The World Health Organization was established in 1948 as a specialized agency ofthe United Nations serving as the directing and coordinating authority for internationalhealth matters and public health. One of WHO’s constitutional functions is to provideobjective and reliable information and advice in the field of human health, a respon-sibility that it fulfils in part through its extensive programme of publications. TheOrganization seeks through its publications to support national health strategies andaddress the most pressing public health concerns of populations around the world.To respond to the needs of Member States at all levels of development, WHO pub-lishes practical manuals, handbooks and training material for specific categories ofhealth workers; internationally applicable guidelines and standards; reviews and anal-yses of health policies, programmes and research; and state-of-the-art consensusreports that offer technical advice and recommendations for decision-makers. Thesebooks are closely tied to the Organization’s priority activities, encompassing diseaseprevention and control, the development of equitable health systems based on pri-mary health care, and health promotion for individuals and communities. Progresstowards better health for all also demands the global dissemination and exchange ofinformation that draws on the knowledge and experience of all WHO’s Member coun-tries and the collaboration of world leaders in public health and the biomedicalsciences. To ensure the widest possible availability of authoritative information andguidance on health matters, WHO secures the broad international distribution of itspublications and encourages their translation and adaptation. By helping to promoteand protect health and prevent and control disease throughout the world, WHO’sbooks contribute to achieving the Organization’s principal objective — the attainmentby all people of the highest possible level of health.

The WHO Technical Report Series makes available the findings of various interna-tional groups of experts that provide WHO with the latest scientific and technicaladvice on a broad range of medical and public health subjects. Members of suchexpert groups serve without remuneration in their personal capacities rather than asrepresentatives of governments or other bodies; their views do not necessarily reflectthe decisions or the stated policy of WHO. An annual subscription to this series,comprising about six such reports, costs CHF 168.00/US$ 106.00 (CHF 128.40/US$ 115.00 in developing countries). For further information, please contact: WHOPress, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland(tel. +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int; order online: http://www.who.int/bookorders).

92-4-120938-0_FM_a

92-4-120938-0_FM_b

WHO Technical Report Series938

PREVENTING HIV/AIDSIN YOUNG PEOPLE

A SYSTEMATIC REVIEW OF THEEVIDENCE FROM DEVELOPING COUNTRIES

UNAIDS Inter-agency Task Team on Young People

Edited byDavid A. Ross, Bruce Dick & Jane Ferguson

92-4-120938-0_FM_i

WHO Library Cataloguing-in-Publication Data

Preventing HIV/AIDS in young people : a systematic review of the evidence from developing countries :UNAIDS interagency task team on HIV and young people / editors: David Ross, Bruce Dick, Jane Ferguson.

(WHO technical report series ; no. 938)

1.HIV infections - prevention and control. 2.Acquired immunodeficiency syndrome- prevention and control. 3.Adolescent. 4.Sex education. 5.Program evaluation.6.Developing countries. I.Ross, David A. II.Dick, Bruce. III.Ferguson, Jane. IV.WorldHealth Organization. V.Series.

ISBN 92 4 120938 0 (NLM classification: WC 503.6)ISBN 978 92 4 120938 0ISSN 0512-3054

© World Health Organization 2006

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, WorldHealth Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 7914857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address(fax: +41 22 791 4806; e-mail: permissions@who.int).

The designations employed and the presentation of the material in this publication do not imply the expressionof any opinion whatsoever on the part of the World Health Organization concerning the legal status of anycountry, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsedor recommended by the World Health Organization in preference to others of a similar nature that are notmentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initialcapital letters.

All reasonable precautions have been taken by the World Health Organization to verify the informationcontained in this publication. However, the published material is being distributed without warranty of any kind,either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader.In no event shall the World Health Organization be liable for damages arising from its use.

The named authors alone are responsible for the views expressed in this publication.

Typeset in IndiaPrinted in Geneva

92-4-120938-0_FM_ii

Table of contents

1. Introduction and rationaleBruce Dick, Jane Ferguson, & David A. Ross1.1 Background 1.2 Young people, HIV/AIDS and the global goals 1.3 Priorities for action 1.4 Objectives and limitations 1.5 Process and methodology 1.6 Scope and limitations of the data 1.7 Challenges in interpreting the findings and follow up

2. Young people: the centre of the HIV epidemicRoeland Monasch & Mary Mahy2.1 Introduction 2.2 Data and methods 2.3 Types of epidemics 2.4 Progress towards UNGASS commitments 2.5 Limitations of the data 2.6 Conclusions

3. Overview of effective and promising interventions to preventHIV infectionJudith D. Auerbach, Richard J. Hayes, & Sonia M. Kandathil3.1 Introduction 3.2 Interventions to change behaviour 3.3 Biomedical interventions: evaluating technologies 3.4 Social interventions 3.5 Behavioural and social issues in developing and

implementing interventions 3.6 Conclusion

4. The weight of evidence: a method for assessing thestrength of evidence on the effectiveness of HIV preventioninterventions among young peopleDavid A. Ross, Danny Wight, Gary Dowsett, Anne Buvé, &Angela I.N. Obasi4.1 Introduction 4.2 Types of interventions and evidence on effectiveness 4.3 Thresholds for strength of evidence needed for widespread

implementation 4.4 What information do policy-makers need? 4.5 Assessing the quality of an intervention 4.6 Types of evidence and their relative weight 4.7 Conclusion

1124579

10

15161717243435

4343445158

6163

798081

8488919298

iii

92-4-120938-0_FM_iii

5. The effectiveness of sex education and HIV educationinterventions in schools in developing countriesDouglas Kirby, Angela Obasi, & B.A. Laris5.1 Introduction and background 5.2 Methods 5.3 Findings 5.4 Discussion and recommendations

6. Review of the evidence for interventions to increase youngpeople’s use of health services in developing countriesBruce Dick, Jane Ferguson, Venkatraman Chandra-Mouli,Loretta Brabin, Subidita Chatterjee, & David A. Ross6.1 Introduction 6.2 Methods 6.3 Findings 6.4 Discussion 6.5 Conclusions

7. The effectiveness of mass media in changing HIV/AIDS-related behaviour among young people in developingcountriesJane T. Bertrand & Rebecca Anhang7.1 Introduction 7.2 Methods 7.3 Findings 7.4 Discussion

8. The effectiveness of community interventions targeting HIVand AIDS prevention at young people in developingcountriesEleanor Maticka-Tyndale & Chris Brouillard-Coyle8.1 Introduction 8.2 Methods 8.3 Findings 8.4 Go, ready, steady, do not go 8.5 Conclusions

9. Achieving the global goals on HIV among young people mostat risk in developing countries: young sex workers, injectingdrug users and men who have sex with menOliver Hoffmann, Tania Boler, & Bruce Dick9.1 Introduction 9.2 Methods 9.3 Findings 9.4 Discussion

103104111117142

151152153158191199

205206207226236

243244244247276281

287288289293306

iv

92-4-120938-0_FM_iv

10. Conclusions and recommendationsJane Ferguson, Bruce Dick, & David A. Ross10.1 Introduction 10.2 The road to “Steady, Ready, Go” 10.3 Results 10.4 Discussion 10.5 Recommendations

Glossary

Acknowledgements

317317319322328335

343

347

v

92-4-120938-0_FM_v

92-4-120938-0_FM_vi

1. Introduction and rationaleBruce Dick,a Jane Ferguson,a & David A. Rossb

1.1 Background

In 1995, WHO in collaboration with UNFPA and UNICEF convened a studygroup on programming for adolescent health and development. One of theproducts of this group was a joint technical report publication on Program-ming for adolescent health and development (1). The report synthesized theevidence for the effectiveness of interventions for adolescent health and de-velopment, and it set the direction and provided the conceptual frameworkfor much of the programming for young people’s health and developmentthat has taken place since its publication (2–6).

The challenges posed by HIV have progressed inexorably during the pastdecade, especially for young people in developing countries. (Young peopleare defined in this report as those aged 10–24 years; this group combinesadolescents – aged 10–19 years – and youth – aged 15–24 years). At the sametime, many lessons have been learnt about developing and implementingprogrammes for young people’s health and development, including pro-grammes to prevent the spread of HIV. In 2004, the UNAIDS Inter-AgencyTask Team on Young People decided that it was time to review the progressthat had been made and to look again at the evidence for the effectiveness ofinterventions, focusing explicitly on interventions to prevent the spread ofHIV among young people in developing countries.

This report is an attempt to rise to the challenge by providing systematicreviews of the evidence for policies and programmes to decrease HIV preva-lence among young people, as a contribution towards achieving universalaccess to prevention, treatment and care (7) and attaining the MillenniumDevelopment Goal on AIDS (8).

a Department of Child and Adolescent Health and Development, WHO, Geneva, Switzerland.Correspondence should be sent to Bruce Dick (email: dickb@who.int).

b Infectious Disease Epidemiology Unit, London School of Hygiene and Tropical Medicine,London, England.

1

92-4-120938-0_CH01_1

1.2 Young people, HIV/AIDS and the global goals

During the past 20 years, and despite the continued lack of an effective vac-cine, the armamentarium for preventing the transmission and decreasing theimpact of HIV and AIDS has slowly grown (9, 10) (see also chapter 3).

HIV/AIDS has its roots in a range of problems that undermine people’s healthand human rights, such as inequity and discrimination, poverty, social unrestand migration, exploitation and abuse. Changing these structural and con-textual determinants (11) will be fundamental to making the prevention ofHIV sustainable. However, there have been growing experiences with a rangeof shorter-term interventions that have been directed towards encouragingpeople to avoid the behaviours that underlie the transmission of HIV or toreduce the risk associated with these behaviours (9).

To achieve widespread implementation of these preventive interventionsmany things will need to be done through many sectors and by many actors.At the same time, it will be important to ensure that the interventions reachthose people who are vulnerable and most at risk of becoming infected withHIV, both in terms of where the virus is and where the virus is going, as thepandemic develops and matures.

Young people make up a segment of the population that is particularly vul-nerable to HIV. Altogether, 50% of HIV transmission takes place amongthose aged 15–24, and 5 000–6 000 young people become infected every day(12, 13). The second decade of life is a period of experimentation and risk,and many factors increase young people’s vulnerability to HIV during theseyears of rapid physical and psychosocial development. These factors includea lack of knowledge about HIV/AIDS, lack of education and life skills, pooraccess to health services and commodities, early sexual debut, early marriage,sexual coercion and violence, trafficking and growing up without parents orother forms of protection from exploitation and abuse.

In recognition of young people’s vulnerability to HIV/AIDS, the UnitedNations General Assembly Special Session on HIV/AIDS (14) (UNGASS onHIV/AIDS) outlined a number of goals and targets focusing on young peopleaged 15–24. These are based on the core elements of the joint WHO/UNFPA/UNICEF document Action for adolescent health: towards a commonagenda (2). The goals of UNGASS on HIV/AIDS build on and are reflectedin the commitments made at a range of other global fora (Box 1.1), includingthe International Conference on Population and Development’s programmeof action (known as ICPD+5) (15) and the United Nations Special Sessionon Children (16). The goals and targets endorsed during the UNGASS onHIV/AIDS not only focus on decreasing HIV prevalence among young peo-ple but also on promoting the core elements of the programme framework

2

92-4-120938-0_CH01_2

that was developed during the 1995 study group – that is, they focus onproviding access to information, skills and services as well as decreasingvulnerability.

The UNGASS on HIV/AIDS goals and targets help to unpack the prevalencegoal, and provide both light and heat for all people working to decrease thetransmission and impact of HIV and AIDS among young people. Achievingthese goals and targets will make an important contribution towards achievingthe goal of universal access to prevention, treatment and care, and this will

Box 1.1

Highlights of important goals for young people’s health and development, witha focus on HIV/AIDS

The UN General Assembly Special Session on Children (17)

Develop and implement national health policies and programmes foradolescents, including goals and indicators, to promote their physicaland mental health

The Millennium Development Goal on HIV/AIDS (7)

By 2015 halt and begin to reverse the spread of HIV/AIDS (using theprevalence of HIV among pregnant 15–24 year olds as an indicator)

The UN General Assembly Special Session on HIV/AIDS (14)

By 2005, ensure that at least 90% (and by 2010 that 95%) of youngpeople have access to the information they need to reduce their vul-nerability to HIV

By 2005, ensure that at least 90% (and by 2010 that 95%) of youngpeople have access to the skills they need to reduce their vulnera-bility to HIV

By 2005, ensure that at least 90% (and by 2010 that 95%) of youngpeople have access to the services they need to reduce their vul-nerability to HIV

By 2003, develop and/or strengthen strategies, policies and pro-grammes which reduce the vulnerability of children and youngpeople

By 2005 HIV prevalence among young people (15–24 years)reduced by 25% in the most affected countries, and by 2010 reduceprevalence by 25% globally

3

92-4-120938-0_CH01_3

be necessary, if not sufficient, to achieve the Millennium Development Goalthat aims to halt and begin to reverse the spread of HIV/AIDS.

1.3 Priorities for action

Now that there are global goals and targets, and a growing number of inter-ventions that may contribute to their achievement, it is important to synthesizethe evidence base for these interventions in ways that assist the decision-making of policy-makers and programme planners. Research findings needto help them decide how to most effectively allocate resources in differentepidemic settings and for different groups of young people. With 5 000–6 000 young people becoming infected with HIV every day, these are clearlydecisions that need to be taken today, despite the fact that the evidence maybe less than complete. We know that there is no magic bullet, and that a rangeof interventions will need to be implemented. We also know that many thingswill influence the choices made about which interventions to focus on, in-cluding moral opinions and political expediency. But the evidence of effec-tiveness needs to be one of them.

The decisions that need to be taken are made all the more difficult by the factthat evidence from multiple interventions is needed; the evidence for manyinterventions is weak; and most evidence comes from developed countries.In addition, it is not always clear what different groups – for example, re-searchers, programme managers and policy-makers – understand by the termevidence. And it is often not clear what they have used as evidence: random-ized controlled trials, quasi-experimental trial designs, recommendations ofbest practice, or anecdotes. So there is not only a need to be clear about theevidence but also to be more systematic, transparent and consistent about howthe available evidence is reviewed and assessed.

There is now wide consensus about the main settings through which youngpeople can be reached with preventive interventions; these include schools,health services, the mass media and through communities and outreach pro-grammes targeting the young people who are most at risk of HIV. Further-more, although the evidence of the effectiveness of interventions remainsincomplete for many of these settings, there is a growing research base fromwhich to draw, and this includes research from developing countries. In ad-dition, the global goals provide a range of outcomes that can be used to reviewthe evidence: decreased prevalence, decreased vulnerability and increasedaccess to relevant information, skills and services.

4

92-4-120938-0_CH01_4

1.4 Objectives and limitations

1.4.1 Objectives

The various chapters in this report focus on ways of meeting the global goalson young people and HIV. They also emphasize the sense of urgency thatshould accompany the drive to achieve these goals, as well as the need for aspecific emphasis on prevention, and within that, a focus on the young peoplewho remain at the centre of the HIV pandemic. The chapters also explore theneed to have a better understanding of the evidence base for making decisionsabout the allocation of resources, and they particularly focus on developingcountries.

This report has three specific objectives:

1. first, to clarify our collective understanding of the term “evidence” incomplex areas of programme development and delivery – such as theprevention of HIV among young people – and to develop a transparentmethodology for reviewing the effectiveness of different types of inter-ventions in different settings – such as schools, health services, the massmedia, within geographically defined communities and for services tar-geting the young people most at risk of HIV infection;

2. second, to provide a comprehensive review of the evidence on the effec-tiveness of interventions to prevent HIV among young people in devel-oping countries;

3. third, to inform the choices of policy-makers, people responsible forprogramme development and delivery, and researchers about interven-tions to achieve the global goals on HIV and young people that wereendorsed during the UNGASS on HIV/AIDS. The report also seeks toprovide decision-makers with guidance on which interventions they cansupport with confidence, which interventions need to be implementedmore cautiously along with careful evaluation of their impact on key healthoutcomes, which interventions require further development and demon-stration of effectiveness before they can be recommended for widespreadimplementation, and which interventions should not be implemented be-cause there is sufficient evidence of their lack of effectiveness.

The chapters in this report are divided into three sections.

Chapters 1, 2 and 3 provide an outline of the aims and objectives of thesubsequent chapters, a synthesis of the epidemiological data that describethe epidemic among young people and an overview of what is known aboutthe effectiveness of prevention interventions in general.

5

92-4-120938-0_CH01_5

Chapters 4, 5, 6, 7, 8 and 9 explain the methods used to review the evidenceand provides detailed reviews of the evidence from each of the key settingsthrough which young people can be reached by interventions for the pre-vention of HIV.

Chapter 10 contains the overall conclusions from the reviews of the evi-dence, including recommendations for policy-makers, programme devel-opment and delivery staff, and researchers.

1.4.2 Limitations

It is hoped that this report will make an important contribution to discussionsand decisions about priorities for action, by providing a snapshot of theknowledge base for the effectiveness of different interventions. It is alsoanticipated that this report will contribute to increasing the transparency ofhow the evidence for effectiveness is assessed. However, it is important tobe clear from the outset about some of the limitations of the scope and aimsof this report.

First, in order to limit the scope of each chapter, the authors have focused oninterventions that were primarily intended to prevent HIV transmission. Theyhave not dealt with studies that focused on providing treatment, care or sup-port for young people living with HIV and AIDS. This does not in any wayimply that treatment is unimportant or that treatment does not have the po-tential to make important contributions to prevention. Rapidly increasingaccess to effective HIV treatment is likely to provide many opportunities tostrengthen HIV prevention efforts as well as mitigate the impact of AIDS.These chapters have also not dealt with interventions designed to mitigate theimpact of HIV, for example interventions with orphans and other young peo-ple affected and made vulnerable by HIV and AIDS.

Second, chapters do not review structural interventions that primarily aim toprevent HIV by decreasing young people’s vulnerability, for example bydecreasing poverty, marginalization, stigma or discrimination. Many youngpeople are vulnerable to HIV as a result of belonging to a group or subcultureor living in a particular setting, because of the poor quality and coverage ofservices and other programmes available to them, or as a result of broadersocietal and environmental influences, including behavioural norms. Butagain this is not to imply that interventions that aim to alleviate these vul-nerabilities are unimportant. The decision not to focus on these types ofinterventions was based on preliminary work that indicated that althoughthere have been some successes, such as increasing the enrolment of adoles-cent girls in school, it is not always clear what can be done to change thedeterminants of vulnerability, and for those interventions that have been

6

92-4-120938-0_CH01_6

implemented the mechanisms of action are not clear and the evidence for theireffectiveness remains weak.

Third, the chapters have not reviewed evidence for the effectiveness ofinterventions in all settings where they could possibly be delivered. In par-ticular, they have not reviewed the evidence for the effectiveness of inter-ventions in the political environment – those delivered, for example, throughactivism, political commitment and policies that create a supportive envi-ronment to enable specific interventions to be implemented. Few rigorousstudies have looked at the effectiveness of actions to create a favourableenvironment for intervention delivery. Although a chapter reviewing suchinterventions was originally foreseen, a preliminary assessment indicated thatthere were insufficient studies to carry out a review using the methods appliedto the other settings included in this report.

Fourth, we have not reviewed the evidence for the effectiveness of interven-tions among all groups who are particularly at risk of HIV. For example, whilethere has been an explicit focus on young injecting drug users, young sexworkers and young men who have sex with men; young prisoners and youngmigrant workers have not received specific attention.

Finally, although the primary focus of this report is to examine interventionsaffecting young people in developing countries, we have had to refer to find-ings from developed countries in order to place the evidence in a widercontext. In some of the chapters, studies have also been included in whichthe interventions were directed towards populations that included young peo-ple but that did not disaggregate data by age.

1.5 Process and methodology

This report has been developed over a 2-year period. The process started inMay 2004, when a meeting was organized in Talloires, France. This meetingbrought together policy-makers, people who make decisions about pro-gramme development and delivery, and researchers who have an interest andexpertise in interventions to prevent HIV among young people. At this time,the participants reviewed a set of background papers that had been speciallyprepared for the meeting, and they made recommendations for improving thepapers and the methods used to review the evidence, and for developing ad-ditional papers.

Following this meeting the papers were re-drafted and additional paperswere developed. An information brief was prepared based on the outcome ofthe meeting (17), and presentations were made in different fora to assesswhether the approach that was being developed was useful to people makingdecisions about priorities for action. It was clear that the comprehensive

7

92-4-120938-0_CH01_7

and transparent approach, and the classification of the interventions as“Steady”, “Ready” and “Go”, resonated with policy-makers and programmedevelopers alike.

A second meeting was held in Gex, France, in March 2005. This meetingincluded the authors of the chapters and selected external advisers who alsoprovided further peer review and suggestions for refining the papers. Thiswas followed in June 2005 by a meeting in Chavannes, Switzerland, whichinvolved the editors of this report and reviewers from different regions whohad not previously been involved in the process. These reviewers were invitedto provide external review of the papers and to assist with developing theconclusions and recommendations. Final changes were made to the papersduring the second half of 2005, prior to the papers going through furtherexternal peer review and editorial review processes.

As described in more detail in the first paper in section 2, the authors ofchapters 5 to 9 in section 2 were asked to use the following approach to reviewthe evidence for the effectiveness of the interventions in their respectivesettings.

1. First, the interventions provided through each of the settings were to beclassified into different types of interventions based on common charac-teristics and the choices policy-makers and programme developers needto make in deciding what to do.

2. Second, the authors were asked to assess the strength of evidence (theevidence threshold) needed to recommend the widespread implementa-tion of the different types of interventions.

3. Third, authors were asked to assess the strength of the empirical evidenceavailable from the studies for each of the different types of interventions,in terms of specific outcomes as defined by the UNGASS goals on youngpeople, by grading the evidence using standard criteria.

4. Finally, this evidence was to be compared with the threshold of evidencerequired to recommend a particular type of intervention for widespreaduse and a decision made as to whether the threshold had been fully met,partially met, not met but had encouraging characteristics, or if there wasevidence of a lack of effectiveness.

Based on the categorizations in point number 4 each type of intervention wasclassified as “Do not go”, “Steady”, “Ready” and “Go”, as shown in Box 1.2.

For each of the settings, the authors have attempted to review the evidencein relation to the UNGASS goals and targets for young people and HIV/AIDS, to assess whether the interventions are effective in terms of increasingyoung people’s access to information, skills and services, decreasing their

8

92-4-120938-0_CH01_8

vulnerability to HIV and decreasing HIV prevalence. In some settings, theoutcome that has been the focus of the studies reviewed has been more lim-ited, for example the UNGASS goal on providing access to services for thehealth services setting. And in some cases, behavioural outcomes, such asdelaying sexual debut, decreasing the number of sexual partners, and in-creasing the consistent and correct use of condoms, have been used as proxyindicators for decreased prevalence. The assumption is that all of these be-haviours are important in preventing the spread of HIV and that the balancebetween them is likely to vary depending on the specific groups of youngpeople under consideration and the contexts in which they live.

1.6 Scope and limitations of the data

A number of factors need to be considered when reviewing and interpretingthe findings of the chapters in this report. First, in general the findings showthat despite the importance of young people in the HIV/AIDS pandemic,surveillance and monitoring data are often unavailable for them; data that arecollected are frequently not disaggregated by age; and many important indi-cators are not routinely collected (18). These issues have their roots in a much

Box 1.2

Categorization of types of interventions

Category CriteriaGo Evidence threshold met

Sufficient evidence to recommend widespreadimplementation on large scale now, as long as there iscareful monitoring of coverage, quality and cost, andoperations research is implemented to better understandthe mechanisms of action

Ready Evidence threshold partially metEvidence suggests interventions are effective but large-scale implementation must be accompanied by furtherevaluation and operations research to clarify impact andmechanisms of action

Steady Evidence threshold not metSome of the evidence is promising but furtherdevelopment, pilot-testing and evaluation are neededbefore it can be determined whether these interventionsshould move into the “Ready” category or “Do not go”

Do not go Strong enough evidence of lack of effectiveness or of harmNot the way to go

9

92-4-120938-0_CH01_9

more widespread problem: good research on young people in developingcountries remains scarce.

Second, there is wide variability in the research that is available in differentsettings, with schools, for example, having a much more extensive evidencebase than interventions to reach the young people who are most at risk. Thisreflects a number of factors, from the ease with which research can be carriedout in different settings to the priorities of researchers and the people whofund research.

Third, despite extensive efforts by the authors to identify relevant researchstudies and programme reports, there is never enough time to access all eval-uations, particularly those published in the grey literature and in differentlanguages. Linked to this is the much more general problem of reporting biaswith which all authors had to contend: negative evaluations are generallymuch less likely to be published.

Fourth, few studies have included any costing data, and this has importantimplications for decision-makers as they try to use the evidence to chooseinterventions. However, attempts have been made to take this into consider-ation when assessing the threshold of evidence required to categorize thevarious types of interventions.

Finally, it is clear that much is going on that is not evaluated. So it is importantto remember that just because an intervention has not been evaluated scien-tifically or an evaluation has not been made accessible in the publishedliterature it does not necessarily mean that it is not effective.

1.7 Challenges in interpreting the findings and follow up

This report is timely, especially in view of the attention that is being paid tothe challenge of achieving universal access to HIV prevention interventions,treatment and care. While young people are at the centre of the epidemic’stransmission and impact, they are certainly not at the centre of the resources,and have been pushed even farther away as a result of the growing focus ontreatment.

One of the most important issues that will affect the interpretation and useof the findings in this report is context. Contextual factors are important notonly in terms of the transmission and impact of HIV but also in relation tothe implementation of interventions, which is affected by the availabilityof resources and the broader socioeconomic environment. The context isalso important because HIV touches on many issues that are sensitive in arange of cultural, religious and political settings. This is particularly anissue for young people because sex is at the heart of most HIV transmission,albeit frequently coerced sex, and because many of the groups who are most

10

92-4-120938-0_CH01_10

seriously affected are already suffering from marginalization, discriminationand stigma. Young people are not all alike and the epidemic itself is differentin different countries, even between different subgroups within a specificcountry. This is likely to have important repercussions that need to be con-sidered when deciding on the intervention mix.

For all of the settings, it was frequently impossible for authors to find suffi-cient details of the interventions and the outcomes from published reports ofthe original studies. These problems were compounded by the challenge ofinterpreting the findings of interventions that contained a number of differentcomponents.

The intention of this report was to focus on HIV. However, HIV and AIDSare associated with other problems that undermine young people’s health anddevelopment, that grow from common roots and that frequently are linked interms of cause and effect, for example alcohol and drug use, gender-basedviolence, sexually transmitted infections and pregnancy. Making the linksbetween the evidence base for interventions to prevent HIV among youngpeople and that from other issues facing young people will clearly be impor-tant both in interpreting and building on the findings in this report.

In the Conclusion and recommendations chapter there are clear messagesfor policy-makers, programme developers and researchers about how tomove interventions from “Ready” to “Go” and from “Steady” to “Ready” or,depending on the evidence, to “Do not go”. However, all of the authors real-ize that their reviews will not answer all the questions that policy-makers,programme developers and researchers might have after reading the reportand that decisions will still be difficult. Challenges that will need to be facedinclude addressing issues of replicability, adaptation, cost and sustainability;ensuring the quality of the interventions as they are scaled-up; understandingthe individual components of complex interventions and how they interact;determining the suitability of different interventions and intervention mixesfor different phases of the epidemic; achieving clarity about what is effec-tive “in the laboratory” and what is known about implementing effectiveinterventions in the real world; being able to more clearly define the contentof information, skills and services for different groups in different cul-tures; and knowing more about the “how” of interventions in addition tothe “what”.

This report provides one perspective on defining priorities for action, and theauthors hope that it will contribute to ongoing discussions and debates andwill be enriched by other methods of assessing the evidence. If we are toengage the people responsible for policies, programmes, and resource allo-cation in order to give young people the attention that they warrant and toaccelerate action for achieving the global goals, it will be necessary to make

11

92-4-120938-0_CH01_11

a compelling case for action, be clear about what needs to be done (based onthe evidence) and demonstrate that what needs to be done is doable on areasonable scale in a reasonably sustainable way. This report focuses partic-ularly on the first and second of these issues and has prepared the foundationsfor the third. The challenge for a report in 2015 will be to demonstrate thatwhat needs to be done, has be done.

References

1. WHO. Programming for adolescent health and development: report of a WHO/UNFPA/UNICEF study group. Geneva, WHO, 1999 (Technical Report SeriesNo. 886).

2. WHO. Action for adolescent health: towards a common agenda.Recommendations from a joint study group. Geneva, WHO, 1997.

3. Pathfinder International, Focus on Young Adults. Advancing young adultreproductive health: actions for the next decade, 2001 (http://www.pathfind.org/pf/pubs/focus/pubs/eop_report.pdf).

4. Family Health International. YouthNet: partners in reproductive health and HIVprevention, 2005 (http://www.fhi.org/en/Youth/YouthNet/About/index.htm).

5. African Youth Alliance. What is AYA?, 2005 (http://www.ayaonline.org/overview.htm).

6. EU/UNFPA Reproductive Health Initiative for Youth in Asia. What is RHIYA?,2006 (http://www.asia-initiative.org/rhiya_in_brief_what.html).

7. UNAIDS. The road towards universal access: scaling up access to HIVprevention, treatment, care and support, 2006 (http://data.unaids.org/pub/Periodical/2006/Universal_Access_bulletin_8_en.pdf?preview=true).

8. United Nations. What are the Millennium Development Goals?,(http://www.un.org/millenniumgoals/).

9. Global HIV Prevention Working Group. Global mobilization for HIV prevention,a blueprint for action, 2002 (http://www.kff.org/hivaids/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=14190).

10. UNAIDS. Intensifying HIV prevention: a UNAIDS policy position paper. Geneva,UNAIDS, 2005.

11. UNAIDS. Sex and youth: contextual factors affecting risk for HIV. Geneva,UNAIDS, 1999.

12. UNICEF, UNAIDS, WHO. Young people and HIV/AIDS – opportunity in crisis.New York, UNICEF, 2002.

13. UNAIDS, WHO. AIDS epidemic update: December 2005,(http://data.unaids.org/Publications/IRC-pub06/epi_update2005_en.pdf).

14. United Nations. Declaration of commitment on HIV/AIDS. United NationsGeneral Assembly Special Session on HIV/AIDS, 2001 (http://www.un.org/ga/aids/coverage/FinalDeclarationHIVAIDS.html).

15. United Nations. Key actions for the further implementation of the Programmeof Action of the International Conference on Population and Development:report of the Ad Hoc Committee of the Whole of the Twenty First SpecialSession of the General Assembly. New York, United Nations, 1999.

12

92-4-120938-0_CH01_12

16. United Nations. A world fit for children. United Nations Special Session onChildren, 2002 (http://www.unicef.org/specialsession/wffc).

17. WHO. “Steady, Ready, GO!”: an information brief on the global consultation toreview the evidence for policies and programmes to achieve the global goalson young people and HIV/AIDS, 2004 (http://www.who.int/child-adolescent-health/publications/ADH/IB_SRG.htm).

18. WHO. National AIDS programmes: a guide to indicators for monitoring andevaluating national HIV/AIDS prevention programmes for young people.Geneva, WHO, 2004.

13

92-4-120938-0_CH01_13

92-4-120938-0_CH01_14

2. Young people: the centre of the HIVepidemicRoeland Monascha & Mary Mahyb

Objectives This chapter reviews data on the situation of young people andHIV/AIDS. It assesses whether young people have access to the information,skills and services required to reduce their vulnerability and whether therehas been any reduction in HIV prevalence among 15—24-year-olds.

Methods We reviewed the data on knowledge, behaviour, life skills, accessto services and HIV prevalence among young people from nationally repre-sentative household surveys, antenatal care surveillance reports, behaviouralsurveillance surveys, a global coverage survey and other special studies.

Findings In countries where HIV is concentrated among sex workers, in-jecting drug users or men who have sex with men, high-risk behaviourcommences for most during adolescence, and large proportions of these high-risk populations are younger than 25 years. In countries with generalizedepidemics, the epidemic is also driven by young people. Half of all new in-fections in sub-Saharan Africa occur among this group. Many young peopledo not have the basic knowledge and skills to prevent themselves from be-coming infected with HIV. Young people continue to have insufficient accessto information, counselling, testing, condoms, harm-reduction strategies andtreatment and care for sexually transmitted infections. Other socioeconomicfactors beyond the control of individuals need to be addressed. Countries thathave reported a decline in HIV prevalence have recorded the biggest changesin behaviour and prevalence among younger age groups.

Conclusions The epidemic varies greatly in different regions of the world,but in each of these epidemics young people are at the centre, both in termsof new infections as well as being the greatest potential force for change ifthey can be reached with the right interventions.

a United Nations Children’s Fund, 6 Fairbridge Avenue, Belgravia, Harare, Zimbabwe.Correspondence should be sent to Dr Monasch (email: romonasch@unicef.org).

b UNICEF, New York, NY, USA.

15

92-4-120938-0_CH02_15

2.1 Introduction

Globally, an estimated 40 million people were living with HIV/AIDS at theend of 2005 (1). More than 10 million of them are young people aged 15–24years. Half of the 4.2 million new infections in adults in 2005 occurred in thisage group. Each day 5 000–6 000 new infections occur among young people.Sub-Saharan Africa contains almost two thirds of all young people living withHIV or AIDS (6.2 million); 76% of them are female (Figure 2.1). The regionwith the second highest prevalence is Asia, which has an estimated 2.2 millionyoung people who are living with the virus. The regions where young peopleaccount for the biggest share of the overall number of infections are easternEurope and Central Asia, where nearly half of adults living with HIV or AIDS(600 000/1.3 million) are younger than 25 years; most of them are male.

A clear understanding of the situation of young people and their needs isrequired to design and successfully implement interventions to stem the tideof infections among young people. Without this information, the scale of theresponse required and the focus and relative urgency of the interventionsremain unknown. Governments must strategically target their resources tointerventions that respond to the specific situation in each individual country.

This information also allows governments to measure how well they aremoving towards reaching the goals that have been agreed as being necessary

Figure 2.1Worldwide prevalence of HIV among young women and men aged 15–24 years. (Thesize of the pie chart indicates the size of the population affected)

70%30%

24%

76%

40%

60%

South and South East Asia1.8 million

High IncomeCountries188,000

68%

32%

Middle East & North Africa118,000

Central Asia and Eastern Europe

630,000

East Asia & Pacific351,000

Sub-Saharan Africa6.2 million

28%72%

38%62%

Latin America610,000

31% 69%

Caribbean125,000

29%71%

Source: UNAIDS, UNICEF 2004 (Updated from reference (70))

16

92-4-120938-0_CH02_16

to slow the epidemic and that were defined in the Millennium DevelopmentGoals. During the UN General Assembly Special Session on HIV/AIDS(UNGASS), 189 governments committed themselves to meeting specificgoals in the fight against the HIV/AIDS pandemic; these goals included spe-cific targets for young people (2). This paper reviews the data on the situationof young people in relation to the UNGASS goals and looks specifically atwhether young people have access to the information, skills and services thatthey need to reduce their vulnerability and whether there has been any re-duction in HIV prevalence among 15–24 year olds.

2.2 Data and methods

Data on knowledge, sexual behaviour and life skills among the general pop-ulation of young people were tabulated from nationally representative house-hold surveys, such as the Demographic and Health Surveys (3) and theMultiple Indicator Cluster Surveys (4). These surveys use similar methodsand instruments to ensure that data are comparable between survey roundsand between countries (5). Data on vulnerable groups with high risk be-haviour come mainly from Behavioral Surveillance Surveys and other specialstudies. Information on access to services comes from a 2003 coveragesurvey implemented by the Policy Project (6). HIV prevalence data are prin-cipally based on information from country surveillance reports and theepidemiological fact sheets available from UNAIDS, WHO and UNICEF(7). In addition, data were used from EuroHIV (8), which collects routinelyreported data from countries in Europe and Central Asia, but, because theyare based on HIV diagnoses reported through the health system, they maysubstantially underestimate the true population prevalence.

2.3 Types of epidemics

Young people are exposed to HIV infection in different ways depending onthe type of epidemic present in the country in which they live. In this section,the situation of young people living in countries with a low-level epidemic,a concentrated epidemic or a generalized epidemic is reviewed. In low-levelepidemics HIV may have been recorded for many years, but prevalence hasnever consistently exceeded 5% in any subpopulation. In concentrated epi-demics, HIV is well established in subpopulations with behaviours known toput them at high risk, such as injecting drug users, sex workers or men whohave sex with men. In concentrated epidemics, HIV prevalence consistentlyexceeds 5% in at least one of these groups, but there is no sign of substantialspread beyond these groups. Countries where HIV has spread to the generalpopulation – with more than 1% HIV prevalence among pregnant women –are said to have generalized epidemics (9). These exact values do not preciselydelineate where a concentrated epidemic ends and a generalized epidemic

17

92-4-120938-0_CH02_17

begins. However, these classifications are useful for understanding the trans-mission routes that drive epidemics and are critical for developing appropriateresponses.

2.3.1 Concentrated epidemics

2.3.1.1 Injecting drug users

Sharing needles and syringes with an infected person is the most efficientmeans of transmitting HIV. People who share injecting equipment are there-fore at high risk of contracting HIV. In eastern Europe and many Asiancountries, most of the reported HIV infections are linked to drug injecting.Data on known sources of infection in this region show that more than 55%are the result of intravenous drug use (Table 2.1). An estimated 60–70% ofreported HIV infections in China occur among injecting drug users (10). In-jecting drug users also often engage in other high-risk activities that exposethem and their partners to an increased risk of heterosexual transmission (1).

There has been a marked growth in the use of injected drugs in eastern Europesince 1990 (11). In the Russian Federation an estimated 1–2% of the adultpopulation injects drugs (12), and the use of injected drugs has become par-ticularly widespread among young people, especially young men. Accordingto the Ministry of Health in Russia, since 1991 the number of teenage drugusers has grown 18-fold. A survey of adolescents in Moscow found that 8%of young people overall, and 12% of young males, had injected drugs (13).

Data from a number of countries in eastern Europe and Asia confirm that drugabuse often begins during adolescence (14). A review of studies suggestedthat at least half of injecting drug users in Russia are aged 25 years or youngerand that on average they inject drugs for about 3–4 years. Most studies esti-mate that the average age at first use of injected drugs is between 18 and 20years, although some suggest that the average age at first use may be falling(14). In Saint Petersburg, Russia, almost one third of injecting drug users areyounger than 19 years. In Ukraine, 20% of injecting drug users are adoles-cents (15). In a study in five cities in India, 24% of respondents reported thatthey started injecting drugs before the age of 20 (16). In Indonesia, 70% ofinjecting drug users were younger than 25 years (17).

The combination of being an injecting drug user and being young potentiallyincreases the risk of becoming infected with HIV. For example, in Kaza-khstan, where 54% of injecting drug users are younger than 25, young peoplewere more likely to share needles and inject in a group than older drug users(18). Limited age-specific data on HIV infection among injecting drug usersshows that large proportions of young injecting drug users are infected. Inthe city of Togliatti in Russia, 65% of all injecting drug users were younger

18

92-4-120938-0_CH02_18

than 20, and 55% of injecting drug users aged 20–24 years were HIV positive(14). In Santos, Brazil, 56% of injecting drug users who were younger than25 years were HIV positive (19).

Data from Central Asia show that 48% of people diagnosed with HIV andsuspected of having become infected through the use of injected drugs wereaged 15–24 years. In eastern Europe, 40% of newly diagnosed HIV infectionsamong injecting drug users were estimated to occur among those aged 15–24 years. Young people in Belarus have been particularly affected: 60% ofthose living with HIV are aged between 15 and 24 years (20). In westernEurope this ratio is lower, but still significant at 19% (Table 2.1).

2.3.1.2 Sex workers

Sex workers are at an increased risk of HIV because they engage frequentlyin sexual acts with multiple partners; and their clients are also at an increasedrisk. HIV prevalence among female sex workers is therefore much higherthan among the general population. In Myanmar, HIV prevalence among sexworkers in 2004 was estimated to be 27% compared with 1.8% among preg-nant women (21). A study in Ghana found prevalences of HIV among sexworkers as high as 40% , while the prevalence among the general populationwas only 3% (22). And in Ecuador, sex workers had an HIV prevalence of11%, while among the general population it was estimated to be 0.3% (23).

Data from behavioural surveillance surveys of female sex workers show thata large majority are younger than 25 years of age. For example, in Cambodia

Table 2.1Percentage of HIV diagnoses among young people aged 15–24 years by risk group,Europe and Central Asia, 1993-2003

Risk group

Region Injectingdrug usersa

Homosexualor bisexual

Heterosexual Other Total

WesternEurope

19 (19 093) 10 (54 742) 13 (49 628) 10 (53 138) 12 (176 601)

CentralEurope

40 (5 740) 14 (2 033) 15 (2 977) 11 (10 355) 19 (21 105)

CentralAsia

48 (180 612) 21 (1 176) 33 (26 195) 52 (116 125) 48 (324 108)

Source: Data provided by EuroHIV 2004 (8)a Values are percentages (numbers) of infections. Percentages are weighted by the number of

infections in the region.

19

92-4-120938-0_CH02_19

(24), China (10), Lao People’s Democratic Republic (25), Myanmar (26), theRussia Federation (27) and Viet Nam (28), between 60% and 70% of sexworkers were younger than 25 years of age. Estimates of the absolute numberof young people involved in sex work are limited and range widely. In Thai-land it is estimated that between 27 500 and 35 000 children (younger than18) are engaged in sex work (29).

Sex work often starts at an early age. A rapid assessment in 74 establishmentsin four urban areas in Viet Nam found that 37% were children (< 18 years)at the time of the survey (30). In Jamaica, 50% of female sex workers reportedthat they had begun sex work by their 18th birthday (31). In Djibouti, 63%of female sex workers reported that they were younger than 20 when theyfirst had sex, with about 14% reporting that they were younger than 16 (32).

Evidence from surveys suggests that these young sex workers are at high riskof acquiring HIV. In Eritrea, a survey found that 12% of female sex workersaged 15–19 years and 24% of those aged 20–24 years were HIV positive(33). In Myanmar, 41% of female sex workers aged 15–19 years and 20–24years were HIV positive (34). However, evidence from Cambodia suggeststhat young sex workers may also benefit most rapidly from effective inter-ventions. Cambodia is one of the rare countries where HIV/AIDS preventionefforts have led to a decline in HIV prevalence among both high-risk groupsand the general population. HIV prevalence in Cambodia, while still thehighest in Asia, has dropped among the general population, from 3% in 1997to 1.9% in 2003, and among female brothel-based sex workers, from 43% in1998 to 21% in 2003 (35). HIV prevalences have declined most dramaticallyamong younger sex workers (36). A decline in prevalence among female sexworkers has also been reported in Benin and Côte d’Ivoire (37, 38).

Many clients of sex workers are also young. Data from behavioural surveysin India (39) and Nepal (40) show that between 17% and 70% of clients areyoung people, with the majority aged 20–24 years. In Kosovo, 18% of clientssurveyed were younger than 20 years, and 20% were aged 20–24 years (41).

Clients who are younger than 25 are more likely to use condoms consistently(an important factor in reducing the prevalence among sex workers) (42). Astudy in the Dominican Republic also found that men who were younger than25 were more likely to consistently use a condom compared with older men(43). The success of Thailand’s “100% condom” programme, which man-dated the use of condoms in brothels, has been well documented (44). Lesswell known is the success of the country’s efforts to alter long-establishednorms regarding male patronage of commercial sex businesses. Between1990 and 1993, the percentage of men who reported having visited brothelsduring the prior 12 months fell dramatically. The decline was especially no-table among young men aged 20–24 years (45).

20

92-4-120938-0_CH02_20

2.3.1.3 Men who have sex with men

Sexual transmission of HIV between men, which occurs principally duringanal sex, is an important factor driving the epidemic not only in the industri-alized world but also in a number of countries in Latin America and in somecountries in Asia. Men who have unprotected anal sex with other men are atincreased risk of HIV infection (46). In Argentina 14% of men who hadsex with men were HIV positive, and in El Salvador 18% of men who hadsex with men were HIV positive compared with 0.7% of the general popu-lation (47).

A substantial proportion of men who have sex with men are younger than 25.In behavioural studies among this group in five countries in Central America,carried out at places where men meet other men, such as gay bars, discos andother public areas, 20% of those surveyed were found to be younger than 20,and 34% were aged 20–24 years (48). In a study in Lima, Peru, conductedamong men who have sex with men 50% were younger than 25, and 18% ofthe men (of all ages) were HIV positive. In Central Asia and eastern Europe,14–20% of new diagnoses attributed to transmission by men having sex withmen have been reported to occur among young people aged 15–24 years; inwestern Europe this proportion was 10% (Table 2.1). Unfortunately, fewstudies have reported data disaggregated by age, which makes it difficult tocompare the behaviour of and prevalence among young men and older men.

Evidence from Cambodia suggests that young men who have sex with mentend to start having sex at an earlier age than young men who have sex withwomen. In Cambodia the reported mean age at first sexual intercourse was17.7 years among men having sex with men, whereas the average age amongthe general population of males in Cambodia was 22 years (49). Additionally,young people may be disproportionately represented among male sexworkers. In a study in Moscow, 40% of male commercial sex workers wereaged 19 years or younger, with another 45% being between the ages of 20and 24 (50).

2.3.1.4 Bridging to the general population

Transmission of HIV from groups with high prevalence to other groups islikely, and the future occurrence of a generalized epidemic in countries cur-rently experiencing concentrated epidemics cannot be ruled out (51). Youngpeople will be an important bridge between different population groups. Forexample, young injecting drug users are likely to be sexually active, whichmay put their partners at increased risk of HIV in addition to the risks posedby the high rates of sexually transmitted infections (STIs) and hepatitis thathave been documented among injecting drug users (52). In India, a survey ofinjecting drug users found that more than one quarter were currently married

21

92-4-120938-0_CH02_21

and living with their spouse (16). In a study in Cambodia, one fifth of menwho said they had had sex with men during the 6 months before the studyreported also having had sex with one or more women (49).

A study among male injecting drug users (63% of whom were younger than25) in three Indonesian cities found that 35% had had unprotected commercialsex and 29% had had sex with a casual female partner in the 12 months priorto the survey (53). In Russia a survey among young female sex workers foundthat 93% had injected drugs during the past 12 months, with the median ageat first use of injecting drugs being 18.7 years; one third of adolescent sexworkers were HIV positive. Altogether, 63% of the sex workers were aged20–24 years (54).

Mobile populations and migrants are important “bridging populations” thattake HIV to the general population (55). Studies on highly mobile groupshave identified travel and migration as important factors related to infectionas the mobile groups come into contact with networks of high-risk groups(56–58). For example, in Kenya a survey showed that men who slept awayfrom their house five or more times in the 12 months prior to the survey hadthree times the risk of being infected with HIV than did men who did notsleep away from home (59). In one community in Nepal, HIV prevalence was8 times higher among migrants than non-migrants (60). Young people areoften involved in migration because they have the most to gain economicallyby starting out in a new setting. A study in Myanmar found that the majorityof migrants were aged 14 to 18 years, and that most were migrating for eco-nomic reasons (61). In Estonia a survey found that 17% of young people (aged17–27 years) had already worked abroad (62).

2.3.2 Generalized epidemics

In generalized epidemics the main mode of HIV transmission is through pen-etrative heterosexual sex in the general population. Such epidemics arecurrently found mainly in sub-Saharan Africa and in some countries in theCaribbean. Generalized epidemics are also driven by young people: half ofall new infections in sub-Saharan Africa are estimated to occur among thosebetween the ages of 15 and 24 years (23). In sub-Saharan Africa HIV preva-lence varies considerably across the continent, ranging from less than 1% inSenegal to 40% in Swaziland (among young pregnant women aged 15–24years attending antenatal clinics). Although political instability in severalcountries in central Africa makes it difficult to assess their current situation,Cameroon may have the highest HIV prevalence levels in this subregion,reporting a median prevalence of 11.9% among pregnant women aged 15–24 years in 27 sentinel sites. HIV prevalence in western Africa varies from< 1% in countries in the Sahelian belt to 5–6% in Côte d’Ivoire and Nigeria.

22

92-4-120938-0_CH02_22

Southern Africa is the most seriously affected subregion. In Botswana,Lesotho, South Africa, Swaziland and Zambia, more than 20% of pregnantwomen aged 15–24 years attending antenatal clinics are HIV positive. Basedon data from women attending antenatal clinics in capital cities, the epidemicin eastern Africa seems to be slowly declining. However, the prevalenceof HIV infection in most urban antenatal clinics remains between 10% and15% (63).

A country that has seen well documented reductions in HIV prevalence isUganda. A declining HIV prevalence over the past 10 to 15 years has beenobserved, especially among young women aged 15–24 years attending ante-natal clinics. For example, at Nsambya hospital in Kampala, HIV infectionrates among women aged 15–19 years attending antenatal clinics declinedfrom 29% in 1991 to 9% in 1998 and further to 5% in 2002.

In generalized epidemics, HIV prevalence among young women is consid-erably higher than among young men. In 11 countries with nationally repre-sentative surveys of HIV prevalence, young women aged 15–24 years werebetween 1.3 times and 12 times more likely to be infected than young men(Figure 2.2). Adolescent girls are especially vulnerable to HIV infection.About two thirds of newly infected young people aged 15–19 years in sub-Saharan Africa are female (63).

Figure 2.2HIV prevalence among young men and women aged 15–24 years, selected countries,2001–2003

0

5

10

15

20

Do

min

ica

n

Re

pu

blic

20

02

Nig

er 2

00

2

Gh

an

a 2

00

3

Bu

rkin

a F

aso

20

03

Ma

li 20

01

Bu

run

di 2

00

2

Ta

nza

nia

20

03

Ke

nya

20

03

Za

mb

ia 2

00

1

So

uth

Afric

a

20

03

Zim

ba

bw

e 2

00

1

% H

IV-p

os

itiv

e

Male

Female

Source: Demographic and Health Surveys (3) and WHO Regional Office for Africa, 2002 (63)

23

92-4-120938-0_CH02_23

The social reasons why young women have higher HIV prevalence and in-cidence than young men include the fact that many women are younger,sometimes considerably younger, than their male sexual partners. Studiesfrom several countries show that the prevalence of HIV among young womenwho reported having had sex with older men is significantly higher than theprevalence among those who had sex only with partners their own age (64).In a survey among young women aged 15–19 in rural Zimbabwe, the risk ofHIV infection was significantly associated with the age of their most recentsexual partner. HIV prevalence among women aged 21–24 whose last partnerwas less than 5 years older than they were was 16%, whereas among youngwomen with partners 10 or more years older, the prevalence was twice ashigh (65). In Kisumu, Kenya, similar trends were found: no woman who wasyounger than 20 and was married to a man less than 4 years older than herselfwas infected with HIV compared with 38% of those who had husbands 10 ormore years older (66). Sexual relationships between young women and oldermen, whether inside marriage or outside, have the potential to drive the spreadof HIV in high-prevalence generalized epidemics.

Other STIs play a large part in the spread of HIV in many populations (67).For example, a study in South Africa showed that young men infected withherpes simplex virus–type 2 (HSV-2) were 5 times more likely to be HIVpositive than sexually active people who were not infected with HSV-2.Young women with HSV-2 were 8 times more likely to be infected with HIV(68). WHO estimates that more than 100 million STIs, excluding HIV, occureach year among people younger than 25 (69). Treatment of STIs has provento be an effective method of preventing HIV (see chapter 3).

In summary, it is clear that, although there are many different HIV epidemicsacross the world, young people are at their centre in all cases.

2.4 Progress towards UNGASS commitments

The previous section highlighted the fact that young people in low-level,concentrated and generalized epidemics represent a large proportion of thosebecoming infected. The Declaration of Commitment signed at the UNGASSdedicated governments to meeting specific goals to fight HIV/AIDS amongyoung people. They agreed to:

ensure that at least 95 per cent of young men and women aged 15 to 24 haveaccess to the information, education, including peer education and youth-specific HIV education, and services necessary to develop the life skillsrequired to reduce their vulnerability to HIV infection by 2010 (2).

This section reviews the response to these goals.

24

92-4-120938-0_CH02_24

2.4.1 Information

An important, but not sufficient, foundation for any prevention effort aimedat young people is to provide them with basic information on how to protectthemselves and their partners from acquiring the virus. Although significantprogress has been achieved during the past decade, surveys suggest that de-spite the fact that the majority of young people have heard of AIDS, manystill do not know how to prevent transmission. Furthermore, misconceptionsabout HIV and AIDS are widespread. They vary from one culture to another,and specific rumours gain credibility in some populations, both on how HIVis spread (by mosquito bites or witchcraft, for example) (70) and on how itcan be avoided (for example, by eating a certain fish or having sex with avirgin).

In 17 countries surveyed between 1999 and 2003, the average proportion ofyoung people aged 15–24 years deemed to have “sufficient knowledge” aboutHIV/AIDS was 24% among young women and 29% among young men (5)(Table 2.2). (Sufficient knowledge was defined as the percentage of youngmen and women aged 15–24 who both correctly identified two ways of pre-venting the sexual transmission of HIV and rejected three major misconcep-tions about HIV.)

These surveys showed that, in countries with generalized HIV epidemics,such as Burkina Faso, Haiti, Mozambique and Nigeria, more than 80% ofyoung women aged 15–24 still did not have sufficient knowledge about HIV.(Because the indicator has five components, one might not expect a score of100% even if knowledge levels were high.) The simple question “Can ahealthy looking person have the AIDS virus” has been asked of young womenin repeated surveys in more than 25 countries. The data generally show animprovement in knowledge in responses to this question in recent years (Fig-ure 2.3). The most seriously affected countries in southern Africa havereached levels where around 80% of participants respond correctly. However,in nearly all countries one fifth or more of young women in this age groupremain uncertain about the response to this question.

2.4.2 Education

HIV/AIDS information and life-skills education can be provided to youngpeople in a number of ways, including through peer education or counselling,community activities that include parents, and through the mass media andschool-based education programmes. Often, these interventions are dispersedacross many organizations and community groups and their effects are dif-ficult to measure and evaluate consistently. However, schools are a keysetting for providing information and teaching adolescents the life skills nec-essary to prevent HIV/AIDS; they have therefore been used as a proxy for

25

92-4-120938-0_CH02_25

Tab

le 2

.2K

no

wle

dg

e o

f H

IV/A

IDS

an

d s

exu

al b

ehav

iou

r am

on

g y

ou

ng

men

an

d w

om

en a

ged

15–

24 y

ears

fo

r se

lect

ed c

ou

ntr

ies,

199

9–20

03(3

, 4).

(V

alu

es a

re p

erce

nta

ges

)

Fem

ales

Mal

es

Co

un

trya

Kn

ow

that

ah

ealt

hy-

loo

kin

gp

erso

nca

n h

ave

AID

S

Co

mp

reh

ensi

veco

rrec

tkn

ow

led

ge

abo

ut

AID

S

Sex

bef

ore

age

15b

Hig

her

risk

sex

in t

he

last

year

Co

nd

om

use

d a

tla

sth

igh

erri

skse

x

Kn

ow

that

ah

ealt

hy-

loo

kin

gp

erso

nca

n h

ave

AID

S

Co

mp

reh

ensi

veco

rrec

tkn

ow

led

ge

abo

ut

AID

S

Sex

bef

ore

age

15b

Hig

her

risk

sex

in t

he

last

year

Co

nd

om

use

dat

last

hig

her

risk

sex

Eas

tern

an

d S

ou

ther

n A

fric

aB

otsw

ana

8140

NA

cN

A75

7933

NA

NA

88E

thio

pia

39N

A14

717

54N

A5

6430

Ken

ya83

3415

3025

8647

3184

47M

alaw

i84

3417

1732

8941

2971

38M

ozam

biqu

e65

20N

A37

2982

33N

A83

33N

amib

ia82

3110

8048

8741

3185

69R

wan

da64

233

1023

6920

NA

4255

Uni

ted

Rep

ublic

of T

anza

nia

7444

1036

4278

4911

8147

Uga

nda

7628

1422

4483

4016

5962

Zam

bia

7431

1830

3373

3327

8642

Zim

babw

e74

NA

320

4283

NA

682

69W

est

Afr

ica

Ben

in56

816

3619

6914

2490

34

26

92-4-120938-0_CH02_26

Bur

kina

Fas

o56

1521

2354

6123

1478

67G

hana

7838

750

3383

444

8352

Gui

nea

60N

A27

2317

56N

A20

9232

Mal

i46

926

1814

5915

1185

30N

iger

ia52

1820

2924

6521

878

46C

arib

bea

nD

omin

ican

Rep

ublic

92N

A13

2929

89N

A18

8352

Hai

ti68

1512

5919

7828

2893

30C

om

mo

nw

ealt

h o

f In

dep

end

ent

Sta

tes

Arm

enia

537

10

NA

488

169

44K

azak

hsta

n63

NA

127

3273

NA

678

65U

zbek

ista

n55

80

1N

A58

7N

A45

50W

eig

hte

dav

erag

e67

2312

2833

7329

1677

49

aC

ount

ries

incl

uded

in th

is ta

ble

are

only

thos

e fo

r w

hich

ther

e ar

e da

ta b

oth

for

fem

ales

and

mal

es a

nd d

ata

colle

cted

with

in th

e pa

st 5

yea

rs.

b A

mon

g yo

ung

peop

le a

ged

15–1

9 ye

ars.

c NA

= n

ot a

vaila

ble.

27

92-4-120938-0_CH02_27

educational prevention efforts in some countries. For example, 57% of ado-lescent boys in Zimbabwe reported that their only source of sex education onHIV/AIDS was school (71). In many countries, especially in west Africa andsome parts of Asia, large proportions of children do not attend school (72).

The region where general HIV prevention through school is likely to havethe most impact is sub-Saharan Africa. In 2003, 36 countries in sub-SaharanAfrica had a generalized epidemic; 30 of these countries reported to the globalcoverage survey on selected services for HIV/AIDS prevention, care andsupport; and 11 of these indicated that AIDS education was not part of theircurriculum in primary school (6). Additionally, in six countries, AIDS edu-cation was not part of the curriculum in secondary school. Overall it wasestimated that only 58% of primary school students and 64% of secondaryschool students were exposed to AIDS-related education through the educa-tion system in sub-Saharan Africa. These numbers are likely to overestimatethe proportion of students receiving effective AIDS-related education sincemany teachers either have not learnt the appropriate skills or do not feel com-fortable teaching topics related to HIV/AIDS and sexuality (73, 74) (seechapter 5). Furthermore, the quality of the interventions is also an issue. In astudy among students in South Africa, less than one quarter of the respondents

Figure 2.3Proportion of young women aged 15–24 years who know that a healthy lookingperson can have the AIDS virus, by region with data from early-to-mid 1990scompared with data from early 2000 (3, 4)

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Period: early/mid 1990s

Pe

rio

d:

ea

rly

20

00

s

West AfricaEastern & Southern AfricaLatin America & CaribbeanAsiaEastern Europe

Increased

Decreased

Y=X, no change in

knowledge level

28

92-4-120938-0_CH02_28

recalled having discussed all eight core life-skills topics of the curriculumduring their last year of school (75).

2.4.3 Services

Providing access to youth-friendly health services is an integral part of anynational prevention programme. The main services necessary to prevent HIVand other STIs include providing access to information, condoms and harmreduction (where injecting drug use is prevalent) and access to diagnosis(testing), treatment and care for STIs and HIV/AIDS. Access to services re-mains insufficient (76). In most countries, young people’s access to effectivehealth services is lower than older people’s, and this is particularly true foradolescents (70). The types of interventions that have been used in developingcountries to try to improve young people’s access to health services, and theireffectiveness, are described in chapter 6.

2.4.3.1 Condoms

Globally, the number of condoms available has increased (6). However theavailability of condoms does not ensure that condoms are used. In addition,there are still significant proportions of young men in countries with gener-alized epidemics who do not know where to obtain condoms (Figure 2.4).

Figure 2.4Proportion of young people who knew where to obtain condoms, by age group,selected countries in sub-Saharan Africa, 1999–2004 (3)

0

10

20

30

40

50

60

70

80

90

100

Gh

an

a (2

00

3)

Ke

ny

a (2

00

3)

Ma

law

i (20

00

)

Na

mib

ia (2

00

0)

Ta

nza

nia

(20

03

-04

)

Za

mb

ia (2

00

1-0

2)

Zim

ba

bw

e (1

99

9)

% k

no

w a

so

urc

e

15-19 years

20-24 years

29

92-4-120938-0_CH02_29

2.4.3.2 Voluntary counselling and testing

As antiretroviral therapy becomes more widely available, the demand forcounselling and testing will increase. In order for young people to use testingservices they need to have access to such services. Many different factorsaffect access, but knowing where testing and counselling are offered is clearlyan essential first step. Surveys have shown that many young people do notknow where to obtain these services. In 25 of 39 countries surveyed, less than50% of young women aged 15–24 knew where they could go to be tested forHIV. Women with higher levels of education were more likely to know wherethey could go (77).

2.4.3.3 STI treatment

Adolescents are less likely to seek treatment for STIs than people aged 20–24 and older adults, despite having higher rates of STIs and the strong asso-ciation between STIs and HIV (Figure 2.5). Even when adolescents suspectthat they have an infection, they often do not seek medical care because theymay be too embarrassed or feel too guilty or fear that their privacy will notbe respected. Additionally, services may be inaccessible because clinics arefar away or have limited or inconvenient opening hours (78). Health providers

Figure 2.5Proportion of women who reported having a sexually transmitted infection withinthe past 12 months and sought treatment for it, by age group for selected countries,1999–2003 (3)

0

10

20

30

40

50

60

70

80

90

100

Bu

rkin

a F

aso

(20

03

)

Gh

an

a (2

00

3)

Gu

ine

a (1

99

9)

Ma

law

i (20

00

)

Ma

li (20

01

)

Mo

za

mb

iqu

e (2

00

3)

Ug

an

da

(20

01

)

Za

mb

ia (2

00

2)

Arm

en

ia (2

00

0)

Do

min

ica

n

Re

pu

blic

(20

02

)

Ha

iti (20

00

)

Pe

ru (2

00

0)

% s

ee

kin

g t

rea

tme

nt

15-19

20-24

25-49

30

92-4-120938-0_CH02_30

may be reluctant to serve adolescents, and when services are located in ma-ternal and child health centres, they are unlikely to be used by young men (70).

2.4.3.4 Harm reduction for injecting drug users

Among the six countries in eastern Europe that reported to the global coveragesurvey in 2003 on the number of injecting drug users that received needle andsyringe exchange services, it is estimated that 70 000 of an estimated 2.5million injecting drug users (2.8%) were reached (6). In the Middle East,north Africa, and south-east Asia, it was estimated that 4–5% of injectingdrug users were reached with harm reduction services. All other regions hadlower coverage. Although the information was not disaggregated by age, wecan assume from these numbers that the majority of young people are notbeing reached. While there is relatively little information available about theutilization of health services by the general population of young people,data are more scarce on the extent to which services reach vulnerable youngpeople engaged in behaviours that put them at high risk of acquiring HIV(see chapter 9).

2.4.3.5 Special services for sex workers and men who have sex with men

In 2003, global access to prevention interventions for men who have sex withmen was reported to be 11%, and for sex workers it was reported to be 16%(6). The region with the highest coverage for both of these high-risk groupswas Latin America and the Caribbean, where 31% of men who have sex withmen and 25% of sex workers were estimated to be reached. Again, no infor-mation had been disaggregated by age, but since many sex workers and menwho have sex with men are aged 15–24 (see above), we can assume that themajority of young people in these two high-risk groups are not being reached.

2.4.4 Life skills

Information, education, and access to services should contribute to the de-velopment of life skills that can help reduce a young person’s vulnerabilityto HIV infection. However, there is no standardized internationally compa-rable method for assessing directly whether young people have developedsufficient adaptive and positive behaviours to enable them to deal effectivelywith the demands of everyday life (79). As a proxy indicator, “reported be-haviours” can be used (5). The assumption is that regardless of high levels ofknowledge about prevention strategies, young people may engage in unpro-tected sex because they lack the skills to negotiate abstinence, reduce thenumber of partners that they have or use condoms. If young peoplepossess adequate life skills, levels of risky behaviour should be lower. (This

31

92-4-120938-0_CH02_31

assumption obviously ignores the fact that certain risk behaviours may bebeyond the control of the individual, such as forced sex.)

Young people may be fearful or embarrassed to talk with a partner about sexor may simply not be aware of their individual risk. Data from Demographicand Health Surveys in Burkina Faso, Nigeria and the United Republic ofTanzania showed that the proportion of young unmarried boys who reportedthey did not use a condom at last sexual intercourse was substantial. Themajority who did not use a condom felt that they were not at risk. In Nigeria,93% of men aged 15–24 years perceived their risk of getting AIDS to beminimal or non-existent; in Burkina Faso the figure was 77% and in theUnited Republic of Tanzania the proportion was 53%.

2.4.4.1 Age at first sex

Delaying the age at which young people first engage in sexual intercoursecan protect them from infection. Adolescents who begin sexual activity earlyare at a higher risk of becoming infected with HIV; research in differentcountries has shown that adolescents who start sexual activity early are morelikely to have sex with high-risk partners or multiple partners and are lesslikely to use condoms (80, 81). Sexual activity begins in adolescence for themajority of people, and in some countries it starts for young women beforethey are 15 years old. Table 2.2 shows that in the 20 countries for which thereare recent data, in 10 countries more than 1 in 7 girls aged 15–19 reportedhaving had sex before the age of 15. Among young men aged 15–19 years inHaiti, Kenya, Malawi, Namibia and Zambia, more than one quarter reportedhaving had sex before they were 15 years old.

2.4.4.2 Condom use

When young people become sexually active, they must have the skills topractise safe sex. This means either being faithful to one faithful partneror consistently using a condom properly. Data from household surveysshow that the proportion of young people using condoms is still quite loweven when they have sex with people who are not their regular partner(Table 2.2). In Malawi, where 1 out of 6 people aged 15–49 is infected withHIV, only 32% of young women and 38% of young men reported using acondom the last time they had had sex with a non-cohabiting partner. In manycountries, the reported use of a condom is higher among young men thanyoung women. In Zimbabwe, for example, where approximately one quarterof all people are infected, 69% of young men aged 15–24 years reported usinga condom during their last episode of sex with a high-risk partner while only42% of young women reported using a condom during their last episode ofsex with a high-risk partner.

