Virginia A. Fonner

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.

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.

Social Cohesion, Social Participation, and HIV Related Risk among Female Sex Workers in Swaziland

Social capital is important to disadvantaged groups, such as sex workers, as a means of facilitating internal group-related mutual aid and support as well as access to broader social and material resources. Studies among sex workers have linked higher social capital with protective HIV-related behaviors; however, few studies have examined social capital among sex workers in sub-Saharan Africa. This cross-sectional study examined relationships between two key social capital constructs, social cohesion among sex workers and social participation of sex workers in the larger community, and HIV-related risk in Swaziland using respondent-driven sampling. Relationships between social cohesion, social participation, and HIV-related risk factors were assessed using logistic regression. HIV prevalence among the sample was 70.4% (223/317). Social cohesion was associated with consistent condom use in the past week (adjusted odds ratio [AOR]  = 2.25, 95% confidence interval [CI]: 1.30–3.90) and was associated with fewer reports of social discrimination, including denial of police protection. Social participation was associated with HIV testing (AOR = 2.39, 95% CI: 1.36–4.03) and using condoms with non-paying partners (AOR = 1.99, 95% CI: 1.13–3.51), and was inversely associated with reported verbal or physical harassment as a result of selling sex (AOR = 0.55, 95% CI: 0.33–0.91). Both social capital constructs were significantly associated with collective action, which involved participating in meetings to promote sex worker rights or attending HIV-related meetings/ talks with other sex workers. Social- and structural-level interventions focused on building social cohesion and social participation among sex workers could provide significant protection from HIV infection for female sex workers in Swaziland.

''They are human beings, they are Swazi'': intersecting stigmas and the positive health, dignity and prevention needs of HIV-positive men who have sex with men in Swaziland

Despite the knowledge that men who have sex with men (MSM) are more likely to be infected with HIV across settings, there has been little investigation of the experiences of MSM who are living with HIV in sub‐Saharan Africa. Using the framework of positive health, dignity and prevention, we explored the experiences and HIV prevention, care and treatment needs of MSM who are living with HIV in Swaziland.

A systematic review of income generation interventions, including microfinance and vocational skills training, for HIV prevention.

Income generation interventions, such as microfinance or vocational skills training, address structural factors associated with HIV risk. However, the effectiveness of these interventions on HIV-related outcomes in low- and middle-income countries has not been synthesized. The authors conducted a systematic review by searching electronic databases from 1990 to 2012, examining secondary references, and hand-searching key journals. Peer-reviewed studies were included in the analysis if they evaluated income generation interventions in low- or middle-income countries and provided pre-post or multi-arm measures on behavioral, psychological, social, care, or biological outcomes related to HIV prevention. Standardized forms were used to abstract study data in duplicate and study rigor was assessed. Of the 5218 unique citations identified, 12 studies met criteria for inclusion. Studies were geographically diverse, with six conducted in sub-Saharan Africa, three in South or Southeast Asia, and three in Latin America and the Caribbean. Target populations included adult women (N = 6), female sex workers/bar workers (N = 3), and youth/orphans (N = 3). All studies targeted females except two among youth/orphans. Study rigor was moderate, with two group-randomized trials and two individual-randomized trials. All interventions except three included some form of microfinance. Only a minority of studies found significant intervention effects on condom use, number of sexual partners, or other HIV-related behavioral outcomes; most studies showed no significant change, although some may have had inadequate statistical power. One trial showed a 55% reduction in intimate partner violence (adjusted risk ratio 0.45, 95% confidence interval 0.23–0.91). No studies measured incidence/prevalence of HIV or sexually transmitted infections among intervention recipients. The evidence that income generation interventions influence HIV-related behaviors and outcomes is inconclusive. However, these interventions may have important effects on outcomes beyond HIV prevention. Further studies examining not only HIV-related outcomes but also causal pathways and intermediate variables, are needed. Additional studies among men are also needed.

