Addressing structural determinants of HIV

Many sex workers become involved in sex work while young, sometimes migrating from
rural areas to cities. Young migrants frequently move to the city to escape childhood
marriages or to assume responsibility for contributing to family income, sometimes as sole
providers. Measures are needed to prevent children and young people from being recruited
into sex work, including ensuring the availability of educational and work opportunities,
addressing family and social breakdown, increasing awareness of the health and other risks
associated with sex work, ensuring the availability of social protection safety nets (including
those required to mitigate the impacts of AIDS) and ensuring that all forms of child labour
are eliminated.
Addressing structural determinants of HIV risk and vulnerability is inevitably challenging,
as such approaches seek to alter complex and longstanding social, economic, political and
environmental factors80. While some may argue that structural interventions are too timeconsuming
or open-ended or that they divert resources from immediate HIV control
priorities, it is clear that the epidemic will not be reversed, nor will progress on HIV be
sustained, unless effective action is taken to address the structural factors that increase HIV
risk and vulnerability।
Gender equality, gender norms and relations
Gender inequality causes many women to enter sex work. Globally, most sex workers
are women or girls. With unequal access to education, employment, credit or financial
support outside marriage, women and girls often see sex work as one of the few options
available to support themselves81. Such economic pressures are compounded for women
whose husbands have died or abandoned them or who otherwise bear the primary burden
of supporting their families. Gender inequalities also result in stricter regulation of sexual
behaviour of women, girls, and men who have sex with men. Hypocrisy, denial, and taboos
associated with sex and sexuality impede effective programming on HIV and sex work.
An effective, sustainable response to HIV requires evidence-informed measures to address
the unequal relations between women and girls, men and boys, and men who have sex
with men82. Evidence-informed programmes to forge norms of gender equity should
be brought to scale, with particular attention to initiatives focused on men and boys83.
For example, programmes to promote dialogue and critical reflection among young men
regarding gender inequalities have been shown to significantly reduce their support for
inequitable gender norms, and to significantly increase condom use and decrease intimate
partner violence84. There is a much broader need for programmes that address norms and
practices concerning sexuality, marriage and reproduction; harmful cultural practices that
injure or disadvantage women; and the unequal access of women and girls to social, legal,
and political rights.85 Family and community structures should be strengthened to protect
young people from sexual exploitation. Religious leaders, educators and other community
leaders should be mobilized to advocate for a cultural environment that refuses to tolerate
sexual exploitation, including child marriage86