32

92-4-120938-0_CH02_32

2.4.5 Vulnerability

A person’s ability to avoid HIV infection depends only partly on their ownindividual knowledge and skills. There are other social and economic factorsthat are beyond the individual’s control and that can put young people athigher or lower risk of infection (82). Such factors include social norms, thestatus of women in society and the socioeconomic environment (83). Thesecontextual factors often result in young people having less power to reducetheir risk of HIV than adults.

2.4.5.1 Social norms

There are norms and values in communities that increase or reduce the riskof HIV infection. Parents and other family members have an important rolein providing information and skills to their children. However, open com-munication about sexuality remains a challenge in many cultures and soci-eties. Boys and girls may be embarrassed to discuss issues related to sex;parents may be unwilling to talk about sex or be uncomfortable doing so, bothof which may result in young people having limited knowledge and skillsabout prevention. Demographic and Health Surveys have asked men andwomen whether they feel that children aged 12–14 years should be taughtabout using a condom to avoid AIDS. Out of five countries surveyed in east-ern and southern Africa, the proportion of respondents who agreed thatchildren should be taught this skill varied from just over 40% among men inUganda to over 80% among women in Namibia.

Among men having sex with men, social taboos and stigma may increasetheir risks of contracting HIV. These men may hide their sexuality and con-sequently not have access to the information or support that they need toreduce risky behaviour.

2.4.5.2 Gender inequality

When the status of women within sexual relationships is low they are at anincreased risk of contracting HIV (82, 84). For example, for many girls andyoung women the onset of sexual activity does not occur by choice. In Ja-maica 12% of young women aged 15–19 and 10% of this group in SouthAfrica reported they were unwilling or coerced during their first sexual ex-perience (81, 85). In a study among secondary school students in Swaziland,18% of female students reported being coerced during their first sexual en-counter (86). In Zambia, 1 in 8 young women aged 15–19 years reportedhaving been forced to have sex by a man in the 12 months prior to a generalpopulation-based survey (87). In Zimbabwe, more than 1 in 5 women aged15–29 years reported ever having been forced to have sex by a man (71).In many societies people turn a blind eye to sexual abuse against young

33

92-4-120938-0_CH02_33

women, and to gender-based violence more generally, both of which haveimportant implications for HIV transmission.

2.4.5.3 Socioeconomic environment

The socioeconomic situation in which young people live can have both pos-itive and negative impacts on their vulnerability to HIV infection. Forexample, in the United Republic of Tanzania young women aged 15–24 yearsin the highest wealth quintile were more likely to engage in higher risk sexualactivities (such as having sex with a non-marital non-cohabiting partner) thanwomen in the lowest quintile (48% in the highest quintile versus 30% in thelowest quintile). To a large extent this can be explained by the fact that womenin the lowest quintile were more likely to be married. However, the youngwomen in the highest income quintile were more than twice as likely to haveused a condom during their last episode of higher risk sexual activity than theyoung women in the lowest quintile (58% highest quintile versus 23% lowestquintile) (88). Lower socioeconomic status may result in lower educationalattainment, which may result in gaining less information and skills to protectoneself from HIV (89). Lower socioeconomic status may also provide a rea-son for engaging in sexual relationships in exchange for financial compen-sation or support.

Young people with lower socioeconomic status have been reported to expe-rience more physical abuse and sexual coercion within relationships (82). Anincreasing number of young people who do not grow up in a protective en-vironment in which they have parental support, as a result of adult mortalityfrom AIDS, may be increasingly vulnerable to infection. A study in ruralZimbabwe found that among women aged 15–18 years, young people whosemother had died and young women with an infected parent had a significantlyhigher prevalence of HIV than other young women, and they also had moreSTI symptoms and were more likely to become pregnant (90).

Another example of a socioeconomic situation that is inherently unsafe foryoung people, provides no protection for them and puts them at an increasedrisk of HIV, is people trafficking. Children are increasingly being taken fromtheir usual environments by means of threat, force or other abuses of powerfor the purpose of sexual exploitation. Studies commissioned by the Interna-tional Labour Organization in eastern Europe, Asia and west Africa foundthat most young people involved in prostitution have been forced into thework (91–93).

2.5 Limitations of the data

Most surveys of young people are targeted at those aged 15 years and older.In many situations, however, a significant proportion of 15-year-olds have

34

92-4-120938-0_CH02_34

already begun to have sex or are involved in other risky behaviours. There isa need to collect systematically more data from younger adolescents – thatis, those aged 10–14 years. However, there remains uncertainty about theappropriateness of questions, the reliability of responses, parental consentand other ethical issues (6). These will need to be addressed before data fromthis age group will be improved.

Most research among injecting drug users, sex workers and men who havesex with men, analyse data using an epidemiological lens and do not considerthe data in terms of HIV prevention programmes. As a result data in reportsare rarely disaggregated by the age and sex of the respondent for groups athigh risk of becoming infected with HIV. For example, 16-year-old girls whoinject drugs and are involved in sex work are likely to have different needsand require a different response from a prevention programme than olderinjecting drug users who have been injecting for a long time. BehavioralSurveillance Surveys need to be analysed with a stronger focus on their im-plications for programmes.

A number of the tables and figures in this chapter compare two variables, forexample age and knowledge or behaviour. The analysis has been madewithout controlling for other variables, such as household wealth or the par-ticipant’s education level. A regression analysis would clarify whether dif-ferences are related to the age of the participant or to other variables that mightalso affect knowledge or behaviour, but it was not possible to conduct suchan analysis for this broad review of HIV among young people. The findingsin this chapter suggest areas in which further research and analysis are needed.

2.6 Conclusions

This chapter shows that young people are at the centre of the global AIDSepidemic, both in terms of new infections and opportunities for halting thetransmission of HIV. The epidemic varies greatly among the different regionsof the world, but in each of these epidemics young people are potentially thegreatest force for change if they can be reached with the right interventions(as outlined in the UNGASS goals). There is increasing evidence from severalcountries that where HIV prevalence is decreasing it is young people who arereversing the trends. Young people are much more likely to adopt and main-tain safe behaviours, and it is therefore important to implement interventionsearly.

While there have been a number of efforts to scale-up interventions aimed atyoung people, large numbers of young people continue to lack the basic in-formation and skills they need to protect themselves. The majority of youngpeople start sexual activity during adolescence, and this review suggests thatin all regions large proportions of young people still know little about HIV

35

92-4-120938-0_CH02_35

transmission and prevention; they continue to have serious misconceptions;and access to effective health services, such as treatment for STIs and vol-untary counselling and testing, remains inadequate.

Given that about half of all new infections occur among those aged 15–24,and that young people account for a substantial proportion of the groups whoare at particularly high risk of acquiring HIV – such as injecting drug users,sex workers and men who have sex with men – there is a clear need to focusprevention activities on these behaviours and the populations that engage inthem and to ensure that those interventions for which there is strong evidenceof effectiveness are rapidly and intensively scaled-up. Efforts to increaseyoung people’s knowledge, life skills and access to services need to be in-tensified. These efforts must consider the different needs of young men andyoung women and the different age groups among those aged 10–24 years.In addition, societal–contextual issues should be addressed to ensure thatyoung people grow up in a safe and protective environment that reduces theirvulnerability.

Each year new cohorts will be added to the large numbers of young men andwomen (115 million) (94) reaching the stage in their life where they will needto be prepared and supported to make the right choices in order to minimizetheir risk of HIV infection and thus turn the epidemic around. Without thisfocus on young people, the global HIV-related goals that have been agreedby 189 nations are not likely to be met, and the number of new infectionscould even increase before 2010.

References

1. UNAIDS. AIDS epidemic update 2005. Geneva, UNAIDS, WHO, 2005.

2. United Nations. Declaration of commitment on HIV/AIDS. United NationsGeneral Assembly Special Session on HIV/AIDS, 2001 (available athttp://www.un.org/ga/aids/coverage/FinalDeclarationHIVAIDS.html).

3. Demographic and Health Surveys. Tools (http://www.measuredhs.com/accesssurveys/tools.cfm).

4. UNICEF. End decade assessment: multiple indicator cluster survey,(http://www.childinfo.org/MICS2/Gj99306m.htm).

5. UNAIDS, UNICEF, WHO. National AIDS programmes: a guide to indicators formonitoring and evaluating national HIV/AIDS prevention programmes for youngpeople. Geneva, UNAIDS, 2004.

6. USAID, UNAIDS, WHO, UNICEF, Policy Project. Coverage of selected servicesfor HIV/AIDS prevention, care and support in low and middle income countriesin 2003. Washington, DC, Policy Project, 2004.

7. WHO. Global health atlas, 2004 (http://www.who.int/GlobalAtlas/predefinedReports/EFS2004/index.asp).

8. EuroHIV. HIV/AIDS surveillance in Europe, (http://www.eurohiv.org/).

36

92-4-120938-0_CH02_36

9. UNAIDS/WHO. Second generation surveillance for HIV: the next decade.Geneva, UNAIDS, 2000.

10. Kong-lai Zhang, Shao-Jun Ma. Epidemiology of HIV in China: intravenous drugusers, sex workers, and large mobile populations are high risk groups. BMJ,2002, 324:803-804.

11. Dehne K et al. The HIV/AIDS epidemic in eastern Europe: recent patterns andtrends and their implications for policy-making. AIDS 1999, 13:741-749.

12. Dehne K, Kobyshcha Y. The HIV epidemic in central and eastern Europe:update 2000. Geneva, UNAIDS, 2000.

13. Médecins Sans Frontières. Knowledge and attitude of ‘safe sex’ in Moscow.Moscow, MSF, 2000.

14. Rhodes T et al. Review: HIV transmission and HIV prevention associated withinjecting drug use in the Russian Federation. International Journal of DrugPolicy, 2004, 15:1-16.

15. Kelly JA, Amirkhanian YA. The newest epidemic: a review of HIV/AIDS incentral and eastern Europe. International Journal of STD and AIDS, 2003,14:361-371.

16. National AIDS Control Organisation. National baseline high risk and bridgepopulation behavioural surveillance survey (2002) report. Part II: men who havesex with men and injecting drug users. New Delhi, Ministry of Health and FamilyWelfare, Government of India, 2002.

17. Indonesia Ministry of Health and Central Bureau of Statistics. Behaviouralsurveillance in 13 provinces 2002-2003. Jakarta, Ministry of Health, 2004.

18. Zhusupov B, Behavioural surveillance among injecting drug users in nine citiesof Kazakhstan (Almaty, Pavllodar, Shymkent, Karaganda, Temiirtau, Astana,Petropavllovsk, Urallsk, Ust Kamenogorsk) within the framework of HIVepidemiological surveillance. Almaty, Center on Research of Public Opinion(CRPO), 2002.

19. Mesquita F et al. Trends of HIV infection among injection drug users in Brazilin the 1990s: the impact of changes in patterns of drug use. Journal of AcquiredImmune Deficiency Syndromes, 2001, 28:298-302.

20. UNAIDS. HIV/AIDS Belarus epidemic update. Minsk, UNAIDS, 2000.

21. Myanmar AIDS Prevention and Control Project, Department of Health. Sentinelsurveillance data for March-April 2004. Yangon, AIDS Prevention and ControlProject, 2004.

22. Asamoah-Adu C et al. HIV infection among sex workers in Accra: need to targetnew recruits entering the trade. Journal of Acquired Immune DeficiencySyndromes, 2001, 28:358-366.

23. UNAIDS. 2004 report on the global HIV/AIDS epidemic: 4th global report.Geneva, UNAIDS, 2004.

24. Cambodia, National Center for HIV/AIDS, Dermatology and STIs (NCHADS).HIV sentinel surveillance in Cambodia. Phnom Penh, NCHADS, 2002.(Unpublished report.)

25. Lao People’s Democratic Republic, National Committee for the Control of AIDSBureau, , Family Health International. Behavioral surveillance survey in LaoPeople’s Democratic Republic, 2000-2001. Lao PDR; 2003.

37

92-4-120938-0_CH02_37

26. Myanmar AIDS Prevention and Control Project, Department of Health. Sentinelsurveillance data for March-April 2000, Yangon, AIDS Prevention and ControlProject, 2000.

27. Population Services International Russia. Study of sexual behavior amongfemale commercial sex works in Saratov Oblast. Moscow, Population ServicesInternational, 2000.

28. Viet Nam, National AIDS Standing Bureau, Family Health International. HIV/AIDS behavioral surveillance survey in Vietnam, 2000. Hanoi, National AIDSStanding Bureau, 2001.

29. Steinfatt T. Working at the bars: sex work and health communication inThailand. New Haven, CT, Greenwood, 2002.

30. Duong LB. Children in prostitution in Hanoi, Hai Phong, Ho Chi Minh City andCan Tho: a rapid assessment. Bangkok, International Labour Organization,International Programme on the Elimination of Child Labour, 2002.

31. Family Health international. HIV/AIDS behavioral surveillance survey Jamaica1999-2000: female sex workers. Kingston, IMPACT/FHI/UNAIDS, 2002.

32. Michael T, Ahmed M, Lemma W. HIV/AIDS behavioral surveillance survey(BSS): round one. Djibouti, Ministry of Health, 2003. (Draft report.)

33. Eritrea Ministry of Health, CTMRE Consultancy Service. HIV/AIDS risk groupsand risk behaviours identification survey. Eritrea, Ministry of Health, CTMREConsultancy Service, 2001.

34. Myanmar AIDS Prevention and Control Project, Department of Health. Sentinelsurveillance data for 1989-2003. Yangon, AIDS Prevention and Control Project,2004

35. Cambodia, National Center for HIV/AIDS, Dermatology and STIs (NCHADS).HIV sentinel surveillance (HSS) 2003: trends results, and estimates. PhnomPenh, NCHADS, 2004.

36. Cambodia, National Center for HIV/AIDS, Dermatology and STDs. CambodiaHIV sentinel surveillance 2000. Phom Penh, NCHADS, 2000.

37. Alary M et al. Decline in the prevalence of HIV and sexually transmitted diseasesamong female sex workers in Cotonou, Benin, 1993-1999. AIDS, 2002,16:463-470.

38. Ghys PD et al. Increase in condom use and decline in HIV and sexuallytransmitted diseases among female sex workers in Abidjan, Cote d’Ivoire.AIDS, 2003, 17:1691-1694.

39. National AIDS Control Organisation. National baseline high risk and bridgepopulation behavioural surveillance survey (2001) report. Part I: female sexworkers and their clients. New Delhi, Ministry of Health and Family Welfare,Government of India, 2002.

40. Family Health international. Behavioral surveillance survey of female sexworkers and clients in Kathmandu valley: round 1. Kathmandu, 2003.

41. Population Services International. The study of knowledge, attitude andpractices related to HIV/AIDS and antenatal care. Kosovo, PSI, 2001.

42. Alary M, Lowndes CM. The central role of clients of female sex workers in thedynamics of heterosexual HIV transmission in sub-Saharan Africa. AIDS, 2004,18:945-947.

38

92-4-120938-0_CH02_38

43. Kerrigan D et al. Environmental-structural factors significantly associated withconsistent condom use among female sex workers in the Dominican Republic.AIDS, 2003, 17:415-423.

44. AIDS Division, Department of Communicable Disease Control, Thailand. 2002report on HIV/AIDS and STI in Thailand. Bangkok, Ministry of Public Health,2003.

45. Thongthai V, Guest P. Thai sexual attitudes and behaviour: results from a recentnational survey. Canberra, Australian National University, 1995. (Unpublisheddata presented at conference on Gender and sexuality in modern Thailand.)

46. UNAIDS. AIDS and men who have sex with men: UNAIDS points of view.Geneva, UNAIDS, 1998.

47. De los Angeles Pando M et al. High human immunodeficiency virus type 1seroprevalence in men who have sex with men in Buenos Aires, Argentina: riskfactors for infection. Journal of Epidemiology, 2003, 32:735-740.

48. Latin American Institute of Prevention and Education in Health. Baseline studyfor condom use promotion in Central American cities. Washington, DC,Population Services International, 1997.

49. Girault P et al. Sexual behaviour, STIs and HIV among men who have sex withmen in Phnom Penh, Cambodia 2000. Phnom Penh, Family HealthInternational, 2002.

50. Population Services International. The study of sexual behaviour of maleCSW’s in Moscow. Moscow, PSI Russia, 1999.

51. Wiessing L, Kretzschmar M. Can HIV epidemics among IDUs ‘trigger’ ageneralised epidemic? International Journal of Drug Policy, 2003, 14:99-102.

52. Kelly JA, Amirkhanian YA. The newest epidemic: a review of HIV/AIDS incentral and eastern Europe. International Journal of STD and AIDS, 2003,14:361-371.

53. Pisani E et al. Sexual behavior among injection drug users in 3 Indonesian citiescarries a high potential for HIV spread to non-injectors. Journal of AcquiredImmune Deficiency Syndromes, 2003, 34:403-406.

54. Smolskaya T et al. Sentinel sero-epidemiological and behavioural surveillanceamong female sex workers. St Petersburg, Russian Federation, St PetersburgPasteur Institute, 2003.

55. UNAIDS. Population mobility and AIDS: UNAIDS technical update. Geneva,UNAIDS, 2001.

56. UNDP, South East Asia HIV and Development Programme. The impacts ofmapping assessments on population movement and HIV vulnerability in SouthEast Asia. Bangkok, UNOPS,UNDP, 2001.

57. Lurie MN et al. Who infects whom? HIV-1 concordance and discordance amongmigrant and non-migrant couples in South Africa. AIDS, 2003, 17:2245-2252.

58. Lydie N et al. Mobility, sexual behavior, and HIV Infection in an urban populationin Cameroon. Journal of Acquired Immune Deficiency Syndromes, 2004,35:67-74.

59. Kenya Central Bureau of Statistics, Ministry of Health and ORC Macro. Kenyademographic and health survey 2003. Calverton, MD, ORC Macro, 2004.

39

92-4-120938-0_CH02_39

60. New ERA/ STD/AIDS Counseling and Training Service, Family HealthInternational. HIV/STD prevalence and risk factors among migrant and non-migrant males of Achham District in far-western Nepal. Kathmandu, New ERA/SACTS, FHI, 2002.

61. Dorning K. Reducing migration among young people, 2005 (http://tilz.tearfund.org/Publications/Footsteps+51-60/Footsteps+55/Reducing+migration+among+young+people.htm). (Tearfund International LearningZone.)

62. Kruusvall J, Tomson L. [Estonian youth on the way to the European Union].Tallinn, Estonia, Estonian Youth Institute and Department of Sociology, TallinnPedagogical University, 2004. (In Estonian.)

63. WHO Regional Office for Africa. HIV/AIDS epidemiological surveillance updatefor the WHO African Region: 2002. Harare, WHO Regional Office for Africa,2003.

64. Kelly RJ et al. Age differences in sexual partners and risk of HIV-1 infection inrural Uganda. Journal of Acquired Immune Deficiency Syndromes, 2003,32:446-451.

65. Gregson S et al. Sexual mixing patterns and sex-differentials in teenageexposure to HIV infection in rural Zimbabwe. Lancet, 2002, 359:1896-1903.

66. Glynn J, Caraël M, Auvert B. Why do young women have a much higherprevalence of HIV than young men? A study in Kisumu, Kenya, and Ndola,Zambia. AIDS 2001, 15 Supplement 4: S51-60.

67. Weiss HA et al. The epidemiology of HSV-2 infection and its association withHIV infection in four urban African populations. AIDS, 2001, 15 Suppl 4:S97-108

68. Auvert B et al. HIV infection among youth in a South African mining town isassociated with herpes simplex virus-2 seropositivity and sexual behaviour.AIDS, 2001, 15:885-898.

69. WHO. Global prevalence and incidence of selected curable sexuallytransmitted diseases: overview and estimates. Geneva, WHO, 2001.

70. UNICEF, UNAIDS, WHO. Young people and HIV/AIDS – opportunity in crisis.New York, UNICEF, 2002.

71. Ministry of Health and Child Welfare, Zimbabwe. The Zimbabwe young adultsurvey, 2001-2002. Harare, Ministry of Health and Child Welfare, 2004.

72. UNICEF. The state of the world’s children 2005. New York, UNICEF, 2004.

73. Schenker II. Nyirenda JM. Preventing HIV/AIDS in schools. Paris, UNESCO,2002. (Education Practices Series – 9.)

74. Chen J, Zhao D, Dunne MP. HIV/AIDS prevention: knowledge, attitudes andeducation practices of secondary school health personnel in 14 cities of China.Asia Pacific Journal of Public Health, 2004, 16:9-14.

75. Rutenberg N et al. Transitions to adulthood in the context of AIDS in SouthAfrica: report of wave I. Washington, DC, Population Council, 2001.

76. WHO, UNAIDS, UNFPA, UNODC, YouthNet. Protecting young people fromHIV/AIDS: the role of health services. Geneva, WHO, 2004.

77. UNICEF. Girls, HIV/AIDS and education. New York, UNICEF, 2004.

40

92-4-120938-0_CH02_40

78. UNAIDS. HIV voluntary counseling and testing: gateway to prevention and care.Five case studies related to prevention of mother-to-child transmission of HIV,tuberculosis, young people, and reaching general population groups. Geneva,UNAIDS, 2002.

79. WHO. Skills for health. Skills-based health education including life skills: animportant component of a child-friendly/health-promoting school. Geneva,WHO, 2003. (WHO Information Series on School Health No. 9.)

80. Pettifor AE et al. Early age of first sex: a risk factor for HIV infection amongwomen in Zimbabwe. AIDS, 2004, 18:1435-1442.

81. Manzini N. Sexual initiation and childbearing among adolescent girls inKwaZulu Natal, South Africa. Reproductive Health Matters, 2001, 9:44-52.

82. Eaton L, Flisher AJ, Aaro LE. Unsafe sexual behaviour in South African youth.Social Science and Medicine, 2003, 56:149-165.

83. The World Bank. Confronting AIDS: public priorities in a global epidemic.Revised edition. Washington, DC, World Bank, 1999.

84. Ng’weshemi J et al. HIV prevention and AIDS care in Africa: a district levelapproach. Amsterdam, Royal Tropical Institute, 1997.

85. Hope Enterprises. Report of the adolescent condom survey Jamaica, 2001.Kingston, , Hope Enterprises, 2001.

86. Buseh AG. Patterns of sexual behaviour among secondary school students inSwaziland, southern Africa. Culture, Health and Sexuality, 2004, 4:355-367.

87. Central Statistical Office, Zambia. Zambia Demographic and Health Survey2001-2002. Calverton, MD, Central Statistical Office, Central Board of Health,ORC Macro, 2003.

88. Tanzania Commission for AIDS. Tanzania 2003 AIDS indicator survey finalreport. Dar es Salaam, Commission for AIDS, National Bureau of Statistics,ORC Macro, Calverton, MD, 2003.

89. Taffa N et al. STD and sexual risk behaviour of Ethiopian youths. SexuallyTransmitted Diseases, 2002, 29:828-833

90. Gregson S et al. HIV infection and reproductive health care in teenage womenorphaned and made vulnerable by AIDS in Zimbabwe. AIDS Care 2005,17:785-794.

91. International Labour Organization International Programme on the Eliminationof Child Labour. Rapid assessment of trafficking in children for labour andsexual exploitation in Romania. Bucharest, ILO, 2003.

92. International Labour Organization International Programme on the Eliminationof Child Labour. Rapid assessment on trafficking in children for exploitativeemployment in Bangladesh. Geneva, ILO, 2002.

93. Amorim A, Murray U, Bland J. Girl child labour in agriculture, domestic work andsexual exploitation. Rapid assessments on the cases of the Philippines, Ghanaand Ecuador. Geneva, ILO, 2004.

94. Population Division of the Department of Economic and Social Affairs, UnitedNations Secretariat. World population prospects: the 2004 revision. New York,United Nations, 2005.

41

92-4-120938-0_CH02_41

92-4-120938-0_CH02_42

3. Overview of effective and promisinginterventions to prevent HIVinfectionJudith D. Auerbach,a Richard J. Hayes,b & Sonia M.Kandathila

Objective To review the evidence for the effectiveness of a variety ofapproaches to preventing HIV infection.

Methods We reviewed what is known about the efficacy and effectivenessof a range of prevention approaches that are at various stages of research.These interventions attempt to induce behavioural change, apply technolo-gies or modify social environments. Our intention was not to provide anexhaustive review of all types of HIV prevention strategies but rather to il-lustrate the landscape of interventions that have been developed and evaluatedin different settings and that have the potential for widespread applicationamong both adults and young people.

Findings There is a large quantity of evidence from experimental and ob-servational research as well as from practical real-world experience in bothdeveloped and developing countries. This evidence supports the implemen-tation and scale-up of a number of interventions and strategies. At the sametime, there is a need to continue to develop new and more effective interven-tions while attending to a number of behavioural and social issues that cutacross virtually all interventions designed to prevent the spread of HIV.

Conclusion We caution against confusing lack of implementation with lackof effectiveness and call for continual improvement in the quality and quantityof evidence. We have also identified a number of important directions forfuture HIV prevention research.

3.1 Introduction

In the face of increasing rates of HIV infection around the world, there arethose who doubt that HIV prevention strategies work, despite extensive ev-idence of the effectiveness of several interventions (1–4). In large part, thisdoubt is due either to a lack of understanding that prevention strategies maybe working even when HIV infection rates are high or increasing (see

a The Foundation for AIDS Research (amfAR), 1150 17th Street NW, Washington, DC, 20036,USA. Correspondence should be sent to Dr Auerbach (email: judy.auerbach@amfar.org).

b London School of Hygiene and Tropical Medicine, University of London, London, England.

43

92-4-120938-0_CH03_43

chapter 2) or to a belief that only certain kinds of data constitute valid evidenceof effectiveness (see chapter 4). Perceptions that HIV prevention “doesn’twork” may also be a function of confusing the efficacy of interventions withnot having taken effective interventions to scale.

Despite these challenges the field of HIV prevention is alive and well. In thecourse of the past 20 years, many approaches for stemming the spread of HIVhave been developed, tested and evaluated (although relatively few have beenevaluated systematically and rigorously) in different populations and settings,and a number have been widely adopted. The following is a brief review ofwhat is known about the effectiveness of a range of interventions at variousstages of research that attempt to induce behavioural change, apply tech-nologies or modify social environments in order to prevent the spread of HIV.Some of these interventions have involved young people, and some inter-ventions are more appropriate for young people than are others. Our intentionis not to provide an exhaustive review of all types of HIV prevention strate-gies, nor to systematically evaluate the strength of evidence for them, butrather to illustrate the landscape of interventions that have the potential forwidespread application among both adults and young people. Our reviewincludes evidence from experimental studies (including quasi-experimentalstudies) and observational studies and related analyses that have used a rangeof designs and evaluation methods. The merits of different study designs, aswell as criteria for assessing their quality and evaluating their evidence ofeffectiveness, are described in detail in chapter 4. Other chapters elaborateon the evidence for particular types of youth-focused interventions imple-mented in different settings.

3.2 Interventions to change behaviour

The goal of interventions aimed at changing behaviours is to reduce the riskof HIV-related sexual and drug-use behaviours. Behavioural change inter-ventions seek to delay the onset of sexual intercourse, reduce the number ofsexual partners a person has and reduce the incidence of unprotected sex byincreasing condom use. Behavioural change interventions also target druguse and seek to reduce or eliminate the incidence of drug injecting and theincidence of sharing needles, syringes and other drug-use equipment. Truereductions in such behavioural risks would reduce the transmission and ac-quisition of HIV infection.

Interventions aimed at changing behaviours focus on counselling individuals,couples and small groups (and these interventions sometimes include HIVtesting) and running workshops and other programmes that provide infor-mation and skills (including, for example, sex education, instructions on howto use condoms and other harm reduction strategies). These interventions may

44

92-4-120938-0_CH03_44

also aim to change social norms by seeking the involvement of opinion lead-ers or they may be peer-based, use social networks or be targeted at thecommunity. Additionally, they may include social marketing, communica-tions and mass media campaigns (2–6). These interventions are based onpsychological and social science theories that emphasize the importance ofknowing about the risks of HIV transmission, instilling motivation to protectoneself and others, changing expectations of outcomes, developing skills forengaging in protective behaviours and the ability to maintain protective be-haviours, and providing social support for protective actions (5, 6). Evalua-tion designs have included experimental and observational studies.

Behavioural change interventions have been tested in a range of social set-tings, including health-care systems, HIV/AIDS service organizations,schools, churches, community centres, commercial establishments, work-places, correctional facilities, the military and in homes. Outcomes related toHIV/AIDS that were assessed in these interventions generally fall into threecategories:

psychosocial (such as self-efficacy, perceived risk, personal or interper-sonal skills, HIV/AIDS knowledge, intentions to adopt risk-reductionbehaviours, communication with partners)

behavioural (such as the safe use of injected drugs, reducing the incidenceof sharing drug paraphernalia, encouraging the use of male or female con-doms, reducing the number of partners and frequency of unprotected sexualactivity and encouraging HIV testing), and

biological (such as the incidence or prevalence of HIV or other sexuallytransmitted infections [STIs], hepatitis and, sometimes, pregnancy, par-ticularly in studies with young people) (5, 6).

In fact, most behavioural interventions target a number of risk reductionoutcomes.

Hundreds of studies of behavioural change interventions have been con-ducted since the early 1980s, both in the developed and the developing world.Until recently, these have almost entirely targeted people who are not infectedwith HIV, although there is a growing body of studies of interventionsfocusing on people who are HIV positive (7). Several systematic reviews andmeta-analyses have summarized findings from these studies (5–18).

Most meta-analyses have included only experimental studies, and so haveonly reported on a subset of all studies of behavioural interventions, most ofwhich have been conducted in North America and western Europe. Studiesin these meta-analyses and systematic reviews of experimentally designedbehavioural interventions have focused on HIV-negative heterosexual adults

45

92-4-120938-0_CH03_45

and adolescents, injecting drug users and men who have sex with men. Theyhave found that such interventions can result in as little as no reduction inrisk behaviours to as much as a 40% reduction in risk behaviours amongdifferent population groups and exposure categories over periods that gen-erally have ranged from 3 months to 2 years. Of those interventions that haveshown efficacy in reducing risk, most have had small to moderate effect sizes(not all of which are statistically significant) (5, 7–13, 19, 20), although sub-stantial effect sizes were found in some studies included in reviews ofinterventions among men who have sex with men (14, 18). Within the overallcategory of behavioural change interventions, those considered to work bestin reducing sexual risk include small-group cognitive behavioural interven-tions, educational interventions and face-to-face counselling and skill-building programmes (for example, teaching proper condom use, negotiationand refusal skills). Those that work best for reducing risks from drug useinclude outreach programmes, needle exchange activities, addiction treat-ment programmes and face-to-face counselling (21).

Beyond these meta-analyses, other reviews have provided additional evi-dence of the efficacy and effectiveness of behavioural interventions in re-ducing the risk of HIV infection in developing countries among commercialsex workers, adolescents, injecting drug users and men who have sex withmen (14–16, 18, 22, 23).

There are some important caveats to meta-analyses and the behavioural in-terventions they assess. First, most behavioural intervention studies measuremultiple outcomes and many report a composite risk-reduction outcome soone would have to tease out the data for each outcome from each study toknow exactly what had been achieved, and this has often not been done.Indeed, it is possible that published studies tend to emphasize the one outcomethat is significant, leading to reporting bias. Second, behavioural outcomesare not operationalized or measured consistently across studies. For example,condom use is measured as “never, sometimes, always used”, “number ofunprotected acts of intercourse” or “condom used at last act of intercourse”,to name just a few. So we cannot be certain that like outcomes have beenpooled.

Additionally, most studies of behavioural intervention are population-specific, with the reference group being defined variously by age, sex of theparticipant, sexual orientation, ethnicity, cultural community, geographicalsetting or exposure category. Thus, most summary reviews of behaviouralinterventions are specific to these particular social groups (7, 8, 10–19).Consequently, it takes careful sifting to determine which of the effectiveinterventions ought to and could be replicated and scaled-up for differentpopulations and settings.

46

92-4-120938-0_CH03_46

But perhaps the most important limitation of studies of behavioural inter-ventions is that virtually all behavioural outcomes are self-reported, whichraises questions about their veracity and validity. It is both difficult and oftenundesirable to directly observe and measure HIV risk and protective be-haviours related to sexual intercourse and drug use, so we must rely chieflyon the indirect measures of self-reporting (24–26). Given the sensitivity ofthese behaviours, there is the possibility that people will consciously or sub-consciously misreport them in ways they consider to be socially desirable.This has been demonstrated by studies that have compared self-reported dataand biological markers; and it may be especially severe in studies of adoles-cents and young people. For example, a study of adolescents in the UnitedRepublic of Tanzania found substantial discrepancies in reported behaviourusing five different methods of data collection. On self-completed question-naires or during structured interviews, most young women denied havingengaged in any sexual activity but many had biological markers of activity(such as pregnancy or an STI), and during in-depth interviews most admittedto engaging in sexual activity (26). Also, reporting bias may differ betweenthe intervention and control arms of a study or between those exposed orunexposed to the intervention in an observational study, thereby distortingthe effects of the intervention. Thus although there have been significant ad-vances in developing techniques to optimize the validity of self-reports (suchas through the use of computer-assisted survey instruments and carefully de-signed questionnaires), questions remain about the validity of study resultsbased exclusively on self-reported behaviours. This has led to the increasinginterest in including biological outcomes (such as STI or HIV incidence) instudies of behavioural interventions as complementary measures and some-times as primary endpoints.

There are only a few published experimental studies testing the effectivenessof an intervention to reduce behavioural risk using both behavioural andbiomedical endpoints (incidence of STIs or HIV, or both), and these havefound mixed results. For example, two multisite intervention studies amongheterosexual men and women in the United States found significant positiveeffects both on outcomes of behavioural change and STI incidence (27, 28).As a result, one of the protocols (Project RESPECT) has been widelyreplicated in the United States. But a study in London among men who havesex with men found only modest positive change in reported behaviours andan unexpectedly higher rate of STI acquisition among the intervention groupthan the control group, although this difference attenuated over time (29). Alarge multisite behavioural intervention trial in the United States among menwho have sex with men, and which included HIV incidence as an outcomemeasure, found an 18.2% lower rate of HIV infection (15.7% after adjustmentfor baseline covariates) in the intervention group compared with the controlgroup and a 20.5% lower incidence of unprotected receptive anal intercourse

47

92-4-120938-0_CH03_47

with partners who were HIV positive or of unknown serostatus in the inter-vention group compared with the control group. Although the behaviouraloutcome was statistically significant, the HIV incidence outcome was not(30). A randomized community trial of a multicomponent adolescent sexualhealth programme in rural Mwanza, United Republic of Tanzania, assessedboth behavioural and biological outcomes, including HIV incidence and STIprevalence. The intervention had a significant impact on knowledge aboutHIV, reported attitudes towards HIV and some reported behaviours, withvariations occurring by the sex of the participant, but it did not have a con-sistent impact in either direction on STI outcomes (31, 32). Finally, inMasaka, Uganda, the effects of a community-wide behavioural intervention,with and without improved STI treatment services, were assessed in a three-arm community-randomized trial. Comparison of the behavioural interven-tion and control arms showed an increase in condom use with casual partners,but there was no significant impact on HIV incidence, possibly because thetrial was carried out at a time when incidence was already falling as a resultof larger changes toward safer behaviour in Uganda (33).

In addition to experimental data, surveillance and other observational dataprovide evidence of behavioural change at the population level that is plau-sibly related to behavioural interventions, including information and educa-tion provided by nongovernmental organizations, social institutions, peersand the media. However, if we look at the observational data from countriesand communities that have documented behavioural change, it is difficult toascertain exactly what produced the change; this is especially true for specificbehavioural interventions. This leaves us in a quandary and makes it difficultto determine what really works and how it might be replicated elsewhere. Forexample, documented declines in HIV prevalence in Uganda have been at-tributed to the promotion of a strategy known as “ABC”: “abstain” (chieflyaimed at delaying sexual debut among young people); “be faithful” (aimedchiefly at reducing the number of partners); and “use condoms” (chieflyaimed at use with non-regular partners). But the actual interventions (scien-tifically tested or otherwise) that produced these behavioural changeshave not been specified (34). In the absence of clear data, a controversyemerged – and continues – about the relative importance of delayed sexualdebut, partner reduction and condom use in influencing the dynamics of theepidemic in Uganda (35). Similarly, a population-based study in Zimbabwehas shown evidence of a decline in HIV prevalence, particularly among youngpeople, that was accompanied by changes in reported sexual behaviour. Againit is not possible to attribute this change to specific interventions (36).

Attribution issues notwithstanding, observational data from these and othercountries provide evidence that delaying sexual debut, reducing the numberof sexual partners and increasing the use of condoms has been achieved

48

92-4-120938-0_CH03_48

through the implementation of various behavioural change interventions –both formal and informal – and that these behavioural changes appear to havecontributed to 50–90% reductions in HIV incidence and prevalence in anumber of populations in the 1990s, as measured by epidemiological surveil-lance (37–42). Most analysts have concluded that it was the combination ofbehavioural intervention strategies and involvement by high-level politicaland community leaders that produced significant behavioural changes and,as a result, reductions in HIV incidence and prevalence in these countries(3, 4, 34, 36, 42).

Some of the observed trends in HIV incidence and prevalence may be due tothe natural dynamics of the epidemic, including an “exhaustion of suscepti-bles” and people modifying their behaviour in the light of knowing otherswho have AIDS; and behavioural trends may reverse over time, erasing someof the gains made in earlier years. An analysis by researchers leading theRakai cohort study in Uganda illustrates these possibilities. HIV prevalence,reported age at first sexual intercourse, reported number of sexual partnersand condom use had probably all improved in this cohort in the late 1980sand early 1990s, as they had in other areas of southern Uganda. However,although HIV prevalence declined by 6.2% between 1994 and 2003, most ofthis decline (about 5%) was attributable to HIV-related mortality. In thiscommunity, between 1995 and 2002 the age at first sexual intercourse actu-ally dropped among both males and females, and from 1994 to 2003 theproportion of adolescent girls aged 15–19 reporting having had two or morenon-marital sexual partners increased significantly. But despite these be-havioural changes, HIV incidence remained stable, which the study authorsattributed to an increase in condom use with casual partners occurring amongboth males and females (43).

These observations underscore the need for, and the usefulness of, combiningepidemiological and behavioural data for the same time periods. They alsoemphasize the usefulness of prevalence data for young people, which can beused as a marker of recent change and lead to a better understanding of whatis really occurring in terms of HIV transmission and prevention and to whatbehavioural changes epidemiological outcomes may be attributed (36, 44).

3.2.1 Voluntary counselling and testing

The establishment of voluntary counselling and testing programmes has beena feature of national HIV prevention strategies in a number of countries. Thekey goals of these programmes are to provide people with the opportunity tolearn their HIV status, to counsel people about how to avoid becoming in-fected or spreading HIV and to refer people to appropriate medical and psy-chosocial care. A number of studies in developed and developing countries

49

92-4-120938-0_CH03_49

have been undertaken to determine if, in addition to its diagnostic and referralbenefits, voluntary counselling and testing may lead to reductions in riskybehaviours and reductions in HIV infection rates (45). Overall, data fromrandomized controlled trials and observational studies show mixed results inthis regard (46). For example, in a randomized trial of an intervention forcouples, which was conducted in Kenya, Trinidad and the United Republicof Tanzania, both male and female participants who had counselling and weretested were significantly more likely to report a reduction in the incidence ofunprotected intercourse with a non-primary partner than those in the controlgroup, who received only basic health information. Among those in the in-tervention group, HIV-positive men were more likely than HIV-negative mento report a reduction in the incidence of unprotected intercourse with bothprimary and non-primary partners (47). (This study also looked at STI end-points, but it was underpowered and the effect was non-significant.) Otherresearch from sub-Saharan Africa has found that behavioural changes in-duced by voluntary counselling and testing programmes among coupleswhose HIV status is discordant (that is, one partner is HIV positive and oneis not) varied by the sex of the participant: condom use within these coupleswas more frequent and consistent when men were the HIV-negative partners(48–50). Thus, it appears that the effectiveness of these programmes in pre-venting HIV infection is limited to certain individuals and couples.

Additionally, utilization of voluntary counselling and testing remains low inmost communities with a high prevalence of HIV, chiefly because access toservices is often limited and stigma and discrimination continue to surroundHIV infection. To address this situation, a large community-randomized in-tervention study of voluntary counselling and testing is under way in SouthAfrica, Thailand, the United Republic of Tanzania and Zimbabwe. The in-tervention aims to increase the availability of services in community settings,to engage communities through outreach and to provide post-test support –all of which are intended to change community norms, mitigate stigma andreduce the risk of HIV infection among all community members regardlessof whether they participate directly in the intervention (51).

3.2.2 Treatment for drug addiction

Numerous studies have shown that substance abuse treatment programmescan have a significant effect on HIV transmission among injecting drug users(52, 53), although few of these studies are experimental and most have oc-curred in the United States. These drug treatment programmes usually involveboth opiate substitution (particularly with methadone) and the provision ofbehavioural counselling; they generally attempt to help injecting drug usersdecrease the number and frequency of injections or to cease injecting alto-gether. Reducing drug-related risk behaviours leads to fewer potential

50

92-4-120938-0_CH03_50

exposures to HIV. Some of the earliest data demonstrating the efficacy ofdrug treatment programmes to prevent the spread of HIV came from an ob-servational study in the United States of in-treatment and out-of-treatmentintravenous opiate users randomly recruited from a methadone maintenanceprogramme and its surrounding neighbourhood in Philadelphia, Pennsylvania.At follow up at 18 months, 3.5% of the methadone maintenance patients whohad been in treatment continuously were HIV positive compared with 22%of out-of-treatment injecting drug users, representing a 6-fold difference inthe rate of seroconversion (54). Another prospective study showed that at36 months 8% of injecting drug users in treatment had become infected com-pared with 30% of those not in treatment (55). Although these data come fromobservational studies rather than experimental studies, the large differencesobserved suggest that such interventions can be effective. But the availabilityof methadone maintenance programmes is limited throughout the world, notleast because drug substitution is illegal or highly regulated in many coun-tries, including those with HIV epidemics strongly associated with the use ofinjected drugs.

3.3 Biomedical interventions: evaluating technologies

Research into biomedical interventions to prevent HIV infection involvestesting the effectiveness of physical and chemical technologies to prevent thetransmission or acquisition of HIV. The goal of such interventions is to mod-erate the influence of biological or physiological factors that may increaseinfectiousness or susceptibility to HIV or to prevent infection from progress-ing after actual exposure. Some biomedical strategies have been well testedand implemented; others are still at the early stages of development. Althoughmost studies of biomedical interventions assess outcomes at the individuallevel, some have been designed to effect community-level change.

3.3.1 Reducing iatrogenic transmission

As soon as it was understood that AIDS was caused by a bloodbornepathogen, the importance of the health services taking steps to avoidparenteral iatrogenic transmission became apparent. Beginning in themid-1980s, several strategies were introduced to reduce the likelihood ofpatients acquiring HIV infection from blood transfusions both in developedand developing countries; these included the widespread use of diagnosticassays for detecting HIV in blood and imposing restrictions on donorsknown to be at risk of HIV infection (56–59). Other strategies that have beenused to reduce iatrogenic transmission include educating the public aboutthe risks of engaging in non-sterile medical practices, such as sharing needles,and demonstrating to patients that the medical care they are receiving issafe by taking a new auto-disable syringe out of a sealed package and using

51

92-4-120938-0_CH03_51

single-dose phials (60). Although rigorous studies testing the effectivenessof these interventions are lacking, implementing such practices in developedcountries has been effective in virtually eliminating HIV transmissionthrough blood donation and medical practices (61, 62). However, some epi-demiologists continue to argue that unsafe injection practices account for agreater proportion of HIV transmissions in resource-poor settings than sexualintercourse does (63). But this has been countered by a thorough assessmentof the epidemiological data from across sub-Saharan Africa and by a cohortstudy in rural Zimbabwe both of which unequivocally concluded that sexualinteraction and not unsafe injections remains the primary mode of HIV trans-mission in that region (64, 65). Despite these conflicting perspectives, allagree that there is a need to effectively monitor injection practices at healthfacilities and to ensure the scale-up of safe procedures.

3.3.2 Managing STIs

A large body of evidence accumulated from epidemiological and clinicalstudies has shown that the risk of sexual transmission of HIV is substantiallyincreased in the presence of other STIs (66). The evidence shows thatSTIs – particularly those associated with genital ulceration – can enhance theinfectiousness of people who are HIV positive as well as the susceptibility ofpeople who are HIV negative. STI prevalence is high in many countries withsubstantial HIV epidemics, and this is often due at least partly to poor STItreatment services. Therefore, the diagnosis and treatment of STIs have thepotential to be effective prevention strategies by reducing STI prevalence incouples whose HIV status is discordant. Three large randomized trials havemeasured the effects of community-wide STI treatment interventions in dif-ferent populations living close to Lake Victoria in east Africa. The first,conducted in the Mwanza region of the United Republic of Tanzania, showedthat improved STI treatment services, using syndromic management and de-livered through government-run primary health-care units, reduced HIVincidence in the general adult population by an estimated 38% (67, 68). Thesecond, conducted in the Rakai district of Uganda, evaluated the effect ofperiodic mass treatment of STIs. All adults living in intervention communitieswere treated for STIs at 10-monthly intervals, whether or not they reportedSTI symptoms. After 20 months of follow up, this intervention showed nosignificant effect on HIV incidence (69). The third trial, conducted in theMasaka district of Uganda, evaluated whether a combined behavioural andSTI syndromic management intervention was more effective than a be-havioural intervention alone in reducing HIV transmission; it found nosignificant difference in HIV incidence between study arms after 3.6 yearsof follow up (33). All three trials reported some significant reductions in theincidence and prevalence of STIs.

52

92-4-120938-0_CH03_52

The contrasting results of these studies call for careful analysis and interpre-tation. A synthesis of data from these trials concluded that differences in thestudy populations – with respect to sexual risk behaviour and STI rates aswell as the stage of the HIV epidemic – and not differences in interventionstrategy, were the key determinants of the contrasting HIV outcomes in thethree locations (70, 71). The investigators concluded that using STI controlmeasures to prevent the spread of HIV is likely to be most effective in pop-ulations with sexually transmitted epidemics that are early and concentratedand in populations with a high prevalence of STIs and sexual risk behaviours.The results of the Mwanza trial have led to widespread implementation ofsyndromic STI management in many countries.

It has been recognized that infection with herpes simplex virus type 2(HSV-2) plays a particularly important role in HIV transmission. A system-atic review and a meta-analysis summarized evidence from observationalstudies (72, 73). The more recent review found that prevalent HSV-2 infectionwas associated with a 3-fold increase in the risk of HIV acquisition both inmen and women in studies in the general population; weaker effects wereseen in studies of at-risk groups, possibly because such groups also have ahigh prevalence of other STIs (73). It is likely that HSV-2 infection alsoincreases the infectiousness of people who are HIV positive. Data from arandomized controlled trial of valacyclovir in Burkina Faso showed that sup-pressive therapy administered during a 3-month period reduced genitalshedding of HSV-2 and HIV and also reduced HIV plasma load (74). Basedon these observational data, and strengthened by the findings of the study inBurkina Faso, a number of phase III randomized trials are under way in Peru,South Africa, the United Republic of Tanzania, the United States, Zambiaand Zimbabwe to measure the effects of episodic or suppressive antiviraltherapy in people who are infected with HSV-2 on HIV acquisition or trans-mission (75).

3.3.3 Antiretrovirals to prevent HIV infection

3.3.3.1 Preventing mother to child transmission

One of the most significant developments in HIV prevention was the findingthat certain antiretroviral drugs could be administered to pregnant women andtheir newborns in such a way as to significantly reduce the likelihood of HIVbeing passed from mother to child before, during and after delivery. Threekey randomized controlled trials provided the proof. The first, conducted inthe United States, involved a three-part regimen of zidovudine given to themother and her newborn; it reduced HIV transmission by two thirds (76). Thesecond, conducted in Thailand and Côte d’Ivoire, involved a shorter regimenof zidovudine, and it reduced transmission by 44–50% (77, 78). The third

53

92-4-120938-0_CH03_53

trial, conducted in Uganda, demonstrated that a single dose of nevirapineadministered to the mother at the onset of labour and to the infant soon afterbirth reduced HIV transmission by nearly 50% (79). Together these studiesdemonstrate that long-course and short-course zidovudine and single-dosenevirapine are effective interventions for reducing mother to child transmis-sion of HIV (80). Several studies are under way in resource-poor settings toassess the effects of using highly active antiretroviral treatment (HAART)during pregnancy (that is, treating the woman for her own infection) on thesubsequent incidence of mother to child transmission. Preliminary resultsfrom one study conducted in Côte d’Ivoire showed the HIV transmission rateamong pregnant women on HAART was 1.45% compared with 3.89% forthose on a standard short-course antiretroviral regimen (81).

Interventions to reduce the incidence of HIV transmission that occurs throughbreastfeeding have also been tested. Where feasible and acceptable, the useof breast-milk substitutes has been shown to significantly reduce infectionamong infants (82, 83). Where implemented fully, antiretroviral treatmentand breastfeeding interventions have had a remarkable effect: in the UnitedStates, for example, the number of children who acquired HIV perinatallydecreased by 89% between 1992 and 2001 (84).

3.3.3.2 Antiretrovirals for post-exposure prophylaxis

In some countries health-care workers and prison officers have had access totreatment with antiretroviral drugs following assumed (chiefly parenteral)exposure to HIV infection in the workplace. A retrospective study of occu-pational post-exposure prophylaxis concluded that zidovudine monotherapy(administered within 24 hours of exposure and over the course of 28 days)reduced occupational HIV transmission (chiefly through needle-stick in-juries) by approximately 81% (85). In more recent years, this approach hasbeen extended to become a medical strategy for coping with non-occupational exposures, such as sexual assault or condom breakage, and itappears to be effective (86, 87). However, studies have not included data onuntreated individuals, so these findings should be interpreted with caution.Also, adherence to the full regimen of post-exposure prophylaxis is difficultto achieve but it is likely to be important. In a programme in San Francisco,40% of all eligible survivors of sexual abuse initiated post-exposure prophy-laxis regimens but less than 10% completed them (88). Lack of completeadherence might compromise the effectiveness of using antiretrovirals forpost-exposure prevention, as has been shown for incomplete adherence inHIV treatment.

54

92-4-120938-0_CH03_54

3.3.3.3 Antiretrovirals for preventing sexual transmission

A key benefit of using HAART for treatment of HIV disease is that it reducesplasma viral load. Strict adherence to HAART regimens contributes to thesustained suppression of virus. Some data indicate that the risk of HIV trans-mission is directly associated with the infected individual’s viral load (89).These findings have led many experts and laypeople to believe that thewidespread use of HAART could have important effects on the sexual trans-mission of HIV. There are no prospective data yet to prove this, although amultisite randomized controlled trial is under way to determine whether an-tiretroviral treatment can prevent sexual transmission of HIV-1 in serodis-cordant couples (90, 91). The primary data establishing the relationshipbetween lower plasma viral load and reduced sexual transmission of HIVcome from a cohort in Rakai, Uganda, who were not taking HAART (92).

It is making a significant leap to assume that the effects of HAART at theindividual level will translate into similar effects at the population level.Mathematical models have demonstrated that at the population level the ben-eficial effect of HAART on reducing sexual transmission of HIV could beoffset by an increase in the circulation of drug-resistant strains of HIV andincreases in risky sexual behaviour that might occur if people believe HIVtransmission is unlikely or if HIV infection becomes less feared becausetreatment is available (93, 94). Furthermore, because HAART extends sur-vival time, where it is widely used there is a larger pool of HIV-positiveindividuals who have the potential to spread the infection over a longer periodof time. The net effect of all these competing factors is, therefore, difficult topredict. However, an observational study in Taiwan, China, concluded thatthe estimated HIV transmission rate in the country declined by 53% after theintroduction of free access to HAART in 1997, while no significant be-havioural change occurred. The researchers were careful to note that thewidespread use of HAART can be an effective measure to control HIV epi-demics in countries with a low prevalence, but may not be as effective, ormay not be effective at all, in settings with an already high prevalence ofinfection, for a number of reasons having to do with the exponential courseof HIV epidemics (95).

Considering these data together – data from studies in animals, of post-exposure prophylaxis, of preventing mother to child transmission and datafrom Rakai on lower viral loads and lowered rates of transmission – has ledto an interest in exploring the possibility of using antiretroviral treatment forpre-exposure prophylaxis. Randomized trials are planned or under way inBotswana, Ghana, Peru, Thailand and the United States to test the hypothesisthat administering antiretroviral treatment (specifically tenofovir) to peoplewho are HIV negative but at high risk will reduce HIV acquisition amongthem (96).

55

92-4-120938-0_CH03_55

3.3.4 Male circumcision

Numerous studies have found evidence that uncircumcised men have higherrates of HIV infection than their circumcised counterparts (97). It has beenhypothesized that male circumcision protects against HIV infection chieflybecause the foreskin, which contains a high density of HIV-specific cellulartargets, has been removed (98). In the Rakai STI trial in Uganda, no HIV-negative male partner of an HIV-positive female acquired HIV if he had beencircumcised, even when the female had a high viral load (99). Two meta-analyses of observational studies (reviewing 37 and 25 studies, respectively)found that the prevalence of HIV among circumcised men was about half thatof uncircumcised men (100, 101), and this finding has been reinforced by acohort study in India (98). The association was even stronger in the 15 studiesthat adjusted for potential confounders; and it was stronger among men athigher risk of HIV infection than those in the general population (100, 101).

Results from the first randomized controlled trial testing the efficacy of malecircumcision as an intervention to prevent HIV infection confirmed findingsfrom earlier observational studies. This trial, conducted in Orange Farm,South Africa, involved more than 3 000 uncircumcised, HIV-negative menaged 18–24 years. At interim analysis, results indicated that circumcision(which was performed by physicians under sterile conditions) conferred 70%protection against HIV infection (102). This remarkable result caused thestudy to be halted and the intervention to be offered to participants in thecontrol group. Additional trials of male circumcision, including one that willassess protection from male-to-female transmission, are ongoing in Kenyaand Uganda to determine whether the results from South Africa can bereplicated. Meanwhile, discussions of the public health implications ofmale circumcision interventions already have begun, including the possibil-ities of circumcision occurring under non-sterile conditions and “riskcompensation” (that is, circumcised men may engage in riskier behaviourbecause they think they are protected against infection) (103).

3.3.5 Vaccines

There is general consensus that the HIV prevention strategy with the potentialto have the greatest impact would be an HIV vaccine. Unfortunately, no ef-fective vaccine exists, nor is one expected for many years. The complexityof HIV, the multiplicity of its variants, the ability of the virus to mutate, thelack of validated correlates of protection – not to mention the costs andlogistics of mounting large-scale clinical trials – have made it extremelydifficult to develop and test candidate vaccines. Moreover, there is little ex-pectation that any vaccine that emerges in the near future will be close to100% effective. More than 30 products or combinations of products have

56

92-4-120938-0_CH03_56

been tested in more than 50 phase I and phase II trials, but only oneproduct (AIDSVAX gp120) so far has completed phase III testing – in theNetherlands, Thailand and the United States – and it showed no efficacy(104). Another phase III trial is under way at several sites in Thailand; it istesting two vaccine candidates, ALVAC-HIV vCP1521 and AIDSVAXgp120 B/E (105).

3.3.6 Microbicides

A microbicide is a chemical compound designed to block the sexual trans-mission of HIV by killing or inactivating the virus, blocking the entry of thevirus into target cells or interrupting the viral life cycle once it has enteredtarget cells. Microbicides are being developed chiefly for vaginal use, al-though research on products for rectal use is also under way. The drive behindmicrobicide development is the urge to provide women with an HIV preven-tion technology that does not depend on male cooperation to the same extentas the male, or even the female, condom. The earliest randomized trials wereconducted with nonoxynol-9, which has been used as a spermicide but hasalso shown anti-HIV activity in vitro. Altogether there were five rigorousrandomized controlled trials conducted in a number of countries, chieflyamong female commercial sex workers; these studies found no evidence thatnonoxynol-9 protects against vaginal acquisition of HIV infection (106,107). There was some evidence that it may, in fact, cause harm by increasinggenital lesions. For example, the large multisite study of COL-1492 vaginalgel, which contains nonoxynol-9, found a significant increase in HIV inci-dence among female sex workers who used the gel compared with those whodid not (106, 107).

There are more than 60 products in preclinical and clinical development, tar-geting a number of different mechanisms of action and different phases ofthe HIV life-cycle (108). In early 2006, there were about 10 compounds inphase I trials, 6 in phase II trials, and 4 in phase III trials (109). The difficultiesof developing and testing microbicides are similar to those of vaccines, in-cluding scientific uncertainties, the complexity of trial designs and the costs(3). Also, as in the case of vaccines, it is unlikely that any microbicide willbe 100% effective. Yet, it is estimated that the introduction of even a partiallyeffective microbicide could prevent as many as 2.5 million new HIV infec-tions over 3 years (110).

3.3.7 Cervical barrier methods

In addition to microbicides, which function as a chemical barrier, interest hasgrown in examining other female-initiated barrier methods that may offersome physical protection against the transmission and acquisition of HIV

57

92-4-120938-0_CH03_57

infection. The female condom is a lubricated polyurethane sheath with a ringon either end that is inserted into the vagina before sexual intercourse. It hasbeen studied primarily for its effectiveness in preventing pregnancy and STIsother than HIV. Laboratory studies and clinical trials have shown that thefemale condom provides an effective barrier to organisms smaller than thosethat cause most STIs, and it is at least equivalent to male condoms in termsof preventing gonorrhoea, trichomoniasis and chlamydia (111). There havebeen no clinical trials specifically assessing the efficacy or effectiveness ofthe female condom in preventing HIV infection. However, based on studiesin which STI prevention and pregnancy prevention were assessed, it is esti-mated that the female condom is 94–97% effective in reducing the risk ofHIV infection if used correctly and consistently (111). The female condommay be a more attractive choice than male condoms for some women becauseit resists breaks and tears and covers both the internal and external genitals,which are primary sites of STI lesions (112–114).

Findings from basic and clinical research indicate that HIV susceptibility maynot be equally distributed across the epithelial surfaces in the vagina and thatthe cervix may be particularly vulnerable to HIV and STI transmission(115, 116). This has led to an interest in the risk-reduction potential of cervicalbarrier methods, such as the diaphragm and cervical cap. These barriers aremade of soft latex or silicone and are used with spermicidal cream or jellyand then inserted into the vagina to fit over the cervix. Several observationalstudies have indicated that when the diaphragm is used in conjunction withspermicide it may offer protection against some STIs and their associatedsequelae (117–121). As of March 2006, seven clinical trials at various stages(phase I to phase III) were under way to examine the diaphragm’s effective-ness in preventing STIs (122). Of these studies, the furthest along is theMethods for Improving Reproductive Health in Africa Trial, a phase III trialthat will measure the effectiveness of the diaphragm when used with Replenslubricant gel in preventing heterosexual acquisition of HIV infection amongwomen in South Africa and Zimbabwe (123).

3.3.8 Summary

There are a number of biomedical technologies under development that showpromise for preventing the spread of HIV. Unfortunately, for some of theseinterventions, the scientific, logistical and ethical complexities inherent inrunning large-scale trials of effectiveness mean that it may be many yearsbefore this promise is realized.

3.4 Social interventions

Social arrangements, institutions, laws, policies and customs can influencegreatly the ability of individuals to engage in protective behaviours and to

58

92-4-120938-0_CH03_58

use biomedical technologies to avoid becoming infected with HIV. In recentyears, increased attention has been paid to the possibilities of modifying so-cial arrangements that affect HIV prevention. Whether they are called “socialstrategies” (2), “structural interventions” (124–127) or “environmental in-terventions” (125), efforts to create social conditions that facilitate healthpromotion and risk reduction have proven to be effective in a number oflocales, although there are few examples of rigorously tested approaches.

3.4.1 100% condom use

Perhaps the most notable example of a social intervention aimed at preventingthe spread of HIV is the Thai “100% condom” use programme, which madecondom use mandatory in all brothels, even while prostitution remainedtechnically illegal. The promotion of condom use was coupled with an em-phasis on decreasing visits to sex workers and other non-regular partners,particularly among Thai military recruits. But the Thai national response, likethat in Uganda, also included national sentinel surveillance, mass mediacampaigns, community mobilization and interaction between nongovern-mental organizations, community-based organizations and industry, as wellas strong public statements and resource commitments made by politicalleaders at the highest levels (128). As a result of this comprehensive socialstrategy, the rate of Thai military recruits having sex with commercial sexworkers decreased from 57.1% in 1991 to 23.8% in 1995; of those who con-tinued to have sex with commercial sex workers, the proportion that usedcondoms increased from 61% in 1991 to 92.6% in 1995. Between 1991 and1993 the rate of HIV incidence among military conscripts fell from 3/100person-years to 0.3/100 person-years (42, 129, 130).

A cohort study of repeat blood donors in the northern provinces in Thailandfound similar results: HIV incidence decreased from 1.7/100 person-years in1989 to 0.5/100 person-years in 1994 (42). As a result of the success of theThai programme, a number of other Asian nations have implemented similarprogrammes, which have involved making policy changes in order to workaround the continued illegality of prostitution. Data from these countries in-dicate that there have been increases in the use of condoms and decreases inthe incidence of STIs (131). In Cambodia, declining HIV rates between 1996and 2000 have been attributed to the 100% condom use programme and im-provements in STI care (131).

3.4.2 Access to syringes

Perhaps the most studied social intervention is that of increasing access tosterile syringes for those who use injected drugs. Although such drug use isillegal nearly everywhere in the world, many countries have adopted harm

59

92-4-120938-0_CH03_59

reduction policies that allow, if not provide, for access to sterile injectingequipment for those who continue to inject. The implementation of needle/syringe-exchange programmes, in particular, has resulted in decreased nee-dle-sharing and related practices, and reduced HIV incidence and prevalencein numerous locales (124, 132–136). A review of data from 81 cities acrossEurope, Asia, and North America with and without syringe-exchange pro-grammes found that, on average, HIV prevalence among injecting drug usersincreased by 5.9% per year in the 52 cities without exchange programmesand decreased by 5.8% per year in the 29 cities with exchange programmes.Thus the average annual change in prevalence was 11% lower in cities withexchange programmes (132). But political resistance to strategies that maybe construed as condoning drug use has prevented many countries andcities from implementing exchange programmes and other harm reductioninterventions.

3.4.3 Economic empowerment interventions for women

The increasingly disproportionate impact of HIV and AIDS on women andgirls throughout the world (see chapter 2) has implicated gender inequity asa driver of the epidemic. The cultural construction and social organization ofgender have disempowered women and girls in many settings, making themparticularly vulnerable to HIV infection and its consequences. These socialfactors operate in a number of ways, including through low educational at-tainment, early marriage, fertility expectations and sexual violence and alsothrough economic inequities, such as lower wages and unpaid care work anda lack of property and inheritance rights. As a result of such arrangements,many women and girls do not have basic information about their bodies, sexor sexuality, and do not know how to prevent HIV and other STIs; they cannotdemand that male partners use condoms; they cannot refuse sex; they areoften forced to sell sex; and if they inject drugs they often are given a dirtyneedle to use after their male partner.

In response to these situations, interest has been growing in implementingincome-generation interventions, such as microfinance projects – anotherform of social or structural intervention – as a means of empowering womenin their relationships and reducing their material dependence on men. Severalstudies of micro-credit interventions targeting women and their fertility out-comes (pregnancy rates and contraceptive use) indicated that economicempowerment translated into increased self-esteem, improved social net-works, increased control over household decision-making, increased bar-gaining power and increased contraceptive use (137). Micro-financing hasonly recently been applied to HIV prevention, so few empirical examples ofinterventions exist. One large-scale community-level randomized controlledtrial in South Africa of an integrated, comprehensive intervention that

60

92-4-120938-0_CH03_60

simultaneously provided micro-credit to women and HIV/AIDS education tothe whole community has been completed. The study assessed intermediateattitudinal and behavioural outcomes and HIV incidence (138). In this struc-tural intervention, eight communities were matched and randomly allocatedto receive the intervention at onset of the study or after 3 years. There was noevidence of an effect on community-level HIV incidence or risky sexual be-haviour in the short-term, although there was a significant reduction inphysical and sexual abuse among intervention participants (139).

Although the need for more social interventions has been recognized, thereare a number of obstacles to evaluating their effectiveness. Chief among theseis the fact that it can be exceedingly difficult to fit social-level analysis andinterventions into an experimental study design (127). Essentially, the prob-lem is that complex social phenomena – such as gender, poverty, economicinequality and violence – cannot be reduced to a few variables that can easilybe modified or controlled for testing in experimental designs; and the attri-bution of effects to such interventions is often difficult without suitablecomparison groups.

3.5 Behavioural and social issues in developing and implementinginterventions

There are a number of interrelated issues that cut across virtually all inter-ventions designed to prevent the spread of HIV, and these must be attendedto in developing and implementing such interventions. Space limitations donot allow us to discuss these in detail, but they are important to mention.

3.5.1 Recruitment to and retention in studies

The requirements of rigorous randomized controlled trials, the range andnumber of HIV prevention technologies under study, and HIV incidence lev-els necessary to enable researchers to detect true effects from an interventionmean that large numbers of people must be recruited and retained in multisitestudies over many years. This is logistically challenging and also expensive(127, 140, 141).

3.5.2 Adherence to prevention protocol

Once recruited and retained, it is essential that study participants adhere tothe prevention protocol if the full effectiveness of the intervention is to becaptured. For some technologies and in some social and familial circum-stances, this may prove impossible for study participants. If significantnumbers of participants have less than optimal adherence, the study and itsoutcomes may be compromised. Counselling about the importance of

61

92-4-120938-0_CH03_61

adherence is an essential but labour-intensive and costly component of HIVprevention trials (142, 143).

