Health interventions can change systemic and cultural determinants of STI/HIV transmission

The causal pathway linking intimate partner violence (IPV) and health may be two-way.  We are used to thinking of IPV as a determinant of STI; but sexual health also has an impact on IPV.  This, at any rate, is the conclusion of a recently issued working-paper from the US National Bureau of Economic Research uniting a highly interdisciplinary team of researchers from a range of US universities and medical institutions.  The researchers seek to demonstrate that health is kind of human capital, and that a technological advance in medicine can affect ‘some of the most frustratingly persistent social problems’.  This finding will be particularly interesting to readers of this journal.  Health, in the context of this study, happens to be sexual health, and the technological advance is the introduction of HAART in 1996.

Papageorge & Pollack (P&P) base their work on data from the Women’s Intra-Agency HIV Study (WIHS), and compare a cohort of HIV+ women who were, in 1996, just beginning to experience immune system deterioration, with two control cohorts, using a ‘difference in difference’ approach.  One control consisted in HIV+ women not experiencing such effects, another in HIV- women included in the same WIHS data.  Much of the researchers’ task consists in establishing the relative dependence/independence of causal pathways linking IPV with drug use, perceived mental and physical health, and employment.  Their headline finding is a c.10% reduction in IPV a c.15% reduction in IDU attributable to HAART introduction.

The idea that the causative link could flow from STIs to IPV, as well as from IPV to STIs, may not be new to our readers.  Indeed, an ongoing concern for sexual health interventions has been that STI/HIV disclosure (a potentially important element of risk reduction) could result in domestic violence (Partner delivered STI self-testing (STI/blogs)).  This has not prevented other studies from pointing to a potentially positive role for sexual health clinics in relation to IPV (Lockart & McNulty (STIs); Decker and Silverman I (STIs); Decker & Silverman II (STIs)).  The nature of IPV itself is not always well understood, and probably varies with social and cultural context.  For example, it is not restricted to short-term or casual relationships (Silverman & Raj (STIs)), and may be reciprocal (Norris & Hindin (STIs)) as well as man-on-woman.  The nature of the causal link with HIV/STI might be expected to vary with the nature of the IPV itself.

So there is nothing new about the idea that a change in respect to sexual health could influence IPV.  What P&P contribute to the debate is genuinely encouraging, for all that.  Recent characterizations of the global efforts to curb the HIV epidemic (e.g. UNAIDS: On the Fast Track) make a two-fold classification of interventions into, on the one hand, biomedical interventions such as PrEP or cART, and, on the other, vaguer, and longer-term non-biomedical interventions such as legislative or attitudinal change.  The latter correspond to systemic or cultural determinants of sexual health that can seem to mark the ultimate limits on sexual health interventions rather than realistic targets for those interventions.  However, P&P point in this report to the case of a biomedical intervention that would, for once, seem to have achieved something more than an immediate biomedical impact.  HAART introduction, on P&P’s interpretation, effectively provided an additional ‘source of human value’ – an enhancement of women’s social ‘capital’.  Thereby, it would seem to have impacted the fundamental social and cultural determinants of sexual health – those ‘frustratingly persistent social problems’ that constitute the constraints within which sexual health is normally compelled to operate.

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