HIV infection and related risk behaviors: does school support level the playing field between orphans and nonorphans in Zimbabwe?

Cash transfers for HIV prevention: A systematic review

BACKGROUND

Given the success of cash programs in improving health outcomes and addressing upstream drivers of HIV risk such as poverty and education, there has been an increasing interest in their potential to improve HIV prevention and care outcomes. Recent reviews have documented the impacts of structural interventions on HIV prevention, but evidence about the effects of cash transfer programs on HIV prevention has not been systematically reviewed for several years.

METHODS AND FINDINGS

We did a systematic review of published and unpublished literature to update and summarize the evidence around cash programs for HIV prevention from January 2000 to December 17, 2020. We included studies with either a cash transfer intervention, savings program, or program to reduce school costs. Included studies measured the program's impact on HIV infection, other sexually transmitted infections (STIs), or sexual behaviors. We screened 1,565 studies and examined 78 in full-text review to identify a total of 45 peer-reviewed publications and reports from 27 different interventions or populations. We did not do a meta-analysis given the range of outcomes and types of cash transfer interventions assessed. Most studies were conducted in sub-Saharan Africa (N = 23; South Africa, Tanzania, Malawi, Lesotho, Kenya, Uganda, Zimbabwe, Zambia, and eSwatini) followed by Mexico (N = 2), the United States (N = 1), and Mongolia (N = 1)). Of the 27 studies, 20 (72%) were randomized trials, 5 (20%) were observational studies, 1 (4%) was a case-control study, and 1 (4%) was quasi-experimental. Most studies did not identify a strong association between the program and sexual behaviors, except sexual debut (10/18 finding an association; 56%). Eight of the 27 studies included HIV biomarkers, but only 3 found a large reduction in HIV incidence or prevalence, and the rest found no statistically significant association. Of the studies that identified a statistically significant association with other STIs (N = 4/8), 2 involved incentives for staying free of the STI, and the other 2 were cash transfer programs for adolescent girls that had conditionalities related to secondary schooling. Study limitations include the small number of studies in key populations and examining interventions to reduce school costs and matched saving programs.

CONCLUSIONS

The evidence base for large-scale impacts of cash transfers reducing HIV risk is limited; however, government social protection cash transfer programs and programs that incentivize school attendance among adolescent girls and young women show the greatest promise for HIV prevention.

Is it time to RE-AIM? A systematic review of economic empowerment as HIV prevention intervention for adolescent girls and young women in sub-Saharan Africa using the RE-AIM framework

Background

Economic empowerment (EE) HIV prevention programs for adolescent girls and young women (AGYW) in sub-Saharan Africa are gaining traction as effective strategies to reduce HIV risk and vulnerabilities among this population. While intervention effectiveness is critical, there are numerous factors beyond effectiveness that shape an intervention’s impact. The objective of this systematic review was to assess the reporting of implementation outcomes of EE HIV prevention programs for AGYW in SSA, as conceptualized in the RE-AIM (reach, efficacy/effectiveness, adoption, implementation, and maintenance) framework.

Methods

We searched PubMed, Ovid/MEDLINE, Science Direct, Ebscohost, PsycINFO, Scopus, and Web of Science for EE HIV interventions for AGYW in SSA. Study selection and data extraction were conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Two researchers coded each article using a validated RE-AIM data extraction tool and independently extracted information from each article. The reporting of RE-AIM dimensions were summarized and synthesized across included interventions.

Results

A total of 25 unique interventions (reported in 45 articles) met the predefined eligibility criteria. Efficacy/effectiveness 19(74.4%) was the highest reported RE-AIM dimension, followed by adoption 17(67.2%), reach 16(64.0%), implementation 9(38.0%), and maintenance 7(26.4%). Most interventions reported on RE-AIM components such as sample size 25(100.0%), intervention location 24(96.0%), and measures and results for at least one follow-up 24(96.0%). Few reported on RE-AIM components such as characteristics of non-participants 8(32.0%), implementation costs 3(12.0%), and intervention fidelity 0(0.0%).

Conclusions

Results of the review emphasize the need for future economic empowerment HIV prevention interventions for AGYW in SSA to report multiple implementation strategies and highlight considerations for translating such programs into real-world settings. Researchers should pay close attention to reporting setting-level adoption, implementation cost, and intervention maintenance. These measures are needed for policy decisions related to the full merit and worth of EE HIV interventions and their long-term sustainability for AGYW.

Positive Youth Development Programs in Low- and Middle-Income Countries: A Conceptual Framework and Systematic Review of Efficacy

PURPOSE

Positive youth development (PYD) has served as a framework for youth programs in high-income countries since the 1990s and has demonstrated broad behavioral health and developmental benefits. PYD programs build skills, assets, and competencies; foster youth agency; build healthy relationships; strengthen the environment; and transform systems to prepare youth for successful adulthood. The goal of this article was to systematically review the impact of PYD programs in low- and middle-income countries (LMICs).