3.5.3 Behavioural disinhibition (risk compensation)

As discussed in the context of circumcision and pre-exposure prophylaxis, itis possible that when people perceive that a particular HIV prevention methodis effective (even if it is only partially effective), they may stray from usingother methods that are already known to be equally or more effective (forexample, using male condoms, delaying their first experience of sexual in-tercourse and reducing their number of sexual partners). Such behaviouraldisinhibition (or risk compensation) may slow the progress of new interven-tions in reducing HIV infection rates at the individual level and the populationlevel (43, 144). This concern is relevant to all prevention modalities – be-havioural, biomedical and social – and for those who are participating instudies and those who are not (145). However, we must not let fears overdisinhibition impede efforts to develop and implement interventions becausewe need as many effective tools as possible to tackle the HIV/AIDS epidemic.It is essential that service providers diligently promote behavioural changeand communicate the need to continue to engage in risk reduction or avoid-ance even as new prevention methods emerge.

3.5.4 Partial efficacy and partial effectiveness

No single prevention method is 100% effective. Even sexual abstinence,which may be theoretically effective, is imperfectly practised. The most ef-fective prevention technology is the male latex condom, which has anestimated 80–90% level of expected risk reduction with correct and consistentuse. Based on the outcomes of the first randomized controlled trial of malecircumcision, that intervention appears to have the next highest level of ef-ficacy, at 65–70% for a single procedure (102). Additional methods understudy (such as vaccines, microbicides, pre-exposure antiretroviral prophy-laxis) are estimated to have only a 25–50% level of effectiveness using currentstudy-design calculations and are methods that require repeated administra-tion (145, 146). This means that researchers, service providers, programmemanagers, policy-makers and community advocates must not promise toomuch for any particular method; they must be clear about the need to use acombined approach to preventing the spread of HIV; and they must empha-size the importance of adherence to behavioural changes.

3.5.5 Engaging communities in research

The question of how best to facilitate the involvement of affected communi-ties in research has been present since the beginning of the epidemic. Much

62

92-4-120938-0_CH03_62

has been written about culture clashes between scientists and community ad-vocates. Recently, this conflict has affected the inauguration of HIV preven-tion trials, particularly pre-exposure antiretroviral prophylaxis trials (usingtenofovir), in a number of developing countries (147, 148).

Although researchers may feel they are abiding by ethical standards in theconduct of trials and consulting with community leaders and representatives,community advocates continue to raise questions about the adequacy of HIVprevention counselling, informed consent, provision of treatment for peoplewho acquire HIV infection during the time they are participating in studiesand the limited involvement of communities in designing studies. These ten-sions must be resolved because most researchers and advocates believe thatHIV prevention studies should go forward as long as they are ethically con-ducted and are done with, rather than on, communities (147, 148).

3.6 Conclusion

This review of the landscape of HIV prevention strategies tells us a numberof things. First, we have a great deal of evidence from research studies – bothexperimental and observational – and from practical real-world experienceto make the case for the effectiveness – and potential effectiveness – of anumber of interventions to prevent the spread of HIV. (See Table 3.1 for asummary of the evidence reviewed in this chapter.) Although not all researchhas been rigorous, and not all interventions have shown significant results,we do know that reductions in risk and rates of HIV infection can be achievedthrough behavioural, biomedical and social strategies, particularly when theyoccur together. Principles derived from infectious disease epidemiology andbehavioural and social theory can be incorporated into rigorous interventiondesigns and real-world practices that are relevant and appropriate in differentsettings. These may yield different effects as a result of such things as havingto vary the intervention to fit different contexts (including local culture andsocial structure), variations in the quality of implementation, and variationsin underlying HIV and STI epidemiology (as in the case of the STI manage-ment trials in Rakai and Masaka in Uganda and Mwanza in the UnitedRepublic of Tanzania, described above). No intervention will be 100% ef-fective, but implementing many that have been shown to work, and doing soin different combinations in different places as befits the local situation, willyield important prevention outcomes at a population level.

63

92-4-120938-0_CH03_63

Tab

le 3

.1S

um

mar

y o

f ev

iden

ce a

nd

key

ref

eren

ces

for

beh

avio

ura

l, b

iom

edic

al a

nd

so

cial

inte

rven

tio

ns

to p

reve

nt

HIV

infe

ctio

n

Typ

e o

f in

terv

enti

on

Co

mm

ents

on

th

e ev

iden

ceK

ey r

efer

ence

s

Beh

avio

ura

lIn

terv

entio

ns a

imed

at r

educ

ing

sexu

al r

isks

and

ris

ksas

soci

ated

with

inje

ctin

g dr

ug u

se th

at in

volv

e co

unse

lling

for

indi

vidu

als,

cou

ples

or s

mal

l gro

ups;

wor

ksho

ps; s

kill-

build

ing

prog

ram

mes

; use

of p

opul

ar o

pini

on le

ader

s, p

eer-

base

d,ne

twor

ks, c

omm

unity

mem

ber;

mas

s m

edia

inte

rven

tions

Sys

tem

atic

rev

iew

s an

d m

eta-

anal

yses

con

duct

ed a

mon

g:

H

eter

osex

uals

In

ject

ing

drug

use

rs

M

en w

ho h

ave

sex

with

men

Y

oung

peo

ple

H

IV-p

ositi

ve p

eopl

e

• M

uch

evid

ence

from

man

y R

CT

sa in

dev

elop

ed a

ndde

velo

ping

cou

ntrie

s•

Num

erou

s sy

stem

atic

rev

iew

s an

d m

eta-

anal

yses

• G

ener

ally

indi

cate

sm

all t

o m

oder

ate

effe

ct s

izes

ove

r lim

ited

follo

w-u

p pe

riods

• T

arge

ted

at s

peci

fic p

opul

atio

ns o

r gr

oups

• B

ehav

iour

al o

utco

mes

are

chi

efly

sel

f-re

port

ed; s

ome

ST

Ib

and

HIV

out

com

es• S

ome

obse

rvat

iona

l evi

denc

e fo

r im

pact

of b

ehav

iour

cha

nge

on H

IV in

cide

nce

and

prev

alen

ce a

t cou

ntry

leve

l

• W

eak

to m

oder

ate

effe

cts

for

redu

ctio

ns in

sex

ual r

isk

and

ST

I out

com

es•

Mod

erat

e ef

fect

s on

sex

ual r

isk

redu

ctio

n; w

eak

to s

tron

gef

fect

s on

redu

ctio

n of

risk

s as

soci

ated

with

dru

g us

e an

d H

IVou

tcom

es•

Mod

erat

e to

str

ong

effe

cts

on s

exua

l ris

k re

duct

ion;

wea

k to

stro

ng e

ffect

s on

ST

I and

HIV

out

com

es•

Wea

k to

mod

erat

e ef

fect

s on

sex

ual r

isk

redu

ctio

n•

Mod

erat

e to

str

ong

effe

cts

on s

exua

l ris

k re

duct

ion

and

ST

Iou

tcom

es

5–21

, 27–

32

8–10

13, 1

7, 1

9

11, 1

4, 1

8

12, 1

5, 1

67

64

92-4-120938-0_CH03_64

Vol

unta

ry c

ouns

ellin

g an

d te

stin

g•

Few

RC

Ts

and

obse

rvat

iona

l stu

dies

in d

evel

oped

and

deve

lopi

ng c

ount

ries

• 1

syst

emat

ic r

evie

w•

Mix

ed r

esul

ts fo

r se

xual

ris

k be

havi

ours

and

HIV

inci

denc

e•

Effe

cts

of in

terv

entio

ns v

arie

d by

sex

of p

artic

ipan

t and

sero

stat

us

45–4

7

Tre

atm

ent f

or d

rug

addi

ctio

n (m

etha

done

mai

nten

ance

)•

Obs

erva

tiona

l stu

dies

in d

evel

oped

cou

ntrie

s su

gges

tsi

gnifi

cant

effe

ctiv

enes

s in

red

ucin

g H

IV in

cide

nce

(3.7

-fol

dto

6-f

old

diffe

renc

e in

ser

ocon

vers

ion

betw

een

thos

e in

trea

tmen

t and

thos

e ou

t of t

reat

men

t)

52, 5

4, 5

5

Bio

med

ical

Iatr

ogen

ic tr

ansm

issi

on•

Few

rig

orou

s st

udie

s ei

ther

in d

evel

oped

or

deve

lopi

ngco

untr

ies

• R

estr

ictin

g bl

ood

dono

rs a

nd r

educ

ing

unsa

fe in

ject

ing

prac

tices

hav

e be

en e

ffect

ive

in r

educ

ing

iatr

ogen

ictr

ansm

issi

on

56–6

0

61, 6

2

Man

agem

ent o

f ST

Is

Com

mun

ity tr

ials

H

SV

-2c i

nfec

tion

• F

ew R

CT

s in

dev

elop

ed a

nd d

evel

opin

g co

untr

ies.

Tria

lsfo

und

mix

ed r

esul

ts fo

r re

duci

ng S

TD

and

HIV

inci

denc

e.E

ffect

s of

inte

rven

tion

varie

d by

stu

dy p

opul

atio

ns w

ithre

spec

t to

sexu

al r

isk

beha

viou

r, S

TI r

ates

and

sta

ge o

f HIV

epid

emic

• 2

met

a-an

alys

es a

sses

sing

cor

rela

tion

betw

een

HS

V-2

and

prev

alen

ce o

f HIV

• 1

RC

T c

ompl

eted

and

oth

ers

unde

r way

mea

surin

g ef

fect

s of

supp

ress

ive

HS

V-2

ther

apy

on H

IV tr

ansm

issi

on o

rac

quis

ition

67–7

1

72, 7

3

74, 7

5

65

92-4-120938-0_CH03_65

Typ

e o

f in

terv

enti

on

Co

mm

ents

on

th

e ev

iden

ceK

ey r

efer

ence

s

Ant

iretr

ovira

ls fo

r pr

even

ting

HIV

infe

ctio

n

Pre

vent

ing

mot

her

to c

hild

tran

smis

sion

P

ost-

expo

sure

pro

phyl

axis

A

ntire

trov

irals

for

prev

entin

g se

xual

tran

smis

sion

• R

CT

s an

d sy

stem

atic

rev

iew

in d

evel

oped

and

dev

elop

ing

coun

trie

s sh

ow s

tron

g ef

ficac

y of

ant

iretr

ovira

l the

rapy

bef

ore,

durin

g an

d af

ter

deliv

ery

for

prev

entin

g m

othe

r to

chi

ldtr

ansm

issi

on•

RC

Ts

show

effi

cacy

of b

reas

tfeed

ing

inte

rven

tions

• O

bser

vatio

nal s

tudi

es in

dev

elop

ed a

nd d

evel

opin

g co

untr

ies

indi

cate

effi

cacy

of p

ost-

expo

sure

pro

phyl

axis

• N

o R

CT

s co

mpl

eted

but

one

und

er w

ay in

bot

h de

velo

ping

and

deve

lope

d co

untr

ies

to e

xam

ine

rela

tions

hip

betw

een

low

erpl

asm

a vi

ral l

oad

due

to H

AA

RT

d and

redu

ced

sexu

al tr

ansm

issi

onof

HIV

• 1

obse

rvat

iona

l stu

dy in

dica

ted

decl

ine

in H

IV tr

ansm

issi

on ra

te a

tco

untr

y le

vel s

ince

intr

oduc

tion

of H

AA

RT

• R

CT

s un

der

way

in d

evel

oped

and

dev

elop

ing

coun

trie

s to

exam

ine

usin

g an

tiret

rovi

ral t

hera

py a

s pr

e-ex

posu

re p

roph

ylax

isam

ong

unin

fect

ed p

eopl

e

76–8

1

82 85–8

8

90 95 96, 1

47

Mal

e ci

rcum

cisi

on•

Obs

erva

tiona

l dat

a fr

om d

evel

opin

g co

untr

ies

sugg

est p

rote

ctiv

eef

fect

of c

ircum

cisi

on a

gain

st m

ale

acqu

isiti

on o

f HIV

infe

ctio

n fr

omfe

mal

es•

1 R

CT

in d

evel

opin

g co

untr

y co

nfirm

s fin

ding

s fr

om o

bser

vatio

nal

stud

ies;

sho

ws

stro

ng e

ffica

cy (

65–7

0% r

educ

tion

in r

isk)

• A

dditi

onal

RC

Ts

unde

r w

ay in

dev

elop

ing

coun

trie

s to

con

firm

100,

101

102

103

Vac

cine

s•

Onl

y 1

com

plet

ed p

hase

III R

CT

in d

evel

oped

and

dev

elop

ing

coun

trie

s; s

how

ed n

o ef

ficac

y•

Sec

ond

phas

e III

RC

T in

dev

elop

ing

coun

try

unde

r w

ay

104

105

66

92-4-120938-0_CH03_66

Mic

robi

cide

s•

RC

Ts

in d

evel

opin

g co

untr

ies

of n

onox

ynol

-9 p

rodu

cts

show

ed n

oef

ficac

y an

d po

ssib

le h

arm

• 4

cand

idat

es ta

rget

ing

diffe

rent

mec

hani

sms

of a

ctio

n in

pha

se II

Itr

ials

106,

107

109

Cer

vica

l bar

rier

met

hods

• Bas

ed o

n S

TI a

nd p

regn

ancy

dat

a, fe

mal

e co

ndom

s ar

e es

timat

edto

be

94%

to 9

7% e

ffect

ive

in r

educ

ing

risk

of H

IV in

fect

ion

• 7

RC

Ts

unde

r w

ay to

exa

min

e ef

fect

iven

ess

of d

iaph

ragm

inpr

even

ting

HIV

and

ST

I

111

122

So

cial

100%

con

dom

use

pro

gram

me

• O

bser

vatio

nal d

ata

show

dec

reas

ed v

isits

to s

ex w

orke

rs,

incr

ease

d co

ndom

use

and

dec

reas

ed H

IV in

cide

nce

amon

g T

hai

mal

e m

ilita

ry c

onsc

ripts

in 4

- ye

ar p

erio

d

128–

130

Syr

inge

acc

ess,

incl

udin

g ne

edle

or

syrin

ge e

xcha

nge

• O

bser

vatio

nal d

ata

from

dev

elop

ed c

ount

ries

show

ed s

tron

gev

iden

ce o

f effe

ctiv

enes

s of

syr

inge

acc

ess

prog

ram

mes

in te

rms

of d

ecre

ased

nee

dle

shar

ing

and

othe

r un

safe

dru

g us

e pr

actic

esas

wel

l as

posi

tive

effe

cts

on H

IV in

cide

nce

and

prev

alen

ce

132–

135

Eco

nom

ic e

mpo

wer

men

t int

erve

ntio

ns ta

rget

ing

wom

en•

Evi

denc

e fr

om 1

RC

T o

f mic

rocr

edit

prog

ram

me

in d

evel

opin

gco

untr

y in

dica

tes

no e

ffect

on

com

mun

ity-le

vel H

IV in

cide

nce

orre

duct

ion

in s

exua

l ris

k bu

t sig

nific

ant r

educ

tion

in p

hysi

cal a

ndse

xual

abu

se

138,

139

a R

CT

s =

ran

dom

ized

con

trol

led

tria

ls.

b S

TI =

sex

ually

tran

smitt

ed in

fect

ion.

c HS

V-2

= h

erpe

s si

mpl

ex v

irus-

type

2.

d H

AA

RT

= h

ighl

y ac

tive

antir

etro

vira

l the

rapy

.

67

92-4-120938-0_CH03_67

Second, we must not confuse a lack of implementation with a lack of effec-tiveness. Those who quickly dismiss HIV prevention interventions as “notworking” usually do not take into account the fact that most interventionswith proven effectiveness have not been implemented on a large scale normade available to a high proportion of the people in need of them, even amongthe populations where they have been implemented. Based on data fromUNAIDS, the Global HIV Prevention Working Group estimates that the pro-portion of individuals at risk of acquiring or transmitting HIV infection andwho have access to selected key prevention interventions is as follows: 5%have access to care to prevent mother to child transmission; 12% have accessto voluntary counselling and testing; 19% to harm reduction strategies; 24%to AIDS education; and 42% to condoms (149).

Of course, providing access to interventions is not the same as ensuring thequality of the intervention, so scale-up must include a quality assurance com-ponent. Moreover, where financial, political, social and individual commit-ments to HIV prevention wane, we can expect to see the erosion of preventionsuccess, as appears to be the case in such places as Thailand and Uganda.Prevention only works if it is sustained over time by individuals practisingrisk reduction or avoidance and by societies making commitments of humanand financial resources to facilitate and support prevention efforts for the longhaul.

Third, given that there is no perfect method for ascertaining the true effec-tiveness of interventions, we should accept different levels and types ofevidence (as described in chapter 4) that taken together are appropriate forguiding public health policy and practice. This means that for cases in whichwe do not have sufficient evidence from rigorous experimental studies, wemust use observational data; and our interpretation of the strength of evidencemust take into account the methodological strengths and weaknesses of dif-ferent data sources. Yet, as we commit to implementing and scaling-up thoseinterventions that we know work, we must also continually strive to improvethe quality and quantity of evidence on the effectiveness of HIV preventionstrategies, which means we must continue to push for more rigorous research.

In this regard we can identify a number of important directions for HIV pre-vention research. First, we must develop and test more behavioural interven-tions that target people who are HIV positive since the psychosocial bases ofthese interventions may be slightly different from those directed at peoplewho are HIV negative. And we must develop and test more social interven-tions to address many of the factors underlying vulnerability to HIV infectionamong specific groups of people. Second, we can improve and expand ourresearch methods. This should include developing more rigorously conductedintervention trials and observational (plausibility) studies, making better use

68

92-4-120938-0_CH03_68

of observational data, recording and analysing data on time trends in be-haviour and infection rates in settings with different mixes and intensities ofinterventions, using statistical modelling with study results and other data togain a better understanding of interventions’ effects and determiningappropriate outcome indicators for social-level interventions. Third, we mustcollect and provide more data on the costs, as well as the effectiveness, ofinterventions in order to make a more compelling case to policy-makers.Fourth, we must continue to invest in the prevention technologies that havethe greatest potential for bringing about population-level effects. Finally, wemust be more explicit and specific with the public and with policy-makersabout HIV prevention successes (and failures) and the evidence behind them.

Acknowledgements

The authors are grateful to the World Health Organization and UNAIDS, inparticular Bruce Dick and Jane Ferguson from the WHO Department of Childand Adolescent Health and Development, for inviting us to prepare thischapter and for convening meetings with the authors of other chapters andreviewers to discuss and improve its content. We owe particular thanks toDavid Ross from the London School of Hygiene and Tropical Medicine forhis excellent comments and editorial suggestions. JA and SK thank amfARfor providing the work environment and organizational resources that facil-itated our research and writing.

References

1. Stover J et al. Can we reverse the HIV/AIDS pandemic with an expandedresponse? Lancet, 2002, 360:73-77.

2. Auerbach JD, Coates TJ. HIV prevention research: accomplishments andchallenges for the third decade of AIDS. American Journal of Public Health,2000, 90:1029-1032.

3. Global HIV Prevention Working Group. Global mobilization for HIV prevention:a blueprint for action, 2002 (http://www.gatesfoundation.org/nr/downloads/globalhealth/aids/HIVprevreport_final.pdf).

4. Valdiserri RO, Ogden LL, McCray E. Accomplishments in HIV preventionscience: implications for stemming the epidemic. Nature Medicine, 2003,9:881-886.

5. Semaan S et al. A profile of U.S.-based trials of behavioural and socialinterventions for HIV risk reduction. Journal of Acquired Immune DeficiencySyndromes, 2002, 30 Suppl:S30-50.

6. Kelly JA, Kalichman SC. Behavioural research in HIV/AIDS primary andsecondary prevention: recent advances and future directions. Journal ofConsulting and Clinical Psychology, 2002, 70:626-639.

7. Crepaz N et al. Do prevention interventions reduce HIV risk behaviours amongpeople living with HIV? A meta-analytic review of controlled trials. AIDS, 2006,20:143-157

69

92-4-120938-0_CH03_69

8. Neumann MS et al. Review and meta-analysis of HIV prevention interventionresearch for heterosexual adult populations in the United States. Journal ofAcquired Immune Deficiency Syndromes, 2002, 30 Suppl 1:S106-117.

9. Kalichman S, Carey M, Johnson B. Prevention of sexually transmitted HIVinfection: a meta-analytic review of the behavioural outcome literature. Annalsof Behavioral Medicine, 1996, 18:6-15.

10. Elwy R et al. Effectiveness of interventions to prevent sexually transmittedinfections and human immunodeficiency virus in heterosexual men. Archivesof Internal Medicine, 2002, 162:1818-1830.

11. Johnson WD, Hedges LV, Diaz RM. Interventions to modify sexual riskbehaviors for preventing HIV infection in men who have sex with men. CochraneDatabase of Systematic Reviews, 2004, 1:CD001230

12. Mullen PD et al. Meta-analysis of the effects of behavioral HIV preventioninterventions on the sexual risk behavior of sexually experienced adolescentsin controlled studies in the United States. Journal of Acquired ImmuneDeficiency Syndromes, 2002, 30 Suppl 1:S94-105.

13. Prendergast M, Urada D, Podus D. Meta-analysis of HIV risk-reductioninterventions within drug abuse treatment programs. Journal of Consulting andClinical Psychology, 2001, 69:389-405.

14. Herbst JH et al. A meta-analytic review of HIV behavioral interventions forreducing sexual risk behavior of men who have sex with men. Journal ofAcquired Immune Deficiency Syndromes, 2005, 39:228-241.

15. Gallant M, Maticka-Tyndale E. School-based HIV prevention programmes forAfrican youth. Social Science and Medicine, 2004, 58:1337-1351.

16. Speizer IS, Magnani RJ, Colvin CE. The effectiveness of adolescentreproductive health interventions in developing countries: a review of theevidence. Journal of Adolescent Health, 2003, 33:324-348.

17. Semaan S et al. A meta-analysis of the effect of HIV prevention interventionson the sex behaviors of drug users in the United States. Journal of AcquiredImmune Deficiency Syndromes, 2002, 30 Suppl 1:S73-93.

18. Johnson WD et al. HIV intervention research for men who have sex with men:a 7-year update. AIDS Education and Prevention, 2005, 17:568-589.

19. Gibson DR, Flynn NM, Perales D. Effectiveness of syringe exchange programsin reducing HIV risk behavior and HIV seroconversion among injecting drugusers. AIDS, 2001,15

20. Ellis S et al. HIV prevention: a review of reviews assessing the effectiveness ofinterventions to reduce the sexual risk of HIV transmission, Health DevelopmentAgency, National Institute for Health and Clinical Excellence, 2003 (http://www.publichealth.nice.org.uk/page.aspx?o=502573, accessed 11 May 2004).

21. National Institutes of Health Consensus Development Program. Interventionsto prevent HIV risk behaviors, 1997 (http://consensus.nih.gov/1997/1997PreventHIVRisk104html.htm, accessed 15 May 2004).

22. Rosenfield A, Myer L, Merson M. The HIV/AIDS pandemic: the case forprevention, (http://www.kff.org/hivaids/upload/Fact-Sheet-The-HIV-AIDS-Pandemic-The-Case-for-Prevention.pdf, accessed 25 May 2005).

23. Merson MH, Dayton JM, O’Reilly K. Effectiveness of HIV preventioninterventions in developing countries. AIDS, 2000, 14 Suppl 2:S68-84.

70

92-4-120938-0_CH03_70

24. Catania JA et al. Methodological problems in AIDS behavioral research:influences on measurement error and participation bias in studies of sexualbehavior. Psychological Bulletin, 1990, 108:339-362.

25. Weinhardt LS et al. Reliability and validity of self-report measures of HIV-relatedsexual behavior: progress since 1990 and recommendations for research andpractice. Archives of Sexual Behavior, 1998, 27:155-180.

26. Plummer ML et al. “A bit more truthful”: the validity of adolescent sexualbehaviour data collected in rural northern Tanzania using five methods.Sexually Transmitted Infections, 2004, 80 Suppl 2:S49-56.

27. Kamb ML et al. Efficacy of risk-reduction counseling to prevent humanimmunodeficiency virus and sexually transmitted diseases: a randomizedcontrolled trial. Journal of the American Medical Association, 1998,280:1161-1167.( Project RESPECT Study Group.)

28. National Institute of Mental Health (NIMH) Multisite HIV Prevention Trial Group.The NIMH Multisite HIV Prevention Trial: reducing HIV sexual risk behavior.Science, 1998, 280:1889-1894.

29. Imrie J et al. A cognitive behavioural intervention to reduce sexually transmittedinfections among gay men: randomised trial. BMJ, 2001, 322:1451-1456.

30. Koblin B, Chesney M, Coates T. Effects of a behavioural intervention to reduceacquisition of HIV infection among men who have sex with men: the EXPLORErandomised controlled study. Lancet, 2004, 364:41-50.

31. Hayes RJ et al. The MEMA kwa Vijana project: design of a community-randomised trial of an innovative adolescent sexual health intervention in ruralTanzania. Contemporary Clinical Trials, 2005, 26:430-442

32. Ross DA et al. Community randomised trial of an innovative adolescent sexualhealth interventin programme in rural Tanzania: the MEMA kwa Vijana trial.(Unpublished data.)

33. Kamali A et al. Syndromic management of sexually-transmitted infections andbehaviour change interventions on transmission of HIV-1 in rural Uganda: acommunity randomised trial. Lancet, 2003, 361:645-652.

34. Stoneburner RL, Low-Beer D. Population-level HIV declines and behavioral riskavoidance in Uganda. Science, 2004, 304:714-718.

35. Halperin DT et al. The time has come for common ground on preventing sexualtransmission of HIV. Lancet, 2004, 364:1913-1915.

36. Gregson S et al. HIV decline associated with behavior change in easternZimbabwe. Science, 2006, 311:664-666.

37. Nelson KE et al. Changes in sexual behavior and a decline in HIV infectionamong young men in Thailand. New England Journal of Medicine, 1996,335:297-303.

38. Asiimwe-Okiror G et al. Change in sexual behaviour and decline in HIV infectionamong young pregnant women in urban Uganda. AIDS, 1997, 11:1757-1763.

39. Bessinger R, Akwara P, Helperin D. Sexual behvior, HIV and fertility trends: acomparative analysis of six countries, (http://www.cpc.unc.edu/measure/publications/pdf/sr-03-21b.pdf).

40. Shelton JD et al. Partner reduction is crucial for balanced “ABC” approach toHIV prevention. BMJ, 2004, 328:891-893.

71

92-4-120938-0_CH03_71

41. Serwadda D. Monitoring and evaluation of national HIV prevention, AIDS careand STD control programs: Uganda case study. (Unpublished data presentedat Towards Improved Monitoring and Evaluation of HIV Prevention, AIDS Careand STD Control Programs, 17–20 November 1999.)

42. Phoolcharoen W. HIV/AIDS prevention in Thailand: success and challenges.Science, 1998, 280:1873-1874.43.

43. Wawer M et al. Declines in HIV prevalence in Uganda: not as simple as ABC.(Unpublished data presented at 12th Conference on Retroviruses andOpportunistic Infections, Boston, MA, 22–25 February 2005.)

44. Hayes R, Weiss H. Epidemiology: understanding HIV epidemic trends in Africa.Science, 2006, 311:620-621.

45. Painter TM. Voluntary counselling and testing for couples: a high-leverageintervention for HIV/AIDS prevention in sub-Saharan Africa. Social Science andMedicine, 2001, 53:1397-1411.

46. Weinhardt LS et al. Effects of HIV counseling and testing on sexual riskbehavior: a meta-analytic review of published research, 1985-1997. AmericanJournal of Public Health, 1999, 89:1397-1405.

47. Coates TJP et al. Efficacy of voluntary HIV-1 counselling and testing inindividuals and couples in Kenya, Tanzania, and Trinidad: a randomised trial.Lancet, 2000, 356:103-111.

48. Maposhere C et al. General political issues raised in HIV counseling of 200couples in Zimbabwe (Unpublished data presented at XI InternationalConference on AIDS, Vancouver, 7–12 July 1996.)

49. Serwadda D et al. Gender specific HIV transmission/prevention in discordantcouples in rural Uganda. (Unpublished data presented at X InternationalConference on AIDS, Yokohama, 7–12 August 1994.)

50. Van der Straten A et al. Couple communication, sexual coercion and HIV riskreduction in Kigali, Rwanda. AIDS, 1995, 9:935-944.

51. NIMH Project Accept: A phase III randomized trial of community mobilization,mobile testing, same-day results, and post-test support for HIV in Sub-SaharanAfrica and Thailand (http://www.cbvct.med.ucla.edu/overview.html)

52. Gibson DR, Flynn NM, McCarthy JJ. Effectiveness of methadone treatment inreducing HIV risk behavior and HIV seroconversion among injecting drug users.AIDS, 1999, 13:1807-1818.

53. Institute of Medicine. No time to lose: getting more from HIV prevention.Washington, DC, National Academy Press, 2001.

54. Metzger DS et al. Human immunodeficiency virus seroconversion amongintravenous drug users in- and out-of-treatment: an 18-month prospectivefollow-up. Journal of Acquired Immune Deficiency Syndromes, 1993,6:1049-1056.

55. McLellan AT et al. Evaluating the effectiveness of addiction treatments:reasonable expectations, appropriate comparisons. Milbank Quarterly, 1996,74:51-85.

56. Mundee Y et al. Infectious disease markers in blood donors in northernThailand. Transfusion, 1995, 35:264-267.

72

92-4-120938-0_CH03_72

57. Chattopadhya D, Riley LW, Kumari S. Behavioural risk factors for acquisitionof HIV infection and knowledge about AIDS among male professional blooddonors in Delhi. Bulletin of the World Health Organization, 1991, 69:319-323.

58. Lackritz EM et al. Blood transfusion practices and blood-banking services in aKenyan hospital. AIDS, 1993, 7:995-999.

59. Schutz R et al. Excluding blood donors at high risk of HIV infection in a westAfrican city. BMJ, 1993, 307:1517-1519.

60. Gisselquist D et al. Four policies to reduce HIV transmission through unsterilehealth care. International Journal of STD and AIDS, 2003, 14:717-722.

61. Sloand EM, Pitt E, Klein HG. Safety of the blood supply. Journal of the AmericanMedical Association, 1995, 274:1368-1373.

62. Wong ES et al. Are universal precautions effective in reducing the number ofoccupational exposures among health care workers? A prospective study ofphysicians on a medical service. Journal of the American MedicalAssociation, 1991, 265:1123-1128.

63. Gisselquist D et al. Does selected ecological evidence give a true picture of HIVtransmission in Africa? International Journal of STD and AIDS, 2004,15:434-439.

64. Schmid GP et al. Transmission of HIV-1 infection in sub-Saharan Africa andeffect of elimination of unsafe injections. Lancet, 2004, 363:482-488.

65. Lopman BA et al. Individual level injection history: a lack of association with HIVincidence in rural Zimbabwe. PLoS Medicine, [Online journal] 2005, 2:e37.(http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0020037)

66. Fleming DT, Wasserheit JN. From epidemiological synergy to public healthpolicy and practice: the contribution of other sexually transmitted diseases tosexual transmission of HIV infection. Sexually Transmitted Infections, 1999,75:3-17.

67. Grosskurth H et al. A community trial of the impact of improved sexuallytransmitted disease treatment on the HIV epidemic in rural Tanzania. 2:baseline survey results. AIDS, 1995, 9:927-934.

68. Mayaud P et al. Improved treatment services significantly reduce theprevalence of sexually transmitted diseases in rural Tanzania: results of arandomized controlled trial. AIDS, 1997, 11:1873-1880.

69. Wawer MJ et al. Control of sexually transmitted diseases for AIDS preventionin Uganda: a randomised community trial. Lancet, 1999, 353:525-535. (RakaiProject Study Group.)

70. Orroth KK et al. Higher risk behaviour and rates of sexually transmitted diseasesin Mwanza compared to Uganda may help explain HIV prevention trialoutcomes. AIDS, 2003, 17:2653-2660.

71. Korenromp EL et al. Determinants of the impact of sexually transmitted infectiontreatment on prevention of HIV infection: a synthesis of evidence from theMwanza, Rakai, and Masaka intervention trials. Journal of InfectiousDiseases, 2005, 191 Suppl 1:S168-178.

72. Wald A, Link K. Risk of human immunodeficiency virus infection in herpessimplex virus type 2-seropositive persons: a meta-analysis. Journal ofInfectious Diseases, 2002, 185:45-52.

73

92-4-120938-0_CH03_73

73. Freeman EE et al. Herpes simplex virus 2 infection increases HIV acquisitionin men and women: systematic review and meta-analysis of longitudinalstudies. AIDS, 2006, 20:173-183

74. Nagot et al. Effect of HSV-2 suppressive therapy on HIV-1 genital shedding andplasma viral load: a proof of concept randomized double-blind placebocontrolled trial (ANRS 1285 trial). (Unpublished data presented at 13thConference on Retroviruses and Opportunistic Infections, Denver, CO, 5–8February 2006.)

75. Celum CM. Herpes simplex and the global epidemiology of HIV. (Unpublisheddata presented at the 11th Conference on Retroviruses and OpportunisticInfections, San Francisco, 8–11 February 2004.)

76. Connor EM et al. Reduction of maternal-infant transmission of humanimmunodeficiency virus type 1 with zidovudine treatment. New England Journalof Medicine, 1994, 331:1173-1180. (Pediatric AIDS Clinical Trials GroupProtocol 076 Study Group.)

77. Shaffer N et al. Short-course zidovudine for perinatal HIV-1 transmission inBangkok, Thailand: a randomised controlled trial. Lancet, 1999, 353:773-780.(Bangkok Collaborative Perinatal HIV Transmission Study Group.)

78. Wiktor SZ et al. Short-course oral zidovudine for prevention of mother-to-childtransmission of HIV-1 in Abidjan, Cote d’Ivoire: a randomised trial. Lancet,1999, 353:781-785.

79. Guay LA et al. Intrapartum and neonatal single-dose nevirapine compared withzidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala,Uganda: HIVNET 012 randomised trial. Lancet, 1999, 354:795-802.

80. Brocklehurst P. Interventions aimed at decreasing the risk of mother-to-childtransmission of HIV infection. Cochrane Database of Systematic Reviews,2004, 2:CD000102.

81. Tonwe-Gold B. Management of pregnant women in the MTCT plus program,(http://www.mtctplus.org/pdf/Maputo%202005/Pregnant%20Women/Cote%20dIvoire%20Experience_Tonwe-Gold.pdf).

82. Nduati R et al. Effect of breastfeeding and formula feeding on transmission ofHIV-1: a randomized clinical trial. Journal of the American MedicalAssociation, 2000, 283:1167-1174.

83. Amornwichet P et al. Preventing mother-to-child HIV transmission: the first yearof Thailand’s national program. Journal of the American Medical Association,2002, 288:245-248.

84. Cooper ER et al. Combination antiretroviral strategies for the treatment ofpregnant HIV-1-infected women and prevention of perinatal HIV-1transmission. Journal of Acquired Immune Deficiency Syndromes, 2002,29:484-494.

85. Cardo DM et al. A case-control study of HIV seroconversion in health careworkers after percutaneous exposure. New England Journal of Medicne, 1997,337:1485-1490. (Centers for Disease Control and Prevention NeedlestickSurveillance Group.)

86. Wulfsohn A. Post-exposure prophylaxis for HIV after sexual assault in SouthAfrica. (Unpublished data presented at the 2003 National HIV PreventionConference, Atlanta, GA, 27–30 July 2003.)

74

92-4-120938-0_CH03_74

87. Roland ME et al. Seroconversion following nonoccupational postexposureprophylaxis against HIV. Clinical Infectious Diseases, 2005, 41:1507-1513.

88. Bamberger J. HIV post-exposure prophylaxis after sexual assault and otherunprotected non-occupational exposures. (Unpublished data presented at the2003 National HIV Prevention Conference, Atlanta, GA, 27–30 July 2003).

89. Quinn TC et al. Viral load and heterosexual transmission of humanimmunodeficiency virus type 1. New England Journal of Medicine, 2000,342:921-929. (Rakai Project Study Group.)

90. HIV Prevention Trials Network. HPTN 052: a randomized trial to evaluate theeffectiveness of antiretroviral therapy plus HIV primary care versus HIV primarycare alone to prevent the sexual transmission of HIV-1 in serodiscordantcouples, (http://www.hptn.org/research_studies/hptn052.asp).

91. Cohen M. HIV prevention rsearch: new advances, continued challenges.(Unpublished data presented at the 13th Conference on Retroviruses andOpportunistic infections, Denver, CO, 5–8 February 2006.)

92. Gray R et al. Probability of HIV-1 transmission per coital act in monogamous,heterosexual, HIV-1-discordant couples in Rakai, Uganda. Lancet, 2001,357:1149-1153.

93. Blower S et al. Predicting the impact of antiretrovirals in resource-poor settings:preventing HIV infections whilst controlling drug resistance. Current DrugTargets. Infectious Disorders, 2003, 3:345-353.

94. Velasco-Hernandez JX, Gershengorn HB, Blower SM. Could widespread useof combination antiretroviral therapy eradicate HIV epidemics? LancetInfectious Diseases, 2002, 2:487-493.

95. Fang CT et al. Decreased HIV transmission after a policy of providing freeaccess to highly active antiretroviral therapy in Taiwan. Journal of InfectiousDiseases, 2004, 190:879-885.

96. Centers for Disease Control and Prevention. CDC’s clinical studies of daily oraltenofovir for HIV prevention, 2005 (http://www.cdc.gov/hiv/pubs/faq/Tenofovir_Q&A.pdf).

97. Cameron DW et al. Female to male transmission of human immunodeficiencyvirus type 1: risk factors for seroconversion in men. Lancet, 1989, 2:403-407.

98. Reynolds SJ et al. Male circumcision and risk of HIV-1 and other sexuallytransmitted infections in India. Lancet, 2004, 363:1039-1040.

99. Gray RH et al. Male circumcision and HIV acquisition and transmission: cohortstudies in Rakai, Uganda. AIDS, 2000, 14:2371-2381. (Rakai Project Team.)

100. Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infectionin sub-Saharan Africa: a systematic review and meta-analysis. AIDS, 2000,14:2361-2370.

101. Siegfried N et al. HIV and male circumcision – a systematic review withassessment of the quality of studies. Lancet Infectious Diseases, 2005,5:165-173.

102. Auvert B et al. Randomized, controlled intervention trial of male circumcisionfor reduction of HIV infection risk: the ANRS 1265 trial. PLoS Medicine, [Onlinejournal] 2005, 2:e298. (http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0020298)

75

92-4-120938-0_CH03_75

103. UNAIDS. UNAIDS statement on South African trial findings regarding malecircumcision and HIV, 2005 (http://www.who.int/mediacentre/news/releases/2005/pr32/en/).

104. AIDS Vaccine Advocacy Coalition. AIDS vaccine fails to show efficacy in Thaitrial, (http://www.avac.org/AIDSVAXthai.htm).

105. International AIDS Vaccine Initiative. Ongoing trials of preventive AIDSvaccines, (http://www.iavireport.org/specials/OngoingTrialsofPreventiveHIVVaccines.pdf).

106. Wilkinson D et al. Nonoxynol-9 for preventing vaginal acquisition of HIVinfection by women from men. Cochrane Database of Systematic Reviews,2002, 4:CD003936.

107. Van Damme L et al. Effectiveness of COL-1492, a nonoxynol-9 vaginal gel, onHIV-1 transmission in female sex workers: a randomised controlled trial.Lancet, 2002, 360:971-977.

108. Alliance for Microbicide Development. Microbiciodes and clinical trials, (http://www.microbicide.org/microbicideinfo/reference/clinical.trials.factsheet.pdf).

109. Alliance for Microbicide Development. Microbicide Research and DevelopmentDatabase (MRDD), (http://www.microbicide.org/microbicideinfo/reference/TMQvol2no12004.pdf).

110. Rockefeller Foundation. The public health benefits of microbicides in lower-income countries: model projections. New York, Rockefeller Foundation, 2002.

111. Trussell J et al. Comparative contraceptive efficacy of the female condom andother barrier methods. Family Planning Perspectives, 1994, 26:66-72

112. Gollub EL, Stein ZA.The new female condom–item 1 on a women’s AIDSprevention agenda. American Journal of Public Health, 1993, 83:498-500.

113. Gollub EL. The female condom: STD protection in the hands of women.American Journal of Gynecologic Health, 1993, 7:91-92.

114. Leeper MA. Preliminary evaluation of reality, a condom for women. AIDSCare, 1990, 2:287-290.

115. Moench TR, Chipato T, Padian NS. Preventing disease by protecting the cervix:the unexplored promise of internal vaginal barrier devices. AIDS, 2001,15:1595-1602.

116. Howell AL et al. Human immunodeficiency virus type 1 infection of cells andtissues from the upper and lower human female reproductive tract. Journal ofVirology, 1997, 71:3498-3506.

117. Magder LS et al. Factors related to genital Chlamydia trachomatis and itsdiagnosis by culture in a sexually transmitted disease clinic. American Journalof Epidemiology, 1988, 128:298-308.

118. Rosenberg MJ et al. Barrier contraceptives and sexually transmitted diseasesin women: a comparison of female-dependent methods and condoms.American Journal of Public Health, 1992, 82:669-674.

119. Kelaghan J et al. Barrier-method contraceptives and pelvic inflammatorydisease. Journal of the American Medical Association, 1982, 248:184-187.

120. Austin H, Louv WC, Alexander WJ. A case-control study of spermicides andgonorrhea. Journal of the American Medical Association, 1984, 251:2822-2824.

76

92-4-120938-0_CH03_76

121. Becker TM et al. Sexually transmitted diseases and other risk factors for cervicaldysplasia among southwestern Hispanic and non-Hispanic white women.Journal of the American Medical Association, 1994, 271:1181-1188.

122. Matthews J, personal communication, 2006.

123. Cervical Barrier Advancement Society. can diaphragms protect women fromHIV: an update on the mira trial. Cervical Barrier Advancement SocietyNewsletter, 2005, 2:1.

124. Sumartojo E. Structural factors in HIV prevention: concepts, examples, andimplications for research. AIDS, 2000, 14 Suppl 1:S3-10.

125. Sweat MD, Denison JA. Reducing HIV incidence in developing countries withstructural and environmental interventions. AIDS, 1995, 9 Suppl A:S251-257.

126. Blankenship KM, Bray SJ, Merson MH. Structural interventions in public health.AIDS, 2000, 14 Suppl 1:S11-21.

127. Blankenship KM et al. Structural interventions: concepts, challenges andopportunities for research. Journal of Urban Health: Bulletin of the New YorkAcademy of Medicine, 2006, 1-14.

128. Phoolcharoen W et al. Thailand: lessons from a strong national response toHIV/AIDS. AIDS, 1998, 12 Suppl B:S123-135.

129. Hanenberg RS et al. Impact of Thailand’s HIV-control programme as indicatedby the decline of sexually transmitted diseases. Lancet, 1994, 344:243-245.

130. Celentano DD et al. Decreasing incidence of HIV and sexually transmitteddiseases in young Thai men: evidence for success of the HIV/AIDS control andprevention program. AIDS, 1998, 12 Suppl F:S29-36.

131. WHO Regional Office for the Western Pacific. Meeting on the 100% CondomUse Programme For Prevention of HIV/AIDS and STI. (Unpublished data frommeeting in Vientiane, Lao People’s Democratic Republic, 18–21 August 2003.)

132. Hurley SF, Jolley DJ, Kaldor JM. Effectiveness of needle-exchangeprogrammes for prevention of HIV infection. Lancet, 1997, 349:1797-1800.

133. Des Jarlais DC et al. Maintaining low HIV seroprevalence in populations ofinjecting drug users. Journal of the American Medical Association, 1995,274:1226-1231.

134. Ksobiech K. A meta-analysis of needle sharing, lending, and borrowingbehaviors of needle exchange program attenders. AIDS Education andPrevention, 2003, 15:257-268.

135. Satcher D-SG. Evidence-based findings on the efficacy of syringe exchangeprograms: an analysis of the scientific research completed since April 1998.Washington, DC, U.S. Department of Health and Human Services, 2000.

136. National Research Council. Preventing HIV transmission: the role of sterileneedles and bleach. Washington, DC, National Academy Press, 1995.

137. Pitt MM et al. Credit programs for the poor and reproductive behavior in low-income countries: are the reported causal relationships the result ofheterogeneity bias? Demography, 1999, 36:1-21.

138. Hargreaves J et al. Social interventions for HIV/AIDs: intervention with micro-finance for AIDS and gender equity, (http://www.sarpn.org.za/mitigation_of_HIV_AIDS/m0025/index.php).

77

92-4-120938-0_CH03_77

139. Pronyk P, Hargreaves J, personal communication, 2006.

140. Newman PA et al.. Challenges for HIV vaccine dissemination and clinical trialrecruitment: if we build it, will they come? AIDS Patient Care and STDS, 2004,18:691-701.

141. AIDS Vaccine Advocacy Coalition. AIDS vaccines trials: getting the globalhouse in order. New York, AIDS Vaccine Advocacy Coalition, 2004.

142. Mantell JE et al. Microbicide acceptability research: current approaches andfuture directions. Social Science and Medicine, 2005, 60:319-330

143. Fleming TR, Richardson BA. Some design issues in trials of microbicides forthe prevention of HIV infection. Journal of Infectious Diseases, 2004,190:666-674.

144. Blower S. Modeling the potential public health impact of imperfect HIV vaccines.Journal of Infectious Diseases, 2005, 192:1494-1495. (Author reply:1495-1496.)

145. Cassell MM et al. Risk compensation: the Achilles’ heel of innovations in HIVprevention? BMJ, 2006, 332:605-607.

146. Cates W. Future HIV prevention trials: sexual transmission.(Unpublished datapresented at the 3rd International AIDS Society Conference, Rio de Janeiro,26 July 2005.)

147. AIDS Vaccine Advocacy Coalition. Will a pill a day prevent HIV? New York,AIDS Vaccine Advocacy Coalition, 2005:9.

148. Community HIV/AIDS Mobilization Project, AIDS Vaccine Advocacy Coalition,Gay Men’s Health Crisis, Group TA. A statement of support for HIV preventionresearch on pre-exposure prophylaxis. New York, Community AIDS/HIVMobilization Project, 2006.

149. Global HIV Prevention Working Group. Access to HIV prevention: closing thegap, (http://www.kff.org/hivaids/200305-index.cfm).

78

92-4-120938-0_CH03_78

4. The weight of evidence: a methodfor assessing the strength ofevidence on the effectiveness ofHIV prevention interventions amongyoung peopleDavid A Ross,a Danny Wight,b Gary Dowsett,c Anne Buvé,d

& Angela I N Obasie

Objectives To design a method for assessing the strength of evidence on theeffectiveness of different interventions to prevent the spread of HIV that willbe the basis for the reviews in this series.

Methods The literature on the evaluation of public health interventions wasreviewed, and a method was developed in consultation with colleagues in-volved in this series of reviews and others.

Findings The method involves the following steps. First, define the key typesof intervention that policy-makers need to choose between in the populationsetting under consideration. Second, define the strength of evidence thatwould be needed to justify widespread implementation of the intervention.Third, develop explicit inclusion and exclusion criteria for the studies underreview. Fourth, critically review all eligible studies and their findings, byintervention type. Fifth, summarize the strength of the evidence on the ef-fectiveness of each type of intervention. Sixth, compare the strength of theevidence provided by the studies against the threshold of evidence that wouldbe needed to recommend widespread implementation. Seventh, from thiscomparison, derive evidence-based recommendations related to the imple-mentation of each type of intervention in the setting or population group.

a Infectious Disease Epidemiology Unit, London School of Hygiene and Tropical Medicine,Keppel Street, London WC1E 7HT, England. Correspondence should be sent to Dr Ross(email: david.ross@lshtm.ac.uk).

b MRC Social and Public Health Sciences Research Unit, Glasgow, Scotland.c Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne,

Australia.d STD/HIV Research and Intervention Unit, Institute of Tropical Medicine, Antwerp, Belgium.e Liverpool School of Tropical Medicine, Liverpool, England.

79

92-4-120938-0_CH04_79

Conclusions The method proposed here provides a systematic, rigorous andtransparent approach to reviewing evidence on the effectiveness of interven-tions of different types and in different population settings in order to generaterecommendations for policy-makers.

4.1 Introduction

The AIDS epidemic is a major public health emergency, and young peopleare bearing the main brunt of new infections worldwide. There is an urgentneed to work towards a consensus on what should be done in order to meetthe internationally accepted goals for the prevention of HIV among youngpeople that were defined at the United Nations General Assembly SpecialSession on HIV/AIDS (UNGASS) in 2001 (1). These global goals are pre-sented and discussed in chapter 1, but in sum they give specific targets forimproving access to information, skills and services; reducing vulnerability;and reducing HIV prevalence.

In an area as important as preventing the spread of HIV among young peoplein developing countries, difficult choices have to be made by policy-makersand programme developers irrespective of whether the evidence that is avail-able to guide these decisions is weak or strong. Although evidence on theeffectiveness of interventions will be only one of the factors that policy-makers use when deciding in which programmes to invest, a systematicreview of the evidence related to all the options will be more useful to themthan piecemeal reviews using different criteria and weights for different typesof evidence. As in most areas of social policy, gaining consensus on the rel-ative weights that should be given to different types of evidence has beendifficult, but for policy decisions to be rational and transparent, reaching suchconsensus is crucially important. Furthermore, the lack of any explicit policyor programme is in fact a policy decision. And, finally, because of the com-plexity of the interventions, the evidence for and against any interventionstrategy is likely also to be complex, requiring the synthesis of multiple typesof evidence of varying quality and weight. Evaluation researchers shouldprovide evidence that is as valid as possible to policy-makers and ensure thatit is synthesized and presented in a way that will make it relevant, accessibleand easy to interpret and act on.

While recognizing that there are major obstacles to rational evidence-baseddecision-making in this field, this chapter aims to indicate a way forward bypresenting a structure within which researchers, advisers and policy-makerscan assess the strength of the evidence for each of the interventions discussedin subsequent chapters in this series. In this chapter we are concerned withthe broad principles involved in assessing the evidence. Later chapters in theseries will address how these principles apply to specific interventions. The

80

92-4-120938-0_CH04_80

criteria that we propose for assessing the evidence draw on recent debates onthe relative merits and limitations of randomized controlled trials (2–7), andsuggestions for approaches to the evaluation of evidence on public healthinterventions (6, 8–10), and to the presentation and systematic review of studyresults (11–15).

4.2 Types of interventions and evidence on effectiveness

Most of the programmes that have been introduced or advocated to reducethe prevalence of HIV among adolescents are complex, often comprisingcombinations of components, such as:

in-school teacher-led sex and/or life skills education;

in-school peer education and/or mentoring or counselling;

specific interventions (such as peer education) for out-of-school youths(including those who would be expected to be in school but are not), forspecific groups of youths (for example, groups affiliated with religiousorganizations) and for groups at high risk of HIV (such as intravenous drugusers, commercial sex workers or men who have sex with men);

condom promotion and improved access to condoms (for example, throughsocial marketing, health-worker training, providing supplies or reorganiz-ing clinical services);

youth-friendly health services;

access to counselling and voluntary HIV testing;

access to care, support and treatment for people who are HIV positive;

community development approaches to modifying sexual and socialnorms;

mass media approaches to changing social values, norms and behaviours;

legislative changes.

These components may be targeted at different levels, including the individ-ual (for example, by providing life skills training), the family (for example,by improving intrafamily communication about sexuality) and the commu-nity (for example, by providing access to youth-friendly health services, massmedia campaigns aimed at changing norms in society regarding gender rolesor interventions directed towards men to decrease girls’ vulnerability). Fur-thermore, many of these specific components are, in themselves, complex in-terventions. To be effective, most would involve bringing about profound socialand behavioural changes among both the implementers (for example, who

81

92-4-120938-0_CH04_81

must respect confidences and understand and empathize with young people’sconcerns) and the potential target groups; however, evaluating such outcomesis notoriously difficult. Finally, when a programme is made up of severalinterventions, often with a different emphasis given to each, it is difficult toassess the relative effectiveness of each component.

The key policy questions are:

which interventions should be selected?

in which contexts are they appropriate?

what proportion of the available resources should be allocated to each?

The complexity of the interventions and the inadequacy of evaluations ofthem mean that policy decisions will often need to be based only on partialor imperfect evidence. Some of the reasons for this imperfect evidence aresummarised in Box 4.1.

Box 4.1

Obstacles to obtaining perfect evidence

HIV prevention interventions are complex

There are numerous interventions and strategies to choose from.

The content and quality of interventions may differ substantially from oneanother, and interventions may be implemented in different ways by dif-ferent people. For example, two life-skills programmes in secondaryschools that have different content and theoretical bases and are deliv-ered in different ways are likely to have different impacts.

The interventions needed to address the five UNGASS goals (seechapter 1) will be social interventions of varying and often substantialdegrees of complexity. This will necessarily complicate their evaluation.

The mechanisms by which these strategies are meant to work arediverse, complex and poorly understood. In contrast to the biologicalmechanisms by which therapeutic drugs work, there is far less con-sensus on the workings of the social world in and through whichbehavioural interventions operate (16).

Lack of understanding of the mechanisms raises the added problemthat purported intermediate outcomes may or may not be valid. Forexample, an increase in the skills needed to avoid HIV infection maynot necessarily result in a reduction in HIV prevalence amongadolescents.

82

92-4-120938-0_CH04_82

Specific interventions may be synergistic or even antagonistic, and yetmost programmes will combine several intervention strategies, makingevaluation of the effects of specific interventions or components withinthe programme package difficult or impossible to disentangle.

Evaluating interventions targeting young people is difficult

Measuring the ultimate goal of reducing HIV prevalence among youngpeople requires that substantial numbers of young people are followedup for several years at considerable cost.

The validity of surrogate outcome measures, such as reported sexualbehaviour, may be particularly problematic among young people be-cause of the effects of social desirability biases, age differencesbetween researchers and respondents, etc. (17).

This age group is particularly mobile and therefore difficult to followthrough longitudinal research.

Evaluation strategies cannot be standardized

It is intrinsically easier to evaluate the effectiveness of some interven-tions (such as those targeted at individuals) than others (such as thosetargeted at whole communities or nations).

The timescales in which the various interventions might work varywidely. For example, condom promotion and supply or treatment of othersexually transmitted infections may produce measurable outcomes in arelatively short time, while other approaches, such as changing the so-cioeconomic status of women, may be expected to have a substantialimpact on HIV prevalence among adolescents only in the longer term.Furthermore, some interventions may have longer lasting effects thanothers.

Evaluation results are not always generalizable

The impact of an intervention may vary substantially according to thesetting in which it is delivered and the broader context. For instance, theeffectiveness of a life-skills programme may differ according to the de-gree of control young women have over their sexuality in that culture.

Furthermore, the impact of an intervention within a tightly controlledevaluation setting may be different from that within a routine programme.

The contested nature of evidence itself

Different people accord different weight to different types of evidence.This often reflects their disciplinary background, and sterile debates be-tween “positivists” and “interpretivists” or “relativists” have been at leastas common as constructive discussions in this field (18).

83

92-4-120938-0_CH04_83

The need to make decisions using imperfect evidence is the norm when for-mulating social policy. In fact, within the field of HIV prevention, theevidence available to enable us to make rational policy decisions, and theconsensus among researchers and policy-makers, may be greater than it is inmany other areas of social policy (19). One reason for this relative consensushas been the fact that explicit theoretical models for how interventions arepostulated to work exist for most, if not all, of the major interventions thathave been proposed for inclusion in programmes to reduce HIV prevalencein adolescents. These models are often imperfect, and empirical evidence forthe causal chain within any given model is often weak and sometimes missing,but plausible models usually do exist, often based on social or psychologicaltheory, though also occasionally on biological theory (such as the potentialeffectiveness of condoms if used correctly).

4.3 Thresholds for strength of evidence needed for widespreadimplementation

Some types of interventions need stronger evidence than others in order tobe recommended for widespread implementation. The strength of the evi-dence needed depends on their feasibility (including cost), potential foradverse outcomes, acceptability, potential size of effect and potential for otherhealth or social benefits.

The more feasible the intervention, the lower the threshold of evidenceneeded. Key areas in this domain include the logistics, cost and humanresources required for its implementation. The question is: can it be im-plemented on a large scale in a way that will be sustainable?

The lower the potential for adverse outcomes, the lower the threshold ofevidence needed. For example, is there any evidence that the interventioncould actually lead to increased HIV incidence or to violations of humanrights (20) or could it put individuals at an increased risk of domesticviolence? Ideally, the assessment of potential adverse outcomes should notbe limited to short-term outcomes among the specific individuals targetedbut should also include longer-term outcomes within the wider community.For example, in evaluating male circumcision, the assessment should notrestrict itself to the impact on the young men who are circumcised. It shouldalso consider the possibility that encouraging male circumcision might leadto more circumcisions being performed in informal non-sterile circum-stances, that appearing to endorse “circumcision” might lead to increasedfemale genital cutting, and that it might increase sexual risk-taking becausethose circumcised may think they are “immune” from HIV and other sex-ually transmitted infections.

84

92-4-120938-0_CH04_84

The more acceptable the intervention, the lower the threshold of evidenceof effectiveness required. The intervention’s acceptability needs to be as-sessed not only among the target group but also among implementers,politicians, donors, religious and other community leaders, and within thewider community. A controversial intervention will require stronger evi-dence than a well accepted intervention simply because of the greaterreluctance that policy-makers will have to introduce it because of the riskof opposition or protest from key stakeholders. For example, in most con-texts policy-makers are likely to be reluctant to introduce active condompromotion and provision within primary schools and more likely to allowthe provision of basic information about what HIV is and how it is spread.

The greater the potential size of the effect, the lower the required evidencethreshold. Not surprisingly, given the complexity described above, mostinterventions do not have empirical evidence of their impact on key out-comes such as HIV prevalence. In the absence of this, however, it mightbe possible to make a plausible assessment of maximum potential impactbased on theoretical grounds, process evaluation data or data on interme-diate outcomes. Policy-makers might be more willing to gamble on anintervention that has the potential to bring about a major beneficial impact(as long as its cost and potential for adverse outcomes are low and its ac-ceptability and potential sustainability are high) than on another interven-tion that may have only a marginally beneficial impact. A related issue isthe time required to achieve a measurable effect: the longer the timeneeded, the higher the evidence threshold.

Some interventions, such as increased access to schooling for girls, mayreceive additional justification because they are associated with otherhealth or social benefits. If so, policy-makers might reasonably have alower threshold for the strength of evidence of the intervention’s impacton HIV risk.

Subsequent papers in this series review the evidence on interventions in fivedifferent “settings”: schools, health services, geographically definedcommunities, specific population groups at high risk of HIV infection, andinterventions delivered through the mass media. The grid in Box 4.2 has beenused in the “settings” papers in this series to decide what threshold of evidencea particular type of intervention requires in order for it to be recommendedfor widespread implementation in developing countries. The decision on thestrength of evidence needed for widespread implementation should be takenprior to considering the actual evidence that is available for a particular typeof intervention. The examples in Box 4.3 illustrate why some interventionsrequire stronger evidence (that is, have a higher evidence threshold) thanothers.

85

92-4-120938-0_CH04_85

Box

4.2

Th

resh

old

of

evid

ence

nee

ded

to

rec

om

men

d w

ides

pre

ad im

ple

men

tati

on

in a

dev

elo

pin

g c

ou

ntr

y, b

ased

on

fiv

e ke

y at

trib

ute

s o

f th

ein

terv

enti

on

Th

resh

old

of

evid

ence

nee

ded

Att

rib

ute

s o

f th

e in

terv

enti

on

Fea

sib

leL

ow

ris

k o

f ad

vers

eo

utc

om

esA

ccep

tab

le (

to t

arg

etp

op

ula

tio

n, p

ract

itio

ner

s,g

atek

eep

ers)

Lar

ge

po

ten

tial

eff

ect

size

Oth

er h

ealt

h o

r so

cial

ben

efit

s

Low

DD

Med

ium

DD

DH

igh

XX

XX

X

Key =

nec

essa

ryD

= d

esira

ble

X =

not

nec

essa

ry

86

92-4-120938-0_CH04_86

Box

4.3

Exa

mp

les

of

inte

rven

tio

ns

and

th

resh

old

s o

f ev

iden

ce n

eed

ed t

o r

eco

mm

end

wid

esp

read

imp

lem

enta

tio

n

Inte

rven

tio

nF

easi

ble

Lo

w r

isk

of

adve

rse

ou

tco

mes

Acc

epta

ble

(to

tar

get

po

pu

lati

on

,p

ract

itio

ner

s,g

atek

eep

ers)

Lar

ge

po

ten

tial

effe

ct s

ize

Oth

er h

ealt

h o

r so

cial

ben

efit

sT

hre

sho

ld o

fev

iden

ce

Info

rmat

iona

Yes

Yes

Yes

Pro

babl

y no

tY

es (

cont

race

ptio

n m

aybe

use

d, p

reva

lenc

e of

ST

Iscm

ay b

e re

duce

d)

Low

Con

dom

s in

sch

ools

bY

esP

erce

ived

pot

entia

l to

incr

ease

pro

mis

cuity

(alth

ough

ther

e is

evid

ence

that

this

rare

ly, i

f eve

r, o

ccur

s)

No

(esp

ecia

lly a

mon

gte

ache

rs a

ndga

teke

eper

s)

Yes

Yes

(pr

ovid

esco

ntra

cept

ion,

prev

alen

ce o

f ST

Is m

aybe

red

uced

)

Hig

h

a F

or e

xam

ple,

pro

visi

on o

f bas

ic in

form

atio

n on

the

caus

e of

AID

S, h

ow it

can

be

tran

smitt

ed, a

nd h

ow it

can

be

avoi

ded,

esp

ecia

lly e

arly

inan

epi

dem

ic.

b F

or e

xam

ple,

pro

mot

ion

of th

e us

e of

con

dom

s an

d pr

ovis

ion

of c

ondo

ms

with

in s

choo

ls.

c ST

Is =

sex

ually

tran

smitt

ed in

fect

ions

.

87

92-4-120938-0_CH04_87

For each type of intervention, the recommendations relating to whether aparticular intervention should be implemented depend on the pre-definedthreshold of evidence needed and the degree to which the evidence meets thatthreshold. Four kinds of recommendation are found in the papers: widespreadimplementation now (categorized as “Go”), widespread implementation withcareful evaluation in terms both of outcomes and processes (“Ready”), im-plementation within specific evaluation studies but not yet in large-scaleroutine intervention programmes (“Steady”), or do not implement becausethere is strong evidence of a lack of effectiveness or there is evidence ofharmful effects (“Do not go”) (see also chapter 1). In this series of papers,the guidelines in Box 4.4 were developed to assist authors in reaching deci-sions about which recommendation should be made for each intervention.

4.4 What information do policy-makers need?

Ideally, detailed and clear information is needed on all of the following as-pects of any intervention under consideration:

a detailed description of the characteristics of the most promising ap-proaches or strategies for implementing a particular intervention, includingits content, delivery setting, intensity of implementation (for example, thenumber of hours of training or education involved) and the human, finan-cial and other resource requirements;

the theoretical mechanism by which the intervention is postulated to leadto a reduction in HIV prevalence in young people. Ideally, as well as therebeing a plausible mechanism, there should also be empirical evidence thatthe intervention actually works through this mechanism and evidence thatrelevant changes can occur through this mechanism. As will be discussedin the next section, this evidence need not necessarily come from the spe-cific field of HIV prevention in young people or even HIV prevention atall. It could equally well be drawn from evaluations of interventions usingthe same mechanism to achieve other outcomes. For example, evidence ofthe effectiveness of mass media as a mechanism for influencing behaviourcould come from interventions related to, for instance, drug abuse, health-ier eating, safer driving or the use of seat-belts (18, 19);

the feasibility and cost of its implementation, including its sustainabilityand acceptability to different stakeholders. For instance, there is little valuein implementing an intervention that would be too expensive to disseminatewidely, would require skills or knowledge that the implementers do nothave or could be trained in readily, or that is resisted by the professionalsthat are meant to implement it. Clearly, taking practitioners’ views intoaccount is likely to be critical in assessing feasibility;

88

92-4-120938-0_CH04_88

Box

4.4

Gu

idel

ines

fo

r m

akin

g r

eco

mm

end

atio

ns

of

“Ste

ady”

, “R

ead

y”, “

Go

” o

r “D

o n

ot

go

”

Min

imu

m c

rite

ria

to r

eco

mm

end

Inte

rven

tio

ns

nee

din

g a

hig

hth

resh

old

of

evid

ence

to

be

reac

hed

Inte

rven

tio

ns

nee

din

g a

tle

ast

a lo

wth

resh

old

of

evid

ence

tob

e re

ach

edG

oR

ead

yS

tead

yD

o n

ot

go

Go

Rea

dy

Ste

ady

Do

no

t g

oQ

ual

ity

of

inte

rven

tio

n

Ide

ntifi

ed m

echa

nism

of a

ctio

nN

NN

Na

NA

NN

NN

aN

A

Exp

erie

ntia

l bas

e

Ade

quat

e in

tens

ity, d

urat

ion

and

com

plet

enes

sN

Na

NN

a

Qu

alit

y o

f ev

iden

ce f

or

po

siti

ve o

utc

om

es

Car

eful

pilo

t or

info

rmed

judg

emen

tN

AN

A(N

eg)

NA

NA

(Neg

)

Evi

denc

e of

ass

ocia

tions

NA

NA

NN

a(N

eg)

NA

NN

a(N

eg)

P

laus

ibili

ty e

vide

nceb

NA

NN

aN

egN

Na

NN

(Neg

)

Pro

babi

lity

evid

ence

cN

Na

NN

Neg

NN

NN

NN

Neg

Evi

den

ce

Pro

babl

e si

ze o

f pos

itive

effe

ctd

MS

aN

AN

egS

aS

aS

Neg

P

ositi

ve e

ffect

is in

the

cultu

ral c

onte

xt b

eing

pro

pose

dN

Na

NN

aN

egN

Na

NN

aN

eg

Con

sist

ency

of f

indi

ngs

in >

1 s

tudy

NN

aN

egN

Na

Neg

a A

reas

whe

re fu

rthe

r re

sear

ch s

houl

d co

ncen

trat

e.b

Cas

es in

whi

ch o

ther

pot

entia

l exp

lana

tions

hav

e be

en la

rgel

y di

scou

nted

.c E

vide

nce

from

ran

dom

ized

con

trol

led

tria

ls.

d T

his

is b

ased

on

the

stat

istic

al e

ffect

siz

e pl

us th

e “r

each

” of

the

inte

rven

tion.

