POPS Chapter 24 – Structural Interventions for HIV Prevention


24.1 Effective Structural Interventions

24.2 Minimum Required Components of Structural Interventions 

24.3 Confidentiality 

24.4 Quality Assurance and Evaluation Requirements 

24.5 Satisfaction Surveys

24.6 Retention of Client Records and Record Destruction

Purpose: This chapter provides guidelines for the delivery of Structural Interventions (SIs). SIs may vary widely, therefore this guidance is broad in nature and is designed to help agencies identify community or system needs and implement programmatic activities while evaluating and assuring the quality of interventions.

For more information, visit CDC’s Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention Structural Interventions Chapter. For specific technical assistance related to an intervention or activity, contact your HIV Prevention Consultant at DSHS.

24.1 Effective Structural Interventions

SIs are projects designed to reduce HIV acquisition and transmission through changing community norms, behaviors, policy, organizational structures, systems of care and/or power structures. SI projects can include activities, events, meetings, or campaigns that can have the following outcomes:

  • Increasing social support for persons in priority populations;
  • Reducing stigma;
  • Addressing needs for social services in highly impacted areas where priority populations live; or
  • Changing policies or organizational structures that are barriers to HIV services.

SIs focus on establishing a network of collaborative partners within the community, activities or events for priority populations, and engagement within the community. Program activities should be designed to change policies, social or organizational structures, procedures to increase access and acceptance of services and remove barriers to prevention, or HIV/STD/HCV testing and treatment services.

24.1.1 Priority Populations

Behavioral change interventions must focus on populations most vulnerable to acquiring or transmitting HIV. Local epidemiological data should be used to determine which populations should be prioritized.

Adapting or tailoring interventions may be necessary to meet the unique needs of the local priority population. These adaptations must be based on theory, justified need, and/or observation, and must be approved by DSHS in writing prior to implementation.

24.2 Minimum Required Components of Structural Interventions

Agencies may adopt or create effective interventions that match their organizational resources, existing programming, and the local prevention landscape. Required program components for SIs include:

  1. Community and systems need assessments;
  2. Intervention plan;
  3. Community engagement and recruitment plans; and
  4. Collaborations with community partners.

24.2.1 Community Assessment

Agencies funded for structural level interventions are required to conduct an initial assessment of their community. Once the initial assessment is conducted, agencies may perform follow-up surveys as needed to gauge the effectiveness of the intervention within the community. Programs can conduct ongoing assessments and integrate data from assessments to determine changes that may have occurred in the community.

DSHS contractors must use community assessments to evaluate and improve community engagement and recruitment strategies. If it is determined that your program is not reaching the priority population, or your agency is not on track to meet performance measures, different recruitment strategies should be considered. Agencies will make changes to programs accordingly.

24.2.2 Intervention Plan

Agencies should develop an intervention plan that identifies priority populations to be served and summarizes program activities or events that will foster structural, systemic or community change. Intervention plans can be influenced by established evidence-based interventions or be home-grown interventions that are informed by theory, justified need, and/or observation. Established evidence-based structural interventions are listed on the CDC’s Effective Interventions or Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention websites.

SI plans include a variety of activities to engage the community and partners and can effect change. Plans must summarize anticipated major activities, milestones, and goals within the given year and describe ways of monitoring and reporting progress. Events should be culturally responsive and resonate with members of the priority population that the agency wishes to reach.

Agencies are expected to create an intervention plan for each separate intervention and submit them to the DSHS Prevention Consultant for approval. Agencies may adapt their intervention plan with DSHS approval and as guided by new information about community needs and resources.

24.2.3 Community Engagement

Agencies implementing SIs must have the ability to access priority populations through face-to-face interactions, social media or online methods, and traditional marketing strategies. Below is a table detailing the types of engagement activities and which structural interventions might be used to engage the community.

Face-to-Face Social Media/Online Traditional
  • Street/venue-based outreach
  • Community events (e.g., Health fairs, Pride events)
  • Condom distribution
  • Workshops, seminars, and event-based presentations
  • Community partnerships and mobilization
  • Small/medium scale events
  • Large scale events
  • New media engagement (e.g., apps, social networking sites)
  • Online dating platform/app outreach
  • Social media/app campaigns
  • Livestreamed events on new media platforms
  • Virtual workshops, seminars, and event-based presentations
  • Print media placement
  • Television/Radio commercials or interviews
  • Billboards
  • Poster campaigns
  • Mailer campaigns

Programs should develop a mechanism, data table, or spreadsheet for tracking engagement according to their intervention plan. The mechanism and documentation of community engagement should be detailed in the workplan and updated as necessary. This shall assist programs in filling out the Texas DSHS Structural and Community Intervention Spreadsheet, which will be submitted through GlobalScape monthly or as per reporting requirements.

24.2.4 Recruitment

For structural interventions to be successful, agencies will need input from and participation from members of the priority populations who will benefit from the actions of the agency. Recruitment of individuals to intervention activities will need to be tailored to the social, cultural, and linguistic needs of these communities. This process will help agencies tailor messages, events, and services in a way that resonates with priority population(s) and develop a plan for how to engage these communities.

As part of their workplan, DSHS contractors are expected to develop a recruitment plan that outlines when, where, and how recruitment of the priority population(s) will be conducted. The plan must include ideas about where to reach the priority population(s), as well as the specific recruitment strategies and messages that will be used for engaging them in HIV prevention services.

