for the future.
One such economic intervention is CCTs. These programs link the receipt of cash transfers to individuals or households conditionally on certain behaviors, such as keeping children in school or visiting health centers for preventive care.64 Compelling evidence in favor of the promising effect of CCT interventions on structural pathways, such as access to education and health services, comes from one of the largest of such programs, Oportunidades, which is located in Mexico. In addition to national investments in the health care and educational systems to improve availability of services, Oportunidades offered cash transfers to poor families conditionally on their participation in primary health center visits and children's school attendance. Major findings from a community randomized controlled trial of the program included an overall increase in household income, a 40% reduction in childhood and adult illness, improved child nutrition, and improved consistency with school attendance.64–66 Evaluations of similar programs in Nicaragua and Columbia have shown comparable effects.
Microcredit is a second promising economic strategy that provides small loans to the poor outside formal banking structures, usually through group lending models. Because loans are guaranteed by each member of the group, this collective guarantee overcomes the need for collateral required by formal banks and has the secondary benefit of promoting social and community relations that build social capital.67 A recent review of studies conducted on microcredit programs involving women showed significant increases in household income, contraceptive use, and child nutrition. However, these effects were diminished among women who had relatively less control over their income (highlighting the importance of addressing gender norms).68 Although microcredit can greatly reduce poverty, this strategy may not be appropriate for all population groups, such as the poorest of the poor or youth, for whom taking loans may only propel them into greater poverty and therefore greater risk.69 In such cases, a broader array of microfinance services, such as microgrants (capital that is not repaid) and saving programs, either alone or in combination with livelihoods promotion (described below), may be more appropriate.68,69
The goal of an economic livelihood approach, our third example of promising economic interventions, is to enhance the capabilities, resources, and opportunities that enable individuals to pursue their economic goals.70 This approach entails building capabilities through training in life skills, formal and informal education, enhancing self-confidence, facilitating the formation of peer and social support networks, and promoting decision-making ability. It seeks to increase such resources as physical assets (e.g., housing, land, and infrastructure), social assets (e.g., social ties, networks, and trusting relationships), and, when appropriate, financial assets (e.g., loans and savings). Finally, it expands participants' current and future opportunities through vocational, job, and business training; financial literacy; and/or linkages to microfinance. Although this approach could be targeted to a variety of population groups, recent interest has focused on women and adolescents, and in particular girls and orphans.71
Strategies for Gender Transformation
Enhancing the strategies described above to specifically address gender-power inequities directly is critical to their success in mitigating the effects of structural pathways to HIV infection on women. Many microcredit and livelihood programs have begun to address gender norms through life skills training and HIV education; the social support and peer networks inherent in the design of these programs can foster not just individual- but also group-level changes in perceptions of gender. This assertion is supported by recent research that has demonstrated that focused educational activities in small-group settings can lead to the adoption of gender-equitable attitudes.72 Recently, the IMAGE study conducted in South Africa evaluated the effectiveness of a microcredit program combined with gender education in reducing HIV risk behavior and acquisition among women. Although researchers found a decrease in reported IPV among those in the intervention villages, they detected no change in HIV incidence or the rate of unprotected sexual intercourse with a nonspousal partner.73
Similarly, CCT programs could target low education levels and poor health service utilization more directly while working to reduce gender inequities. For example, greater incentives could be provided to families to keep girls in school than boys. Evidence suggests that when support is provided for girls' education, families are more likely to send boys as well.74 CCT could also be used to increase women's uptake of preventive reproductive health care or VCT, mitigating poverty- and gender-related barriers to health service utilization.
Transforming gender norms also entails working with men. During the last decade, there has been increasing recognition of the importance of addressing the links among gender norms, risky male sexual behavior, and women's HIV risk.75 This recognition has been accompanied by a variety of efforts to involve men in reproductive health promotion, to work with men as partners, and to focus on men's sexual health and HIV risk.75,76 Whereas the first two have engaged men on issues, such as safe motherhood and family planning, the last emphasized the need to meet men's own sexual and reproductive health needs. All three approaches have demonstrated some change in knowledge; gender-related attitudes; and to a limited extent, behaviors (including gender-based violence and sexual risk behaviors) within relatively short project timeframes.77,78
Creating an enabling environment for change also requires support from families and communities.79 Relatively few HIV prevention interventions have focused on families. One promising example is CHAMP (Collaborative HIV Prevention and Adolescent Mental Health Project), which was originally developed in the United States and later adapted for South African and Caribbean settings.80,81 A preliminary study of CHAMP in South Africa and Trinidad and Tobago suggested that the intervention improved parental knowledge of HIV transmission, increased communication between parents and youth on sensitive topics, such as puberty and sex, and reduced HIV/AIDS stigma among parents. Another similar strategy is the motivation of a diverse set of community actors (e.g., key opinion leaders, youth groups, local businesses, or community-based organizations) to tackle a common concern, such as HIV/AIDS.82 Such community mobilization may include community-employed health workers to engage in HIV prevention, care and support activities, and the organization of HIV/AIDS awareness rallies. Although promising, the effect of these efforts on HIV risk remains to be investigated.
Although evidence suggests that young women who believe that their future economic prospects are bright are less likely to engage in risky behavior,83 few economic interventions either alone or combined with gender education/transformation (except the IMAGE study described earlier73) components have yet targeted or been rigorously evaluated for reducing HIV infection. Nevertheless, we posit that these promising multicomponent strategies, which simultaneously address women's poverty and gender-power inequities, can greatly reduce HIV risk among women and girls in ways not achieved previously.