= n

eces

sary

con

ditio

nN

N =

not

a n

eces

sary

con

ditio

nN

A =

not

app

licab

leN

eg =

neg

ativ

e (h

arm

ful)

effe

ct is

suf

ficie

nt c

ondi

tion

for

“Do

not g

o”(N

eg)

= s

uffic

ient

con

ditio

n to

rec

omm

end

“Do

not g

o” if

lack

of e

ffect

iven

ess

or h

arm

ful e

ffect

s fo

und

in s

ever

al s

tudi

es fo

r th

is ty

pe o

f int

erve

ntio

nS

= p

roba

ble

size

of b

enef

icia

l effe

ct is

at l

east

sm

all

M =

pro

babl

e si

ze o

f ben

efic

ial e

ffect

is a

t lea

st m

oder

ate.

89

92-4-120938-0_CH04_89

in evaluating the strength of evidence provided by a particular study, it isessential to have detailed evidence on the actual process of delivery of theintervention that establishes the extent and quality of delivery as well asevidence on intermediate indicators that support the theoretical mechanismof the intervention (16). For example, for an intervention based on in-school teaching sessions, process information might include data on thenumber and quality of sessions taught, attendance rates at these sessionsand a qualitative assessment by the participants of the sessions’ usefulness,appropriateness and relevance. The evidence collected by implementers orpractitioners in their daily work can be valuable in offering insights intothe daily operations of an intervention and into the kinds of evidence prac-titioners draw on in their work. Evidence and evaluations at the level ofdaily practice or through “learning by doing” are often needed to framefuture policy. Yet evaluators sometimes do not take into account the keyfact that – to be effective when it is scaled-up from a pilot project to thenational scale – interventions are likely to need further modifications. Ad-ditionally, issues such as political commitment, feasibility, cost and ac-ceptability to implementers and gatekeepers will increase in importance;

the degree to which the intervention’s effectiveness is dependent on thespecific context in which it is being implemented, for instance the setting,the local and national sociocultural contexts and the specific time periodor specific group involved. Information on the context will elucidate fac-tors that may have been necessary preconditions for the intervention tohave had the effects observed. Conversely, such evidence will help policy-makers decide on its likely generalizability to other settings or populations.If an intervention has been shown to be highly effective in multipledifferent, but relevant, contexts, this increases the likelihood that it mayalso be effective in a new context (21);

the effectiveness of the intervention in achieving each of the five keyUNGASS goals (1) described in the introductory chapter using appropriateoutcomes. These goals are:

Goal 1 – provide appropriate information to young people and evidenceof improvements in their resulting knowledge.Goal 2 – provide appropriate skills training to young people and evi-dence of their ability to demonstrate these skills, and, if possible,evidence that they have actually used these skills to decrease their riskof becoming infected.Goal 3 – provide appropriate skills-based training, equipment and sup-plies to health-workers and evidence of this resulting in increaseddelivery of effective, high quality health services to young people. Inthis context, the health services that are particularly important include

90

92-4-120938-0_CH04_90

providing advice, counselling on the sexual health (and other concerns)of young people, condoms, treatment for sexually transmitted infec-tions, HIV counselling and testing, and family planning. Clean needles,and other medical instruments and uninfected blood products are es-sential (see chapter 6).Goal 4 – provide evidence of decreased vulnerability to HIV amongyoung people, such as changes in the attitudes and behaviours of adultcommunity members, fewer girls having to resort to “survival sex”, andreductions in HIV prevalence among young people’s potential sexualpartners.Goal 5 – provide evidence of a reduction in HIV prevalence amongyoung people that can be attributed to the intervention.

Policy-makers will also need to know many other things: the scale, trendsand likely future course of the epidemic in their region, country or districtand within specific subgroups of the population (for example, among youngpeople as a whole – that is, those aged 10–24 years, adolescents – those aged10–19 years – and youths – aged 15–24 years, married and unmarried youngpeople, rural and urban young people, injecting drug users, commercial sexworkers and men who have sex with men). Furthermore, policy-makers arelikely to put much more weight on some outcomes, such as a decrease inincidence or prevalence of HIV, than on other outcomes, such as those relatedto the global goals on knowledge, skills, services and vulnerability.

4.5 Assessing the quality of an intervention

Results from a high quality evaluation of a poor quality intervention (that is,an intervention that is badly conceived or badly implemented) merit lessweight than those from a high quality evaluation of a good quality interven-tion. For example, only low weight should be given to the outcome results ofa rigorous evaluation of an intervention in schools in which only 20% of thesessions were actually taught. On the other hand, a process evaluation thatseeks to explain why this intervention was not delivered effectively in thisparticular context might be of great value for future attempts to develop aneffective delivery strategy for this intervention.

Some criteria that may be used to assess the quality and appropriateness ofan intervention are listed below.

Relevance: How relevant is the intervention to HIV prevention amongyoung people? Are the main objectives relevant? Is the intervention rele-vant to this context? For example, in contexts where most HIV infectionis transmitted through injecting drug use, an intervention that ignores thismode of transmission will be of only limited relevance.

91

92-4-120938-0_CH04_91

Experiential base: To what extent was the intervention developed in thelight of existing experience with similar interventions either by drawingon the literature or practitioners’ experience?

Theoretical basis: Is there an explicit and plausible theoretical mechanismby which the intervention is postulated to contribute to a reduction in HIVprevalence among young people? Added weight should be given to thiscriterion if there is evidence that a particular mechanism has worked inother contexts or for other outcomes. For example, if the intervention in-volves peer education, what is the evidence that peer education has workedin other contexts, such as among older adults or in high-income countries,or for other outcomes, for example programmes directed at preventing do-mestic violence or decreasing the consumption of alcohol, tobacco andother drugs?

Careful pilot testing: Has the intervention undergone successful pilottesting in the relevant target group? Has it been appropriately evaluatedand modified?

Feasibility: Is the intervention logistically viable, acceptable to the rele-vant stakeholders, and can it be widely disseminated and sustained givenexisting and projected funds and human resources?

Quality and completeness of implementation: Has the intervention beenimplemented to a high standard?

Other chapters in this series will address the extent to which specific inter-ventions to achieve the global UNGASS goals meet these criteria.

4.6 Types of evidence and their relative weight

There is a wide array of types of evidence that can be used to guide policy.These range from informed judgements based on experience without any ob-jective evidence of impact on the indicators of the five UNGASS goalsthrough to evidence that is based on more rigorous qualitative and quantitativeevaluations of the processes, implementation and outcomes of interventions.One can distinguish between criteria by which to assess the methodologicalquality or soundness of evidence in its own right and criteria by which moreor less weight might be given to findings from different types of evaluationresearch of equally high quality.

4.6.1 Assessing the methodological quality of evidence

The criteria for good evaluation evidence are largely the same as those forresearch evidence in general, and they can be found in numerous research

92

92-4-120938-0_CH04_92

methodology textbooks (22, 23). Some of the main criteria that apply to bothqualitative and quantitative research are summarized below.

Transparency: How clear are all aspects of the research design, the the-oretical framework for the study and the literature base? Are the aims andobjectives explicit? Is there a clear description of the data collection meth-ods and how the data were analysed? Is the completeness of the data clear(such as, refusals to participate, partial participation, losses to follow-up)?Are possible biases of the researchers made explicit?

Representativeness of the data: Can the findings be assumed to apply tothe whole population or group that they are purported to apply to?

Data presentation: Are sufficient data included to mediate between thedata and the interpretation?

Analysis: Does the analysis take account of all relevant data?

Validity: Is there an objective assessment of the internal and external va-lidity of the indicators used?

Plausibility: Is a plausible argument made as to why alternative potentialexplanations for the findings are unlikely or at least less likely than that thefindings were due to the intervention itself?

4.6.2 Criteria for attaching weight to different kinds of evidence

Given interventions (section 4.5) and evaluations of equally high quality(section 4.6), policy-makers should place different values or weights on dif-ferent types of evidence. Criteria that can be used to assess the weight thatshould be placed on evidence include the repeatability of the findings insimilar and/or different contexts. Also, evidence based on multiple evalua-tions with consistent findings should receive more weight than evidence froma single evaluation. If a programme is to be implemented in a similar contextto where the evaluations were done, the key issue will be the repeatability ofthe results from evaluations done in that context. However, for a new or dif-ferent context, the key issues will be the repeatability of the results fromevaluations done in as many different contexts as possible.

In terms of evidence related to the impact of interventions on health and socialoutcomes, a useful framework for categorising evidence from summativeevaluations has been proposed by Victora, Habicht and colleagues (8, 9). Thisframework proposes three levels of evidence:

adequacy evidence. (This is the term used by Victora, Habicht and col-leagues (8, 9) though “supportive” might be a better term). For this level

93

92-4-120938-0_CH04_93

of evidence, all that needs to be shown is that an intervention was imple-mented and the expected changes occurred;

plausibility evidence. Here, in addition to the expected changes occurring,it needs to be shown that the effects related to the programme were greaterthan could be explained by any other external influences;

probability evidence. In addition to plausibility evidence, it needs to beshown there was only a small statistical probability that the programme’sobserved effects would have occurred by chance. This type of evidencecan come only from randomized controlled trials.

It is important to note that plausibility evaluations must include an adequacycomponent, and that probability evaluations benefit from assessing adequacyand plausibility at the same time (for example, through careful process eval-uation and through comparisons of the effects among those who actuallyreceived the intervention, sometimes known as “compliers”, versus those inthe group that was allocated to the intervention but did not receive it, some-times known as “non-compliers”).

This hierarchical typology of evaluation evidence is demonstrated by theexample given in Box 4.5. In this framework, evidence may come either fromexperimental studies (randomized controlled trials or quasi-experimentalstudies) or from observational studies, such as cross-sectional, case–controlor cohort studies. Quasi-experimental studies are those in which individualsor groups are deliberately and prospectively allocated to intervention orcomparison groups, but this allocation is not done randomly. The advantagesand disadvantages of randomized controlled trials for evaluating behaviouralinterventions have been discussed in detail elsewhere (2–9, 24). Assumingthat both the design and implementation of the intervention and evaluationare of high quality, and that there is evidence of ethical practice andgeneralizability, the hierarchy of evidence used in this series of papers willbe as follows. The greatest weight will be put on evidence from “probabilityevaluations” (that is, randomized controlled trials) that potentially providevery strong evidence. Next in the hierarchy will be quasi-experimental eval-uations that have one or more contemporaneous comparison groups thatpotentially provide strong evidence. These will be followed by before-and-after or time-series evaluation studies in individuals or groups of individuals(all of whom receive the intervention) that potentially provide weak-to-moderate evidence depending on the degree to which other potential causesof any observed effects have been ruled out. The least weight will be givento reports of anecdotal or experiential evidence or informed judgement, whichpotentially provide very weak to weak evidence depending on the degree towhich other potential causes of any observed effects have been ruled out.

94

92-4-120938-0_CH04_94

Box 4.5

Examples of evaluations providing supportive (adequacy), plausibility, andprobability evidence

Example: A condom promotion programme is initiated amongyoung people throughout a developing country using mass mediaand social marketing approaches.

Key outcome evaluated: Use of condoms

Supportive (adequacy) evaluation: The number of condomsrecorded as having been distributed to young people and the pro-portion of sexually active young people who reported having useda condom during their last sexual intercourse were substantial afterthe introduction of the intervention.

Plausibility evaluation: In addition to supportive (adequacy) evi-dence, there is well documented evidence that both the condomsdistributed and the proportion of young people using condoms weresubstantially greater than before the programme was launched. Thiscould be demonstrated from before–after or time-series studies.There is also evidence that the impact was proportional to the in-tensity of the intervention in various geographical areas or amongvarious population groups, and the impact was substantially greaterin areas that received the intervention when compared with areasthat did not. This is best demonstrated through quasi-experimentalmethods using a control group that is similar to the interventiongroup. Finally, there is documented evidence that no other activitiesor background (secular) changes could explain the effects seen. Itis therefore plausible that the programme was responsible for theincreases that were observed.

Probability evaluation: In addition to plausibility evidence, a suf-ficient number of individuals (or, where relevant, clusters of indi-viduals) were randomly allocated to receive the new programme.For example, the programme was phased in and during the initialevaluation phase 12 regions were randomly allocated to receive theprogramme immediately, while the other 12 received the pro-gramme after the probability evaluation (randomized controlledtrial) period.

95

92-4-120938-0_CH04_95

Two important caveats should be emphasized. First, there is an importantdistinction between evaluations of efficacy and effectiveness. Efficacy stud-ies aim to measure the impact of an intervention when delivered in a mannerthat is as close as possible to the ideal; effectiveness studies measure impactwhen the intervention is delivered through routine real-life channels. Usuallythe efficacy of an intervention will be greater than its effectiveness whenimplemented on a large scale through routine channels. The second caveat isthe importance of considering context (for example, delivery setting, culture,country or timing) in evaluating all such evidence. The fact that there may bestrong evidence from a well conducted plausibility or probability evaluationthat a particular intervention has the intended effects, does not necessarilymean that it will bring similar benefits if implemented in a different context.For instance, bar-based HIV peer education for gay men was effective in theUnited States of America in the early 1990s (25) but not in Scotland a decadelater, probably because of different cultural norms and the fact that the in-tervention was implemented at a different stage in the epidemic (26). It isimportant, therefore, to include at least an adequacy or plausibility evaluationwhen an intervention that has been found to be efficacious or effective in onecontext is implemented in a substantially different context.

For simplicity, in this series the policy recommendations (“Do not go”,“Steady”, “Ready” or “Go”) will be made for developing countries as a whole.However, policy-makers should review these in the light of local contexts toensure that the interventions are important and relevant to their context. Forexample, the priority given to interventions among intravenous drug userswill obviously depend on the frequency of intravenous drug use; equally wellthe likely effectiveness of interventions in schools will depend on, amongother things, the proportion of young people in the relevant age group whoattend school.

Information that comes from informed judgment – that is, the consideredassessments, decisions and opinions of experienced practitioners or keyinformants – constitutes a different kind of evidence. This might ordinarilybe thought of as being less objective in scientific terms and may not alwaysfit directly into the three-part model discussed above. Nevertheless, suchevidence can offer important guidance to policy-makers in the absence ofevidence of adequacy, plausibility or probability from formal evaluations ofa programme’s impact. It can also be useful for triangulation with other datato provide extra certainty in terms of indicators of a programme’s operationsand effects when aspects of programmes are not documented in ways that areeasily accessed by other methods of data collection. Informed judgement andexpert-generated evidence (sometimes called evidence of best practice) canbe gathered by methods such as interviewing key informants and Delphi scans(27). Each of these methods may have different levels of theoretical

96

92-4-120938-0_CH04_96

sophistication and methodological rigour depending on the design and re-sources deployed. Such techniques gain strength with repetition over time(for example, repeated interviews with key informants used as a part of aprocess evaluation) and can be particularly valuable in contextualizinginterventions.

Ideally all the different types and sources of evidence for and against the likelyeffectiveness of an intervention should be appraised in the assessment ofwhether that intervention should be adopted. The decision should be takenafter careful appraisal of the quality of the intervention (see 4.5), the qualityof each piece of evidence (see 4.6.1), assignment of weights based on boththe evidence threshold for that type of intervention (see 4.3) and the strengthof the evidence available (see 4.6.2). To some extent this follows Tones’argument for the use of a “judicial review” in deciding on interventions(28) but, unlike us, he avoids weighting one kind of evidence over anotherand simply calls for triangulation.

Common situations faced by policy-makers include that of having differenttypes of evidence for different interventions or a situation in which the evi-dence for one intervention is more comprehensive than that for another. Inthese situations it will be important to carefully assess the evidence and beexplicit about what weight is assigned to the different types of evidence. Thiscan be illustrated by comparing the evidence available for the “SteppingStones” community-wide intervention in the Gambia (29) with the evidenceavailable from a recent trial of a complex package of interventions largelytargeted directly at young people within the “MEMA kwa Vijana” project inthe United Republic of Tanzania (30). Put simplistically, there is now a lotof evidence from relatively small-scale programmes that the Stepping Stonesapproach is feasible to implement (if expensive per person involved) and isassociated with changes in knowledge, reported attitudes and reported sexualbehaviours (31). However, no evaluation has yet reported on the impact ofthe Stepping Stones community-wide interventions on HIV incidence orprevalence or on other biological markers of sexual behaviour. The relativelylarge-scale MEMA kwa Vijana project showed that the package of interven-tions tested within this rigorous community-based randomized trial resultedin substantial improvements in knowledge, reported attitudes and somereported sexual behaviours. However, this trial also evaluated the impact onHIV and other biological markers of sexual risk behaviour, and showed that,at least within a 3-year follow-up period, there was no consistent impact onthese biological outcomes (32, 33). Policy-makers may be tempted to choosethe Stepping Stones intervention because there is no discouraging, short-termbiological outcome data but this would be illogical.

97

92-4-120938-0_CH04_97

Policy-makers must beware of equating evidence from high quality, rigorousevaluations with evidence from less rigorous evaluations. Although a recentsystematic review comparing effect sizes in randomized and non-randomizedstudies did not find a consistent difference (34), for interventions of equalquality and effectiveness, the less rigorous the evaluation the more likely itis to give encouraging results (35, 36). This has been demonstrated in a reviewof pregnancy prevention among adolescents (37) and presents a real threat toevidence-based decision-making when rigorous evaluations are not available.

4.7 Conclusion

This chapter has proposed a method for reviewing evidence on the effective-ness of interventions that aim to contribute towards achieving the global goalsrelated to HIV prevention among young people in developing countries (im-proving access to information, skills and services; reducing vulnerability; andreducing HIV prevalence). This method has been used in the five chaptersthat follow, each of which reviews the evidence for the effectiveness of in-terventions in a key prevention setting or population group (in schools, healthservices, geographically-defined communities or groups at high risk of HIV,and through the mass media).

The method involves the following key steps.

1. Define the key types of intervention that policy-makers need to choosebetween in the population setting under consideration (for example,schools).

2. Define the strength of evidence that would be needed to justify thewidespread implementation of this type of intervention (“the evidencethreshold”).

3. Describe explicit inclusion and exclusion criteria for the studies that willreviewed.

4. Critically review all studies that meet the inclusion criteria and their find-ings, by type of intervention. This review should include a criticalappraisal of:

the quality of the intervention. In particular, is it feasible and does ithave a clearly identified mechanism by which it operates in order for itto be effective?the data on the process of implementation. Is there evidence that inter-mediate outcomes predicted by the theoretical mechanism of action areachievable?the context. Is the context in which the evaluation evidence was gen-erated relevant to the context in which the intervention is now proposed?

98

92-4-120938-0_CH04_98

the quality. What was the quality of the outcome evaluations, and whatwere their findings?

5. Summarize the strength of the evidence for the effectiveness of each typeof intervention in making progress towards each of the global goals.

6. Compare the strength of the evidence provided by the studies against thethreshold of evidence needed to recommend widespread implementation.

7. From this comparison, derive evidence-based recommendations relatedto implementation of each type of intervention in this setting or populationgroup, putting each type of intervention into one of the “Do not go”,“Steady”, “Ready” or “Go” categories.

It is important not to be misguided by positive results from poor research. Weargue that it is preferable to roll-out a well evaluated programme with goodevidence of modest impact than to roll-out a poorly evaluated programmewith weak evidence of a larger impact.

The evidence on which we have to make decisions about interventions toprevent the spread of HIV is extremely complex, being about different kindsof interventions, most of which are themselves complex, and arising fromdiverse evaluation methods. Furthermore, the evidence is imperfect, partic-ularly due to the scarcity of rigorous evaluations of outcomes. Anothercomplication in assessing the evidence is that the very existence of evidencefor some interventions and not for others does not occur for reasons that areneutral, but is often the result of past policy preferences, the intrinsic ease ofconducting either the intervention or its evaluation, or because the interven-tion has been seen as controversial. In spite of these difficulties,policy-makers must strive to apply rigour and logic to the selection of inter-vention strategies, resisting political and other pressures that fly in the faceof the evidence.

Finally, even if the evidence that is available leads policy-makers to investin a particular intervention, this does not mean that there is sufficient evidenceabout that intervention. Rather, we should always be building on and refiningthe evidence in the course of implementing public health interventions. Fur-thermore, evaluators should strive to provide as much detail as possible aboutthe actual intervention, process indicators of the coverage and quality of itsimplementation, and its costs and effectiveness.

Acknowledgements

We thank Jane Ferguson, Bruce Dick and Ties Boerma of WHO; MarkPetticrew of the MRC Social and Public Health Sciences Unit, Glasgow;Cesar Victora of the University of Pelotas, Brazil; and the participants at

99

92-4-120938-0_CH04_99

several meetings including Talloires (May 2004), Gex (March 2005) andBogis-de-Chavannes (June 2005) for their stimulating comments and sug-gestions on earlier versions of this paper.

References

1. United Nations. Declaration of commitment on HIV/AIDS. United NationsGeneral Assembly Special Session on HIV/AIDS. Geneva, United Nations,2001 (also available from http://www.un.org/ga/aids/coverage/FinalDeclarationHIVAIDS.html).

2. Kippax S, van de Ven P. An epidemic of orthodoxy? Design and methodologyin the evaluation of the effectiveness of HIV health promotion. Critical PublicHealth, 1998, 8:371-386.

3. Kippax S. Sexual health interventions are unsuitable for experimentalevaluation. In: Stephenson JM, Imrie J, Bonell C, eds. Effective sexual healthinterventions: issues in experimental evaluation. Oxford, Oxford UniversityPress, 2003:17-34.

4. Klein R. From evidence-based medicine to evidence-based policy? Journal ofHealth Services Research and Policy, 2000, 5:65-66.

5. Heller RF, Page J. A population perspective to evidence based medicine:“evidence for population health”. Journal of Epidemiology and CommunityHealth, 2002, 56:45-47.

6. Rychetnik L et al. Criteria for evaluating evidence on public health interventions.Journal of Epidemiology and Community Health, 2002, 56:119-127.

7. Ross DA, Wight D. The role of randomized controlled trials in assessing sexualhealth interventions. In: Stephenson JM, Imrie J, Bonell C, eds. Effective sexualhealth interventions: issues in experimental evaluation. Oxford, OxfordUniversity Press, 2003: 35-48.

8. Victora C, Habicht J-P, Bryce J. Evidence-based public health: moving beyondrandomized trials. American Journal of Public Health, 2004, 94:400-405.

9. Habicht JP, Victora CG, Vaughan JP. Evaluation designs for adequacy,plausibility and probability of public health programme performance and impact.International Journal of Epidemiology, 1999, 28:10-18.

10. Briss PA et al. Developing an evidence-based guide to community preventiveservices: methods. American Journal of Preventive Medicine, 2000, 18 Suppl1:S35-43.

11. Moher D et al. The CONSORT statement: revised recommendations forimproving the quality of parallel group randomized trials. Lancet, 2001,357:1191-1194.

12. Campbell MK, Elbourne DR, Altman DG. CONSORT statement: extension tocluster randomised trials. BMJ, 2004, 328:702- 708.

13. Campbell C et al. Framework for design and evaluation of complex interventionsto improve health. BMJ, 2000, 321:694-696.

14. Des Jarlais DC et al. Improving the reporting quality of non-randomizedevaluations: the TREND statement. American Journal of Public Health, 2004,94:361-366.

100

92-4-120938-0_CH04_100

15. Cochrane Collaboration. Preparing, maintaining and promoting the accessibilityof systematic reviews of the effects of health care interventions (http://www.update-software.com/Cochrane).

16. Wight D, Obasi A. Unpacking the black box: the importance of process data toexplain outcomes. In: Stephenson J, Imrie J, Bonell C, eds. Effective sexualhealth interventions: issues in experimental evaluation. Oxford, OxfordUniversity Press, 2003.

17. Plummer ML et al. “A bit more truthful”: the validity of adolescent sexualbehaviour data collected in rural northern Tanzania using five methods.Sexually Transmitted Infections, 2004, 80 Suppl II:S49-56.

18. Pawson R, Tilley N. Realistic evaluation. London, Sage, 1997.

19. Pawson R. Evidence-based policy: The promise of ‘realist synthesis’.Evaluation, 2002, 8:340-358.

20. Human Rights Watch. The less they know, the better: abstinence-only HIV/AIDS programs in Uganda. Human Rights Watch, 2005, 17(4):1-79.

21. Victora CG et al. Context matters: interpreting impact findings in child survivalevaluations. Health Policy and Planning, 2005, 20 Suppl i:S18-31.

22. Bowling A. Research methods in health. Maidenhead, Open University Press,2002.

23. Bryman A. Social research methods. Oxford, Oxford University Press, 2004.

24. Stephenson JM, Imrie J, Bonell C, eds. Effective sexual health interventions:issues in experimental evaluation. Oxford, Oxford University Press, 2003.

25. Kelly JA et al. Outcomes of a randomized controlled community-level HIVprevention intervention: effects on behaviour amongst at-risk gay men in smallUS cities. Lancet, 1997, 350:1500-1505.

26. Flowers P et al. Does bar-based, peer-led sexual health promotion have acommunity-level effect amongst gay men in Scotland? International Journal ofSTD and AIDS, 2002, 13;102-108.

27. Sarantakos S. Social research. 3rd edition. Melbourne, Palgrave Macmillan,2004.

28. Tones K. Beyond the RCT: a case for “judicial review”. Health EducationResearch Theory and Practice, 1997, 12:i-iv.

29. Welbourn A. Gender, sex and HIV: how to address issues that no-one wants tohear about. In: Tant qu’on a la Santé. Geneva, DDC, 1999:195-227. (Chapterin English.)

30. Hayes RJ et al. The MEMA kwa Vijana project: design of a community-randomised trial of an innovative adolescent sexual health intervention in ruralTanzania. Contemporary Clinical Trials, 2005, 26:430-442.

31. Paine K et al. ‘Before we were sleeping, now we are awake’: preliminaryevaluation of the Stepping Stones sexual health programme in the Gambia.African Journal of AIDS Research, 2002, 1:39-50.

32. Ross DA et al. MEMA kwa Vijana, a randomised controlled trial of an adolescentsexual and reproductive health intervention programme in rural Mwanza,Tanzania. 3. Results: knowledge, attitudes and behaviour. In: InternationalSociety for Sexually Transmitted Diseases Research 15th biennialconference. Ottawa, ISSTDR, 2003. (Abstract No. 0698.).

101

92-4-120938-0_CH04_101

33. Changalucha J et al. MEMA kwa Vijana, a randomised controlled trial of anadolescent sexual and reproductive health intervention programme in ruralMwanza, Tanzania. 4. Results: biomedical outcomes. In: International Societyfor Sexually Transmitted Diseases Research 15th biennial conference. Ottawa,ISSTDR, 2003:253. (Abstract No. 0699.)

34. MacLehose RR et al. A systematic review of comparisons of effect sizes derivedfrom randomized and non-randomized studies. Health Technology Assessment(Winchester), 2000, 4:1-154.

35. Rossi P. The iron law of evaluation and other metallic rules. Research in SocialProblems and Public Policy, 1987, 4:3-20.

36. Schulz K et al. Empirical evidence of bias dimensions of methodological qualityassociated with estimates of treatment effects in controlled trials. Journal of theAmerican Medical Association, 1995, 273:408-412.

37. Guyatt GH et al. Randomized trials versus observational studies in adolescentpregnancy prevention. Journal of Clinical Epidemiology, 2000, 53:167-174.

102

92-4-120938-0_CH04_102

5. The effectiveness of sex educationand HIV education interventions inschools in developing countriesDouglas Kirby,a Angela Obasi,b & B.A Larisa

Objective To review the impact of sex education and HIV education inter-ventions in schools in developing countries on both risk behaviours for HIVand the psychosocial factors that affect them.

Methods We conducted a systematic review. Searches identified studies indeveloping countries that evaluated interventions using either experimentalor strong quasi-experimental designs and measured the impact of the inter-vention on sexual risk behaviours. Each study was summarized and coded,and the results were tabulated by type of intervention.

Findings Twenty-two intervention evaluations met the inclusion criteria: 17were based on a curriculum and 5 were not, and 19 were implemented pri-marily by adults and 3 by peers. These 22 interventions significantly im-proved 21 out of 55 sexual behaviours measured. Only one of theinterventions (a non-curriculum-based peer-led intervention) increased anymeasure of reported sexual intercourse; 7 interventions delayed the reportedonset of sex; 3 reduced the reported number of sexual partners; and 1 reducedthe reported frequency of sexual activity. Furthermore, 16 of the 22 inter-ventions significantly delayed sex, reduced the frequency of sex, decreasedthe number of sexual partners, increased the use of condoms or contraceptivesor reduced the incidence of unprotected sex. Of the 17 curriculum-based in-terventions, 13 had most of the characteristics believed to be importantaccording to research in developed and developing countries and were taughtby adults. Of these 13 studies, 11 significantly improved one or more reportedsexual behaviours, and the remaining 2 showed non-significant improve-ments in reported sexual behaviour. Among these 13 studies, interventionsled by both teachers and other adults had strong evidence of positive im-pact on reported behaviour. Of the 5 non-curriculum-based interventions, 2of 4 adult-led and the 1 peer-led intervention improved one or more sexualbehaviours.

a ETR Associates 4 Carbonero Way, Scotts Valley, CA 95061, USA. Correspondence shouldbe sent to Dr Kirby (email: dougk@etr.org).

b Liverpool School of Tropical Medicine, Pembroke Place Liverpool, L3 5QA England.

103

92-4-120938-0_CH05_103

Conclusions A large majority of school-based sex education and HIV edu-cation interventions reduced reported risky sexual behaviours in developingcountries. The curriculum-based interventions having the characteristics ofeffective interventions in the developed and developing world should beimplemented more widely. All types of school-based interventions need ad-ditional rigorous evaluation, and more rigorous evaluations of peer-led andnon-curriculum-based interventions are necessary before they can be widelyrecommended.

5.1 Introduction and background

In many respects, schools are well placed to achieve the ultimate goal ofdecreasing HIV prevalence among youths. In many societies they are the oneinstitution that is regularly attended by most young people. Of those youthswho attend school, most do so before they begin having sexual intercourse,and many are enrolled in school when they actually initiate sex. Thus, schoolsprovide an opportunity for interventions to achieve high coverage of youngpeople before or around the time they become sexually active; they also offerthe opportunity to encourage young people to delay the onset of sexual ac-tivity and increase their use of condoms and contraceptives after sexualinitiation. Of course, school-based interventions are less useful where manyor most adolescents are no longer in school.

This chapter will examine school-based interventions in relation to the globalgoals of the United Nations General Assembly Special Session on HIV/AIDSfor young people (UNGASS) (1). Briefly, these goals are to provide youngpeople with access to information (goal 1), with skills to avoid becominginfected with HIV (goal 2), with access to services (goal 3) and to decreasetheir vulnerability to infection (goal 4) as well as decrease the prevalence ofHIV among young people (goal 5).

Numerous, well-conducted studies have demonstrated the effectiveness ofschool-based programmes in producing improvements in knowledge abouthow to avoid HIV infection in developing countries (2–4). However, the ev-idence is much less clear about the effectiveness of schools in meeting theremaining goals. This is partly due to difficulty in formulating and measuringoutcomes such as skills, vulnerability and HIV prevalence (5). It may also bebecause refusal, negotiation and condom-use skills require teaching tech-niques or cultures that are often unfamiliar to school environments in thedeveloping world (6–9). However, in order to truly affect HIV prevalence,schools in the developing world must move beyond making an impact onknowledge alone to demonstrating significant and sustained improvementsin sexual risk behaviours and addressing the more complex affective factors

104

92-4-120938-0_CH05_104

influencing them, such as the values, attitudes and perceived norms about sexand condom use (8, 10).

There have been a few reviews of studies that examined school-based inter-ventions in the developing world and that examined their impact on be-haviour. However, they have been limited by a focus on a particulargeographical area (2) or by the strengths of the evaluations, and they havenot examined the characteristics of interventions in developing countriesworldwide (4, 11, 12).

One review has identified key characteristics of curriculum-based interven-tions shown to be effective in changing behaviours in both developed anddeveloping countries in the settings of schools, clinics and other communityorganizations (12). However, similar analyses are needed of all school-basedprogrammes in developing countries if schools are to fulfil their potential forcombating HIV among youths.

5.1.1 Objectives

This article reviews the literature on the effects of school-based sex educationand HIV education interventions on sexual risk behaviours among youngpeople in all developing countries. This review builds on previous work(2–4, 7, 8, 11–14) by (i) focusing specifically on studies that examine anintervention’s impact on sexual behaviour, (ii) including more interven-tion studies that measure the impact on behaviour than previous reviews,(iii) assessing the strength of the evaluation design of different study strate-gies and (iv) assessing the characteristics of effective interventions.

5.1.2 Schools and their interventions

For the purposes of this review, schools are defined as any formal educationalestablishment providing training or education to youths who are youngerthan 25 years of age. As the field of HIV prevention evolves, schools areincreasingly being included as part of multicomponent HIV interventions.This review evaluates such interventions only if the specific impact of theschool intervention has been separately evaluated or if the school componentrepresents the major part of the overall intervention and a substantial partof the overall impact of the intervention could be attributed to the schoolintervention.

A large number of sex education and HIV education interventions are beingimplemented in schools worldwide. They vary widely in terms of objectives,structure, length, content, implementation strategy and other characteristics(4, 12, 13). In practice, however, the choice and implementation of interven-tions in schools in developing countries is constrained by the availability of

105

92-4-120938-0_CH05_105

teachers and curricular materials as well as teacher training; access to otherfinancial, material and technical resources; and the culture and norms of boththe local communities and the schools themselves (9, 15). Inadequate levelsof training and the prevalence of didactic teaching methods may mean thatteachers are sometimes unable to use the participatory, student-centred tech-niques that are often necessary for effective skill building (6, 9). Furthermore,in many societies, resistance among teachers to discussing sexual behaviourwith adolescents or issues such as age, sex and status differentials may meanthat pupils or teachers, or both, feel uncomfortable discussing sexual mattersin the classroom (8, 16). Resistance to discussing the use of condoms is par-ticularly widespread in schools (2, 9); authors have reported that sometimes,where discussions of condoms are included in an intervention, the informa-tion communicated to pupils about condoms has been mostly negative inorder to discourage condom use and encourage abstinence (17).

In order to overcome some of these obstacles to school-based interventions,programme developers and staff have provided structured curricula to guideactivities, have trained teachers, and have involved trained individuals otherthan teachers in delivering the interventions. Curriculum is defined here asan organized set of activities or exercises designed to convey specific knowl-edge, skills or experiences in an ordered or incremental fashion. Suchactivities may be implemented either in the classroom during the school dayor after school.

5.1.3 Categories of interventions

School-based interventions can be categorized according to at least three dif-ferent dimensions. These are described below. (In reviews of school-basedinterventions, whether the school was primary, secondary or post-secondarymight be considered important. However, in this review, all of the studies ofinterventions in primary schools were conducted in Africa and the age rangeof the youths who participated – 10 to 18 years – was within the age range ofyouths in secondary schools in other developing countries – 10 to 25 years.Thus, studies were not grouped by school level in this review.)

5.1.3.1 Curriculum-based versus non-curriculum-based

Curriculum-based interventions are often more intensive and more structuredthan non-curriculum-based interventions. In addition, curriculum-based in-terventions are more likely to be based on theory and previous research andmay have been extensively pilot-tested and sanctioned by the appropriateauthorities. The curricula serve to guide and inform the educators, and theiruse may overcome or ameliorate some of the educators’ personal prejudices

106

92-4-120938-0_CH05_106

or limitations in teaching skills. These characteristics may enhance the ef-fectiveness of these interventions.

Non-curriculum-based interventions include a variety of activities such asone-on-one spontaneous or opportunistic counselling about sexual activityand HIV while the student is on school grounds, school health fairs, dramasthat present stories about HIV during school assemblies, the use of posters orleaflets, or combinations of these. Some of these activities may be easier toimplement in schools, at least initially, because they may not require thatteachers be trained. In addition, some people have argued that spontaneousone-on-one interaction between educators and youths may be more effective,given the personal nature of sexual behaviour. However, such interactionsrequire a degree of sensitivity, skill and empathy that may be beyond thescope of many implementers or may necessitate a high level of training.

5.1.3.2 Interventions with and without characteristics of effective curriculum-basedinterventions

There are a variety of other characteristics of interventions, especiallycurriculum-based interventions, that may affect their effectiveness (for ex-ample, the focus of the activities, the information provided and the instruc-tional methods implemented).

In developed countries, there have been at least 65 evaluations of curriculum-based sex education and HIV education interventions, and there have alsobeen additional studies of non-curriculum-based interventions. Reviews ofthese studies have identified some of the characteristics of interventions be-lieved to be important in producing behavioural change (12, 14, 17–21).

While these characteristics of effective interventions have not been derivedfrom interventions used primarily in developing countries, they neverthelessprovide a potential set of guidelines that can be used to assess these inter-ventions in developing countries. The most recent set of characteristicsidentified by Kirby et al. (12) is based on the greatest number of studies andincludes some studies from developing countries. That review identified 17characteristics that appear to distinguish effective programmes and that de-scribe programme development, the curricula and programme implementa-tion. These characteristics are described in Box 5.1.

107

92-4-120938-0_CH05_107

Box

5.1

Ch

arac

teri

stic

s o

f ef

fect

ive

curr

icu

lum

-bas

ed p

rog

ram

mes

Dev

elo

pin

g t

he

curr

icu

lum

Co

nte

nt

Imp

lem

enta

tio

n1.

Invo

lve

mul

tiple

peo

ple

with

diff

eren

tba

ckgr

ound

s in

theo

ry, r

esea

rch

and

sex/

HIV

edu

catio

n.

Cu

rric

ulu

m g

oal

s an

d o

bje

ctiv

es1.

Foc

us o

n cl

ear

heal

th g

oals

, suc

h as

thep

reve

ntio

n of

ST

Isa

and

HIV

and

/or

preg

nanc

y.

1. S

ecur

e at

leas

t min

imal

sup

port

from

appr

opria

te a

utho

ritie

s, s

uch

asm

inis

trie

s of

hea

lth, s

choo

l dis

tric

ts o

rco

mm

unity

org

aniz

atio

ns.

2. A

sses

s re

leva

nt n

eeds

and

ass

ets

ofta

rget

gro

up.

2. F

ocus

nar

row

ly o

n sp

ecifi

c be

havi

ours

lead

ing

to th

ese

heal

th g

oals

(su

ch a

sab

stai

ning

from

sex

or

usin

g co

ndom

sor

oth

er c

ontr

acep

tives

); g

ive

clea

rm

essa

ges

abou

t the

se b

ehav

iour

s;an

d ad

dres

s si

tuat

ions

that

mig

ht le

adto

them

and

how

to a

void

them

.

2. S

elec

t edu

cato

rs w

ith d

esire

dch

arac

teris

tics,

trai

n th

em a

nd p

rovi

dem

onito

ring,

sup

ervi

sion

and

sup

port

.

3. U

se a

logi

c m

odel

app

roac

h to

deve

lop

the

curr

icul

um th

at s

peci

fies

the

heal

th g

oals

, the

beh

avio

urs

affe

ctin

g th

ose

heal

th g

oals

, the

ris

kan

d pr

otec

tive

fact

ors

affe

ctin

g th

ose

beha

viou

rs, a

nd th

e ac

tiviti

esad

dres

sing

thos

e ris

k an

d pr

otec

tive

fact

ors.

3. A

ddre

ss m

ultip

le s

exua

l–ps

ycho

soci

alris

k an

d pr

otec

tive

fact

ors

affe

ctin

gse

xual

beh

avio

urs

(suc

h as

know

ledg

e, p

erce

ived

ris

ks, v

alue

s,at

titud

es, p

erce

ived

nor

ms

and

self-

effic

acy)

.

3. If

nee

ded,

impl

emen

t act

iviti

es to

recr

uit a

nd r

etai

n yo

uths

and

over

com

e ba

rrie

rs to

thei

r inv

olve

men

t(f

or e

xam

ple,

pub

liciz

e th

epr

ogra

mm

e, o

ffer

food

or

obta

inco

nsen

t fro

m y

outh

s or

par

ents

).

4. D

esig

n ac

tiviti

es c

onsi

sten

t with

com

mun

ity v

alue

s an

d av

aila

ble

reso

urce

s (s

uch

as s

taff

time,

sta

ffsk

ills,

faci

lity

spac

e an

d su

pplie

s).

Act

ivit

ies

and

tea

chin

g m

eth

od

s4.

Cre

ate

a sa

fe s

ocia

l env

ironm

ent i

nw

hich

you

ths

can

part

icip

ate.

4. Im

plem

ent v

irtua

lly a

ll ac

tiviti

es a

sde

sign

ed.

108

92-4-120938-0_CH05_108

5. P

ilot-

test

the

prog

ram

.5.

Incl

ude

mul

tiple

act

iviti

es to

cha

nge

each

of t

he ta

rget

ed ri

sk a

nd p

rote

ctiv

efa

ctor

s.6.

Use

inst

ruct

iona

lly s

ound

teac

hing

met

hods

that

act

ivel

y in

volv

epa

rtic

ipan

ts, t

hat h

elp

part

icip

ants

pers

onal

ize

the

info

rmat

ion

and

that

are

desi

gned

to c

hang

e ea

ch g

roup

of

risk

and

prot

ectiv

e fa

ctor

s.7.

Use

act

iviti

es, i

nstr

uctio

nal m

etho

dsan

d be

havi

oura

l mes

sage

s th

at a

reap

prop

riate

to th

e cu

lture

,de

velo

pmen

tal a

ge a

nd s

exua

lex

perie

nce

of th

e pa

rtic

ipan

ts.

8. C

over

topi

cs in

a lo

gica

l seq

uenc

e.

Sou

rce:

Kirb

y D

, Lar

is B

A, R

olle

ri L.

The

impa

ct o

f sex

and

HIV

edu

catio

n pr

ogra

ms

in s

choo

ls a

nd c

omm

uniti

es o

n se

xual

beh

avio

rsam

ong

youn

g ad

ults

. Was

hing

ton,

DC

, Fam

ily H

ealth

Inte

rnat

iona

l, 20

06.

a S

TIs

= s

exua

lly tr

ansm

itted

infe

ctio

ns.

109

92-4-120938-0_CH05_109

5.1.3.3 Adult-led versus peer-led interventions

The choice of educator also represents a balance among pedagogy, pre-vailing culture and infrastructure capacity. Adults most commonly imple-ment curriculum-based interventions because typically they have more ofthe experience, knowledge and skills needed. The adults who implement aparticular curriculum may include both schoolteachers and others, such ashealth-workers.

Teacher-led interventions are logistically the easiest to implement in schoolsonce teachers have been adequately trained. Such interventions are alsohighly replicable. However these benefits may be offset by the limitations ofteachers discussed above, including their status in relation to pupils or theirdiscomfort in using interactive teaching methods and discussing sensitivetopics such as adolescents’ sexual behaviour.

Because of these limitations, people in some communities favour usinghealth-workers or other local experts to teach these curricula. These expertsmay be more knowledgeable about the sexual topics covered, more comfort-able discussing these topics and more comfortable using interactive learningmethods. In addition, using health-workers or other trained adults to discusssensitive matters, such as condoms, in schools may help teachers avoid theinternal conflicts mentioned above and may allay fears of community cen-sure. However, limited infrastructure, transportation, time and other re-sources may prevent health-workers from teaching intensive and lengthycurricula to many students in many schools.

Peer educators have been widely advocated as alternatives or adjuncts toteachers or other adults (22). Many believe that peer educators may be ableto relate more closely to other young adults than older adults can. However,peers are less likely to be knowledgeable about these topics and less likely tohave the skills needed to teach curriculum activities (23). Furthermore, theinevitable annual student turnover and subsequent requirements for recurringtraining and supervision raise doubts about the sustainability and cost effec-tiveness of using peer educators (11).

In order to provide a discussion that is helpful to programme developers, wehave categorized all 22 interventions studied according to whether they arebased on a curriculum, whether they incorporate most of the characteristicsin Box 5.1 and whether they are taught by adults or peers. These three di-mensions produced the following six categories with one or more studies percategory:

curriculum-based interventions that incorporate most of the 17 character-istics and are led by adults;

110

92-4-120938-0_CH05_110

curriculum-based interventions that incorporate most of the 17 character-istics and are led by peers;

curriculum-based interventions that lack several of the 17 characteristicsand are led by adults;

curriculum-based interventions that lack several of the 17 characteristicsand are led by peers;

non-curriculum-based interventions that incorporate several of the 17 char-acteristics and are led by adults;

non-curriculum-based interventions that lack several of the 17 character-istics and are led by peers.

5.2 Methods

5.2.1 Identification of studies

For this review, we sought to identify and retrieve studies meeting the criteriain Table 5.1. For the most part, the review is limited to studies that measuredan intervention’s impact on behaviour for two reasons: first, because it is wellestablished that school-based sex education and HIV education interventionscan increase knowledge (all studies that measured impact on knowledgefound a positive impact) and second because changes in knowledge, skillsand other mediating factors will not lead to a decrease in HIV prevalenceunless behaviour also changes.

In order to identify and retrieve as many of the studies from developingcountries as possible we:

1. reviewed the results of a previous search for studies undertaken by ETRAssociates and the University of Minnesota and identified those studiesmeeting the criteria specified above;

2. reviewed studies already summarized in previous reviews of theseinterventions;

3. reviewed multiple computerized list-serves for studies meeting the crite-ria (including PubMed, PsycINFO, POPLINE, Sociological Abstracts,Psychological Abstracts, Bireme, Dissertation Abstracts Online, ERIC, Com-bined Health Information Database – CHID, and Biological Abstracts);

4. contacted researchers in the process of completing studies and obtainedresults (sometimes preliminary) whenever appropriate and possible;

5. attended professional meetings, scanned abstracts, spoke with authors andobtained studies whenever possible;

111

92-4-120938-0_CH05_111

6. scanned each issue from 1990 to 2005 of 12 journals in which relevantstudies might appear;

7. reviewed reports of intervention development, training materials, andprocess evaluation reports.

5.2.2 Threshold of evidence needed for widespread implementation

Overall, because of the potential ability of school-based interventions to beimplemented broadly and to reach large proportions of young people, theseinterventions should require low-to-moderate thresholds of evidence beforebeing recommended for widespread implementation. However, because thediscussion of sexual activity, especially condom use, in schools may be con-troversial, the threshold varies somewhat according to the community, the

Table 5.1Inclusion and exclusion criteria used to identify studies for review

Inclusion criteria Exclusion criteria

Characteristics of the programmeProgramme was implemented in adeveloping country

Programme was implemented in developedcountry

Programme implemented in primary,secondary or post-secondary schools (forexample, night schools or universities)Focused on young people aged 24 years Focused on a cross-section of age groups

that included some young people but did notinclude a sample with at least 80% ofparticipants aged < 25 years

Characteristics of the studyWas published in EnglishUsed a reasonably strong experimental orquasi-experimental design with bothintervention and comparison groups andbaseline and follow-up data

Lacked a comparison group or baseline andfollow-up data

Had a minimum sample size of 100Measured the impact of the programme onone or more reported sexual behaviours(initiation of sexual intercourse, frequency ofsexual intercourse or number of sexualpartners), reported use of condoms orcontraception, pregnancy rates, birth ratesand STIa rates

Measured impact only on knowledge,values, attitudes or intentions and notbehaviour

Was completed or published betweenJanuary 1990 and June 2005

a STI = sexually transmitted infection.

112

92-4-120938-0_CH05_112

grade level in which the intervention is designed to take place and the inter-vention’s content, targeted behaviour and implementer. Conclusions made inthis review are based on the consideration of these issues and thresholds(Table 5.2).

5.2.3 Review of studies

All studies were summarized in a template by one of this review’s authors(BL) and then reviewed by a second author (DK). The summaries were thensent to the author of the original study for verification. Changes were madeas appropriate. The complete version of these summaries is available on theweb (www.who.int/child-adolescent-health/).

For this review, all reported outcomes (for example, effects on behaviour)were considered significant if they were statistically significant at the 0.05level and this significance was based either on the total sample or a subsamplethat was roughly one third of the total sample or larger (for example, eithermales or females, youths younger or older than a certain age, or sexuallyexperienced or sexually inexperienced youths). Some studies found signifi-cant effects for important subgroups but not for the entire sample.

Studies sometimes reported results for multiple measures of each behaviour,for different time periods, for different subgroups or for combinations ofthese. Thus, some studies reported only one or a small number of significantpositive effects on behaviour as well as a large majority of results that werenot significant. To avoid presenting only the positive results and to providea more balanced overview, the following rules for summarizing results wereadopted. First, for different measures of the same outcome behaviour: allmeasures across all the studies were rank-ordered according to their probableimpact on prevalence. For example, the use of condoms over a long periodof time was ranked higher than condom use at first sexual intercourse. Onlythe results from the highest ranked measure reported in each study were in-cluded in the tables. Second, because short-term effects on behaviour wouldhave little impact on HIV prevalence, only those results reported for periodsof 3 months or longer were included in the tables. In addition, because studieswere not likely to have sufficient statistical power to measure the impact onthose behaviours or outcomes that change slowly (that is, initiation of sex,pregnancy rates or rates of sexually transmitted infections [STIs]), onlythose results measuring impact on these outcomes for at least 6 months wereincluded.

113

92-4-120938-0_CH05_113

Tab

le 5

.2T

hre

sho

ld o

f ev

iden

ce n

eed

ed t

o r

eco

mm

end

wid

esp

read

imp

lem

enta

tio

n o

f ea

ch t

ype

of

inte

rven

tio

n

Inte

rven

tio

n t

ype

Cri

teri

on

aO

vera

llT

hre

sho

ldC

om

men

ts

Feasibility

Lack of poten-tial for adverse

outcomes

Acceptability

Potentialsize of effect

Other health orsocial benefits

By

bro

ad in

terv

enti

on

typ

eC

urric

ulum

-bas

ed+

++

++

++

+Lo

wC

urric

ulum

-bas

ed in

terv

entio

ns p

rovi

de c

onsi

dera

ble

guid

ance

toth

e ed

ucat

or a

bout

impl

emen

ting

the

inte

rven

tion

and

may

hav

ebe

en p

revi

ousl

y ev

alua

ted.

Thu

s, th

ey h

ave

less

pot

entia

l for

adve

rse

outc

omes

and

a g

reat

er p

oten

tial e

ffect

siz

e th

anin

terv

entio

ns th

at a

re n

ot c

urric

ulum

-bas

ed.

Not

cur

ricul

um-b

ased

++

+-

++

+Lo

wIn

terv

entio

ns th

at a

re n

ot c

urric

ulum

-bas

ed m

ay b

e ea

sier

toim

plem

ent a

nd m

ay n

ot re

quire

as

muc

h cl

assr

oom

tim

e or

as

muc

htr

aini

ng o

f as

man

y ed

ucat

ors

as c

urric

ulum

-bas

ed in

terv

entio

ns.

By

char

acte

rist

ics

of

the

inte

rven

tio

nb

With

cha

ract

eris

tics

ofef

fect

ive

inte

rven

tions

++

++

++

++

Low

Cha

ract

eris

tics

of e

ffect

ive

inte

rven

tions

req

uire

that

the

inte

rven

tion

focu

s on

HIV

, oth

er S

TIs

c an

d pr

egna

ncy,

the

risk

and

prot

ectiv

e be

havi

ours

affe

ctin

g th

em a

nd th

at th

ey u

se in

tera

ctiv

eac

tiviti

es to

cha

nge

beha

viou

rs. T

hese

cha

ract

eris

tics

mig

ht m

ake

the

inte

rven

tion

mor

e di

fficu

lt to

impl

emen

t and

less

acc

epta

ble

toth

ose

who

pre

fer

not t

o fo

cus

on s

exua

l beh

avio

ur. H

owev

er, t

hey

grea

tly in

crea

se th

e po

tent

ial s

ize

of th

e ef

fect

.W

ithou

t cha

ract

eris

tics

of e

ffect

ive

inte

rven

tions

++

++

++

++

Low

Inte

rven

tions

with

out e

ffect

ive

char

acte

ristic

s m

ay b

e ea

sier

toim

plem

ent a

nd m

ore

acce

ptab

le. H

owev

er, t

heir

estim

ated

effe

ctsi

ze is

sm

alle

r.

114

92-4-120938-0_CH05_114

By

typ

e o

f ed

uca

tor

Adu

lt-le

d (t

each

er)

++

-+

++

+Lo

wT

each

ers

may

hav

e to

be

trai

ned

both

to d

iscu

ss s

exua

l top

ics

and

to u

se in

tera

ctiv

e te

achi

ng m

etho

ds. O

nce

trai

ned,

they

can

impl

emen

t the

inte

rven

tion

durin

g sc

hool

at r

elat

ivel

y lit

tle c

ost.

The

re is

the

poss

ibili

ty o

f mal

e te

ache

rs ta

king

adv

anta

ge o

fdi

scus

sion

s of

sex

ualit

y to

pre

ssur

e fe

mal

e st

uden

ts to

hav

e se

xual

rela

tions

.A

dult-

led

(oth

er a

dult)

++

++

++

++

Low

Oth

er a

dults

(su

ch a

s co

mm

unity

hea

lth p

erso

nnel

) m

ay b

e m

ore

accu

stom

ed to

dis

cuss

ing

sexu

al to

pics

and

may

hav

e le

arnt

how

to u

se in

tera

ctiv

e te

achi

ng m

etho

ds. H

owev

er, o

ngoi

ng r

esou

rces

are

need

ed to

allo

w th

em to

trav

el to

sch

ools

and

impl

emen

tin

terv

entio

ns.

Pee

r-le

d+

++

++

++

Low

Pee

rs m

ay r

equi

re c

onsi

dera

ble

trai

ning

bef

ore

they

hav

e th

ekn

owle

dge

and

skill

s to

impl

emen

t an

inte

rven

tion.

The

y m

ayre

quire

res

ourc

es to

trav

el to

the

scho

ols,

and

they

will

mat

ure

and

ceas

e be

ing

peer

s af

ter

a fe

w y

ears

ther

eby

crea

ting

a ne

ed fo

ron

goin

g re

crui

tmen

t and

trai

ning

.P

eers

may

lear

n im

port

ant s

kills

as

peer

edu

cato

rs.

By

sch

oo

llev

elP

rimar

y sc

hool

++

--

++

Mod

erat

eT

he p

ossi

bilit

y of

mal

e te

ache

rs ta

king

adv

anta

ge o

f the

ir po

wer

and

the

disc

ussi

on o

f sex

ualit

y to

pre

ssur

e fe

mal

e st

uden

ts to

hav

ese

xual

rela

tions

is m

ost l

ikel

y in

prim

ary

scho

ol o

r sec

onda

ry s

choo

l.T

he d

iscu

ssio

n of

con

dom

s in

prim

ary

scho

ol m

ay b

e le

ssac

cept

able

initi

ally

to s

ome

adul

ts in

the

com

mun

ity. A

bstin

ence

-on

ly in

terv

entio

ns m

ay b

e m

ore

acce

ptab

le, b

ut m

ay h

ave

less

impa

ct (

or a

neg

ativ

e im

pact

) on

con

dom

use

.In

terv

entio

ns m

ay h

ave

a gr

eate

r im

pact

on

dela

ying

sex

ual

rela

tions

am

ong

prim

ary

and

seco

ndar

y sc

hool

stu

dent

s, a

t a ti

me

befo

re m

ost y

oung

peo

ple

have

sex

ual r

elat

ions

, tha

n in

pos

t-se

cond

ary

scho

ol w

hen

mos

t stu

dent

s ha

ve a

lread

y ha

d se

xual

rela

tions

.

115

92-4-120938-0_CH05_115

Inte

rven

tio

nty

pe

Cri

teri

on

aO

vera

llT

hre

sho

ldC

om

men

ts

Feasibility

Lack of poten-tial for adverse

outcomes

Acceptability

Potentialsize of effect

Other health orsocial benefits

Sec

onda

rysc

hool

++

-+

++

+M

oder

ate

The

pos

sibi

lity

of m

ale

teac

hers

taki

ng a

dvan

tage

of t

heir

pow

er a

ndth

e di

scus

sion

of s

exua

lity

to p

ress

ure

fem

ale

stud

ents

to h

ave

sexu

alre

latio

ns is

mos

t lik

ely

in p

rimar

y sc

hool

or

seco

ndar

y sc

hool

.In

terv

entio

ns m

ay h

ave

a gr

eate

r im

pact

on

dela

ying

sex

ual r

elat

ions

amon

g pr

imar

y an

d se

cond

ary

scho

ol s

tude

nts,

at a

tim

e be

fore

mos

tyo

ung

peop

le h

ave

sexu

al r

elat

ions

, tha

n in

pos

t-se

cond

ary

scho

ol w

hen

mos

t stu

dent

s ha

ve a

lread

y ha

d se

xual

rel

atio

ns.

Pos

t sec

onda

rysc

hool

s+

++

++

++

Low

Inte

rven

tions

may

hav

e a

grea

ter

impa

ct o

n de

layi

ng s

exua

l rel

atio

nsam

ong

prim

ary

and

seco

ndar

y sc

hool

stu

dent

s at

a ti

me

befo

re m

ost

youn

g pe

ople

hav

e se

xual

rel

atio

ns th

an in

pos

t-se

cond

ary

scho

ol w

hen

mos

t stu

dent

s ha

ve a

lread

y ha

d se

xual

rel

atio

ns b

ut in

terv

entio

n in

pos

tse

cond

ary

scho

ol m

ay s

till h

ave

an im

pact

on

cond

om u

se.

a D

egre

e of

des

irabi

lity

is in

dica

ted

with

a m

axim

um o

f 3 “

+”

sign

s. D

egre

e of

und

esira

bilit

y is

indi

cate

d w

ith a

max

imum

of 3

“-”

sig

ns.

b S

ee B

ox 5

.1 a

nd th

e te

xt fo

r fu

ll de

scrip

tion

of th

ese

char

acte

ristic

s.c S

TIs

= s

exua

lly tr

ansm

itted

infe

ctio

ns.

116

92-4-120938-0_CH05_116

Even these rules for summarizing the results may have provided a more pos-itive picture than an analysis of all the results from all studies. However, thisprobable positive bias was offset by a different negative bias: many resultspresented in the studies were based on samples with insufficient power. Thus,interventions may have produced programmatically meaningful results thatwere found to be not significant. (Insufficient statistical power is further dis-cussed in the section below.)

5.3 Findings

Our search identified 22 studies (16, 17, 24–44) meeting the inclusion criteria.The characteristics of the 22 interventions and their respective evaluationsare summarized in Table 5.3 and Table 5.4, respectively. The impact of allthese interventions on specified behaviours is summarized in Table 5.5 aswell as in Table 5.4a and Table 5.4b.

5.3.1 Characteristics of interventions

Of the 22 studies and respective interventions, 17 were curriculum-based and5 were non-curriculum based. Of the 17 curriculum-based interventions, 14incorporated at least four fifths of the characteristics described in Box 5.1.Altogether, 15 of the 17 were taught primarily by adults and 2 were taughtsolely by peers. Of the 15 taught by adults, 10 were taught by the schools’teachers and the remaining 5 were taught by other adults, such as health-workers, trained counsellors and facilitators, and young adult volunteers.However, of the 15 interventions led by adults, 2 also involved peer educatorsin significant ways. Of the five non-curriculum-based interventions, fourwere primarily led by teachers or other adults and one by peers.

A total of 16 of the interventions evaluated had been implemented in sec-ondary schools; five had been implemented in primary schools; and three hadbeen implemented in night schools or teacher-training colleges. (The sumexceeds 22 because one intervention was implemented in both primary andsecondary schools and another in both secondary and night schools.)

Finally, only three of the interventions were abstinence-only interventions;the remainder of the interventions encouraged abstinence but also discussedor promoted the use of condoms or contraception for young people who choseto be sexually active.

5.3.2 Characteristics of the studies

Eight of these studies used an experimental design, while the remaining 14used a quasi-experimental design. In order to be included in the review, all

117

92-4-120938-0_CH05_117

Tab

le 5

.3D

escr

ipti

on

s o

f th

e in

terv

enti

on

s b

y st

ud

y

Stu

dy,

loca

tio

n a

nd

pro

gra

mm

eT

arg

et p

op

ula

tio

n a

nd

pri

mar

yo

bje

ctiv

esD

escr

ipti

on

Cu

rric

ulu

m-b

ased

inte

rven

tio

ns

wit

h c

har

acte

rist

ics

of

effe

ctiv

e p

rog

ram

mes

Ad

ult

-led

(te

ach

ers)

A –

Tha

iland

,T

eens

on

Sm

art S

ex (

16)

• Y

outh

s ag

ed 1

8–21

yea

rs in

urba

n ar

eas

• T

arge

ted

sexu

al in

itiat

ion,

num

ber

of p

artn

ers

and

cond

omus

e

• 16

hou

rs•

Add

ress

ed is

sues

of l

ove,

atti

tude

s to

war

d H

IV a

nd s

exua

lity,

livi

ng w

ith H

IV/A

IDS

, HIV

and

pre

gnan

cy p

reve

ntio

n, h

ealth

ser

vice

s•

Pra

ctic

ed n

egot

iatin

g sk

ills

B –

Chi

le,

Tee

n S

tar

(24)

• Y

outh

s ag

ed 1

5–16

yea

rs in

urba

n ar

eas

• P

regn

ancy

pre

vent

ion

• M

inim

um 1

0.5

hour

s in

volv

ing

part

icip

ants

in g

roup

dis

cuss

ions

,br

ains

torm

ing

• T

ackl

ed is

sues

suc

h as

gen

der,

pre

judi

ce, a

nato

my,

pub

erty

, fer

tility

,em

otio

ns, m

edia

, sel

f-as

sura

nce,

dec

isio

n-m

akin

g, m

arria

ge a

nd fa

mily

,fa

mily

pla

nnin

g m

etho

ds, p

regn

ancy

and

birt

h•

Use

d cl

ass

disc

ussi

ons,

fert

ility

aw

aren

ess

activ

ities

, rol

e-pl

ayin

g an

dho

mew

ork

C –

Uni

ted

Rep

ublic

of T

anza

nia,

“Nga

o” (

25)

• Y

outh

s ag

ed 1

0–16

yea

rs in

urba

n an

d ru

ral a

reas

• T

arge

ted

sexu

al in

itiat

ion

• 20

hou

rs o

ver

2–3

mon

ths

• C

over

ed tr

ansm

issi

on o

f AID

S, p

erso

nal H

IV r

isk,

ref

usal

ski

lls,

com

mun

icat

ion

with

par

ents

and

com

mun

ity•

Use

d le

ctur

es, p

oste

rs, s

ongw

ritin

g, d

iscu

ssio

n, r

ole-

play

ing,

etc

.D

– K

enya

,P

rimar

y sc

hool

act

ion

for

bette

rhe

alth

(17

)•

You

ths

aged

11–

17 y

ears

inur

ban

and

rura

l are

as•

Tar

gete

d se

xual

initi

atio

n

• T

ackl

ed is

sues

suc

h as

abs

tinen

ce, c

ondo

m u

se, s

choo

l pla

nnin

g,gu

idan

ce, t

rans

mis

sion

and

pre

vent

ion

of S

TIs

,a HIV

and

AID

S; l

ife s

kills

;he

alth

, sex

ualit

y, H

IV m

anag

emen

t•

Use

d pa

rtic

ipat

ory

met

hods

• S

et u

p sc

hool

hea

lth c

lubs

E –

Mex

ico,

Pla

nead

o tu

Vid

a (2

6)• Y

outh

s w

ith m

ean

age

14.4

yea

rs•

Tar

gete

d se

xual

initi

atio

n an

dco

ntra

cept

ive

use

• D

iscu

ssed

rel

atio

nshi

ps, s

exua

lity,

ana

tom

y, p

hysi

olog

y, r

epro

duct

ion,

ST

Is, c

ontr

acep

tion,

dec

isio

n-m

akin

g, c

onse

quen

ces,

sel

f-es

teem

,va

lues

, com

mun

icat

ion,

ass

ertiv

enes

s•

Use

d ro

le-p

lays

and

writ

ing

exer

cise

s

118

92-4-120938-0_CH05_118

F –

Sou

th A

fric

a,Li

fe s

kills

(27

, 28)

• Y

outh

s ag

ed 1

2–21

yea

rs in

urba

n an

d ru

ral a

reas

• T

arge

ted

freq

uenc

y of

sex

ual

activ

ity, c

ondo

m u

se, n

umbe

r of

part

ners

• 16

hou

rs•

Cov

ered

HIV

/AID

S, i

mm

une

syst

em, s

elf-

este

em, s

elf-

awar

enes

s,re

latio

nshi

ps, v

alue

s, s

exua

lity,

abs

tinen

ce, c

ondo

m u

se, r

ape/

abus

e,de

cisi

on-m

akin

g, c

onfli

ct r

esol

utio

n, e

tc.

