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Behavior Change Interventions to Prevent HIV among Women Living in Low and Middle Income Countries

Behavior Change Interventions to Prevent HIV among Women Living in Low and Middle Income Countries. Sandra I. McCoy, MPH PhD 1 R. Abigail Kangwende, MPH MD 2 Nancy S. Padian, MPH PhD 1,3 1 RTI International, San Francisco, California, USA 2 Africa University, Mutare, Zimbabwe

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Behavior Change Interventions to Prevent HIV among Women Living in Low and Middle Income Countries

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  1. Behavior Change Interventions to Prevent HIV among Women Living in Low and Middle Income Countries Sandra I. McCoy, MPH PhD1 R. Abigail Kangwende, MPH MD2 Nancy S. Padian, MPH PhD1,3 1 RTI International, San Francisco, California, USA 2 Africa University, Mutare, Zimbabwe 3 Center of Evaluation for Global Action, University of California, Berkeley, California, USA Perspectives on Impact Evaluation Conference ● April 2, 2009 ● Cairo, Egypt

  2. Women and HIV Infection • Globally, women and girls are especially vulnerable to HIV infection • Women represent ~50% of all people with HIV infection, but 59% in Sub-Saharan Africa • Structural and social factors drive transmission in women and decrease women’s ability to avoid HIV infection • Gender inequities ■ Violence • Harmful gender norms ■ Poverty • Lack of education

  3. HIV Prevalence by Age and Sex among 15-24 year olds, Zimbabwe, 2001 Source: Ministry of Health and Child Welfare (Zimbabwe), Zimbabwe National Family Planning Council, National AIDS Council (Zimbabwe), and U.S. Centers for Disease Control and Prevention. 2004. The Zimbabwe Young Adult Survey 2001-2002.

  4. HIV Prevention Approaches HIV prevention for women has been discouraging • Not (yet) effective: female barrier methods, microbicides, and vaccines • Male circumcision may not directly lower women’s risk • Male and female condoms require male partner knowledge and consent • Sexually transmitted disease (STD) services may not be available to all women, esp. those in the developing world

  5. HIV Prevention Approaches HIV prevention for women has been discouraging • Not (yet) effective: female barrier methods, microbicides, and vaccines • Male circumcision may not directly lower women’s risk • Male and female condoms require male partner knowledge and consent • Sexually transmitted disease (STD) services may not be available to all women, esp. those in the developing world HIV prevention efforts in women (and men) must continue to focus on behavior change

  6. Behavior Change for HIV Prevention Behavior change interventions aim to: • Delay age of sexual debut • Decrease the number of sexual partners or timing of partnerships (e.g., concurrency) • Increase protected sex acts • Increase voluntary counseling and testing (VCT) • Improve adherence to other successful strategies (e.g., condoms) Source: Coates, T. Lancet 2008; 372:669-84

  7. Behavior Change for HIV Prevention • Focus on individuals, peers, couples, groups, families, institutions, or communities • Need to incite change in enough people for enough time to impact population transmission dynamics • Behavioral change interventions are effective at reducing reported HIV-related risk behaviors in: • MSM (Herbst 2005) • STD clinic patients (Crepaz 2007) • U.S. adolescents (Mullen 2002) • Heterosexual African Americans (Darbes 2008) • People living with HIV (Crepaz 2006)

  8. Impact on HIV, Behavior, and STIs • Untangling this (population-level) relationship is critical: ↓ HIV Behavior change (how much?) ? ? ? Intervention ↓ Other STIs

  9. Behavioral Intervention Trials • Few studies of behavioral interventions for HIV prevention are evaluated with rigorous designs and with HIV infection as an outcome • Evaluation of HIV incidence is critical: • Reported behavior can be biased • Behavior is inconsistently related to STIs, including HIV • The ultimate objective is to prevent HIV infection

  10. Goal • Systematically review and summarize the effect of behavioral change interventions for HIV prevention in women and girls living in low and middle income countries

  11. Study Inclusion Criteria Dates: 1990 - February 28, 2009 Designs: Randomized controlled trials, quasi-experimental, or prospective designs with a control group Settings: Low- and middle-income countries Outcome: Incident HIV infection Language: No restrictions Grey Literature: Yes (meeting abstracts) Population: Stratified, female-only estimate OR combined estimate where women were at least 50% of population

  12. Study Inclusion Criteria Eligible interventions included, but not limited to: • Individual or group counseling • Conditional and unconditional cash transfers • Targeted messages and social marketing campaigns • School-based HIV prevention education • Voluntary counseling and testing • Vocational training • Empowerment training • Non-cash incentives (like school uniforms) • Social support programs • Condom promotion Control interventions could be inactive (e.g., no treatment, waiting list control, or standard of care) or active (e.g., a diluted or different variant of the intervention being investigated) Per-protocol analyses acceptable if community RCT

