Caitlin E. Kennedy

HIV Voluntary Counseling and Testing and Behavioral Risk Reduction in Developing Countries: A Meta-analysis, 1990–2005

The effectiveness of HIV voluntary counseling and testing (VCT) in reducing HIV risk behaviors in developing countries was assessed using meta-analytic methods. A standardized protocol was used for searching, acquiring, and extracting study data and meta-analyzing the results. Seven studies met the inclusion criteria. VCT recipients were significantly less likely to engage in unprotected sex when compared to behaviors before receiving VCT, or as compared to participants who had not received VCT [OR 1.69; 95%CI 1.25–2.31]. VCT had no significant effect on the number of sex partners [OR 1.22; 95%CI 0.89–1.67]. While these findings provide only moderate evidence in support of VCT as an effective prevention strategy, neither do they negate the need to expand access to HIV testing and counseling services. Such expansion, however, must be accompanied by rigorous evaluation in order to test, refine and maximize the preventive benefits of learning one’s HIV infection status through HIV testing and counseling.

Effectiveness of peer education interventions for HIV prevention in developing countries: a systematic review and meta-analysis

Peer education for HIV prevention has been widely implemented in developing countries, yet the effectiveness of this intervention has not been systematically evaluated. We conducted a systematic review and meta-analysis of peer education interventions in developing countries published between January 1990 and November 2006. Standardized methods of searching and data abstraction were utilized. Merged effect sizes were calculated using random effects models. Thirty studies were identified. In meta-analysis, peer education interventions were significantly associated with increased HIV knowledge (odds ratio [OR]: 2.28; 95%, confidence interval [CI]:1.88, 2.75), reduced equipment sharing among injection drug users (OR: 0.37; 95% CI: 0.20, 0.67), and increased condom use (OR: 1.92; 95% CI: 1.59, 2.33). Peer education programs had a nonsignificant effect on sexually transmitted infections (OR: 1.22; 95% CI:0.88, 1.71). Meta-analysis indicates that peer education programs in developing countries are moderately effective at improving behavioral outcomes but show no significant impact on biological outcomes. Further research is needed to determine factors that maximize the likelihood of program success.

Effectiveness and safety of oral HIV preexposure prophylaxis for all populations.

Objective:Preexposure prophylaxis (PrEP) offers a promising new approach to HIV prevention. This systematic review and meta-analysis evaluated the evidence for use of oral PrEP containing tenofovir disoproxil fumarate as an additional HIV prevention strategy in populations at substantial risk for HIV based on HIV acquisition, adverse events, drug resistance, sexual behavior, and reproductive health outcomes. Design:Rigorous systematic review and meta-analysis. Methods:A comprehensive search strategy reviewed three electronic databases and conference abstracts through April 2015. Pooled effect estimates were calculated using random-effects meta-analysis. Results:Eighteen studies were included, comprising data from 39 articles and six conference abstracts. Across populations and PrEP regimens, PrEP significantly reduced the risk of HIV acquisition compared with placebo. Trials with PrEP use more than 70% demonstrated the highest PrEP effectiveness (risk ratio = 0.30, 95% confidence interval: 0.21–0.45, P < 0.001) compared with placebo. Trials with low PrEP use did not show a significantly protective effect. Adverse events were similar between PrEP and placebo groups. More cases of drug-resistant HIV infection were found among PrEP users who initiated PrEP while acutely HIV-infected, but incidence of acquiring drug-resistant HIV during PrEP use was low. Studies consistently found no association between PrEP use and changes in sexual risk behavior. PrEP was not associated with increased pregnancy-related adverse events or hormonal contraception effectiveness. Conclusion:PrEP is protective against HIV infection across populations, presents few significant safety risks, and there is no evidence of behavioral risk compensation. The effective and cost-effective use of PrEP will require development of best practices for fostering uptake and adherence among people at substantial HIV risk.

