Changing Public Policy to Prevent HIV Transmission

The Role of Structural and Environmental Interventions
  • Michael D. Sweat
  • Julie Denison
Part of the AIDS Prevention and Mental Health book series (APMH)


Why is it that interventions at the individual level, such as health education and counseling, have become so dominant in the effort to slow the transmission of HIV and AIDS? Are interventions that include a focus on environmental changes perhaps more cost-effective than those that rely only on individual persuasion? Moreover, what can be done to facilitate greater attention to imaginative environmental interventions and the policy changes necessary to implement and sustain such interventions? In this chapter we attempt to answer these questions. First we examine some of the reasons why individually oriented intervention approaches have become so dominant. Next we review theories that have incorporated the role of environmental factors in the promotion of disease. Then we take a closer look at the role of the environment in the transmission of HIV and discuss interventions that can affect change at the environmental level. Finally, we examine the role of public policy in shaping environmental outcomes to stem HIV transmission and look at some of the ways policy advocacy has been conducted with regard to HIV and AIDS issues in rich and poor countries.


Migration Hepatitis Filtration Depression Europe 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Coates T, Stall R, Cantania J, Kegeles S. Behavioral factors in the spread of HIV infection. AIDS 1988; 2: s239–s246.PubMedCrossRefGoogle Scholar
  2. 2.
    Prochaska J, DiClemente C, Norcross J. In search of how people change. Am Psychol 1992; 47: 1102–1114.PubMedCrossRefGoogle Scholar
  3. 3.
    Ajen I, Fishbein M. Understanding Attitudes and Predicting Behavior. Englewood Cliffs, NJ Prentice-Hall; 1980.Google Scholar
  4. 4.
    Leventhal H, Meyer D, Nerenz D. The common sense: Representation of illness danger. In Rachman S, ed. Medical Psychology. New York: Pergamon Press; 1980; pp. 7–30.Google Scholar
  5. 5.
    Green L, Kreuter M, Deeds S, K.P. Health Education Today and the PRECEDE Framework. Palo Alto Medfield; 1979.Google Scholar
  6. 6.
    Becker CM. The demo-economic impact of the AIDS pandemic in sub-Saharan Africa. World Dev 1990; 18: 1599–1619.CrossRefGoogle Scholar
  7. 7.
    Becker M, Janz N. On the effectiveness and utility of health/hazard risk appraisal in clinical and nonclinical settings. Health Serv Res 1987; 22: 537–551.PubMedGoogle Scholar
  8. 8.
    Emmons C, Joseph J, Kessler R, Wortman C, Montgomery S, D.O. Psychosocial predictors of reported behavior change in homosexual men at risk for AIDS. Health Educ Q 1986; 13: 331–345.PubMedCrossRefGoogle Scholar
  9. 9.
    Montgomery SJJ, Becker M, Ostrow D, Kessler R, Kirscht J. The health belief model in understanding compliance with preventative recommendations for AIDS: How useful? AIDS Educ Prev 1989; 1: 303–323.PubMedGoogle Scholar
  10. 10.
    Bandura A. Social Learning Theory. Edgewood, NJ Prentice-Hall; 1977.Google Scholar
  11. 11.
    Botvin G, Baker E, Botvin E, Filazzola B, Millman R. Prevention of alcohol misuse through development of personal and social competence. J Studies of Alcohol 1984; 45: 550–552.Google Scholar
  12. 12.
    Des Jarlais D, Freidman S. The psychology of preventing AIDS among intravenous drug users. Am Psychol 1988; 43: 865–870.PubMedCrossRefGoogle Scholar
  13. 13.
    Chirot D. Social Change in the Modern Era. San Diego, CA Harcourt Brace Jovanovich; 1986.Google Scholar
  14. 14.
    Snow J. On the mode of communication of cholera. In Snow on Cholera. New York: The Commonwealth Fund; 1936; pp. 1–175.Google Scholar
  15. 15.
    Lilienfeld A, Lilienfeld D. Foundations of Epidemiology, 2nd ed. New York: Oxford University Press, 1980.Google Scholar
  16. 16.
    Alland A, McCay B. The concept of adaptation in biological and cultural evolution. In Honigmann J, ed. Handbook of Social and Cultural Anthropology. Chicago Rand McNally; 1973.Google Scholar
