Behaviour Change Programmes have had Little Impact on HIV Incidence Amongst Girls and Women in Poorer Countries. 19/5/10
Behavioural change interventions to prevent sexual transmission of HIV among women and girls in resource-limited settings have had limited success,
Behavioural change interventions to prevent sexual transmission of HIV among women and girls in resource-limited settings have had limited success, according to a systematic review published in the online edition of AIDS and Behavior.
Only eight randomised controlled trials or prospective studies with a control arm could be identified by the investigators. Moreover, only two of these programmes reduced HIV incidence. Three other interventions had an impact on HIV risk behaviours or the incidence of sexually transmitted infections.
Approximately 50% of worldwide HIV infections are in women and girls. However, the impact of HIV on women in the countries hardest hit by HIV has been more severe, with 60% of HIV infections in sub-Saharan Africa being in girls or women.
The development of female-controlled biomedical methods of HIV prevention, such as microbicides, has been slow and disappointing. Therefore HIV prevention for women and girls is reliant upon behaviour change – for example, delayed sexual debut, a reduction in the number of partners, and condom use. These methods of prevention are largely controlled by male partners, and in many cases women and girls are unable to insist on behaviour that could protect their sexual and reproductive health.
Mindful of these circumstances, an international team of investigators conducted a systematic review of behaviour change interventions to see if they reduced either HIV incidence or HIV risk behaviours.
Randomised controlled trials or prospective studies with a control arm conducted after 1990 was eligible for inclusion.
After an exhaustive literature search, the investigators were only able to identify eight studies (reported in eleven research papers) that met their inclusion criteria.
Six of the studies were conducted in Africa, one was carried out in India, and one in Mexico.
A total of 42,000 women or girls were included in these studies, and these people were followed for an average of 2.6 years.
The type of intervention varied from a single counselling session to more extensive and long-term support.
Only two interventions had an impact on HIV incidence.
The first of these was a six-month programme of group education and motivational sessions for female sex workers and brothel madams in Mumbai, India.
The intervention for the sex workers consisted of the use of motivational literature and videos, group discussions, and the use of pictorial resources focusing on HIV and condom use. The women were instructed how to use condoms correctly, and encouraged to educate their clients about condom use.
Brothel madams were educated about the economic benefits and importance of maintaining the good health of their sex workers.
HIV incidence was reduced by 67% in the intervention arm compared to the control arm. However, the investigators noted that condoms and lubricant were only provided to women in the intervention arm, and were not given to the sex workers in the control group.
This intervention was also shown to reduce the incidence of both syphilis and hepatitis B.
The second study was conducted in Uganda, and this showed that attendance at an HIV study event in the previous year reduced HIV incidence by up to 59%. Incidence of herpes simplex type-2 (HSV-2) was also reduced by 45%.
Three other interventions were successfully reduced the incidence of sexually transmitted infections, but not HIV. Condom use higher in the intervention arm in the Mexican study than in the controls (27 vs 18%, p < 0.01).
“This review has highlighted the reality that current behavior change interventions, by themselves, have been limited in their ability to control HIV infection in women and girls in low- and middle-income countries,” comment the investigators.
The investigators highlight that women and girls often have little control over their sexual and reproductive health and in many cases are unable to insist on condom use.
A “combination” approach to prevention is advocated by the study’s authors, one that addresses both behavioural and biomedical risk factors.
They write, “the diminishing hope that a single behavioral or biomedical prevention intervention will be sufficient to address the growing HIV pandemic has heralded a programmatic shift towards combination HIV prevention programming.”
McCoy SI et al. Behavior change interventions to prevent HIV infection among women living in low and middle income countries: a systematic review. AIDS Behav, online edition, DOI 10. 1007/s10461-009-9644-9, 2010.