Behavior change interventions to prevent HIV infection among women living in low and middle income countries: a systematic review

The role of the social sciences and humanities in pandemic preparedness responses: insights gained from COVID-19, HIV and AIDS and related epidemics

The COVID-19 pandemic, particularly from 2020 to mid-2022, debilitated the management of the HIV epidemic in Africa. The multiple effects included well-documented HIV service interruptions, curtailment of HIV prevention programmes, the associated marked increase in both the risk for HIV infection among key populations and vulnerability of sub-populations (e.g. adolescent girls and young women) who are the focus of these programmes and - as importantly but less well-documented - the diverse negative socio-economic effects that accentuate HIV risk and vulnerability generally (e.g. loss of earnings, gender-based violence, stigma, police harassment of people during "lockdowns"). The global biomedical response to COVID-19 was necessary and remarkable for mitigating the bio-physical impacts of the pandemic (e.g. wide-spread surveillance coupled with rapid updates on the epidemiology of infections, rapid development of vaccines and revisions of treatment). However, drawing upon the widespread criticisms of state responses to the socio-economic effects of the COVID-19 pandemic and of "lockdowns" themselves, this article elaborates a core argument within those criticisms, namely that key lessons learnt during the HIV and AIDS and other pandemics were ignored, at least during the early stages of COVID-19. Our critique is that better integration of the social sciences and humanities in responses to pandemics can counter the reflex tendency to uncritically adopt a biomedical paradigm and, more importantly, to enable consideration of the social determinants of health in pandemic responses. At root, we re-assert a key value of 'integrated' interventions, namely the accommodation of context-sensitive considerations in the formulation of strategies, policies, plans and programme designs.

Menstrual cups and cash transfer to reduce sexual and reproductive harm and school dropout in adolescent schoolgirls in western Kenya: a cluster randomised controlled trial

Background

High rates of sexual and reproductive health (SRH) harms and interrupted schooling are global challenges for adolescent girls, requiring effective interventions. We assessed the impact of menstrual cups (MCs) or cash transfers conditioned on school attendance (CCTs), or both, on SRH and schooling outcomes in western Kenya.

Methods

In this cluster-randomised Cups or Cash for Girls (CCG) trial, adolescent girls in Forms two and three at 96 secondary schools in Siaya County (western Kenya) were randomised to receive either CCT, MC, combined CCT and MC, or control (1:1:1:1) for an average of 30 months. The CCT intervention comprised 1500KES (US$15 in 2016) via a cash card each school trimester. All four treatment groups received puberty and hygiene training. Assenting girls with parent or guardian consent who were post-menarche, not pregnant, area residents, not boarding, and had no disabilities precluding participation were eligible. Socio-behavioural risk factors and incidence of HIV and herpes simplex virus type 2 (HSV-2) were measured annually. School retainment and adverse events were monitored throughout. The primary outcome comprised a composite of incident HIV, HSV-2 and/or all-cause school dropout by school exit examination. The primary analysis was by intention-to-treat (ITT) using generalised linear mixed models, controlling for a priori selected baseline covariates. The trial is registered with ClinicalTrials.gov, NCT03051789.

Findings

Between February 28, 2017 and June 30, 2021, 4137 girls (median age 17.1 [interquartile range (IQR): 16.3-18.0]) were enrolled and followed annually until completion of secondary school (median 2.5 years [IQR: 2.4-2.7]); 4106 (99.3%) contributed to the ITT analysis. No differences in the primary composite outcome between intervention and control groups were seen (MC: 18.2%, CCT: 22.1%, combined: 22.1%, control: 19.6%; adjusted risk ratio [aRR]: 0.97, 95% confidence interval 0.76-1.24; 1.14, 0.90-1.45; and 1.13, 0.90-1.43, respectively). Incident HSV-2 occurred in 8.6%, 13.3%, 14.8%, and 12% of the MC, CCT, combined and control groups, respectively (MC: RR: 0.67, 0.47-0.95, p = 0.027; aRR: 0.71, 0.50-1.01, p = 0.057; CCT: aRR: 1.02, 0.73-1.41, p = 0.92; combined aRR: 1.16, 0.85-2.58, p = 0.36). Incident HIV was low (MC: 1.2%, CCT: 1.5%, combined: 1.0%, and control: 1.4%; aRR: 0.88, 0.38-2.05, p = 0.77, aRR: 1.16, 0.51-2.62, p = 0.72, aRR: 0.80, 0.33-1.94, p = 0.62, respectively). No intervention decreased school dropout (MC: 11.2%, CCT: 12.4%, combined: 10.9%, control: 10.5%; aRR: 1.16, 0.86-1.57; 1.23, 0.91-1.65; and 1.06, 0.78-1.44, respectively). No related serious adverse events were seen.

Interpretation

MCs, CCTs, or both, did not protect schoolgirls against a composite of deleterious harms. MCs appear protective against HSV-2. Studies of longer follow-up duration with objective measures of health impact are needed in this population.

Funding

Department of Health and Social Care, the Foreign, Commonwealth & Development Office, the Medical Research Council and Wellcome.