• U

sed

inte

ract

ive

and

dida

ctic

met

hods

, inc

ludi

ng g

roup

wor

k an

d ro

le-

play

sG

– U

nite

d R

epub

lic o

f Tan

zani

a,M

EM

A k

wa

Vija

na (

Goo

d th

ings

for

youn

g pe

ople

) (2

9)

• You

ths

aged

12–

19 y

ears

in ru

ral

area

s•

Tar

gete

d se

xual

initi

atio

n,co

ndom

use

, num

ber

ofpa

rtne

rs, S

TIs

, pre

gnan

cy

• In

-sch

ool p

rogr

amm

e w

as te

ache

r-le

d, a

lso

peer

-ass

iste

d•

Cov

ered

ref

usal

, sel

f-ef

ficac

y, s

elf-

este

em, S

TI/H

IV, s

exua

lity,

cont

race

ptio

n, a

bstin

ence

, acc

ess

to r

epro

duct

ive

care

and

cont

race

ptio

n, s

ocia

l val

ues,

res

pect

, gen

der

• U

sed

dram

a, s

torie

s, g

ames

• A

lso

deve

lope

d m

ore

yout

h-fr

iend

ly h

ealth

ser

vice

sH

– C

hile

,T

een

ST

AR

cam

paig

n (3

0)• Y

outh

s w

ith m

ean

age

15.8

yea

rsin

urb

an a

reas

• T

arge

ted

sexu

al in

itiat

ion

• 18

uni

ts•

Dis

cuss

ed m

ale

and

fem

ale

fert

ility

, men

stru

al c

ycle

, psy

chos

exua

lde

velo

pmen

t, se

xual

res

pons

ibili

ty, r

elat

ions

hips

, con

trac

eptio

n, S

TIS

• U

sed

expe

rient

ial l

earn

ing

met

hods

to e

xplo

re fe

elin

gs, v

alue

s an

dat

titud

esA

du

lt-l

ed (

oth

er t

han

tea

cher

s)I –

Bra

zil,

Sex

ualit

y, R

epro

duct

ion

and

AID

S P

reve

ntio

n (3

1)

• Y

outh

s ag

ed 1

8–25

yea

rs in

urba

n ar

eas

• T

arge

ted

sexu

al in

itiat

ion,

cond

om u

se, f

requ

ency

of s

ex,

num

ber

of p

artn

ers,

type

of

part

ners

, unp

rote

cted

sex

• 12

hou

rs•

Cov

ered

AID

S s

ymbo

lism

, kno

wle

dge

and

impa

ct o

f AID

S, r

isk

perc

eptio

n, s

exua

l nor

ms,

repr

oduc

tion

and

sexu

al p

leas

ure,

con

dom

use

nego

tiatio

n•

Use

d di

scus

sion

s, r

ole-

play

s, g

roup

dyn

amic

s, m

odel

s, d

emon

stra

tions

Cu

rric

ulu

m-b

ased

inte

rven

tio

ns

wit

h c

har

acte

rist

ics

of

effe

ctiv

e p

rog

ram

mes

J –

Jam

aica

,G

rade

7 p

roje

ct (

32)

• Y

outh

s ag

ed 1

1–14

yea

rs in

urba

n an

d ru

ral a

reas

• T

arge

ted

sexu

al in

itiat

ion,

cont

race

ptiv

e us

e

• 27

hou

rs•

Cov

ered

rep

rodu

ctiv

e an

atom

y an

d ph

ysio

logy

, ST

Is, c

ontr

acep

tive

met

hods

and

myt

hs, r

isks

and

con

sequ

ence

s of

sex

and

pre

gnan

cy,

med

ia, n

orm

s•

Use

d cl

assr

oom

lect

ures

, vis

ual a

ids,

que

stio

n an

d an

swer

ses

sion

s,sm

all g

roup

dis

cuss

ions

119

92-4-120938-0_CH05_119

Stu

dy,

loca

tio

n a

nd

pro

gra

mm

eT

arg

et p

op

ula

tio

n a

nd

pri

mar

yo

bje

ctiv

esD

escr

ipti

on

K –

Nig

eria

, Sch

ool-b

ased

AID

Sed

ucat

ion

(33)

• Y

outh

s w

ith m

ean

age

17.7

inur

ban

area

s•

Tar

gete

d se

xual

initi

atio

n,co

ntra

cept

ive

use,

num

ber

ofpa

rtne

rs, S

TIs

• 12

–36

hour

s• C

over

ed tr

ansm

issi

on a

nd p

reve

ntio

n of

AID

S, a

ttitu

des

tow

ards

HIV

/A

IDS

, sex

ual p

ract

ices

, con

trac

eptiv

e us

e•

Use

d le

ctur

es, f

ilms,

rol

e-pl

ays,

sto

ries,

son

gs, d

ebat

es, e

ssay

s,co

ndom

use

dem

onst

ratio

nsL

– M

exic

o, H

IV p

reve

ntio

nw

orks

hop

and

cond

omdi

strib

utio

n (3

4)

• Y

outh

s w

ith m

ean

age

17.6

yea

rsin

urb

an a

reas

• T

arge

ted

sexu

al in

itiat

ion,

freq

uenc

y of

sex

ual i

nter

cour

se,

unpr

otec

ted

sex

• 3

hour

s•

Cov

ered

HIV

atti

tude

s, m

yths

, fac

ts a

nd r

isk,

effe

cts

of A

IDS

, HIV

tran

smis

sion

and

pre

vent

ion,

livi

ng w

ith H

IV, c

ondo

m u

se a

ndne

gotia

tion

skill

s•

Use

d dr

amas

, gam

es, r

ole-

play

s, v

ideo

s, H

IV-p

ositi

ve s

peak

er,

disc

ussi

ons,

con

dom

use

dem

onst

ratio

nM

– N

amib

ia, M

y fu

ture

is m

ych

oice

(35

)•

You

ths

aged

9–1

1 ye

ars

in u

rban

and

rura

l are

as•

Tar

gete

d se

xual

initi

atio

n, n

umbe

rof

par

tner

s, c

ondo

m u

se,

freq

uenc

y of

sex

ual a

ctiv

ity

• 28

hou

rs•

Dis

cuss

ed r

epro

duct

ive

biol

ogy

and

HIV

/AID

S, r

isk

beha

viou

rs,

com

mun

icat

ion

skill

s, fr

amew

ork

for

deci

sion

-mak

ing

• U

sed

narr

ativ

es, g

ames

, fac

ts, e

xerc

ises

, que

stio

ns a

nd d

iscu

ssio

ns

Pee

r-le

dN

– B

eliz

e,P

roje

ct L

ight

(36

)•

You

ths

aged

13–

17 y

ears

in u

rban

area

s•

Tar

gete

d se

xual

initi

atio

n, n

umbe

rof

par

tner

s, c

ondo

m u

se

• 14

hou

rs•

Cov

ered

HIV

tran

smis

sion

and

pre

vent

ion,

bar

riers

and

sol

utio

ns to

avoi

ding

sex

or

usin

g co

ndom

s, p

eer

pres

sure

, con

dom

use

,co

mm

unic

atio

n•

Use

d ro

le-p

lays

, exe

rcis

es, s

kill-

build

ing

activ

ities

, pee

r ro

le-m

odel

test

imon

ials

Cu

rric

ulu

m-b

ased

inte

rven

tio

ns

wit

ho

ut

char

acte

rist

ics

of

effe

ctiv

e p

rog

ram

mes

Ad

ult

-led

(te

ach

ers)

O –

Mex

ico,

A T

eam

Aga

inst

AID

S (

37)

• Y

outh

s ag

ed 1

3–23

yea

rs in

urb

anar

eas

• T

arge

ted

sexu

al in

itiat

ion,

con

dom

use

• 25

hou

rs•

Cov

ered

sex

ualit

y, a

nato

my

and

phys

iolo

gy, v

alue

s, H

IV/A

IDS

tran

smis

sion

, myt

hs, p

reve

ntio

n, r

isk

perc

eptio

n, s

afer

sex

,ab

stin

ence

, ass

ertiv

enes

s, s

elf-

este

em, e

tc.

120

92-4-120938-0_CH05_120

P –

Chi

le,

Ado

lesc

ence

, a ti

me

ofde

cisi

on-m

akin

g (3

8)

• U

rban

you

ths

• T

arge

ted

sexu

al in

itiat

ion,

cont

race

ptiv

e us

e

• D

urat

ion

of 2

yea

rs•

Cov

ered

rel

atio

nshi

ps, p

aren

t–ch

ild c

omm

unic

atio

n, g

oals

,re

prod

uctiv

e ph

ysio

logy

, pos

tpon

ing

sex,

ST

Is, g

ende

r, r

isk

beha

viou

rs•

Use

d sm

all g

roup

dis

cuss

ions

, par

ticip

ator

y ed

ucat

iona

l mod

ules

Pee

r-le

dQ

– Z

ambi

a,T

he Z

ambi

a P

eer

Sex

ual H

ealth

Inte

rven

tion

(39)

• Y

outh

s ag

ed 1

4–23

in u

rban

are

as•

Tar

gete

d ab

stin

ence

, con

dom

use

• 1.

75 h

ours

• C

over

ed H

IV tr

ansm

issi

on a

nd p

reve

ntio

n, a

bstin

ence

, con

dom

use

,S

TIs

, asy

mpt

omat

ic p

hase

s, r

efus

al s

kills

• U

sed

disc

ussi

on, s

kits

, con

dom

dem

onst

ratio

n an

d a

leaf

let

ST

I - W

hy s

houl

d I w

orry

?N

on

-cu

rric

ulu

m-b

ased

inte

rven

tio

ns

Ad

ult

-led

R –

Sou

th A

fric

a,D

ram

Aid

e (4

0)•

You

ths

aged

13–

29 y

ears

in u

rban

and

rura

l are

as•

Tar

gete

d se

xual

initi

atio

n, n

umbe

rof

par

tner

s, c

ondo

m u

se, S

TIs

• C

over

ed H

IV/A

IDS

tran

smis

sion

, pre

vent

ion

and

mis

conc

eptio

ns;

pers

onal

sus

cept

ibili

ty a

nd th

reat

; atti

tude

s to

war

ds p

eopl

e w

ith A

IDS

• U

sed

part

icip

ator

y pr

oces

s of

lear

ning

and

then

pre

sent

ing

info

rmat

ion

usin

g dr

ama

Cu

rric

ulu

m-b

ased

inte

rven

tio

ns

wit

h c

har

acte

rist

ics

of

effe

ctiv

e p

rog

ram

mes

S –

Zim

babw

e,IE

C h

ealth

edu

catio

n (4

1)•

You

ths

age

10–1

9 ye

ars

in u

rban

and

rura

l are

as•

Tar

gete

d se

xual

initi

atio

n

• C

over

ed r

epro

duct

ion,

AID

S/S

TIs

, sex

ualit

y, p

regn

ancy

pre

vent

ion,

impa

ct o

f unp

lann

ed p

regn

ancy

• Use

d he

alth

edu

catio

n, in

form

atio

n an

d co

unse

lling

; lea

flets

, pos

ters

,an

d pa

mph

lets

T –

Nig

eria

,S

TD

inte

rven

tion

(42)

• Y

outh

s ag

ed 1

2–21

yea

rs in

urb

anar

eas

• T

arge

ted

cond

om u

se a

nd S

TIs

• C

over

ed S

TI p

reve

ntio

n an

d tr

eatm

ent

• U

sed

repr

oduc

tive

heal

th c

lubs

and

pee

r ed

ucat

ors

to p

rovi

deco

unse

lling

and

ref

erra

lsU

– U

gand

a,S

choo

l hea

lth e

duca

tion

prog

ram

me

(43)

• Y

outh

s ag

ed 9

–22

year

s in

urb

anar

eas

• T

arge

ted

sexu

al in

itiat

ion,

freq

uenc

y of

sex

ual a

ctiv

ity,

num

ber

of p

artn

ers

• C

over

ed h

ealth

y se

xual

dec

isio

n-m

akin

g, p

eer

inte

ract

ions

, AID

S,

sexu

ality

, hea

lth•

Use

d hi

ghly

inte

ract

ive,

chi

ld-t

o-ch

ild c

ompe

titio

n in

pla

ys, e

ssay

s,po

ems

and

song

s, q

uest

ion

box

121

92-4-120938-0_CH05_121

Stu

dy,

loca

tio

n a

nd

pro

gra

mm

eT

arg

et p

op

ula

tio

n a

nd

pri

mar

yo

bje

ctiv

esD

escr

ipti

on

Pee

r-le

dV

– G

hana

and

Nig

eria

,W

est A

fric

an Y

outh

Initi

ativ

e (4

4)

• U

rban

you

ths

• T

arge

ted

freq

uenc

y of

sex

ual

activ

ity, c

ontr

acep

tive

use

• C

over

ed r

epro

duct

ive

heal

th, p

regn

ancy

, ST

Is, H

IV, c

ontr

acep

tion,

com

mun

icat

ion

• U

sed

peer

lead

ers

to p

rovi

de in

form

atio

n, e

duca

tion

and

coun

selli

ngon

rep

rodu

ctiv

e he

alth

and

ref

erra

ls

a S

TIs

= s

exua

lly tr

ansm

itted

infe

ctio

ns.

122

92-4-120938-0_CH05_122

Tab

le 5

.4D

escr

ipti

on

of

ou

tco

me

eval

uat

ion

s b

y st

ud

y

Stu

dy

Des

ign

an

d s

amp

le s

izea

Eva

luat

ion

res

ult

sbA

llM

ales

Fem

ales

Fac

tors

aff

ecti

ng

str

eng

th o

f ev

iden

ce

Cu

rric

ulu

m-b

ased

inte

rven

tio

ns

wit

h c

har

acte

rist

ics

of

effe

ctiv

e p

rog

ram

mes

Ad

ult

-led

pro

gra

mm

es (

teac

her

s)A

(16)

D

esig

n: q

uasi

-exp

erim

enta

l(c

ohor

t by

scho

ol)

Sam

ple

size

: 245

0ba

selin

e, 1

786

last

follo

w u

p•

3 in

terv

entio

n, 3

com

paris

onsc

hool

s•

Mat

ched

pre

-tes

t and

pos

t-te

stsu

rvey

s•

Bas

elin

e, 4

and

8 m

onth

follo

wup

All

resu

lts fo

r fo

llow

up

at 4

and

8 m

onth

s

• In

itiat

ion

of s

ex (

4 an

d 8

mon

th)

• C

onsi

sten

t con

dom

use

• N

umbe

r se

xual

par

tner

s

0 0

0 0

0 0

0 0

+ 0 0 0

Str

engt

hs: l

arge

sam

ple

size

Lim

itatio

ns: b

iase

d by

hig

h re

fusa

l rat

e;co

ntro

l gro

up s

igni

fican

tly y

oung

er a

nd m

ore

likel

y to

be

livin

g w

ith fa

mily

; ana

lysi

s di

d no

tco

mpa

re c

hang

e ov

er ti

me

betw

een

grou

ps

B (

24)

Des

ign:

exp

erim

enta

l (co

hort

by

clas

s)S

ampl

e si

ze: 1

259

base

line,

1259

at l

ast f

ollo

w u

p•

One

sch

ool w

ith in

terv

entio

nan

d co

ntro

l gro

ups

• M

atch

ed c

linic

al d

ata

• B

asel

ine,

4 y

ear

follo

w u

p

• B

irths

/spo

ntan

eous

abor

tion

+S

tren

gths

: lar

ge s

ampl

e si

ze; l

ong-

term

follo

w u

p; la

rge

effe

ct s

ize

Lim

itatio

ns: r

epor

ting

of p

regn

ancy

unc

lear

;on

e sc

hool

onl

y

123

92-4-120938-0_CH05_123

Stu

dy

Des

ign

an

d s

amp

le s

izea

Eva

luat

ion

res

ult

sbA

llM

ales

Fem

ales

Fac

tors

aff

ecti

ng

str

eng

th o

f ev

iden

ce

C (

25)

Des

ign:

qua

si-e

xper

imen

tal

(coh

ort b

y sc

hool

)S

ampl

e si

ze: 2

026

base

line,

814

at la

st fo

llow

up

• 6

inte

rven

tion

, 12

com

paris

on s

choo

ls•

Cro

ss-s

ectio

nal s

urve

ys•

Bas

elin

e, 6

, and

12

mon

thfo

llow

up

• In

itiat

ion

of s

exua

l rel

atio

ns0

00

Str

engt

hs: l

arge

sam

ple

size

; wel

l con

duct

edco

mm

unity

tria

l; al

l sch

ools

incl

uded

Lim

itatio

ns: B

asel

ine

sam

ple

of s

exua

llyin

expe

rienc

ed y

outh

und

erpo

wer

edN

ote:

larg

e de

sire

d ef

fect

siz

e; 1

7 vs

7%

initi

ated

but

P =

0.1

9.

D (

17)

Des

ign:

qua

si-e

xper

imen

tal

(coh

ort b

y sc

hool

)S

ampl

e si

ze: 9

036

base

line,

1344

1 at

last

follo

w u

p•

120

inte

rven

tion,

100

com

paris

on s

choo

ls•

Cro

ss-s

ectio

nal s

urve

ys•

Bas

elin

e, 2

4 (o

r 15

)m

onth

s

• In

itiat

ion

of s

exua

l rel

atio

ns

• C

ondo

m u

sed

at la

st s

ex

+ 0

+ +

Str

engt

hs: v

ery

stro

ng tr

ial w

ith a

larg

e sa

mpl

esi

ze a

nd lo

ng-t

erm

follo

w u

pN

ote:

var

ious

inte

rven

tions

in c

ompa

rison

scho

ols

E (

26)

Des

ign:

exp

erim

enta

l(c

ohor

t by

clas

sroo

m)

Sam

ple

size

: 491

bas

elin

e,41

6 at

last

follo

w u

p•

6 sc

hool

s w

ith in

terv

entio

nan

d co

ntro

l gro

ups

• Mat

ched

pre

-tes

t and

pos

t-te

st s

urve

ys•

Bas

elin

e,6

wee

ks, 4

and

8m

onth

s fo

llow

up

• S

exua

l int

erco

urse

• C

ontr

acep

tive

use

at fi

rst

sexu

al in

terc

ours

e

0 +

Lim

itatio

ns: m

oder

ate

sam

ple

size

; sho

rt fo

llow

up

124

92-4-120938-0_CH05_124

Sam

ple

size

: 114

1 ba

selin

e,64

6 at

last

follo

w u

p•

11 in

terv

entio

n an

d 11

com

paris

on s

choo

ls• M

atch

ed p

re-t

est a

nd p

ost-

test

sur

veys

• B

asel

ine,

6 a

nd 1

0 m

onth

follo

w u

p

• F

requ

ency

of s

exua

lin

terc

ours

e•

Con

dom

use

• N

umbe

r of

sex

ual p

artn

ers

+ 0 0

did

not c

ompa

re th

e ch

ange

ove

r tim

e be

twee

ntr

ial g

roup

s

G (

29)

Des

ign:

exp

erim

enta

l(c

ohor

t by

com

mun

ity)

Sam

ple

size

: 964

5 ba

selin

e,70

40 a

t las

t fol

low

up

• 10

inte

rven

tion

com

mun

ities

with

62

scho

ols

and

10 c

ontr

olco

mm

uniti

es w

ith 6

3sc

hool

s• M

atch

ed p

re-t

est a

nd p

ost-

test

sur

veys

• B

asel

ine,

18,

and

36

mon

ths

follo

w u

p

• In

itiat

ion

of s

exua

lin

terc

ours

e•

> 1

par

tner

in p

ast 1

2m

onth

s•

Con

dom

use

: at l

ast s

exua

lin

terc

ours

e/ev

er•

ST

Id

0 +

+ /

+

0

0 0

0 / + -

Str

engt

hs: v

ery

stro

ng R

CT

c eva

luat

ion

with

ala

rge

sam

ple

size

and

long

-ter

m fo

llow

-up;

use

of b

iolo

gica

l out

com

es

H (

30)

Des

ign:

qua

si-e

xper

imen

tal

(coh

ort b

y cl

assr

oom

s)S

ampl

e si

ze: 3

05 b

asel

ine,

243

at la

st fo

llow

up

• 5

scho

ols

with

inte

rven

tion

and

cont

rol g

roup

s• M

atch

ed p

re-t

est a

nd p

ost-

test

sur

veys

• B

asel

ine

and

12 m

onth

sfo

llow

up

• In

itiat

ion

of s

exua

lin

terc

ours

e+

Lim

itatio

ns: b

iase

d by

teac

her s

elec

tion

of s

tudy

grou

ps; s

mal

l sam

ple

size

125

F (

27,2

8)

Des

ign:

qua

si-e

xper

imen

tal

(coh

ort b

y sc

hool

)•

Initi

atio

n of

sex

ual

inte

rcou

rse

00

0Li

mita

tions

: non

-ran

dom

ass

ignm

ent o

f sch

ools

;sh

ort f

ollo

w u

p; h

igh

loss

es to

follo

w u

p; a

naly

sis

92-4-120938-0_CH05_125

Stu

dy

Des

ign

an

d s

amp

le s

izea

Eva

luat

ion

res

ult

sbA

llM

ales

Fem

ales

Fac

tors

aff

ecti

ng

str

eng

th o

f ev

iden

ce

Ad

ult

-led

pro

gra

mm

es (

oth

er t

han

tea

cher

s)I (

31)

Des

ign:

exp

erim

enta

l (co

hort

by s

choo

l)S

ampl

e si

ze: 3

94 b

asel

ine,

198

at la

st fo

llow

up

• 2

inte

rven

tion

and

2 co

ntro

lsc

hool

s•

Mat

ched

pre

-tes

t and

pos

t-te

st s

urve

ys•

Bas

elin

e, 6

, and

12

mon

ths

follo

w u

p

• In

itiat

ion

of s

exua

lin

terc

ours

e/se

xual

act

ivity

durin

g pa

st6

mon

ths

• C

ondo

m u

se•

Unp

rote

cted

sex

ual

inte

rcou

rse

with

ste

ady

part

ner

• U

npro

tect

ed s

exua

lin

terc

ours

e w

ith c

asua

l/non

-m

onog

amou

s pa

rtne

r

0/0 0 0 0/0

0/0 0 0 0 /+

Lim

itatio

ns: s

mal

l sam

ple

size

; hig

h dr

op-o

utra

te b

y 12

mon

ths

desp

ite tr

acki

ng a

ttem

pts

J (3

2)D

esig

n: q

uasi

-exp

erim

enta

l(c

ohor

t by

scho

ol)

Sam

ple

size

: 945

bas

elin

e,71

8 at

last

follo

w u

p•

5 in

terv

entio

n an

d 5

com

paris

on s

choo

ls•

Mat

ched

pre

-tes

t and

pos

t-te

st s

urve

ys•

Bas

elin

e, 9

, and

21

mon

ths

follo

w u

p

All

resu

lts fo

r fo

llow

up

at 9

and

21 m

onth

s•

Initi

atio

n of

sex

ual

inte

rcou

rse

• C

ontr

acep

tion

use

at fi

rst

sexu

al in

terc

ours

e

0 0

0 0

Str

engt

hs: s

choo

ls s

elec

ted

to b

ere

pres

enta

tive;

larg

e sa

mpl

e si

ze; l

ong-

term

follo

w u

pLi

mita

tions

: com

paris

on s

choo

ls r

ecei

ved

varie

d cu

rric

ula

K (

33)

Des

ign:

exp

erim

enta

l (co

hort

by s

choo

l)S

ampl

e si

ze: 4

50 b

asel

ine,

433

at la

st fo

llow

up

• 2

inte

rven

tion

and

2 co

ntro

lsc

hool

s•

Cro

ss-s

ectio

nal s

urve

ys

• In

itiat

ion

of s

ex•

Num

ber

of s

exua

l par

tner

s•

Con

dom

: use

at l

ast s

ex/

cons

iste

nt u

se•

ST

I

+ +0

/ 0 0

Lim

itatio

ns: m

oder

ate

sam

ple

size

; cha

nge

scor

es o

ver

time

for

each

exp

erim

enta

l gro

upw

ere

not c

alcu

late

d an

d co

mpa

red

126

• B

asel

ine

and

6 m

onth

sfo

llow

up

92-4-120938-0_CH05_126

L (3

4)D

esig

n: b

oth

expe

rimen

tal

and

quas

i-exp

erim

enta

lS

ampl

e si

ze: 3

20 b

asel

ine,

309

at la

st fo

llow

up

• 4

scho

ols

had

clas

sroo

ms

rand

omly

ass

igne

d to

inte

rven

tion

and

cont

rol

grou

ps; a

t tw

o sc

hool

sco

ndom

s w

ere

dist

ribut

edth

roug

h ki

osks

• M

atch

ed p

re-t

est a

nd p

ost-

test

sur

veys

• B

asel

ine,

3 a

nd 6

mon

ths

follo

w u

p

All

resu

lts fo

r fo

llow

up

at 3

and

6 m

onth

s•

Initi

atio

n of

sex

ual

inte

rcou

rse

• S

exua

l int

erco

urse

in p

ast 3

mon

ths

• U

npro

tect

ed s

exua

lin

terc

ours

e in

pas

t 3 m

onth

s

+ + 0 0

0 0

NA

e +

NA

0

NA

0

NA

+

NA

0

NA

0

Str

engt

hs: 4

-way

con

ditio

n an

alys

is

Lim

itatio

ns: s

mal

l sam

ple

size

M (

35)

Des

ign:

exp

erim

enta

l (co

hort

by s

tude

nt)

Sam

ple

size

: 515

bas

elin

e,35

9 at

last

follo

w u

p•

10 s

choo

ls w

ith in

terv

entio

nan

d co

ntro

l gro

ups

• M

atch

ed p

re-t

est a

nd p

ost-

test

sur

veys

• B

asel

ine,

2, 6

, and

12

mon

ths

follo

w u

p

• In

itiat

ion

of s

exua

lin

terc

ours

e/fr

eque

ncy

ofse

xual

inte

rcou

rse

(at 6

mon

ths)

• Num

ber o

f par

tner

s (a

t 6 a

nd12

mon

ths)

• A

bstin

ence

am

ong

virg

ins

atba

selin

e (a

nd a

t 6 a

nd 1

2m

onth

s)•

Abs

tinen

ce a

mon

g se

xual

lyex

perie

nced

at b

asel

ine

(and

at 6

and

12

mon

ths)

• C

ondo

m u

se a

mon

g al

l (at

6an

d 12

mon

ths)

0/0

00 0+ 00 00

0/0

00 00 00 00

0/0

0+ 00 00 00

Str

engt

hs: s

tron

g ev

alua

tion

desi

gn w

ithra

ndom

ass

ignm

ent a

nd lo

ng-t

erm

follo

w u

p

Lim

itatio

ns: m

oder

ate

sam

ple

size

127

92-4-120938-0_CH05_127

Stu

dy

Des

ign

an

d s

amp

le s

izea

Eva

luat

ion

res

ult

sbA

llM

ales

Fem

ales

Fac

tors

aff

ecti

ng

str

eng

th o

f ev

iden

ce

Pee

r-le

d p

rog

ram

mes

N (

36)

Des

ign:

qua

si-e

xper

imen

tal

(coh

ort)

Sam

ple

size

: 150

bas

elin

e, 1

50at

last

follo

w u

p•

3 in

terv

entio

n an

d 3

com

paris

on s

choo

ls•

Mat

ched

pre

-tes

t and

pos

t-te

stsu

rvey

s• B

asel

ine

and

4 m

onth

follo

w u

p

• C

ondo

m u

se +

Lim

itatio

ns: b

iase

d sc

hool

sel

ectio

n; s

mal

lsa

mpl

e si

ze; s

hort

follo

w u

p

Cu

rric

ulu

m-b

ased

inte

rven

tio

ns

wit

ho

ut

char

acte

rist

ics

of

effe

ctiv

e p

rog

ram

mes

Ad

ult

-led

(tea

cher

s)O

(37

)D

esig

n: q

uasi

-exp

erim

enta

l(c

ohor

t by

scho

ol)

Sam

ple

size

: 206

4 ba

selin

e,94

6 at

last

follo

w u

p•

2 in

terv

entio

n an

d 2

com

paris

on s

choo

ls•

Mat

ched

pre

-tes

t and

pos

t-te

stsu

rvey

s•

Bas

elin

e, 4

, and

10

mon

thfo

llow

up

• In

itiat

ion

of s

exua

lin

terc

ours

e•

Con

dom

use

0 0

Lim

itatio

ns: c

hang

e sc

ores

ove

r tim

e fo

r ea

chex

perim

enta

l gro

up w

ere

not c

alcu

late

d an

dco

mpa

red

P (

38)

Des

ign:

qua

si-e

xper

imen

tal

(coh

ort b

y sc

hool

)sa

mpl

e si

ze: 4

238

base

line,

4135

at l

ast f

ollo

w u

p•

2 in

terv

entio

n an

d 3

com

paris

on s

choo

ls

• In

itiat

ion

of s

exua

lin

terc

ours

e•

Con

trac

eptiv

e us

e,ev

er•

Con

trac

eptiv

e us

e,la

st s

exua

lin

terc

ours

e

+ 0 0

+ + 0

Str

engt

hs: l

arge

sam

ple

size

; lon

g te

rm fo

llow

up Lim

itatio

ns: n

on-r

ando

m a

ssig

nmen

t of

scho

ols;

adj

ustm

ent f

or e

xpos

ure

toin

terv

entio

n m

ay o

vere

stim

ate

effe

ct

128

92-4-120938-0_CH05_128

• M

atch

ed p

re-t

est a

nd p

ost-

test

surv

eys

• B

asel

ine,

8, 2

0, a

nd 3

2 m

onth

follo

w u

pP

eer-

led

pro

gra

mm

esQ

(39

)D

esig

n: e

xper

imen

tal (

coho

rt b

ysc

hool

)•

3 in

terv

entio

n an

d 2

com

paris

on s

choo

ls•

Mat

ched

pre

-tes

t and

pos

t-te

stsu

rvey

s• B

asel

ine

and

6 m

onth

follo

w u

p

• M

ultip

le r

egul

arpa

rtne

rs•

Dis

cuss

con

dom

use/

abst

ain

with

regu

lar

part

ner

• C

ondo

m u

se w

ithre

gula

r pa

rtne

r:ev

er/la

st ti

me

• C

asua

l par

tner

0 0/0

0/0 0

Lim

itatio

ns: m

oder

ate

sam

ple

size

; diff

eren

ces

betw

een

inte

rven

tion

and

cont

rol g

roup

s lik

ely

to fa

vour

inte

rven

tion

No

n-c

urr

icu

lum

-bas

ed in

terv

enti

on

s w

ith

ou

t ch

arac

teri

stic

s o

f ef

fect

ive

pro

gra

mm

esA

du

lt-l

edR

(40

)D

esig

n: e

xper

imen

tal (

coho

rt b

ysc

hool

) us

ing

adul

ts n

otaf

filia

ted

with

the

scho

olS

ampl

e si

ze: 1

080

base

line,

699

at la

st fo

llow

up

• 10

inte

rven

tion

and

10 c

ontr

olsc

hool

s•

Mat

ched

pre

-tes

t and

pos

t-te

stsu

rvey

s•

Bas

elin

e an

d 18

mon

th fo

llow

up

• In

itiat

ion

of s

exua

lin

terc

ours

e•

Con

dom

use

• N

umbe

r of

par

tner

s•

ST

I in

past

6m

onth

s

0 0 0 0

Str

engt

hs: l

arge

-sca

le e

valu

atio

n in

are

pres

enta

tive

sam

ple;

long

-ter

m fo

llow

up

Lim

itatio

ns: h

igh

drop

-out

rat

e; n

umbe

r of

scho

ols

not r

epor

ted

129

92-4-120938-0_CH05_129

Stu

dy

Des

ign

an

d s

amp

le s

izea

Eva

luat

ion

res

ult

sbA

llM

ales

Fem

ales

Fac

tors

aff

ecti

ng

str

eng

th o

f ev

iden

ce

S (

41)

Des

ign:

exp

erim

enta

l (co

hort

by

scho

ol);

teac

her-

led

Sam

ple

size

: 168

9 ba

selin

e, 1

605

at la

st fo

llow

up

• In

terv

entio

n sc

hool

s: n

ot r

epor

ted

and

3 co

ntro

l sch

ools

• M

atch

ed p

re-t

est a

nd p

ost-

test

surv

eys

• B

asel

ine

and

5 m

onth

follo

w u

p

• In

itiat

ion

of s

exua

lin

terc

ours

e0

Str

engt

hs: l

arge

-sca

le r

epre

sent

ativ

e sa

mpl

e

Lim

itatio

ns: l

imite

d in

form

atio

n ab

out t

he s

tatis

tical

anal

ysis

; sho

rt fo

llow

up

T (

42)

Des

ign:

qua

si-e

xper

imen

tal

(coh

ort b

y sc

hool

); p

eer-

led

with

heal

th w

orke

rS

ampl

e si

ze: 1

886

base

line,

1801

at f

ollo

w u

p•

4 in

terv

entio

n an

d 8

com

paris

onsc

hool

s•

Cro

ss-s

ectio

nal s

urve

ys•

Bas

elin

e an

d 11

mon

th fo

llow

up

• C

ondo

m u

se•

ST

I+ +

0+

Str

engt

hs: l

arge

sam

ple

size

U (

43)

Des

ign:

qua

si-e

xper

imen

tal (

coho

rtby

sch

ool a

nd s

tude

nt);

impr

oved

scho

ol h

ealth

inst

ruct

ion

Sam

ple

size

: 400

- ba

selin

e, 4

00 a

tfo

llow

up

• 38

inte

rven

tion

scho

ols

and

com

paris

on s

choo

ls•

Cro

ss-s

ectio

nal s

urve

ys•

Bas

elin

e an

d 32

mon

th fo

llow

up

• In

itiat

ion

of s

exua

lin

terc

ours

e•

Sex

ual i

nter

cour

se in

the

past

mon

th•

Life

time

num

ber

ofpa

rtne

rs

+ 0 0

++

Str

engt

hs: l

ong-

term

follo

w u

p

Lim

itatio

ns: r

epor

ted

sexu

al a

ctiv

ity a

mon

g m

ales

diffe

rent

at b

asel

ine

130

92-4-120938-0_CH05_130

Pee

r-le

d p

rog

ram

mes

V (

44)

Des

ign:

qua

si-e

xper

imen

tal (

coho

rtby

sch

ool a

nd c

omm

unity

)S

ampl

e si

ze: 1

784

base

line,

1801

at l

ast f

ollo

w u

p•

6 in

terv

entio

n sc

hool

s an

d 2

inte

rven

tion

com

mun

ities

,co

mpa

rison

com

mun

ities

not

repo

rted

• C

ross

-sec

tiona

l sur

veys

• B

asel

ine

and

18-2

6 m

onth

follo

wup

• E

ver

had

sexu

alin

terc

ours

e•

Use

mod

ern

cont

race

ptiv

es

– +

Str

engt

hs: l

arge

-sca

le in

mul

tiple

set

tings

; lon

g-te

rm fo

llow

up

Lim

itatio

ns: n

on-r

ando

m a

ssig

nmen

t; la

ck o

fm

ultiv

aria

te s

tatis

tical

dat

a fo

r be

havi

oura

lou

tcom

es

a E

xper

imen

tal i

s de

fined

as

rand

omiz

ed a

lloca

tion

of p

artic

ipan

ts, s

choo

ls o

r co

mm

uniti

es in

to in

terv

entio

n or

con

trol

gro

ups.

b R

esul

ts r

epor

ted

are

for

last

follo

w u

p un

less

oth

erw

ise

indi

cate

d. R

esul

ts c

ateg

oriz

ed a

s: “

0” fo

r no

sig

nific

ant c

hang

e, “

+”

for

sign

ifica

nt d

esira

ble

chan

ge, “

-” f

or s

igni

fican

t und

esira

ble

chan

ge.

c RC

T =

ran

dom

ized

con

trol

led

tria

l.d

ST

I = s

exua

lly tr

ansm

itted

infe

ctio

n.e

NA

= n

ot a

pplic

able

.

131

92-4-120938-0_CH05_131

Tab

le 5

.4a

Su

mm

ary

of

effe

cts

of

sch

oo

l-b

ased

inte

rven

tio

ns1

Typ

e o

fin

terv

enti

on

NIn

itia

tio

n o

f se

xF

req

uen

cy o

f sex

Nu

mb

er o

fp

artn

ers

Co

nd

om

use

Bir

th c

on

tro

lu

seU

np

rote

cted

sex

An

y b

ehav

ior

-N

S+

-N

S+

-N

S+

-N

S+

-N

S+

-N

S+

-N

S+

Cu

rric

ulu

m-b

ased

Wit

h c

har

acte

rist

ics

of

effe

ctiv

e p

rog

ram

mes

Ad

ult

-led

130

75

03

10

22

05

30

11

01

10

211

Pee

r-le

d o

nly

10

00

00

00

00

00

10

00

00

00

01

Wit

ho

ut

char

acte

rist

ics

of

effe

ctiv

e p

rog

ram

mes

Ad

ult

-led

20

11

00

00

00

01

00

01

00

00

11

Pee

r-le

d o

nly

10

00

00

00

10

01

00

00

00

00

10

No

n-c

urr

icu

lum

-bas

edW

ith

ou

t ch

arac

teri

stic

s o

f ef

fect

ive

pro

gra

mm

esA

du

lt-l

ed4

02

10

10

02

00

11

00

00

00

02

2P

eer-

led

on

ly1

10

00

00

00

10

01

00

10

00

00

1T

ota

l22

110

70

41

05

30

86

01

30

11

06

16

1 “-

” m

eans

an

incr

ease

in r

isk

in te

rms

of H

IV, e

.g.,

a ha

sten

ing

of th

e in

itiat

ion

of s

ex, m

ore

sexu

al p

artn

ers

or le

ss c

ondo

m u

se.

“NS

” m

eans

not

sig

nific

ant.

“+”

mea

ns a

red

uctio

n in

ris

k in

term

s of

HIV

, e.g

., a

dela

y in

the

initi

atio

n of

sex

, few

er s

exua

l par

tner

s, o

r gr

eate

r co

ndom

use

.

132

92-4-120938-0_CH05_132

Tab

le 5

.4b

Su

mm

ary

of

effe

cts

for

adu

lt-l

ed c

urr

icu

lum

-bas

ed s

cho

ol i

nte

rven

tio

ns2

NIn

itia

tio

n o

fse

xN

um

ber

of

par

tner

sF

req

uen

cy o

fse

xC

on

do

m u

seB

irth

co

ntr

ol

use

Un

pro

tect

ed s

exA

ny

beh

avio

r

-N

S+

-N

S+

-N

S+

-N

S+

-N

S+

-N

S+

-N

S+

To

tal

130

84

02

20

32

04

30

11

01

111

Sch

oo

l set

tin

gP

rimar

y33

02

10

01

nana

na0

02

nana

nana

nana

01

2S

econ

dary

28

04

30

11

02

10

40

01

10

10

01

7C

olle

ge/N

ight

sch

ool

30

21

01

00

10

01

1na

nana

00

10

03

Pro

gra

m e

du

cato

rsT

each

ers

80

52

02

10

01

01

30

01

nana

na0

17

Oth

er A

dults

50

23

00

10

30

04

00

10

01

10

14

Par

tici

pan

ts s

ex4

Mal

es6

05

10

11

02

00

41

00

00

10

04

2F

emal

es6

04

20

20

02

00

23

00

00

10

02

4T

ype

of

eval

uat

ion

des

ign

Qua

si-e

xper

imen

tal

60

33

03

00

11

02

20

10

01

00

15

Exp

erim

enta

l7

04

20

02

02

00

31

00

10

01

01

6

2 T

his

is th

e gr

oup

of in

terv

entio

ns g

iven

a “

Go”

rec

omm

enda

tion.

“-”

mea

ns a

n in

crea

se in

ris

k in

term

s of

HIV

, e.g

., a

hast

enin

g of

the

initi

atio

n of

sex

, mor

e se

xual

par

tner

s or

less

con

dom

or

cont

race

ptiv

e us

e.“N

S”

mea

ns n

ot s

igni

fican

t.“+

” m

eans

a r

educ

tion

in r

isk

in te

rms

of H

IV, e

.g.,

a de

lay

in th

e in

itiat

ion

of s

ex, f

ewer

sex

ual p

artn

ers,

or

grea

ter

cond

om u

se.

“na”

mea

ns n

o st

udy

in th

is g

roup

mea

sure

d th

is o

utco

me.

3 O

ne s

tudy

incl

uded

bot

h pr

imar

y an

d se

cond

ary

scho

ols

and

its r

esul

ts a

re in

clud

ed in

bot

h ca

tego

ries.

4 O

nly

6 of

the

13 s

tudi

es p

rovi

ded

sepa

rate

res

ults

for

each

sex

. The

se 6

stu

dies

pro

vide

d re

sults

for

both

mal

es a

nd fe

mal

es.

133

92-4-120938-0_CH05_133

Tab

le 5

.5S

tren

gth

of

evid

ence

of

effe

ctiv

enes

s fo

r ea

ch in

terv

enti

on

typ

e an

d r

eco

mm

end

atio

ns

for

pro

gra

mm

es

Eva

luat

ion

des

ign

Po

siti

ve e

ffec

tN

o s

ign

ific

ant

effe

ctN

egat

ive

effe

ctS

tren

gth

of

evid

ence

and

rec

om

men

dat

ion

Cu

rric

ulu

m-b

ased

inte

rven

tio

ns

Wit

h c

har

acte

rist

ics

of

effe

ctiv

e p

rog

ram

mes

Adu

lt-le

d

Qua

si-e

xper

imen

tal

A, D

, F,H

JV

ery

stro

ng

RC

Ta

(< 6

clu

ster

s pe

r gr

oup)

I, K

Go

R

CT

( 6

clu

ster

s pe

r gr

oup)

B, E

, G, L

, MC

Pee

r-le

dW

eak

Q

uasi

-exp

erim

enta

lN

Ste

ady

Wit

ho

ut

char

acte

rist

ics

of

effe

ctiv

e p

rog

ram

mes

Adu

lt-le

dW

eak

Q

uasi

-exp

erim

enta

lP

OS

tead

yP

eer-

led

Wea

k

RC

T (

< 6

clu

ster

s pe

r gr

oup)

QS

tead

yN

on

-cu

rric

ulu

m-b

ased

inte

rven

tio

ns

Wit

ho

ut

char

acte

rist

ics

of

effe

ctiv

e p

rog

ram

mes

Adu

lt-le

dW

eak

Q

uasi

-exp

erim

enta

lT

, US

tead

y

RC

T (

< 6

clu

ster

s pe

r gr

oup)

R, S

Pee

r-le

dbE

quiv

ocal

Q

uasi

-exp

erim

enta

lV

VS

tead

ya

RC

T =

ran

dom

ized

con

trol

led

tria

l.b T

here

was

onl

y on

e st

udy

of a

non

-cur

ricul

um-b

ased

onl

y pe

er-le

d pr

ogra

mm

e. It

had

a s

tatis

tical

ly s

igni

fican

t neg

ativ

e im

pact

on

initi

atio

n of

sex

and

sta

tistic

ally

si

gnifi

cant

pos

itive

effe

cts

on th

e nu

mbe

r of

sex

ual p

artn

ers

and

the

use

of c

ondo

ms

and

cont

race

ptiv

es. T

hus,

it is

cou

nted

twic

e in

the

tabl

e, b

oth

as h

avin

g

a ne

gativ

e im

pact

and

a p

ositi

ve im

pact

.

134

92-4-120938-0_CH05_134

quasi-experimental designs had to have both intervention and comparisongroups and both pre-test and follow-up data.

Of the 22 studies, nine clearly lacked sufficient statistical power to detectprogrammatically meaningful effects on behaviour. For example, if an inter-vention reduced the percentage of young people who initiated sexual activity(or who had sexual intercourse without a condom) from 30% to 20%, thisreduction would be programmatically meaningful. However, to have an 80%chance of finding an absolute change of 10 percentage points in a dichoto-mous outcome and to achieve significance at the 0.05 level, a completed pre-test follow-up sample size of close to 600 would be needed. The smallestmatched baseline and follow-up sample was 150. This study and eight othersclearly lacked statistical power.

However, the problem of insufficient power was greatly aggravated by thefact that studies typically had to divide their samples into sexually inexperi-enced youths at baseline in order to measure initiation of sex and sexuallyexperienced youths at follow up to measure impact on condom and contra-ceptive use among those who did have sex. Some studies further divided theirsample into males and females because prior studies had found that resultssometimes differed according to the sex of the participant. This further in-creased the problem of statistical power.

Although many studies lacked sufficient statistical power, they are includedin the results because some of them produced statistically significant results.Nevertheless, their inclusion biases the results and may suggest that inter-ventions were less effective than they actually were. This may offset some ofthe positive biases discussed above. When two studies produced large pro-grammatically important results that were not significant, they were codedin the tables as not having an impact but their possible impact is noted inthe text.

The statistical analyses in the studies ranged from marginally acceptable torigorous. For example, a few studies compared whether the intervention andcomparison groups were statistically different at baseline and then also useda separate test to determine whether they were significantly different at followup instead of comparing the change over time in the intervention group withthe change over time in the comparison group. Some failed to statisticallycontrol for background characteristics that may have been related to outcomebehaviours. And still others assigned entire schools to intervention groupsbut failed to control for clustering. It is difficult to assess the net impact ofthese limitations in the statistical analyses. Fortunately, a few studies usedrigorous statistical analyses.

135

92-4-120938-0_CH05_135

5.3.3 Impact on prevalence and sexual behaviours

5.3.3.1 STI/HIV prevalence

Ideally, these studies would have measured the intervention’s impact on theincidence or prevalence of STIs or, preferably, HIV. However, only onestudy, the study with the largest sample size, measured impact on STI andHIV prevalence and even it was underpowered for some of these tests.

That one study was the randomized trial in Mwanza, United Republic ofTanzania (study G) (45). It found that the “MEMA kwa Vijana” (“Goodthings for young people”) intervention did not have a significant impact onthe prevalence of genital herpes, syphilis or chlamydia among either boysor girls. Furthermore, it did not have a significant impact on prevalence oftrichomoniasis among girls (it was not measured among boys) nor on gon-orrhoea among boys. However, it found a slight but significant negativeimpact on prevalence of gonorrhoea among girls.

This study was one of only two to attempt to measure an intervention’s impacton pregnancy or childbearing. It did not demonstrate an effect, but the otherstudy, a teacher-led curriculum-based intervention in Chile (study B) (24),demonstrated a marked decrease in reported births or miscarriages over a 4-year follow-up period. However, the authors noted that this outcome was nota true marker of pregnancy because of the likely bias caused by the illegalstatus of abortion in Chile.

5.3.3.2 Impact on behaviours

Because of the criteria used to select these studies, all of them measuredimpact on one or more reported sexual behaviours, which logically wouldaffect STI or HIV incidence or prevalence in the long term. Thus, those resultsare also presented.

Because the patterns of results are quite similar regardless of the type ofintervention or the type of evaluation design, they are first discussed as awhole and then the results for the group of interventions with the strongestevidence are further discussed.

5.3.3.3 Sexual activity

These studies present strong evidence that sex education and HIV educationinterventions do not increase sexual behaviour and that a substantial percent-age of interventions significantly decrease one or more types of sexualactivity.

136

92-4-120938-0_CH05_136

One important measure of sexual activity is the initiation of sex (having sex-ual intercourse for the first time). This was measured in 18 of the studies.Importantly, only one of these studies found a significantly greater increasein the reported initiation of sex among the intervention group than among thecomparison group (study V) (44). That intervention was a non-curriculum-based peer-led programme. (It should be noted that when 14 or more studiesare reviewed, there is a greater than even chance that one or more outcomeswill be found to be statistically significant by chance alone.) More impor-tantly, none of the remaining 17 interventions hastened the reported initiationof sex, and 7 significantly delayed reported initiation.

A second common measure of sexual activity is the reported frequency ofengaging in sex. This measure includes both the number of acts of sexualintercourse during a specified number of months prior to the survey andwhether respondents had sexual intercourse at all during that period: it thusmeasures the possible return to secondary abstinence. This measure is im-portant for the prevention of pregnancy and STIs and HIV. Only eight studiesmeasured the programmatic impact on the reported frequency of sexual ac-tivity. None of them found an increase, and three of them found a decreasein frequency.

A third measure of sexual activity is the reported number of sexual partners.This measure is especially important for preventing the transmission of STIsand HIV. Again, there were no increases in the reported number of sexualpartners, and 3 out of 8 interventions reported decreases in the number ofpartners.

5.3.3.4 Impact on use of condoms and contraceptives

Fourteen studies measured the impact on reported use of condoms; none ofthem found a decrease, and six found a significant increase in use. Althoughcontraceptives other than condoms do not markedly affect the transmissionof STIs or HIV, some of these interventions were sex education interventionsthat encouraged contraceptive use to prevent teen pregnancy as well as con-dom use to prevent STIs and HIV. Four studies measured the impact onreported contraceptive use, and three of them found significantly increasedreports of their use.

Two studies examined the impact on measures of unprotected sex that in-volved both the reported frequency of sexual activity or numbers of partnersand condom use. One of these two studies found a positive impact.

137

92-4-120938-0_CH05_137

5.3.3.5 Impact on one or more behaviours

Of the 22 interventions, 16 had a positive impact on one or more of the re-ported behaviours, and five had a positive impact on two or more behaviours.Only six had no significant impact on any reported behaviour. Overall, these22 interventions were found to have significantly improved 21 of 55 measuresof reported sexual behaviour across the studies.

5.3.4 Summary of behavioural effects

In sum, these studies present strong evidence that school-based sex educationand HIV education interventions did not increase sexual activity and somehad positive effects on each of the reported sexual and protective behavioursmeasured. It is possible for some school-based interventions to delay partic-ipants’ reported sexual activity, reduce their number of sexual partners,reduce their frequency reported of sexual activity or increase their use of con-doms or their use of contraception and thereby reduce their unprotected sex.

In addition, in all three categories of adult-led interventions at least half ofthe interventions had a positive impact on at least one of the reported sexualor protective behaviours. In addition, two of the three peer-led interventionshad a positive impact on one or more behaviours. These overall resultsdemonstrate that there is no single type of intervention that is effective: mosthave the potential to be effective in some situations.

However, it is also true that there are more studies and much stronger evidenceshowing that curriculum-based interventions that incorporated at least fourfifths of the characteristics described in Box 5.1 can change behaviour. Theseinterventions are discussed more fully below.

5.3.5 Impact on psychosocial factors affecting behaviour

5.3.5.1 Knowledge

Altogether, 10 of the 22 studies measured the intervention’s impact onknowledge, and all found that their respective interventions increased knowl-edge about one or more topics including STIs or HIV/AIDS and theirprevention. The interventions did not always increase knowledge about everyitem measured, perhaps because a particular curriculum may not have focusedon those specific facts. However, all of the interventions increased knowledgeabout one or more facts and increased overall knowledge.

This finding is consistent with 10 different studies from developing countriesthat did not measure an intervention’s impact on behaviour but did measurethe impact on knowledge (46–55). All of these studies found that their re-spective interventions significantly increased knowledge. This finding is also

138

92-4-120938-0_CH05_138

consistent with findings from developed countries that have repeatedly shownthat school-based sex education and HIV education interventions can increaseknowledge about sexuality, just as classes can increase knowledge aboutmaths, science and other topics. Sometimes they may be even more effectivein increasing students’ knowledge about various aspects of sexual behaviourbecause this is a topic that is often of greater interest and relevance to students’lives.

5.3.5.2 Reported values, attitudes, peer norms, skills, intentions and other risk andprotective behaviours

Skills, as identified in UNGASS goal 2, are one of a number of psychosocialfactors necessary to effectively change behaviour. Nineteen studies measuredintervention impact on sexual and psychosocial factors (such as personalvalues and perceptions of peer norms) or other behaviours (such as commu-nication about sex and condoms or use of alcohol) that are known to be relatedto sexual risk and protective behaviours. The results were not nearly as con-sistent as they were for knowledge.

The results indicate that interventions consistently did not negatively affectthese factors, and roughly half had positive effects. More specifically, one ormore studies found that their respective interventions improved reported val-ues about sex, values about pressuring someone to have sex, attitudes towardscondoms, attitudes towards people living with AIDS, perceptions of peernorms regarding condoms, self-efficacy to refuse to have sex, self-efficacyto obtain condoms and to use condoms, and intentions to discuss condom useor to use a condom. None of the three studies that measured intentions toabstain from sex or restrict the number of sexual partners found that the in-terventions increased these intentions. One study found that its interventiondecreased the use of alcohol or drugs; one study found the intervention helpedyouths avoid situations that might lead to sex; and a final study found that itsintervention increased the percentage of youths who reported having obtainedcondoms.

The results from these 22 studies measuring impact on reported behaviourare also supported by results from other studies that measured impacts onvalues, attitudes and norms but did not measure impact on behaviour. Sixsuch studies found that school-based interventions improved one or more ofthese reported values, attitudes, norms or intentions (46–48, 51, 54, 55).

5.3.6 Strength of evidence for curriculum-based adult-led interventions withthe characteristics in Box 5.1

The behavioural results for all six intervention types are summarized in Table5.5, as well as Table 5.4a and Table 5.4b. Although at least half of the studies

139

92-4-120938-0_CH05_139

in five of the six intervention types reported positive behavioural results, oneintervention type has particularly strong evidence for its impact on behaviour.Curriculum-based interventions that incorporated most of the characteristicsin Box 5.1 and that were led by adults have particularly strong evidence fortheir impact on behaviour. That evidence is strong for three reasons: there area large number of studies within that category; the strength of the evidencefor some of the individual studies is stronger than for the studies in othercategories; and the interventions more consistently had a positive impact onbehaviour.

Among the 13 interventions in that type:

5 out of 12 were successful in encouraging participants to delay the re-ported initiation of sex;

2 out 4 were successful in terms of participants reducing the reportednumber of sexual partners;

1 out of 4 were able to encourage participants to reduce the reported fre-quency of sexual relations;

3 out of 8 reported an increase in reported condom use;

1 out of 2 reported an increase in the reported use of contraceptives;

1 out of 2 reduced the reported frequency of unprotected sex as measuredin other ways; and

11 out of 13 significantly improved one or more reported sexual or pro-tective behaviours.

Notably, only 2 of the 13 interventions did not produce significant be-havioural changes. However, in the first of those two interventions, 17% ofthe control group initiated sex while only 7% of the intervention group didso (study C) (25). While this would have been programmatically meaningful,it was not statistically significant. Similarly, in the second study that did notreport significant results, the odds ratio for contraceptive use was 2.25 (P =0.08) (study J) (32). Thus, the only two studies that failed to report statisticallysignificant benefits may have produced programmatically meaningful resultsbut they lacked statistical power.

While the positive effects of some interventions lasted only a few months,the effects of other interventions lasted for years. For example, the MEMAkwa Vijana intervention found positive effects on reported behaviours overa 36-month period (study G) (45).

The positive effects of these interventions were remarkably robust (Table5.4b). In particular, roughly equal proportions of interventions were found to

140

92-4-120938-0_CH05_140

be effective regardless of whether they were implemented in primary or sec-ondary school or college or night school. Similar proportions of these cur-riculum-based interventions were effective regardless of whether they weretaught by teachers or other adults. They were also effective for both male andfemale students. It is encouraging that interventions may increase reports ofcondom use even among females who have less direct control over their use.And the interventions were equally likely to be effective regardless of whetherthey were evaluated with experimental or quasi-experimental designs.

In general, these patterns of findings are remarkably similar to those from theUnited States and other developed countries (12). Those studies also demon-strated that school-based interventions encouraging abstinence and condomuse do not increase sexual behaviour, and sometimes they delay participants’sexual activity, reduce participants’ frequency of sexual relations, reducetheir number of sexual partners and increase their use of condoms or contra-ceptives. Those studies also demonstrate that the positive effects of suchinterventions are quite robust (12, 14). This is encouraging and suggests thatthese interventions may be effective regardless of the level of economic de-velopment and prevalence of HIV.

5.3.6.1 Characteristics of curriculum-based adult-led interventions that changedbehaviour

As discussed above, this review coded each study according to the charac-teristics of interventions that have been found to be effective anywhere in theworld. This raises the important question: what are the characteristics of ef-fective school-based programmes in developing countries?

The results of coding revealed that these interventions had the same charac-teristics as effective curricula evaluated anywhere in the world. That is, mostof the effective programmes incorporated at least four-fifths of the charac-teristics described in Box 5.1. However, in part because of the limitations ofthe studies, we could not determine whether three particular characteristicshad been included. In particular, it was often difficult to determine whetherprogramme developers used a logic model to develop programmes, wheth-er curriculum activities had been pilot-tested before implementation orwhether educators created a safe environment for group discussions in theclassrooms.

5.3.7 Health services

Schools in the developing world may have an important role in achieving theUNGASS goal of improving access to health services for youths. However,full assessment of this question is beyond the scope of this chapter.

141

92-4-120938-0_CH05_141

5.3.8 Vulnerability

Schools in the developing world potentially also have a key role in addressingvulnerability among youths at several levels, for example, at the individuallevel, by improving their life chances through education and at the societallevel, by addressing adverse gender norms and contributing to incrementalchanges in norms and values. However, it is also true that schools themselvesmay contribute to adolescent vulnerability by subjecting young girls to sexualabuse by teachers (9, 56, 57) and by reinforcing adverse gender norms. How-ever, a review of all of these effects is also beyond the scope of this chapter.

5.4 Discussion and recommendations

Despite limitations in the documentation of interventions and in research re-sults, we reviewed school-based studies that were divided into six differentcategories, summarized the strength of evidence for each category and maderecommendations about each category (Table 5.5).

The recommendations used in this review are the same as those used in theintroduction and methods sections (chapter 1 and chapter 4) and elsewherein this report, namely:

“Go” – the evidence threshold has been met and there is sufficient evidenceto recommend widespread implementation on a large scale now with care-ful monitoring of coverage, quality and costs;

“Ready” – the evidence threshold has been partially met and the evidencesuggests these interventions are effective but large-scale implementationmust be accompanied by further evaluation to clarify their impact andmechanisms;

“Steady” – there is some encouraging evidence of effectiveness but thisevidence is still weak and further development, pilot testing and evaluationare urgently needed before they can move into the “Ready” category;

“Do not go” – there is strong enough evidence of a lack of effectiveness orof harm to indicate that this is not the type of intervention to pursue.

5.4.1 Knowledge

Given that these school-based interventions have a low-to-moderate thresh-old for evidence, given that all the studies that measured impact on knowledgefound a positive impact on knowledge, and given that innumerable studies ofschool-based interventions in developed countries have also found that theseinterventions increase knowledge, these interventions are clearly a “Go” forknowledge.

142

92-4-120938-0_CH05_142

5.4.2 Behaviour

Curriculum-based interventions incorporating most of the characteristics inBox 5.1 and led by adults had been evaluated by the greatest number of stud-ies, had the strongest evidence, and had the most consistent results demon-strating positive reports of behavioural change. These results are all based onreported behaviour with all of the limitations of self-reported sexual be-haviour, which include the potential for presentation bias, that may occur,especially within the context of interventions promoting specific behaviours.Thus, positive effects on actual STI or HIV prevalence are more credible.Nevertheless, the consistency of these positive results on reported sexual be-haviours is encouraging. Thus, these results warrant a “Go” for this type ofintervention. This does not mean that these interventions should not contin-ually be evaluated and improved, for they clearly should be, and theirimportant characteristics should be further refined.

Curriculum-based adult-led interventions without most of the characteristicsin Box 5.1 did not increase any measure of sexual risk behaviour but there islittle evidence that they decreased sexual risk behaviour. Studies of theseinterventions included only one with a quasi-experimental design that showeda positive impact and one study with the same design that showed no impact.Thus, this group of interventions warrants a “Steady” rating.

Some curricula are called “life-skills interventions”. These are quite popularthroughout the world but they constitute a heterogeneous group of interven-tions. Calling them “life skills” is not very descriptive. Some of theseinterventions focus on sexual behaviour and incorporate many or all of thecharacteristics in Box 5.1. These should be classified accordingly.

On the other hand, other life-skills interventions not studied in this reviewteach only general social skills, life-planning skills or other skills and do notfocus on sexual behaviour, do not provide a clear message about sexual be-haviour and do not incorporate some of the other characteristics described inBox 5.1. Few of these interventions have been evaluated. Thus, without muchinformation about them, these interventions would have to be classified“Steady”.

Only two curriculum-based interventions were implemented primarily bypeers. One of these incorporated many of the characteristics in Box 5.1 andincreased the use of condoms among participants, while the other did notincorporate these characteristics and did not significantly change any be-haviour. Thus, both of these types of peer-led interventions should also beclassified as “Steady”.

Results for non-curriculum-based interventions were not clear. Four out offive were adult-led and two of the four had a positive effect on one or more

143

92-4-120938-0_CH05_143

behaviours, while two did not. Of the four adult-led interventions, only onewas evaluated in a randomized trial and it failed to find an impact. Thus, thistype must be given a “Steady” rating both because of the small number ofstudies and the mixed results.

The fifth non-curriculum-based intervention was led by peers. While the re-sults indicate that it had important positive behavioural effects (fewer sexualpartners, increased condom use and increased use of contraception), the re-sults also include the only negative behavioural results, namely a hasteningof the initiation of sexual activity. Thus, this type must also be given a“Steady” rating.

All of these recommended ratings are affected by positive biases (as is thecase in the reporting of many results) and negative biases (for example, in-sufficient statistical power). They are limited by far too many weak evaluationdesigns that could either obscure or enhance effects and by reliance on re-ported behaviour instead of actual behaviour or measurement of STD or HIVrates. Finally, they are limited by inadequate descriptions of interventions, afew of which were only a couple of sentences long. This undoubtedly addederror to the categorization and coding of interventions.

5.4.3 HIV prevalence

Only one of the 22 interventions increased any measure of reported sexualbehaviour; the remaining 21 either had no impact on sexual behaviour ordelayed the onset of sexual activity, reduced the frequency of sexual activityor decreased the number of sexual partners. These results provide strong ev-idence that interventions focusing on sexual behaviour and its consequencesdo not lead to an increase in reported sexual behaviour. This conclusion isespecially strong and consistent for interventions taught by adults. Further-more, the majority of these interventions led to reductions in sexual activity,increased condom use or increases in contraceptive use. Given these changesin sexual behaviour, one could expect a reduction in both pregnancy and STIs.

However, only one study measured an intervention’s impact on STI rates andit did not find positive significant effects (study G) (45). This may be in partbecause sample sizes were too small to detect programmatically meaningfuleffects on HIV and bacterial STIs. However, the study was sufficiently wellpowered to estimate the effect of the intervention on rates of infection withherpes simplex virus–type 2 and pregnancy. Despite having strong evidencefor effects on reported sexual behaviours, this intervention had no impact onthese biomedical outcomes. Thus, greater understanding of this disarticula-tion between reported effects on behaviour and a lack of biomedical impactis clearly critical, and more studies need to measure an intervention’s impacton rates of STIs and pregnancy.

144

92-4-120938-0_CH05_144

5.4.4 Cost effectiveness

None of these studies included any cost–effectiveness analyses. This is animportant omission. Nevertheless, general experience in developing and im-plementing these types of programmes can provide some guidance.

If programmes are effective at reducing risky sexual behaviour, they have thepotential to be cost effective. Initially, effective curricula must be developedand teachers trained. This can be costly. Moreover, once teachers are trained,they must spend time in the classroom implementing programmes and thisclassroom time carries a cost. On the other hand, once effective curricula havebeen designed, training may be incorporated into the training of all newteachers. Furthermore, the length of these curricula is not long (28 hours isthe longest and most are much shorter) and thus the cost of classroom timeis relatively modest. Finally, relatively few materials are needed to implementthe programmes.

5.4.5 Conclusion

In terms of effectiveness in increasing knowledge, our review suggests a “Go”for most school-based sex education and HIV education interventions. Interms of changes in reported behaviour, our review suggests a “Go” forcurriculum-based interventions incorporating the characteristics described inBox 5.1 and led by adults. In part because of the limited number of studies,all other types warrant a “Steady” rating for reported behavioural change.These conclusions suggest a series of recommendations for different groups(Box 5.2).

It is encouraging that patterns of results were similar across both developingand developed countries. In general, interventions were just as likely to beeffective in developing countries as in developed countries (12). They wereeffective for different age groups and for both males and females. Thus, theyappear quite robust.

While studies have not yet demonstrated that these interventions in the de-veloping world significantly reduced the rates of STIs and HIV, many studiesdemonstrated that their intervention produced positive behavioural changesthat logically should lead to reductions in STIs and HIV. Thus, they may bean important component of larger, more comprehensive initiatives and shouldbe implemented more widely.

Funding: Financial support for this research was provided by the UnitedStates Agency for International Development (USAID) through the FamilyHealth International (FHI)/YouthNet Project, from WHO and from the Liv-erpool School of Tropical Medicine.

145

92-4-120938-0_CH05_145

References

1. United Nations. Declaration of commitment on HIV/AIDS. Geneva, UnitedNations, 2001 (available at (http://www.un.org/ga/aids/coverage/FinalDeclarationHIVAIDS.html).

Box 5.2

Recommendations for interventions in schools

For policy-makers

There is a sufficiently strong evidence base to support widespreadimplementation of school-based interventions that incorporate thecharacteristics of effective programmes that have been found to bepotentially important throughout the world (Box 5.1) and that areled by adults.

There is strong evidence that these programmes reduce sexual riskbehaviour.

Nearly all school-based programmes have strong evidence for in-creasing knowledge.

For programme development and delivery staff

To increase the chances of reducing sexual risk behaviour, school-based programmes should include as many of the characteristics ofeffective programmes as possible because these have been found tobe potentially important throughout the world (Box 5.1).

For researchers

More well designed studies of school-based programmes need to becompleted, particularly in rural areas in developing countries. Ifpossible, these studies should use randomized designs, have suffi-ciently large sample sizes and measure the impact on rates ofsexually transmitted infections, HIV and pregnancy.

Studies also need to examine more thoroughly the impact of pro-grammes on important mediating factors.

Improvements also need to be made in documenting and evaluatingintervention processes.

146

92-4-120938-0_CH05_146

2. Gallant M, Maticka-Tyndale E. School-based HIV prevention programmes forAfrican youth. Social Science and Medicine, 2004, 58:1337-1351.

3. Speizer IS, Magnani RJ, Colvin CE. The effectiveness of adolescentreproductive health interventions in developing countries: a review of theevidence. Journal of Adolescent Health, 2003, 33:324-348.

4. Grunseit A et al. Sexuality education and young people’s sexual behavior: areview of studies. Journal of Adolescent Research, 1997, 12:421-453.

5. MacPhail C, Campbell C. Evaluating HIV/STD interventions in developingcountries: do current indicators do justice to advances in interventionapproaches. South African Journal of Psychology, 1999, 29:149-165.

6. World Health Organization. Key issues in the implementation of adolescentsexual and reproductive health programmes. Geneva, Department of Child andAdolescent Health and Development, WHO, 2004.

7. Visser MJ, Schoeman JB, Perold JJ. Evaluation of HIV/AIDS prevention inSouth African schools. Journal of Health Psychology, 2004, 9:263-280.

8. Smith G et al. HIV/AIDS school-based education in selected Asia-Pacificcountries. Sex Education, 2003, 3-21.

9. James-Traore T et al. Teacher training: essential for school-based reproductivehealth and HIV/AIDS education: focus on sub-Saharan Africa. Arlington, VA,Family Health International, YouthNet Program, 2004.

10. Resnick MD et al. Protecting adolescents from harm: findings from the NationalLongitudinal Study on Adolescent Health. Journal of the American MedicalAssociation, 1997, 278:823-832.

