What Works for Women and Girls

Strengthening the enabling environment must be done at a structural level (Rao Gupta etal., 2008). Structural interventions need a multi-pronged strategy, as well as political will andcommitment at all levels, as evident, for example, in Uganda in the 1990s where “an array ofpreventive policies and strategies, mounted by different agencies, with strong partnershipsbetween the media, government, NGOs, sex workers, people living with HIV/AIDS and internationaland local public health agencies, endorsed at the highest political level...the need forbroader, integrated programmes in which all components are mutually reinforcing” (Wellingset al., 2006: 39).Yet, structural interventions are challenging to evaluate. [See Chapter 2. Methodology] Giventhe discussion in the methodology section about determinants of HIV infection and the pathwaysthrough which interventions must work, it is clear that enhancing the enabling environmentis important but that structural interventions, as described in this chapter, are more difficultto correlate with HIV infection. Proving “what works,” is challenging. For example, thepathway from changing gender norms to women being able to refuse sex or insist on condomuse is indirect and can be influenced by many other factors. In the case of the enabling environment,it would not be possible to conduct a study using randomized control trial methodology,therefore the level of evidence, as measured by the Gray Scale, tends to be lower. Studies tendto be cross sectional, without control groups. Nevertheless, the environment in which womenand girls live and work plays an enormous role in women’s vulnerability to HIV. Strengtheninga supportive environment for women and girls is integral to their ability to overcome the challengeswomen face in prevention, treatment and care of HIV.Building Social Capital is Central to Strengthening theEnabling EnvironmentMuch has been written on the relationship between HIV/AIDS and social capital, characterizedby Putnam (1993: 167) as “features of social organization, such as trust, norms andnetworks that can improve the efficiency of society by facilitating co-ordinated actions.” Thenotion that networks, relationships and a sense of belonging matter is at the core of work onsocial capital and HIV. Building social capital is central to strengthening the enabling environment.A review of the importance of NGO involvement in responding to the AIDS epidemic inUganda concluded that “well-developed social capital leads to social inclusion, it helps in informationflow, [and] reduces stress” (Jamil and Murhsa, 2004: 26). Through fostering supportsystems of groups of people living with HIV and AIDS, NGOs in Uganda and other countrieshave helped build social capital. In the United States, increased social capital has been foundto be associated with lower HIV rates (Holtgrave and Crosby, 2003). Research in Namibia onthe effect of involvement in social support on prevention behavior found “support for the linkbetween social capital and greater HIV-related efficacies,” or the notion that one could actto protect against HIV (Smith and Rimal, 2008: 142). The IMAGE program in South Africa288 CHAPTER 11 STRENGTHENING THE ENABLING ENVIRONMENT