  13. Systematic Review Methods Systematic search of: • PubMed/MEDLINE • Cochrane Library, including: • Cochrane Central Register of Controlled Trials (CENTRAL) • Database of Abstracts of Reviews of Effects (DARE) • PsycInfo • Sociological Abstracts • Web of Science • African Index Medicus • Regional Index for Latin America and the Caribbean: Virtual Health Library • IndMed • NLM Gateway

  14. Systematic Review Methods • Communication with investigators for other studies and unpublished trials • Current Controlled Trials Register • International Clinical Trials Registry Platform Search Portal • clinical trials.gov • Computer Retrieval of Information on Scientific Projects (CRISP) • Cited Reference Search (Web of Science) of key articles • Reviewed reference lists of included papers and other reviews • Searched recent conference websites • Conference on Retroviruses and Opportunistic Infections (CROI) • International AIDS Society (IAS) • International Society for STD Research (ISSTDR)

  15. 3,864 potentially relevant articles retrieved from electronic databases 3,265 articles excluded after title-level review (e.g., excluding studies in men, those in the USA, other types of interventions) 599 articles eligible for abstract-level review • 551 articles excluded after abstract level review (e.g., studies without biological outcomes or uncontrolled designs) • 195 studies of behavioral interventions in women and girls without HIV infection as an outcome 48 articles for detailed review Literature Search 11 articles included in review(8 unique study populations) 3neweligible articles identified via reference lists 8met inclusion criteria

  16. Results: 11 Included Studies C-RCT=Community randomized controlled trial, I-RCT=individual randomized controlled trial, PP=per protocol, LT=Long term

  17. Intervention Characteristics G=Group, I=individual, C=couple, CM=community

  18. Impact on HIV incidence * Note: Quigley (2004) and Gregson (2007b) are per-protocol analyses of C-RCTs described in Kamali (2003) and Gregson (2007a). Doyle (2009) is the 6-8 year follow-up of the MKV study described in Ross (2007).

  19. Impact on Behavior and STIs NR=not reported, HBV=Hepatitis B Virus, HSV=Herpes Simplex Virus* No effect found for active syphilis, Chlamydia, or gonorrhea** Incidence rate ratio for women: 0.69, 95% CI (0.47, 1.03)

  20. Conclusions • Only two of 11 studies in women and girls showed an effect on HIV incidence • 3 of 10 studies reduced any risk behavior • 4 of 6 studies reduced STI incidence (non-HIV) • Important research and prevention gaps remain • How and whether to incorporate behavioral change programs into existing prevention packages in the absence of clear data on effectiveness

  21. Limitations • One study not peer-reviewed (meeting abstract) • Per-protocol analyses included & 1 follow-up • Potential to miss studies if biological outcomes not reported in abstract • Potential to miss studies from other databases • Variable statistical power to detect effects

  22. Ongoing Behavioral Intervention Trials for HIV Prevention

  23. Acknowledgements • International Initiative for Impact Evaluation (3ie) • Center of Evaluation for Global Action (CEGA), University of California, Berkeley • Women’s Global Health Imperative (RTI International)

  24. Questions?

  25. HIV Prevalence by Age and Sex among 15-24 year olds, South Africa, 2003 Source: Pettifor, A. AIDS 2005;19:1525-34.

  26. Data Abstraction • Data were abstracted from each eligible study by one investigator (SM) and reviewed for accuracy • Most adjusted measure of effect on HIV incidence (e.g. incidence rate ratio or risk ratio) in women • Overall incidence rate ratio if women-only not presented • Measure of effect and/or 95% CI calculated if necessary • Trial years, location, population, intervention • Impact on knowledge, behavior and other sexually transmitted infections, when available, in women

  27. Why don’t behavioral interventions translate to reductions in HIV incidence? • Greater than observed behavioral change required • Follow-up times too short • Behavior changes misreported • Traditionally “low-risk” women may be at high-risk independent of their personal behavior • We are measuring the wrong behavioral intermediates • Sexual networks or concurrency, or • Which behavior is important depends on the STI in question • Structural factors (e.g., poverty) further up the causal chain drive transmission and individual behavior

  28. Impact on HIV, Behavior, and STIs • Despite variability in the intensity, delivery, and target populations, only 2 interventions reduced HIV incidence • 6-month program for female sex workers in India • ↑condom use with clients, ↓ syphilis and HBV infection • Per-protocol analysis of sexually active women in Uganda who attended at least one intervention activity • No reduction in risk behavior, STIs not measured

  29. Intervention Characteristics

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