  17. 17.
    Brown P, Inhorn M. Disease, ecology, and human behavior. In Medical Anthropology: Contemporary Theory and Method. New York: Praeger; 1990; pp. 187–214.Google Scholar
  18. 18.
    McElroy A, Townsend P. Medical Anthropology in Ecological Perspective, 2nd ed. Boulder, CO: Westview Press; 1989.Google Scholar
  19. 19.
    Tawil O, Verster A, O’Reilly K. Enabling approaches for HIV/AIDS prevention: Can we modify the environment and minimize the risk? AIDS 1995; 9: 1299–1306.PubMedCrossRefGoogle Scholar
  20. 20.
    Sweat M, Denison J. Reducing HIV incidence in developing countries with structural and environmental interventions. AIDS 1995; 9: S251–S257.PubMedGoogle Scholar
  21. 21.
    Sorensen G, Pechacek T. Implementing nonsmoking policies in the private sector and assessing their effects. NY State J Med 1989: 11–15.Google Scholar
  22. 22.
    Rigotto N. Trends in the adoption of smoking restrictions in public places and worksites. NY State J Med 1989: 19–26.Google Scholar
  23. 23.
    Becker M, Joseph J. AIDS and behavioral change to reduce risk: A review. Am J Pub Health 1988; 78: 394–410.CrossRefGoogle Scholar
  24. 24.
    Anonymous. Poor man’s plague. The Economist 1991; 21: 21-24.Google Scholar
  25. 25.
    Krueger L, Wood R, Diehr P, Maxwell C. Poverty and HIV seropositivity: The poor are more likely to be infected. AIDS 1990; 4: 811–814.PubMedCrossRefGoogle Scholar
  26. 26.
    Carovano K. AIDS and poverty in the developing world. Policy Focus 1987; 7: 1–11.Google Scholar
  27. 27.
    Ainsworth M, Over M. The economic impact of AIDS on Africa. In AIDS in Africa. Essex M, Mboup S, Kanki P, Kalengayi M, eds. New York: Raven Press; 1994; pp. 559–587.Google Scholar
  28. 28.
    Singer M. AIDS and the health crisis of the urban poor; the perspective of critical medical anthropology. Soc Sci Med 1994; 39(7): 931–948.PubMedCrossRefGoogle Scholar
  29. 29.
    Wallace R. US Apartheid and the spread of AIDS to the suburbs: A multi-city analysis of spatial epidemic threshold. Soc Sci Med 1995; 41: 333–345.PubMedCrossRefGoogle Scholar
  30. 30.
    Mulder D, Nunn A, Wagner H, Kamali A, Kengeya Kayondo J. HIV-1 incidence and HIV-1 associated mortality in a rural Ugandan population cohort. AIDS 1994; 8: 87–92.PubMedCrossRefGoogle Scholar
  31. 31.
    Wagner H, Kamali A, Nunn A, Kengeya Kayondo J, Mulder D. General and HIV-1 associated morbidity in a rural Ugandan community. AIDS 1993; 7: 1461–1467.PubMedCrossRefGoogle Scholar
  32. 32.
    Lurie R, Hintzen P. The impact of International Monetary Fund and World Bank policies on HIV transmission in developing countries. International Conference on AIDS. Yokohama, August 994.Google Scholar
  33. 33.
    Hawkes S, Hart G. Travel, migration and HIV. AIDS Care 1993; 5: 207–214.PubMedCrossRefGoogle Scholar
  34. 34.
    Romero-Daza N. Multiple sexual partners, migrant labor, and the makings for an epidemic: Knowledge and beliefs about AIDS among women in Highland Lesotho. Hum Org 1994; 53: 192–205.Google Scholar
  35. 35.
    Jochelson K, Mothibeli M, Leger J. Human immunodeficiency virus and migrant labor in South Africa. Int J Health Serv 1991; 21: 157–173.PubMedCrossRefGoogle Scholar
  36. 36.
    Hunt C. Migrant labor and sexually transmitted disease. J Health Soc Behavior 1989; 30: 353–373.CrossRefGoogle Scholar
  37. 37.
    Anarfi J. Sexuality, migration and AIDS in Ghana—a socio-behavioral study. Health Transition Rev 1993; 3: 45–67.Google Scholar
  38. 38.
    Stichter S. Migrant Laborers. New York Cambridge University Press; 1985.Google Scholar
  39. 39.
    Loewenson R. Labour insecurity and health: An epidemiological study in Zimbabwe. Soc Sci Med 1988; 27: 733–741.PubMedCrossRefGoogle Scholar
  40. 40.
    Sanders D, Davies R. The economy, the health sector and child health in Zimbabwe since independence. Soc Sci Med 1988; 27: 723–731.PubMedCrossRefGoogle Scholar
  41. 41.
