Bronfenbrenner’s (1979) ecological systems theory provides a useful framework from which to multidimensionally examine the macro-level factors associated with the HIV epidemic among young people. As in adults, HIV infection among youth, including ethnic minority youth, is influenced by a broad number of factors, including biological, genetic, individual, interpersonal (including family and peer), as well as social and economic determinants. These determinants can be mapped onto Bronfenbrenner’s four subsystems that explain the multiple influences on adolescent development according to their proximity: macrosystems—the broad social and philosophical ideals that define a particular culture (e.g., cultural values); exosystems—contexts in which the adolescent does not participate directly but that impact the functioning of important persons in the adolescent’s life (e.g., parents’ support system); mesosystems—contexts that comprise the interactions between important persons in the different contexts in which the adolescent participates directly (e.g., parental monitoring of peers); microsystems—contexts in which the adolescent participates directly (e.g., family); and interpersonal psychological or cognitive factors such as knowledge and beliefs. Given the present article’s emphasis on macro-level factors, we focus on interventions originating in the macrosystem or targeting macrosystem processes or factors.

Components of the macrosystem include cultural and societal values, gender norms, bodies of knowledge, customs, material resources, opportunity structures, potential life-course trajectories, and the economic stability of the country in which one lives (Bronfenbrenner, 1979, 1989). Embedded within the cultural and social context are a myriad of factors that contribute to young people’s vulnerability to HIV infection and its extant health disparities. Macro-level determinants of adolescent HIV risk include stigma and discrimination, access to quality preventive and educational services and programs, residential segregation, national economic stability, and socioeconomic factors. Additionally, gender norms constitute another important macro-level factor that influences HIV infection (Laub, Somera, Gowen, & Diaz, 1999). We propose that these macro-level characteristics can elevate risk for both precipitating risky sexual behaviors and deterring the use of testing services. Below, we discuss the evidence involving mediational pathways to these behavioral outcomes. To understand the mediational pathways from macro-level determinants to behavioral outcomes, such as unsafe sexual behavior, it is important to understand frameworks, such as ecodevelopmental theory (Szapocznik & Coatsworth, 1999), that describe the influence of macro-level determinants on individual-level behaviors.

Ecodevelopmental theory (Szapocznik & Coatsworth, 1999), an extension of Bronfenbrenner’s work on the social ecology (Bronfenbrenner, 1979, 1986), is a theoretical framework that can be used to illustrate how macro-level determinants can have an indirect effect on individual-level characteristics. For example, one of the key elements of ecodevelopmental theory is social interactions. Ecodevelopmental theory postulates that risk and protection are expressed in the patterns of relationships and direct transactions between individuals within and across different contextual levels, including macrosystemic levels (Szapocznik & Coatsworth, 1999). For example, in the case of Hispanic/Latino immigrant youth, ecodevelomental theory suggests that macrosystemic phenomena, such as the mismatch between a family’s culture of origin and that of the host country, produce a “trickle-down” effect by contributing to exosystemic problems such as parental isolation, which in turn may cut parents off from their adolescents’ peer networks (i.e., mesosystemic problems; Pantin, Schwartz, Sullivan, Prado, & Szapocznik, 2004). Clinical literature suggests that when immigrant parents are unfamiliar with the culture of their new homeland, they tend to remain isolated and to not reach out for social support (Leon & Dziegielewski, 2000). Lack of social support, in turn, may inhibit supportive and involved parenting (Simons, Beaman, Rand, & Chao, 1993). Lack of parental involvement in the adolescent’s peer world (mesosystemic problem) then increases the likelihood that youth will engage in HIV risk behaviors (Boyer, Tschann, & Shafer, 1999; Luster & Small, 1994). Prado and colleagues (2010) showed that macro-level determinants of health, such as culture, had an indirect effect on Hispanic/Latino adolescent HIV risk behaviors through their effect on parental stressors, parental social support, family functioning, school functioning, and peer sexual behavior. Thus, macro-level factors have a direct or an indirect impact on HIV risk behaviors and HIV infection and deserve greater attention if we are to more fully understand how to best intervene in HIV transmission.