The impact of HIV treatment on risk behaviour in developing countries: A systematic review

Abstract In developing countries, access to antiretroviral therapy (ART) is improving as HIV treatment becomes a greater priority in the global fight against AIDS. While ART has clearly beneficial clinical effects, increased access to treatment may also affect sexual behaviour. To examine the strength of evidence for the impact of medical treatment for HIV-positive individuals on behavioural outcomes in developing countries, we conducted a comprehensive search of the peer-reviewed literature. Studies were included if they provided clinical treatment to HIV-positive individuals in a developing country, compared behavioural, psychological, social, care, or biological outcomes related to HIV-prevention using a pre/post or multi-arm study design, and were published between January 1990 and January 2006. Only three studies were identified that met the inclusion criteria. All were conducted in Africa, utilized before/after or multi-arm study designs, and relied on self-reported behaviour. In all three studies, a majority of HIV-infected individuals reported being sexually abstinent, and access to ART was not associated with an increase in HIV-related risky sexual behaviours. However, one cross-sectional study found that ART patients were more likely to report STD treatment. The available evidence indicates a significant reduction in risk behaviour associated with ART in developing countries. However, there are few existing studies and the rigor of these studies is weak. More studies are needed to build an evidence base on which to make programmatic and policy decisions.

Behavioural interventions for HIV positive prevention in developing countries: a systematic review and meta-analysis

OBJECTIVE To assess the evidence for a differential effect of positive prevention interventions among individuals infected and not infected with human immunodeficiency virus (HIV) in developing countries, and to assess the effectiveness of interventions targeted specifically at people living with HIV. METHODS We conducted a systematic review and meta-analysis of papers on positive prevention behavioural interventions in developing countries published between January 1990 and December 2006. Standardized methods of searching and data abstraction were used. Pooled effect sizes were calculated using random effects models. FINDINGS Nineteen studies met the inclusion criteria. In meta-analysis, behavioural interventions had a stronger impact on condom use among HIV-positive (HIV+) individuals (odds ratio, OR: 3.61; 95% confidence interval, CI: 2.61-4.99) than among HIV-negative individuals (OR: 1.32; 95% CI: 0.77-2.26). Interventions specifically targeting HIV+ individuals also showed a positive effect on condom use (OR: 7.84; 95% CI: 2.82-21.79), which was particularly strong among HIV-serodiscordant couples (OR: 67.38; 95% CI: 36.17-125.52). Interventions included in this review were limited both in scope (most were HIV counselling and testing interventions) and in target populations (most were conducted among heterosexual adults or HIV-serodiscordant couples). CONCLUSION Current evidence suggests that interventions targeting people living with HIV in developing countries increase condom use, especially among HIV-serodiscordant couples. Comprehensive positive prevention interventions targeting diverse populations and covering a range of intervention modalities are needed to keep HIV+ individuals physically and mentally healthy, prevent transmission of HIV infection and increase the agency and involvement of people living with HIV.

A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up

A community empowerment-based response to HIV is a process by which sex workers take collective ownership of programmes to achieve the most effective HIV outcomes and address social and structural barriers to their overall health and human rights. Community empowerment has increasingly gained recognition as a key approach for addressing HIV in sex workers, with its focus on addressing the broad context within which the heightened risk for infection takes places in these individuals. However, large-scale implementation of community empowerment-based approaches has been scarce. We undertook a comprehensive review of community empowerment approaches for addressing HIV in sex workers. Within this effort, we did a systematic review and meta-analysis of the effectiveness of community empowerment in sex workers in low-income and middle-income countries. We found that community empowerment-based approaches to addressing HIV among sex workers were significantly associated with reductions in HIV and other sexually transmitted infections, and with increases in consistent condom use with all clients. Despite the promise of a community-empowerment approach, we identified formidable structural barriers to implementation and scale-up at various levels. These barriers include regressive international discourses and funding constraints; national laws criminalising sex work; and intersecting social stigmas, discrimination, and violence. The evidence base for community empowerment in sex workers needs to be strengthened and diversified, including its role in aiding access to, and uptake of, combination interventions for HIV prevention. Furthermore, social and political change are needed regarding the recognition of sex work as work, both globally and locally, to encourage increased support for community empowerment responses to HIV.

Linking family planning with HIV/AIDS interventions: a systematic review of the evidence.

