Executive Summary

Background

For 30 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 Africathe region most affected by HIV/AIDSwomen 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 resource 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 close to 100 countries with a focus on developing countries and contains approximately 4000 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 more than 2500 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, Medline, and Popline searches of peer-reviewed literature. Searches were conducted for 2005-2012, 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.

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 resource.


Prevention for Women

Prevention is key. 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, treating STIs and treatment as prevention 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:

Male and Female Condom Use:

  1. Consistent use of male condoms can reduce the chance of HIV acquisition by more than 95%.
  2. Male and female condoms when used consistently and correctly are comparable in effectiveness.
  3. Expanding distribution of female condoms may increase female condom use, thus increasing the number of protected sex acts and preventing HIV acquisition and transmission.
  4. Increasing couple communication about HIV risk can increase preventive behaviors, including condom use.
  5. Promoting the dual use of condoms as a contraceptive as well as for HIV prevention may make use more acceptable and easier to negotiate.
  6. Peer education for women may increase condom use.
  7. Promoting condoms, either in individual or group sessions, along with skills training, provision of condoms, and motivational education can increase condom use.

Voluntary Medical Male Circumcision:

  1. Male circumcision reduces HIV acquisition for men and reduces the likelihood of transmission to HIV-negative women.

Treating Sexually Transmitted Infections (STIs):

  1. 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.

Treatment as Prevention:

  1. ARV therapy can reduce (but does not eliminate) the risk of HIV transmission and is an additional prevention strategy.
  2. Providing antiretroviral treatment to people living with HIV can increase HIV prevention behaviors, including condom use.

Prevention for Key Affected Populations

Some groups of women are at particular risk of HIV transmission: sex workers; women who use drugs 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:

Female Sex Workers:

  1. Comprehensive prevention programs that include components such as peer education, medical services and supplies, 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 and HIV testing 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 condom use.
  6. Creating a sense of community and empowerment among sex workers can help support effective HIV prevention.

Women Who Use Drugs and Female Partners of Men Who Use Drugs:

  1. Opioid agonist therapy, particularly maintenance programs with methadone and buprenorphine, leads to reduction in drug use, HIV acquisition and risk behavior among PWID, and is safe and effective for use by pregnant women.
  2. Comprehensive harm reduction programs, including needle exchange programs, condom distribution, agonist therapy and outreach, and nonjudgmental risk reduction counseling can reduce HIV risk behaviors and prevalence among PWID.
  3. Peer education can increase protective behaviors, including condom use among women who use drugs and and female partners of men who use drugs.
  4. Gender-sensitive sex-segregated group sessions for couples who use drugs can result in increased condom use and safer injection behaviors.
  5. Instituting harm reduction programs for PWID in prisons can reduce HIV prevalence in female prison populations.

Women Prisoners and Female 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 in female prison populations.
  2. Making opioid agonist 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:

Encouraging Behavior Change:

  1. Sex and HIV education with certain characteristics (see introduction) prior to the onset of sexual activity may be effective in reducing stigma and preventing transmission of HIV by increasing age at first sex and, for those who are sexually active, increasing condom use, testing, 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. Comprehensive programs for youth can improve HIV knowledge and encourage protective behavior.
  5. Increased employment opportunities, microfinance, or small-scale income generating activities can reduce risky behavior particularly among young women.

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, which allow choice and that do not jeopardize human rights, consent and confidentiality. What works in HIV testing and counseling:

  1. HIV testing and counseling (HTC) can help women know their HIV status and increase their protective behaviors, particularly among those who test HIV-positive.
  2. Providing HIV testing and counseling together with other health services can increase the number of people accessing HTC.
  3. Mass media interventions can increase the numbers of individuals and couples accessing HIV testing and counseling.
  4. Community outreach and mobilization can increase uptake of HIV testing and counseling by reaching clients who may not present at a hospital or clinic.
  5. Home testing, consented to by household members, can increase the number of people who learn their serostatus.
  6. Counseling may reduce risk behaviors and HIV acquisition.
  7. Incorporating discussions of alcohol use into HIV testing and counseling may increase protective behaviors such as condom use, partner reduction and reduction of alcohol use.
  8. Encouraging couple dialogue and counseling, including techniques to avert gender-based violence, may increase the number of couples who receive and disclose their test results.


