Modified social ecological model: A tool to guide the assessment of the risks and risk contexts of HIV epidemics

BMC Public Health (Impact Factor: 2.26). 05/2013; 13(1):482. DOI: 10.1186/1471-2458-13-482
Source: PubMed


Social and structural factors are now well accepted as determinants of HIV vulnerabilities. These factors are representative of social, economic, organizational and political inequities. Associated with an improved understanding of multiple levels of HIV risk has been the recognition of the need to implement multi-level HIV prevention strategies. Prevention sciences research and programming aiming to decrease HIV incidence requires epidemiologic studies to collect data on multiple levels of risk to inform combination HIV prevention packages.

Proximal individual-level risks, such as sharing injection devices and unprotected penile-vaginal or penile-anal sex, are necessary in mediating HIV acquisition and transmission. However, higher order social and structural-level risks can facilitate or reduce HIV transmission on population levels. Data characterizing these risks is often far more actionable than characterizing individual-level risks. We propose a modified social ecological model (MSEM) to help visualize multi-level domains of HIV infection risks and guide the development of epidemiologic HIV studies. Such a model may inform research in epidemiology and prevention sciences, particularly for key populations including men who have sex with men (MSM), people who inject drugs (PID), and sex workers. The MSEM builds on existing frameworks by examining multi-level risk contexts for HIV infection and situating individual HIV infection risks within wider network, community, and public policy contexts as well as epidemic stage. The utility of the MSEM is demonstrated with case studies of HIV risk among PID and MSM.

The MSEM is a flexible model for guiding epidemiologic studies among key populations at risk for HIV in diverse sociocultural contexts. Successful HIV prevention strategies for key populations require effective integration of evidence-based biomedical, behavioral, and structural interventions. While the focus of epidemiologic studies has traditionally been on describing individual-level risk factors, the future necessitates comprehensive epidemiologic data characterizing multiple levels of HIV risk.

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Available from: Andrea L Wirtz, Apr 29, 2014
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    • "The survey included modules characterizing multiple levels of HIV risk as explained in the Modified Social Ecological Model (MSEM), which characterizes the various levels of HIV risk among key populations. These levels include the individual, network, community, public policy, and prevalence or incidence of HIV in country (or epidemic stage) (Baral et al., 2013). "
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    ABSTRACT: Objectives. This study examined correlates of condom use among 248 female sex workers (FSW) in The Gambia. Methods. Between July and August 2011, FSW in The Gambia who were older than 16 years of age, the age of consent in The Gambia, were recruited for the study using venue-based sampling and snowball sampling, beginning with seeds who were established clients with the Network of AIDS Services Organizations. To be eligible, FSW must have reported selling sex for money, favors, or goods in the past 12 months. Bivariate and multivariate logistic regressions were used to determine associations and the relative odds of the independent variables with condom use. Four different condom use dependent variables were used: consistent condom use in the past six months during vaginal or anal sex with all clients and partners; consistent condom use in the past month during vaginal sex with new clients; consistent condom use in the past month during vaginal sex with nonpaying partners (including boyfriends, husbands, or casual sexual partners); and condom use at last vaginal or anal sex with a nonpaying partner. Results. Many FSW (67.34%, n = 167) reported it was not at all difficult to negotiate condom use with clients in all applicable situations, and these FSW were more likely to report consistent condom use with all clients and partners in the past 6 months (aOR 3.47, 95% CI [1.70-7.07]) compared to those perceiving any difficulty in condom negotiation. In addition, FSW were more likely to report using condoms in the past month with new clients (aOR 8.04, 95% CI [2.11-30.65]) and in the past month with nonpaying partners (aOR 2.93, 95% CI [1.09-7.89]) if they had been tested for HIV in the past year. Women who bought all their condoms were less likely than those who received all of their condoms for free (aOR 0.38, 95% CI [0.15-0.97]) to have used a condom at last vaginal or anal sex with a nonpaying partner. Conclusions. HIV and sexually transmitted infection (STI) prevention interventions for FSW should aim to improve condom negotiation self-efficacy since women who report less difficulty negotiating condom use are more likely to use condoms with clients. Interventions should also be aimed at structural issues such as increasing access to free condoms and HIV testing since these were positively associated with condom use among FSW.
    PeerJ 08/2015; 3(2):e1076. DOI:10.7717/peerj.1076 · 2.11 Impact Factor
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    • "The strength or weakness of the economy of a region also plays an important role in determining the health of the community, due to factors such as employment and standard of living. At the community level, social norms may promote health behaviors or worsen them through stigma and other cultural or religious beliefs (Baral et al., 2013; Poundstone et al., 2004). Therefore, consideration of the totality of the risk environment is tantamount to understanding what drives the HIV epidemic in each diverse region. "
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    • "One possible explanation for this is that younger FSWs may be more likely to inject drugs, as the age disaggregation among non-FSW-PWIDs for Kyrgyzstan shows a similar pattern. There is also limited evaluation of the multi-level risk factors potentiating HIV risk among FSWs in the region, particularly network and structural factors (Baral et al., 2013). For example, in considering structural factors, sex work and substance use are illegal in most of Central Asia and police have been mentioned as a threat to FSWs in Turkmenistan, Kazakhstan, Uzbekistan, and Kyrgyzstan . "
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