Structural factors integral to understanding girls' vulnerability to HIV in sub-Saharan Africa

The findings are published in the journal Social Science & Medicine.

Carol Underwood, PhD, lead author of the study and assistant professor at the Bloomberg School of Public Health's Department of Health, Behavior and Society, explained, "This study represents one of the few efforts to explore community members' perceptions of vulnerability to HIV. It is unique because it offers insights into developing an HIV response that is grounded in the views of communities most affected by HIV/AIDS rather than a response based primarily on perspectives from the outside."

Underwood directed the Gender Initiative on Girls' Vulnerability to HIV (Go Girls! Initiative), an intervention informed by this study and carried out by the Bloomberg School of Public Health's Center for Communication Programs. The Go Girls! Initiative used focus group discussions with adolescent girls and boys, adult men and women and community opinion leaders, in Botswana, Malawi and Mozambique to develop social, gender, and behavior change communication approaches to reduce adolescent girls' susceptibility to HIV infection.

The study found that structural factors, especially insufficient economic, educational, socio-cultural and legal support for adolescent girls, were identified as the root causes of girls' vulnerability to HIV through exposure to unprotected sexual relationships, primarily relationships that are transactional and age-disparate. This finding is in line with current HIV prevention practice, which advocates for combination prevention that comprises biomedical, behavioral and structural interventions.

"Nevertheless, while greater attention is being paid to the importance of structural interventions in HIV prevention efforts," cautions Underwood, "most efforts still focus on the individual and disregard the complex socio-economic context where the infections are occurring, a situation which must be met with nuanced and multi-level responses."

"We found that both adolescents and adults in HIV-affected communities highlighted structural interventions, behavioral interventions, and testing -- in that order -- for prevention," she said. Community members explicitly called for policies and interventions to strengthen cultural, economic, educational and legal structures to protect girls, findings that were used to develop the interventions implemented by the Go Girls! Initiative.

Funding for the research was provided by the President's Emergency Plan for AIDS Relief (PEPFAR) and the United States Agency for International Development (USAID).