HIV and chemoprophylaxis, the importance of considering social structures alongside biomedical and behavioral intervention

This manuscript draws connections between chemoprophylaxis and the biomedical model of disease that emphasizes individual behavior. We argue that chemoprophylactic HIV interventions have limited utility at the population-level, and that structural interventions need to be prioritized. We use the recent CAPRISA 004 and iPrEx trials to (a) critique the utility of these trials from a public health perspective by highlighting the difference between efficacy and effectiveness, (b) apply an alternative theory of health behavior as a way to reorient the field toward the discussion of the need to employ structural interventions, and (c) examine two aspects of HIV prevention efforts – funding structures and iatrogenic effects of biomedical approaches – as a means of overcoming obstacles to more widespread adoption of structural interventions.

► CAPRISA 004 and iPrEx are efficacy trials; these interventions will have limited effectiveness in populations. ► Human behavior is the product of autonomy and structural constraints; this highlights the primacy of structural change. ► Individually focused interventions, whether behavioral or biomedical, will have limited utility without structural change. ► Our funding structures reflect biomedical thinking; there is little room to develop or evaluate structural interventions. ► Utilizing individually focused interventions can increase stigma within communities.