Chapter

Structural Violence and Structural Vulnerability Within the Risk Environment: Theoretical and Methodological Perspectives for a Social Epidemiology of HIV Risk Among Injection Drug Users and Sex Workers

DOI: 10.1007/978-94-007-2138-8_10

ABSTRACT The transmission of HIV is shaped by individual-environment inter­actions. Social epidemiologic approaches thus seek to capture
the dynamic and reciprocal relationships of individual-environment interactions in the production and reduction of risk. This
presents considerable methodological, theoretical and disciplinary challenges. Drawing upon four research case studies, we
consider how methods and concepts in the social and epidemiologic sciences might be brought together towards understanding
HIV risk as an effect of social, cultural and political condition. The case studies draw upon different combinations of methods
(qualitative, ethnographic and quantitative) and disciplines (sociology, anthropology and epidemiology) in different social
contexts of HIV vulnerability (street settings in Russia, Serbia and North America and a cross-border setting in Mexico) among
a range of marginalised high-risk populations (injection drug users and female and transvestite sex workers). These case studies
illustrate the relevance of the social science concepts of “structural violence” and “structural vulnerability” for a social
epidemiology of HIV risk. They also explore how social epidemiologic work can benefit from the mixing of social science methods
and theories. We contend that social epidemiology cannot advance in its understanding of structural vulnerability without
embracing and relying upon ethnographic and qualitative approaches. We put ­forward the linked concepts of “structural violence,”
“structural vulnerability” and “risk environment” as building blocks for a theory-informed social epidemiology of HIV risk
among marginalised populations.

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    ABSTRACT: Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome surveillance data are critical for monitoring epidemic trends, but they can mask dynamic subepidemics, especially in vulnerable populations that underuse HIV testing. In this case study, we describe community-based epidemiologic data among injection drug users (IDUs) and female sex workers (FSWs) in two northern Mexico-U.S. border states that identified an emerging HIV epidemic and generated a policy response. We draw from quantitative and qualitative cross-sectional and prospective epidemiologic studies and behavioral intervention studies among IDUs and FSWs in Tijuana, Baja California, and Ciudad Juarez, Chihuahua. The recognition that the HIV epidemic on Mexico's northern border was already well established in subgroups in whom it had been presumed to be insignificant was met with calls for action and enhanced prevention efforts from researchers, nongovernmental organizations, and policy makers. Successful policies and program outcomes included expansion of needle-exchange programs, a nationwide mobile HIV prevention program targeting marginalized populations, a successful funding bid from the Global Fund for HIV, TB, and Malaria to scale up targeted HIV-prevention programs, and the establishment of bi-national training programs on prevention of HIV and substance use. We discuss how epidemiologic data informed HIV prevention policies and suggest how other countries may learn from Mexico's experience.
    Annals of epidemiology 06/2012; 22(6):426-38. · 2.95 Impact Factor
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    ABSTRACT: Women new to sex work and those with a greater degree of mobility have higher risk of HIV infection. Using social capital as a theoretical framework, we argue that better understanding of the interactions of micro-level structural factors can be valuable in reshaping and restructuring health promotion programmes in Bali to be more responsive to the concerns and needs of newcomer and mobile female sex workers (FSWs).
    BMC Public Health 08/2014; 14(1):832. · 2.08 Impact Factor
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    ABSTRACT: HIV among people who inject drugs (PWID) is a major public health concern in Eastern and Central Europe and Central Asia. HIV transmission in this group is growing and over 27 000 HIV cases were diagnosed among PWID in 2010 alone. The objective of this systematic review was to examine risk factors associated with HIV prevalence among PWID in Central and Eastern Europe and Central Asia and to describe the response to HIV in this population and the policy environments in which they live. A systematic review of peer-reviewed and grey literature addressing HIV prevalence and risk factors for HIV prevalence among PWID and a synthesis of key resources describing the response to HIV in this population. We used a comprehensive search strategy across multiple electronic databases to collect original research papers addressing HIV prevalence and risk factors among PWID since 2005. We summarised the extent of key harm reduction interventions, and using a simple index of 'enabling' environment described the policy environments in which they are implemented. Of the 5644 research papers identified from electronic databases and 40 documents collected from our grey literature search, 70 documents provided unique estimates of HIV and 14 provided multivariate risk factors for HIV among PWID. HIV prevalence varies widely, with generally low or medium (<5%) prevalence in Central Europe and high (>10%) prevalence in Eastern Europe. We found evidence for a number of structural factors associated with HIV including gender, socio-economic position and contact with law enforcement agencies. The HIV epidemic among PWID in the region is varied, with the greatest burden generally in Eastern Europe. Data suggest that the current response to HIV among PWID is insufficient, and hindered by multiple environmental barriers including restricted access to services and unsupportive policy or social environments.
    BMJ Open 01/2012; 2(5). · 1.58 Impact Factor

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