11. James-Traore T et al. Intervention strategies that work for youth: summary ofFOCUS on young adults end of program report. Arlington, VA, Family HealthInternational, YouthNet Program, 2002.

12. Kirby D, Laris B, Rolleri L. Impact of sex and HIV education programs on sexualbehaviors of youth in developing and developed countries. Washington, DC,Family Health International, 2005:1-45.

13. Grunseit A. Impact of HIV and sexual health education on the sexual behaviourof young people: a review update. Geneva, UNAIDS, 1997

14. Kirby D. Emerging answers: research findings on programs to reduce teenpregnancy. Washington, DC, National Campaign to Prevent Teen Pregnancy,2001.

15. Oshi DC, Nakalema S, Oshi LL. Cultural and social aspects of HIV/AIDS sexeducation in secondary schools in Nigeria. Journal of Biosocial Science, 2005,37:175-183.

16. Baker S et al. Evaluation of a HIV/AIDS program for college students inThailand. Washington, DC, Population Council, 2003

17. Maticka-Tyndale E et al. Primary School Action for Better Health: 12-18 monthevaluation. Final Report on PSABH Evaluation in Nyanza and Rift Valley.Windsor, Ontario, University of Windsor, 2004.

18. Kirby DL, Ryan G. Sexual risk and protective factors – factors affecting teensexual behavior, pregnancy, childbearing and sexually transmitted disease:Which are important? Which can you change? Washington, DC, NationalCampaign to Prevent Teen Pregnancy, 2005.

147

92-4-120938-0_CH05_147

19. Pedlow CT, Carey MP. Developmentally appropriate sexual risk reductioninterventions for adolescents: rationale, review of interventions, andrecommendations for research and practice. Annals of Behavioral Medicine,2004, 27:172-184.

20. Robin LD et al. Behavior interventions to reduce incidence of HIV, STD, andpregnancy among adolescents: a decade in review. Journal of AdolescentHealth, 2004, 34:3-26.

21. Gallant M, Maticka-Tyndale E. School-based HIV prevention programmes forAfrican youth. Social Science and Medicine, 2004, 58:1337-1351.

22. UNAIDS. Peer education and HIV/AIDS: concepts, uses and challenges.Geneva, UNAIDS, 1999.

23. Irvin A. Taking steps of courage: teaching adolescents about sexuality andgender in Nigeria and Cameroon. New York, International Women’s HealthCoalition, 2000.

24. Cabezon C et al. Adolescent pregnancy prevention: An abstinence-centeredrandomized controlled intervention in a Chilean public high school. Journal ofAdolescent Health, 2005, 36:64-69.

25. Klepp KI et al. AIDS education in Tanzania: promoting risk reduction amongprimary school children. American Journal of Public Health, 1997,87:1931-1936.

26. Pick De Weiss S. Givaudan M, Givaudan S. Planeando tu vida: sex and familylife education. Fundamentals of development, implementation, and evaluation.International Journal of Adolescent Medicine and Health, 1993, 6:211-224.

27. Reddy P, James S, McCauley AP. Programming for HIV prevention in SouthAfrican schools: a report on program implementation. Cape Town, USAID andPopulation Council, 2003.

28. Reddy P, James S, McCauley AP. Programming for HIV prevention in SouthAfrican schools: horizons research summary. Washington, DC, PopulationCouncil, 2003

29. Ross DA et al. Community randomised trial of an innovative adolescent sexualhealth intervention programme in rural Tanzania: the MEMA kwa Vijana trial.(Unpublished data.)

30. Seidman M et al. Fertility awareness education in the schools: a pilot programin Santiago, Chile. San Diego, CA, American Public Health Association, 1995.(Unpublished data presented 31 October 1995.)

31. Antunes MC et al. Evaluating an AIDS sexual risk reduction program for youngadults in public night schools in Sao Paulo, Brazil. AIDS, 1997, 11 Suppl 1:S121-127.

32. Eggleston E et al. Evaluation of a sexuality education program for youngadolescents in Jamaica. Revista Panamericana Salud Pública, 2000,7:102-112.

33. Fawole IO et al. A school-based AIDS education programme for secondaryschool students in Nigeria: a review of effectiveness. Health EducationResearch, 1999, 14:675-683.

34. Martinez-Donate AP et al. Evaluation of two school-based HIV preventioninterventions in the border city of Tijuana, Mexico. Journal of Sex Research,2004, 41:267-278.

148

92-4-120938-0_CH05_148

35. Stanton BF et al. Increased protected sex and abstinence among Namibianyouth following a HIV risk-reduction intervention: a randomized, longitudinalstudy. AIDS, 1998, 12:2473-2480.

36. Kinsler J et al. Evaluation of a school-based intervention for HIV/AIDSprevention among Belizean adolescents. Health Education Research, 2004, 19:730-738.

37. McCauley AP. Programming for HIV prevention in Mexican schools.Washington, DC, Population Council, 2004.

38. Murray N et al. An evaluation of an integrated adolescent development programfor urban teenagers in Santiago, Chile. Futures Group International, Center forthe Reproductive Health of Adolescents , Johns Hopkins University, 2000.(Unpublished data.)

39. Agha S, Van Rossem R. Impact of a school-based peer sexual healthintervention on normative beliefs, risk perceptions, and sexual behavior ofZambian adolescents. Journal of Adolescent Health, 2004, 34:441-452.

40. Harvey B, Stuart J, Swan T. Evaluation of a drama-in-education programme toincrease AIDS awareness in South African high schools: a randomizedcommunity intervention trial. International Journal of STD and AIDS, 2000,11:105-111.

41. Mbizvo MT et al. Effects of a randomized health education intervention onaspects of reproductive health knowledge and reported behaviour amongadolescents in Zimbabwe. Social Science and Medicine, 1997, 44:573-577.

42. Okonofua FE et al. Impact of an intervention to improve treatment-seekingbehavior and prevent sexually transmitted diseases among Nigerian youths.International Journal of Infectious Diseases, 2003, 7:61-73.

43. Shuey DA et al. Increased sexual abstinence among in-school adolescents asa result of school health education in Soroti district, Uganda. Health EducationResearch, 1999, 14: 411-419.

44. Brieger WR et al. West African Youth Initiative: outcome of a reproductive healtheducation program. Journal of Adolescent Health, 2001, 29:436-446.

45. Changalucha J et al. MEMA kwa Vijana, a randomised controlled trial of anadolescent sexual and reproductive health intervention programme in ruralMwanza, Tanzania. 4. Results: biomedical outcomes. In: International Societyfor Sexually Transmitted Diseases Research 15th biennial conference. Ottawa,ISSTDR, 2003:253. (Abstract.)

46. Aplasca MA et al. Results of a model AIDS prevention program for high schoolstudents in the Philippines. AIDS, 1995, 9 Suppl 1:S1-13.

47. Caceres CF et al. Evaluating a school-based intervention for STD/AIDSprevention in Peru. Journal of Adolescent Health, 1994, 15:582-591.

48. Kuhn L, Steinberg M, Mathews C. Participation of the school community in AIDSeducation: an evaluation of a high school programme in South Africa. AIDSCARE, 1994, 6:161-171.

49. Munodawafa D, Marty PJ, Gwede C. Effectiveness of health instructionprovided by student nurses in rural secondary schools of Zimbabwe: a feasibilitystudy. International Journal of Nursing Studies, 1995, 32:27-38.

50. Perez F, Dabis F. HIV prevention in Latin America: reaching youth in Colombia.AIDS CARE, 2003, 15:77-87.

149

92-4-120938-0_CH05_149

51. Kim H. The effects of sex education programs on knowledge and attitude relatedto sex of elementary school high grade students. (Unpublished data presentedat 16th World Congress of Sexology 2005.)

52. Rusakaniko S et al., Trends in reproductive health knowledge following a healtheducation intervention among adolescents in Zimbabwe. Central AfricanJournal of Medicine, 1997, 43:1-6.

53. Samkaranarayan S et al. Impact of school-based HIV and AIDS education foradolescents in Bombay, India. AIDS Education in India, 1996, 27:692-695.

54. Singh S. Study of the effect of information, motivation and behavioural skills(IMB) intervention in changing AIDS risk behaviour in female universitystudents. AIDS CARE, 2003, 15:71-76.

55. Visser M. Evaluation of the First AIDS Kit: the AIDS lifestyle educationprogramme for teenagers. South African Journal of Psychology, 1996,26:103-113.

56. Gachuhi D. The impact of HIV/AIDS on education systems in the eastern andsouthern africa region and the response of education systems to HIV/AIDS:education/life skills programmes. Nairobi, UNICEF/East and Southern AfricaRegion,1999.

57. Schapink D, Hema J, Mujaya B. Youth and HIV/AIDS programmes. In:Ng’weshemi J et al, eds. HIV prevention and AIDS care in Africa: a district levelapproach. Amsterdam, Royal Tropical Institute, KIT Press, 1997:163-184.

150

92-4-120938-0_CH05_150

6. Review of the evidence forinterventions to increase youngpeople’s use of health services indeveloping countriesBruce Dick,a Jane Ferguson,a Venkatraman Chandra-Mouli,a

Loretta Brabin,b Subidita Chatterjee,c & David A. Rossd

Objective This chapter reviews the evidence base for interventions that aimto increase young people’s use of health services in developing countries.

Methods We identified published and unpublished studies and reports fromdeveloping countries that provided information about interventions designedto increase young people’s use of health services. The studies were classifiedinto six different types based on whether they included some or all of thefollowing characteristics: training for service providers and clinic staff; mak-ing efforts to improve the quality of the facilities; implementing communityactivities to generate demand and support for the services; and involvingother sectors, notably schools and the media. The levels of evidence requiredto make decisions about policies and programmes were defined for each ofthese types.

Findings Despite the lack of detailed descriptions of interventions in thestudies and difficulties interpreting the data reported in the evaluations, thestudies provided evidence of increased use of health services by young peoplefor those types of interventions that included training for service providers,making improvements to clinic facilities and implementing activities in thecommunity, with or without the involvement of other sectors.

Conclusion The evidence for the effectiveness of interventions to increaseyoung people’s use of health services was sufficient to recommend that in-terventions that include training for service providers, making improvements

a Department of Child and Adolescent Health and Development, WHO, Geneva, Switzerland.Correspondence should be sent to Dr Bruce Dick (email: dickb@who.int).

b Department of Obstetrics and Gynaecology, University of Manchester, Manchester, England.c Consultant in Reproductive Health, Geneva, Switzerland.d Infectious Disease Epidemiology Unit, London School of Hygiene and Tropical Medicine,

London, England.

151

92-4-120938-0_CH06_151

to clinics and using activities in the community should be widely imple-mented with careful monitoring of quality and coverage and that those thatadditionally involve other sectors should also be widely but cautiously im-plemented, provided they include a strong evaluation component. Operationsresearch is also required to better understand the content of the interventionsand their mechanisms of action.

6.1 Introduction

During the past 10–15 years there has been growing awareness of the needto make health services more responsive to the specific needs of young people(1, 2). The HIV/AIDS epidemic has contributed to this increasing attention,and the United Nations General Assembly Special Session (UNGASS) onHIV/AIDS includes an explicit target related to ensuring young people’s ac-cess to health services (3, 4). Governments attending the special sessionagreed that by 2005, 90% of young people aged 15–24 years – and by 2010,95% of this age group – should have access to the services that they need todecrease their vulnerability to HIV.

In 2003, WHO and its partners organized a technical consultation in Montreux,Switzerland, to review the evidence base for a set of interventions that couldbe provided though health services and that would contribute to the preven-tion and care of HIV infection among young people (5). The package ofservices included providing reproductive health information and counselling;reducing risk by encouraging the use of condoms among sexually activeyoung people and the use of sterile injecting equipment and other harm re-duction interventions by young injecting drug users; and providing servicesto diagnose, treat and care for young people with sexually transmitted infec-tions (STIs) and HIV/AIDS. The evidence base for these and other interven-tions provided through health services is further elaborated in chapter 3.

The evidence-based package of interventions developed at Montreux needsto form the basis for the goal for services endorsed during UNGASS. Unfor-tunately, the data available to monitor these health service targets are gener-ally weak. Some data have been provided in chapter 2, and a major effort isbeing initiated by the Futures Group, Policy Project, using the triangulationof information obtained from interviews with key informants (6). Methodsthat use community surveys and health facility statistics are also being de-veloped (7). Although the data are scarce, what little data there are indicatethat we are far from achieving the global target on providing access to ser-vices, either for the general population of young people or for those who aremost at risk from HIV (8). (The evidence for interventions targeted towardsyoung people most at risk of HIV is reviewed in chapter 9.)

152

92-4-120938-0_CH06_152

The purpose of this paper is to review the evidence for interventions that aimto increase young people’s use of health services and to determine what it isthat needs to be done if we are to achieve the global goals on increasing youngpeople’s access to services.

6.2 Methods

This review has adopted a similar process to the other papers in this seriesin terms of assessing the evidence in a systematic and transparent way(chapter 4).

6.2.1 Inclusion and exclusion criteria

Details of the inclusion and exclusion criteria for the studies in this revieware outlined in Table 6.1. Several points require clarification.

First, it should be noted that the UNGASS target refers to young people’saccess to services. This review focuses on studies that have attempted to in-crease young people’s use of health services, which goes beyond merelyincreasing availability and includes elements of accessibility and acceptabil-ity. There was no attempt to explore “effectiveness coverage”, which not onlyanswers the question “were the services used” but also “did the services thatwere used make a difference?” (9). With one exception, a study from Nigeria(10), the data from studies included in this review were not sufficiently de-tailed to answer the second of these questions.

Second, studies were selected based on the contribution that the interventionmade specifically to the UNGASS target of increasing young people’s accessto services. Although health services may provide information to young peo-ple and help them develop skills, such as learning how to use a condom, theUNGASS targets that relate to information, skills and vulnerability were notincluded as outcomes in this review. The rationale for this was that generallythose studies that include data on changes in knowledge, skills, attitudes andbehaviour are multicomponent interventions, and it is difficult to tease outthe relative contribution of the health services’ component to any changesthat are reported. Those studies that include such data are indicated in thetables, although these data are not included in the analysis.

Third, studies were included if they had as their primary focus interventionsinvolving interactions between a young person (aged 10–24 years) and ahealth-care worker, such as a doctor, a nurse or a clinical officer. Studies werenot included if they had as their major focus interactions between adolescentsor youth and people who are not health-care workers, such as community-based condom distributors, peer educators, counsellors and other individualsand groups who provide information, education, counselling or supplies toyoung people.

153

92-4-120938-0_CH06_153

Table 6.1Inclusion and exclusion criteria used to identify studies for review

Inclusion criteria Exclusion criteria

Intervention studies and programmes orprojects carried out in developing countriesand where sufficient details given to allow thereader to know (at least in outline) of what theintervention consisted.

Intervention studies carried out indeveloped countries or where insufficientdetails given to allow the reader to be ableto know (at least in outline) of what theintervention consisted.

Intervention studies and programmes orprojects that attempted to increase utilizationof health services by adolescents (aged 10–19 years), young people (10– 24 years) oryouths (15–24 years) and that also tracked ordocumented utilization. Interventions thatshowed an increase in young people’s be-haviours that are related to service utilization(such as condom use) were also included.

Intervention studies and programmes orprojects that did not gather data showingutilization of health services byadolescents, young people or youths.

Intervention studies and programmes orprojects that provided health services for HIVprevention (including sexual andreproductive health), such as information,counselling, condom distribution, STIa

management and voluntary counselling andtesting in the context of an interactionbetween a health-service provider and ayoung person.

Intervention studies and programmes orprojects that provided information,counselling or condoms outside the contextof an interaction between a health-serviceprovider and a young person.

Intervention studies using the followingdesigns:• randomized controlled trials• quasi-experimental study designs• data collected before and after the study

(without data from comparison sites)• time-series data on service utilization after

the start of the intervention• Cross-sectional (that is, “after-only”) survey

data where service utilization data for youngpeople were presented either by their levelof exposure to the interventions orcompared with other clinics or services thatwere not exposed to the intervention.

Intervention studies that did not usedesigns that would enable the reader toevaluate the impact of the intervention or tomake inferences based on statistical tests.

Reports with interpretable quantitative dataon the use of health services by youngpeople.

Reports without interpretable quantitativedata on health service use by youngpeople.

a STI = sexually transmitted infection.

154

92-4-120938-0_CH06_154

Finally, studies were included if one of their primary aims was to increaseyoung people’s use of health facilities, including government clinics, privateclinics, stand-alone youth clinics or clinics that are included as a componentof multipurpose youth centres. Studies were not included if they did not havea health facility component, for example, if they focused primarily on otherfacilities where information and commodities are provided to young people,such as kiosks, pharmacies and youth centres that do not include a healthfacility (11, 12).

6.2.2 Identification of studies and reports

Studies were identified through different processes. This paper built on lit-erature reviews of adolescent-friendly health services that had been carriedout for previous WHO meetings that took place in 1995 (13), 2001 (14) and2002 (15). An additional search was undertaken for published papers usingelectronic reference databases (Medline, PubMed, EMBASE) and the Inter-net. In order to identify unpublished reports and evaluations, contact was alsomade with 24 agencies known to support programmes and projects in devel-oping countries that aim to make health services more responsive to the needsof adolescents and young people. A WHO collection of papers and reportson adolescent-friendly health services was also reviewed. The literature re-view focused primarily on articles and reports written in English.

Twenty one studies and projects were initially identified that met the inclusioncriteria. However, this number decreased to 16 following a more in-depthanalysis of the quality of the information provided in the studies in terms ofclarity about the interventions, the evaluation methods and results. The ninestudies that did not fully meet the inclusion criteria either had insufficientdata to allow an adequate assessment of the interventions or the evaluationdata were inadequate. Some of these excluded studies are referred to in thediscussion. In this paper the word “studies” has been used to describe bothstudies that were explicitly designed to explore the effectiveness of an inter-vention and projects where there were sufficient evaluation data to meet theinclusion and exclusion criteria.

6.2.3 Typology of studies

Once the studies had been identified, they were grouped into different typesbased on the specific activities that had been implemented. Strategies to in-crease young people’s use of services have generally included some combi-nation of the following: improving the knowledge and skills of serviceproviders and other clinic staff; making facilities more responsive to thespecific needs of young people, for example by changing the physical envi-ronment or opening hours; reaching out from the facility into the community

155

92-4-120938-0_CH06_155

to provide information, generate demand and create community support; andinvolving other sectors, such as schools and the media, to provide informationand mobilize community support.

The typology for this review was based on a combination of these differentcomponents, resulting in a 2 by 3 matrix of six types, as outlined in Box 6.1.

Type 1, type 3 and type 5 interventions (those included in the first row) ex-plicitly provided training to service providers, and sometimes other staff inthe health facility, on how to respond more appropriately to the health needsof young people. This training included improving their knowledge, skillsand attitudes in order to increase their capacity to provide information andtreat young people effectively, in a respectful and confidential manner.

Type 2, type 4 and type 6 interventions (those in the second row) includedtraining for service providers and other clinic staff and additionally containedexplicit actions that aimed to improve specific aspects of the health facility,such as changing the opening hours, decreasing the amount paid by youngpeople for services or commodities, changing the layout or other aspects ofthe physical environment to make it more appealing or to increase privacy,introducing recreational opportunities and involving peer educators in thefacility. Interventions were not placed in this row if a health facility had beenincluded in a multipurpose youth centre without some additional focus on theareas outlined above. Interventions were placed in this row only if there wasan indication that significant efforts had been made to improve the facility,so merely providing information materials in the facility would not havewarranted inclusion in this row.

Interventions allocated to the first column (types 1 and 2) included a rangeof activities that were conducted within the community. For example, theseactivities included having health-workers provide information outside thehealth facility, having young people provide information and counselling inthe community, holding meetings with gatekeepers and community leadersand providing information about the need for and availability of services,including putting up posters and distributing information materials, placingadvertisements in local newspapers and showing videos at communitygatherings.

Interventions allocated to the second column (types 3 and 4) involved othersectors, such as education or the media. Interventions were included in thistype if there were curriculum-based interventions, peer educators, healthclubs that linked or referred pupils to health services, or other activities thatrequired significant investment on the part of the education sector. For mediainterventions to be included, there had to be significant involvement ofthe print, radio or television media in terms of providing information or

156

92-4-120938-0_CH06_156

“edutainment”, generating debate and dialogue and encouraging youngpeople to use health services.

The interventions were classified based on the information contained in thestudies; this information was not always complete. Although every attempthas been made to ensure that decisions about classifying the interventionswere open and standardized, there was inevitably some level of interpretationthat occurred in allocating studies to the different types because it was notalways clear from the papers what had actually been done or with what in-tensity of effort.

6.2.4 Threshold of evidence required

Once the typology for the interventions had been defined, it was necessaryto make a decision about the threshold of evidence that would be required tocategorize the different intervention types as “Go”, “Ready”, “Steady” or Do

Box 6.1

Typology of interventions implemented to increase young people’s use ofhealth services

Interventionsin the healthfacility

Interventions outside the health facilityInterventionsin thecommunitya

Interventionswith othersectorsb

Interventionsin thecommunityand withother sectors

Trainingserviceproviders andclinic staff only

Type 1 Type 3 Type 5

Trainingserviceproviders andclinic staff plusinterventionsin the facility tomake it moreyouth-friendly

Type 2 Type 4 Type 6

a These may include the use of peer educators working in the communityor other forms of information and community sensitization about theavailability of services and the needs of adolescents.b The focus for these studies was the involvement of schools or the massmedia.

157

“

92-4-120938-0_CH06_157

not go” (see chapter 4). Table 6.2 provides an overview of the thresholds ofevidence required to recommend widespread implementation of the differenttypes of interventions.

For type 1 interventions (training health-workers and other clinic staff alongwith activities in the community) and type 2 interventions (training health-workers and other clinic staff along with taking action to improve facilitiesand implement activities in the community) only weak evidence for effec-tiveness is considered to be required to recommend interventions forwidespread implementation (“Go”). Once other sectors become involved,however, the design and implementation of the intervention is likely to be-come more complex, and coordination of the programme components andsustainability is likely to become more of a challenge (even if both the impactof the interventions and other possible health and social benefits may in-crease). It was therefore decided that in order to be able to recommend types3, 4, 5 and 6 as “Go”, they would require a moderate threshold of evidence.

6.3 Findings

Summaries of the analysis of the 16 papers are found in Table 6.3 andTables 6.4a–e. Table 6.3 synthesizes information about the interventions fromthe different studies, and Tables 6.4a–e summarizes the evaluation methodsand results, as well as assessing the strength of the evidence for an increasein the use of services by young people.

6.3.1 Characteristics of studies

There were 12 studies from Africa, 3 from Asia and 1 from Latin America.Most studies included here endeavoured to improve existing services, andmost frequently these were offered in public facilities. Only one study – inNigeria (10) – focused exclusively on private providers, although the fran-chised interventions in Madagascar (12) included both private and publicproviders. There were three studies that involved the creation of new facili-ties; these took place in China (19), Ghana (29) and Mongolia (23). Threestudies integrated clinical services into multipurpose youth centres; thesetook place in Ghana (29), Rwanda (12) and Zimbabwe (18). In Uganda (17)recreational activities were added to existing health facilities as a way ofattracting young people.

158

92-4-120938-0_CH06_158

Tab

le 6

.2.

Th

resh

old

of

evid

ence

nee

ded

to

rec

om

men

d w

ides

pre

ad im

ple

men

tati

on

of

each

typ

e o

f in

terv

enti

on

a

Inte

rven

tio

nty

pe

Fea

sib

ility

bL

ack

of

po

ten

tial

for

adve

rse

ou

tco

mes

c

Acc

epta

bili

tyfo

r ta

rget

gro

up

d

Acc

epta

bili

tyfo

r co

mm

un

ity

and

po

licy-

mak

erse

Po

ten

tial

size

of

effe

ctf

Oth

erh

ealt

h o

rso

cial

ben

efit

sg

Ove

rall

thre

sho

ldC

om

men

ts

1. In

terv

entio

nsw

ith s

ervi

cepr

ovid

ers

only

plus

inte

rven

tions

inth

e co

mm

unity

++

++

++

++

++

+Lo

wT

his

type

of

inte

rven

tion

is li

kely

tobe

eas

iest

and

mos

tac

cept

able

but t

o ha

ve le

ast

impa

ct b

ecau

se it

invo

lves

onl

yse

rvic

e pr

ovid

ers

with

out c

hang

es in

the

faci

litie

s2.

Inte

rven

tions

with

ser

vice

prov

ider

s an

d in

faci

litie

s pl

usin

terv

entio

ns in

the

com

mun

ity

++

++

++

++

++

++

Low

Incl

udin

g a

focu

s on

impr

ovin

g fa

cilit

ies

is li

kely

to in

crea

seth

e im

pact

with

out

sign

ifica

ntly

incr

easi

ng fe

asib

ility

or d

ecre

asin

gac

cept

abili

ty3.

Inte

rven

tions

with

ser

vice

++

++

++

++

Mod

erat

eW

ith th

e ad

ditio

n of

othe

r se

ctor

s th

ere

159

92-4-120938-0_CH06_159

Inte

rven

tio

n

typ

eF

easi

bili

tyb

Lac

k o

fp

ote

nti

alfo

r ad

vers

eo

utc

om

esc

Acc

epta

bili

tyfo

r ta

rget

gro

up

d

Acc

epta

bili

tyfo

r co

mm

un

ity

and

po

licy-

mak

erse

Po

ten

tial

size

of

effe

ctf

Oth

erh

ealt

h o

rso

cial

ben

efit

sg

Ove

rall

thre

sho

ldC

om

men

ts

prov

ider

s on

lypl

usin

terv

entio

nsw

ith o

ther

sect

ors

are

likel

y to

be

prob

lem

s of

acce

ptab

ility

by

scho

ols

and

poss

ibly

the

med

ia, a

nd th

ede

bate

is li

kely

to b

ew

ider

in th

eco

mm

unity

, whi

ch m

ayha

ve b

oth

posi

tive

and

nega

tive

impl

icat

ions

4. In

terv

entio

nsw

ith s

ervi

cepr

ovid

ers

and

infa

cilit

ies

plus

inte

rven

tions

with

oth

erse

ctor

s

++

++

++

++

++

Mod

erat

eA

s ab

ove

5. In

terv

entio

nsw

ith s

ervi

cepr

ovid

ers

plus

inte

rven

tions

inth

e co

mm

unity

and

with

oth

erse

ctor

s

++

++

++

++

+M

oder

ate

Invo

lvin

gco

mm

unity

outr

each

and

oth

erse

ctor

s is

likel

y to

incr

ease

som

e of

the

diffi

culti

es b

ut it

160

92-4-120938-0_CH06_160

may

als

o in

crea

seth

e im

pact

and

othe

r he

alth

and

soci

al b

enef

its6.

Inte

rven

tions

with

ser

vice

prov

ider

s an

d in

faci

litie

s pl

usin

terv

entio

ns in

the

com

mun

ityan

d w

ith o

ther

sect

ors

++

++

++

++

++

+M

oder

ate

As

abov

e

a D

egre

e of

des

irabi

lity

is in

dica

ted

with

a m

axim

um o

f 3 “

+”

sign

s. D

egre

e of

und

esira

bilit

y is

indi

cate

d w

ith a

max

imum

of 3

“-”

sig

ns.

b F

easi

bilit

y de

crea

ses

with

incr

easi

ng a

ctiv

ities

insi

de a

nd o

utsi

de th

e fa

cilit

y.c T

he p

oten

tial f

or a

dver

se o

utco

mes

incr

ease

s w

ith th

e in

volv

emen

t of o

ther

sec

tors

.d

Acc

epta

bilit

y lik

ely

to b

e in

crea

sed

if se

rvic

e pr

ovid

ers

and

faci

litie

s ar

e im

prov

ed; t

his

wor

ks s

imila

rly a

s in

terv

entio

ns o

utsi

de th

e fa

cilit

ies

are

incr

ease

d.e

Invo

lvin

g ot

her

sect

ors

is li

kely

to in

crea

se c

omm

unity

acc

epta

nce

but a

t the

sam

e tim

e in

crea

se c

halle

nges

for

polic

y-m

aker

s.f T

he m

ore

com

preh

ensi

ve th

e in

terv

entio

ns, t

he m

ore

likel

y th

ey a

re to

hav

e an

impa

ct.

g T

he m

ore

othe

r se

ctor

s ar

e in

volv

ed, t

he m

ore

likel

y it

is th

at p

rovi

ding

acc

ess

to s

ervi

ces

for

youn

g pe

ople

and

thei

r he

alth

and

dev

elop

men

t in

gene

ral w

illbe

com

e fo

cuse

s fo

r ad

voca

cy a

nd a

ctio

n.

161

92-4-120938-0_CH06_161

Tab

le 6

.3D

escr

ipti

on

of

the

inte

rven

tio

ns

by

stu

dy.

(T

her

e w

ere

no

stu

die

s o

f ty

pe

4 in

terv

enti

on

s.)

Stu

dy,

loca

tio

nT

arg

et p

op

ula

tio

n a

nd

pri

mar

y o

bje

ctiv

esD

escr

ipti

on

Inte

rven

tio

n t

ype

1 (w

ith

ser

vice

pro

vid

ers

and

in t

he

com

mu

nit

y)C

– L

usak

a, Z

ambi

a:8

clin

ics

at 3

site

s (1

6)•

Ove

rall

obje

ctiv

e: to

impr

ove

the

heal

th a

ndw

ell-b

eing

of y

outh

s in

Lus

aka

• H

ealth

ser

vice

obj

ectiv

e: to

mak

e se

rvic

esm

ore

yout

h fr

iend

ly, f

or e

xam

ple,

dev

elop

ing

attr

ibut

es to

attr

act y

outh

s, m

eet t

heir

need

san

d re

tain

you

ng c

lient

s fo

r fo

llow

-up

visi

ts• T

arge

t gro

up: y

oung

peo

ple

aged

10–

24 y

ears

• 4-

year

stu

dy

• P

roje

ct c

linic

s se

lect

ed fr

om th

ose

alre

ady

prov

idin

g qu

ality

ser

vice

s or

rec

eptiv

e to

wor

king

with

you

ng p

eopl

e•

Tra

inin

g of

hea

lth-c

are

prov

ider

s an

d pe

ered

ucat

ors

to c

omm

unic

ate

abou

t ado

lesc

ent

sexu

al a

nd r

epro

duct

ive

heal

th; m

ajor

diffe

renc

e in

pro

ject

site

s w

as e

xten

t to

whi

chco

mm

unity

was

invo

lved

; par

ticip

ator

y“le

arni

ng fo

r act

ion”

exe

rcis

es u

sed

to s

ensi

tize

com

mun

ities

abo

ut a

dole

scen

t sex

ual a

ndre

prod

uctiv

e he

alth

.In

terv

enti

on

typ

e 2

(act

ion

s in

th

e cl

inic

, wit

h s

ervi

ce p

rovi

der

s an

d in

th

e co

mm

un

ity)

L –

Jinj

a di

stric

t, U

gand

a:4

heal

th c

entr

es w

ith c

atch

men

t pop

ulat

ion

of 1

00 0

00 p

eopl

e (1

7)

• T

o ev

alua

te th

e im

pact

of a

dole

scen

t frie

ndly

heal

th s

ervi

ces

pilo

ted

in J

inja

dis

tric

t, U

gand

ato

red

uce

ST

D, H

IV a

nd u

nwan

ted

preg

nanc

ies.

• T

arge

t gro

up: a

dole

scen

ts 1

0–19

yea

rs•

17-m

onth

stu

dy

• H

ealth

wor

kers

trai

ned

to c

omm

unic

ate

and

coun

sel a

dole

scen

ts (

4 he

alth

wor

kers

/cen

tre,

2 cl

inic

al o

ffice

rs, 1

3 nu

rses

/mid

wiv

es, 1

disp

ense

r); d

istr

ict h

ealth

team

trai

ned

to b

uild

capa

city

for

furt

her

trai

ning

and

sup

ervi

sion

,al

so tr

aine

d in

ado

lesc

ent s

exua

l and

repr

oduc

tive

heal

th, c

omm

unic

atio

n an

dco

unse

lling

• H

ealth

cen

tres

reo

rgan

ized

to c

ater

toad

oles

cent

s; g

ames

and

rec

reat

iona

l ser

vice

sin

trod

uced

at h

ealth

uni

ts•

Pro

vide

bas

ic s

uppl

ies

(ST

Ia tr

eatm

ent a

ndco

ntra

cept

ives

)

162

92-4-120938-0_CH06_162

• G

ames

and

recr

eatio

nal s

ervi

ces

intr

oduc

ed a

the

alth

uni

ts•

Dis

tric

t hea

lth te

am tr

aine

d to

bui

ld c

apac

ity fo

rfu

rthe

r tra

inin

g an

d su

perv

isio

n. A

lso

trai

ned

inad

oles

cent

sex

ual a

nd r

epro

duct

ive

heal

th,

com

mun

icat

ion,

and

cou

nsel

ling

• A

dole

scen

ts in

volv

ed in

des

ign

and

subs

eque

nt s

tage

s of

pro

ject

I – S

ongj

iang

dis

tric

t,S

hang

hai,

Chi

na:

1 to

wn

in S

ongj

iang

, 1 c

linic

and

net

wor

kof

loca

l fam

ily p

lann

ing

prov

ider

s (1

9)

• O

bjec

tive:

to b

uild

aw

aren

ess

and

offe

rco

unse

lling

and

ser

vice

s re

late

d to

sex

ualit

yan

d re

prod

uctio

n to

unm

arrie

d yo

uths

• S

peci

fic o

bjec

tives

: to

incr

ease

con

trac

eptiv

eus

e (c

ondo

m u

se)

amon

g un

mar

ried

yout

hsth

roug

h a

mul

tifac

eted

inte

rven

tion

prog

ram

me

prov

idin

g in

form

atio

n, s

kills

,co

unse

lling

and

ser

vice

s•

Tar

get g

roup

: you

ths

15–2

4 ye

ars

• 20

-mon

th in

terv

entio

n

• B

uild

ing

awar

enes

s: a

wid

e ra

nge

ofin

form

atio

n ac

tiviti

es fo

r yo

ung

peop

le c

arrie

dou

t in

the

inte

rven

tion

com

mun

ity; i

nfor

mat

ion

prov

ided

abo

ut s

exua

l and

rep

rodu

ctiv

e he

alth

and

the

avai

labi

lity

of s

ervi

ces

• C

ouns

ellin

g: a

you

th h

ealth

cou

nsel

ling

cent

rese

t up

in th

e in

terv

entio

n to

wn

prov

ided

rout

ine

and

tele

phon

e co

unse

lling

• T

rain

ing

of s

ervi

ce p

rovi

ders

(bu

ildin

gkn

owle

dge

and

skill

s ab

out a

dole

scen

t sex

ual

and

repr

oduc

tive

heal

th, s

ensi

tizin

g th

em to

inte

ract

with

you

ng p

eopl

e, te

achi

ng th

em h

owto

ass

ist y

oung

peo

ple

in d

ealin

g w

ith s

ex-

rela

ted

issu

es)

• D

istr

ibut

ing

free

con

trac

eptiv

e su

pplie

sN

– C

entr

e D

ushi

shoz

e, R

wan

da:

1 cl

inic

in B

utar

e (1

2)•

To

mot

ivat

e yo

ung

peop

le e

ither

to u

seco

ndom

s co

nsis

tent

ly o

r to

not

hav

e se

x, to

lear

n th

eir

HIV

sta

tus,

and

see

k to

trea

tmen

tfo

r ot

her

ST

Is•

Tar

get g

roup

: you

ths

15–2

4 ye

ars

• R

esul

ts a

fter

18 m

onth

s of

impl

emen

tatio

n of

4-ye

ar p

rogr

amm

e

• P

rovi

de s

ubsi

dize

d yo

uth-

frie

ndly

sex

ual a

ndre

prod

uctiv

e he

alth

ser

vice

s (in

clud

ing

volu

ntar

y co

unse

lling

and

test

ing

for

HIV

, ST

Itr

eatm

ent,

emer

genc

y co

ntra

cept

ion,

preg

nanc

y te

stin

g an

d re

prod

uctiv

e he

alth

coun

selli

ng)

alon

g w

ith s

kills

-bui

ldin

g an

dso

cial

act

iviti

es w

ithin

a p

urpo

se-b

uilt

cent

re;

163

92-4-120938-0_CH06_163

Stu

dy,

loca

tio

nT

arg

et p

op

ula

tio

n a

nd

pri

mar

y o

bje

ctiv

esD

escr

ipti

on

serv

ices

pro

vide

d by

hea

lth-w

orke

rs a

nd fu

ll-tim

e pa

id p

eer

educ

ator

s; P

eer

educ

ator

s an

dhe

alth

-wor

kers

pro

vide

d sm

all-g

roup

and

indi

vidu

al c

ouns

ellin

g se

ssio

ns fo

r yo

uths

at

the

cent

re a

nd a

lso

in c

hurc

hes,

clu

bs, s

choo

lsan

d ru

ral c

omm

unity

cen

tres

• P

eer

educ

ator

s he

lped

iden

tify

and

prom

ote

yout

h-fr

iend

ly c

ondo

m s

elle

rs in

rur

al a

reas

0 –

Gw

eru,

Zim

babw

e (1

8)•

Cre

ate

a m

ore

favo

urab

le e

nviro

nmen

t for

the

prov

isio

n of

rep

rodu

ctiv

e he

alth

info

rmat

ion

and

serv

ices

for

yout

hs•

Incr

ease

util

izat

ion

of c

linic

al r

epro

duct

ive

heal

th s

ervi

ces

by y

outh

s by

20%

abo

veba

selin

e•

Incr

ease

kno

wle

dge

of s

elec

ted

sexu

ality

and

repr

oduc

tive

heal

th is

sues

am

ong

youn

gpe

ople

atte

ndin

g N

dhlo

vu Y

outh

Cen

tre

by20

%•

Inte

rven

tion

last

ed 1

1 m

onth

s

• R

aise

aw

aren

ess

of r

epro

duct

ive

heal

th n

eeds

of y

oung

peo

ple

thro

ugh

mee

tings

with

com

mun

ity le

ader

s, p

aren

ts, t

each

ers,

etc

• T

rain

clin

ic n

urse

s, d

evel

op “

yout

h co

rner

s” in

clin

ics,

trai

n pe

er e

duca

tors

to p

rovi

dein

form

atio

n an

d co

ntra

cept

ives

, and

est

ablis

ha

recr

eatio

nal y

outh

cen

tre

to s

uppo

rt th

epr

ovis

ion

of r

epro

duct

ive

heal

th s

ervi

ces

(Ndh

lovu

You

th C

entr

e)

Inte

rven

tio

n t

ype

3 (w

ith

ser

vice

pro

vid

ers

and

invo

lvem

ent

of

oth

er s

ecto

rs)

J –

Bah

ia s

tate

, Bra

zil:

10 r

efer

ence

clin

ics

paire

d w

ithse

cond

ary

scho

ols

(5 p

airs

inS

alva

dor,

5 in

inte

rior)

(20

)

• O

vera

ll ob

ject

ive:

to r

educ

e hi

gh p

regn

ancy

rate

s am

ong

adol

esce

nts

and

grow

ing

num

ber

of n

ew H

IV in

fect

ions

am

ong

youn

g ad

ults

• H

ealth

ser

vice

obj

ectiv

e: to

inte

grat

e sc

hool

base

d se

xual

and

rep

rodu

ctiv

e he

alth

educ

atio

n w

ith p

rovi

sion

in p

ublic

clin

ics

ofre

prod

uctiv

e he

alth

ser

vice

s ap

prop

riate

toad

oles

cent

s•

Tar

get g

roup

: you

ng p

eopl

e 10

–24

year

s•

Initi

ativ

e w

as u

nder

take

n ov

er a

2-y

ear

perio

d

• 30

0 se

rvic

e pr

ovid

ers

took

par

t in

19 tr

aini

ngse

ssio

ns in

rep

rodu

ctiv

e he

alth

ser

vice

s fo

rad

oles

cent

s ov

er 2

yea

r pe

riod

• A

t end

of t

his

time,

an

aver

age

of 3

.2 s

ervi

cepr

ovid

ers

per c

linic

had

bee

n tr

aine

d to

pro

vide

thes

e se

rvic

es in

a m

anne

r ap

prop

riate

for

adol

esce

nts;

no

desc

riptio

n of

con

tent

of

trai

ning

• S

exua

l and

rep

rodu

ctiv

e he

alth

cur

ricul

umin

trod

uced

in 1

0 “p

artn

er”

scho

ols

164

92-4-120938-0_CH06_164

• R

efer

rals

mad

e to

clin

ics

• C

onta

ct e

stab

lishe

d be

twee

n he

alth

ser

vice

and

educ

atio

nal s

taff

Inte

rven

tio

n t

ype

5 (w

ith

ser

vice

pro

vid

ers,

in t

he

com

mu

nit

y an

d in

volv

ing

oth

er s

ecto

rs)

D –

Zim

babw

e:5

pilo

t site

s (1

urb

an a

nd4

grow

th p

oint

s), 2

6 fa

mily

pla

nnin

g cl

inic

s(2

1)

• O

vera

ll ob

ject

ive:

to e

ncou

rage

you

ng p

eopl

eto

ado

pt b

ehav

iour

s th

at r

educ

e th

e ris

k of

preg

nanc

y an

d S

TIs

, inc

ludi

ng H

IV•

Hea

lth s

ervi

ce o

bjec

tive:

to e

ncou

rage

you

ngpe

ople

to u

se s

ervi

ces

• T

arge

t gro

up: y

oung

peo

ple

10–2

4 ye

ars

• M

ultim

edia

cam

paig

n fo

r 6

mon

ths;

inte

rven

tion

for

1 ye

ar

• C

ampa

ign

used

a v

arie

ty o

f cha

nnel

s in

clud

ing

post

ers,

leaf

lets

, new

slet

ters

, rad

iopr

ogra

mm

e, d

ram

a, c

omm

unity

eve

nts

and

hotli

nes;

som

e dr

amas

per

form

ed in

, and

prin

tm

ater

ial d

istr

ibut

ed th

roug

h, s

choo

ls b

ut n

osc

hool

-bas

ed c

urric

ulum

. Thr

ough

out

cam

paig

n pe

er e

duca

tors

, dra

ma

grou

ps a

ndpr

int m

ater

ials

refe

rred

you

ng p

eopl

e to

clin

ics.

• H

ealth

ser

vice

s: F

amily

pla

nnin

g pr

ovid

ers

wer

e tr

aine

d in

26

desi

gnat

ed c

linic

s in

com

mun

icat

ion

and

coun

selli

ng s

kills

dur

ing

a1-

wee

k co

urse

; exp

ecta

tion

that

atte

ndee

sw

ould

trai

n co

-wor

kers

in c

ouns

ellin

gG

– M

wan

za r

egio

n, U

nite

d R

epub

lic o

fT

anza

nia:

10

com

mun

ities

in 4

rur

al d

istr

icts

and

59 in

terv

entio

n sc

hool

s, 1

8 go

vern

men

the

alth

faci

litie

s (2

2)

• Hea

lth s

ervi

ce o

bjec

tive:

to in

crea

se a

cces

s to

(and

app

ropr

iate

util

izat

ion

of)

high

-qua

lity

sexu

al a

nd r

epro

duct

ive

heal

th s

ervi

ces

for

youn

g pe

ople

• Tar

get g

roup

: you

ng p

eopl

e ag

ed 1

2–24

yea

rsw

ith a

par

ticul

ar fo

cus

on th

ose

aged

12–

19ye

ars

• In

terv

entio

n ov

er 3

yea

rs

• Key

hea

lth w

orke

rs in

all

18 in

terv

entio

n an

d 21

com

paris

on h

ealth

faci

litie

s re

ceiv

ed e

ither

an

initi

al 1

-wee

k co

urse

or

1-w

eek

refr

eshe

rco

urse

in th

e sy

ndro

mic

man

agem

ent o

f ST

Is.

The

sam

e w

orke

rs fr

om th

e in

terv

entio

nfa

cilit

ies

rece

ived

a 1

-wee

k pa

rtic

ipat

ory

trai

ning

wor

ksho

p fo

cusi

ng o

n th

e ne

eds

ofyo

ung

peop

le a

nd m

etho

ds fo

r pro

vidi

ng s

exua

lan

d re

prod

uctiv

e he

alth

ser

vice

s fo

r th

em.

• A

ll 39

hea

lth fa

cilit

ies

rece

ived

4 s

uper

visi

onvi

sits

per

yea

r•

Add

ition

al in

terv

entio

ns in

clud

ed

165

92-4-120938-0_CH06_165

Stu

dy,

loca

tio

nT

arg

et p

op

ula

tio

n a

nd

pri

mar

y o

bje

ctiv

esD

escr

ipti

on

In-s

choo

l sex

ual a

nd r

epro

duct

ive

heal

thed

ucat

ion

impl

emen

ted

thro

ugh

a te

ache

r-le

d, p

eer-

assi

sted

pro

gram

me

of p

artic

ipat

ory

less

ons

Com

mun

ity-b

ased

con

dom

pro

mot

ion

and

dist

ribut

ion,

for

and

by y

outh

s, u

sing

a s

ocia

lm

arke

ting

appr

oach

; mor

e th

an 3

000

cond

oms

per

year

wer

e di

strib

uted

by

yout

hco

ndom

pro

mot

ers

and

dist

ribut

ors

Com

mun

ity a

ctiv

ities

• T

he c

ost p

aper

sho

ws

that

68.

9% o

f ove

rall

impl

emen

tatio

n co

sts

wer

e fo

r th

e in

-sch

ool

com

pone

nt, 1

2.3%

for

the

com

mun

ity-b

ased

com

pone

nt, 1

0.1%

for

the

yout

h co

ndom

prom

oter

s an

d di

strib

utor

s, a

nd 8

.8%

for

the

yout

h-fr

iend

ly h

ealth

ser

vice

s co

mpo

nent

with

the

heal

th w

orke

rs a

nd c

linic

sIn

terv

enti

on

typ

e 6

(wit

h s

ervi

ce p

rovi

der

s, in

th

e co

mm

un

ity

and

invo

lvin

g o

ther

sec

tors

)A

– M

ongo

lia:

pilo

t of m

ultis

ecto

r pr

ojec

t (2

rura

l dis

tric

tsan

d 3

dist

ricts

in c

apita

l) (2

3)

• O

bjec

tive:

to in

crea

se a

dole

scen

ts’ a

cces

s to

qual

ity h

ealth

ser

vice

s•

Tar

get g

roup

: ado

lesc

ents

10–

19 y

ears

• A

sses

smen

t con

duct

ed a

fter

1 ye

ar o

f the

3-ye

ar p

roje

ct

• S

tand

ards

of q

ualit

y of

car

e fo

r ad

oles

cent

sw

ere

deve

lope

d•

Tra

inin

g st

aff i

n ad

oles

cent

hea

lth a

ndde

velo

pmen

t, in

clud

ing

teac

hing

new

ski

lls in

com

mun

icat

ion

and

coun

selli

ng, p

rovi

ding

basi

c eq

uipm

ent a

nd s

uppl

ies

to h

ealth

faci

litie

s (s

uch

as s

cale

s, c

ontr

acep

tives

),m

akin

g th

e fa

cilit

ies

mor

e at

trac

tive

to y

oung

peop

le, d

esig

ning

info

rmat

ion

and

educ

atio

nm

ater

ials

on

heal

th a

nd d

evel

opm

ent i

ssue

san

d di

strib

utin

g th

ese

mat

eria

ls to

ado

lesc

ents

,an

d de

velo

ping

pol

icie

s an

d pr

oced

ures

on

166

92-4-120938-0_CH06_166

conf

iden

tialit

y an

d ap

plyi

ng th

ese

atpa

rtic

ipat

ing

site

s•

Com

mun

ity m

obili

zatio

n at

eac

h si

te in

volv

edgo

vern

ors,

teac

hers

, hea

lth w

orke

rs, p

aren

tsan

d ad

oles

cent

s•

Ofte

n it

was

the

heal

th w

orke

rs w

ho tr

aine

dot

hers

• A

dole

scen

ts w

ere

part

of a

dole

scen

t boa

rds

and

invo

lved

in d

esig

n of

edu

catio

n m

ater

ials

and

advo

cacy

B –

Sou

th A

fric

a:na

tiona

l pro

gram

me

star

ted

in 1

999

and

linke

d w

ith “

love

Life

” m

ultim

edia

prog

ram

me

(24)

• O

vera

ll ob

ject

ive:

to c

ontr

ibut

e to

red

ucin

gpr

eval

ence

of H

IV, S

TIs

and

unw

ante

dpr

egna

ncie

s am

ong

Sou

th A

fric

an y

outh

s•

Hea

lth s

ervi

ce o

bjec

tives

: cat

alys

e an

adol

esce

nt-f

riend

ly e

thos

in a

ll go

vern

men

tcl

inic

s; p

rovi

de a

brid

ge b

etw

een

prev

entio

nan

d tr

eatm

ent t

hrou

gh im

prov

ed m

anag

emen

tsy

stem

s, in

fras

truc

ture

and

clin

ical

cap

acity

• Tar

get g

roup

: you

ng p

eopl

e ag

ed 1

0–24

yea

rs,

with

prim

ary

targ

et g

roup

age

d 12

–17

year

s•

Pro

gram

me

star

ted

in 1

999

Clin

ics

will

ing

to jo

in th

e in

itiat

ive

unde

rgo

the

follo

win

g st

eps:

• in

trod

uced

to id

ea o

f a Q

ualit

y Im

prov

emen

tT

eam

from

with

in th

e cl

inic

sta

ff an

d se

lect

sta

ffto

par

ticip

ate;

• un

derg

o a

base

line

asse

ssm

ent m

easu

red

agai

nst 1

0 na

tiona

l sta

ndar

ds;

• de

velo

p an

d im

plem

ent a

ctio

n pl

an a

gree

d by

Qua

lity

Impr

ovem

ent T

eam

;•

unde

rgo

exte

rnal

ass

essm

ent a

nd r

ecei

vera

ting

as a

n ad

oles

cent

-frie

ndly

clin

ic (

ratin

gva

lid fo

r 2

year

s);

• un

derg

o re

peat

ed e

xter

nal a

sses

smen

ts a

ndra

ting

ever

y 2

year

s•

Rea

sona

bly

high

pro

port

ion

of c

linic

s pr

ogre

ssto

acc

redi

tatio

n (v

ia e

xter

nal a

sses

smen

t); b

yD

ecem

ber

2004

, 65%

of c

linic

s in

volv

ed fo

r at

leas

t 12

mon

ths

had

been

acc

redi

ted

167

92-4-120938-0_CH06_167

Stu

dy,

loca

tio

nT

arg

et p

op

ula

tio

n a

nd

pri

mar

y o

bje

ctiv

esD

escr

ipti

on

E –

nor

ther

n S

eneg

al:

“Fro

ntie

rs s

tudy

” (2

inte

rven

tion

arm

sin

volv

ing

com

mun

ities

, clin

ics

and

scho

ols)

(25

)

• O

vera

ll ob

ject

ive:

to im

prov

e re

prod

uctiv

ehe

alth

of y

oung

peo

ple

aged

10–

19 y

ears

• H

ealth

ser

vice

obj

ectiv

es: t

o de

term

ine

the

feas

ibili

ty, c

ost a

nd e

ffect

of i

mpr

ovin

g yo

uth-

frie

ndlin

ess

of s

ervi

ces

and

the

will

ingn

ess

and

abili

ty o

f ser

vice

pro

vide

rs to

offe

r qu

ality

coun

selli

ng a

nd s

ervi

ces

to y

outh

and

on

the

num

ber

of y

outh

s us

ing

thes

e se

rvic

es; t

ode

term

ine

whe

ther

ther

e is

an

addi

tiona

lco

ntrib

utio

n fr

om a

sch

ool-b

ased

inte

rven

tion

on th

e re

prod

uctiv

e he

alth

kno

wle

dge

ofyo

uths

, the

ir at

titud

es, s

exua

l beh

avio

ur a

ndus

e of

rep

rodu

ctiv

e he

alth

ser

vice

s•

Tar

get g

roup

: ado

lesc

ents

10–

19 y

ears

• 15

-mon

th in

terv

entio

n

• T

rain

ing

of h

ealth

-car

e pr

ovid

ers

and

peer

educ

ator

s in

8 c

linic

s; fi

ve s

choo

l hea

lth n

urse

sre

ceiv

ed th

e sa

me

trai

ning

• M

odifi

catio

n of

phy

sica

l lay

out o

f clin

ics

toim

prov

e pr

ivac

y fo

r ado

lesc

ents

(wai

ting

room

sfo

r ad

oles

cent

s an

d do

ors

to fa

cilit

ate

priv

ate

adol

esce

nt a

cces

s)•

Pee

r ed

ucat

ors

cond

ucte

d cl

asse

s in

the

com

mun

ity s

imila

r to

thos

e at

the

clin

ic•

Impl

emen

tatio

n co

sts

tota

lled

abou

tU

S$

100

000

over

2 y

ears

; com

mun

ity c

osts

wer

e U

S$

40 0

00; c

linic

inte

rven

tion

cost

s w

ere

US

$ 34

000

; and

sch

ool c

osts

wer

e U

S$

26 0

00•

Mos

t exp

endi

ture

s w

ere

for

plan

ning

and

trai

ning

at b

egin

ning

of i

nter

vent

ion

F –

Ban

glad

esh:

“Fro

ntie

rs”

stud

y (2

urb

an in

terv

entio

n ar

ms

invo

lvin

g co

mbi

natio

n of

com

mun

ity, c

linic

and

scho

ol)

(26)

• O

vera

ll ob

ject

ive

: to

dete

rmin

e th

e fe

asib

ility

and

effe

ctiv

enes

s of

a s

yste

mat

ic in

terv

entio

nto

fost

er a

sup

port

ive

envi

ronm

ent t

o ad

dres

sth

e pr

oble

ms

face

d by

ado

lesc

ents

by

mak

ing

heal

th s

ervi

ces

mor

e ac

cess

ible

and

pro

vidi

nged

ucat

ion

to e

nabl

e th

em to

man

age

thei

r ow

nre

prod

uctiv

e he

alth

• H

ealth

ser

vice

s ob

ject

ives

: to

impr

ove

the

repr

oduc

tive

heal

th o

f ado

lesc

ents

by

prov

idin

g in

form

atio

n an

d ad

oles

cent

-frie

ndly

serv

ices

to o

ut-o

f-sc

hool

and

in-s

choo

lad

oles

cent

s; to

ass

ess

the

effe

ct o

f an

educ

atio

n in

terv

entio

n on

ado

lesc

ents

’re

prod

uctiv

e he

alth

kno

wle

dge,

atti

tude

s an

dbe

havi

our,

incl

udin

g ut

iliza

tion

of s

ervi

ces;

to

• H

ealth

-car

e pr

ovid

ers

trai

ned

to b

e w

elco

min

gan

d m

aint

ain

non-

judg

emen

tal a

ttitu

de; o

ffer

min

imum

wai

ting

time,

priv

acy,

con

fiden

tialit

yan

d af

ford

able

ser

vice

s•

Non

-clin

ical

sta

ff tr

aine

d in

pro

vidi

ngre

prod

uctiv

e he

alth

car

e to

ado

lesc

ents

• A

dole

scen

ts w

ho a

ttend

ed e

duca

tion

sess

ions

rece

ived

a c

ard

allo

win

g th

em to

vis

it a

doct

orfr

ee fo

r 1

year

• C

linic

sta

ff vi

site

d th

e co

mm

unity

and

sch

ools

to m

onito

r ed

ucat

ion

sess

ions

and

info

rmad

oles

cent

s ab

out s

ervi

ces

• P

eer

educ

ator

s an

d te

ache

rs r

efer

red

adol

esce

nts

to s

ervi

ces

168

92-4-120938-0_CH06_168

dete

rmin

e w

heth

er a

n ad

ditio

nal c

ontr

ibut

ion

is m

ade

from

sch

ool-b

ased

inte

rven

tion

onre

prod

uctiv

e he

alth

and

atti

tude

s an

dut

iliza

tion

of s

ervi

ces

• T

arge

t gro

up: y

outh

s 13

–19

year

s•

Dur

atio

n of

inte

rven

tion:

20

mon

ths

• 2

year

stu

dy

• S

ervi

ces

prov

ided

bas

ed o

n go

vern

men

t-de

fined

ess

entia

l pac

kage

(fa

mily

pla

nnin

g,S

TI,

teta

nus

toxo

id v

acci

natio

n, a

nten

atal

and

post

nat

al s

ervi

ces)

• In

the

com

mun

ity, i

nfor

mat

ion

was

pro

vide

dth

roug

h te

leph

one

hotli

ne a

nd q

uest

ion

and

answ

er c

olum

ns in

loca

l new

spap

er; l

ette

rbo

xes

for r

espo

ndin

g to

ado

lesc

ents

’ que

stio

nsin

stal

led

outs

ide

clin

ics

• Tot

al c

ost o

f bot

h in

terv

entio

n si

tes

$US

41

388;

site

with

sch

ool-b

ased

inte

rven

tion

twic

e as

cost

ly (m

ajor

cos

t was

trai

ning

teac

hers

); c

osts

of c

omm

unity

and

sch

ool i

nter

vent

ions

abo

utU

S$

12 0

00 e

ach;

fina

ncia

l cos

ts o

f hea

lthse

rvic

e in

terv

entio

n (U

S$

2 35

3) w

ere

low

erbe

caus

e us

ed e

xist

ing

stru

ctur

es a

nd s

taff

(alth

ough

non

-fin

anci

al c

osts

, suc

h as

tim

esp

ent b

y st

aff i

n pl

anni

ng w

ere

note

d). T

rain

ing

cost

s lo

w in

clin

ics

due

to in

volv

emen

t of

inte

rnat

iona

l age

ncy

in s

tudy

(P

opul

atio

nC

ounc

il)H

– M

ozam

biqu

e:“G

eraç

ão B

iz”

prog

ram

me

(30

clin

ics

in 6

pro

vinc

es; 8

clin

ics

in M

aput

oci

ty e

valu

ated

) (2

7)

• O

vera

ll ob

ject

ive:

to im

prov

e ad

oles

cent

sexu

al a

nd r

epro

duct

ive

heal

th s

ervi

ces,

incr

ease

gen

der

awar

enes

s, r

educ

e th

ein

cide

nce

of u

npla

nned

pre

gnan

cies

and

decr

ease

vul

nera

bilit

y to

ST

Is, H

IV a

nd u

nsaf

eab

ortio

n•

Hea

lth s

ervi

ce o

bjec

tives

: to

esta

blis

h a

netw

ork

of q

ualit

y re

prod

uctiv

e he

alth

ser

vice

s

• 3 s

peci

aliz

ed a

dole

scen

t-on

ly c

linic

s in

2 u

rban

(Map

uto)

cen

tres

(1

in h

ospi

tal,

1 in

you

thce

ntre

, 1 in

cen

tre

offe

ring

voca

tiona

l ski

lls)

• C

entr

e in

hos

pita

l pro

vide

d pr

even

tive,

clin

ical

,co

unse

lling

and

con

trac

eptio

n se

rvic

es,

incl

udin

g em

erge

ncy

cont

race

ptio

n; a

lso

prov

ides

car

e fo

r S

TIs

and

pre

nata

l and

post

nata

l car

e; o

ffers

pos

t-ab

ortio

n

169

92-4-120938-0_CH06_169

Stu

dy,

loca

tio

nT

arg

et p

op

ula

tio

n a

nd

pri

mar

y o

bje

ctiv

esD

escr

ipti

on

and

coun

selli

ng fo

r ad

oles

cent

s w

ithin

the

publ

ic h

ealth

sys

tem

and

at a

ltern

ativ

e si

tes

• T

arge

t gro

up: y

oung

peo

ple

10–2

4 ye

ars

• A

ctiv

ities

sta

rted

in N

ovem

ber

1999

, dat

a to

2001

coun

selli

ng; o

ffers

vol

unta

ry c

ouns

ellin

g an

dte

stin

g fo

r H

IV•

Ser

vice

s fr

ee e

xcep

t ST

I tre

atm

ent

• Clin

ics

refu

rbis

hed

and

equi

pped

to m

ake

them

yout

h-fr

iend

ly a

nd to

offe

r pr

ivac

y•

Tra

inin

g cu

rric

ulum

dev

elop

ed; p

rovi

ders

trai

ned;

spe

cial

ized

per

sonn

el r

ecru

ited,

info

rmat

ion

mat

eria

ls d

evel

oped

; dev

elop

edm

anag

emen

t inf

orm

atio

n sy

stem

for

clin

ic;

cond

ucte

d pe

riodi

c te

chni

cal m

eetin

gs fo

rse

rvic

e pr

ovid

ers

to e

xcha

nge

info

rmat

ion

• P

eer

activ

ists

situ

ated

in w

aitin

g ar

eas

tow

elco

me

and

educ

ate

clie

nts

M –

Mad

agas

car:

1 pr

ovin

ce w

ith “

fran

chis

ed”

clin

ics

(12)

• O

vera

ll ob

ject

ive:

to p

reve

nt H

IV/A

IDS

and

unpl

anne

d pr

egna

ncie

s by

mot

ivat

ing

sexu

ally

activ

e yo

uth

to b

e tr

eate

d fo

r S

TIs

; to

enco

urag

e th

em to

use

con

dom

s co

nsis

tent

lyor

not

hav

e se

x•

Tar

get g

roup

: you

ths

aged

15–

24 y

ears

• R

esul

ts a

fter

18 m

onth

s of

impl

emen

tatio

n of

4-ye

ar p

rogr

amm

e

• 13

for-

prof

it an

d 2

priv

ate

non-

prof

it cl

inic

s“f

ranc

hise

d” a

s a

netw

ork

of y

outh

-frie

ndly

clin

ics;

clin

ics

mee

t min

imum

sta

ndar

dsin

clud

ing

havi

ng w

ell-t

rain

ed n

on-ju

dgem

enta

lpr

ovid

ers,

flex

ible

hou

rs, w

elco

min

g de

cor a

nddi

scre

et p

hysi

cal l

ocat

ions

; ser

vice

s ar

esu

bsid

ized

(pric

e of

US

$ 1.

45 fo

r ST

I dia

gnos

isan

d ot

her

repr

oduc

tive

heal

th s

ervi

ces)

• S

pons

orin

g te

chni

cal o

rgan

izat

ion

prov

ided

trai

ning

, sup

ervi

sion

and

sup

port

to h

ealth

wor

kers

and

mat

eria

ls; d

urat

ion

and

cont

ent o

ftr

aini

ng n

ot s

peci

fied

• C

linic

s an

d he

alth

pro

mot

ion

activ

ities

are

adve

rtis

ed th

roug

h m

ass

med

ia a

nd fa

ce-t

o-fa

ce c

omm

unic

atio

n pr

ovid

ed b

y pa

id fu

ll-tim

epe

er e

duca

tors

who

con

duct

sm

all-g

roup

and

indi

vidu

al c

ouns

ellin

g se

ssio

ns a

t div

erse

170

92-4-120938-0_CH06_170

loca

tions

and

in m

obile

uni

ts. P

eer

educ

ator

sre

ceiv

ed in

itial

trai

ning

of 4

-5 d

ays.

• S

essi

ons

held

with

par

ents

and

rel

igio

usle

ader

s to

pro

mot

e ad

oles

cent

–par

ent

dial

ogue

on

repr

oduc

tive

heal

th is

sues

• T

rain

ed a

nd c

aref

ully

sup

ervi

sed

peer

educ

ator

s fa

cilit

ated

gro

up d

iscu

ssio

ns to

hel

pyo

ung

peop

le g

ain

conf

iden

ce a

nd s

kills

tone

gotia

te s

afer

sex

; ass

esse

d w

heth

er c

linic

sw

ere

adol

esce

nt-f

riend

ly;

P –

End

o, N

iger

ia (

10)

• Ove

rall

obje

ctiv

e: to

impr

ove

trea

tmen

t of S

TIs

amon

g ad

oles

cent

s• T

arge

t gro

up: y

oung

peo

ple

aged

14–

20 y

ears

atte

ndin

g sc

hool

• T

rain

ing

give

n to

ST

I tre

atm

ent p

rovi

ders

(priv

ate

prac

titio

ners

, pat

ent m

edic

ine

deal

ers,

phar

mac

ists

iden

tifie

d by

ado

lesc

ents

as

used

by y

outh

s in

the

neig

hbou

rhoo

d fo

r S

TI

trea

tmen

t)•

90%

(45

) of

pat

ent m

edic

ine

deal

ers

iden

tifie

dby

ado

lesc

ents

par

ticip

ated

in a

nd c

ompl

eted

trai

ning

as

did

81%

(29

) of

pha

rmac

ists

and

70%

(28)

of p

rivat

e pr

actit

ione

rs; a

ll w

ere

give

nce

rtifi

cate

of p

artic

ipat

ion;

priv

ate

prac

titio

ners

wer

e lis

ted

as a

dole

scen

t-fr

iend

ly c

linic

s an

dth

e lis

t was

pro

vide

d to

pee

r ed

ucat

ors

• D

iffer

ent c

ateg

orie

s of

hea

lth-w

orke

rs w

ere

trai

ned

sepa

rate

ly (

each

for

30 h

ours

) in

ST

Idi

agno

sis

and

trea

tmen

t usi

ng W

HO

syn

drom

icm

anag

emen

t gui

delin

es; d

iffer

ent a

lgor

ithm

sus

ed fo

r ea

ch g

roup

;•

Hea

lth-w

orke

rs tr

aine

d in

adv

ance

of

impl

emen

tatio

n of

sch

ool-b

ased

inte

rven

tions

171

92-4-120938-0_CH06_171

Stu

dy,

loca

tio

nT

arg

et p

op

ula

tio

n a

nd

pri

mar

y o

bje

ctiv

esD

escr

ipti

on

• H

ealth

clu

bs s

et u

p in

eac

h sc

hool

; hea

lthpr

ofes

sion

als

prov

ided

info

rmat

ion

abou

t ST

Ipr

even

tion

and

trea

tmen

t; di

strib

uted

info

rmat

ion;

org

aniz

ed d

iscu

ssio

ns a

nd fi

lms

• 10

pee

r ed

ucat

ors

trai

ned

over

4 w

eeks

abo

utS

TIs

; pee

r ed

ucat

ors

prov

ided

cou

nsel

ling

toot

her

in-s

choo

l ado

lesc

ents

on

indi

vidu

al a

ndgr

oup

basi

s, d

urin

g sc

hool

bre

aks

and

afte

rho

urs

K –

Gha

na:

“Inn

ovat

e” p

rogr

amm

e (2

9)•

Ove

rall

obje

ctiv

e: to

incr

ease

you

ng p

eopl

e’s

know

ledg

e ab

out a

nd a

cces

s to

rep

rodu

ctiv

ean

d se

xual

hea

lth s

ervi

ces

• Tar

get g

roup

: you

ng p

eopl

e ag

ed 1

0–24

yea

rs•

Dat

a co

llect

ed o

ver

8-m

onth

per

iod

• P

lann

ed P

aren

thoo

d in

Gha

na c

reat

ed th

e“Y

oung

and

Wis

e C

entr

e”, w

hich

incl

uded

acl

inic

(pro

vidi

ng S

TI t

estin

g an

d tr

eatm

ent,

HIV

test

ing

and

coun

selli

ng, p

regn

ancy

test

ing,

post

-abo

rtio

n ca

re a

nd fa

mily

pla

nnin

g), a

libra

ry a

nd c

ompu

ter

cent

re; i

t offe

red

a ra

nge

of e

duca

tiona

l, ar

tistic

and

ent

erta

inm

ent

activ

ities

• A

mul

timed

ia “

Be

Wis

e” c

ampa

ign

to p

rom

ote

the

cent

re in

clud

ed te

levi

sion

, rad

io, p

rint a

ndel

ectr

onic

med

ia•

Clin

ic h

ad y

outh

-frie

ndly

faci

litie

s, in

clud

ing

flexi

ble

open

ing

hour

s an

d pr

ivac

y po

licie

s as

wel

l as

deco

r at

trac

tive

to y

oung

peo

ple

a S

TI =

sex

ually

tran

smitt

ed in

fect

ion.