    Byerlee D. Rural-urban migration in Africa: Theory, policy and research implications. Int Migration Rev 1974; 8: 543–566.CrossRefGoogle Scholar
  42. 42.
    Padian N. Prostitute women and AIDS: Epidemiology. AIDS 1988; 2: 413–419.PubMedCrossRefGoogle Scholar
  43. 43.
    Hunt C. Africa and AIDS: Dependent development, sexism and racism. Mon Rev 1988; 39: 10–22.Google Scholar
  44. 44.
    Mann J, Chin J, Piot P, Quinn T. The international epidemiology of AIDS. Sci Am 1988; 259: 82–89.PubMedCrossRefGoogle Scholar
  45. 45.
    Carael M, Van de Perre P, Lepage H, et al. Human immunodeficiency virus transmission among heterosexual couples in central Africa. AIDS 1988; 2: 201–205.PubMedCrossRefGoogle Scholar
  46. 46.
    Day S. Prostitute women and AIDS. AIDS 1988; 2: 421–428.PubMedCrossRefGoogle Scholar
  47. 47.
    Hudson C, Anselm J, Hennis P, et al. Risk factors for the spread of AIDS in rural Africa: Evidence from a comparative epidemiological survey of AIDS, hepatitis B and syphilis in southwest Uganda. AIDS 1988; 2: 255–260.PubMedCrossRefGoogle Scholar
  48. 48.
    Mitchell-Weaver C. Urban systems theory and Third World development: A review. J Urban Aff 1991; 13: 419–441.CrossRefGoogle Scholar
  49. 49.
    Kentor J. Structural determinants of peripheral urbanization: The effects of international dependence. Am Sociol Rev 1981; 46: 201–211.CrossRefGoogle Scholar
  50. 50.
    Edwards S, Borsten G, Nene L, Kunene S. Urbanization and changing perceptions of responsibilities among African fathers. J Psychol 1986; 120: 433–438.CrossRefGoogle Scholar
  51. 51.
    Kadushin C. Mental health and interpersonal environment: A reexamination of some effects of social structure on mental health. Am Sociol Rev 1983; 48: 20188–20198.CrossRefGoogle Scholar
  52. 52.
    Amato P. The effects of urbanization on interpersonal behavior: Field studies in Papua, New Guinea. J Cross Cult Psychol 1983; 14: 353–367.CrossRefGoogle Scholar
  53. 53.
    Torrey B, Boyle B, Way P. Seroprevalence of HIV in Africa. US Bureau Census, CIR Staff paper: Winter, 1990: 7-9.Google Scholar
  54. 54.
    Rweymamu C. Refugee AIDS tragedy? Panos World AIDS 1994; 35: 1–2.Google Scholar
  55. 55.
    Kellett J. The impact of prolonged war and epidemic AIDS on medical care. CMAJ 1989; 140: 699–701.PubMedGoogle Scholar
  56. 56.
    Moodie D. Mine culture and miners’ identity on the South African gold mines. In Bozzoli B, ed. Town and Countryside in the Transvaal. Johannesburg Raven Press; 1983.Google Scholar
  57. 57.
    Burgess AW, Baker T. AIDS and victims of sexual assault. Hosp Community Psychiatry 1992; 43: 447–448.PubMedGoogle Scholar
  58. 58.
    Cunningham RM, Stiffman AR, Dore P, Earls F. The association of physical and sexual abuse with HIV risk behaviors in adolescence and young adulthood: Implications for public health. Child Abuse & Neglect 1994; 18: 233–245.CrossRefGoogle Scholar
  59. 59.
    Zierler S, Feingold L, Laufer D, Velentgas P, Kantrowitz-Gordon I, Mayer K. Adult survivors of childhood sexual abuse and subsequent risk of HIV infection. Am J Public Health 1991; 81: 572–575.PubMedCrossRefGoogle Scholar
  60. 60.
    Benson JD. Abuse and HIV-related risk. Focus 1995; 10: 5–6.Google Scholar
  61. 61.
    Baribwira C, Muteganya D, Ndihokubwayo JB, Moreno JL, Nduwimana M, Rufyikiri T. Aspects of sexually transmissible diseases in young children in Burundi: Gonorrhea caused by sexual abuse. Medecine Tropicale 1994; 54: 231–233.PubMedGoogle Scholar
  62. 62.
    Carballo-Dieguez A, Dolezal C. Association between history of childhood sexual abuse and adult HIV-risk sexual behavior in Puerto Rican men who have sex with men. Child Abuse Neglect 1995; 19: 595–605.Google Scholar
  63. 63.
    Lodico MA, DiClemente RJ. The association between childhood sexual abuse and prevalence of HIV-related risk behaviors. Clin Pediatr 1994; 33: 498–502.CrossRefGoogle Scholar
  64. 64.
    Lyon ME, Richmond D, LJ DA. Is sexual abuse in childhood or adolescence a predisposition factor for HIV infection during adolescence? Pediatr AIDS HIV Infect 1995; 6: 271–275.PubMedGoogle Scholar
