In Botswana an estimated 21.9% of adults aged 15-49 years are living with HIV, amongst the HIV prevalence rates among adults worldwide. Despite prevention efforts, the annual incidence of HIV among the adult population aged 15-49 years remains close to 1.5%: some 12,000 new infections every year in a population of about two million. Most of the new infections are among young women. A study in Botswana, Namibia, and Swaziland found that young women who suffer intimate partner violence, have high or lower incomes than their partners, have less education, and who are very poor have a much higher risk of HIV than young women who have none of these four factors.

Although structural factors are recognised as maintaining the HIV epidemic, there are few controlled trials of structural interventions that measure the impact on HIV infection. Most of these have failed to show an impact on HIV infection, perhaps because they did not create real structural shifts. The Inter-ministerial National Structural Intervention Trial (INSTRUCT) is an HIV prevention initiative in Botswana that tests the impact of a package of structural interventions focused on young women and the choice disabled. The nationwide study, led by CIET and Botswana’s National AIDS Coordinating Agency (NACA), is a cluster randomised controlled trial (trial registered as ISRCTN54878784). The INSTRUCT interventions include: supporting young women to access government structural support programmes; working with the government programmes to refocus them towards young women; and using an audio-drama to create an enabling environment in communities for young women to begin to make protective choices.