Although there are established theoretical frameworks (e.g., the theory of reasoned action, the health belief model) that have been used to guide the development of individual-level HIV preventive interventions, there are no “standard” theoretical frameworks that currently guide macro-level interventions. One theoretical framework that has received recent attention in the HIV literature is intersectionality theory. Historically used in Black feminist theory, inter-sectionality theory (Bowleg, 2012) is a theoretical framework that explores how micro-social characteristics (e.g., race, ethnicity, gender, sexual orientation, SES, gender) and inequalities at the macro level (e.g., racism, sexism) are mutually constructed and interdependent (Bowleg, 2012; Logie, James, Tharao, & Loutfy, 2011). Because ethnicity, race, sexual orientation, poverty, discrimination, and stigma are at the heart of the HIV epidemic, intersectionality is one framework that has the potential to inform future structural HIV preventive interventions (Bowleg, 2012).

Since the first HIV/AIDS cases were reported in the 1981 Morbidity and Mortality Weekly Report (CDC, 2001), and the subsequent increase in diagnoses and deaths, HIV/AIDS-related discrimination has had serious consequences at every level of the ecosystem. The ambiguity surrounding the rare “pneumonia” diagnosed in homosexual men in the 1980s perpetuated a rapid surge of fear, anxiety, and stereotyping around the world. Physicians, law enforcement personnel, and school superintendents reflected the public’s pervasive distress by refusing to treat patients with HIV/AIDS, engaging in police brutality toward gay men, and dismissing young people living with HIV/AIDS from school (Comstock, 1991; Klein, Karchner, & O’Connell, 2002). By the end of the decade, the gay community became the poster child for HIV/AIDS and the lynchpin for hate crimes, discriminatory laws, and modern-day homophobia (Herek, 2011; Herek & Capitanio, 1999; Herek, Gillis, & Cogan, 2009). By the mid-1990s, the public’s outcry for the forced quarantining of people living with HIV/AIDS dissipated, but other overt forms of discrimination went on unchecked: People with or suspected of having HIV/AIDS were denied housing and employment, served more stringent sentences, and were banished from social organizations (Stewart, Cianfrini, & Walker, 2005). Despite the efforts of powerful HIV/AIDS activists and prevention organizations, evidence of socially significant decreases in HIV/AIDS discrimination is scarce (Herek, Capitanio, & Widaman, 2002; Nachega et al., 2012; Schuster et al., 2005). HIV/AIDS discrimination and stigma continue to operate at macrosystemic levels and function as a determinant of health that impacts behavior.

Perhaps one of the most widely publicized macro-level determinants of adolescent HIV risk is how social and cultural norms manifest as stigma and discrimination. Generalized stigmatization of chronic disease, sexuality, and drug use, as well as HIV-specific stigma, affect HIV risk and vulnerability. HIV-related stigma refers to prejudice, discounting, discrediting, and discrimination targeted at individuals perceived to be infected with HIV or AIDS (Herek & Capitanio, 1999). HIV stigma is not limited by sociodemographic factors and, as a result, can generate mass societal aversion toward marginalized groups of people. Social stigma and cultural taboos regarding HIV and HIV risk behaviors act to increase risk among adolescents by influencing adolescents’ HIV knowledge and impeding adolescents’ efforts to practice HIV prevention strategies (e.g., condom use, HIV/STD testing; Tinsley, Lees, & Sumartojo, 2004). For example, fear and stigma may make it difficult for some young MSM to be open about same-sex behaviors, which can increase stress and limit social support and consequently increase risk for HIV infection (Carballo-Diéguez, 1989; Rosario, Scrimshaw, & Hunter, 2006). Similarly, stigma and discrimination may lead young MSM to be rejected by their families, which in turn increases the likelihood of their engaging in HIV risk behaviors (Carballo-Diéguez, 1989; Ryan, Huebener, Diaz, & Sanchez, 2010). The stigma associated with HIV and homosexuality compounds the problem because stigma prevents many from getting tested and seeking treatment due to fear of revealing risky behavior or disclosing sexual orientation (CDC, 2011c). Studies have demonstrated that negative attitudes about HIV are related to a lack of testing, lack of treatment knowledge, and lack of HIV/AIDS discussion (Genberg et al., 2009). This results in a lack of information on how to prevent infection and a lack of knowledge about HIV status. Differential experiences and expressions of stigma have also been reported among Hispanics/Latinos living in the United States, particularly among women, youth, and individuals living in migrant communities (Hirsch, Higgins, Bentley, & Nathanson, 2002). The CDC (2011e) reported that Hispanic/Latino machismo places a unique emphasis on the belief that HIV is a disease of homosexuality. While MSM are clearly direct targets of HIV-related stigma, individuals who engage in heterosexual relations are also affected by stigma: Conversations regarding HIV risk are not had, the seeking of testing services is delayed, and personal risk is underestimated (CDC, 2011e). Beyond perpetuating misinformation and risky sexual behaviors, the persistence of disease stigmatization and cultural taboos threaten disclosure of HIV status and medication adherence among young people living with HIV (Rao, Kekwaletswe, Hosek, Martinez, & Rodriguez, 2007; Valdiserri, 2002).

