Economic interventions for prevention of HIV risk and HIV infection
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
To evaluate the effects of economic interventions in preventing HIV risk and HIV infection
To evaluate the effects of economic interventions in preventing intimate partner violence
Background
Description of the condition
The total number of people living with HIV has increased to 33 million people globally with nearly 7,500 new infections each day (UNAIDS 2008a) The impact of HIV/AIDS is stronger in poor households and communities. Although HIV has no socioeconomic boundaries, poverty plays an important role in the transmission of HIV with infection rates being highest among poor countries (UNAIDS (2007d). The majority of people living with HIV are in low‐ and middle‐income countries. Sub‐Saharan Africa, which has one of the highest rates of extreme poverty in the world, is home to just over ten percent of the world’s population but accounts for sixty eight percent of all people living with HIV (PRB 2007; UNAIDS (2007d)).
Gender inequality and poverty are the factors that exacerbate the AIDS epidemic (ICWR 2006; Dworkin 2007). It has been argued that women's economic vulnerability and dependence on men increases their vulnerability to HIV and limits their ability to negotiate the conditions such as unprotected sexual practices which shape the risk of infection (Kim 2008). Food insecurity has been associated with increased chances of risky sexual practices among women, including increased likelihood of selling sex for money or resources, and of engaging in unprotected or intergenerational sex (Weiser 2007). In many generalized epidemics, the relationship between physical, emotional, sexual violence and HIV has been well documented. Studies from Rwanda, Tanzania, and South Africa report about three fold increase in risk of HIV among women who have experienced violence compared to those who have not (Dunkle 2004; Maman 2002; van der Straten 1998)
Description of the intervention
Economic interventions may be critical for prevention of HIV risk and new infection. Although economic interventions can be operationalized in diverse ways, this review proposes an inclusive definition of economic interventions to include any planned activity or program that includes an economic component to address poverty‐reduction and/or livelihood strengthening.
Economic interventions for HIV prevention aim to use financial or economic incentives, strategies, or processes to increase the opportunities and capacities among targeted individuals to make voluntary and informed decisions regarding behaviors to prevent HIV risk and transmission. Economic interventions may differ in their manner of implementation. Some economic intervention programs include micro finance, economic incentives, welfare grant distribution, livelihood and life skill training, women's property and inheritance rights advocacy, vocational training and employment. Moreover, some economic interventions for HIV prevention might also include psychosocial support and counseling components to address individual‐level factors associated with HIV risk. With regard to HIV prevention, economic interventions might take a primary prevention emphasis by reducing risk for infection among HIV‐uninfected individuals or they might take a secondary prevention emphasis by reducing risk for re‐infection, transmission of other STI infection among HIV‐positive individuals.
Economic interventions are different from many individual‐focused HIV prevention interventions that use social‐cognitive theories of behavior change, which tend to dominate much of the HIV prevention literature. Interventions based on social cognitive theories generally focus on changing people’s HIV‐related attitudes, knowledge, perceptions of risk, and intentions to use condoms (Noah 2007). While many HIV prevention interventions based on social cognitive theories have been proven efficacious for changing sexual risk behavior (Noah 2008), these interventions tend to focus solely on individual‐level beliefs and behaviors and might overlook other levels of analysis including societal factors that influence sexual behavior such as poverty and unemployment (Waldo 2000). By contrast, economic interventions directly target the hypothesized roles of poverty and unemployment as factors that might influence people’s sexual risk behaviors(Sherer 2004)
How the intervention might work
Some microfinance institutions (MFIs) pair HIV/AIDS prevention activities with the activities of microfinance solidarity groups; regular meetings of solidarity groups are used as an avenue to distribute health services, legal advice to women on inheritance rights, provide information on the prevention of HIV/AIDS (Sherer 2004; Parker 2000). Other types of microfinance programmes provide credit and resources (Dworkin 2009) for those excluded from the formal banking system and potentially can play a major role in reducing participants'(usually women) vulnerability to HIV and AIDS by strengthening their economic stability and reducing the need to engage in risky behaviors such as selling sex for money (Gupta 2006).
