Executive Summary

Background

For more than 25 years AIDS has been taking a devastating global toll. Women now make up half of those living with HIV infection. While HIV epidemics around the world vary, gender inequalities and biological differences still make women and girls especially vulnerable to the epidemic. In sub-Saharan Africa—the region most affected by HIV/AIDS—women account for nearly 60% of those living with HIV. There is increasing interest among governments and donors to address the needs of women and girls in the global AIDS pandemic and to support women as agents of change. As global attention is focused on the unique vulnerabilities of women and girls, identification of which interventions work specifically for women and girls becomes vitally important.


Purpose

The purpose of this document is to compile and summarize the base of evidence to support successful interventions in HIV programming for women and girls. National AIDS programs, government ministries, implementing partners, donors, civil society groups and others need an easy to understand format for identifying what works for women. This review contains findings from evaluated interventions in 90 countries with a focus on developing countries and contains approximately 2000 references for programming related to the continuum of HIV and AIDS; from prevention to treatment, care and support and strengthening the enabling environment for policies and programming. In all, the evidence for What Works and Promising interventions includes 455 studies.  While this review covers many aspects of HIV/AIDS programming that are relevant for both women and men, it is not intended to be an exhaustive review of all HIV/AIDS programming. Instead, the review focuses on interventions that have an effect on HIV outcomes for women and girls; documenting practices for which there is evidence of successful approaches.


Methodology

Measuring “what works” is complicated since the outcomes and impacts of interventions depend on a number of factors. Operating in specific socioeconomic, cultural (including gender), and demographic settings, interventions, such as counseling and testing, must affect “proximate determinants” such as number of concurrent partners, condom use, blood safety practices, etc., which must act through biological determinants (exposure, efficiency of transmission per contact and duration of infectivity) to affect HIV transmission. Interventions are determined to work in this compendium of evidence when they have been shown to work through a pathway to affecting HIV – or at least a proximate determinant, such as partner reduction or condom use.  

The evidence in this review was identified using SCOPUS searches of peer-reviewed literature.  Searches were conducted for 2005-2009, using the search words HIV or AIDS and wom*n, plus a number of other search word combinations for additional topics.  Searches also included gray literature from key relevant organizations.  The review focused primarily on interventions in developing countries.  Studies met the inclusion criteria if they included an intervention which had an outcome, or outcomes, and had been evaluated for effectiveness. A wide range of experts were enlisted in preparation of this compendium and in reviewing drafts of the document.


What Works? 

This review has found a number of interventions in all aspects of HIV/AIDS programming that work for women or can be seen as promising. These interventions have strong supporting evidence and many are ready to be scaled up. Main findings of only “what works” for women and girls are outlined below by chapter. There are also a number of promising strategies that may be found within the full document.


Prevention for Women

Prevention is key. In 2007 more people acquired HIV than those who could access treatment. Prevention efforts for women and girls have been successful in numerous countries, but ongoing efforts are needed. Male and female condoms, partner reduction, male circumcision and treating STIs are all important components of prevention efforts. Prevention efforts are also strengthened by addressing factors such as gender norms, violence against women, income and education. Male circumcision has been shown in randomized controlled trials to reduce HIV acquisition for men by 60%, and may, in the long run, reduce transmission for women. Vaccines and microbicides are under development and have not yet been approved for use outside of clinical trial settings. What works in prevention for women:

  1. Consistent use of male condoms can reduce the chances of HIV acquisition by more than 95%.
  2. The plausibility of the female condom to prevent HIV transmission is similar to the male condom.
  3. Partner reduction, particularly concurrent partnerships, can be effective in reducing transmission of HIV.
  4. STI counseling, diagnosis and treatment represent an important access point for women at high risk of HIV, particularly in the earlier stages of the epidemic.


Prevention for Key Affected Populations

Some groups of women are at particular risk of HIV transmission: sex workers; intravenous drug users (IDUs) or female partners of IDUs; women prisoners and female partners of prisoners: women and girls in complex emergencies; migrants and female partners of migrants; transgendered men and women; and women who have sex with women. Very little evidence exists on effective programming for women in complex emergencies, for migrant women, transgender men and women, and women who have sex with women. What works in the remaining categories of key affected populations:

Sex Workers:

  1. Comprehensive prevention programs that include components such as peer education, medical services, and support groups, can be effective in enabling sex workers to adopt safer sex practices.
  2. Clinic-based interventions with outreach workers can be effective in increasing condom use among sex workers.
  3. Policies that involve sex workers, brothel owners and clients in development and implementation of condom use can increase condom use.  
  4. Providing accessible, routine, high quality, voluntary and confidential STI clinical services that include condom promotion can be successful in reducing HIV risk among sex workers.
  5. Peer education can increase protective behaviors.
  6. Interventions targeting male clients can increase condom use and thus reduce HIV risk for sex workers.