Discrimination, defined as prejudicial action or treatment directed at people with or perceived to have HIV (Klein et al., 2002), can be enough to affect health behaviors, including HIV risk behaviors (Parker & Aggleton, 2003). Further, one does not have to be the direct recipient of prejudicial treatment to be affected by its aversive consequences. A growing body of literature evidences that growing up in a discriminatory environment is associated with lower ratings of self-efficacy, greater psychological distress, and fewer attempts to negotiate safe sex practices or take other preventive actions (e.g., routine HIV/STD testing; Adimora & Schoenbach, 2005; Díaz et al., 2004). For example, African Americans report experiencing racial discrimination more than any other ethnic minority group (Landrine, Klonoff, Corral, Fernandez, & Roesch, 2006) and have a shared experience of historical trauma, not just with slavery but also with sexually transmitted disease and medical research (e.g., the Tuskeege Syphilis Study; Freimuth et al., 2001). While the contribution of historical trauma and other types of discrimination to HIV is impossible to measure, the fact that in 2009, African American adolescents accounted for 73% of HIV cases and only 17% of the U.S. adolescent population (CDC, 2012c) suggests that interventions for this vulnerable group need to address how these cultural and historical experiences affect HIV risk behaviors. Additionally, recent research with lesbian, gay, bisexual, and transgender (LGBT) adolescents suggests that social discrimination contributes to disease risk not only by lowering self-efficacy but also by narrowing the individual’s opportunity to reap protective benefits embedded in social and cultural contexts, such as peer connectedness and family relationships (Markham et al., 2010; Ryan et al., 2010). Moreover, there is some evidence that individuals who possess multiple determinants of social discrimination (e.g., LGBT, minority status, and low SES) are significantly less likely to take preventive action, utilize clinical services, and adhere to medical recommendations (Ahmed, Kaplan, Symington, & Kismodi, 2011; Pollini, Blanco, Crump, & Zuniga, 2011). Individuals at higher risk for social discrimination are also more likely to suffer from psychological distress and, consequently, are more likely to engage in high-risk sexual behavior practices (Díaz et al., 2004; Organista et al., 2012). Finally, the clustering of risk factors associated with discrimination has extremely troubling implications for youth with, or at risk for, HIV/AIDS. Darrow, Montanea, and Gladwin (2009) found that African American, Caribbean, Haitian, and Hispanic/Latino young adults living in a pro-stigmatizing environment were significantly less likely to be tested for HIV and to participate in community mobilization efforts, despite perceiving themselves at higher risk. Taken together, these trends and findings call for structural–environmental interventions to address social stigma and discrimination at a societal level (Organista et al., 2012). Such interventions have the potential to reduce HIV infection by targeting environmental (e.g., discrimination), individual (e.g., psychological distress), and HIV sexual risk behaviors (Organista et al., 2012).

The marginalization of gay youth promotes HIV infection and transmission at the macrosystemic level. Gay youth marginalization takes place across both majority and minority groups. For example, among ethnic minorities, African Americans and Asian Americans historically demonstrate relatively conservative attitudes toward homosexuality (Ahrold & Meston, 2010). Moreover, homophobia and homonegativity have been translated into laws that restrict the sexual behavior and relationships (e.g., marriage) of this group. This societal marginalization and exclusion create the stigma and discrimination that can force youth to not publicly identify as gay and, as a result, miss important prevention messages (Yon-Leau & Muñoz-Laboy, 2010). Stigma and internalized homophobia have been associated with higher rates of unprotected sexual intercourse (Preston et al., 2004; Radcliffe et al., 2010; Ross, Rosser, & Neumaier, 2008). The consequences of HIV/AIDS discrimination are many: apprehension toward HIV-testing, low participation in HIV/AIDS prevention campaigns, and an array of mental health problems (Herek & Capitanio, 1997; Paz-Bailey et al., 2012; Pollini et al., 2011). Addressing HIV stigma within specific sociocultural contexts has far-reaching implications for preventing HIV risk behaviors and dispelling deleterious attitudes and beliefs.

