From population to HIV: the organizational and structural determinants of HIV outcomes in sub-Saharan Africa

There exists no consistent explanation for why some countries are successful in combating HIV/AIDS and others are not, and we need such an explanation in order to design effective policies and programmes. Research evaluating HIV interventions from a biomedical or public health perspective does not always take full account of the historical and organizational characteristics of countries likely to influence HIV outcomes. The analysis in this paper addresses this shortcoming by testing the impact of organizational and structural factors, particularly those resulting from population interventions, on HIV outcomes at the country level in sub-Saharan Africa.

The primary independent variables are factors that originated from efforts to slow population growth: whether a country has a long-time affiliate of the International Planned Parenthood Federation and whether a country has a population policy. Additional structural factors likely to impact HIV outcomes include the level of wealth, the level of cultural fractionalization, and the former colonial power. The present study uses multivariate regression techniques with countries in sub-Saharan Africa as the unit of analysis, and four measures of success in addressing HIV: the change in prevalence between 2001 and 2009; the change in incidence between 2001 and 2009; the level of overall antiretroviral coverage in 2009; and the level of antiretroviral coverage for prevention of vertical transmission in 2009.

Countries with the greatest declines in HIV prevalence and incidence had older International Planned Parenthood Federation affiliates and had adopted population policies, even after controlling for age of epidemic, level of antiretroviral coverage, and funding for HIV. Population policies are also important predictors of levels of overall antiretroviral coverage and of coverage of HIV-positive pregnant women to prevent vertical transmission. Structural factors with significant impacts include wealth, cultural fractionalization and former colonial power.

The organizational and structural context of African countries is strongly predictive of HIV outcomes. This finding implies that policy and programmatic efforts should be put towards strengthening existing organizations and perhaps even creating new ones. The fact that cultural fractionalization also influences HIV outcomes suggests that efforts must be put towards identifying ways to reach political consensus in diverse societies.