Increasing HIV serostatus disclosure in low and middle-income countries: A systematic review of intervention evaluations

Objective:To review the effectiveness of interventions to increase HIV serostatus disclosure in low and middle-income countries. Design:Systematic review of peer-reviewed articles providing prepost or multiarm evaluations of disclosure interventions, defined broadly as any intervention with the goal of increasing rates of voluntary disclosure of HIV serostatus through self-disclosure or partner notification. Methods:Articles were included if they reported postintervention evaluation results and were published between 1 January 1990 and 1 August 2014. Searching was conducted through five electronic databases, secondary searching of four journals, and hand searching reference lists of included articles. Systematic methods were used for screening and data abstraction, which was conducted in duplicate. Study quality (rigor) was assessed with eight items. Results:Fourteen articles evaluating 13 interventions met the inclusion criteria, all from sub-Saharan Africa. Most interventions focused on people living with HIV and used cognitive-behavioral group sessions or peer/community health worker support to encourage disclosure to sexual partners, family members, or friends. One focused on maternal disclosure to HIV-uninfected children, whereas two examined voluntary partner notification interventions. Several studies had limitations due to weak designs, small sample sizes, or high attrition. Findings on disclosure were mixed, with most effect sizes being relatively small, and some more rigorous studies showing no effect. Partner notification interventions had the strongest evidence of impact. Conclusion:The existing evidence base for interventions to increase disclosure is limited and shows variable results. Further research is needed to determine whether current approaches to increasing disclosure are effective or whether new approaches should be considered.

Family planning counseling for women living with HIV: a systematic review of the evidence of effectiveness on contraceptive uptake and pregnancy incidence, 1990 to 2011

BackgroundFamily planning is an important public health intervention with numerous potential health benefits for all women. One of those key benefits is the prevention of mother-to-child transmission of HIV, through the prevention of unintended pregnancies among women living with HIV.MethodsWe conducted a systematic review of the effectiveness of family planning counseling interventions for HIV infected women in low- and middle-income countries.ResultsWe found nine articles which met the inclusion criteria for this review, all from Africa. Though these studies varied in the specifics of the interventions provided, research designs and measures of outcomes, key features were discernible. Providing concerted information and support for family planning use, coupled with ready access to a wide range of contraceptive methods, seemed most effective in increasing use. Effects on pregnancy overall were difficult to measure, however: no studies assessed the effect on unintended pregnancy.ConclusionsThough these results are far from definitive, they do highlight the need for strengthened efforts to integrate family planning counseling and access to services into HIV prevention, and for greater consistency of effort over time. Studies which specifically investigate fertility intentions and desires of women living with HIV, contraception use following interventions to increase knowledge, awareness, motivation and access to the means to act on those intentions and unintended pregnancies would be valuable to help clinic personnel, programme planners and policy makers guide the development of the integrated services they offer.

A Systematic Review of the Effects of Behavioral Counseling on Sexual Risk Behaviors and HIV/STI Prevalence in Low- and Middle-Income Countries

The purpose of this study was to assess the effectiveness of behavioral counseling interventions in reducing sexual risk behaviors and HIV/STI prevalence in low- and middle-income countries. A systematic review of papers published between 1990 and 2011 was conducted, identifying studies that utilized either a multi-arm or pre-post design and presented post-intervention data. Standardized methods of searching and data abstraction were used, and 30 studies met inclusion criteria. Results are summarized by intervention groups: (a) people living with HIV; (b) people who use drugs and alcohol; (c) serodiscordant couples; (d) key populations for HIV prevention; and (e) people at low to moderate HIV risk. Evidence for the effectiveness of behavioral counseling was mixed, with more rigorously designed studies often showing modest or no effects. Recommendations about the use of behavioral counseling in developing countries are made based on study results and in light of the field’s movement towards combination prevention programs.

Advancing the strategic use of HIV operations research to strengthen local policies and programmes: the Research to Prevention Project.

In the field of HIV prevention, there is renewed interest in operations research (OR) within an implementation science framework. The ultimate goal of such studies is to generate new knowledge that can inform local programmes and policies, thus improving access, quality, efficiency and effectiveness. Using four case studies from the USAID‐funded Research to Prevention (R2P) project, we highlight the strategic use of OR and the impact it can have on shaping the focus and content of HIV prevention programming across geographic and epidemic settings and populations. These case studies, which include experiences from several sub‐Saharan African countries and the Caribbean, emphasize four unique ways that R2P projects utilized OR to stimulate change in a given context, including: (1) translating findings from clinical trials to real‐world settings; (2) adapting promising structural interventions to a new context; (3) tailoring effective interventions to underserved populations; and (4) prioritizing key populations within a national response to HIV. Carefully crafted OR can bridge the common gap that exists between research‐generated knowledge and field‐based practice, lead to substantial, real‐world changes in national policies and programmes, and strengthen local organizations and the use of data to be more responsive to a given topic or population, ultimately supporting a locally tailored HIV response.