Female IDUs and Partners of Male IDUs:

  1. Opioid substitution therapy, particularly maintenance programs with methadone and buprenorphine, leads to reduction in HIV risk behavior among male and female IDUs, and is safe and effective for use by pregnant women.  
  2. Comprehensive harm reduction programs, including needle exchange programs, condom distribution, substitution therapy and outreach, can reduce HIV risk behaviors and prevalence among male and female IDUs.
  3. Peer education can increase protective behaviors among IDUs.
  4. Instituting harm reduction programs for IDUs in prisons can reduce HIV prevalence in female prison populations.


Female Prisoners and Partners of Male Prisoners:

  1. Harm reduction strategies such as education, peer distribution of clean needles and condom provision within prisons can reduce the risk of HIV infection and IDU use in female prison populations.
  2. Making opioid substitution treatment available in prisons can be effective in reducing HIV transmission.


Prevention for Young People

Young people ages 15 to 24 account for an estimated 45% of new HIV infections with young women facing particular risks due to gender norms which value sexual ignorance and limited power in sexual relations.  At the same time, gender norms that promote risk taking among young men put both young women and men at risk. Providing young people with information and services, as well as issues such as gender norms can reduce the risk of HIV acquisition. What works for young women in encouraging behavior change and increasing access to services:

Encouraging Behavior Change:

  1. Sex and HIV education with certain characteristics prior to the onset of sexual activity may be effective in preventing transmission of HIV by increasing age at first sex and, for those who are sexually active, increasing condom use and reducing the number of sexual partners.  
  2. Training for teachers to conduct age-appropriate participatory sexuality and AIDS education can improve students’ knowledge and skills.
  3. Mass media and social marketing campaigns are modestly effective in persuading both female and male adolescents to change risky behaviors.    
  4. Communication between adults and young people about reproductive health information can increase protective behaviors.


Increasing Access to Services:

  1. Providing clinic services that are youth friendly, conveniently located, affordable, confidential and non-judgmental can increase use of clinic reproductive health services, including VCT.


HIV Testing and Counseling

Increasing the number of women – and men – who know their serostatus is critical to expanding access to treatment and care and to reducing transmission of HIV.  A current challenge for HIV/AIDS programs is how to increase HIV testing and counseling in ways that are equitable for women and men, that allow choice and that do not jeopardize human rights, consent and confidentiality.  What works in HIV testing and counseling:  

  1. Voluntary counseling and testing can help women know their HIV infection status and increase their protective behaviors, particularly among those who test HIV-positive.
  2. Providing VCT together with other health services can increase the number of people accessing VCT.
  3. Mass media interventions can increase the numbers of individuals and couples accessing VCT.
  4. Community outreach and mobilization can increase uptake of VCT.
  5. Home testing, consented to by household members, can increase the number of people who learn their serostatus.


Treatment

Antiretroviral treatment (ARVs) is not a cure for HIV but does increase life expectancy, often dramatically. ARVs have been provided to both men and women in resource-poor settings with good adherence, good patient retention and good clinical outcomes similar to those in resource-rich settings.  Therefore while ARV treatment definitely “works” for women, few interventions have been evaluated using sex-disaggregated data, therefore specifying what works specifically for women in terms of treatment access and overcoming barriers to adherence is a continuing challenge. HIV prevention in addition to treatment remains critical.


Meeting the Sexual and Reproductive Health Needs of Women Living With HIV

Given that most HIV transmission occurs through sexual intercourse, it is essential to include a sexual and reproductive health (SRH) lens in HIV programming. Because so many women do not know their HIV status, many of the SRH interventions reviewed are appropriate for all women irrespective of their serostatus. Interventions with evidence for what works for meeting the SRH needs of women living with HIV:  

  1. Promoting contraceptives and family planning counseling as part of routine HIV services (and vice versa) can increase condom use, contraceptive use, and dual method use, thus averting unintended pregnancies among women living with HIV.
  2. Hormonal contraception is safe for women living with HIV and does not seem to affect HIV acquisition or HIV progression.
  3. Women with HIV can use IUDs if they have access to medical services in case of IUD expulsion.
  4. Providing information and skills-building support to HIV-positive people can reduce unprotected sex.
  5. Interventions to support disclosure can increase condom use in discordant couples.