Designing for two: How enhancing human-centered design with behavioral nudges unlocked breakthroughs to promote young women's psychological safety and access to reproductive care in Tanzania

Adolescent girls and young women (AGYW; ages 15-24) in sub-Saharan Africa face many barriers to accessing preventive sexual and reproductive health (SRH) services. We drew upon the strengths of two complementary approaches, human-centered design and behavioral economics, to craft a holistic, highly-tailored, and empathetic intervention to motivate AGYW to seek contraception and HIV self-test kits at community drug shops. To encourage engagement, we embedded "nudge" strategies at different opportunity points (uncovered during our design research) along the care-seeking and service delivery journey. Our Malkia Klabu intervention is a loyalty program designed to enhance drug shops' role as SRH providers through which AGYW earned punches for shop purchases redeemable for small prizes; free SRH products could be requested at any time. From our 4-month pilot in Shinyanga, Tanzania, we assess the extent to which different behavioral nudge strategies motivated behaviors as predicted by synthesizing findings from (1) in-depth interviews with AGYW and shopkeepers, (2) shop program records, (3) shop observations, and (4) customer exit surveys. Overall, we find that AGYW and shopkeepers were motivated by many intervention features as intended and consistent with hypothesized mechanisms. We found strong evidence of social norms for helping to spread awareness of Malkia Klabu among peers, prize incentives for drawing AGYW back to shops, and the opt-out default membership gift of an HIV self-test kit for encouraging testing uptake and exploration of contraceptives. Shopkeepers in both arms noted increased community status from distributing HIV self-testing kits (ego). Malkia Klabu shopkeepers experienced increased customer traffic and business revenues (incentives), which reduced shopkeepers' gatekeeping tendencies and earned them additional recognition as champions of AGYW well-being. Integrating human-centered design and behavioral economics was effective for developing an innovative and effective intervention that simultaneously met the different needs of economic actors in support of public health priorities.

Strengthening women's empowerment and gender equality in fragile contexts towards peaceful and inclusive societies: A systematic review and meta-analysis

BACKGROUND

Across the globe, gender disparities still exist with regard to equitable access to resources, participation in decision-making processes, and gender and sexual-based violence. This is particularly true in fragile and conflict-affected settings, where women and girls are affected by both fragility and conflict in unique ways. While women have been acknowledged as key actors in peace processes and post-conflict reconstruction (e.g., through the United Nations Security Council Resolution 1325 and the Women, Peace and Security Agenda) evidence on the effectiveness of gender-specific and gender-transformative interventions to improve women's empowerment in fragile and conflict-affected states and situations (FCAS) remains understudied.

OBJECTIVES

The purpose of this review was to synthesize the body of evidence around gender-specific and gender-transformative interventions aimed at improving women's empowerment in fragile and conflict-affected settings with high levels of gender inequality. We also aimed to identify barriers and facilitators that could affect the effectiveness of these interventions and to provide implications for policy, practice and research designs within the field of transitional aid.

METHODS

We searched for and screened over 100,000 experimental and quasi-experimental studies focused on FCAS at the individual and community levels. We used standard methodological procedures outlined by the Campbell Collaboration for the data collection and analysis, including quantitative and qualitative analyses, and completed the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology to assess the certainty around each body of evidence.

RESULTS

We identified 104 impact evaluations (75% randomised controlled trials) assessing the effects of 14 different types of interventions in FCAS. About 28% of included studies were assessed as having a high risk of bias (45% among quasi-experimental designs). Interventions supporting women's empowerment and gender equality in FCAS produced positive effects on the outcomes related to the primary focus of the intervention. There are no significant negative effects of any included interventions. However, we observe smaller effects on behavioural outcomes further along the causal chain of empowerment. Qualitative syntheses indicated that gender norms and practices are potential barriers to intervention effectiveness, while working with local powers and institutions can facilitate the uptake and legitimacy of interventions.

CONCLUSIONS

We observe gaps of rigorous evidence in certain regions (notably MENA and Latin America) and in interventions specifically targeting women as actors of peacebuilding. Gender norms and practices are important elements to consider in programme design and implementation to maximise potential benefits: focusing on empowerment only might not be enough in the absence of targeting the restrictive gender norms and practices that may undermine intervention effectiveness. Lastly, programme designers and implementation should consider explicitly targeting specific empowerment outcomes, promoting social capital and exchange, and tailoring the intervention components to the desired empowerment-related outcomes.

Why interventions to prevent intimate partner violence and HIV have failed young women in southern Africa

INTRODUCTION

Adolescent girls and young women aged 15 to 24 years have some of the highest HIV incidence rates globally, with girls two to four times more likely to be living with HIV than their male peers. High levels of intimate partner violence (IPV) experienced by this age group is a significant risk factor for HIV acquisition. While behavioural interventions to prevent IPV and HIV in southern Africa have seen some success in reducing self-reported experiences of IPV, these interventions have largely failed to achieve similar outcomes for young women.

DISCUSSION

We identify three main reasons for the failure of IPV/HIV interventions for many young women in southern Africa. First, interventions are usually developed without the meaningful involvement of both young women and young men. Youth input into research design is largely focused on user testing or consultation of targeted groups, involving relatively low levels of participation. Second, interventions are focused on addressing individual risk factors rather than broader social and structural contexts of being a young woman. "Risk factor" interventions, rather than supporting women's agency, can pose a major barrier for supporting changes in behaviour among young women because they often fail to dislodge well-entrenched gender and age-related inequalities. Third, current intervention models have not adequately accounted for changes in gender norms and relationships across southern Africa. Individuals are getting married later in life (or not at all), new technologies are transforming romantic interactions and opening new opportunities for violence, and discussions about women's rights are both challenging gender inequalities and reinforcing them.

CONCLUSIONS

In order to move beyond the status quo of current approaches, and to support real innovation, IPV/HIV prevention interventions need to be co-developed with youth as part of a meaningful participatory process of research, intervention design, youth involvement in development and implementation. This process of co-development needs to be radical and break with the current focus on adapting existing interventions to meet the needs of young people, which are not well understood and often do not directly reflect their priorities. Broader social contexts and compound lenses are needed to avoid narrow approaches and to accommodate evolving norms.