METHODS

Targeted searches of knowledge repository Web sites and keyword searches of Scopus and PubMed identified over 21,500 articles and over 3,700 evaluation reports published between 1990 and mid-2016. Ninety-four PYD programs with evaluations in LMICs were identified, of which 35 had at least one experimental or rigorous quasi-experimental evaluation.

RESULTS

Sixty percent of the 35 programs with rigorous evaluations demonstrated positive effects on behaviors, including substance use and risky sexual activity, and/or more distal developmental outcomes, such as employment and health indicators.

CONCLUSIONS

There is promising evidence that PYD programs can be effective in LMICs; however, more rigorous examination with long-term follow-up is required to establish if these programs offer benefits similar to those seen in higher income countries.

The protective role of family structure for adolescent development in sub-Saharan Africa

Several studies have focused on the risk factors associated with adolescent developmental outcomes, but the literature on the role of protective factors at the family and community level for positive adolescent development is scarce, especially in sub-Saharan Africa (SSA). We hypothesize that ensuring a supportive environment for adolescents may result in delayed sexual debut for adolescents in SSA. The relationship between family structure and positive adolescent sexual behaviour, measured as delay in sexual debut, was examined using the bioecological theory framed by a risk and resilience perspective. We used nationally representative data on female and male adolescents (aged 15–17 years) from 12 countries in SSA. We modelled logistic regressions to test for associations between family structure and delayed sexual debut while controlling for other covariates in SSA. The majority (90%) of the young adults delayed sexual debut, and this delay varied by family structure. After controlling for other covariates, adolescents living with neither parent had lower odds of delaying sexual debut although results were only significant for males. Interaction terms with community socio-economic status showed an interaction between community education and males living with neither parent. Future studies must investigate the gender differentials in the relationship between family structure and delayed sexual debut among adolescents in SSA.

Process Evaluation of a Clinical Trial to Test School Support as HIV Prevention Among Orphaned Adolescents in Western Kenya

Orphaned adolescents are a large and vulnerable population in sub-Saharan Africa, at higher risk for HIV than non-orphans. Yet prevention of new infection is critical for adolescents since they are less likely than adults to enter and remain in treatment and are the only age group with rising AIDS death rates. We report process evaluation for a randomized controlled trial (RCT) testing support to stay in school (tuition, uniform, nurse visits) as an HIV prevention strategy for orphaned Kenyan adolescents. The RCT found no intervention effect on HIV/HSV-2 biomarker outcomes. With process evaluation, we examined the extent to which intervention elements were implemented as intended among the intervention group (N = 412) over the 3-year study period (2012-2014), the implementation effects on school enrollment (0-9 terms), and whether more time in school impacted HIV/HSV-2. All analyses examined differences as a whole, and by gender. Findings indicate that school fees and uniforms were fully implemented in 94 and 96% of cases, respectively. On average, participants received 79% of the required nurse visits. Although better implementation of nurse visits predicted more terms in school, a number of terms did not predict the likelihood of HIV/HSV-2 infection. Attending boarding school also increased number of school terms, but reduced the odds of infection for boys only. Four previous RCTs have been conducted in sub-Saharan Africa, and only one found limited evidence of school impact on adolescent HIV/HSV-2 infection. Our findings add further indication that the association between school support and HIV/HSV-2 prevention appears to be weak or under-specified.

School Support as Structural HIV Prevention for Adolescent Orphans in Western Kenya

PURPOSE

Using a clustered randomized controlled trial design, we evaluated whether support to keep Kenyan orphaned adolescents in school reduces the risk of HIV infection.

METHODS

Participants included 835 orphaned boys and girls in grades 7 and 8 (mean age at the baseline = 15 years) in western Kenya. Primary schools (N = 26) were randomized to the study condition. Intervention participants received school uniforms, payment of tuition when they transitioned into high school, and nurse visits to monitor school absenteeism and provide assistance to stay in school. Annual surveys were conducted from 2011 through 2014, and HIV and herpes simplex virus 2 (HSV-2) biomarker data were collected at the baseline and the end line. Data were analyzed using survey logistic regression or generalized estimating equations controlling for age, gender, and socioeconomic status.

RESULTS

Intervention and control groups were equivalent at the baseline and did not differ on new HIV or HSV-2 incidence at the end line. The school support intervention increased school retention but had few HIV-related effects, except increased circumcision among male participants and reduced likelihood of transactional sex.

CONCLUSIONS

Despite a strong study design, we found no relative reduction in HIV or HSV-2 infection after 3 years of intervention implementation. New incidence of HIV was lower than expected in this region among youth whose average age at end line was 18 years (range = 14-23). Although support for secondary school promises many benefits for vulnerable youth, our study adds to the growing body of research showing weak evidence for its effectiveness as an HIV prevention.