Safe Motherhood and Prevention of Vertical Transmission

Of the 136 million women who gave birth each year globally between 2005-1010, an estimated 60 million give birth at home and may not have access to prevention of mother-to-child transmission (PMTCT) services. PMTCT programs will only be effective if maternal health programs are strengthened and provided to all women because so many women only learn their HIV status during their pregnancy. Improving health systems and providing evidence-based interventions to ensure safe motherhood is critical for all women, and especially so for women living with HIV. The evidence for what works in preventing perinatal transmission is organized according to the way women access health services, particularly maternal health services: prevention of unintended pregnancies, preconception planning; antenatal care (testing and counseling, treatment); delivery; and postpartum. Some promising strategies exist for preconception planning and delivery, however further evidence is needed.  What works for women in the other categories include are below. The science surrounding breastfeeding and the risk of vertical transmission is still unresolved.
 
Preventing Unintended Pregnancies:

  1. Preventing unintended pregnancies can reduce perinatal transmission.


Antenatal Care–Testing and Counseling:

  1. Routinely offered testing that is voluntary and accompanied by counseling is acceptable to most women.
  2. Informed and appropriate counseling during ANC can lead to increased discussion between partners and increased protective behaviors such as condom use.
  3. Involving partners, with women’s consent, can result in increased testing and disclosure.


Antenatal Care–Treatment:

  1. Antiretroviral treatment regimens for pregnant women living with HIV can improve the health of the mother when used as treatment and can reduce the risk of mother-to-child transmission when used as prophylaxis.
  2. For women who are pregnant and not eligible for HAART for their own health, short-course ARV therapy used for prophylaxis can reduce nevirapine resistance.
  3. Extending an HIV-positive woman’s life increases the long-term survival of her infant.  
  4. National scale-up of HAART in pregnancy improves maternal and infant outcomes.


Postpartum:

  1. ARVs, when used for treatment or prophylaxis, can reduce transmission of HIV from mother to infant.
  2. Early postpartum visits can result in increased condom use, contraceptive use, HIV testing and treatment.


Preventing, Detecting and Treating Critical Co-infections

Certain infections, when combined with HIV, can be significantly more severe and lead to early death for people living with HIV. Tuberculosis has become the leading cause of death for those living with HIV. HIV/TB co-infection is particularly deadly to women during their childbearing years. Malaria can have serious impacts on pregnant women and HIV/hepatitis co-infection can limit the effectiveness of both HIV and hepatitis treatments. Little evidence is available on HIV/hepatitis co-infection for women in resource-poor settings. More effective diagnostics, treatment and treatment literacy programs are needed for hepatitis C. Evidence for what works for women in TB/HIV and malaria/HIV co-infection is limited:

Tuberculosis:

  1. IPT, as well as HAART, can reduce the incidence of TB.


Malaria:

  1. Co-trimoxazole prophylaxis, antiretroviral therapy and ITNs can reduce the incidence of malaria in women living with HIV by 95%.
  2. Monthly doses of Intermittent Preventive Treatment (IPT) of malaria with sulfadoxine-pyrimethamine (SP) is effective in preventing malaria among pregnant HIV-positive women (but should not be combined with co-trimoxazole).


Strengthening the Enabling Environment

Addressing structural factors and the enabling environment, such as gender norms; violence against women; legal norms; women’s employment, income and livelihood; advancing education; reducing stigma and discrimination and promoting women’s leadership are critical to effective HIV/AIDS interventions for women and girls. However, direct impact on HIV outcomes has been more difficult to measure. Strengthening women’s NGOs and women leaders who can mobilize in-country efforts in the interests of women and girls who are affected by HIV is also critical.

Transforming Gender Norms:

  1. Training, peer and partner discussions, and community-based education about changing gender norms can increase HIV protective behaviors.
  2. Mass media campaigns concerning gender equality as part of comprehensive and integrated services can increase HIV protective behaviors.


Addressing Violence Against Women:

  1. Community-based participatory learning approaches involving men and women can create more gender-equitable relationships, thereby decreasing violence.
  2. Establishing comprehensive post-rape care protocols, which include PEP, can improve services for women.
  3. Microfinance programs can lead to reduction in gender-based violence when integrated with participatory training on HIV, gender, and violence.