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. HIV prevention in addition to treatment remains critical. There are indications that certain interventions can be highly beneficial to women specifically in treatment provision and access, adherence and support, and staying healthy and reducing transmission:

Provision and Access:

  1. Antiretroviral therapy has been successfully administered with good adherence, good patient retention, and good clinical outcomes in resource-poor settings with increased patient survival; results have been similar to those achieved in resource-rich countries.
  2. Early initiation of antiretroviral therapy results in improved quality of life and reduced mortality.
  3. Antiretroviral therapy initiated at CD4 counts between 350 and 550 can result in fewer serious HIV-1-related clinical events or death.
  4. Integrating CD4 count service with VCT or primary health clinics can increase access to CD4 measurement, hastening initiation of treatment.
  5. Integration of HIV/AIDS services into primary care increases access to testing and treatment services.

Adherence and Support:

  1. Adults in resource-poor settings have achieved good adherence to antiretroviral therapy with results similar to those achieved in resource-rich countries.
  2. Peer support groups can increase adherence.
  3. Counseling improves adherence.
  4. Providing treatment support and literacy, including by HIV-positive peers and by providers, can increase adherence.
  5. Pill counts and pillbox organizers increase adherence and are a low-technology empowerment tool.
  6. Mobile phone text messages from health providers may improve adherence by providing patient support.

Staying Health and Reducing Transmission:

  1. ARV therapy can reduce (but does not eliminate) the risk of HIV transmission and is an additional prevention strategy.
  2. Providing antiretroviral treatment to people living with HIV can increase HIV prevention behaviors, including condom use.
  3. Providing information and skills-building support to HIV-positive people can reduce unprotected sex.


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 family planning counseling and voluntary contraceptive use as part of routine HIV services (and vice versa) can increase contraceptive use, including dual method use, thus averting unintended pregnancies and transmission of infection among women living with HIV.
  2. A wide range of contraceptive method choices are safe and effective for women living with HIV, including hormonal contraception and IUDs. However, further research is awaited on hormonal contraception and HIV.
  3. Providing information and skills-building support to people living with HIV can reduce self-reported unprotected sex.
  4. Cervical cancer screening and treatment integrated into HIV care can reduce morbidity and mortality in women living with HIV.
  5. Providing antiretroviral treatment to people living with HIV can increase HIV prevention behaviors, including condom use.

Safe Motherhood and Prevention of Vertical Transmission

Conservative estimates are that from 2011 to 2015 there will be between 130 million to 180 million births without skilled birth attendants in South Asia and sub-Saharan Africa, where there may not be access to prevention of mother-to-child transmission (PMTCT) services. Prevention of Vertical Transmission 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 is included 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.

Testing and Counseling:

  1. Routinely offered testing that is voluntary and accompanied by counseling is acceptable to most women.
  2. Involving partners, with womens consent, can result in increased testing and disclosure and may reduce risk of vertical transmission and infant mortality.

Treatment:

  1. Triple antiretroviral treatment regimens are efficacious for pregnant women living with HIV to improve the health of the mother when used as treatment.
  2. Triple antiretroviral treatment regimens are efficacious to reduce vertical transmission of HIV when used as prophylaxis (though questions remain about the effect of termination on future drug resistance for both mother and infant).
  3. Early initiation of HAART in HIV-positive pregnant women results in reduced vertical transmission.
  4. For women who are pregnant and cannot access HAART either for their own health or for prevention of vertical transmission, short-course duo ARV therapy reduces vertical transmission and can reduce nevirapine resistance for both mothers and infants.
  5. Extending an HIV-positive womans life increases the long-term survival of her infant.
  6. National scale-up of HAART in pregnancy improves maternal and infant outcomes.
  7. Integrating ARV therapy into antenatal care, rather than referring women separately for HIV treatment, may reduce time to treatment initiation for pregnant women living with HIV.
  8. Efavirenz may be safe to use for HIV-positive women who become pregnant, with little difference in the incidence of birth defects compared to other ART treatments.