Implementing Evidence-Based HIV Prevention for Female Sex Workers in Mexico: Provider Assessments of Feasibility and Acceptability

This study examined service provider perceptions of feasibility and acceptability of implementing evidence-based practices for preventing HIV/AIDS and STIs in female sex workers (FSWs) in Mexico. Semi-structured interviews were conducted with 124 directors, supervisors and counselors from 12 reproductive health clinics located throughout Mexico participating in a large randomized controlled trial to scale-up the use of a psychoeducational intervention designed to promote FSW condom use and enhance safer sex negotiation skills. Feasibility was based on assessment of personal, organizational and social costs, benefits, and capacity. Costs included anxiety over intervention competency, purchase of condoms and other supplies, expenses of laboratory tests for HIV/STIs, and stigma associated with FSWs. Benefits included increase in personal knowledge and experience, enhanced clinic reputation and service delivery capacity, and increased public health. Capacity was expressed in terms of provider skills to deliver the intervention and additional workload. Acceptability was expressed in terms of provider enthusiasm in delivering these services and FSWs willingness to receive the services. Service provider evaluations of feasibility and acceptability of implementing evidence-based prevention interventions are grounded in local contexts that define costs and benefits of and capacity for implementation and determine features of the intervention and its implementation that are acceptable.

HIV Prevalence and Associated Risk Factors Among Men Who Have Sex With Men in Dar es Salaam, Tanzania

INTRODUCTION

Limited studies and differential risk behaviors among men who have sex with men (MSM) in Africa calls for population-specific studies. We present results from the largest integrated biobehavioral survey among MSM in Africa to inform programming.

METHODS

This was a cross-sectional study using respondent-driven sampling to recruit MSM aged 18 and above. Data on sociodemographic characteristics and HIV-related risks were collected and all participants were tested for HIV, herpes simplex virus type-2 (HSV-2), hepatitis-B virus (HBV), and syphilis RESULTS:: A total of 753 MSM with a mean age of 26.5 years participated in the study and 646 (85.7%) provided blood for biological testing. The prevalence of HIV was 22.3%, HSV-2 40.9%, syphilis 1.1%, and HBV 3.25%. Significant risk factors for HIV were age above 25, having no children [adjusted odds ratio (aOR), 2.4, 95% confidence interval (CI): 1.4 to 4.2], low HIV-risk perception (aOR, 2.6, 95% CI: 1.2 to 5.3), receptive position (aOR, 8.7, 95% CI: 1.2 to 5.3), and not using water-based lubricants (aOR, 2.6, 95% CI: 1.0 to 4.5) during the last anal sex. Also associated with HIV infection was, having sexual relationships with women (aOR, 8.0, 95% CI: 4.1 to 15.6), engaging in group sex (aOR, 3.8, 95% CI: 1.6 to 8.4), HSV-2 seropositivity (aOR, 4.1, 95% CI: 2.6 to 6.5), and history of genital ulcers (aOR, 4.1, 95% CI: 1.1 to 7.2).

CONCLUSIONS

HIV infection and HSV-2 were highly prevalent among MSM. Low perceived HIV risk, practice of risk behaviors, and infection with HSV-2 were significant predictors of HIV infection. Behavioral interventions, HSV-2 suppressive therapies, and pre-exposure prophylaxis are highly needed.

The effectiveness of using entertainment education narratives to promote safer sexual behaviors of youth: A meta-analysis, 1985-2017

BACKGROUND

Risky sexual behaviors are associated with the transmission of sexually transmitted infections (STIs) and unwanted pregnancies, both major health concerns for youth worldwide. This review studies the effectiveness of narrated mass media programs in promoting safer sexual practices among youth in developed and developing countries.

METHODS

Electronic and manual searches were conducted to identify experimental and quasi-experimental studies with robust counterfactual designs published between 1985 and the first quarter of 2017. Effect sizes were meta-analyzed using mixed-effects models.

RESULTS

Eight experimental and two quasi-experimental studies met our inclusion criteria. The aggregated sample size was 23,476 participants, with a median of 902 participants per study. Entertainment education narratives had small but significant effects for three sexual behaviors. It reduced the number of sexual partners [standardized mean difference, (SMD) = 0.17, 95% confidence interval (CI) = 0.02-0.33, three effect sizes], reduced unprotected sex (SMD = 0.08, 95% CI = 0.03-0.12, nine effect sizes), and increased testing and management for STIs (SMD = 0.29, 95% CI = 0.11-0.46, two effect sizes). The interventions were not effective in reducing inter-generational sex, measured through the age-gap with sexual partners (SMD = 0.06, 95% CI = -0.06-0.19, four effect sizes). Entertainment education had medium-size effects on knowledge outcomes (SMD = 0.67, 95% CI = 0.32-1.02, seven effect sizes), where a time-decay relationship is observed. No effects were found on attitudes.

CONCLUSION

Although mass media entertainment had small effects in promoting safer sexual practices, its economies of scales over face-to-face interventions suggest its potential to be a cost-effective tool above an audience threshold. The use of study participants from the general youth population and the use of mostly effectiveness trials mitigate concerns regarding its scalability. The overall paucity of high-quality studies affirms the need for strengthening the evidence base of entertainment education. Future research should be undertaken to understand the moderator effects for different subgroups and intervention characteristics.

Methodology and Baseline Results From the Evaluation of a Sexuality Education Activity in Mpumalanga and KwaZulu-Natal, South Africa

In South Africa, adolescents and young adults (ages 15-24) are at risk of HIV, sexually transmitted infections, and unintended pregnancies. Recently, the Department of Basic Education has revised its sexuality education content and teaching strategies (using scripted lessons plans) as part of its life orientation curriculum. This paper presents the methodology and baseline results from the evaluation of the scripted lesson plans and supporting activities. A rigorous cluster-level randomized design with random assignment of schools as clusters is used for the evaluation. Baseline results from grade 8 female and male learners and grade 10 female learners demonstrate that learners are at risk of HIV and early and unintended pregnancies. Multivariable analyses demonstrate that household-level food insecurity and living with an HIV-positive person are associated with sexual experience and pregnancy experience. Implications are discussed for strengthening the current life orientation program for future scale-up by the government of South Africa.

Interventions to strengthen the HIV prevention cascade: a systematic review of reviews

BACKGROUND

Much progress has been made in interventions to prevent HIV infection. However, development of evidence-informed prevention programmes that translate the efficacy of these strategies into population effect remain a challenge. In this systematic review, we map current evidence for HIV prevention against a new classification system, the HIV prevention cascade.