Poverty, lower educational attainment, and limited access to health care in Hispanic/Latino and African American communities limit access to HIV prevention services such as HIV testing and adequate treatment (CDC, 2011b). The literature describes a “nexus of risk” in which social disadvantage factors such as poverty, incarceration experiences, drug use, and lack of social support interact to increase HIV risk behaviors among those who are most vulnerable (German & Latkin, 2012). For instance, results from the 2011 Youth Risk Behavior Surveillance System show that African American female youth in the general population outpace their male counterparts in accessing HIV testing services (CDC, 2012d). However, the relationship is reversed among low-SES youth; African American boys enrolled in a free-lunch program more readily accessed HIV testing services than did African American girls enrolled in the program (Swenson et al., 2009).

Emerging data suggest that HIV prevalence is higher among people who are poor (Denning & DiNenno, 2010). The pathway between poverty and HIV infection may be explained in part by decreased access to care and reduced treatment for HIV and other STIs (Aral, 1999; Mays, Cochran, & Zamudio, 2004). For example, impoverished individuals living in underserved areas may test later in the course of HIV disease and access treatment services more irregularly, thereby increasing the cumulative viral load of positive testers and of the communities to which they return (Das et al., 2010; Wilson, Law, Frulich, Cooper, & Kaldor, 2008). Preventive education and intervention do not always reach populations most needing services. For example, MSM, a population with high risk and high need for intervention, may be at risk because effective HIV interventions or prevention education are not accessible to them. Indeed, a CDC study of MSM in 15 cities found that an astounding 80% had not been reached in the past year by HIV interventions known to be most effective (CDC, 2011d). Additionally, research indicates a lack of knowledge among poor African Americans with regard to HIV status. While one in five adults and adolescents in the United States are unaware of their HIV infection status, the undiagnosed infection rate among African American men is nine times that of White men; and the undiagnosed infection rate among Hispanics/Latinos is three times that of White men (CDC, 2011b). Also, poor Hispanics/Latinos and Hispanic/Latino undocumented immigrants may have limited access to programs and testing because of their fear of institutions, fear of deportation, and language barriers.

The epidemiology of illicit drug use in the community, the ratio of men to women, and racial segregation have been found to influence sexual behavior both directly and indirectly through various mechanisms, such as the destabilization of partnering patterns (Adimora & Schoenbach, 2005) and relationships (Mays et al., 2004). The destabilization of partnering patterns is associated with a justice system that disproportionately imprisons ethnic minority youth. African American and Hispanic/Latino youth not only demonstrate the highest HIV prevalence rates but are also disproportionately represented in the justice system in the United States. The disproportionate imprisonment of African Americans and Hispanics/Latinos is the result of a war on drugs that has targeted people of color (Fellner, 2000). Also, pervasive racial/ethnic differences in sentencing for convictions of people of color results in longer sentences, in more secure settings (e.g., prison vs. jail; Kansal & Mauer, 2005). “High incarceration rates disrupt sexual partnerships and stable families, impoverish individuals and communities, and alter the ratio of men to women that, together, help drive sexual network patterns, and ultimately increase the vulnerability of communities and individuals to HIV infection” (Adimora & Auerbach, 2010, p. S133). Additionally, incarceration places youth at risk since HIV cases in prisons are five to seven times the number in the general population; imprisoned youth are also more likely to engage in risk behaviors that lead to HIV (Teplin, Mericle, McClelland & Abram, 2003). There is a great need to address these macro-level factors if we are to effectively prevent HIV infection and transmission.

