Strengthening the Enabling Environment

What Works

Transforming Gender Norms
Addressing Violence Against Women
Advancing Human Rights and Access to Justice for Women and Girls
Promoting Women’s Employment, Income and Livelihood Opportunities
Advancing Education
Reducing Stigma and Discrimination
Promoting Women’s Leadership

In order for HIV and/or AIDS interventions for women and girls to succeed, factors beyond the health services need to be addressed through multisectoral interventions. These environmental factors include 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 tolerance for violence against women, experience of HIV and/or AIDS-related and gender-related stigma and discrimination. Addressing these environmental factors through multisectoral interventions will determine whether any HIV intervention will truly help women and girls. “Bolstering control over resources – such as income, land and property, food security… and education – also helps to minimize HIV/AIDS risk” (Dworkin et al., 2011: 995). 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 that interventions to prevent treat or care for those with HIV will have their intended effect. As the HIV epidemic proceeds into its third decade, “a key component of the shift from an emergency to a long-term response to AIDS is a change in focus from HIV prevention interventions focused on individuals to a comprehensive strategy in which social/structural approaches are core elements” (Auerbach et al., 2011).

“The choice between food or shelter and safer sex is not a free one, since almost everyone will choose daily survival over the comparatively abstract risk of HIV” (Pinkham and Malinowska-Sempruch, 2008: 169).Strengthening the enabling environment must be done at a structural or societal level (Gupta et al., 2008a; Piot 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: 1721).

Yet, structural interventions are challenging to evaluate (McCoy et al., 2010). 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 and their ability to cope with the impact of HIV. Women are often “blamed” for bringing HIV into the family; women face stigma, are kicked out of their homes and denied property, leading to further vulnerability to infection. “Almost uniformly across the world, women have less access to and control of productive resources outside the home. Evidence for this imbalance in power includes the gender gaps in literacy levels, employment patterns, access to credit, land ownership and school enrollment fees. This imbalance in access to, and control of, productive forces and resources translates into an unequal balance in sexual relations in favor of men” (Abdool Karim et al., 2010a: S126). Women have provided most of the care in the epidemic. [See Care and Support] 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. Social protection and impact mitigation are important for women living with HIV, as well as structural interventions which prevent women from acquiring HIV in the first place.

Building Social Capital is Central to Strengthening the Enabling Environment

Social capital refers to the connections and networks among individuals and the norms of reciprocity and trust that result from these networks (Ehrhardt et al., 2009; Ogden et al., 2012). “The basic idea of social capital is that one’s connections, be it with family, kinsmen, friends, neighbors or associates, constitute an important asset that can be called upon in a crisis, leveraged to build mutually advantageous resources and tapped to maintain or improve well-being” (Thomas-Slayter and Fisher, 2011: S325). The central factors in social capital include trust, reciprocity, and cooperation among members of a social network that aims to achieve common goals. Social capital may affect health in a number of ways: by establishing social norms that promote and support healthy behaviors, by leading to the development of and fostering access to health care services and facilities; by fostering mutual trust and respect among members of communities, and by supporting egalitarian democratic political participation, thereby leading to the development of policies that protect all citizens (Holtgrave and Crosby, 2003). However, there is no universally accepted way to measure social capital (Pronyk et al., 2008 cited in Gregson et al., 2011b).

Many things contribute to building social capital for women including teaching women their legal rights so that they can be empowered to know and claim their rights, utilizing the community-building capacity of faith-based organizations (Frumence et al., 2010); or, as one adolescent girl who participated in Stepping Stones put it: "(the benefits of) sitting with people and always chatting" (Jewkes et al., 2010c: 1077). “Growing evidence also suggests that social capital approaches can positively influence health policy…” (Ogden et al., 2012: 1). Many early HIV prevention programs built on social movements, such as TASO in Uganda, but other countries, such as Botswana, marginalized the community response (Low-Beer and Sempala, 2010). A survey study of 70 women in Zimbabwe from 1998 – 2003 found a correlation of greater female membership in community groups (excluding church membership) with women reporting adoption of lower risk sexual behaviors with a significant effect after controlling for confounding factors (Gregson et al., 2011b). Building social capital is central to strengthening the enabling environment because it enables allows women the opportunity to benefit from the resources and support within their communities and contributes to addressing the unequal balance in power between men and women.

Women in many countries often have weaker access to social capital than men, especially in countries where women’s mobility and chance for interaction with others is limited. For example, in the Middle East and North Africa, women are expected to spend most of their lives at home and their networks are limited to close family (Ehrhardt et al., 2009). 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 Muriisa, 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, 2009: 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; Pronyk et al., 2008b).

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 greater impact.