Free Condom Distribution: What We Don’t Know May Hurt Us

The provision of commodities is an important element of nearly all public health programs. In HIV programs, commodities can be very expensive, like antiretroviral drugs for treatment or prevention, or they can be relatively cheap, like male condoms. Because of the contrast between incomes in developing countries and the costs of life-saving medications like antiretroviral drugs, recipients are often provided expensive medications free of all charge to increase access and encourage adherence. Condoms, on the other hand, are equally essential for prevention of HIV infection, are relatively inexpensive and are often judged to be affordable for users, even in the most resource-constrained settings. Condoms are often sold at a subsidized price through social marketing programs in an effort to make them even more affordable and, in theory, more valued and likely to be used since they require payment. Recently, a debate over the relative merit of free versus subsidized distribution of commodities has developed in other areas of public health. [1] The benefits of free versus subsidized distribution of bed nets for malaria prevention, for example, has been debated and examined in a few small-scale studies. [2–4] Given the cost of bed nets relative to disposable income in many countries, the examination of the role of free bed nets is important in the effort to reduce malaria infection. The provision of relatively inexpensive or even heavily subsidized prevention commodities must be considered in the context of the severely constrained resource environments in which they may be provided. As Jim Yong Kim, President of the World Bank, observed in his speech to the 66th World Health Assembly, “Anyone who has provided health care to poor people knows that even tiny out-of-pocket charges can reduce their use of needed services. This is both unjust and unnecessary.” [5] With the question of whether subsidized pricing or free distribution of essential public health commodities results in greater use and better prevention outcomes being discussed anew, we explored this question for condom distribution as well. We attempted to conduct two parallel systematic reviews, one of condom social marketing and the other of free condom distribution, in low- and middle-income countries. Both reviews followed the PRISMA statement [6] and were an output of the Evidence Project, a joint effort of the Medical University of South Carolina, the World Health Organization and the Johns Hopkins Bloomberg School of Public Health, funded by the U.S. National Institutes of Mental Health. The review of condom social marketing yielded valuable information on that approach. [7] Though the number of studies that could be included was limited and the follow-up periods were short, a meta-analysis showed positive and statistically significant effects of social marketing activities on condom use. The analysis suggested that the cumulative effect of condom social marketing over multiple years could be substantial. The review of free condom distribution was not successful. Though we identified 34 studies that met our inclusion criteria (Figure 1), all provided free condoms as only one component of a more complete intervention package. As a result, we found that it was not possible to isolate the effect of free condom distribution from other co-occurring interventions in the available research literature. We also concluded that it is equally likely many other studies evaluating key interventions distributed condoms for free without noting that fact in the publication. Our main conclusion from this review is that insufficient attention has been paid to evaluating the effect of free condom distribution on condom use and other key HIV prevention outcomes. Figure 1 Free Condom Distribution: Flow chart depicting disposition of study citations Condoms are relatively inexpensive per item. Perhaps as a result, the impact of their cost as a potential barrier to their use has not been examined. The total annual expenditure for condoms worldwide is very large. With levelling or decreasing resources for HIV prevention, maximizing the effectiveness of prevention investments is becoming even more crucial. At the same time, the desire to decrease prevention expenditures by increasing users’ contributions to commodity costs is growing, supported by the belief that users value more what they purchase over what they receive for free. Research from behavioural economics demonstrates the attractiveness of “free” in marketing commodities [8] and evidence from malaria prevention has shown the effect of free commodities on increased use. Studies have been done on price sensitivity of socially marketed condoms and have shown a clear negative correlation between condom prices and sales. [9] However, given the vast number of free condoms distributed each year, it is surprising how little is known about the actual effect on condom use. We recommend well-designed studies to isolate the effect of free versus subsidized or socially marketed condom distribution on condom use.