Postpartum:

  1. Triple therapy, when used for treatment or prophylaxis through the postpartum period reduces mother-to-child HIV transmission.
  2. Early postpartum visits, especially with on-site contraceptive services, can result in increased condom use, contraceptive use, HIV testing and treatment.
  3. Exclusive breastfeeding for the first six months of the infants life with a gradual decrease in breastfeeding results in lower rates of HIV transmission to the infant, reduced infant mortality, and improved infant growth compared to mixed feeding or abrupt weaning. Where clean accessible water is not available, breastfeeding after six months reduces infant mortality.

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-limited 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:

Tuberculosis:

  1. Initiating HIV treatment before or during TB therapy can reduce the incidence of TB and increase patient survival for those living with HIV, including for patients with XDR TB.
  2. Isoniazid preventative therapy can reduce the incidence of active TB and increase survival among people living with HIV.
  3. Active case finding increases TB detection, particularly in sub-Saharan Africa where HIV is driving the epidemic.
  4. Routine screening and treatment of TB and HIV patients in endemic countries can increase detection of co-infection and increase patient survival.
  5. Provider-initiated HIV testing and counseling can be acceptable, feasible and lead to high uptake of HIV testing among TB patients.

Malaria:

  1. Co-trimoxazole prophylaxis, antiretroviral therapy and ITNs can substantially reduce the incidence of malaria in women living with HIV.
  2. Intermittent preventive treatment of malaria with sulfadoxine-pyrimethamine (SP) is effective in preventing malaria and decreasing prevalence of anemia among pregnant women with HIV.

Strengthening the Enabling Environment

Addressing structural factors and the enabling environment, such as gender norms; violence against women; legal norms; womens employment, income and livelihood; advancing education; reducing stigma and discrimination and promoting womens 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 womens 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. Evidence for what works to strengthen the environment:

Transforming Gender Norms:

  1. Training, peer and partner discussions, and community-based education that questions harmful gender norms can improve HIV prevention, testing, treatment and care.

Addressing Violence Against Women:

  1. Community-based participatory learning approaches involving men and women can create more gender-equitable relationships, thereby decreasing 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.

Promoting Womens Employment, Income and Livelihood Opportunities:

  1. 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 helps enable 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 (including media) that provide accurate information about HIV transmission can significantly reduce HIV stigma and discrimination.
  2. Training for providers, along with access to the means of universal precautions, can reduce provider discrimination against people with HIV/AIDS.

Care and Support

Under care and support programs the bulk of care, mostly unpaid, is provided by women. Few home-based care programs specifically address the needs of women. HIV and AIDS continue 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) and related training for those who are HIV-positive and those affected by HIV 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. Educational support for orphan girls may reduce risk of HIV acquisition and increase educational attainment.
  3. 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.
  4. Psychological counseling and mentoring for OVC may improve their psychological well-being.
  5. Programs that provide community-wide cash transfers, microenterprise opportunities, old age pensions or other targeted financial and livelihood assistance can be effective in supporting orphans.


Structuring Health Services to Meet Womens 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 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 family planning counseling and voluntary contraceptive use as part of routine HIV services (and vice versa) can increase contraceptive use, including dual method use, thus averting unintended pregnancies and transmission among women living with HIV.
  3. Providing HIV testing and counseling together with other health services can increase the number of people accessing HTC.
  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 and HIV testing among sex workers.
  6. Home testing, consented to by household members, can increase the number of people who learn their serostatus.
  7. Community outreach and mobilization can increase uptake of HIV testing and counseling by reaching clients who may not present at a hospital or clinic.
  8. Training for providers, along with access to the means of universal precautions, can reduce provider discrimination against people with HIV/AIDS.
  9. Early postpartum visits, especially with on-site contraceptive services, can result in increased condom use, contraceptive use, HIV testing and treatment.
  10. Instituting harm reduction programs for PWID in prisons can reduce HIV prevalence in female prison populations.
  11. Provider-initiated HIV testing and counseling can be acceptable, feasible and lead to high uptake of HIV testing among TB patients.
  12. Incorporating discussions of alcohol use into HIV testing and counseling may increase protective behaviors such as condom use, partner reduction and reduction of alcohol use.
  13. Routine screening and treatment of TB and HIV patients in endemic countries can increase detection of co-infection and increase patient survival.

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.