Macro-level factors influence sexual behaviors, including those that are related to increased risk for HIV infection and transmission. The literature on sexual initiation suggests that social/structural factors (Wu & Thomson, 2001), including economic factors such as SES (Duncan & Brooks-Gunn, 1997; Haveman & Wolfe, 1994) and geographic factors such as neighborhood structure and community dynamics, partially explain racial/ethnic differences in sexual initiation. For young women, the psychological stress from coping with lower SES may result in the prioritizing of intimacy in relationships over protective behaviors, such as delaying engagement in sexual behavior (Kerrigan et al., 2007). Further, Browning, Leventhal, and Brooks-Gunn (2004) concluded that “socioeconomic features of the neighborhood context play a consequential role in the unfolding sexual trajectories of urban adolescents” (p. 40; Browning, Burrington, Leventhal, & Brooks-Gunn, 2008). Further, Aronowitz and colleagues (2006) found that the attitudes adolescent girls adopted as a result of exposure to community influences predicted subsequent risk-taking behaviors such as early sexual initiation. Consequently, economic, geographic, and cultural social/structural factors such as SES, neighborhood structure and dynamics, and exposure to sexuality in the community are important influences that might begin to explain the sexual initiation of youth.

While the research examining macro factors in sexual initiation is emerging, a number of studies have also examined the relationship between macro-level factors and established sexual behavior. This literature suggests that macro-level factors can increase behavioral risk for HIV or serve as protective factors that increase safe sexual practices and behaviors. When examining economic macro-level factors, one study found that income inequality and social capital were significantly correlated with AIDS case rates (Holtgrave & Crosby, 2003). In addition, the evidence for geographical factors is emerging as recent studies on social networks of African American youth indicate that low-risk women may be exposed to STI infection through sexual linkage to a higher risk group (Fichtenberg et al., 2009). This emerging literature on economic, geographic, and structural factors and established sexual behaviors demonstrates that these factors are important. They can make a contribution to our understanding of how to prevent HIV among youth.

Although determinants of HIV and HIV risk behaviors among adolescents occur at multiple levels of the social ecology, a significant proportion of HIV preventive interventions for ethnic minority youth are individually focused and target risk and protective factors at the individual level. For example, ¡Cuídate! (Take Care of Yourself), an evidence-based HIV preventive intervention for Hispanic/Latino youth, targets attitudes and knowledge about HIV and safe sexual behavior practices, increasing self-efficacy and skills for condom use, and negotiating safer sex practices (Villarruel, Jemmott, & Jemmott, 2006). A similar, individually focused, evidence-based intervention, Be Proud! Be Responsible!, exists for preventing HIV risk behaviors among African American youth (Jemmott, Jemmott, & Fong, 1992). Like ¡Cuídate!, Be Proud! Be Responsible! is grounded in social cognitive theory, the theory of reasoned action, and the theory of planned behavior (Jemmott & Jemmott, 1996; Villarruel, Jemmott, & Jemmott, 2005), all of which are theoretical frameworks centered around individual-level risk and protective factors. Other evidence-based HIV preventive interventions, such as Familias Unidas, the Strong African American Families program, the Good Behavior Game, and Parents Matter!, target risk and protective factors at the family, peer, and school microsystems level (Ball, Pelton, Forehand, Long, & Wallace, 2004; Dittus, Miller, Kotchick, & Forehand, 2004; Kellam et al., 2012; Murry, Berkel, Brody, Gibbons, & Gibbons, 2007; Prado et al., 2012). In addition to intervening at the microsystem level, these early childhood enrichment programs and youth development programs also address more distal factors of HIV transmission. For example, early childhood programs provide educational enrichment and comprehensive family-support services to foster the health and well-being of children. Reynolds and colleagues (2007) found that an enrichment program provided to children in kindergarten resulted later in higher rates of school completion, lower rates of interaction with the criminal justice system, and higher employment. Each of these outcomes has been negatively associated with HIV transmission. Similarly, youth development programs seek to inspire hope for future aspirations, improve performance in school, and bolster family relationships. Philliber and Allen (1992) showed that adolescents who participated in a youth development program were less likely to initiate sexual intercourse and more likely to have used condoms at last intercourse. Similarly, Kellam et al. (2012) found that a first-grade classroom intervention increased condom use from 40% to 87% in young adulthood in a mostly African American urban environment. It is clear that while great strides have been made to prevent HIV infection among ethnic minority youth, individual-level interventions are insufficient and the need to integrate macro-level approaches is of utmost importance.