The IMAGE Program (Intervention for Microfinance and Gender Equity) which evaluated the impact of a combined microfinance and training intervention on poverty, gender inequalities, intimate partner violence and HIV outcomes reported a 55%reduction in their risk of past year physical and sexual intimate partner violence (Pronyk 2006); improvement in economic well being and indicators of ‘‘women’s empowerment’’ at two years (Kim 2008, Kim 2008b); higher levels of HIV‐related communication, HIV testing, and greater condom use with non‐spousal partners (Pronyk 2008) among program participants.
With greater ownership and control over economic assets, programme participants may have greater capacity to negotiate abstinence, fidelity, and safer sex, and can avoid exchanging sex for money, food, or shelter (GCWA 2006(b); Gupta 2005 ;Strickland 2004).
Why it is important to do this review
Program planners and policy makers need descriptions of interventions and quantitative estimates of intervention effects to make informed decisions concerning prevention funding and research (Johnson 2008). While economic interventions have been identified as an effective strategy for prevention of HIV risk and HIV transmission (ICWR 2006], there are few interventions that have explicitly attempted to combine economic empowerment with the goal of HIV prevention, and even fewer which have been rigorously evaluated. Furthermore, there is some controversy about the effectiveness of economic intervention programs in the prevention of HIV risk and HIV infection. Previous research concluded that most MFIs are ill‐prepared to deal with the epidemic (Motsei 2002). However a recent report suggests that ninety percent of women participating in microfinance initiatives reported significant improvement in their lives (UNAIDS 2008b).
An economic intervention to reduce HIV risks among AIDS orphans attending school in rural Uganda reports a more positive opinion about using HIV prevention methods by participants than non participants but did not observe significant changes in behaviors associated with HIV risk (Ssewamala 2008). The Shaping the Health of Adolescents in Zimbabwe (SHAZ!) programme which deliberately targeted poor adolescent girls to test whether linking microfinance with life skills and business training could result in improved knowledge, increased control over economic resources, and ultimately reductions in HIV infection failed to reach these goals (Kim 2008). The JEWEL (Jewellery Education for Women Empowering Their Lives) project examined the efficacy of economic empowerment and HIV prevention intervention targeting illicit drug‐using women who were involved in prostitution in Baltimore, Maryland suggest that women’s exposure to the possibility of gaining legitimate employment may be related to risk behaviour change (Sherman 2006, Dworkin 2009), and behaviour change sustainability is most likely to succeed if women have access to job training programmes and licit employment opportunities (Sherman 2006). More research is clearly needed on which economic components—combinations of components—and institutional missions in MF organizations might yield reduced HIV risks (Dworkin 2009).
By providing a detailed exploration of how vehicles such as micro finance or other economic interventions might impact on a range of HIV‐related risks and outcomes, this review will be useful.
Objectives
To evaluate the effects of economic interventions in preventing HIV risk and HIV infection
To evaluate the effects of economic interventions in preventing intimate partner violence
Methods
Criteria for considering studies for this review
Types of studies
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Randomised Controlled Trials that evaluated the effects of any economic intervention aiming to reduce HIV risk or HIV infection
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Since many of these interventions are likely not to have been tested in randomised trial, eligibility criteria would be structured to include Non Randomised Trials. This will include trials with a non‐randomized comparison group and pre‐post program evaluations with a historical control.
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Evaluation studies that do not include a control or comparison group will be excluded from this review
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Cross‐sectional and qualitative studies will be excluded from this review
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Evaluation studies that do not include a control or comparison group will be excluded from this review
Types of participants
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HIV negative individuals
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HIV positive individuals
We will include studies comprising of individuals anywhere in the world.There will be no exclusion of individuals based on gender, sexual orientation, language, occupation, racial or ethnic group, or other characteristics.
Types of interventions
Economic interventions include:
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Micro‐finance programs: refers to the provision of financial services including credit, savings, insurance, business training, and small business development for the poor who have been excluded from the formal banking sector.
