What Works for Women and Girls: Evidence for HIV/AIDS Interventions

Melanie Croce-Galis, PHIJill Gay, HPP Consultant

Karen Hardee, HPP/Futures Group

AIDS 2012 - Turning the Tide Together

What Works

• 2012 Update funded by PEPFAR, Gender Technical Working Group through the Health Policy Project and Open Society Foundations

• Website supported by the Public Health Institute

• Compile the evidence on interventions that address the needs of women and girls related to HIV outcomes

Purpose of What Works

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• Translate the evidence into information useful to programs

• Allow access to the evidence for a range of stakeholders

WHAT WORKS WEBSITE

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Who Needs the Evidence Base?

Government ministries and national AIDS programs

DonorsCCMsCivil society organizationsCountry programmersResearchersAdvocates

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What is Unique about What Works?

Only one of its kindCovers all aspects of HIV/AIDS

— one stop shopRelated to HIV outcomes

(results-oriented)Comprehensive evidence base of

interventionsWritten for lay (non-research)

audiences without medical/public health training

Key Features of the Redesign

• Improved search function• How to use the site• News section• Social media buttons• Chapter downloads• Quotes• Hover allows view of full citation, terms• Meta tags for search engines

WHAT WORKS METHODOLOGY

• Focused on developing countries

• Searched SCOPUS, Popline, Medline, websites

• Guided by consultations/reviews by over 100 experts

• Used data primarily from 2008–2011

• Ranked evidence using Gray’s typology

Methodology

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What Is the Evidence Base?

Contains: Approximately 4,000 citations 641 interventions with outcomes summarized –

highlights evidence with programmatic implications focusing on the global South

Data from 94 countriesCriteria:

Various search methodologies (wom*n and HIV, etc.) for evaluated interventions

With measurable outcomesPublished prior to January 2012

Rating the Evidence

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Type Strength of evidence (modified from Gray, 1997)

I Strong evidence from at least one systematic review of multiple well designed, randomized controlled trials.

II Strong evidence from at least one properly designed, randomized controlled trial of appropriate size.

IIIa Evidence from well-designed trials/studies without randomization that include a control group (e.g. quasi-experimental, matched case-control studies, pre-post with control group)

IIIb Evidence from well-designed trials/studies without randomization that do not include a control group (e.g. single group pre-post without, cohort, time series/interrupted time series)

IV Evidence from well-designed, non-experimental studies from more than one center or research group.

V Opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees.

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What Works vs. Promising

What Works

Strongly rated studies (Gray I, II, or IIIa) for at least two countries and/or five weaker studies across multiple settings

Promising Studies that were strongly rated but in only one setting or a number of weaker studies (IIIb, IV and V) in only one country or region.

Gaps Emerged from the literature

Distribution of Studies Supporting What Works and Promising Interventions, by Gray Typology, for each Chapter of What Works

Gray typology of strength of evidence I II IIIa IIIb IV V Abs*

Total No. of Studies

Total 47 65 84 259 74 96 14 641

Strength of the Evidence

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*Abstract from a recent conference

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Countries Included

Through January 1, 2012 (N=94)

Africa

East/ South East Asia

South Asia

Latin America and the

Caribbean

Eastern Europe

and Central

Asia

North Africa/ Near East

North America/ Western

and Central Europe and

Oceania

27 11 4 14 25 5 8

WHAT IS NEW IN 2012

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• Main themes• Prevention• Treatment• Strengthening the

enabling environment

Covering

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Women’s solidarity pin. www.lovingafrica.com

• Exciting time with new prevention and treatment modalities

• Gender equitable interventions still need to be devised and scaled up

• Critical Prevention Approaches Still Under Development – Vaccines, Pre-exposure Prophylaxis, Microbicides

Main Themes

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PREVENTION

In2eastafrica.net

• Wide agreement that prevention is still critical and needs to be scaled up

– WHO et al., 2011b; Zachariah et al., 2011; Over, 2011; Padian et al., 2011; Kurth et al., 2011; Katsidzira and Hakim, 2011; Dieffenbachbach and Fauci, 2011.

• Prevention challenges for women remain – Key affected populations, are underserved – Focusing on key affected groups can leave out other

women also at risk of HIV– Meeting the prevention needs of young women is

particularly critical – Addressing the enabling environment is key

Prevention

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Treatment as prevention: ARV therapy reduces (but does not eliminate) the risk of HIV transmission is an additional

prevention strategy (Works)

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Author/ date

Gray level

Study Countries Findings

Atti a et al., 2009

I Systemati c review of 11 cohorts reporti ng on 5,021 heterosexual couples and 461 HIV transmission events

Sub-Saharan Africa

heterosexual transmission was reduced by 92%

Cohen et al., 2011

II RCT of 1,763 serodiscordant couples in nine countries

9 countries: 5 Africa; 2 Asia, 1 LAC, US

Transmission rate:• Early initiation of ART: .1

per 100 person years • Later initiation: .9 per 100

person years 96% relative risk reduction

Donnell et al., 2010

IIIa Prospecti ve cohort analysis of 3,408 heterosexual HIV serodiscordant couples