METHODS

We searched for systematic reviews on the effectiveness of HIV prevention interventions published in English from Jan 1, 1995, to July, 2015. From eligible reviews, we identified primary studies that assessed at least one of: HIV incidence, HIV prevalence, condom use, and uptake of HIV testing. We categorised interventions as those seeking to increase demand for HIV prevention, improve supply of HIV prevention methods, support adherence to prevention behaviours, or directly prevent HIV. For each specific intervention, we assigned a rating based on the number of randomised trials and the strength of evidence.

FINDINGS

From 88 eligible reviews, we identified 1964 primary studies, of which 292 were eligible for inclusion. Primary studies of direct prevention mechanisms showed strong evidence for the efficacy of pre-exposure prophylaxis (PrEP) and voluntary medical male circumcision. Evidence suggests that interventions to increase supply of prevention methods such as condoms or clean needles can be effective. Evidence arising from demand-side interventions and interventions to promote use of or adherence to prevention tools was less clear, with some strategies likely to be effective and others showing no effect. The quality of the evidence varied across categories.

INTERPRETATION

There is growing evidence to support a number of efficacious HIV prevention behaviours, products, and procedures. Translating this evidence into population impact will require interventions that strengthen demand for HIV prevention, supply of HIV prevention technologies, and use of and adherence to HIV prevention methods.

FUNDING

Bill & Melinda Gates Foundation.

Behavioral Interventions for Preventing Sexually Transmitted Infections and Unintended Pregnancies: An Overview of Systematic Reviews

BACKGROUND

Countless sex education programs have been implemented worldwide in recent decades, but epidemiological data show no improvement in rates of sexually transmitted infections or unintended pregnancies.

OBJECTIVE

To summarize the evidence from higher-quality systematic reviews on the efficacy of behavioral interventions for the prevention of sexually transmitted infections and unintended pregnancies.

METHODS

We conducted an overview of reviews by selecting systematic reviews that met minimum quality criteria in terms of the design of the studies reviewed. We compared the results obtained when the effects of interventions were assessed on the basis of objective criteria (biological data) to those obtained when outcomes were assessed on the basis of subjective criteria (self-reports). The results of Cochrane and non-Cochrane reviews were also compared.

RESULTS

We identified 55 systematic reviews. No overall effect on the sexual behavior of program participants was observed in 72.5% of the reviews that used objective criteria and in 48.1% of the reviews based on subjective criteria. In the Cochrane reviews, no evidence of an overall effect was observed in 86% of reviews based on objective variables and in 70.5% of those based on subjective variables.

CONCLUSIONS

There is no evidence that behavioral interventions modify rates of sexually transmitted infections (including human immunodeficiency virus infections) or unintended pregnancies, particularly when effects are assessed using objective, biological data. Primary prevention strategies for sexually transmitted infections and unintended pregnancies need to be re-evaluated.

Prospects for a Globally Effective HIV-1 Vaccine

A globally effective vaccine strategy must cope with the broad genetic diversity of HIV and contend with multiple transmission modalities. Understanding correlates of protection and the role of diversity in limiting protective vaccines with those correlates is key. RV144 was the first HIV-1 vaccine trial to demonstrate efficacy against HIV-1 infection. A correlates analysis comparing vaccine-induced immune responses in vaccinated-infected and vaccinated-uninfected volunteers suggested that IgG specific for the V1V2 region of gp120 was associated with reduced risk of HIV-1 infection and that plasma Env IgA was directly correlated with infection risk. RV144 and recent non-human primate (NHP) challenge studies suggest that Env is essential and perhaps sufficient to induce protective antibody responses against mucosally acquired HIV-1. Whether RV144 immune correlates can apply to different HIV vaccines, to populations with different modes and intensity of transmission, or to divergent HIV-1 subtypes remains unknown. Newer prime-boost mosaic and conserved sequence immunization strategies aiming at inducing immune responses of greater breadth and depth as well as the development of immunogens inducing broadly neutralizing antibodies should be actively pursued. Efficacy trials are now planned in heterosexual populations in southern Africa and men who have sex with men in Thailand. Although NHP challenge studies may guide vaccine development, human efficacy trials remain key to answer the critical questions leading to the development of a global HIV-1 vaccine for licensure.

Education, HIV, and Early Fertility: Experimental Evidence from Kenya

A seven-year randomized evaluation suggests education subsidies reduce adolescent girls' dropout, pregnancy, and marriage but not sexually transmitted infection (STI). The government's HIV curriculum, which stresses abstinence until marriage, does not reduce pregnancy or STI. Both programs combined reduce STI more, but cut dropout and pregnancy less, than education subsidies alone. These results are inconsistent with a model of schooling and sexual behavior in which both pregnancy and STI are determined by one factor (unprotected sex), but consistent with a two-factor model in which choices between committed and casual relationships also affect these outcomes.

Prospects for a globally effective HIV-1 vaccine

A globally effective vaccine strategy must cope with the broad genetic diversity of HIV and contend with multiple transmission modalities. Understanding correlates of protection and the role of diversity in limiting protective vaccines with those correlates is key. RV144 was the first HIV-1 vaccine trial to demonstrate efficacy against HIV-1 infection. A correlates analysis compared vaccine-induced immune responses in vaccinated-infected and vaccinated-uninfected volunteers suggested that IgG specific for the V1V2 region of gp120 was associated with reduced risk of HIV-1 infection and that plasma Env IgA was directly correlated with infection risk. RV144 and recent NHP challenge studies suggest that Env is essential and perhaps sufficient to induce protective antibody responses against mucosally acquired HIV-1. Whether RV144 immune correlates can apply to different HIV vaccines, to populations with different modes and intensity of transmission, or to divergent HIV-1 subtypes remains unknown. Newer prime-boost mosaic and conserved sequence immunization strategies aiming at inducing immune responses of greater breadth and depth as well as the development of immunogens inducing broadly neutralizing antibodies should be actively pursued. Efficacy trials are now planned in heterosexual populations in southern Africa and MSM in Thailand. Although NHP challenge studies may guide vaccine development, human efficacy trials remain key to answer the critical questions leading to the development of a global HIV-1 vaccine for licensure.