In order to have an effective and innovative program, resources should be dedicated to implementing a recruitment plan. Successful SI programs typically:

  • hire and train recruitment staff who are separate from other prevention staff, and who are from the communities you serve;
  • build partnerships in the community to ensure multidirectional referrals and expand recruitment networks;
  • use innovative approaches for reaching the priority population through the internet and social media;
  • offer tangible reinforcements (see Tangible Reinforcements POPS) to reach previously underserved subpopulations, generate interest in new services, or increase retention; and
  • provide status-neutral supportive services that meet the needs of individuals beyond HIV-related services.

A comprehensive recruitment plan aims to deliver strategic, culturally responsive, community-based recruitment strategies that engage the priority population and motivate them to access HIV prevention services.

24.2.5 Collaboration with Community Partners

SIs require community and stakeholder engagement through mechanisms such as community advisory boards, core groups of priority population members, program material review panels, etc. Agencies are required to solicit and maintain the involvement of community members. Agencies should create, enhance and draw upon formal partnerships, coalitions, networks of individuals and organizations to respond to the HIV prevention needs of their area.

The program should maintain a current and comprehensive record of collaborations which can be documented through:

  • Current agreements for services, referrals and activities, Memoranda of Agreement (MOAs) that are updated as per contract.
  • Community Advisory Board, core group or Community Mobilization meeting minutes or sign-in sheets.
  • Community partner surveys or assessments.

Documentation of collaborations should be explained in the program’s workplan and be available for DSHS review.

24.3 Confidentiality

All information is confidential. At a minimum, facilitators are expected to maintain and demonstrate a high level of confidentiality regarding the information of individuals being served and strictly adhere to the policies and procedures of their agencies. Releasing any information to unauthorized persons which leads to the disclosure of an individual’s identity is a breach of confidentiality and punishable by applicable statutes and administrative regulations.

Violation: In accordance with Health and Safety Code HSC §81.103 Confidentiality; Criminal Penalty, breach of confidentiality is a Class A misdemeanor and is punishable by up to one year in jail and fines of up to $5,000. Violation of confidentiality is also a civil offense that may result in liability for damages plus fines.

24.4 Quality Assurance and Evaluation Requirements

Agencies must carry out activities as indicated in their workplan and must conduct periodic assessments of progress following a formal evaluation and quality assurance (QA) plan. A robust evaluation and QA plan will include clearly identified process and outcome measures, data collection protocols, data analysis, and a process for program modification/improvement based on evaluation results (to include ways to increase the “reach” of services to the populations to be served).

One way to evaluate the results of activities is through process and outcome monitoring. Agencies will incorporate monitoring activities designed to ensure adherence to their approved intervention plan and to adjust in response to changes in the prevention landscape (following discussion and approval by DSHS). Information regarding tools on Outcome Monitoring can be found on the DSHS Outcome Monitoring page. Results of evaluations regarding programmatic effectiveness must be shared with DSHS.

A person or persons responsible for data collection, submission, and quality assurance is to be in place per DSHS requirements. For more detailed information, visit the DSHS Prevention Data Resources page.

24.4.1 Staff training

Contractors must maintain policies and procedures to address quality assurance and training requirements. Prior to implementation of a structural intervention personnel shall:

  1. Complete the required trainings approved by DSHS.
  2. If a program is implementing an established intervention based on CDC’s effective interventions:
    1. Staff implementing the intervention will complete training on the specific intervention, if applicable;
    2. Staff will follow the observation and/or chart documentation tool in the intervention’s training materials. If a staff observation tool is not included, the contractor shall develop its own tools to ensure fidelity to intervention.

24.4.2 Staff Observations

Observations of intervention facilitators must be conducted according to the following schedule:

Length of time the staff member has been performing the intervention: Staff will be monitored at least:
3 months or less One out of every 3 sessions
4 to 6 months Twice a month
7 to 12 months Monthly
1 to 2 years Quarterly
2 years or more Every six months

A staff observation tool specific to the intervention must be used and all staff observations are to be documented and available for DSHS review.

24.4.3 Required Documentation

To report on intervention activities, it will be necessary to document at minimum:

  • Number of clients from priority populations who engage in intervention activities/events;
  • Evidence that intervention activities are developed for and attended by members of the priority population;
  • Engagement with community partners in collaboration meetings or co-hosted events; and
  • Community feedback and review of outreach materials to ensure they are appropriate and culturally resonate with priority populations.

Documentation may take the form of event sign-in sheets; outreach logs; annual or semi-annual survey of intervention activities; community partner meetings; program material review panels (PMRP) etc.

Any agency that receives HIV funding from the CDC or DSHS must convene or identify a PMRP to review educational materials. These education and outreach materials may be written, audiovisual or pictorial and will include social marketing, advertising materials, educational materials, and social media communications. This is required for any materials that provide HIV-related information for the various populations a program may wish to reach. Information about PMRPs requirements and documentation can be found on the PMRP website.

Programs should use their workplan to make it clear how they intend to track, document, store, and report engagement.

Documentation of intervention activities should still abide by parameters set forth in the confidentiality section above. Documentation should be available to DSHS for review.

24.5 Satisfaction Surveys

Satisfaction surveys must be conducted annually. Findings from the surveys should be used to improve services. Documentation of this improvement must be available for DSHS review.

24.6 Retention of Client Records and Record Destruction

The agency will have a system in place that complies with current confidentiality laws to protect client or patient records and documents maintained in connection with HIV/STD prevention activities. Retention and record destruction guidelines are detailed in Program Operation Procedures and Standards Chapter 2. See sections 2.3 and 2.4 for further information on retention and destruction of client records.