7 countries in Africa

Transmission rate• On ART: .37 per 100 person

years • Not yet on ART: 2.24 per

100 person years 92% relative risk reduction

• Monogamy cannot be assumed in serodiscordant couples– In one study, 28% of the cases HIV transmission occurred from

another partner rather than from the HIV-positive partner on treatment (Cohen et al. (2011)

• Early treatment will not stop transmission from those who are acutely infected but cannot know their serostatus with rapid HIV tests (Cohen, 2011b)

• Other challenges include:– long-term adherence, the possibilities of drug resistance, and

the concerns that condom use and other preventive measures would decrease (Shelton, 2011)

• A continued focus on all prevention modalities is warranted (Nguyen et al., 2011)

Treatment as prevention (challenges)

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• VMMC averts HIV infection among women, because as more men are circumcised, women are less likely to encounter sexual partners who are living with HIV (Njeuhmeli, 2011; Hankins et al., 2011; Ally et al., 2012; Hallett et al. 2011)

Voluntary Medical Male Circumcision Can Help Women

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• MC programs could be a platform to promote gender equity and all HIV risk reduction strategies as well as men and women’s sexual and reproductive health with increased couple communication (Wamai et al., 2011; Doyle et al., 2010b).

• There is still a need to scale up female condoms and continue a focus on condom promotion (Abdool Karim et al., 2010; Hughes et al., 2012)

• Condom negotiation skills and peer education for women works (Weschberg et al., 2010; Kaponda et al., 2011).

Condoms Are Still Critical

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“Condom issues are difficult. We know we can prolong our lives if we do not infect each other. On the other hand, marriage is also important… We cannot survive without men. Who will help us meet our needs?” —Woman who dropped out of a PMTCT program, Malawi (Chinkonde et al., 2009: 14).

• HIV prevention is not being scaled up sufficiently among vulnerable groups – Fewer than half of all sex workers are reached in Asia (Baral et

al. 2012)

– Only 1 in 5 IDU reached in Asia (Low-Beer and Sarkar, 2010)

– Modeling suggests 60-80% coverage needed to reduce HIV• Key affected groups need prevention, care, and

treatment– Often not reached with testing and counseling (WHO et al., 2011)

– Issues around treatment access (e.g., prosecution of health workers) (Schwartlander et al. 2011)

Sex Workers and Females Who Inject Drugs/Partners of Males Who Inject

Drugs are Underserved

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What works • Comprehensive prevention programs • Clinic-based interventions with outreach workers • Policies that involve sex workers, brothel owners and clients • Providing STI clinical services • Peer education • Creating a sense of community and empowerment among sex workers. • Sex workers can be as adherent to antiretroviral therapy as other

populationsPromising strategies

• Interventions targeting male clients can increase condom use and thus reduce HIV risk for sex workers

Still needed• Access to information and services for contraception and dual method

use

Sex Workers – We Know What Works; We Need to Do It

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What Works:• Comprehensive harm reduction programs, including needle

exchange programs, condom distribution, opioid agonist therapy and outreach, and nonjudgmental risk reduction counseling.

• Peer education • Sex-segregated group sessions • Instituting harm reduction programs in prisons• Drug users benefit from and can be adherent to antiretroviral

therapy.

• Promising Strategies:• Offering no-cost HIV testing and counseling to people who use

drugs

Women Who Inject Drugs/Partners of Men Who Inject Drugs

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TREATMENT

blog.lass.uk.org.uk

• Treatment is a huge success story for both women and men.– Between 1995 and 2009, an estimated 14.4

million life-years have been gained among adults as a result of ART (Mahy et al., 2010b)

• Universal access and loss to retention and follow-up remain concerns.

• Gender roles and norms affect treatment access for women and men (e.g., Skovdal et al., 2011b; Foster et al., 2010b; Fox et al., 2010a; Thomas et al., 2009; Arrivillaga et al., 2009)

Treatment

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STRENGTHENING THE ENABLING ENVIRONMENT

“Almost uniformly across the world, women have less access to and control of productive resources outside the home. Evidence for this imbalance in power includes the gender gaps in literacy levels, employment patterns, access to credit, land ownership and school enrollment fees. This imbalance in access to, and control of, productive forces and resources translates into an unequal balance in sexual relations in favor of men” (Abdool Karim et al., 2010: S126).

Strengthening the Enabling Environment

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• Transforming gender norms • Addressing violence against women• Transforming legal norms to empower women,

including marriage, inheritance and property rights

• Promoting women’s employment, income and livelihood opportunities

• Advancing education• Reducing stigma and discrimination• Promoting women’s leadership, starting with girls

Aspects of the Enabling Environment

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• Traditional gender norms lead to behaviors that put women – and men – at risk for HIV (Stephenson, 2010; Pulerwitz et al. 2010).

Transforming Gender Norms

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Interventions to address gender norms and reduce HIV need to work with “men and women, boys and girls, in an intentionally and mutually reinforcing way that challenges gender norms, catalyzes the achievement of gender equality and improves health” (Greene and Levack, 2010: vi).

Transforming Gender Norms

What Works• Training, peer and partner discussions, and community-based

education that questions harmful gender norms• Mass media campaigns that take up gender equality as part of

comprehensive and integrated services Promising Strategies:• Changing norms regarding the acceptability of multiple and

concurrent partnerships Still needed• Interventions to change gender norms need to be scaled up

WHAT WORKS WEBSITE

Thank You!

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www.whatworksforwomen.org