HIV and chemoprophylaxis, the importance of considering social structures alongside biomedical and behavioral intervention.

This manuscript draws connections between chemoprophylaxis and the biomedical model of disease that emphasizes individual behavior. We argue that chemoprophylactic HIV interventions have limited utility at the population-level, and that structural interventions need to be prioritized. We use the recent CAPRISA 004 and iPrEx trials to (a) critique the utility of these trials from a public health perspective by highlighting the difference between efficacy and effectiveness, (b) apply an alternative theory of health behavior as a way to reorient the field toward the discussion of the need to employ structural interventions, and (c) examine two aspects of HIV prevention efforts - funding structures and iatrogenic effects of biomedical approaches - as a means of overcoming obstacles to more widespread adoption of structural interventions.