Objective:To conduct a systematic review of the literature and examine the effectiveness, optimal circumstances, and best practices for strengthening linkages between family planning and HIV interventions. Design:Systematic review of peer-reviewed articles and unpublished program reports (‘promising practices’) evaluating interventions linking family planning and HIV services. Methods:Articles were included if they reported post-intervention evaluation results from an intervention linking family planning and HIV services between 1990 and 2007. Systematic methods were used for searching, screening, and data extraction. Quality assessment was conducted using a 9-point rigor scale. Results:Sixteen studies were included in the analysis (10 peer-reviewed studies and six promising practices). Interventions were categorized into six types: family planning services provided to HIV voluntary counseling and testing (VCT) clients, family planning and VCT services provided to maternal and child health clients, family planning services provided to people living with HIV, community health workers provided family planning and HIV services, VCT provided to family planning clinic clients, and VCT and family planning services provided to women receiving postabortion care. Average study design rigor was low (3.25 out of 9). Most studies reported generally positive or mixed results for key outcomes; no negative results were reported. Conclusion:Interventions linking family planning and HIV services were generally considered feasible and effective, though overall evaluation rigor was low.

Sexual stigma and discrimination as barriers to seeking appropriate healthcare among men who have sex with men in Swaziland.

Same‐sex practices and orientation are both stigmatized and criminalized in many countries across sub‐Saharan Africa. This study aimed to assess the relationship of fear of seeking healthcare and disclosure of same‐sex practices among a sample of men who have sex with men (MSM) in Swaziland with demographic, socio‐economic and behavioural determinants.

School Based Sex Education and HIV Prevention in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Objectives School-based sex education is a cornerstone of HIV prevention for adolescents who continue to bear a disproportionally high HIV burden globally. We systematically reviewed and meta-analyzed the existing evidence for school-based sex education interventions in low- and middle-income countries to determine the efficacy of these interventions in changing HIV-related knowledge and risk behaviors. Methods We searched five electronic databases, PubMed, Embase, PsycInfo, CINAHL, and Sociological Abstracts, for eligible articles. We also conducted hand-searching of key journals and secondary reference searching of included articles to identify potential studies. Intervention effects were synthesized through random effects meta-analysis for five outcomes: HIV knowledge, self-efficacy, sexual debut, condom use, and number of sexual partners. Results Of 6191 unique citations initially identified, 64 studies in 63 articles were included in the review. Nine interventions either focused exclusively on abstinence (abstinence-only) or emphasized abstinence (abstinence-plus), whereas the remaining 55 interventions provided comprehensive sex education. Thirty-three studies were able to be meta-analyzed across five HIV-related outcomes. Results from meta-analysis demonstrate that school-based sex education is an effective strategy for reducing HIV-related risk. Students who received school-based sex education interventions had significantly greater HIV knowledge (Hedges g = 0.63, 95% Confidence Interval (CI): 0.49–0.78, p<0.001), self-efficacy related to refusing sex or condom use (Hedges g = 0.25, 95% CI: 0.14–0.36, p<0.001), condom use (OR = 1.34, 95% CI: 1.18–1.52, p<0.001), fewer sexual partners (OR = 0.75, 95% CI:0.67–0.84, p<0.001) and less initiation of first sex during follow-up (OR = 0.66, 95% CI: 0.54–0.83, p<0.001). Conclusions The paucity of abstinence-only or abstinence-plus interventions identified during the review made comparisons between the predominant comprehensive and less common abstinence-focused programs difficult. Comprehensive school-based sex education interventions adapted from effective programs and those involving a range of school-based and community-based components had the largest impact on changing HIV-related behaviors.

Disclosure Outcomes, Coping Strategies, and Life Changes Among Women Living With HIV in Uganda:

An HIV diagnosis is a life-changing event. Disclosure of HIV test results might be related to developing effective coping strategies. We conducted qualitative, in-depth interviews with 30 HIV-infected women in Uganda to explore links between HIV disclosure and coping strategies. Many women experienced an evolution in their ability to cope from initial shame to eventual acceptance. Factors that facilitated adaptive coping included being healthy, feeling responsible for children, support group participation, forming supportive relationships, and low perceived stigma and discrimination. HIV disclosure was often the first step in this coping process. Overall, 80% of the women had disclosed, with most reporting positive outcomes. Development of adaptive coping strategies and HIV serostatus disclosure are closely related, as they allow women to develop support networks and begin coming to terms with their diagnosis. Strategies are needed to safely support women who want to disclose their HIV test results.