COVID-19 combination prevention requires attention to structural drivers

Richard Horton draws parallels between the colliding pandemics of COVID-19 and HIV, observing that both “exploit and accentuate inequalities”.¹ He and others² advocate that responses to COVID-19 learn from HIV combination prevention approaches. However, it is key that in doing so, prevention measures go beyond the behavioural interventions they call for, to include interventions that are structural and systemic in nature.

The HIV movement demanded action on social, economic, political, and legal factors that undermine people adopting effective prevention measures. The aim was to create enabling environments that liberate people, particularly vulnerable groups, to exercise agency to practise healthy behaviours. These efforts ranged from targeting international patent laws and monopolies that put the price of treatment out of reach of people living with HIV; taking steps to decriminalise sex work, drug use, and LGBTI people; ending violence against women, girls, and key populations; and challenging stigma and discrimination, which remains one of the most substantial barriers to an effective HIV response. We advocated for cash transfer programmes to lessen vulnerability to HIV risk and demanded innovative financing to increase AIDS budgets.

A rights-based combination prevention approach that addresses the structural drivers of inequality of risk and inequity of responses is as crucial to COVID-19 as it remains for HIV. We call for measures that include: a people's vaccine;³ a moratorium on debt repayments and progressive taxation to enable a mass roll-out of social protection, food, and income support programmes; removal of punitive laws that block access to health and social services; and civil society expertise and meaningful representation in COVID-19 governance and accountability structures⁴ as key components of COVID-19 combination prevention.