  65. 65.
    Bartholow BN, Doll LS, Joy D, et al. Emotional, behavioral, and HIV risks associated with sexual abuse among adult homosexual and bisexual men. Child Abuse & Neglect 1994; 18: 747–761.CrossRefGoogle Scholar
  66. 66.
    Joseph S. Dragon at the Gates: The Once and Future AIDS Epidemic. New York Carroll & Graf; 1992.Google Scholar
  67. 67.
    Shilts R. And the Band Played On. New York St. Martin’s Press; 1987.Google Scholar
  68. 68.
    Hanenberg R, Rojanapithaykorn W, Kunasol P, Sokal D. Impact of Thailand’s HIV-control programme as indicated by the decline of sexually transmitted diseases. Lancet 1993; 344: 243–245.CrossRefGoogle Scholar
  69. 69.
    Nelson KE, Beyrer C, Eiumtrakol S, Khamboonruang C, Celentano D. HIV prevalence and changes in risk behavior among young men in northern Thailand between 1991 and 1993. Natl Conf Hum Retroviruses Relat Infect 2nd 1995; 2: 164.Google Scholar
  70. 70.
    Nelson K, Celentano D, Eiumtrakol S, et al. Changes in sexual behavior and a decline in HIV infection among young men in Thailand. N Engl J Med 1996; 335: 297–303.PubMedCrossRefGoogle Scholar
  71. 71.
    Rojanapithayakorn W. The one-hundred percent condom programme in Thailand: An update. Int Conf on AIDS. Yokohama, August 1994.Google Scholar
  72. 72.
    Kelly J, Sikkema K, Wintt R, et al. Outcomes of a 16-city randomized field trial of a community-level HIV risk reduction intervention. Int Conf on AIDS, June 1992, Amsterdam, Netherlands.Google Scholar
  73. 73.
    Bhatt P, Baltes R. “100% condom” use for Badii sex workers in Nepal. Int Conf AIDS 1994; 10: 13 (abstract no. 345D); Yokohama, Japan.Google Scholar
  74. 74.
    Sweat M. Personal communication with Martha Butler, Resident Advisor AIDSCAP Dominican Republic; 1996.Google Scholar
  75. 75.
    Morisky D, Detels R, Tiglao T, et al. Innovative behavioral interventions targeting environmental and socio-structural determinants for HIV/AIDS prevention in the Philippines (Abstract # Mo.D.1795). XI International Conference on AIDS. Vancouver, BC; 1996.Google Scholar
  76. 76.
    Santana S, Faas L, K. W. Human immunodeficiency Virus in Cuba: The public health response of a Third World country. Int J Health Serv 1991; 21: 511–537.PubMedCrossRefGoogle Scholar
  77. 77.
    Perez-Stable EJ. Cuba’s response to the HIV epidemic [see comments]. Am J Public Health 1991; 81: 563–567.PubMedCrossRefGoogle Scholar
  78. 78.
    Marconi K, Weissman G, Van Ness P, Bowen GS, Schneider D, McClain M. Creating an agenda for research and evaluation: HIV service delivery, the Ryan White Care Act and beyond. Int Conf AIDS 1993; 9: 947 (abstract no. PO-D36-4375), Berlin, Germany.Google Scholar
  79. 79.
    Bayer R. AIDS, ethics, and activism: Institutional encounters in the epidemic’s first decade. In Bulger RE, ed. Society’s Choices: Social and Ethical Decision Making in Biomedicine. Washington, DC: National Academy Press; 1995: pp. 458–476.Google Scholar
  80. 80.
    Arbaje M, Butler de Lister M, Gomez E, Sweat M. Lessons learned from an AIDS policy program in the Dominican Republic. Int Conf AIDS 1994; 10: 312 (abstract no. PD0426), Yokohama, Japan.Google Scholar
  81. 81.
    Cwikel JG. After epidemiological research: What next? Community action for health promotion. Public Health Rev 1994; 22: 375–394.PubMedGoogle Scholar
  82. 82.
    Rojanapithayakorn W. One hundred percent condom programme. Int Conf AIDS 1992: D498 (abstract no. PoD 5654), Amsterdam, Netherlands.Google Scholar
  83. 83.
    Ford N, Koetsawang S. Factors influencing condom use in a Thai massage parlour. Int Conf AIDS; 1992: D492 (abstract no. PoD 5622), Amsterdam, Netherlands.Google Scholar

Copyright information

© Springer Science+Business Media New York 1998

Authors and Affiliations

  • Michael D. Sweat
    • 1
  • Julie Denison
    • 1
  1. 1.School of Hygiene and Public HealthJohns Hopkins UniversityBaltimoreUSA

Personalised recommendations