172

92-4-120938-0_CH06_172

Tab

le 6

.4a

Des

crip

tio

n o

f o

utc

om

e ev

alu

atio

ns

by

stu

dy

for

typ

e 1

inte

rven

tio

ns

(wit

h s

ervi

ce p

rovi

der

s an

d in

th

e co

mm

un

ity)

Stu

dy

Des

ign

an

d s

amp

le s

ize

Eva

luat

ion

res

ult

s (d

ata

are

esti

mat

es f

rom

gra

ph

s) 1

995-

1999

Str

eng

th o

f ev

iden

ce

C (

16)

Des

ign:

bef

ore–

afte

r stu

dy,

serv

ice

stat

istic

s fr

om 8

trea

tmen

t and

2 c

ontr

olcl

inic

s

Qu

arte

rly

nu

mb

er o

f fa

mily

pla

nn

ing

clie

nts

ag

ed 1

5–24

yea

rs

Inte

rven

tion

and

cont

rol

grou

ps (

No.

clin

ics)

Bas

elin

e(f

irst q

uart

er19

95)

Qua

rter

inte

rven

tion

star

ted

End

(th

irdqu

arte

r19

99)

Tim

e be

twee

nin

terv

entio

nan

d en

d

1 (2

)25

025

010

0021

mon

ths

2 (3

)0

5050

15 m

onth

s

3 (3

)25

017

5034

0015

mon

ths

Con

trol

(2)

250

–12

50–

Qu

arte

rly

nu

mb

er o

f cl

ien

ts f

or

ST

I ser

vice

s ag

ed 1

5–24

yea

rs

Inte

rven

tion

and

cont

rol

grou

ps (

No.

clin

ics)

Bas

elin

e(f

irst q

uart

er19

95)

Qua

rter

inte

rven

tion

star

ted

End

(th

irdqu

arte

r19

99)

Tim

e be

twee

nin

terv

entio

nan

d en

d

1 (2

)22

5050

040

0021

mon

ths

2 (3

)55

055

060

015

mon

ths

3 (3

)95

050

020

0015

mon

ths

Con

trol

(2)

400

–16

00–

Incr

ease

in u

se o

f ser

vice

s bu

tno

sta

tistic

al te

sts

perf

orm

edto

sho

w s

igni

fican

ce in

com

paris

on w

ith c

ontr

olcl

inic

s; d

ata

do n

ot in

dica

tesu

bsta

ntia

l or

cons

iste

ntdi

ffere

nces

in in

crea

se in

utili

zatio

n be

twee

nin

terv

entio

n an

d co

ntro

lcl

inic

s

Lim

itatio

ns: N

o st

atis

tical

test

s ca

rrie

d ou

t

Not

e: D

ata

colle

ctio

n al

soin

clud

ed c

lient

exi

t sur

veys

,fo

cus

grou

p di

scus

sion

s, in

-de

pth

inte

rvie

ws

prov

idin

gda

ta o

n re

latio

nshi

p be

twee

nse

rvic

e ut

iliza

tion,

com

mun

ityac

cept

ance

and

you

th-

frie

ndlin

ess

of c

linic

s

Wea

k ev

iden

ce o

f no

incr

ease

d us

e re

late

d to

the

inte

rven

tion

173

92-4-120938-0_CH06_173

Tab

le 6

.4b

Des

crip

tio

n o

f ou

tco

me

eval

uat

ion

s b

y st

ud

y fo

r typ

e 2

inte

rven

tio

ns

(act

ion

s in

the

clin

ic, w

ith

ser

vice

pro

vid

ers

and

in th

eco

mm

un

ity)

Stu

dy

Des

ign

an

d s

amp

le s

ize

Eva

luat

ion

res

ult

sS

tren

gth

of

evid

ence

fo

r ef

fect

L (1

7)D

esig

n: q

uasi

-exp

erim

enta

l with

non-

equi

vale

nt c

ontr

ol g

roup

;kn

owle

dge–

attit

ude–

prac

tice

surv

eyof

ado

lesc

ents

(n=

128

) and

hea

lth-

wor

kers

(n

= 4

2) in

4 in

terv

entio

ncl

inic

s an

d 4

cont

rol c

linic

s; d

ata

colle

ctio

n al

so in

clud

ed s

ervi

cest

atis

tics,

focu

s gr

oup

disc

ussi

ons,

in-d

epth

inte

rvie

ws

Kno

wle

dge

• A

dole

scen

ts in

the

inte

rven

tion

site

s “h

ad in

crea

sed

know

ledg

e of

ado

lesc

ent h

ealth

pro

blem

s, p

redi

spos

ing

fact

ors,

fam

ily p

lann

ing,

HIV

and

ST

Is …

all

with

P<

0.0

001.

”(17

)%

ado

lesc

ents

usi

ng h

ealth

ser

vice

s ov

er 1

2 m

onth

s•

Out

patie

nt s

ervi

ces:

inte

rven

tion

grou

p= 4

9.3%

, con

trol

grou

p =

13.

1%, P

= 0

.000

1•

Fam

ily p

lann

ing

serv

ices

: int

erve

ntio

n gr

oup

= 6

9.4%

,co

ntro

l gro

up =

21.

1%, P

= 0

.000

1•

ST

Ia ser

vice

s: in

terv

entio

n gr

oup

= 6

5.5%

, con

trol

gro

up =

31.9

%, P

= 0

.000

1•

Labo

rato

ry s

ervi

ces:

inte

rven

tion

grou

p =

49.

8%, c

ontr

olgr

oup

= 4

.4%

, P=

0.0

001

Beh

avio

ur•

Cur

rent

ly u

sing

fam

ily p

lann

ing:

inte

rven

tion

grou

p =

65.6

%, c

ontr

ol g

roup

= 4

6.9%

, P=

0.0

06•

Eve

r us

ed fa

mily

pla

nnin

g : i

nter

vent

ion

grou

p =

68.

8%,

cont

rol g

roup

= 5

3.1%

, P=

0.0

20

Sta

tistic

ally

sig

nific

ant d

iffer

ence

s in

utili

zatio

n of

ser

vice

s am

ong

inte

rven

tion

and

cont

rol s

ites;

but

ther

e w

as a

non

-equ

ival

ent c

ontr

olgr

oup

and

aspe

cts

of s

tudy

des

ign

are

uncl

ear

Lim

itatio

ns: s

tatis

tical

ana

lysi

s do

esno

t tak

e ac

coun

t of c

lust

erin

g; n

ose

rvic

e st

atis

tics

on n

umbe

rs u

sing

heal

th u

nits

(on

ly “

prop

ortio

n of

adol

esce

nts

seek

ing

heal

thse

rvic

es”)

Wea

k ev

iden

ce fo

r in

crea

sed

use

ofse

rvic

es r

elat

ed to

the

inte

rven

tion

I (19

)D

esig

n: q

uasi

-exp

erim

enta

l(b

efor

e–af

ter)

with

1 in

terv

entio

nan

d 1

cont

rol c

omm

unity

Sam

ple

size

: int

erve

ntio

n gr

oup

=12

20, c

ontr

ol g

roup

= 1

007

unm

arrie

d yo

uths

(ag

ed 1

5– 2

4ye

ars)

Incr

ease

d “e

ver

cont

race

ptiv

e us

e”, “

regu

lar

cont

race

ptiv

eus

e” a

nd “

cond

om u

se”

at in

terv

entio

n si

tes,

P<

.001

Am

ong

thos

e w

ho b

ecam

e se

xual

ly a

ctiv

e du

ring

the

stud

ype

riod,

ther

e w

as in

crea

sed

use

of c

ontr

acep

tives

(P<

0.0

001)

and

incr

ease

d co

ndom

use

as

cont

race

ptiv

eof

cho

ice

(P<

0.0

5)

Use

d re

port

ed c

ondo

m u

se a

s a

prox

y fo

r se

rvic

e ut

iliza

tion;

stat

istic

ally

sig

nific

ant i

ncre

ase

inus

e of

ser

vice

s in

inte

rven

tion

site

s

Lim

itatio

ns: n

o ov

eral

l dat

a on

serv

ice

utili

zatio

n on

ly o

n re

port

ed

174

92-4-120938-0_CH06_174

Logi

stic

reg

ress

ion

anal

ysis

and

gen

eral

ized

est

imat

ing

equa

tions

ana

lysi

s of

dat

a fr

om s

exua

lly a

ctiv

e yo

ung

peop

le (n

= 6

44) i

ndic

ated

that

exp

osur

e to

the

inte

rven

tion

was

the

mos

t pow

erfu

l cor

rela

te o

f con

dom

use

(od

ds r

atio

= 1

4.54

, 95%

con

fiden

ce in

terv

al =

6.3

5–33

.30,

P>

0.0

001)

beha

viou

rs (

cond

om u

se)

that

cou

ldre

sult

from

ser

vice

util

izat

ion

Not

e: d

ata

also

ava

ilabl

e on

obst

acle

s to

con

trac

eptiv

e us

e an

d“jo

int d

ecis

ion

with

par

tner

”

Mod

erat

e ev

iden

ce fo

r inc

reas

ed u

seof

ser

vice

sN

(12

)D

esig

n: c

ross

-sec

tiona

l sur

vey

ofyo

uths

afte

r 18

mon

ths

ofin

terv

entio

n, w

ith s

ervi

ce u

seco

mpa

red

by le

vel o

f exp

osur

e to

inte

rven

tion;

200

2 ho

useh

old

surv

ey

Sur

vey

sam

ple

size

: 310

9un

mar

ried

youn

g pe

ople

age

d15

–24

year

s

Dat

a no

t pre

sent

ed o

n pr

e-ex

posu

re v

s po

st-e

xpos

ure

Dos

e–re

spon

se a

naly

sis

of:

Kno

wle

dge

• B

elie

f in

effe

ctiv

enes

s of

con

dom

s: m

ales

with

low

expo

sure

73%

, mal

es w

ith h

igh

expo

sure

92%

; fem

ales

with

low

exp

osur

e 64

%, f

emal

es w

ith h

igh

expo

sure

81%

Ski

lls•

Cor

rect

con

dom

use

: mal

es w

ith lo

w e

xpos

ure

17%

,m

ales

, with

hig

h ex

posu

re 3

0%•

Con

fiden

ce to

buy

con

dom

s: fe

mal

es w

ith lo

w e

xpos

ure

21%

, fem

ales

with

hig

h ex

posu

re 4

4%S

ervi

ces

• U

se o

f ser

vice

(H

IV te

st):

mal

es w

ith lo

w e

xpos

ure

2%,

mal

es w

ith h

igh

expo

sure

9%

; fem

ales

with

low

exp

osur

e2%

, fem

ales

with

hig

h ex

posu

re 7

%A

ll di

ffere

nces

sig

nific

ant a

t P<

0.0

5

Dat

a sh

ow s

tatis

tical

ly s

igni

fican

thi

gher

util

izat

ion

with

incr

ease

dex

posu

re to

the

inte

rven

tions

No

data

on

over

all u

tiliz

atio

n of

serv

ices

by

youn

g pe

ople

.

Lim

itatio

ns: P

re-in

terv

entio

n da

ta n

otpr

esen

ted;

no

over

all d

ata

pres

ente

dfo

r se

rvic

e ut

iliza

tion

Wea

k ev

iden

ce fo

r in

crea

sed

use

ofse

rvic

es in

thos

e w

ith h

igh

expo

sure

to th

e in

terv

entio

ns v

s. th

ose

with

low

expo

sure

O (

18)

Des

ign:

rev

iew

of c

linic

dat

a ov

er 1

year

afte

r the

sta

rt o

f the

inte

rven

tion

Man

y yo

uths

indi

cate

d th

at th

ey h

ad u

sed

the

You

th C

entr

e,bu

t onl

y 0.

2% o

f the

m s

aid

that

this

was

for

repr

oduc

tive

heal

th s

ervi

ces

A n

ew s

ervi

ce w

as p

rovi

ded

and

itw

as u

sed

by y

oung

peo

ple,

alth

ough

175

92-4-120938-0_CH06_175

Stu

dy

Des

ign

an

d s

amp

le s

ize

Eva

luat

ion

res

ult

sS

tren

gth

of

evid

ence

fo

r ef

fect

A h

isto

gram

in th

e re

port

pro

vide

s th

e fo

llow

ing

data

on

the

num

ber

of c

lient

s w

ho u

sed

the

serv

ices

of 4

rep

rodu

ctiv

ehe

alth

clin

ics

(est

imat

ed fr

om h

isto

gram

)

Tim

eA

nten

atal

serv

ices

use

dby

fem

ales

aged

12–

18ye

ars

ST

I clin

icus

ed b

ym

ales

age

d12

–24

year

s

ST

I clin

icus

ed b

yfe

mal

es a

ged

12–2

4 ye

ars

4th

quar

ter

1998

02

3

1st q

uart

er19

9910

514

020

2

2nd

quar

ter

1999

6510

213

0

3rd

quar

ter

1999

5060

70

incr

ease

d ut

iliza

tion

decl

ined

in 2

ndan

d 3r

d qu

arte

rs o

f fol

low

up

Lim

itatio

ns: n

o co

mpa

rison

or c

ontr

olcl

inic

s; n

o st

atis

tical

test

s; n

ode

nom

inat

ors

Not

e: d

ata

also

ava

ilabl

e on

the

type

sof

ser

vice

s us

ed b

y yo

ung

peop

lean

d on

ris

k an

d pr

otec

tive

fact

ors,

know

ledg

e an

d be

havi

ours

from

abe

fore

and

afte

r st

udy

that

did

not

incl

ude

data

on

serv

ice

utili

zatio

n

Wea

k ev

iden

ce o

f inc

reas

ed u

se o

fse

rvic

es

a S

TI =

sex

ually

tran

smitt

ed in

fect

ion.

176

92-4-120938-0_CH06_176

Tab

le 6

.4c

Des

crip

tio

n o

f o

utc

om

e ev

alu

atio

ns

by

stu

dy

for

typ

e 3

inte

rven

tio

ns

(wit

h s

ervi

ce p

rovi

der

s an

d in

volv

emen

t o

f o

ther

sec

tors

)

Stu

dy

Des

ign

an

d s

amp

le s

ize

Eva

luat

ion

res

ult

sS

tren

gth

of

evid

ence

fo

r ef

fect

J –

(20)

Des

ign:

qua

si-e

xper

imen

tal w

ith c

ontr

olgr

oup

of s

choo

ls a

nd c

linic

s in

the

sam

ear

ea; 3

rou

nds

of k

now

ledg

e–at

titud

es–

prac

tice

surv

eys

in in

terv

entio

n sc

hool

san

d 2

in c

ontr

ol s

choo

ls; s

ervi

ce s

tatis

tics

from

inte

rven

tion

and

cont

rol c

linic

s

Ave

rage

ann

ual n

umbe

r of

new

ado

lesc

ent

cont

race

ptiv

e us

ers

(all

met

hods

) at

6in

terv

entio

n cl

inic

s•

1997

(be

ginn

ing

of p

roje

ct):

390

• 19

99 (

end

of p

roje

ct):

500

Ave

rage

ann

ual n

umbe

r of

new

ado

lesc

ent

cont

race

ptiv

e us

ers

(all

met

hods

) at

258

cont

rol c

linic

s•

1997

(be

ginn

ing

of p

roje

ct):

110

• 19

99 (

end

of p

roje

ct):

200

No.

(%

) of

stu

dent

s re

ceiv

ing

info

rmat

ion

from

hea

lth-w

orke

r at

end

of p

roje

ct•

Mal

es: p

roje

ct s

choo

l – 5

88 (

13.7

%),

cont

rol s

choo

l – 6

86 (

10.1

%),

P<

0.0

5•

Fem

ales

: pro

ject

sch

ool –

104

8 (1

5.3%

),co

ntro

l sch

ool –

119

8 (1

2.5%

), P

< 0

.05

Ser

vice

sta

tistic

s in

dica

te n

o di

ffere

nce

amon

g in

terv

entio

n an

d co

ntro

l site

s, b

utno

sta

tistic

al te

sts

perf

orm

ed

Lim

itatio

ns: a

ll da

ta p

rovi

ded

as g

raph

s; n

ost

atis

tical

test

s fo

r se

rvic

e ut

iliza

tion

data

Not

e: d

ata

also

ava

ilabl

e on

qua

lity

stan

dard

s in

clud

ing

surv

ey o

f ser

vice

prov

ider

s (n

= 2

0, 1

00%

of p

rovi

ders

) an

dad

oles

cent

clie

nts

(n=

385

, 89%

of c

lient

s)in

4 r

efer

ence

clin

ics

(in S

alva

dor)

toas

sess

qua

lity

stan

dard

s

Wea

k ev

iden

ce o

f no

incr

ease

d us

e re

late

dto

the

inte

rven

tion

Wea

k ev

iden

ce o

f inc

reas

ed a

cces

s to

info

rmat

ion

rela

ted

to th

e in

terv

entio

n

177

92-4-120938-0_CH06_177

Tab

le 6

.4d

Des

crip

tio

n o

f o

utc

om

e ev

alu

atio

ns

by

stu

dy

for

typ

e 5

inte

rven

tio

ns

(wit

h s

ervi

ce p

rovi

der

s, in

th

e co

mm

un

ity

and

invo

lvin

g o

ther

sect

ors

)

Stu

dy

Des

ign

an

d s

amp

le s

ize

Eva

luat

ion

res

ult

sS

tren

gth

of

evid

ence

fo

r ef

fect

D (

21)

Des

ign:

qua

si-e

xper

imen

tal b

efor

e–af

ter

stud

y w

ith c

ontr

ol g

roup

; com

mun

itysu

rvey

s of

mal

es a

nd fe

mal

es a

ged

10–2

4ye

ars

in in

terv

entio

n ar

ea a

nd 2

con

trol

com

mun

ities

Sam

ple

size

: 3 m

onth

pre

-inte

rven

tion

surv

ey =

142

6;1

year

pos

t-in

terv

entio

n =

140

0.

At e

nd-o

f-st

udy

surv

ey•

28.2

% o

f res

pond

ents

at i

nter

vent

ion

site

sre

port

ed to

hav

e so

ught

ser

vice

s at

hea

lthce

ntre

• 9.

5% o

f res

pond

ents

at c

ontr

ol s

ites

repo

rted

to h

ave

soug

ht s

ervi

ces

at h

ealth

cent

re•

OR

a =

4.7

, P<

0.0

01

Use

of m

oder

n co

ntra

cept

ives

incr

ease

d in

inte

rven

tion

site

s•

Inte

rven

tion

grou

p =

56%

at b

asel

ine,

67%

at e

nd o

f stu

dy, O

R =

1.7

, P<

0.0

5•

No

data

for

cont

rol s

ites

Res

pond

ents

at i

nter

vent

ion

vsco

ntro

l site

s•

Res

pond

ents

at i

nter

vent

ion

site

s m

ore

likel

y to

“st

ick

to o

ne p

artn

er”

than

thos

e in

cont

rol s

ites

(OR

= 2

6.1,

P<

0.0

01)

• R

espo

nden

ts a

t int

erve

ntio

n si

tes

likel

y to

star

t to

use

cond

oms

(OR

= 5

.7,

P =

0.0

5)•

Res

pond

ents

at i

nter

vent

ion

site

s m

ore

likel

y to

hav

e “s

aid

no to

sex

” (O

R =

2.5

,P

= 0

.000

1).

Sta

tistic

ally

sig

nific

ant d

iffer

ence

in in

crea

sein

ser

vice

util

izat

ion

in in

terv

entio

n si

tes

rela

tive

to c

ontr

ol s

ites

(how

ever

ther

e w

asco

ntam

inat

ion

of c

ontr

ol s

ites)

; sta

tistic

ally

sign

ifica

nt in

crea

se in

con

trac

eptiv

e us

e at

inte

rven

tion

site

s at

end

-of-

stud

y su

rvey

rela

tive

to b

asel

ine

surv

ey

Lim

itatio

ns: c

onta

min

atio

n at

con

trol

site

s;m

ajor

inte

rven

tion

in th

e st

udy

was

a m

edia

inte

rven

tion;

no

data

from

ser

vice

sta

tistic

spr

ovid

ed; n

o ba

selin

e da

ta fo

r se

rvic

e us

e;no

acc

ount

take

n of

clu

ster

ing

in s

tatis

tical

anal

ysis

Wea

k ev

iden

ce fo

r inc

reas

ed u

se o

f ser

vice

s

178

92-4-120938-0_CH06_178

G (

22)

Des

ign:

com

mun

ity-r

ando

miz

ed c

ontr

olle

dtr

ial w

ith fo

llow

-up

of a

coh

ort o

f 12–

24-

year

-old

s ov

er 3

yea

rs; d

ata

from

com

mun

ity s

urve

ys

Sur

vey

sam

ple

size

: Int

erve

ntio

n ar

ea –

10

com

mun

ities

(m

ales

= 2

076,

fem

ales

=14

48);

con

trol

are

a =

10

com

mun

ities

(mal

es =

202

4, fe

mal

es =

149

2)

Pro

port

ion

who

rep

orte

d go

ing

to a

hea

lthfa

cilit

y fo

r m

ost r

ecen

t ST

I sym

ptom

s w

ithin

the

last

12

mon

ths

• A

djus

ted

OR

(95

% c

onfid

ence

inte

rval

) fo

rin

terv

entio

n vs

cont

rol f

or m

ales

= 0

.84

(0.5

0–1.

41),

for

fem

ales

= 1

.02

(0.6

2–1.

70)

Pro

port

ion

who

rep

orte

d us

ing

cond

oms

atla

st s

exua

l int

erco

urse

• A

djus

ted

OR

(95

% c

onfid

ence

inte

rval

) fo

rin

terv

entio

n vs

cont

rol f

or m

ales

= 1

.47

(1.1

2–1.

93),

for

fem

ales

= 1

.12

(0.8

5–1.

48)

No

stat

istic

ally

sig

nific

ant i

ncre

ase

inre

port

ed u

se o

f ser

vice

s

Sta

tistic

ally

sig

nific

ant i

ncre

ase

in c

ondo

mus

e on

ly a

mon

g m

ales

but

like

ly to

be

mai

nly

due

to o

ther

com

pone

nts

of th

e in

terv

entio

n,su

ch a

s yo

uth

cond

om p

rom

oter

s an

ddi

strib

utio

n in

com

mun

ities

as

wel

l as

scho

ol-b

ased

inte

rven

tion.

Lim

itatio

ns: b

ased

on

repo

rted

util

izat

ion;

data

on

serv

ice

stat

istic

s no

t yet

pub

lishe

d

Mod

erat

e ev

iden

ce o

f no

effe

ct o

n se

rvic

eut

iliza

tion

a O

R =

odd

s ra

tio.

179

92-4-120938-0_CH06_179

Tab

le 6

.4e

Des

crip

tio

n o

f o

utc

om

e ev

alu

atio

ns

by

stu

dy

for

typ

e 6

inte

rven

tio

ns

(wit

h s

ervi

ce p

rovi

der

s, in

th

e co

mm

un

ity

and

invo

lvin

g o

ther

sect

ors

)

Stu

dy

Des

ign

an

d s

amp

le s

ize

Eva

luat

ion

res

ult

sS

tren

gth

of

evid

ence

fo

r ef

fect

A (

23)

Des

ign:

qua

si-e

xper

imen

tal

desi

gn w

ith c

ompa

rison

of

serv

ice

utili

zatio

n da

ta in

inte

rven

tion

site

s (n

= 5

1,32

urb

an, 1

9 ru

ral)

and

con-

trol

site

s (n

= 2

8, 1

9 ur

ban,

9 ru

ral)

New

vis

itsin

terv

entio

n gr

oup

New

vis

itsco

ntro

l gro

upR

atio

inte

rven

tion:

cont

rol

Fol

low

-up

visi

tsin

terv

entio

n gr

oup

Fol

low

-up

visi

tsco

ntro

l gro

upR

atio

inte

rven

tion:

cont

rol

Tot

al v

isits

inte

rven

tion

grou

pT

otal

vis

itsco

ntro

l gro

upR

atio

inte

rven

tion:

cont

rol

Mal

es

430

296

1.5

P<

0.0

5

257

180

1.4

P<

0.0

5

617

384

1.6

P<

0.0

5

Fem

ales

577

299

1.9

P<

0.0

5

303

206

1.5

P<

0.0

5

770

420

1.8

P<

0.0

5

Tot

al

1007

595

1.7

560

386

1.5

1387

804

1.7

Sta

tistic

ally

sig

nific

antly

gre

ater

use

of s

ervi

ces

Alth

ough

Pva

lues

< 0

.05

thro

ugho

ut,

resu

lts a

re n

ot s

tand

ardi

zed

for

diffe

renc

es in

cat

chm

ent p

opul

atio

ns

Lim

itatio

ns: n

umbe

r of

atte

ndan

ces

com

pare

d am

ong

inte

rven

tion

and

cont

rol s

ites

with

no

atte

mpt

tost

anda

rdiz

e fo

r di

ffere

nces

in n

umbe

rof

ado

lesc

ents

in c

atch

men

t are

as,

desp

ite d

ata

indi

catin

g th

atad

oles

cent

pop

ulat

ion

was

1.4

tim

esgr

eate

r in

inte

rven

tion

area

s th

an in

cont

rol a

reas

; no

pre-

inte

rven

tion

data

pro

vide

d; ti

me-

serie

s in

inte

rven

tion

clin

ics

only

Wea

k ev

iden

ce fo

r sm

all i

ncre

ase

inut

iliza

tion

of s

ervi

ces

rela

tive

to th

ein

terv

entio

n

180

92-4-120938-0_CH06_180

B (

24)

Des

ign:

rev

iew

of c

linic

utili

zatio

n by

10–

19 y

ear

olds

in 3

2 cl

inic

s ta

king

par

tin

nat

iona

l pro

gram

me,

2002

–200

4A

vera

ge m

onth

ly c

linic

atte

ndan

ce20

0220

04

ST

Ia tr

eatm

ent v

isits

2002

2004

Vol

unta

ry c

ouns

ellin

g an

d te

stin

g20

0220

04

Pre

gnan

cy-r

elat

ed v

isits

2002

2004

Vis

its fo

r co

ntra

cept

ion

2002

2004

Tot

al

340

420

P<

0.0

5

30 48 P>

0.0

5

23 52 P<

0.0

01

48 54 P>

0.0

5

237

264

P>

0.0

5

Sta

tistic

ally

sig

nific

ant i

ncre

ase

inov

eral

l util

izat

ion

of s

ervi

ces

and

volu

ntar

y co

unse

lling

and

test

ing

serv

ices

(tim

e-se

ries

anal

ysis

),al

thou

gh th

e st

udy

lack

s co

ntro

l gro

up

Lim

itatio

ns: n

o da

ta p

rovi

ded

from

cont

rol c

linic

s

Not

e: d

ata

also

ava

ilabl

e on

qua

lity

ofse

rvic

es a

nd im

pact

on

info

rmat

ion,

skill

s an

d H

IV p

reva

lenc

e bu

t the

selik

ely

to b

e m

ainl

y re

late

d to

oth

erco

mpo

nent

s of

the

inte

rven

tion

Wea

k ev

iden

ce fo

r in

crea

sed

use

ofse

rvic

es r

elat

ed to

inte

rven

tion

181

92-4-120938-0_CH06_181

Stu

dy

Des

ign

an

d s

amp

le s

ize

Eva

luat

ion

res

ult

sS

tren

gth

of

evid

ence

fo

r ef

fect

E (

25)

Des

ign:

qua

si-e

xper

imen

tal

pre-

test

and

pos

t-te

stde

sign

ass

essi

ng 2

diff

eren

tin

terv

entio

ns (s

ites

A a

nd B

)an

d a

cont

rol s

ite (

site

C)

thro

ugh

com

mun

ity s

urve

ys

Inte

rven

tion

site

AB

efor

eA

fter

Inte

rven

tion

site

BB

efor

eA

fter

Con

trol

site

CB

efor

eA

fter

Ado

lesc

ents

in in

terv

entio

n si

tes

mor

e fa

mili

ar w

ith th

e ex

iste

nce

ofse

rvic

es, a

nd m

ore

likel

y to

use

ser

vice

s•

Exp

osed

site

A:

• U

nexp

osed

site

A:

• E

xpos

ed s

ite B

:•

Une

xpos

ed s

iteB

:Boy

s10

–14

1% 7% (P<

0.0

5)

2% 9% (P<

0.0

5)

0 10%

(P<

0.0

5)

Boy

s15

–19

6% 7% 8% 13%

(P<

0.0

5)

9% 12%

(P<

0.0

5)

Girl

s10

–14

1% 7% (P<

0.0

5)

1% 4% 0 15%

(P<

0.0

5)

13%

7% 12%

5%

Girl

s15

–19

8% 18%

(P<

0.0

5)

12%

14%

8% 20%

(P<

0.0

5)

Sig

nific

ant i

ncre

ases

in r

epor

ted

use

of s

ervi

ces,

but

no

diffe

renc

es a

mon

gco

ntro

l and

inte

rven

tion

site

s(in

crea

ses

mos

t mar

ked

at c

ontr

olsi

tes)

; con

trol

site

con

tam

inat

ed

Lim

itatio

ns: p

oten

tial c

onta

min

atio

n of

cont

rol s

ite b

ecau

se o

fim

plem

enta

tion

of m

edia

inte

rven

tions

Not

e: d

ata

also

ava

ilabl

e on

know

ledg

e of

con

trac

eptiv

e m

etho

dsan

d kn

owle

dge

of a

vaila

bilit

y of

serv

ices

Wea

k ev

iden

ce o

f no

incr

ease

in u

seof

ser

vice

s as

a r

esul

t of t

hein

terv

entio

ns

F (

26)

Des

ign:

qua

si-e

xper

imen

tal

befo

re–a

fter

desi

gn b

ased

on c

olle

ctio

n of

ser

vice

stat

istic

s at

two

inte

rven

tion

site

s (A

and

B) a

nd a

con

trol

site

(C

)

Use

of s

ervi

ces

durin

g 6

mon

ths

Inte

rven

tion

site

AIn

terv

entio

n si

te B

Con

trol

site

C

Bef

ore

inte

rven

tion

135

84 271

Afte

rin

terv

entio

n

444

1216

232

Odd

s ra

tioIn

crea

se in

use

of s

ervi

ces

atin

terv

entio

n si

tes;

gre

ater

incr

ease

at

site

s th

at in

clud

ed a

n in

-sch

ool

com

pone

nt, a

lthou

gh n

o P

valu

esav

aila

ble

182

92-4-120938-0_CH06_182

Use

of s

ervi

ces

incr

ease

d in

the

inte

rven

tion

site

s•

Rat

io A

:C =

2:1

• R

atio

B:C

= 1

0:1

• R

atio

B:A

= 6

:1U

se o

f con

dom

at l

ast s

exua

l int

erco

urse

am

ong

unm

arrie

d m

ales

Inte

rven

tion

site

AIn

terv

entio

n si

te B

Con

trol

site

C

2.31

(P

< 0

. 1)

2.41

(P<

0. 1

)2.

0 (N

S)

No

incr

ease

in c

ondo

m u

se a

mon

gun

mar

ried

mal

es a

mon

g in

terv

entio

nan

d co

ntro

l site

s

Lim

itatio

ns: p

opul

atio

n-ba

sed

surv

eys

carr

ied

out i

n ca

tchm

ent

popu

latio

n bu

t did

not

incl

ude

info

rmat

ion

abou

t use

of s

ervi

ces

only

attit

udes

tow

ards

ser

vice

s; h

owev

erin

form

atio

n on

con

dom

use

obt

aine

d

Not

e: d

ata

also

ava

ilabl

e ab

out t

ypes

of s

ervi

ces

used

Wea

k ev

iden

ce o

f inc

reas

ed u

se o

fse

rvic

es r

elat

ed to

the

inte

rven

tion

M (

12)

Des

ign:

qua

si-e

xper

imen

tal

befo

re–a

fter

stud

y of

clin

icat

tend

ance

rec

ords

for

yout

hs a

ged

15–2

4 ov

er24

-mon

th in

terv

entio

npe

riod

in 1

5 cl

inic

s

• N

o. a

ttend

ing

clin

ic J

anua

ry–M

arch

200

1 =

138

mal

es, 3

89 fe

mal

es•

No.

atte

ndin

g O

ctob

er–D

ecem

ber

2002

= 2

50 m

ales

, 195

9 fe

mal

esS

ervi

ce s

tatis

tics

indi

cate

d in

crea

sed

utili

zatio

n by

mal

es a

nd fe

mal

es

Lim

itatio

ns: n

o co

ntro

l clin

ics;

no

stat

istic

al te

sts

Wea

k ev

iden

ce o

f inc

reas

ed u

se o

fse

rvic

esH

(27

)D

esig

n: b

efor

e–af

ter

com

paris

on o

f clin

icat

tend

ance

by

“you

ths”

ove

r3

year

s (1

999–

2002

);in

terv

entio

n be

gan

in 2

000

Tot

al a

ttend

ance

at t

he 8

inte

rven

tion

clin

ics

• 19

99 =

1 1

73•

2000

= 1

1 72

6•

2001

= 1

8 80

9

Ser

vice

dat

a in

dica

te in

crea

sed

use

by y

outh

Lim

itatio

ns: n

o co

ntro

l gro

up; n

ost

atis

tical

test

s; n

o de

nom

inat

ors;

only

par

tial d

ata

repo

rted

183

92-4-120938-0_CH06_183

Stu

dy

Des

ign

an

d s

amp

le s

ize

Eva

luat

ion

res

ult

sS

tren

gth

of

evid

ence

fo

r ef

fect

Wea

k ev

iden

ce o

f inc

reas

edut

iliza

tion

of s

ervi

ces

Pro

port

ion

usin

gpr

ovid

erC

hang

efr

om p

re-

inte

rven

tion

to p

ost-

inte

rven

tion

Cha

nge

rela

tive

toco

ntro

l

P (

10)

Des

ign:

ran

dom

ized

cont

rolle

d tr

ial w

ith S

TI

trea

tmen

t pro

vide

rs c

lose

tosc

hool

s ra

ndom

ly a

lloca

ted

to in

terv

entio

n si

tes

(4sc

hool

s) a

nd 2

con

trol

site

s(4

sch

ools

eac

h); s

urve

ys in

the

scho

ols

befo

re a

nd a

fter

the

inte

rven

tions

Pro

port

ion

seek

ing

trea

tmen

tfr

om a

priv

ate

prov

ider

for

ST

Is

Inte

rven

tion

Con

trol

1

Con

trol

2

Rep

orte

d co

ndom

use

by m

ales

Inte

rven

tion

Con

trol

1

Bef

ore

17.5

%

19.0

%

24.0

%

Som

eco

ndom

use

30.8

%

32.1

%

Afte

r

40.7

%

29.1

%

30.4

%

Som

eco

ndom

use

40.5

%

36.1

%

OR

(95

%C

I)b

3.24

(1.8

4–5.

73)

1.75

(1.5

1–2.

03)

1.38

(0.7

5–2.

56)

1.5

(1.3

8–1.

69)

1.2

(1.0

7–1.

33)

OR

(95

%C

I)

… – 1.85

(1.0

6-3.

22)

2.35

(1.0

3-5.

17)

– 1.32

(0.9

7–1.

79)

Sta

tistic

ally

sig

nific

ant i

ncre

ase

and

diffe

renc

e am

ong

inte

rven

tion

and

cont

rol s

ites

in te

rms

of u

se o

fse

rvic

es fo

r bo

th m

ales

and

fem

ales

;fo

r fem

ales

am

ong

prox

y in

dica

tors

of

use

of s

ervi

ces

(con

dom

use

and

ST

Isy

mpt

om p

reva

lenc

e)

Lim

itatio

ns: s

tatis

tical

ana

lysi

s di

d no

tta

ke a

ccou

nt o

f clu

ster

ing

Not

e: d

ata

also

ava

ilabl

e on

know

ledg

e an

d sk

ills,

rep

orte

dsy

mpt

oms

of S

TI,

notif

icat

ion

ofpa

rtne

rs

Str

ong

evid

ence

of i

ncre

ased

use

of

serv

ices

184

92-4-120938-0_CH06_184

Con

trol

2R

epor

ted

cond

omus

e by

fem

ales

Inte

rven

tion

Con

trol

1

Con

trol

2

26.6

%

30.2

%

32.6

%

29.2

%

34.3

%

36.5

%

31.8

%

25.4

%

1.4

(1.0

9–2.

32)

1.3

(1.0

5–1.

72)

0.9

(0.7

8–1.

19)

0.8

(0.4

4–1.

59)

1.08

(0.6

0–1.

46)

– 1.82

(1.2

8–2.

60)

1.96

(0.9

4–4.

10)

K (

29)

Des

ign:

rev

iew

of c

linic

stat

istic

s ov

er 8

-mon

thpe

riod

afte

r in

trod

uctio

n of

yout

h ce

ntre

Man

y yo

ung

peop

le v

isite

d th

e ce

ntre

(re

port

ed a

ttend

ance

Jan

uary

=10

05, F

ebru

ary

= 2

685,

Mar

ch =

281

6, A

pril

= 2

993,

May

= 4

494,

Jun

e =

4379

, Jul

y =

253

4, A

ugus

t = 4

809)

but

onl

y 3.

3% o

f tho

se v

isiti

ng th

ece

ntre

use

d ei

ther

the

clin

ic o

r th

e co

unse

lling

ser

vice

s

Dur

ing

first

8 m

onth

s of

ope

ratio

n, th

e ce

ntre

pro

vide

d 18

995

mal

e an

d2

337

fem

ale

cond

oms;

ser

ved

2,64

6 cl

inic

clie

nts;

and

cou

nsel

led

102

yout

hs, w

ith a

n ad

ditio

nal 6

00–8

00 c

ouns

elle

d by

pho

ne. U

ncle

ar w

here

thes

e st

atis

tics

have

bee

n ob

tain

ed fr

om, a

nd th

ey d

o no

t cor

resp

ond

with

the

stat

istic

s in

the

eval

uatio

n. C

ondo

ms

and

coun

selli

ng p

rovi

ded

by o

ther

del

iver

y po

ints

in th

e ce

ntre

in a

dditi

on to

the

clin

ic

Diff

icul

t to

asse

ss tr

ends

ove

r th

e 8

mon

ths

beca

use

data

pre

sent

edso

met

imes

mon

thly

and

som

etim

es 3

-mon

thly

. No

obvi

ous

tren

ds in

num

bers

atte

ndin

g ce

ntre

as

a w

hole

. The

rep

ort s

tate

s: “

the

serv

ice

stat

istic

s in

dica

te th

e nu

mbe

r of

peo

ple

usin

g th

e cl

inic

ove

rall

has

incr

ease

d bu

t act

ual u

se o

f the

clin

ical

ser

vice

s av

aila

ble

is s

till l

imite

d”.

An

exam

ple

of s

tudy

that

look

s at

“a

serv

ice

was

pro

vide

d an

d so

me

youn

g pe

ople

use

d it”

Lim

itatio

ns: n

o co

ntro

l clin

ics;

it w

as a

new

cen

tre

so n

o be

fore

–afte

rst

atis

tics;

not

cle

ar h

ow m

any

clie

nts

wou

ld h

ave

atte

nded

an

alte

rnat

ive

clin

ic if

the

new

cen

tre

had

not

open

ed; n

ot p

ossi

ble

to u

se d

ata

toid

entif

y an

y tr

ends

ove

r tim

e; n

o te

sts

for

stat

istic

al s

igni

fican

ce

Wea

k ev

iden

ce o

f inc

reas

ed u

se o

fse

rvic

es

a S

TI =

sex

ually

tran

smitt

ed in

fect

ions

.b

OR

(95

% C

I) =

odd

s ra

tio (

95%

con

fiden

ce in

terv

al).

185

92-4-120938-0_CH06_185

Among the studies included in this review, the scale varied considerably. Tenof the studies involved fewer than 10 facilities; these took place in Bangladesh(26), Brazil (20), Ghana (29), Mozambique (27), Rwanda (12), Senegal(25), Uganda (17), Zambia (16) and Zimbabwe (18, 21). The remaining stud-ies looked at interventions occurring in larger numbers of facilities, from 15facilities in Madagascar (37) to 328 facilities in South Africa (24). Two stud-ies did not use facilities as the unit of analysis. In China (19) the unit wasnetworks of service providers, and in Nigeria (10) it was individual serviceproviders.

By virtue of their inclusion in this review, the health facilities in the studiesprovided one or several of the packages of services endorsed during theMontreux consultation (5). However, where data were available from thestudies, the Montreux package of services was often not the primary reasonwhy young people chose to use the health facilities. For example, in clin-ics in Gweru, Zimbabwe (18), 60% of adolescents sought curative (non-reproductive) services; in Senegal (25), 51% of services sought were forreasons other than reproductive health; and in 8 clinics in Maputo, Mozam-bique (27), counselling for unspecified issues was sought by 47% of youngclients.

6.3.2 Results by study

There was one study of a type 1 intervention, four of type 2 interventions,one of a type 3 intervention, none of a type 4 intervention, two of a type 5intervention and eight of type 6 interventions. All of the studies includedactions in the community, and all of the interventions that had activities aimedat improving health facilities also included training for service providers and,sometimes, other clinic staff.

The one study that examined a type 1 intervention was from Zambia (16); itreviewed baseline, start-up and end-of-study statistics on family planning andoutpatient attendances by 15–24-year-olds in eight participating clinics andtwo control sites. In the intervention clinics, service providers were trained,and peer educators also received training to work in the community servedby the clinic. Although there were increases in attendance during the studyperiod, these were not significantly greater than the increases seen in controlclinics during the same period.

The four studies of type 2 interventions were conducted in China (19),Rwanda (12), Uganda (17) and Zimbabwe (18). The findings from theRwanda study were based on a cross-sectional survey that assessed the impactof exposure to the interventions on the use of services by young people(12); this was one of only three studies that explored the dose–response effect

186

92-4-120938-0_CH06_186

of interventions. There was weak evidence of increased use of services, mostnotably voluntary counselling and testing, by those with high exposure to theintervention compared with those with low exposure. The Uganda study useda quasi-experimental design with a non-equivalent control group and demon-strated statistically significant increases in service use as a result of theinterventions (17). Although both these studies showed statistically signifi-cant differences in service utilization, aspects of the study designs were notclear, and they were therefore categorized as showing weak evidence of in-creased use of services.

The Zimbabwe study reviewed clinic data for a 1-year period following theimplementation of the interventions, and was one of several studies that didnot include any statistical tests but demonstrated that a service was providedand it was used (18). This was considered to be weak evidence of an increaseduse of services.

The study from China focused explicitly on increasing young people’s use ofcontraceptives, particularly condoms, which were provided by a range of fa-cilities. It was the only study included in the review that did not explicitlymeasure young people’s use of services, but had condom use as the outcomevariable (19). However, it was considered that condom use could be taken asa proxy indicator for service use in terms of how the study had been designed;there was moderate evidence for increased use from the quasi-experimentaldesign that included a before and after component and also included a con-trol site.

There was only one study that examined a type 3 intervention. This was fromBrazil (20) and was designed to strengthen links and referrals among schoolsand health facilities. Although no statistical tests were carried out, the quasi-experimental evaluation showed weak evidence for no increased use ofservices related to the intervention.

No studies of type 4 interventions were identified.

Two studies looked at the effect of type 5 interventions: one from Zimbabwe(21) and the other from the United Republic of Tanzania (22). The inter-vention in Zimbabwe was primarily a media campaign that also providedtraining for service providers in designated clinics in the project area. Thequasi-experimental design, which included a control site, showed statisticallysignificant increases in self-reported health service-seeking behaviours thatwere associated with increased exposure to the intervention. However, therewere no baseline data for these findings, and there was contamination of thecontrol site. This study was therefore designated as providing weak evidencefor an increased use of services, although in this study reported use of ser-vices, rather than actual use, was the outcome measured. The other type 5

187

92-4-120938-0_CH06_187

study, from the United Republic of Tanzania, was one of two randomizedcontrolled trials identified. The study did not show any statistically significantincrease in service provision despite the implementation of health-workertraining and interventions in communities and schools. It therefore providedmoderate evidence for no increased use of services.

Type 6 interventions were the subject of the largest number of studies; theseinterventions include training for service providers and activities in facilities,as well as actions in the community and with other sectors. There were eightstudies in the following countries: Bangladesh (26), Ghana (29), Madagascar(12), Mongolia (23), Mozambique (37), Nigeria (10), Senegal (25) and SouthAfrica (24). As outlined in Table 6.4e, six of these studies showed weakevidence for an increased use of services. The randomized controlled trialfrom Nigeria (10) showed strong evidence of an increase in the use of healthservices; the study from Senegal (25), which used a before and after designand a control site, showed increases in service utilization, but these increaseswere not statistically different from those at the control sites.

6.3.3 Results by intervention

Training health-service providers, and in some cases other clinic staff, wasthe most frequently implemented intervention used to increase service use byyoung people. However, descriptions of the content of the training were lim-ited. The most frequently mentioned topics were counselling and communi-cation skills in the studies in China (19), Mongolia (23), Mozambique (27),Uganda (17), Zambia (16) and Zimbabwe (21); clinical knowledge and skillsrelated to STIs in Madagascar (12), Mozambique (27), Nigeria (10), Senegal(25), South Africa (24) and the United Republic of Tanzania (22); clinicalknowledge and skills related to contraception in China (19), Senegal (25) andSouth Africa (24); and health-workers’ attitudes, particularly in relation toworking with young people and ensuring confidentiality, in Bangladesh(26), China (19) and Mongolia (23). The duration of the training was rarelyprovided, but where indicated it ranged from 30 hours (Nigeria) to 15 days(Mozambique) or 19 sessions (Brazil). In five studies, mention was made ofsupervising health-service providers to reinforce the knowledge and skillsdeveloped during training; this occurred in the studies in Madagascar,Mozambique, Uganda, South Africa and the United Republic of Tanzania.

Only one study explicitly set out to explore the relationship between differentaspects of quality in the facility, actions in the community and service uti-lization; this was conducted in Zambia (16). The analysis indicated that useof services was more strongly associated with levels of community accep-tance than with the “youth friendliness” of the services.

188

92-4-120938-0_CH06_188

Altogether, 11 of the 16 studies were multicomponent interventions that in-cluded involvement with other sectors. This reflects current thinking that acombination of interventions in different settings is likely to have the greatestimpact on young people’s behaviours and, subsequently, on HIV prevalence.In these multicomponent intervention studies, the aim of increasing youngpeople’s use of services was usually one of a number of objectives. Unfor-tunately, the actions implemented in the health services were often poorlydescribed, both those that were carried out in the health facility and those thatwere implemented in the community. Only one study – in Brazil (20) –specifically set out to measure the influence of actions in other sectors on theutilization of health services.

In the studies that included actions taken in health facilities mention was madeof reducing fees, subsidizing commodities and modifying the physical plantin order to improve privacy or make the facilities more appealing to youngpeople. The most frequently described community activities were holdingpublic meetings and advertising the facilities, for example by distributingposters and pamphlets.

Peer educators had a role in half of the studies, carrying out a range of activ-ities such as stimulating demand, referring young people to the facilities,ensuring that the facilities or services were welcoming, and providing infor-mation about sexual and reproductive health in clinics and in the community.This review indicates that merely placing a clinical service in a youth centre

(29) and Zimbabwe (18) where this was done, only a small proportion ofyoung people who used the centre used the clinics: 3.3% in Ghana and 0.2%in Zimbabwe.

The initiative in South Africa (24) was the most extensive in scale and rigour.It included the setting of national standards for delivering adolescent healthservices and the development of an accompanying internal quality improve-ment process that staff could carry out in their facilities, as well as an externalassessment that led to accreditation of the services as being adolescent-friendly. In Madagascar, standards for assessing the quality of servicesprovided to adolescents were part of the franchising approach to services thatwas implemented there (12), although the standards were not described indetail. National standards were also established in Mongolia (23). Elementscommon to the standards set in Mongolia and South Africa include standardsfor referral (for example, from schools to health services and from healthservices to other social services), for improving accessibility (for exampleby advertising the services), for creating an appealing physical environ-ment in the facilities, for instituting policies and procedures that ensure

189

does not ensure it will be used. In the studies reviewing interventions in Ghana

92-4-120938-0_CH06_189

confidentiality, for ensuring the technical competence of providers, ensuringadequate equipment and supplies, and generating community involvement.

Establishing standards for service delivery provides clear direction for actionand accountability through regular monitoring. Monitoring data were avail-able for South Africa but not for Madagascar. In Mongolia, assessments weremade through facility observation and surveys of clients and serviceproviders; these demonstrated that there were improvements in the physicalenvironment of the facilities, service providers’ competencies and attitudes,and in client satisfaction. Further analysis of client satisfaction data high-lighted the importance of basic amenities, such as toilets, in facilities in termsof adolescents’ perceptions of acceptability (30). In South Africa, the major-ity of the 72 clinics that were members of the National Adolescent FriendlyClinics Initiative that were assessed in 2004 complied with between 80% and90% of the initiative’s standards. In addition, the 11 clinics that were assessedannually showed statistically significant better performance on all but onestandard when compared with the control clinics.

Information about the costs of the interventions was provided in five of thestudies. Unfortunately the data do not make it possible to estimate the costsof increasing young people’s use of services. However, these data are usefulin indicating the relative costs of the different components of multisectorinterventions, including the costs of community engagement. In the studiesfrom Rwanda and Madagascar (12), the total in-country costs for all inter-ventions was US$ 1.1 million each. In addition, the costs for technicalassistance from the international nongovernmental organization supportingthese two projects, plus a third project in Cameroon that was excluded fromthis review (12), was US$ 1.7 million for the three countries over 4 years.Information from the Mwanza project in the United Republic of Tanzania(22) showed that 68.9% of overall implementation costs were for the in-school component, 12.3% for the community-based component, 10.1% forthe condom promoters and distributors, and 8.8% for the youth-friendlyhealth services component.

The studies in Senegal and Bangladesh (25, 26, 31) provided information onthe relative costs of making improvements in health services compared withother intervention components. In Senegal, implementation costs totalled ap-proximately US$ 100 000 over 2 years; the costs were shared betweencommunity interventions (US$ 40 000), clinic interventions (US$ 34 000)and school interventions (US$ 26 000). Most of the expenditures were forplanning and training at the beginning of the project. In Bangladesh, the totalcost for both intervention sites was US$ 41 388, with the site that includedschool-based interventions being twice as costly. The major additional costat this site was for teacher training. The costs of the community interventions

190

92-4-120938-0_CH06_190

and the school-based interventions were both approximately US$ 12 000each. The costs of interventions in the health services were lower, at US$ 2 353,because they used existing structures and staff (although non-financial costs,such as time spent by staff in planning, were said to be substantial). Anotherfactor that kept clinic costs low was that much of the training was carried outby the international agency involved in the study, and this was not includedin the costing.

6.4 Discussion

6.4.1 General

Providing young people with health services that will help prevent them be-coming infected with HIV and that will care for them if they do becomeinfected is a basic human right’s obligation (38), and all governments andcommunities need to ensure that these services are delivered. Providing theseservices to young people is also a key programme element for HIV preventionthat has been endorsed by governments in a range of international fora duringthe past decade (1, 3, 4). Policy-makers and programme managers, especiallythose working in resource-constrained settings, need to know which typesof interventions are most likely to increase young people’s use of healthservices.

Despite the fact that the evidence for the most part is weak, the majority ofstudies identified for inclusion in this review demonstrated an increased useof health services by young people as a result of the interventions. This isalso true for the additional studies that were identified but not included inthe review as a result of concerns about the details of the interventions or thequality of the data (32–36). This finding is encouraging because when thetechnical report on programming for adolescent health was published10 years ago (13), there was little evidence to indicate whether it was possibleto increase young people’s use of health services, even though a range ofservice delivery models had been described in the publication. Furthermore,many of the studies included in this review reflect the consensus around goodpractice that has been developing in discussions between researchers andpeople responsible for programme development and delivery during the pastdecade (2, 13, 28).

Table 6.5 summarizes the levels of evidence of effectiveness needed beforedifferent types of interventions can be recommended for widespread imple-mentation. The evidence for an increased use of services by young people iseither negative or equivocal for all types except types 2 and 6, which includeactivities that involve service providers and facilities and taking actions inthe community with or without the involvement of other sectors. For these

191

92-4-120938-0_CH06_191

two types there is weak evidence for an increased use of services. Type 2interventions require a weak level of evidence to recommend them as“Go” (Table 6.2); thus the evidence indicates that interventions that trainservice providers and other clinic staff, implement changes in clinics to makethem more responsive to the needs of young people and organize activitiesin the community should be taken to scale, with careful monitoring of cov-erage and quality. For type 6 interventions, with the weak evidence that isavailable it is possible to recommend them only as “Ready”. This means thatthey should be implemented widely and cautiously, but only if there is a strongevaluation component linked to implementation. These conclusions are sum-marized in Table 6.6. Intervention types that did not include components toimprove facilities or some type of community activity are categorized as“Steady” or “Do not go”. This emphasizes the importance of going beyondsimply training service providers if the aim is to increase service utilization:facilities also need to be improved and there needs to be outreach into thecommunity.

For many of these studies there were a number of unanswered questions aboutthe interventions and their mechanism of action. If interventions are to beimplemented, in addition to careful monitoring and evaluation, there is alsoa need for analytical case descriptions to clarify and document lessons learntand for operations research to specify and explain the content of the inter-ventions (that is, what is being done and why?) and to help answer some ofthe “how?” questions.

In general there is an ongoing need for research to tease out the relative im-portance of the various components of interventions in terms of their contri-bution to increasing the use of services by young people. For example, noneof the studies of type 6 interventions explored the relative contributions ofcommunity activities and the involvement of other sectors. Six of the eighttype 6 studies were multicomponent interventions that included schools andthe media. With one exception – in Brazil (20) – the activities in these sectorshad not been primarily developed to increase service utilization, although thiswas certainly one of their objectives. It will be important to better understandthe contributions that the involvement of schools and the media – as well asother sectors not included in this review, such as the workplace – make toincreasing the use of health services by young people. The question is: howmuch do they add to an effective community component? Also, it was clearfrom reviewing the studies that there was overlap between community ac-tivities and actions in other sectors. For example, it was not possible todisentangle the relative contribution made by health-workers providing in-formation in an ad hoc way to young people in schools and the implementa-tion of systematic curriculum-based programmes that provide pupils withrelevant information.

192

92-4-120938-0_CH06_192

Tab

le 6

.5S

tren

gth

of

evid

ence

of

effe

ctiv

enes

s fo

r ea

ch in

terv

enti

on

typ

e

Inte

rven

tio

n t

ype

and

stu

dy

des

ign

Po

siti

ve e

ffec

tN

o e

ffec

tE

vid

ence

Sta

tist

ical

lysi

gn

ific

ant

Sta

tist

ical

sig

nif

ican

cen

ot

kno

wn

Sta

tist

ical

lysi

gn

ific

ant

Sta

tist

ical

sig

nif

ican

cen

ot

kno

wn

Typ

e 1

(wit

h s

ervi

ce p

rovi

der

s an

d in

th

e co

mm

un

ity)

Ane

cdot

alE

quiv

ocal

Qua

litat

ive

only

Cro

ss-s

ectio

nal (

no c

ompa

rison

gro

up)

Bef

ore–

afte

r (n

o co

mpa

rison

gro

up)

Qua

si-e

xper

imen

tal (

1 c

ompa

rison

gro

up)

CR

CT

a

Typ

e 2

(act

ion

s in

th

e cl

inic

, wit

h s

ervi

ce p

rovi

der

s an

d in

th

e co

mm

un

ity)

Ane

cdot

alW

eak

Qua

litat

ive

Onl

yO

Cro

ss-s

ectio

nal

NB

efor

e–af

ter

Qua

si-e

xper

imen

tal

L, I

RC

TT

ype

3 (w

ith

ser

vice

pro

vid

ers

and

invo

lvem

ent

of

oth

er s

ecto

rs)

Ane

cdot

alE

quiv

ocal

Qua

litat

ive

only

Cro

ss-s

ectio

nal

Bef

ore–

afte

rQ

uasi

-exp

erim

enta

lJ

RC

T

193

92-4-120938-0_CH06_193

Inte

rven

tio

n t

ype

and

stu

dy

des

ign

Po

siti

ve e

ffec

tN

o e

ffec

tE

vid

ence

Sta

tist

ical

lysi

gn

ific

ant

Sta

tist

ical

sig

nif

ican

cen

ot

kno

wn

Sta

tist

ical

lysi

gn

ific

ant

Sta

tist

ical

sig

nif

ican

cen

ot

kno

wn

Typ

e 4

(wit

h s

ervi

ce p

rovi

der

s an

d in

th

e fa

cilit

y, in

volv

ing

oth

er s

ecto

rs)

No

stud

ies

of th

is ty

pe o

f int

erve

ntio

nT

ype

5 (w

ith

ser

vice

pro

vid

ers,

in t

he

com

mu

nit

y an

d in

volv

ing

oth

er s

ecto

rs)

Ane

cdot

alE

quiv

ocal

Qua

litat

ive

only

Cro

ss-s

ectio

nal

Bef

ore–

afte

rQ

uasi

-exp

erim

enta

lD

RC

TG

Typ

e 6

(wit

h s

ervi

ce p

rovi

der

s an

d in

th

e fa

cilit

y, in

th

e co

mm

un

ity

and

invo

lvin

g o

ther

sec

tors

)A

necd

otal

Wea

kQ

ualit

ativ

e on

lyB

, M, K

Cro

ss-s

ectio

nal

Bef

ore–

afte

rH

,Q

uasi

-exp

erim

enta

lA

FE

RC

TP

aR

CT

= r

ando

miz

ed c

ontr

olle

d tr

ial.

194

92-4-120938-0_CH06_194

Tab

le 6

.6R

eco

mm

end

atio

ns

on

th

e st

ren

gth

of

the

evid

ence

fo

r ef

fect

iven

ess

by

inte

rven

tio

n t

ype

Inte

rven

tio

n t

ype

Key

ch

arac

teri

stic

s o

f ef

fect

ive

inte

rven

tio

ns

Co

ncl

usi

on

Co

mm

ents

1. In

terv

entio

ns w

ith s

ervi

cepr

ovid

ers

only

plu

s in

terv

entio

ns in

the

com

mun

ity

• A

dequ

ate

trai

ning

of s

ervi

ce p

rovi

ders

and

othe

r cl

inic

sta

ff•

Ade

quat

e in

terv

entio

ns in

the

com

mun

ity to

pro

vide

info

rmat

ion,

gene

rate

dem

and

and

ensu

reco

mm

unity

sup

port

Ste

ady

(or

Do

not g

o)T

hese

are

like

ly to

be

the

easi

est

inte

rven

tions

to im

plem

ent b

ut a

rele

ast l

ikel

y to

hav

e an

impa

ct; s

tudy

desi

gn w

as w

eak

and

the

resu

lts a

reeq

uivo

cal

2. In

terv

entio

ns w

ith s

ervi

cepr

ovid

ers

and

in fa

cilit

ies

plus

inte

rven

tions

in th

e co

mm

unity

In a

dditi

on to

com

men

ts a

bout

type

1•

Cla

rity

abou

t whi

ch in

terv

entio

ns in

the

heal

th fa

cilit

ies

are

mos

t lik

ely

toco

ntrib

ute

to in

crea

sed

utili

zatio

n

Go

Alth

ough

the

stud

ies

wer

e no

t str

ong,

they

all

indi

cate

d an

incr

ease

d us

e of

serv

ices

by

youn

g pe

ople

Gre

ater

cla

rity

is r

equi

red

betw

een

type

2 a

nd ty

pe 6

inte

rven

tions

inte

rms

of th

e va

lue

adde

d by

the

“oth

erse

ctor

s” c

ompo

nent

3. In

terv

entio

ns w

ith s

ervi

cepr

ovid

ers

only

plu

s in

terv

entio

ns w

ithot

her

sect

ors

In a

dditi

on to

com

men

ts a

bout

type

1•

Cla

rity

abou

t whi

ch s

peci

ficin

terv

entio

ns in

sch

ools

and

in th

em

edia

(an

d ot

her

sect

ors

such

as

the

empl

oym

ent s

ecto

r) a

re m

ost l

ikel

y to

cont

ribut

e to

incr

ease

d ut

iliza

tion

ofse

rvic

es

Ste

ady

(or

Do

not g

o)T

here

was

onl

y on

e st

udy

iden

tifie

d of

this

type

of i

nter

vent

ion

and

it sh

owed

no in

crea

se in

use

All

the

type

s th

at o

nly

focu

sed

ontr

aini

ng s

ervi

ce p

rovi

ders

with

out

mak

ing

chan

ges

in th

e cl

inic

sho

wed

varia

ble

resu

lts

195

92-4-120938-0_CH06_195

Inte

rven

tio

n t

ype

Key

ch

arac

teri

stic

s o

f ef

fect

ive

inte

rven

tio

ns

Co

ncl

usi

on

Co

mm

ents

4. In

terv

entio

ns w

ith s

ervi

cepr

ovid

ers

and

in fa

cilit

ies

plus

inte

rven

tions

with

oth

er s

ecto

rs

No

data

5. In

terv

entio

ns w

ith s

ervi

cepr

ovid

ers

plus

inte

rven

tions

in th

eco

mm

unity

and

with

oth

er s

ecto

rs

In a

dditi

on to

com

men

ts a

bout

type

3•

Cla

rity

abou

t whi

ch c

ombi

natio

n of

trai

ning

, com

mun

ity a

nd m

edia

inte

rven

tions

are

mos

t lik

ely

toin

crea

se u

tiliz

atio

n of

ser

vice

s

Ste

ady

(or

Do

not g

o)D

ata

wer

e eq

uivo

cal,

and

as w

ith ty

pe1

inte

rven

tions

, inc

reas

ed u

se o

fse

rvic

es is

unl

ikel

y w

ithou

t cha

nges

inth

e fa

cilit

ies

6. In

terv

entio

ns w

ith s

ervi

cepr

ovid

ers

and

in fa

cilit

ies

plus

inte

rven

tions

in th

e co

mm

unity

and

with

oth

er s

ecto

rs

In a

dditi

on to

com

men

ts a

bout

type

2•

Cla

rity

abou

t whi

ch c

ombi

natio

n of

inte

rven

tions

in th

e cl

inic

, and

inte

rven

tions

in th

e co

mm

unity

and

with

oth

er s

ecto

rs, a

re m

ost l

ikel

y to

incr

ease

ser

vice

use

by

youn

g pe

ople

Rea

dyT

hese

inte

rven

tions

are

mos

t lik

ely

toha

ve a

n im

pact

, and

eve

n th

ough

the

inte

rven

tions

wer

e no

t alw

ays

clea

ran

d m

ost o

f the

stu

dies

onl

y ha

d w

eak

evid

ence

for

a po

sitiv

e ef

fect

, all

but

one

of th

em h

ad a

pos

itive

effe

ct o

nse

rvic

e ut

iliza

tion

196

92-4-120938-0_CH06_196

There are a number of issues that need to be considered when interpretingthese data. First, although several studies did not show any evidence for ef-fectiveness, there is likely to be both reporting and publication bias – that is,researchers are more likely to report results and have them published if theyhave a positive result. There may also have been misclassification bias interms of the allocation of the studies to specific types of interventions.

Second, a range of studies is included in this review, from randomized con-trolled trials of specific interventions to reports that merely demonstrated thata service was provided and it was used by young people. The challenge ofinterpreting data from studies that merely showed an increase in use afterproviding a service is highlighted by the studies in Zambia (16) and Senegal(25). Both of these studies had a before and after design with a control site.In both of them there was an increase in young people’s use of services at theintervention sites but this was not different from the increase noted at thecontrol sites (and there was no indication that there had been contaminationof these control sites). Thus for these studies there was weak evidence of noeffect on utilization as a result of the intervention. However, if there had been

was used”, as was done in Ghana (29) for example, these interventions wouldhave been considered to have shown weak evidence for increased utilizationas a result of the interventions.

Third, it needs to be recognized that the levels of evidence – weak, moderateand strong – contain a spectrum of evidence. For some of the studies “veryweak” would have been a more appropriate description than “weak” whenthey were compared with some of the other studies also considered to showweak evidence for effectiveness.