Transforming Legal Norms to Empower Women, including Marriage, Inheritance and Property Rights:

  1. Enforcing laws that allow widows to take control of remaining property can increase their ability to cope with HIV.
  2. Promoting Women’s Employment, Income and Livelihood Opportunities:
  3. Increased employment opportunities, microfinance, or small-scale income-generating activities can reduce behavior that increases HIV risk, particularly among young people.


Advancing Education:

  1. Increasing educational attainment can help reduce HIV risk among girls.
  2. Abolishing school fees enables girls to attend (or stay in) school.
  3. Providing life skills-based education can complement formal education in building knowledge and skills to prevent HIV.


Reducing Stigma and Discrimination:

  1. Community-based interventions that provide accurate information about HIV transmission (especially that casual contact cannot transmit the virus) can significantly reduce HIV stigma and discrimination.
  2. Training for providers can reduce discrimination against people with HIV/AIDS.


Care and Support

Under care and support programs the bulk of care is provided—mostly unpaid—by women. Few home based care programs specifically address the needs of women. HIV/AIDS continues to take a huge financial toll on households. While scaling up universal access to treatment is critical, treatment alone will not solve all care and support needs. Below are interventions that work in caring for and supporting women and girls in general, both with respect to their own needs in illness and the burden of caring for others who are ill, as well as the care and support of orphans and vulnerable children, especially the particular vulnerabilities and needs of orphaned girls:

Women and Girls:

  1. Continued counseling (either group or individual) for those who are HIV-positive and those who are caregivers can relieve psychological distress.  
  2. Peer support groups can be highly beneficial to women living with HIV.


Orphans and Vulnerable Children:

  1. Accelerating treatment access for adults with children can reduce the number of orphans, improve pediatric mortality and social well-being.  
  2. Programs that promote the strength of families and offer family-centered integrated economic, health and social support result in improved health and education outcomes for orphans.
  3. ARV treatment with good nutritional intake and regular medical care can improve health and survival of HIV-positive children in resource-poor settings.  
  4. Psychological counseling and mentoring for OVC improves their psychological well-being.
  5. Programs that provide microenterprise opportunities, old age pensions or other targeted financial and livelihood assistance can be effective in supporting orphans.


Structuring Health Services to Meet Women’s Needs

The manner in which health services are structured has an impact on HIV prevention, treatment and care for women and girls. Women often need multiple services, including reproductive health and family planning services in addition to HIV prevention, treatment and care, but most health care facilities are not structured to provide integrated services. Importantly, health care providers must practice in a respectful, non-discriminatory manner.  What works for women in structuring health services includes:

  1. Integrating HIV testing and services with family planning, maternal health care or within primary care facilities can increase uptake of HIV testing and other reproductive health services.
  2. Promoting contraceptives and family planning as part of routine HIV services (and vice versa) can increase condom use, contraceptive use, and dual method use, thus averting unintended pregnancies among women living with HIV.
  3. Providing VCT together with other health services can increase the number of people accessing VCT.
  4. Scaling up PMTCT programs increases the number of women who know their serostatus, and improves HIV knowledge.
  5. Clinic-based interventions with outreach workers can be effective in increasing condom use among sex workers.
  6. Providing accessible, routine, high quality, voluntary and confidential STI clinical services that include condom promotion can be successful in reducing HIV risk among sex workers.
  7. Home testing, consented to by household members, can increase the number of people who learn their serostatus.
  8. Training providers can reduce discrimination against people with HIV/AIDS.
  9. Establishing comprehensive post-rape care protocols, which include PEP, can improve services for women.
  10. Providing clinic services that are youth-friendly, conveniently located, affordable, confidential and non-judgmental can increase use of clinic reproductive health services, including VCT.


Moving Forward with HIV/AIDS Programming for Women and Girls

Overall, the review demonstrates that while there is significant evidence for what works, there are still many programming gaps related to women and girls for which no effective evaluated interventions were found. In addition, many studies still do not include sex-disaggregated data to begin the process of addressing the specific needs of women and girls. Structural interventions to improve the enabling environment, such as transforming gender norms and legal reform, are clearly critical but are more difficult to correlate with HIV outcomes. Evidence-based interventions that have been shown to work must be scaled up with clear understanding of local epidemical and gender contexts.