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Microcredits: designed to spur entrepreneurship, and is the extension of very small loans to the poor who lack collateral, steady employment and a verifiable credit history, and who therefore cannot meet minimal qualifications to gain access to traditional credit.
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Financial incentive programs: involves provision of a monetary reward (including small loans) to encourage safe sexual practices and discourage risky sexual practices.
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Financial planning programs: participants learn how to allocate specific amount of money to achieve certain objectives or goals for improved management of their economic resources
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Job training programs: a systematic process through which individuals learn or acquire new skills, knowledge and attitudes through education to perform specific tasks.
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Any of the above in combination with additional intervention components (e.g., micro‐finance plus psychosocial counseling)
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Any other intervention with an economic component.
Policy interventions: interventions aimed at improving the economic livelihood or economic capacity through administrative or legal decisions; this may include interventions aiming to increase participants' economic security through ownership of and control over land and housing.
Types of outcome measures
Primary outcomes
1. HIV incidence
2. STI incidence
Secondary outcomes
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Incidence or frequency of exchange of sex for money, food, or shelter
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Incidence or frequency of intergenerational sex
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Incidence or frequency of unprotected vaginal sex
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Incidence or frequency of unprotected anal sex·
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Incidence or frequency of unprotected oral sex
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Use of HIV voluntary counselling and testing
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HIV prevention attitudes or educational plans
Tertiary outcomes
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Economic empowerment/Improvement in the economic well being
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Incidence and frequency of Intimate Partner Violence (IPV)
Search methods for identification of studies
See: Cochrane HIV/AIDS Group methods used in reviews.
See: methods used in reviews.
See: HIV/AIDS Collaborative Review Group search strategy.
This will be done with the assistance of the HIV/AIDS Review Group Trials Search Co‐ordinator. We will formulate a comprehensive and exhaustive search strategy in an attempt to identify all relevant studies, regardless of language or publication status (published, unpublished, in press, and in progress). The search strategy will include text terms like economic intervention* OR micro‐finance OR microcredit* OR micro‐credit OR "economic incentive program* " OR "family economic intervention* " AND HIV AND OR HIV risk OR HIV infection AND prevention.
Electronic searches
We will search the following electronic databases:
(1) MEDLINE
(2) EMBASE
(3) PsycINFO
(4) AIDSearch, which includes coverage of the following conferences:
‐ International AIDS Conference
‐ Conference on Retroviruses and Opportunistic Infections(1986‐2004)
‐ The British HIV Association conference(1997‐2003)
‐ International Congress on Drug Therapy in HIV Infection(1994‐2004)
(5) The Cochrane Library Controlled Trials Register
(6) Social Services Abstracts
(7) Sociological Abstracts
(8) Global Health Abstracts
Searching other resources
We will do hand searching of the reference lists of all pertinent reviews and studies found. We will also do grey‐literature searching for policy documents and reports that might not have been published in traditional journals. Finally, we will contact research organizations and experts in the field for unpublished and ongoing studies.
Other relevant libraries of international agencies, especially those concerned with the prevention of HIV/AIDS (UNAIDS, USAID, WHO, UNFPA, World Bank, and Centers for Disease Control and Prevention) will be searched.
There shall be no date restrictions in the searches.
Data collection and analysis
Selection of studies
The search for trials will be performed with the assistance of the Cochrane HIV/AIDS Group. The two authors would critically appraise all identified citations independently to establish their relevance for inclusion into the review. Studies will be reviewed for relevance based on study design, types of participants, interventions and outcome measures. Any disagreement will be resolved by discussion or by contacting an independent author. We will give reasons for excluding potentially relevant trials in an excluded studies table.
Data extraction and management
We will design a data extraction form. Data will be extracted independently by the two authors using the agreed upon form.
Both authors will verify the extracted data. Any disagreement will be resolved by discussion and referral to the Cochrane HIV/AIDS Review Group if necessary. Extracted information will include:
Study Details: citation, study population demographics and risk characteristics, study design, time period, population size, attrition rate and source of funding, trial setting, theoretical basis for intervention, elements of intervention, all relevant outcome measures, and results.