Up until recently, support for macro-level intervention development and evaluation has been lukewarm and sporadic. Of private and federal funding agencies, the CDC has led much of the effort, issuing many initiatives aimed at strengthening capacity, infrastructure, and partnerships with health departments and community-based organizations in order to prevent the spread of HIV among the general population and those at highest risk. One such recent initiative is the “Heightened National Response to Address the HIV/AIDS Crisis Among African Americans.” This national strategy, recently launched by the CDC, aims at engaging public and nonpublic partners to prevent HIV infection among African Americans (Sutton et al., 2009). Another macro-level intervention aimed at reducing HIV health disparities among ethnic minority youth in the United States is the CDC’s “Minority HIV/AIDS Research Initiative to Build Capacity in Black and Hispanic Communities Among Black and Hispanic Researchers to Conduct HIV/AIDS Epidemiologic and Prevention Research.” This initiative appropriates CDC funding to support early career investigators of color to conduct research aimed at reducing the number of new HIV infections in the United States by eliminating racial and ethnic health disparities in African American and Hispanic/Latino populations (Fitzpatrick, Sutton, & Greenberg, 2006). The recently issued National HIV/AIDS Strategy, which aims to reduce the number of HIV-infected individuals, increase access to care for HIV seropositive individuals, and reduce HIV-related health disparities, is another macro-level intervention. While the effects of the National HIV/AIDS Strategy as well as other recent initiatives are yet unknown, it is likely that such structural-level interventions (i.e., policy-level interventions that appropriate government funding, initiatives that address national awareness) will have a positive impact on the HIV epidemic.

There are, however, macro-level interventions that have been implemented both in the United States and abroad that have been found to be effective. For example, access to comprehensive sex education and access to condoms have been found to be an effective structural HIV prevention strategy both in the United States and in other countries (Blake et al., 2001, 2003, 2005; Kirby, Laris, & Rolleri, 2007). Comprehensive sex education includes health promotion, disease prevention information, and contraception information. Youth with access to comprehensive sex education programs are more likely to delay the onset of sexual activity, reduce the frequency of sexual activity, reduce the number of sexual partners, and increase condom and contraceptive use (Alford, 2003; Institute of Medicine, 2001; Kirby et al., 2007; Kohler, Manhart, & Lafferty, 2008). Contingent funding policies that support the broad implementation of comprehensive sex education represent a structural intervention with significant potential to impact HIV transmission among youth.

As discussed above, the link between poverty and HIV in the United States is well established. Preventive interventions that improve economic productivity are likely to impact HIV transmission. Structural interventions to reduce poverty have proven effective in developing countries and to a lesser degree in the United States (Sherman, German, Cheng, Marks, & Bailey-Kloche, 2006). Microfinancing, child development accounts, and cash-transfer interventions have been successful at reducing intimate partner violence (Pronyk et al., 2006), a known factor in HIV transmission and reduced sexual risk-taking intentions (Ssewamala, Han, Neilands, Ismayilova, & Sperber, 2010). Access to housing is a structural intervention that is likely to affect sexual and drug-related behaviors. Among adults, Aidala, Cross, Stall, Harre, and Sumartojo (2005) found that housing status was associated with HIV-related risk behaviors. Those participants who experienced an improvement in their housing status had reduced risk of drug use and unprotected sex (Aidala et al., 2005).

Community-level interventions have also been shown to be efficacious in promoting HIV-related outcomes. For example, the Mpowerment Project is a multilevel intervention for MSM aged 18–29 years that is based on concepts about individual and community empowerment. The intervention has demonstrated efficacy in decreasing HIV-related risk behaviors (Kegeles, Hays, & Coates, 1996). The AIDS Community Demonstration Projects promoted progress toward consistent HIV prevention through community mobilization and distribution of risk reduction information and supplies (e.g., condoms and bleach). The intervention focused on multiple risk groups, including adolescents. This community-level intervention demonstrated significant increases in condom use and condom carrying by community members (CDC AIDS Community Demonstration Projects Research Group, 1999).

These represent but a few of the social/structural interventions that can address the social determinants of the HIV epidemic. Successfully impacting the HIV epidemic requires a move beyond limited, individually focused interventions to those that address social and structural factors. The development of approaches that challenge the underlying social-structural drivers of vulnerability and behavior, while emerging, is the necessary next step in successfully reducing HIV among youth (Auerbach, Parkhurst, Caceres, & Keller, 2009).