The increasingly disproportionate impact of HIV and AIDS on women and girls throughout the world (see chapter 2) has implicated gender inequity as a driver of the epidemic. The cultural construction and social organization of gender have disempowered women and girls in many settings, making them particularly vulnerable to HIV infection and its consequences. These social factors operate in a number of ways, including through low educational attainment, early marriage, fertility expectations and sexual violence and also through economic inequities, such as lower wages and unpaid care work and a lack of property and inheritance rights. As a result of such arrangements, many women and girls do not have basic information about their bodies, sex or sexuality, and do not know how to prevent HIV and other STIs; they cannot demand that male partners use condoms; they cannot refuse sex; they are often forced to sell sex; and if they inject drugs they often are given a dirty needle to use after their male partner.
In response to these situations, interest has been growing in implementing income-generation interventions, such as microfinance projects - another form of social or structural intervention - as a means of empowering women in their relationships and reducing their material dependence on men. Several studies of micro-credit interventions targeting women and their fertility outcomes (pregnancy rates and contraceptive use) indicated that economic empowerment translated into increased self-esteem, improved social networks, increased control over household decision-making, increased bargaining power and increased contraceptive use (137). Micro-financing has only recently been applied to HIV prevention, so few empirical examples of interventions exist. One large-scale community-level randomized controlled trial in South Africa of an integrated, comprehensive intervention that simultaneously provided micro-credit to women and HIV/AIDS education to the whole community has been completed. The study assessed intermediate attitudinal and behavioural outcomes and HIV incidence (138). In this structural intervention, eight communities were matched and randomly allocated to receive the intervention at onset of the study or after 3 years. There was no evidence of an effect on community-level HIV incidence or risky sexual behaviour in the short-term, although there was a significant reduction in physical and sexual abuse among intervention participants (139).
Although the need for more social interventions has been recognized, there are a number of obstacles to evaluating their effectiveness. Chief among these is the fact that it can be exceedingly difficult to fit social-level analysis and interventions into an experimental study design (127). Essentially, the problem is that complex social phenomena - such as gender, poverty, economic inequality and violence - cannot be reduced to a few variables that can easily be modified or controlled for testing in experimental designs; and the attribution of effects to such interventions is often difficult without suitable comparison groups.
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