Assessment of risk of bias in included studies
The quality of all selected studies will be assessed independently by both the authors using the following:
(1)Allocation concealment
Adequate allocation concealment: participants and researchers were unaware of participants’ future allocation to condition until after decisions about eligibility were made and informed consent was obtained;
Unclear concealment: allocation concealment measures were not described in detail;
Inadequate allocation concealment: allocation was not concealed from either participants before informed consent or from researchers before decisions about inclusion were made.
(2) Blinding of participant, assessors and providers of care
Yes: assessor blind to condition;
Unclear: blinding of assessor not reported and information not available from researchers;
No: assessor not blind to condition.
(3) Loss to follow up
Adequate: losses to follow up were equally distributed between treatment and comparison groups;
Unclear: information about losses to follow up unavailable;
Inadequate: losses to follow up in excess of 30% or unevenly distributed between treatment and comparison groups.
(4) Method of generation of the randomisation sequence
(5) The description of the completeness of outcome data for each main outcome
For each trial the authors will classify the risk of bias as high, moderate, or low. Scores will be allotted to each component, and studies will be categorized to be of adequate, inadequate or unclear quality, depending on the total score calculated. In the case of disagreement between the two authors regarding the quality of a particular study, a third reviewer will reconcile the disagreement.
Measures of treatment effect
Measures of effect of the interventions will be assessed based on the outcomes of interest for this review. The outcomes include HIV incidence and the frequency of risky behaviours, as listed in the secondary outcomes. The effects of the intervention will also be measured for any other outcomes assessed by the primary studies.
Unit of analysis issues
Studies with similar units of analysis will be grouped together for the purposes of analysis.
Studies with different units of analysis will not be pooled for analysis.
Dealing with missing data
If a study meets our inclusion criteria but has missing data, attempts will be made to contact the authors for clarification of relevant information.
Assessment of heterogeneity
We would perform a meta‐analysis If the studies are found to be clinically homogenous. For comparable studies, we will summarize the findings using a random‐effects model. Our meta‐analysis will measure the relative risk for each dichotomous outcome measure and the 95% confidence intervals for these relative risks. We shall consider the appropriateness and value of a meta‐analysis if there is significant clinical heterogeneity among the included studies. We will also calculate whether statistical heterogeneity is present using the chi squared test for homogeneity (p< 0.1). The impact of statistical heterogeneity will be quantified using I‐squared statistics available in RevMan, which describes the percentage of total variation across studies due to heterogeneity rather than sampling error. In the event of significant heterogeneity, possible causes will be explored by looking critically at the characteristics of the various studies.
Assessment of reporting biases
Funnel plots will be generated to assess for the presence of reporting bias. The presence of asymmetry will suggest that there is reporting bias. We will conduct a thorough evaluation to determine if there are other reasons for asymmetry. If no other reasons for asymmetry are found, we will document the possible presence of reporting bias.
Data synthesis
All eligible studies will be summarised in RevMan. The two authors will extract the data and enter all data into RevMan, and all the entries will be rechecked by both authors. Disagreements will be resolved by discussion. If no consensus is reached, the HIV/AIDS mentor for this review will be contacted.
Subgroup analysis and investigation of heterogeneity
Possible sources of heterogeneity in this review will include the type of intervention, gender, study location (high income Vs low income settings). HIV status of program recipients, direct program participation versus indirect program participation,age of participant(i.e, interventions targeting adults ages >= 18; interventions targeting minors < 18 years).
This will justify the use of subgroup analysis.
Sensitivity analysis
If the number of studies and data available allows for sensitivity analysis, we shall perform a sensitivity analysis by using one or all of the
following strategies
1. Removing studies with high risk of bias to see if there will be any effect on the results of the metaanalysis.
2. Studies with missing data may be re‐analyzed using a reasonable range of missing values.
3. Data may be re‐analyzed using different statistical approaches.
