Drawing on the tenets of critical medical anthropology, this article illustrates the relation between violence, drug use, prostitution, and HIV risk in a group of 35 impoverished women living in inner-city Hartford, Connecticut. The study presented here provides an illustration of the role prostitution plays in the SAVA (Substance Abuse, Violence, and AIDS) syndemic as conceptualized by Singer (1996). By focusing on the life experiences of women engaged in street-level prostitution, this article attempts to fill the gaps in research that deals simultaneously with these mutually reinforcing epidemics. It shows that street-walkers' continuous exposure to violence, both as victims and as witnesses, often leaves them suffering from major emotional trauma. In the absence of adequate support services, women who have been victimized may turn to drug use in an attempt to deal with the harsh realities of their daily lives. In turn, the need for drugs, coupled with a lack of educational and employment opportunities, may lead women into prostitution. Life on the street increases women's risk for physical, emotional, and sexual abuse as well as their risk for HIV/AIDS. Exposure to traumatic experiences deepens the dependence on drugs, completing a vicious cycle of violence, substance abuse, and AIDS risk.

We present a model for HIV-related behaviors that emphasizes the dynamic and social nature of the structural factors that influence HIV prevention and detection. Key structural dimensions of the model include resources, science and technology, formal social control, informal social influences and control, social interconnectedness, and settings. These six dimensions can be conceptualized on macro, meso, and micro levels. Given the inherent complexity of structural factors and their interrelatedness, HIV prevention interventions may focus on different levels and dimensions. We employ a systems perspective to describe the interconnected and dynamic processes of change among social systems and their components. The topics of HIV testing and safer injection facilities are analyzed using this structural framework. Finally, we discuss methodological issues in the development and evaluation of structural interventions for HIV prevention and detection. KeywordsHIV; AIDS; structural factors; diagnosis; prevention Structural interventions have had a profound impact on public health. Even a casual observer of history can see the connection between structural changes such as water purification or highway safety and reductions in morbidity and mortality. Structural interventions can have a tremendous effect on individual-level health behaviors as well. Legislative changes such as regulating tobacco sales and usage have led individuals to modify their health behaviors and dramatically reduced smoking rates. 1Although structural approaches to health promotion are clearly effective, they are often viewed as outside the purview of behavioral interventionists. Prevailing conceptions of "cause" as immediate and necessary antecedents of health outcomes consider factors that affect outcomes in more indirect and indefinite ways as less important or less relevant. 2,3 Structural factors have also been neglected because researchers in the field of HIV prevention are often unprepared to develop and evaluate strategies to change laws, social organizations, or physical structures. Moreover, because of the scope and focus of structural interventions, randomized controlled trials, the gold standard to evaluate interventions'

Introduction-Research shows that condoms are least likely to be used in primary relationships. A deeper understanding of the expectations women and men hold when entering into these relationships, as well as how decisions related to condom use and other prevention behaviors are made, is essential if we are to curb the spread of HIV.

Here we present results from a process evaluation of a peer-led HIV prevention intervention. The Risk Avoidance Partnership, conducted from 2001 to 2005, trained active drug users to be peer health advocates (PHAs) to provide harm reduction materials and information to their peers. Results indicate that PHAs actively conducted harm reduction outreach both when partnered with staff and on their own time. Although PHAs conducted most of their outreach in public locations, they also provided drug users with harm reduction materials at critical moments in places where HIV risky behaviors were likely to occur. PHAs were credible and trusted sources of information to their drug-using peers who sought PHAs out for HIV prevention materials. Process evaluations of successful HIV prevention interventions are necessary to understand how and why such interventions work for further intervention refinement.

Vaginal microbicides may improve prevention outcomes for high-risk inner-city women.