Women living with HIV/AIDS (WLHA), battling stigma, discrimination and denial and the role of support groups as a coping strategy: a review of literature

BACKGROUND AND OBJECTIVES

Women living with HIV/AIDS, in particular, have been positioned as a latent source of infection, and have captivated culpability and blame leading to a highly stigmatised and discriminated life. Despite the situation, women and their particular concerns have largely been ignored in HIV/AIDS research literature. This review aims to examine and analyze the feelings, experiences and perceptions of Women living with HIV/AIDS (WLHA) and will also access the role of support group as a coping strategy on the basis of 7 primary researches conducted in or on different parts of the world.

METHODOLOGY

A systematic literature search was carried out on major data bases ASSIA, CINAHL, Science Direct, Web of Knowledge, Wiley Inter Science, AMED, Pub Med/Bio Med Central, MEDLINE and Cochrane Library. The articles included for review purpose were gauged against the pre-defined inclusion/exclusion criteria and quality assessment checklist resulting in a final 7 papers.

FINDINGS/RESULTS

The findings were compiled into five thematic areas: (1) Disclosure as a sensitive issue; (2) Stigma and Discrimination associated with HIV/AIDS and the multidimensional effects on women's health and wellbeing; (3) Internalised Stigma; (4) Women living with HIV/AIDS experiences of being rejected, shunned and treated differently by physicians, family and close friends; (5) Support Group as among the best available interventions for stigma and discrimination.

CONCLUSION

Support groups should be offered as a fundamental part of HIV/AIDS services and should be advocated as an effective and useful intervention. Further research is needed to examine the effect of support groups for women living with HIV/AIDS. A community based randomised controlled trial with support group as an intervention and a control group could provide further evidence of the value of support groups.

Population-level impact of Zimbabwe's National Behavioural Change Programme

OBJECTIVE

To assess the impact of Zimbabwe's National Behavioural Change Programme (NBCP) on biological and behavioral outcomes.

METHODS

Representative household biobehavioral surveys of 18- to 44-year-olds were conducted in randomly selected enumeration areas in 2007 and 2011 to 2012. We examined program impact on HIV prevalence among young women, nonregular partnerships, condom use with nonregular partners, and HIV testing, distinguishing between highly exposed and low-exposed communities and individuals. We conducted (1) difference-in-differences analyses with communities as unit of analysis and (2) analyses of key outcomes by individual-level program exposure.

RESULTS

Four thousand seven hundred seventy-six people were recruited in 2007 and 10,059 in 2011 to 2012. We found high exposure to NBCP in 2011. Prevalence of HIV and reported risky behaviors declined between 2007 and 2011. Community-level analyses showed a smaller decline in HIV prevalence among young women in highly exposed areas (11.0%-10.1%) than low-exposed areas (16.9%-10.3%, P = 0.078). Among young men, uptake of nonregular partners declined more in highly exposed areas (25%-16.8%) than low-exposed areas (21.9%-20.7%, P = 0.055) and HIV testing increased (27.2%-46.1% vs. 31.0%-34.4%, P = 0.004). Individual-level analyses showed higher reported condom use with nonregular partners among highly exposed young women (53% vs. 21% of unexposed counterparts, P = 0.037).

CONCLUSIONS

We conducted the first impact evaluation of a NBCP and found positive effects of program exposure on key behaviors among certain gender and age groups. HIV prevalence among young women declined but could not be attributed to program exposure. These findings suggest substantial program effects regarding demand creation and justify program expansion.

Male circumcision for protection against HIV infection in sub-Saharan Africa: the evidence in favour justifies the implementation now in progress

This article responds to a recent 'controversy study' in Global Public Health by de Camargo et al. directed at three randomised controlled trials (RCTs) of male circumcision (MC) for HIV prevention. These trials were conducted in three countries in sub-Saharan Africa (SSA) and published in 2005 and 2007. The RCTs confirmed observational data that had accumulated over the preceding two decades showing that MC reduces by 60% the risk of HIV infection in heterosexual men. Based on the RCT results, MC was adopted by global and national HIV policy-makers as an additional intervention for HIV prevention. Voluntary medical MC (VMMC) is now being implemented in 14 SSA countries. Thus referring to MC for HIV prevention as 'debate' and viewing MC through a lens of controversy seems mistaken. In their criticism, de Camargo et al. misrepresent and misinterpret current science supporting MC for HIV prevention, omit previous denunciations of arguments similar to theirs, and ignore evidence from ongoing scientific research. Here we point out the flaws in three areas de Camargo et al. find contentious. In doing so, we direct readers to growing evidence of MC as an efficacious, safe, acceptable, relatively low-cost one-off biomedical intervention for HIV prevention.

Reporting quality of search methods in systematic reviews of HIV behavioral interventions (2000-2010): are the searches clearly explained, systematic and reproducible?

Systematic reviews are an essential tool for researchers, prevention providers and policy makers who want to remain current with the evidence in the field. Systematic review must adhere to strict standards, as the results can provide a more objective appraisal of evidence for making scientific decisions than traditional narrative reviews. An integral component of a systematic review is the development and execution of a comprehensive systematic search to collect available and relevant information. A number of reporting guidelines have been developed to ensure quality publications of systematic reviews. These guidelines provide the essential elements to include in the review process and report in the final publication for complete transparency. We identified the common elements of reporting guidelines and examined the reporting quality of search methods in HIV behavioral intervention literature. Consistent with the findings from previous evaluations of reporting search methods of systematic reviews in other fields, our review shows a lack of full and transparent reporting within systematic reviews even though a plethora of guidelines exist. This review underscores the need for promoting the completeness of and adherence to transparent systematic search reporting within systematic reviews.