Why Are Orphaned Adolescents More Likely to Be HIV Positive? Distinguishing Between Maternal and Sexual HIV Transmission Using 17 Nationally Representative Data Sets in Africa

PURPOSE

Why do orphans have higher rates of HIV infection than nonorphaned peers? Research consistently assumes that orphans acquire HIV primarily through sexual behavior, but infections may instead be due to maternal transmission. Although these two pathways have very different implications for HIV programs and policies, their relative contribution has not been previously examined. In this research, we compare the contribution of maternal and sexual transmission to HIV infection among orphans in Africa.

METHODS

We use Demographic and Health Survey data for 21,463 women and 18,359 men from 17 countries. We propose a conceptual framework linking orphanhood to HIV, and use mediation analysis and structural equation modeling to compare the potential contribution of maternal transmission (measured through direct pathways from orphanhood to HIV) and sexual transmission (measured through reports of risky sexual behavior) to orphan HIV infection.

RESULTS

Our results suggest that maternal transmission is the predominant pathway of HIV infection among orphaned adolescents: there is strong evidence for a direct pathway from maternal (odds ratio [OR]: 2.45; 95% confidence interval [CI]: 1.72-3.51 for females and OR: 2.45; 95% CI: 1.53-3.90 for males) and double orphanhood (OR: 2.69; 95% CI: 1.97-3.66 and OR: 2.53; 95% CI: 1.68-3.82, respectively) to HIV; greater excess HIV risk in maternal versus paternal orphans. The contribution of sexual behavior is largely not significant. We do not observe correspondingly high orphan disparities in other sexually transmitted diseases.

CONCLUSIONS

Maternal transmission is a more likely explanation than sexual transmission for heightened HIV infection among orphans. These results suggest that programs designed to address HIV infection among adolescents should focus on reducing maternal transmission and on identifying and testing undiagnosed HIV among orphans.

'I thought if I marry the prophet I would not die': The significance of religious affiliation on marriage, HIV testing, and reproductive health practices among young married women in Zimbabwe

This study examines the association between religious affiliation and reasons for marriage, perceived church attitudes, and reproductive health-seeking behaviors, including HIV testing, among young women in eastern rural Zimbabwe. The sample comprised women (N = 35) who had married by 2012 while participating in a larger randomized controlled trial (RCT) to test the effects of school support on HIV-related risk. The RCT sample was identified in 2007 as all female sixth graders in 25 rural eastern Zimbabwe primary schools whose parents, one or both, had died (N = 328). In our previous RCT analyses, we found that participants who affiliated with an Apostolic church were more than four times more likely to marry than those from non-Apostolic churches and that control group participants were twice as likely to marry as those in the intervention group. Other studies had found that marriage greatly increased the odds of HIV infection among adolescent women. Given the link between Apostolic affiliation and marriage, we conducted semi-structured interviews to explore type of marriage, reasons for marrying, church affiliation and attitudes, family planning, HIV testing, schooling, and family life. We were interested in differences, as perceived by our sample of young married women congregants, among Apostolic sects and other denominations in their attitudes about marriage and health-seeking behaviors. We were also interested in the influence of church affiliation on intervention participants' decision to marry, since they had comprehensive school support and education is highly valued in Zimbabwe, but costly and often out of financial reach. Interviews were conducted from October 2012 through November 2013; data were analyzed using a general inductive approach. We found that pressure or perceived deception for coitus or marriage was reported only by intervention participants affiliated with Apostolic denominations. Other reasons for marriage were similar between Apostolic and non-Apostolic adherents, as well as intervention and control conditions. All participants believed HIV testing was important, but while all non-Apostolic denominations encouraged HIV testing and clinic/hospital care, there was considerable heterogeneity in attitudes among Apostolics, with ultraconservative denominations most likely to proscribe non-religious health care. We conclude that some, but not all, Apostolic-affiliated women are afforded discretion in their health-seeking behaviors. Since HIV screening and treatment depend on access to clinic/hospital care, continued public health efforts to engage Apostolic leaders is needed, along with monitoring of progress in access and outcomes.

Influence of school support on early marriage experiences and health services utilization among young orphaned women in Zimbabwe

School support programs reduce school dropout, early marriage, and early pregnancy for a majority of young orphaned women. We used a mixed-methods approach to examine why these programs are less effective for a significant minority by exploring their influence on marriage and health services utilization. Participants were from a randomized controlled trial testing school support as HIV prevention. Half as many intervention as control participants had been married; married intervention participants had 1 more year of education compared with married control participants. Receiving school support did not appear to improve health-related factors. Pregnancy was among the most common reasons for marriage across both groups. The greatest benefit of school support appears to be in delaying marriage and pregnancy while increasing educational attainment.