Strengthening the Enabling Environment

What Works

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For HIV/AIDS interventions for women and girls to succeed, factors outside the health services need to be addressed.   These environmental factors—gender norms that guide how girls and boys grow to be women and men, legal norms that confer or withhold rights for women and girls, access to education, income, levels of toleration for violence against women, experience of HIV/AIDS and gender stigma and discrimination—determine whether any HIV intervention will truly help women and girls. Creating a supportive and enabling environment for females and males to live in equity and for women and girls to be supported by equitable gender norms and legal rights is critical to reduce vulnerability to HIV infection and to ensure interventions to prevent, treat or care for those with HIV will have their intended effect

Strengthening the enabling environment must be done at a structural level (Rao Gupta et al., 2008).  Structural interventions need a multi-pronged strategy, as well as political will and commitment at all levels, as evident, for example, in Uganda in the 1990s where “an array of preventive policies and strategies, mounted by different agencies, with strong partnerships between the media, government, NGOs, sex workers, people living with HIV/AIDS and international and local public health agencies, endorsed at the highest political level...the need for broader, integrated programmes in which all components are mutually reinforcing” (Wellings et al., 2006: 39).

Yet, structural interventions are challenging to evaluate. [See Chapter 2. Methodology] Given the discussion in the methodology section about determinants of HIV infection and the pathways through which interventions must work, it is clear that enhancing the enabling environment is important but that structural interventions, as described in this chapter, are more difficult to correlate with HIV infection.  Proving “what works,” is challenging. For example, the pathway from changing gender norms to women being able to refuse sex or insist on condom use is indirect and can be influenced by many other factors. In the case of the enabling environment, it would not be possible to conduct a study using randomized control trial methodology, therefore the level of evidence, as measured by the Gray Scale, tends to be lower. Studies tend to be cross sectional, without control groups.  Nevertheless, the environment in which women and girls live and work plays an enormous role in women’s vulnerability to HIV. Strengthening a supportive environment for women and girls is integral to their ability to overcome the challenges women face in prevention, treatment and care of HIV.

Building Social Capital is Central to Strengthening the Enabling Environment

Much has been written on the relationship between HIV/AIDS and social capital, characterized by Putnam (1993: 167) as “features of social organization, such as trust, norms and networks that can improve the efficiency of society by facilitating co-ordinated actions.” The notion that networks, relationships and a sense of belonging matter is at the core of work on social capital and HIV.  Building social capital is central to strengthening the enabling environment. A review of the importance of NGO involvement in responding to the AIDS epidemic in Uganda concluded that “well-developed social capital leads to social inclusion, it helps in information flow, [and] reduces stress” (Jamil and Murhsa, 2004: 26).  Through fostering support systems of groups of people living with HIV and AIDS, NGOs in Uganda and other countries have helped build social capital. In the United States, increased social capital has been found to be associated with lower HIV rates (Holtgrave and Crosby, 2003). Research in Namibia on the effect of involvement in social support on prevention behavior found “support for the link between social capital and greater HIV-related efficacies,” or the notion that one could act to protect against HIV (Smith and Rimal, 2008: 142). The IMAGE program in South Africa combining microfinance and training on gender and HIV, which is discussed in more detail in this chapter, provides an example of an intervention to strengthen social capital by creating a support network among the women involved (Pronyk et al., 2006).

The following interventions and supporting evidence demonstrate a number of ways to strengthen the enabling environment for women and girls and tackle the underlying roots of women’s greater vulnerabilities to HIV and AIDS.  Each topic is introduced in more detail in the sections outlined below. Although many of the interventions in this chapter are “promising;” a number could be scaled up to achieve a larger effect.  

Strategies

• Prevention for Women
• Prevention for Key Affected Populations
• Prevention for Young People
• HIV Testing and Counseling for Women
• Treatment
• Meeting the Sexual and Reproductive Health Needs of Women Living With HIV
• Safe Motherhood and Prevention of Vertical Transmission
• Preventing, Detecting and Treating Critical Co-Infections
• Strengthening the Enabling Environment
  • Transforming Gender Norms
  • Addressing Violence Against Women
  • Transforming Legal Norms to Empower Women, including Marriage, Inheritance and Property Rights
  • Promoting Women’s Employment, Income and Livelihood Opportunities
  • Advancing Education
  • Reducing Stigma and Discrimination
  • Promoting Women’s Leadership
• Care and Support
• Structuring Health Services to Meet Women’s Needs