Self-compassion and risk behavior among people living with HIV/AIDS

Sexual risk behavior and illicit drug use among people living with HIV/AIDS (PLWHA) contribute to poor health and onward transmission of HIV. The aim of this collaborative multi-site nursing research study was to explore the association between self-compassion and risk behaviors in PLWHA. As part of a larger project, nurse researchers in Canada, China, Namibia, Puerto Rico, Thailand and the US enrolled 1211 sexually active PLWHA using convenience sampling. The majority of the sample was male, middle-aged, and from the US. Illicit drug use was strongly associated with sexual risk behavior, but participants with higher self-compassion were less likely to report sexual risk behavior, even in the presence of illicit drug use. Self-compassion may be a novel area for behavioral intervention development for PLWHA.

HIV-1 vaccines: challenges and new perspectives

The development of a safe and effective preventive HIV-1 vaccine remains a public health priority. Despite scientific difficulties and disappointing results, HIV-1 vaccine clinical development has, for the first time, established proof-of-concept efficacy against HIV-1 acquisition and identified vaccine-associated immune correlates of risk. The correlate of risk analysis showed that IgG antibodies against the gp120 V2 loop correlated with decreased risk of HIV infection, while Env-specific IgA directly correlated with increased risk. The development of vaccine strategies such as improved envelope proteins formulated with potent adjuvants and DNA and vectors expressing mosaics, or conserved sequences, capable of eliciting greater breadth and depth of potentially relevant immune responses including neutralizing and non-neutralizing antibodies, CD4+ and CD8+ cell-mediated immune responses, mucosal immune responses, and immunological memory, is now proceeding quickly. Additional human efficacy trials combined with other prevention modalities along with sustained funding and international collaboration remain key to bring an HIV-1 vaccine to licensure.

Chlamydia trachomatis, human immunodeficiency virus (HIV) distribution and sexual behaviors across gender and age group in an African setting

OBJECTIVE

The purpose of this study was to (1) describe the distribution of Chlamydia trachomatis (CT) and Human Immunodeficiency Virus (HIV) cases across gender and age groups in Libreville (Gabon); (2) examine Gabonese Sexually Transmitted Infections (STIs)-related risk behaviour.

METHODS

The sampled population was people attending the "Laboratoire National de Santé Plublique". Between 2007 and 2011, 14 667 and 9 542 people respectively, were tested for CT and HIV infections. 1 854 of them were tested for both infections. We calculated CT and HIV rates across gender and age groups. Also analysed was the groups' contribution to the general CT and HIV epidemiology. STIs-related risk behaviours were assessed in 224 men and 795 women (between July 2011 and March 2013) who agreed and answered a questionnaire including questions on their marital status, number of sex partners, sexual practices, history of STIs, sex frequency and condom use.

RESULTS

Data showed a 24% dropped in the CT infection rate between 2007 and 2010, followed by a 14% increase in 2011. The HIV infection rates for the same period were between 15% and 16%. The risk of a CT-positive subject getting HIV is about 0.71 times the risk of a CT-negative subject. Young adult aged between 18 and 35 years old represented 65.2% of people who had STIs. 80% of women and 66% of men confessed to an inconsistent use of condoms. 11.6% of women and 48% of men declared having multiple sex partners. 61% of questioned women and 67% of men declared knowing their HIV status.

CONCLUSIONS

In this Gabonese setting, the population-aged from 18 to 35 years is the most affected by STIs. Other matters of concern are the inconsistent use of protection and sex with non-spousal or non-life partners.

Implementation science perspectives and opportunities for HIV/AIDS research: integrating science, practice, and policy

BACKGROUND

Disparities in the incidence and mortality of HIV/AIDS persist, challenging researchers, practitioners, and communities to develop improved strategies to reach vulnerable and marginalized populations.

METHODS

The emerging field of Implementation Science, with its focus on context, external validity, and innovative design approaches, is well suited to respond to this challenge. We provide an overview of Implementation Science, including its frameworks, tools, and strategies, and how they can inform the response to HIV/AIDS.

RESULTS

We summarize pioneering Implementation Science frameworks, and then present examples using newer models, including RE-AIM (Reach, Effectiveness/Efficacy, Adoption, Implementation, Maintenance) and the Evidence Integration Triangle, a framework for combining research and practice using participatory and adaptive processes in a multilevel context.

CONCLUSIONS

Although still developing, the international field of Implementation Science can offer helpful perspectives for facilitating the more rapid integration of HIV/AIDS research, practice, and policy.

Are female sex workers able to negotiate condom use with male clients? The case of mobile FSWs in four high HIV prevalence states of India

Introduction

Condom promotion among female sex workers (FSWs) is a key intervention in India’s National AIDS Control Program. However, there is limited understanding of how FSWs negotiate condom use with male clients, particularly in the context of their mobility for sex work. The objective of this study is to examine the factors associated with the mobile FSWs’ ability to refuse unsafe sex and successfully negotiate condom use with unwilling male clients.

Methods

Data for 5498 mobile FSWs from a cross-sectional survey conducted in 22 districts of four states in southern India were analyzed. Questions assessed FSWs’ ability to refuse clients unprotected sex, convince unwilling clients for condom use and negotiate condom use in a new location. Logistic regression models were constructed to examine the association between socio-demographics, economic vulnerability, sex work practice, and program exposure and condom negotiation ability.

Results

A majority of FSWs (60%) reported the ability to refuse clients for unprotected sex, but less than one-fifth reported the ability to successfully convince an unwilling client to use a condom or to negotiate condom use in a new site. Younger and older mobile FSWs compared to those who were in the middle age group, those with longer sex work experience, with an income source other than sex work, with program exposure and who purchased condoms for use, reported the ability to refuse unprotected sex, to successfully negotiate condom use with unwilling clients and to do so at new sites.

Conclusion

FSWs need to be empowered to not only refuse unprotected sex but also to be able to motivate and convince unwilling clients for condom use, including those in new locations. In addition to focusing on condom promotion, interventions must address the factors that impact FSWs’ ability to negotiate condom use.

A systematic review to quantitatively evaluate 'Stepping Stones': a participatory community-based HIV/AIDS prevention intervention

This first independent systematic review examined evidence for the effectiveness of the stepping stones intervention in HIV prevention. To reduce HIV transmission it addresses gender roles and promotes equitable relationships. Biomedical, behavioural and psychosocial outcomes extracted from six databases and 'grey' literature identified eight reports of seven studies (n = 14,630) from India, Gambia, S. Africa, Ethiopia, Angola, Tanzania, Uganda and Fiji. Infection incidence tested in the only RCT showed no significant reduction in HIV, although HSV-2 decreased. Condom use increased (two countries out of eight). Risk reduction results were mixed for declining alcohol misuse (two studies in three) and multiple partners (one in two). Communicating HIV information to partners, family or community improved (three studies from seven). Gender inequity was reduced in India (one in five), but stigma decreased in four studies. Future investigations of diverse cultures and older adults should select high quality biomedical and quality of life measures.

Combination implementation for HIV prevention: moving from clinical trial evidence to population-level effects

The promise of combination HIV prevention-the application of multiple HIV prevention interventions to maximise population-level effects-has never been greater. However, to succeed in achieving significant reductions in HIV incidence, an additional concept needs to be considered: combination implementation. Combination implementation for HIV prevention is the pragmatic, localised application of evidence-based strategies to enable high sustained uptake and quality of interventions for prevention of HIV. In this Review, we explore diverse implementation strategies including HIV testing and counselling models, task shifting, linkage to and retention in care, antiretroviral therapy support, behaviour change, demand creation, and structural interventions, and discusses how they could be used to complement HIV prevention efforts such as medical male circumcision and treatment as prevention. HIV prevention and treatment have arrived at a pivotal moment when combination efforts might result in substantial enough population-level effects to reverse the epidemic and drive towards elimination of HIV. Only through careful consideration of how to implement and operationalise HIV prevention interventions will the HIV community be able to move from clinical trial evidence to population-level effects.

HIV/AIDS-Related Knowledge and Behaviors Among Most-at-Risk Populations in Vietnam

The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has supported the Vietnamese Ministry of Health (MOH) in implementing behavior change strategies to slow the HIV epidemic. These programs target commercial sex workers (CSW), injection drug users (IDU), and men who have sex with men (MSM). Using data from a program evaluation to assess effectiveness of the PEPFAR intervention, we conducted a sub-analysis of HIV/AIDS knowledge, sexual behaviors, and injection drug risk behaviors among 2,199 Vietnamese respondents, including those reporting recent contact with an outreach worker and those who did not report contact. We found overall high levels of HIV/AIDS knowledge, low rates of needle sharing, and moderate to high rates of inconsistent condom use. Average knowledge scores of IDU were significantly higher than non-IDU for antiretroviral treatment knowledge, while MSM had significantly less knowledge of treatment compared to non-MSM. HIV/AIDS-related knowledge was not significantly associated with needle-sharing practices. Knowledge was modestly but significantly associated with more consistent use of condoms with primary and commercial sex partners, even after controlling for contact with an outreach worker. Contact with an outreach worker was also an independent predictor of more consistent condom use. Outreach programs appear to play a meaningful role in changing sexual behavior, though the effect of outreach on IDU risk behaviors was less clear. More research is needed to understand the relationship between outreach programs and skill development, motivation, and use of referral services by most-at-risk populations in Vietnam.

Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial

BACKGROUND

Lack of education and an economic dependence on men are often suggested as important risk factors for HIV infection in women. We assessed the efficacy of a cash transfer programme to reduce the risk of sexually transmitted infections in young women.

METHODS

In this cluster randomised trial, never-married women aged 13-22 years were recruited from 176 enumeration areas in the Zomba district of Malawi and randomly assigned with computer-generated random numbers by enumeration area (1:1) to receive cash payments (intervention group) or nothing (control group). Intervention enumeration areas were further randomly assigned with computer-generated random numbers to conditional (school attendance required to receive payment) and unconditional (no requirements to receive payment) groups. Participants in both intervention groups were randomly assigned by a lottery to receive monthly payments ranging from US$1 to $5, while their parents were independently assigned with computer-generated random numbers to receive $4-10. Behavioural risk assessments were done at baseline and 12 months; serology was tested at 18 months. Participants were not masked to treatment status but counsellors doing the serologic testing were. The primary outcomes were prevalence of HIV and herpes simplex virus 2 (HSV-2) at 18 months and were assessed by intention-to-treat analyses. The trial is registered, number NCT01333826.

FINDINGS

88 enumeration areas were assigned to receive the intervention and 88 as controls. For the 1289 individuals enrolled in school at baseline with complete interview and biomarker data, weighted HIV prevalence at 18 month follow-up was 1·2% (seven of 490 participants) in the combined intervention group versus 3·0% (17 of 799 participants) in the control group (adjusted odds ratio [OR] 0·36, 95% CI 0·14-0·91); weighted HSV-2 prevalence was 0·7% (five of 488 participants) versus 3·0% (27 of 796 participants; adjusted OR 0·24, 0·09-0·65). In the intervention group, we noted no difference between conditional versus unconditional intervention groups for weighted HIV prevalence (3/235 [1%] vs 4/255 [2%]) or weighted HSV-2 prevalence (4/233 [1%] vs 1/255 [<1%]). For individuals who had already dropped out of school at baseline, we detected no significant difference between intervention and control groups for weighted HIV prevalence (23/210 [10%] vs 17/207 [8%]) or weighted HSV-2 prevalence (17/211 [8%] vs 17/208 [8%]).

INTERPRETATION

Cash transfer programmes can reduce HIV and HSV-2 infections in adolescent schoolgirls in low-income settings. Structural interventions that do not directly target sexual behaviour change can be important components of HIV prevention strategies.

FUNDING

Global Development Network, Bill & Melinda Gates Foundation, National Bureau of Economic Research Africa Project, World Bank's Research Support Budget, and several World Bank trust funds (Gender Action Plan, Knowledge for Change Program, and Spanish Impact Evaluation fund).

Conditional Cash Transfers and HIV/AIDS Prevention: Unconditionally Promising?

Conditional cash transfers (CCT) have recently received considerable attention as a potentially innovative and effective approach to the prevention of HIV/AIDS. We evaluate a conditional cash transfer program in rural Malawi which offered financial incentives to men and women to maintain their HIV status for approximately one year. The amounts of the reward ranged from zero to approximately 3-4 months wage. We find no effect of the offered incentives on HIV status or on reported sexual behavior. However, shortly after receiving the reward, men who received the cash transfer were 9 percentage points more likely and women were 6.7 percentage points less likely to engage in risky sex. Our analyses therefore question the "unconditional effectiveness" of CCT program for HIV prevention: CCT Programs that aim to motivate safe sexual behavior in Africa should take into account that money given in the present may have much stronger effects than rewards offered in the future, and any effect of these programs may be fairly sensitive to the specific design of the program, the local and/or cultural context, and the degree of agency an individual has with respect to sexual behaviors.

Antiretroviral therapy in prevention of HIV and TB: update on current research efforts

There is considerable scientific evidence supporting the use of antiretroviral therapy (ART) in prevention of human immunodeficiency virus (HIV) and tuberculosis (TB) infections. The complex nature of the HIV and TB prevention responses, resource constraints, remaining questions about cost and feasibility, and the need to use a solid evidence base to make policy decisions, and the implementation challenges to translating trial data to operational settings require a well-organised and coordinated response to research in this area. To this end, we aimed to catalogue the ongoing and planned research activities that evaluate the impact of ART plus other interventions on HIV- and/or TB-related morbidity, mortality, risk behaviour, HIV incidence and transmission. Using a limited search methodology, 50 projects were identified examining ART as prevention, representing 5 regions and 52 countries with a global distribution. There are 24 randomised controlled clinical trials with at least 12 large randomised individual or community cluster trials in resource-constrained settings that are in the planning or early implementation stages. There is considerable heterogeneity between studies in terms of methodology, interventions and geographical location. While the identified studies will undoubtedly advance our understanding of the efficacy and effectiveness of ART for prevention, some key questions may remain unanswered or only partially answered. The large number and wide variety of research projects emphasise the importance of this research issue and clearly demonstrate the potential for synergies, partnerships and coordination across funding agencies.

Treatment as prevention: preparing the way

Potent antiretroviral therapy (ART) reduces mortality and morbidity in people living with HIV by reducing viral load and allowing their immune systems to recover. The reduction in viral load soon after starting ART has led to the hypothesis that early and widespread ART could prevent onward transmission and therefore eliminate the HIV epidemic in the long term. While several authors have argued that it is feasible to use HIV treatment as prevention (TasP), provided treatment is started sufficiently early, others have reasonably drawn attention to the many operational difficulties that will need to be overcome if the strategy is to succeed in reducing HIV transmission. Furthermore, international public health policy must be based on more than theoretical studies, no matter how appealing. Community randomized controlled trials provide the gold standard for testing the extent to which early treatment reduces incidence, but much still needs to be understood and the immediate need is for operational studies to explore the practical feasibility of this approach. Here, we examine some of the issues to be addressed, the obstacles to be overcome, and strategies that may be necessary if TasP is to be effective. Studies of this kind will provide valuable information for the design of large-scale trials, as well as essential information that will be needed if early treatment is to be incorporated into public health policy.

The rapidly changing paradigm of HIV prevention: time to strengthen social and behavioural approaches

A decade after the world's leaders committed to fight the global HIV epidemic, UNAIDS notes progress in halting the spread of the virus. Access to treatment has in particular increased, with noticeable beneficial effects on HIV-related mortality. Further scaling-up treatment requires substantial human and financial resources and the continued investments that are required may further erode the limited resources for HIV prevention. Treatment can play a role in reducing the transmission of HIV, but treatment alone is not enough and cost-effective behavioural prevention approaches are available that in recent years have received less priority. HIV prevention may in the future benefit from novel biomedical approaches that are in development, including those that capitalize on the use of treatment. To date, evidence of effectiveness of biomedical prevention in real-life conditions is limited and, while they can increase prevention options, many biomedical prevention approaches will continue to rely on the behaviours of individuals and communities. These behaviors are shaped and constrained by the social, cultural, political and economic contexts that affect the vulnerability of individuals and communities. At the start of the 4(th) decade of the epidemic, it is timely to re-focus on strengthening the theory and practice of behavioural prevention of HIV.

Combination HIV prevention: significance, challenges, and opportunities

No single HIV prevention strategy will be sufficient to control the HIV pandemic. However, a growing number of interventions have shown promise in partially protecting against HIV transmission and acquisition, including knowledge of HIV serostatus, behavioral risk reduction, condoms, male circumcision, needle exchange, treatment of curable sexually transmitted infections, and use of systemic and topical antiretroviral medications by both HIV-infected and uninfected persons. Designing the optimal package of interventions that matches the epidemiologic profile of a target population, delivering that package at the population level, and evaluating safety, acceptability, coverage, and effectiveness, all involve methodological challenges. Nonetheless, there is an unprecedented opportunity to develop "prevention packages" that combine various arrays of evidence-based strategies, tailored to the needs of diverse subgroups and targeted to achieve high coverage for a measurable reduction in population-level HIV transmission. HIV prevention strategies that combine partially effective interventions should be scaled up and evaluated.