6.4.2 Inclusion and exclusion criteria

Despite using detailed inclusion and exclusion criteria for the studies in thisreview, there was ongoing discussion among the authors about whether toinclude studies of the “we provided a service and young people used it” typebecause we recognized that there is a subtle difference between young peopleusing a newly created service (meeting a provision gap) and implementingspecific interventions to identify the most effective approaches to increaseyoung people’s use of services (evaluation research). An example of a “weprovided a service” paper that was excluded due to insufficient data was thereport of activities of the African Youth Alliance project in the United Re-public of Tanzania (35). In this study, the only service utilization data was acomment that there was a “17% increase in the use of the services” with nodenominator or statistics from before the intervention. Thus it is extremely

197

no control clinics in these studies, if they had simply “provided a service that

92-4-120938-0_CH06_197

difficult to know whether there was a statistically significant increase or noincrease.

In tightening the inclusion and exclusion criteria, some studies that focusedon providing information and commodities in the community may have beenexcluded both from this paper and from the paper in this series on geograph-ically defined communities (chapter 8). The social marketing of condoms isan obvious example of an intervention that would have been excluded(11, 12).

6.4.3 The typology

Two issues need to be mentioned in relation to the typology used for thisreview. First, it needs to be recognized that other typologies could have beendeveloped that would also have helped guide the decisions of policy-makersand programmers. For example, interventions could have been classified de-pending on whether services were provided through government facilities,stand-alone youth clinics or as part of multicomponent youth centres. Severaltypologies were developed and tried but either there were insufficient detailsin the papers to make it possible to allocate the studies or there were insuffi-cient studies in the majority of the types.

Even with the typology that was adopted it was still not always easy to allocatestudies to the different types, mainly due to the inadequacy of informationcontained in the studies. For example, the Uganda study (17) did not includean obvious community component but it was clear from the narrative thatsome efforts took place to make it possible for parents to come and see whatwas happening in the clinic. This was done because the baseline survey dis-covered that some parents were concerned about their children using theclinics. The parents who visited the health facilities then acted as advocatesfor the services in the community.

In placing studies in the different types it was noted that there was a spectrumof “interventions in the facility” and that in some cases the lack of clarity inthe descriptions of the interventions made classifying them difficult. For ex-ample, cases could be made for classifying the study in Zambia (16) as a type2 intervention and the study in Uganda (17) as a type 4. These changes wouldnot, however, have made any differences to the conclusions: weak evidencefor type 2 and type 6 would remain and the evidence for the other types wouldremain equivocal.

6.4.4 Interventions, outcomes and evaluations

This review has indicated the need for researchers and people responsible forprogramme development and delivery to be much clearer about what they

198

92-4-120938-0_CH06_198

do, what the mechanisms of action of the interventions are, what the intendedoutcomes are and how implementation and outcomes can be measured. Interms of intensity of effort, the studies from Gweru, Zimbabwe (18), andBrazil (20) provide some indication that as the intensity of the interventionwaned, there was a decrease in the use of services by young people; thisemphasizes the need to focus on interventions that can be realistically sus-tained over time. Conversely, the analysis of service statistics from both ofthe studies that explicitly developed and measured standards – in Mongolia(23) and South Africa (24) – showed a statistically significant increase in theuse of services as a result of attempts to maintain the quality of the services.

The UNGASS goal specifies that 95% of young people should have accessto services by 2010 (3). Planning for a target such as this requires some senseof the need for services, and this need can only be determined through de-mographic and epidemiological data. None of the studies in our reviewaddressed this issue: at best they provided service statistics (in 9/16 studies)indicative of “contact” coverage (the services were used) but they made noreference to the overall population of young people, the catchment area orother age groups served by the same facilities.

It is encouraging that several of the studies provided information on costs,although few conclusions can be derived. Data about costs are extremelyimportant in terms of the replication and sustainability of interventions, andthese are aspects of monitoring and evaluation that require further develop-ment. Attention should be paid not only to the relative costs of the variousactivities in the health services and in other sectors, but also to the establish-ment of baseline costs of existing services and to the additional costs ofimproving services (in order for the data to be useful to programme planners).

Finally, the context in which interventions are implemented is likely to be animportant consideration, and contextual factors that may have influenced thesuccess or failure of the interventions were mentioned in some of the studies.Again, this has important implications for replication, and contextual factorsthat may influence outcomes need to be a more central focus in futureresearch.

6.5 Conclusions

What do we know about the contribution that health services can make topreventing HIV transmission among young people? In order to answer thisquestion we need to know the following.

1. Have we identified a set of evidence-based interventions that can be pro-vided through health services?

199

92-4-120938-0_CH06_199

2. Do we know what to do to increase young people’s use of health services(the focus of the UNGASS health services target)?

3. Can we provide young people who use health services with the evidence-based package of interventions that have been defined?

4. And, finally, can we determine whether increasing young people’s use ofevidence-based interventions makes a difference to HIV prevalence orother health outcomes?

With the completion of this study, and building on the evidence from theMontreux meeting (5), we now have “yes” answers to questions 1 and 2. Thethird and fourth questions were not the focus of this review. Only one ofthe studies (10) attempted to answer these questions, and clearly these are thequestions for the future as we build the evidence base.

Despite the constraints imposed by the quality of the data from most of thestudies included in this review, if countries want to move towards achievingthe global goals on HIV and young people, there is sufficient evidence tosupport widespread implementation of interventions that include elements oftraining for service providers and other clinic staff, making improvements tofacilities, and informing and mobilizing communities to generate demand andcommunity support. These interventions will require careful planning andimplementation, and their coverage and quality will need to be monitored.Operations research will also be needed as will a better understanding of thecosts.

Interventions that additionally involve other sectors can also be recom-mended for widespread implementation provided that they are carefullyplanned, implemented and monitored and include an evaluation componentthat assesses their impact on service utilization. Again, there is a need foroperational research to be undertaken to better understand the mechanismsof action. It will be important to gain a better understanding of the interven-tions and to be much clearer about the relative merits of actions in thecommunity compared with actions in the community that are implementedalong with additional activities in other sectors.

Future research will be required to demonstrate that we not only have a pack-age of evidence-based interventions and know how to increase young peo-ple’s use of services but that we can also have an impact on young people’sbehaviours and health through interventions provided through health servicesin conjunction with interventions in other settings. Achieving the health ser-vices access goal that was endorsed during UNGASS will have significantimplications for the decisions and resource allocations made by policy-makers, programme managers and researchers. Recommendations for all ofthese actors, based on the findings of this review, are summarized in Box 6.2.

200

92-4-120938-0_CH06_200

Box 6.2

Recommendations for interventions to increase the use of health services byyoung people

For policy-makers

Interventions implemented through health services will be essential forachieving the global goals on HIV and young people, in particular for thetarget of increasing young people’s access to an evidence-based pack-age of services to prevent the spread of HIV.

The evidence is sufficient to support widespread implementation of in-terventions to increase young people’s use of health services. However,these interventions should be implemented only if they are carefullymonitored and evaluated.

Interventions to increase young people’s access to health servicesshould be linked to interventions in other settings that aim to improveyoung people’s knowledge, skills, attitudes and behaviours.

For programme development and delivery staff

In order to increase young people’s use of services it is necessary totrain service providers and other clinic staff, make facilities more acces-sible and acceptable to young people and work in the community togenerate demand and community support.

It will be important to better understand the key components of trainingprogrammes for services providers and other clinic staff, the most im-portant improvements to make in health facilities, and the most strategicactions to take in the community. This will require careful monitoring andlinks with researchers.

Interventions implemented through health services need to be carefullyplanned and monitored, and linked to actions in other sectors. In addi-tion, in order to ensure that these interventions have the desired impact,evaluation and operations research should be actively supported.

For researchers

Evaluation and operations research should be included as core ele-ments of any interventions aimed at increasing young people’s use ofhealth services.

Several research issues have been raised in this review, including theneed to better understand the content and duration of training, the rel-ative contribution that different interventions in the facilities make toincreasing the use of services and the benefit of involving other sectorsin relation to the increased effort required.

A number of specific issues have been highlighted in this review, in-cluding the need to tease out the relative contributions of the differentinterventions and for better costing data to be made available.

201

92-4-120938-0_CH06_201

Acknowledgements

We would like to thank Merlin Wilcox for his contribution to the early de-velopment of this paper. We would also like to thank the members of theHealth Services Working Group at the 2004 Talloires meeting for their ideasand support: Shanti Conly, Siobhan Crowley, Kim Dickson, JoannaNerquaye-Tetteh and Julitta Onabanjo.

References

1. United Nations Population Fund. Summary of the ICPD programme of action,2004 (http://www.unfpa.org/icpd/summary.htm).

2. WHO. Adolescent friendly health services: an agenda for change, 2003 (http://www.who.int/child-adolescent-health/publications).

3. United Nations. Declaration of commitment on HIV/AIDS. United NationsGeneral Assembly Special Session on HIV/AIDS, 2001 (http://www.un.org/ga/aids/coverage/FinalDeclarationHIVAIDS.html).

4. United Nations. A world fit for children. United Nations Special session onChildren, 2002 (http://www.unicef.org/specialsession/wffc).

5. WHO, UNFPA, UNAIDS. Achieving the global goals: access to services. GlobalConsultation Technical Report, 2003 (http://www.who.int/child-adolescent-health/publications/).

6. Tanahashi T. Health service coverage and its evaluation. Bulletin of the WorldHealth Organization, 1978, 56:295-303.

7. USAID, UNAIDS, UNFPA WHO, UNICEF, Policy Project. Coverage of selectedservices for HIV/AIDS prevention, care and support in low and middle incomecountries in 2003. Washington, DC, Futures Group, 2004.

8. WHO, Department of Child and Adolescent Health and Development.Conceptual overview: measuring coverage of interventions for young people.Geneva, WHO, 2004. (Unpublished report.)

9. UNAIDS. Report on the global AIDS epidemic: fourth global report. Geneva,UNAIDS, 2004.

10. Okonofua FE et al. Impact of an intervention to improve treatment-seekingbehavior and prevent sexually transmitted diseases among Nigerian youths.International Journal of Infectious Diseases, 2003, 7:61-73.

11. Townsend JW et al. Sex education and family planning services for youngadults: alternative urban strategies in Mexico. Studies in Family Planning, 1987,18:103-108.

12. Neukom J et al. Changing youth behaviour through social marketing: programexperiences and research findings from Cameroon, Madagascar, andRwanda. Washington, DC, Population Services International, PopulationReference Bureau, 2003.

13. WHO. Programming for adolescent health and development: report of a WHO/UNFPA/UNICEF study group on programming for adolescent health. Geneva,WHO, 1999.

202

92-4-120938-0_CH06_202

14. WHO, Department of Child and Adolescent Health and Development. Globalconsultation on adolescent friendly health services: a consensus statement.Geneva, WHO, 2001. (WHO/FCH/CAH/02.18.)

15. Brabin L. Adolescent friendly health services: an impact model to evaluate theireffectiveness and cost, 2002 (http://www.fhi.org/NR/rdonlyres/elwxby2675hwyyn7whpsj3om4n52wecgvunokzrqf5fn446dktcuo7fi3qufhfuelwm2zhjlcm3rkf/AFHSImpactModelfinalversion.pdf).

16. Mmari KN, Magnani RJ. Does making clinic-based reproductive health servicesmore youth-friendly increase service use by adolescents? Evidence fromLusaka, Zambia. Journal of Adolescent Health, 2003, 33:259-270.

17. Mbonye AK. Disease and health seeking patterns among adolescents inUganda. International Journal of Adolescent Medicine and Health, 2003,15:105-112.

18. Moyo I et al. Reproductive health antecedents, attitudes, and practices amongyouth in Gweru, Zimbabwe. Washington, D.C., Pathfinder International,FOCUS on Young Adults, June 2000.

19. Chao-Hua L et al. Effects of a community-based sex education and reproductivehealth service programme on contraceptive use of unmarried youths inShanghai. Journal of Adolescent Health, 2004, 34:433-440.

20. Magnani RJ et al. Impact of an integrated adolescent health program in Brazil.Studies in Family Planning, 2001, 32:230-243.

21. Kim YM et al. Promoting sexual responsibility among young people inZimbabwe. International Family Planning Perspectives, 2001, 27:11-19.

22. Hayes R et al. The MEMA kwa Vijana Project: design of a community-randomised trial of an innovative adolescent sexual health intervention in rualTanzania. Contemporary Clinical Trials, 2005, 26:430-442.

23. WHO, Ministry of Health Mongolia, UNFPA. Assessment of AFHS initiative inMongolia. Ulaanbaatar, 2003,. (Unpublished document.)

24. loveLife. loveLife 2004: report on activities and progress, Cape Town,Parklands, loveLife, 2004.

25. Diop NJ et al. Improving reproductive health of adolescents in Senegal.Washington, DC, Frontiers Reproductive Health Program, 2004. (Unpublisheddocument.)

26. Bhuiya I et al. Improving adolescent reproductive health in Bangladesh.Washington, DC, Frontiers Reproductive Health Program, 2004. (Unpublisheddocument.)

27. Hainsworth G. Providing sexual reproductive health and STI/HIV informationand services to this generation: insights from the Geracao Biz experience.Maputo, Ministry of Youth and Sports, Ministry of Education, Ministry of Health,AMODEFA and youth associates, UNFPA, Pathfinder International, 2002.

28. Moya C. Creating youth friendly sexual health services in sub-Saharan Africa,Advocates for Youth, 2002 (http://www.advocatesforyouth.org/publications/iag/youthfriendly.htm).

29. Solo J et al. Enjoy your youth, be wise: an evaluation of the Innovate project inGhana. London, International Planned Parenthood Federation, 2001.(Unpublished report.)

203

92-4-120938-0_CH06_203

30. Sovd T et al. Acceptability as a key determinant of client satisfaction: lessonsfrom an evaluation of adolescent friendly health services in Mongolia. Journalof Adolescent Health. (In press.)

31. Family Health International, YouthNet. New findings from intervention research:youth reproductive health and HIV prevention, 2003 (http://www.fhi.org/en/youth/youthnet/index.htm).

32. Askew I et al. A multi-sectoral approach to providing reproductive healthinformation and services to young people in western Kenya: Kenya adolescentreproductive health project Washington, DC, Frontiers Reproductive HealthProgram, 2003. (Unpublished document.)

33. Family Health International. Reaching out to bring young Haitians in: FHI helpstwo organizations work with youth in high-risk settings. Arlington, VA, FHI, 2004.

34. EC/UNFPA initiative for reproductive health in Asia. Learning from the RHIpartnerships 1998–2002. New York, UNFPA, 2003.

35. Senderowitz J. Partnering with African youth: Pathfinder International and theAfrican Youth Alliance experience. Watertown, MA, Pathfinder International,2004.

36. Naguru teenage and information centre: annual report. Kampala, Uganda,2003. (Unpublished report.) </unknown>

37. Correal D et al. Scaling up youth-friendly HIV and SRH services through multi-sectoral program in Mozambique. Bangkok, International AIDS Conference,2004. (Conference abstract WePeE6720.)

38. UN Office of the High Commissioner for Human Rights. Convention on the rightsof the child, 1989 (http://www.unhchr.ch/html/menu3/b/k2crc.htm).

204

92-4-120938-0_CH06_204

7. The effectiveness of mass media inchanging HIV/AIDS-relatedbehaviour among young people indeveloping countriesJane T. Bertranda & Rebecca Anhangb

Objectives To review the strength of the evidence for the effects of threetypes of mass media interventions (radio only, radio with supportingmedia, or radio and television with supporting media) on HIV/AIDS-relatedbehaviour among young people in developing countries and to assess whetherthese interventions reach the threshold of evidence needed to recommendwidespread implementation.

Methods We conducted a systematic review of studies that evaluated massmedia interventions and were published or released between 1990 and 2004.Studies were included if they evaluated a mass media campaign that had themain objective of providing information about HIV/AIDS or sexual health.To be eligible for inclusion studies had to use a pre-intervention versus post-intervention design or an intervention versus control design or analyse cross-sectional data comparing those who had been exposed to the campaign withthose who had not been exposed. Studies also had to comprehensively reportquantitative data for most outcomes.

Findings Of the 15 programmes identified, 11 were from Africa, 2 from LatinAmerica, 1 from Asia, and 1 from multiple countries. One programme usedradio only, six used radio with supporting media, and eight others used tele-vision and radio with supporting media. The data support the effectivenessof mass media interventions to increase the knowledge of HIV transmission,to improve self-efficacy in condom use, to influence some social norms, toincrease the amount of interpersonal communication, to increase condom useand to boost awareness of health providers. Fewer significant effects werefound for improving self-efficacy in terms of abstinence, delaying the age offirst sexual experience or decreasing the number of sexual partners.

Conclusions We found that mass media programmes can influence HIV-related outcomes among young people, although not on every variable or in

a Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs, 111Market Place, Suite 310, Baltimore, MD 21202, USA. Correspondence should be sent to JaneBertrand (email: jbertrand@jhuccp.org).

b Harvard University, Boston, MA, USA.

205

92-4-120938-0_CH07_205

every campaign. Campaigns that include television require the highest thresh-old of evidence, yet they also yield the strongest evidence of effects. Thissuggests that comprehensive mass media programmes are valuable.

7.1 Introduction

In countries worldwide, young people comprise a key audience for messagesabout preventing HIV/AIDS. Unless a young person acquired HIV in uteroor as an infant, almost all young people enter adolescence HIV-negative.Yet the very nature of adolescence – characterized by experimentation, risk-taking and a sense of immortality – make youths particularly vulnerable toHIV. Annually, 50% of all new HIV infections occur among young peopleaged 15–24 years (1).

Given the sheer number of young people and the critical importance of alert-ing them to the threat of HIV and AIDS, most governments have turned tothe mass media as a means of informing their population, shaping socialnorms and influencing behaviour associated with the transmission of HIV.

Given that adolescents are so attuned to mass media for information and cuesabout how to behave, the media have tremendous potential for reaching themwith messages about HIV and AIDS. Mass media campaigns may comple-ment other programmes (for example, the training of personnel or the distri-bution of condoms) designed to stop the spread of HIV.

Because the epidemic has continued to spread in many countries, it has beenconcluded that mass media interventions are not an effective means of pre-venting the spread of HIV (2). The evidence in the published literature on theeffectiveness of communication programmes is sparse but there have beenseveral rigorous studies that identified reported changes in HIV/AIDS-related behaviours, such as avoiding unprotected sex (3). A difficulty inarriving at an assessment of the potential effectiveness of communicationprogrammes is that relatively few countries have mounted full-scale, coor-dinated, comprehensive communication programmes aimed at combating thespread of HIV (4).

The mass media are an increasingly important component of interventionprogrammes when they are scaled-up. Thus, this review evaluates programmesthat have a mass media component although they may also have additionalcommunity or interpersonal components. We define mass media interven-tions as any programmes or other planned, time-limited efforts that have theexplicit goal of changing knowledge, attitudes and behaviours that are relatedto preventing the transmission of HIV and that disseminate messages amongan intended population through channels that reach a broad audience. For thepurposes of this review, these channels include radio, television, video, print

206

92-4-120938-0_CH07_206

media and the Internet; the programming may take a variety of forms, in-cluding variety shows, songs, advertisements or public service announce-ments, soap operas, music videos, films, pamphlets, billboards, posters andinteractive web sites. The review does not include certain media, such as streettheatre, puppetry or the work of itinerant singers, since these media are lessfrequently subject to evaluation, and the evaluation of such interventions mayoften be primarily of local relevance, rather than international.

This article reviews the literature evaluating the effects of mass media inter-ventions on the HIV/AIDS-related behaviour of young people in developingcountries in order to determine whether the evidence provides justificationfor recommending that these types of interventions be implemented morewidely in future.

7.2 Methods

The methods used in this review are similar to those used in other chaptersin this series (see chapter 4). First, we defined the most common types ofinterventions to prevent HIV transmission used in the mass media in devel-oping countries; we categorized them into radio only, radio with othersupporting media, and radio and television with other supporting media.These types were chosen to reflect the key decisions that programme devel-opment and delivery staff and policy-makers need to make when choosing inwhich mass media interventions to invest. The inclusion and exclusion cri-teria were then defined (Table 7.1). The authors, in discussion with the serieseditors, then decided on the strength of evidence needed to recommendwidespread implementation of each of these types of interventions taking intoaccount their feasibility, the potential for adverse outcomes, their acceptabil-ity, the potential size of the intervention effect and the potential for bringingabout other health or social benefits (Table 7.2). The literature was reviewed,and each of the eligible studies was summarized in a standard manner. Ad-ditional information is available on the web (www.who.int/child-adolescent-health/). Key aspects of the intervention, as well as the design of theevaluation study and results, were also summarized (Table 7.3 and Table 7.4).The overall conclusions on the strength of the evidence for the effectivenessof each of the three types of intervention were compared with the thresholdstrength of evidence needed to recommend widespread implementation(Table 7.2).

207

92-4-120938-0_CH07_207

Tab

le 7

.1In

clu

sio

n a

nd

exc

lusi

on

cri

teri

a u

sed

to

iden

tify

stu

die

s fo

r re

view

Incl

usi

on

cri

teri

aE

xclu

sio

n c

rite

ria

Eva

luat

ion

mus

t be

a st

udy

that

com

pare

s ou

tcom

es p

re-in

terv

entio

nve

rsus

pos

t-in

terv

entio

n or

inte

rven

tion

vers

us c

ontr

ol d

esig

n or

a c

ross

-se

ctio

nal d

esig

n co

mpa

ring

thos

e ex

pose

d to

the

cam

paig

n w

ith th

ose

unex

pose

d

Eva

luat

ion

desi

gn th

at d

oes

not c

ompa

re p

re-in

terv

entio

n ou

tcom

esw

ith p

ost-

inte

rven

tion

outc

omes

or

inte

rven

tion

vers

us c

ontr

ol o

rcr

oss-

sect

iona

l

Eva

luat

ion

resu

lts m

ust r

epor

t fin

ding

s co

mpr

ehen

sive

ly, w

hich

is d

efin

edas

incl

udin

g qu

antit

ativ

e an

d st

atis

tical

dat

a fo

r m

ost o

utco

mes

und

erst

udy

Inco

mpl

ete

repo

rtin

g of

find

ings

, inc

ludi

ng fa

ilure

to r

epor

tqu

antit

ativ

e or

sta

tistic

al s

igni

fican

ce fo

r mos

t out

com

es u

nder

stu

dy

Eva

luat

ion

mus

t hav

e be

en p

ublis

hed

or r

elea

sed

betw

een

1990

and

2004

Eva

luat

ions

pub

lishe

d be

fore

or

afte

r th

e de

sign

ated

tim

e fr

ame

Inte

rven

tion

mus

t be

a m

ass

med

ia p

rogr

amm

e, w

hich

is d

efin

ed a

s a

prog

ram

me

that

con

veys

mes

sage

s th

roug

h ch

anne

ls th

at re

ach

a br

oad

audi

ence

. Med

ia in

clud

e ra

dio,

tele

visi

on, v

ideo

, prin

t, an

d th

e In

tern

et;

the

prog

ram

mes

may

take

diff

eren

t for

ms,

suc

h as

rad

io v

arie

ty s

how

s,so

ngs,

adv

ertis

emen

ts o

r pu

blic

ser

vice

ann

ounc

emen

ts, s

oap

oper

as,

mus

ic v

ideo

s, fi

lms,

pam

phle

ts, b

illbo

ards

, pos

ters

and

inte

ract

ive

web

site

s

Inte

rven

tion

is c

omm

unity

-bas

ed, s

choo

l-bas

ed o

r in

terp

erso

nal b

utdo

es n

ot c

onta

in a

mas

s m

edia

com

pone

nt

Obj

ectiv

e of

inte

rven

tion

mus

t be

educ

atio

n ab

out H

IV/A

IDS

or

sexu

alhe

alth

or

risk

redu

ctio

nIn

terv

entio

ns w

hose

mai

n ou

tcom

es a

re n

ot e

xplic

itly

rela

ted

to H

IV/

AID

S, s

uch

as fa

mily

pla

nnin

gIn

terv

entio

n m

ust h

ave

take

n pl

ace

in a

dev

elop

ing

coun

try

Inte

rven

tions

taki

ng p

lace

in o

ther

par

ts o

f the

wor

ld

208

92-4-120938-0_CH07_208

Tab

le 7

.2T

hre

sho

ld o

f ev

iden

ce n

eed

ed t

o r

eco

mm

end

wid

esp

read

imp

lem

enta

tio

n o

f ea

ch t

ype

of

inte

rven

tio

n

Inte

rven

tio

nty

pe

Fea

sib

ility

Lac

k o

fp

ote

nti

al f

or

adve

rse

ou

tco

mes

Acc

ept-

abili

tyP

ote

nti

alsi

ze o

fef

fect

Oth

erh

ealt

h o

rso

cial

ben

efit

s

Ove

rall

thre

sho

ldC

om

men

ts

1. R

adio

-onl

y+

++

++

++

+M

oder

ate

Rad

io-o

nly

inte

rven

tions

targ

eted

at o

ther

hea

lthis

sues

hav

e be

en s

how

n to

hav

e su

bsta

ntia

l effe

cts.

2. R

adio

with

othe

r m

edia

++

++

++

++

+M

oder

ate

Sup

port

ing

med

ia o

ften

incl

ude

post

ers,

prin

tm

ater

ials

, lis

teni

ng g

roup

s an

d pr

omot

iona

lm

ater

ials

, suc

h as

T-s

hirt

s an

d ha

ts. S

uppl

emen

tary

inte

rven

tions

, suc

h as

sch

ool w

orks

hops

and

coun

selli

ng, p

rom

ote

awar

enes

s of

loca

l hea

lth a

ndso

cial

res

ourc

es.

3. R

adio

and

tele

visi

onw

ith o

ther

med

ia

++

++

++

+H

igh

Whi

le th

e br

oad

reac

h of

thes

e in

terv

entio

nsin

crea

ses

the

likel

ihoo

d an

d si

ze o

f the

ir ef

fect

s, th

eyar

e fe

asib

le o

nly

whe

n bu

dget

s pe

rmit,

whe

nte

levi

sion

is w

idel

y av

aila

ble

to th

e ta

rget

aud

ienc

e,an

d w

hen

ther

e is

a h

igh

leve

l of c

reat

ive

tale

nt a

ndpr

oduc

tion

faci

litie

s w

ithin

the

coun

try.

Imag

es a

ndst

orie

s in

crea

se th

e po

wer

of t

he m

essa

ges

but m

ayoc

casi

onal

ly c

ause

con

cern

for

loca

l rel

igio

us a

ndco

mm

unity

lead

ers;

how

ever

, with

suf

ficie

nt p

re-

test

ing

and

endo

rsem

ent f

rom

loca

l lea

ders

hip,

thes

e ca

mpa

igns

can

be

high

ly a

ccep

tabl

e

a D

egre

e of

des

irabi

lity

is in

dica

ted

with

a m

axim

um o

f 3 “

+”

sign

s. D

egre

e of

und

esira

bilit

y is

indi

cate

d w

ith a

max

imum

of 3

“-”

sig

ns.

209

92-4-120938-0_CH07_209

Tab

le 7

.3D

escr

ipti

on

of

the

inte

rven

tio

ns

by

stu

dy

Stu

dy,

loca

tio

n a

nd

cam

pai

gn

Tar

get

po

pu

lati

on

an

d p

rim

ary

ob

ject

ives

Des

crip

tio

na

Inte

rven

tio

n t

ype

1 (r

adio

on

ly)

A –

Sai

nt V

ince

nt a

nd th

eG

rena

dine

s, n

atio

nal c

ampa

ign

(5)

• P

aren

ts o

f ado

lesc

ents

, oth

er a

dults

, ado

lesc

ents

• E

ncou

rage

par

ents

to ta

lk to

ado

lesc

ents

abo

utsa

fer

sex

and

cond

om u

se

• R

adio

adv

ertis

ing

cam

paig

n•

Dur

atio

n: 2

mon

ths

Inte

rven

tio

n t

ype

2 (r

adio

wit

h o

ther

med

ia)

B –

Par

agua

y,A

rte

y P

arte

cam

paig

n (6

)•

Ado

lesc

ents

age

d 15

–19

year

s•

Incr

ease

kno

wle

dge

of s

exua

l and

rep

rodu

ctiv

ehe

alth

issu

es in

ord

er to

pro

mot

e re

spon

sibl

ese

xual

beh

avio

ur•

Impr

ove

com

mun

icat

ion

and

nego

tiatio

n sk

ills

• B

ookl

et, s

tree

t the

atre

ski

ts, r

adio

pro

gram

me

and

new

s fla

shes

, col

umns

in n

ewsp

aper

s an

d te

enm

agaz

ines

, sch

ool w

orks

hops

with

vid

eos

• R

each

: 44%

(%

exp

osed

to a

t lea

st o

ne c

ampa

ign

ac

tivity

or

prod

uct)

• D

urat

ion:

abo

ut 2

4–32

mon

ths

C –

Chi

na,

mul

tiple

mas

s m

edia

cam

paig

n in

east

ern

Chi

na (

7)

• Y

oung

adu

lts a

ged

18–3

0 ye

ars

• P

rom

ote

sexu

al a

bstin

ence

prio

r to

mar

riage

• Pro

mot

e us

e of

con

dom

s fo

r sex

ually

act

ive

peop

le,

rega

rdle

ss o

f mar

ital s

tatu

s

• W

ritte

n m

ater

ials

, vid

eos,

rad

io p

rogr

amm

e,w

orks

hops

, sm

all g

roup

dis

cuss

ions

, hom

e vi

sits

,pe

rson

al c

ouns

ellin

g, fr

ee c

ondo

ms

• D

urat

ion:

12

mon

ths

D –

Cam

eroo

n,H

oriz

on J

eune

s ad

oles

cent

repr

oduc

tive

heal

th p

rogr

amm

e(8

)

• Y

oung

peo

ple

(prim

ary

targ

et p

opul

atio

n); p

aren

ts,

teac

hers

, com

mun

ity le

ader

s (s

econ

dary

)•

Incr

ease

ado

lesc

ents

’ aw

aren

ess

and

use

ofre

prod

uctiv

e he

alth

pro

duct

s an

d se

rvic

es

• R

adio

spo

ts a

nd ta

lk s

how

s, b

roch

ures

, pos

ters

,di

scus

sion

s w

ith p

eer

educ

ator

s, v

ideo

bro

adca

sts,

cond

om d

emon

stra

tions

, pre

sen-

tatio

ns a

t soc

cer

gam

es, t

heat

re s

ketc

hes

• R

each

: 28%

eve

r in

volv

ed w

ith a

ctiv

ities

• D

urat

ion:

13

mon

ths

E –

Gui

nea,

PR

ISM

beh

avio

ur c

hang

e yo

uth

cam

paig

n in

Hau

te G

uine

a (9

)

• Y

oung

peo

ple

aged

15–

24 y

ears

• In

crea

se k

now

ledg

e an

d aw

aren

ess

of S

TIs

b an

dH

IV/A

IDS

• P

rom

ote

resp

onsi

ble

sexu

al p

ract

ices

, inc

ludi

ngde

lay

in s

exua

l deb

ut o

r (a

mon

g se

xual

ly a

ctiv

eyo

uth)

con

dom

use

• In

tera

ctiv

e ra

dio

show

s in

rur

al a

reas

, pos

ters

,br

ochu

res;

thea

tre

grou

ps p

rodu

ced

play

s, le

ddi

scus

sion

s•

Rea

ch: 8

3% o

f mal

es a

nd 6

3% o

f fem

ales

exp

osed

to a

ny c

ampa

ign

activ

ity•

Dur

atio

n: 1

2 m

onth

s

210

92-4-120938-0_CH07_210

F –

Zim

babw

e,pr

omot

ing

sexu

al r

espo

nsib

ility

amon

g yo

ung

peop

le (

10)

• Y

oung

peo

ple

aged

10–

24 y

ears

and

adu

lts•

Incr

ease

kno

wle

dge

of r

epro

duct

ive

heal

th a

ndco

ntra

cept

ion

• P

oste

rs, l

eafle

ts, n

ewsl

ette

r, r

adio

pro

gram

me,

laun

ch e

vent

s, d

ram

as, p

eer

educ

ator

s, h

otlin

e;tr

aini

ng fo

r fam

ily p

lann

ing

prov

ider

s, d

esig

natio

n of

yout

h-fr

iend

ly c

linic

s•

Rea

ch: 9

7% e

xpos

ure

to a

t lea

st o

ne c

ampa

ign

com

pone

nt•

Dur

atio

n: 6

mon

ths

G –

Bot

swan

a,T

sa B

anan

a ad

oles

cent

repr

oduc

tive

heal

th p

rogr

amm

e (1

1)

• A

dole

scen

ts (

prim

ary

targ

et p

opul

atio

n); p

aren

ts,

teac

hers

and

you

th c

omm

unity

lead

ers

(sec

onda

ry)

• P

ersu

ade

adol

esce

nts

that

rep

rodu

ctiv

e he

alth

serv

ices

exi

st fo

r th

em a

nd th

at th

ey s

houl

d us

eth

em

• R

adio

mes

sage

s, p

rinte

d m

edia

• R

each

: 71%

of m

ales

and

68%

fem

ales

exp

osed

toan

y ca

mpa

ign

activ

ity•

Dur

atio

n: 8

mon

ths

Inte

rven

tio

n t

ype

3 (r

adio

an

d t

elev

isio

n w

ith

oth

er m

edia

)H

– G

uine

a,ad

oles

cent

rep

rodu

ctiv

e he

alth

prog

ram

me

(12)

• A

dole

scen

ts a

nd y

oung

adu

lts•

Incr

ease

you

ng p

eopl

e’s

know

ledg

e of

ST

Is a

ndA

IDS

• Inc

reas

e kn

owle

dge

and

use

of c

ondo

ms

and

othe

rm

oder

n co

ntra

cept

ives

• D

elay

age

at s

exua

l deb

ut•

Enc

oura

ge s

exua

l abs

tinen

ce

• P

oste

rs, f

lyer

s, p

eer

educ

ator

dis

cuss

ions

;ca

mpa

ign

supp

lem

ente

d w

ith r

adio

and

tele

visi

onad

vert

isem

ents

for

spec

ific

cond

om b

rand

s•

Rea

ch: 3

9% o

f mal

es a

nd 1

5% o

f fem

ales

part

icip

ated

in p

rogr

amm

e•

Dur

atio

n: 8

-9 m

onth

s

I – Z

ambi

a,H

EA

RT

cam

paig

n (1

3)•

You

ng p

eopl

e ag

ed 1

5–19

yea

rs•

Cha

nge

soci

al n

orm

s an

d in

divi

dual

sex

ual

beha

viou

r, s

peci

fical

ly fo

cusi

ng o

n co

nsis

tent

cond

om u

se, c

ontin

uatio

n of

abs

tinen

ce,

know

ledg

e th

at p

eopl

e w

ho lo

ok h

ealth

y ca

n ha

veH

IV, b

elie

f tha

t con

dom

s an

d ab

stin

ence

are

hip

• T

elev

isio

n sp

ots,

rad

io s

pots

, son

gs, p

oste

rs,

stic

kers

, exe

rcis

e bo

oks,

mes

sage

s on

bus

es,

mus

ic v

ideo

s•

Dur

atio

n: 6

mon

ths

• R

each

: 52%

exp

osed

to a

t lea

st o

ne T

Vad

vert

isem

ent o

r pu

blic

ser

vice

ann

ounc

emen

t

211

92-4-120938-0_CH07_211

Stu

dy,

loca

tio

n a

nd

cam

pai

gn

Tar

get

po

pu

lati

on

an

d p

rim

ary

ob

ject

ives

Des

crip

tio

na

J –

Sou

th A

fric

a,lo

veLi

fe c

ampa

ign

(14,

15)

• Y

oung

peo

ple

aged

12–

17 y

ears

• R

educ

e th

e ra

te o

f HIV

infe

ctio

n, o

ther

ST

Is a

ndpr

egna

ncy

• P

rom

ote

posi

tive

choi

ces

arou

nd s

exua

lpa

rtne

rshi

ps, c

ondo

m u

se, s

exua

l deb

ut, t

reat

men

tse

ekin

g, H

IV r

isk

beha

viou

rs

• M

ultim

edia

cam

paig

n in

clud

ing

radi

o, te

levi

sion

, prin

tan

d bi

llboa

rds.

• D

urat

ion:

abo

ut 2

4 m

onth

s•

Rea

ch: 8

4% o

f you

th h

ad h

eard

of o

r se

en a

com

pone

nt o

f the

love

Life

cam

paig

n

K –

Côt

e d’

Ivoi

re,

PL.

U.S

pos

itive

dev

ianc

eca

mpa

ign

(16)

• Y

oung

fem

ales

age

d 13

–20

year

s (p

rimar

y ta

rget

popu

latio

n); m

ale

yout

h, p

aren

ts (

seco

ndar

y)•

Incr

ease

kno

wle

dge

and

prac

tice

of H

IV/A

IDS

prev

entio

n be

havi

ours

• In

crea

se u

se o

f rep

rodu

ctiv

e he

alth

ser

vice

s

• Tel

evis

ion

spot

s, c

omm

unity

radi

o va

riety

sho

w, a

udio

cass

ette

s of

pop

ular

son

gs, p

hoto

nove

lla, p

oste

rs,

leaf

lets

, adv

ocac

y br

ochu

re•

Dur

atio

n: 9

mon

ths

• Rea

ch: 7

0% o

f mal

es a

nd 6

4% o

f fem

ales

exp

osed

toat

leas

t one

cam

paig

n m

ater

ial o

r ac

tivity

L –

Sou

th A

fric

a,S

oul C

ity c

ampa

ign

(17–

19)

• P

revi

ousl

y di

sadv

anta

ged

“Afr

ican

” an

d “c

olou

red”

Sou

th A

fric

ans

(age

d 16

–65

year

s)•

Affe

ct a

war

enes

s of

and

kno

wle

dge

and

attit

udes

abou

t HIV

/AID

S•

Influ

ence

sub

ject

ive

soci

al n

orm

s, p

erce

ptio

n of

pers

onal

ris

k of

HIV

• In

crea

se s

elf-

effic

acy

with

reg

ard

to H

IV p

reve

ntio

nbe

havi

ours

• P

rom

ote

seek

ing

info

rmat

ion

and

supp

ort,

risk

redu

ctio

n

• T

elev

isio

n an

d ra

dio

dram

as, b

ookl

ets,

nat

iona

lad

voca

cy s

trat

egy

• S

oul B

uddy

z –

radi

o an

d bo

okle

ts d

esig

ned

to ta

rget

child

ren

aged

8–1

2 ye

ars

• R

each

: 82%

(an

y ca

mpa

ign

com

pone

nt)

M –

Sou

th A

fric

a,ad

oles

cent

rep

rodu

ctiv

e he

alth

prog

ram

me

(20)

• Y

oung

fem

ales

age

d 16

–20

year

s•

Edu

cate

ado

lesc

ents

abo

ut r

epro

duct

ive

heal

this

sues

• P

rom

ote

safe

r se

x

• R

adio

mes

sage

s, w

eekl

y ra

dio

talk

sho

ws,

docu

men

tary

sho

wn

on S

outh

Afr

ica

Bro

adca

stin

gC

orpo

ratio

n• D

urat

ion:

Rep

rodu

ctiv

e he

alth

cam

paig

n –

12 m

onth

s;so

cial

mar

ketin

g ca

mpa

ign

ongo

ing

4–5

year

spr

evio

usly

212

92-4-120938-0_CH07_212

N –

44

coun

trie

s w

orld

wid

e,S

tayi

ng A

live

MT

Vca

mpa

ign

(21)

• Y

oung

peo

ple

aged

16–

25 y

ears

• In

crea

se a

war

enes

s of

HIV

• E

ncou

rage

pre

vent

ion

• R

educ

e H

IV-r

elat

ed s

tigm

a an

d di

scrim

inat

ion

• T

elev

isio

n do

cum

enta

ry, p

rogr

amm

e fe

atur

ing

Bill

Clin

ton,

pub

lic s

ervi

ce a

nnou

ncem

ents

, glo

bal f

orum

,co

ncer

ts, w

eb s

ite.

• R

each

: Kat

hman

du: 1

2% e

xpos

ed to

at l

east

one

cam

paig

n m

ater

ial o

r act

ivity

; Sao

Pau

lo: 2

3%; D

akar

:82

%O

– G

hana

, Sto

p A

IDS

Love

Life

, pha

se 1

cam

paig

n (2

2)

• Y

oung

peo

ple

• In

crea

se k

now

ledg

e of

how

to a

void

AID

S a

ndpe

rcei

ved

pers

onal

ris

k of

HIV

infe

ctio

n•

Impr

ove

inte

rper

sona

l com

mun

icat

ion

abou

tH

IV/A

IDS

• In

crea

se p

erce

ptio

ns th

at s

ocia

l nor

ms

that

favo

urH

IV-p

rote

ctiv

e be

havi

ours

• In

crea

se u

se o

f saf

er s

exua

l beh

avio

urs

• La

unch

eve

nt, m

usic

vid

eo a

nd s

ong

perf

orm

ed b

yw

ell k

now

n lo

cal m

usic

ians

, tel

evis

ion

and

radi

osp

ots,

ser

ial d

ram

as, c

omm

unity

ral

lies,

van

s w

ithau

dio-

visu

al d

ispl

ays

• D

urat

ion:

17

mon

ths

• R

each

: 83%

mal

es a

nd 7

7% fe

mal

es o

f tho

se a

ged

15 to

45+

yea

rs e

xpos

ed to

any

cam

paig

n co

mpo

nent

a P

erce

ntag

es d

escr

ibin

g “r

each

” in

dica

te th

e pr

opor

tion

of th

e st

udy

popu

latio

n th

at r

epor

ted

bein

g ex

pose

d to

the

inte

rven

tion.

b S

TIs

= s

exua

lly tr

ansm

itted

infe

ctio

ns.

213

92-4-120938-0_CH07_213

Tab

le 7

.4D

escr

ipti

on

of

ou

tco

me

eval

uat

ion

s b

y st

ud

y

Stu

dy

Des

ign

an

d s

amp

le s

ize

Eva

luat

ion

res

ult

sS

tren

gth

of

evid

ence

fo

r ef

fect

Inte

rven

tio

n t

ype

1 (r

adio

on

ly)

A (

5)D

esig

n: c

ross

-sec

tiona

l sur

vey

com

parin

gex

pose

d pa

rtic

ipan

ts w

ith u

nexp

osed

Sam

ple

size

: 297

(in

terv

entio

n gr

oup

= 2

13, c

ontr

ol g

roup

= 8

4)

No

stat

istic

al a

djus

tmen

ts m

ade

for

diffe

renc

es b

etw

een

expo

sed

and

unex

pose

d

Hea

lth s

ervi

ces

• H

eard

of A

IDS

hot

line

– si

gnifi

cant

Red

uctio

n in

vul

nera

bilit

y•

Frie

nds

use

cond

oms

– si

gnifi

cant

• P

artn

er s

ugge

sted

con

dom

use

– n

otsi

gnifi

cant

Red

uctio

n in

HIV

pre

vale

nce

• Eve

r or a

lway

s us

ed a

con

dom

or s

ugge

sted

cond

om u

se to

one

’s p

artn

er –

not

sign

ifica

nt

Sev

eral

mea

sure

s of

inte

rper

sona

lco

mm

unic

atio

n –

not s

igni

fican

t

Wea

k ev

iden

ce fo

r im

prov

ed p

erce

ptio

ns in

soci

al n

orm

s, in

terp

erso

nal c

omm

unic

atio

nan

d co

ndom

use

Str

ong

evid

ence

for i

ncre

ased

aw

aren

ess

ofA

IDS

hot

line

Inte

rven

tio

n t

ype

2 (r

adio

wit

h o

ther

med

ia)

B (

6)D

esig

n: s

urve

y pr

e-in

terv

entio

n an

d po

st-

inte

rven

tion

in th

ree

inte

rven

tion

citie

s.C

ross

-sec

tiona

l ana

lysi

s co

mpa

ring

expo

sed

with

une

xpos

ed

Sam

ple

size

: pre

-inte

rven

tion

= 9

47, p

ost-

inte

rven

tion

= 1

575

Kno

wle

dge

• 2/

2 ou

tcom

es –

not

sig

nific

ant

Red

uctio

n in

HIV

pre

vale

nce

• Had

sex

for t

he fi

rst t

ime,

con

dom

use

at f

irst

sexu

al r

elat

ions

hip

– no

t sig

nific

ant

• U

sed

a co

ndom

in la

st s

exua

l rel

atio

nshi

p –

not s

igni

fican

t

Wea

k ev

iden

ce fo

r im

prov

ed k

now

ledg

e;w

eak

evid

ence

for

impr

ovem

ents

inab

stin

ence

and

con

dom

-use

beh

avio

urs

C (

7)D

esig

n: e

xper

imen

tal r

ando

miz

edco

ntro

lled

tria

l with

pre

-inte

rven

tion

and

post

-inte

rven

tion

com

pone

nts

mat

chin

g

Kno

wle

dge

• 5/

5 ge

nera

l kno

wle

dge

outc

omes

–si

gnifi

cant

Str

ong

evid

ence

for

incr

easi

ng k

now

ledg

ean

d se

lf-ef

ficac

y to

neg

otia

te c

ondo

m u

se,

redu

cing

the

num

ber

of p

artn

ers

and

cond

om-u

se b

ehav

iour

s

214

92-4-120938-0_CH07_214

two

inte

rven

tion

villa

ges

and

two

cont

rol

villa

ges

Sam

ple

size

: pre

-inte

rven

tion

= 7

48, p

ost-

inte

rven

tion

= 7

10 (

366

in in

terv

entio

ngr

oup

and

344

in c

ontr

ol g

roup

)

• 10

/10

rout

es b

y w

hich

HIV

can

or c

anno

t be

tran

smitt

ed –

sig

nific

ant

Ski

lls•

Con

fiden

ce to

con

vinc

e pa

rtne

r to

use

cond

om –

sig

nific

ant

Red

uctio

n in

HIV

pre

vale

nce

• 3/

3 co

ndom

out

com

es –

sig

nific

ant

• 1/

1 ou

tcom

es r

egar

ding

num

ber o

f par

tner

s–

sign

ifica

ntD

(8)

Des

ign:

sep

arat

e sa

mpl

ing

pre-

inte

rven

tion

and

post

-inte

rven

tion

in o

nein

terv

entio

n ci

ty a

nd o

ne c

ontr

ol c

ity

Sam

ple

size

: pre

-inte

rven

tion

= 1

606,

post

-inte

rven

tion

= 1

633

(811

inin

terv

entio

n gr

oup

and

822

in c

ontr

ol)

Kno

wle

dge

• W

heth

er A

IDS

is a

void

able

– m

ixed

res

ults

Hea

lth s

ervi

ces

• E

ver

visi

ted

a he

alth

cen

tre

for

info

rmat

ion

abou

t con

trac

eptiv

es –

not

sig

nific

ant

Red

uctio

n in

vul

nera

bilit

y•

Sm

all t

o m

oder

ate

diffe

renc

es in

per

cept

ion

of b

eing

at h

igh

risk

for

ST

Ia or

AID

S –

sign

ifica

nt

Red

uctio

n in

HIV

pre

vale

nce

• 3/

6 A

BC

pro

gram

me

(Abs

tain

, Be

faith

ful,

use

Con

dom

s) o

utco

mes

– n

ot s

igni

fican

t•

Rem

aini

ng 3

out

com

es –

mix

ed r

esul

ts b

yse

x of

par

ticip

ant

Fre

quen

t dis

cuss

ion

of s

exua

lity

– si

gnifi

cant

Wea

k ev

iden

ce fo

r in

crea

ses

in k

now

ledg

e,pe

rcei

ved

pers

onal

risk

of H

IV a

nd in

crea

ses

in v

isits

to h

ealth

cen

tres

; wea

k ev

iden

ce o

fim

prov

emen

ts in

abs

tinen

ce, p

artn

erre

duct

ion

and

cond

om u

se

Mod

erat

e ev

iden

ce fo

r im

prov

emen

ts in

inte

rper

sona

l com

mun

icat

ion

215

92-4-120938-0_CH07_215

Stu

dy

Des

ign

an

d s

amp

le s

ize

Eva

luat

ion

res

ult

sS

tren

gth

of

evid

ence

fo

r ef

fect

E (

9)D

esig

n: b

asel

ine

esta

blis

hed

by p

roxy

usin

g D

emog

raph

ic a

nd H

ealth

Sur

vey

data

; dat

a fo

r po

st-t

est c

olle

cted

from

rand

om s

ampl

e of

you

ths

in th

ein

terv

entio

n ar

ea a

nd a

redu

ced

sam

ple

inth

e co

mpa

rison

are

a

Sam

ple

size

: pre

-inte

rven

tion

= 4

17, p

ost-

inte

rven

tion

= 1

008

(908

in in

terv

entio

ngr

oup

and

100

in c

ontr

ol g

roup

)

Kno

wle

dge

• 1/

4 ou

tcom

es –

sig

nific

ant

Ski

lls•

Kno

wle

dge

of h

ow to

use

con

dom

s –

two

times

hig

her

for

mal

es a

nd n

early

thre

etim

es h

ighe

r fo

r fe

mal

es; s

igni

fican

t

Hea

lth s

ervi

ces

• K

now

s w

here

to g

et c

ondo

ms

– si

gnifi

cant

Red

uctio

n in

vul

nera

bilit

y•

Hig

h pe

rcei

ved

pers

onal

ris

k of

con

trac

ting

HIV

/AID

S –

not

sig

nific

ant

• Y

outh

who

rep

ort t

hat o

ther

s ar

e m

ore

open

to d

iscu

ssin

g re

prod

uctiv

e he

alth

que

stio

nsth

an o

ne y

ear

prio

r –

sign

ifica

nt

Red

uctio

n in

HIV

pre

vale

nce

• Eve

r use

a c

ondo

m, c

ondo

m u

se a

t las

t sex

,re

com

men

ding

con

dom

s to

oth

ers

–si

gnifi

cant

Wea

k ev

iden

ce o

f inc

reas

ed k

now

ledg

e an

dpe

rcep

tion

of p

erso

nal r

isk

Str

ong

evid

ence

for

impr

oved

con

dom

-use

skill

s, a

war

enes

s of

con

dom

ven

dors

as

wel

las

impr

ovem

ents

in s

ocia

l nor

ms,

con

dom

use

and

inte

rper

sona

l com

mun

icat

ion

F (

10)

Des

ign:

ran

dom

sam

ple

usin

g pr

e-in

terv

entio

n an

d po

st-in

terv

entio

n de

sign

with

cro

ss-s

ectio

nal a

sses

smen

tco

mpa

ring:

5 in

terv

entio

n an

d 2

com

paris

on s

ites

and

com

bini

ng d

ata

from

all s

ites

and

anal

ysin

g ou

tcom

es b

yex

posu

re to

inte

rven

tion

com

pone

nts

Sam

ple

size

: pre

-inte

rven

tion

= 1

426

(973

in in

terv

entio

n gr

oup

and

453

in c

ontr

ol),

Kno

wle

dge

• 1/

3 ou

tcom

es –

sig

nific

ant

Hea

lth s

ervi

ces

• Li

kelih

ood

of h

avin

g so

ught

ser

vice

s at

heal

th c

entr

e –

sign

ifica

ntly

hig

her

asnu

mbe

r of

cam

paig

n co

mpo

nent

s ex

pose

dto

incr

ease

s

Red

uctio

n in

HIV

pre

vale

nce

Wea

k ev

iden

ce fo

r in

crea

sing

kno

wle

dge

Str

ong

evid

ence

for

impr

ovem

ents

inse

ekin

g he

alth

ser

vice

s, a

bsta

inin

g fr

omse

x, r

educ

ing

num

ber

of p

artn

ers,

usi

ngco

ndom

s an

d in

terp

erso

nal c

omm

unic

atio

n

216

92-4-120938-0_CH07_216

post

-inte

rven

tion

= 1

400

(100

0 in

inte

rven

tion

grou

p an

d 40

0 in

con

trol

)

Sta

tistic

al a

djus

tmen

ts c

ondu

cted

for a

ge,

sex

of p

artic

ipan

t, ed

ucat

ion,

sex

ual

expe

rienc

e, m

arita

l sta

tus

and

urba

n vs

rura

l res

iden

ce

• Lik

elih

ood

of s

ayin

g no

to s

ex a

nd c

ontin

ued

abst

inen

ce –

sig

nific

antly

hig

her

amon

gin

terv

entio

n gr

oup

and

as n

umbe

r of

cam

paig

n co

mpo

nent

s ex

pose

d to

incr

ease

s•

6/7

outc

omes

reg

ardi

ng in

terp

erso

nal

com

mun

icat

ion

– si

gnifi

cant

G (

11)

Des

ign:

pre

-inte

rven

tion

and

post

-in

terv

entio

n co

mpo

nent

com

parin

g an

inte

rven

tion

city

with

a c

ontr

ol c

ity

Sam

ple

size

: pre

-inte

rven

tion

= 1

002,

post

-inte

rven

tion

= 2

396

(123

0 in

inte

rven

tion

grou

p an

d 11

66 in

con

trol

)

Kno

wle

dge

• 2/

2 ou

tcom

es –

not

sig

nific

ant

Red

uctio

n in

vul

nera

bilit

y•

Impr

ovem

ents

in b

oth

inte

rven

tion

and

com

paris

on g

roup

s fo

r st

atem

ent “

very

few

of m

y fr

iend

s us

e co

ndom

s” –

sig

nific

ant

Wea

k ev

iden

ce fo

r im

prov

ed k

now

ledg

ean

d im

prov

emen

ts in

soc

ial n

orm

s

Inte

rven

tio

n t

ype

3 (r

adio

an

d t

elev

isio

n w

ith

oth

er m

edia

)H

(12

)D

esig

n: p

re-in

terv

entio

n an

d po

st-

inte

rven

tion

surv

ey in

citi

es in

two

regi

ons;

inte

rven

tion

and

cont

rol g

roup

s w

ithin

each

city

Sam

ple

size

: pre

-inte

rven

tion

= 2

016,

post

-inte

rven

tion

= 2

005

(100

9 in

inte

rven

tion

grou

p an

d 99

6 in

con

trol

)

Sta

tistic

al a

djus

tmen

ts w

ere

mad

e fo

rdi

ffere

nces

in s

ex o

f par

ticip

ant,

age,

scho

ol e

nrol

men

t, sc

hool

type

,em

ploy

men

t sta

tus,

relig

ion,

mar

ital s

tatu

san

d nu

mbe

r of

chi

ldre

n

Kno

wle

dge

• K

now

ledg

e of

con

dom

as

mea

ns o

fpr

otec

ting

agai

nst A

IDS

– s

igni

fican

t

Hea

lth s

ervi

ces

• V

isiti

ng h

ealth

cen

tre

in th

e pa

st y

ear

–m

ixed

out

com

es b

y se

x of

par

ticip

ant

Red

uctio

n in

vul

nera

bilit

y•

Per

ceiv

ed p

erso

nal r

isk

of H

IV/A

IDS

– n

otsi

gnifi

cant

Wea

k ev

iden

ce fo

r im

prov

emen

ts in

seek

ing

heal

th s

ervi

ces,

per

ceiv

ed p

erso

nal

risk

and

AB

C b

ehav

iour

s (A

bsta

in, B

efa

ithfu

l, us

e C

ondo

ms)

Str

ong

evid

ence

for

impr

oved

kno

wle

dge

217

92-4-120938-0_CH07_217

Stu

dy

Des

ign

an

d s

amp

le s

ize

Eva

luat

ion

res

ult

sS

tren

gth

of

evid

ence

fo

r ef

fect

Red

uctio

n in

HIV

pre

vale

nce

• B

eing

sex

ually

exp

erie

nced

– n

otsi

gnifi

cant

• H

avin

g 2

par

tner

s in

4 w

eeks

– n

otsi

gnifi

cant

• P

rote

ctin

g se

lf fr

om s

exua

l ris

ks b

y us

ing

cond

oms

– no

t sig

nific

ant

• O

nset

of s

exua

l act

ivity

by

age

15 y

ears

– m

ixed

out

com

es b

y se

x of

par

ticip

ant

• Usu

ally

use

s co

ndom

s –

mix

ed o

utco

mes

by s

ex o

f par

ticip

ant

• C

ondo

m u

se d

urin

g la

st s

ex –

sig

nific

ant

I (13

)D

esig

n: s

epar

ate

sam

ple

with

pre

-in

terv

entio

n an

d po

st-in

terv

entio

nco

mpo

nent

; cro

ss-s

ectio

nal a

naly

sis

com

parin

g pa

rtic

ipan

ts w

ho s

aw a

ll or

som

eof

the

tele

visi

on h

ealth

com

mun

icat

ion

spot

s an

d th

ose

who

saw

non

e

Sam

ple

size

: pre

-inte

rven

tion

= 9

01, p

ost-

inte

rven

tion

= 1

100;

vie

wer

s =

572

, non

-vi

ewer

s =

528

Sta

tistic

al a

djus

tmen

ts w

ere

mad

e fo

rdi

ffere

nces

in a

ge, e

duca

tion,

sex

of

part

icip

ant,

and

urba

n vs

rura

l res

iden

ce

Kno

wle

dge

• R

ecal

l abs

tinen

ce a

s a

way

to p

reve

ntH

IV –

sig

nific

ant

• R

ecal

ling

that

usi

ng c

ondo

ms

is a

way

topr

even

t HIV

– n

ot s

igni

fican

t

Ski

lls•

Sel

f-ef

ficac

y sc

ore

for

cond

om u

se –

sign

ifica

nt

Hea

lth s

ervi

ces

• A

war

enes

s of

vol

unta

ry c

ouns

ellin

g an

dte

stin

g –

sign

ifica

nt•

Aw

aren

ess

of p

lace

s to

pur

chas

eco

ndom

s –

sign

ifica

nt

Red

uctio

n in

vul

nera

bilit

y•

Per

ceiv

ed r

isk

of H

IV –

not

sig

nific

ant

Wea

k ev

iden

ce fo

r kn

owle

dge

of c

ondo

ms

Str

ong

evid

ence

for

incr

easi

ng k

now

ledg

eof

abs

tinen

ce, i

ncre

asin

g se

lf-ef

ficac

y in

use

of c

ondo

ms

and

impr

ovem

ents

inaw

aren

ess

of h

ealth

ser

vice

s, a

bstin

ence

and

cond

om-u

se b

ehav

iour

s

218

92-4-120938-0_CH07_218

Red

uctio

n in

HIV

pre

vale

nce

• 1/

1 ab

stin

ence

out

com

es –

sig

nific

ant

• 2/

2 co

ndom

-use

out

com

es –

sig

nific

ant

• M

ean

num

ber

of p

eopl

e w

ith w

hom

disc

usse

d ab

stin

ence

– s

igni

fican

tJ (1

4, 1

5)D

esig

n: r

ando

m s

ampl

e w

ith o

nly

post

-in

terv

entio

n cr

oss-

sect

iona

l ana

lysi

sco

mpa

ring

part

icip

ants

who

wer

e ex

pose

dto

the

inte

rven

tion

with

thos

e w

ho w

ere

not

Sam

ple

size

: 11

904

Ski

lls•

Eve

r te

sted

for

HIV

– s

igni

fican

t

Red

uctio

n in

HIV

pre

vale

nce

• P

reva

lenc

e of

HIV

am

ong

yout

h w

hopa

rtic

ipat

ed in

love

Life

pro

gram

mes

–fe

mal

es, a

djus

ted

odds

rat

io =

0.6

1(P

< 0

.01)

; mal

es: a

djus

ted

odds

rat

io=

0.6

0 (P

= 0

.01)

• E

ver

talk

ed to

par

ents

abo

ut H

IV –

sign

ifica

nt

Str

ong

evid

ence

for

impr

ovem

ents

inpa

rtic

ipat

ion

in H

IV te

stin

g, in

terp

erso

nal

com

mun

icat

ion

abou

t HIV

and

dec

reas

es in

HIV

infe

ctio

n ra

tes

K (

16)

Des

ign:

sep

arat

e sa

mpl

e pr

e-in

terv

entio

nan

d po

st-in

terv

entio

n

Sam

ple

size

: pre

-inte

rven

tion

= 2

681,

pos

t-in

terv

entio

n =

223

2

Ski

lls•

Sel

f-ef

ficac

y to

ref

use

sex

with

gift

-giv

ers

– si

gnifi

cant

• Sel

f-ef

ficac

y to

con

sist

ently

use

con

dom

s–

sign

ifica

nt

Red

uctio

n in

vul

nera

bilit

y•

Per

ceiv

ed p

eer

supp

ort f

or a

bstin

ence

–m

argi

nally

sig

nific

ant d

iffer

ence

Red

uctio

n in

HIV

pre

vale

nce

• C

onsi

sten

t con

dom

use

– m

argi

nally

sign

ifica

nt d

iffer

ence

s•

Dis

cuss

ion

abou

t abs

tinen

ce w

ithpa

rent

– s

igni

fican

t• E

ncou

ragi

ng s

omeo

ne to

use

con

dom

s in

the

past

12

mon

ths

– si

gnifi

cant

Wea

k ev

iden

ce fo

r in

crea

ses

in p

erce

ived

peer

sup

port

for

abst

inen

ce a

nd c

ondo

mus

e

Str

ong

evid

ence

for

incr

ease

s in

sel

f-ef

ficac

y an

d in

terp

erso

nal c

omm

unic

atio

n

219

92-4-120938-0_CH07_219

Stu

dy

Des

ign

an

d s

amp

le s

ize

Eva

luat

ion

res

ult

sS

tren

gth

of

evid

ence

fo

r ef

fect

Lb –

stud

y 1

(17,

18)

;st

udy

2 (1

9)

Stu

dy 1

Des

ign:

ran

dom

sam

ple

with

pre

-in

terv

entio

n an

d po

st-in

terv

entio

nco

mpo

nent

, fol

low

ing

a pa

nel o

fre

spon

dent

s in

one

urb

an a

nd o

ne r

ural

site

; cro

ss-s

ectio

nal a

naly

sis

com

parin

gpa

rtic

ipan

ts w

ho w

ere

expo

sed

to th

ein

terv

entio

n to

thos

e w

ho w

ere

not

Sam

ple

size

: pre

-inte

rven

tion

= 2

000,

post

-inte

rven

tion

= 2

000

Stu

dy 2

Des

ign:

pre

-inte

rven

tion

and

post

-in

terv

entio

n tr

ial;

cros

s-se

ctio

nal

anal

ysis

com

parin

g pa

rtic

ipan

ts w

how

ere

expo

sed

to th

e in

terv

entio

n(in

terv

entio

n ar

m) t

o th

ose

who

wer

e no

tex

pose

d (c

ompa

rison

arm

), c

ontr

ollin

gfo

r ex

posu

re to

oth

er H

IV/A

IDS

prog

ram

mes

Sam

ple

size

: pre

-inte

rven

tion

= 4

21,

post

-inte

rven

tion

= 4

16

Kno

wle

dge

• D

isag

reem

ent w

ith id

ea th

at th

ere

is a

cure

for

AID

S –

sig

nific

ant d

iffer

ence

spr

e-in

terv

entio

n an

d po

st-in

terv

entio

n(2

1, 2

6)•

AID

S k

now

ledg

e in

dex

asso

ciat

ed w

ithex

posu

re to

Sou

l Bud

dyz

TV

and

rad

iopr

ogra

mm

ing

– si

gnifi

cant

ly lo

wer

(8)

Red

uctio

n in

vul

nera

bilit

y•

4/4

soci

al n

orm

out

com

es r

egar

ding

abst

inen

ce, c

ondo

ms

and

stig

ma

–si

gnifi

cant

(21

, 27)

Red

uctio

n in

HIV

pre

vale

nce

• A

lway

s us

e a

cond

om –

sig

nific

antly

high

er a

s ex

posu

re to

num

ber

of S

oul

City

med

ia in

crea

ses

• O

ften

talk

to s

omeo

ne c

lose

abo

ut H

IV/

AID

S –

sig

nific

antly

hig

her a

s ex

posu

re to

num

ber

of S

oul C

ity m

edia

incr

ease

s(2

1, 2

7)•

Hig

her

cons

iste

nt c

ondo

m u

se in

dex

–as

soci

ated

with

exp

osur

e to

Sou

l City

radi

o dr

ama

(8)

Mix

ed e

vide

nce

for

incr

ease

s in

know

ledg

e

Str

ong

evid

ence

for

impr

ovem

ents

inso

cial

nor

ms

rega

rdin

g ab

stin

ence

,co

ndom

s an

d st

igm

a, a

nd in

crea

ses

inco

ndom

use

and

inte

rper

sona

lco

mm

unic

atio

n

M (

20)

Des

ign:

ran

dom

sam

ple

with

pre

-in

terv

entio

n an

d po

st-in

terv

entio

nco

mpo

nent

s co

mpa

ring

two

purp

osiv

ely

sele

cted

com

mun

ities

Kno

wle

dge

• K

now

ledg

e th

at c

ondo

ms

are

the

best

way

to p

reve

nt H

IV/A

IDS

– s

igni

fican

t

Red

uctio

n in

HIV

pre

vale

nce

• E

ver

had

sex

– no

t sig

nific

ant

Wea

k ev

iden

ce fo

r in

crea

ses

in c

ondo

mus

e

Str

ong

evid

ence

for

incr

ease

s in

know

ledg

e ab

out c

ondo

ms

220

92-4-120938-0_CH07_220

Sam

ple

size

: pre

-inte

rven

tion

= 2

26,

(118

in in

terv

entio

n gr

oup

and

108

inco

ntro

l gro

up),

pos

t-in

terv

entio

n =

204

(no

data

on

inte

rven

tion

vs c

ontr

ol)

• E

ver

used

a c

ondo

m –

not

sig

nific

ant

• C

ondo

m u

sed

durin

g la

st s

ex a

ct –

not

sign

ifica

nt

N (

21)

Des

ign:

ran

dom

sam

ple

with

pre

-in

terv

entio

n an

d po

st-in

terv

entio

nco

mpo

nent

s us

ing

hous

ehol

d su

rvey

san

d po

pula

tion-

base

d su

rvey

s; c

ross

-se

ctio

nal a

naly

sis

com

parin

gpa

rtic

ipan

ts w

ho w

ere

expo

sed

to th

ein

terv

entio

n to

thos

e w

ho w

ere

not

expo

sed

in K

athm

andu

, Nep

al, S

aoP

aulo

, Bra

zil,

and

Dak

ar, S

eneg

al

Sam

ple

size

: pre

-inte

rven

tion

= 3

000

(100

0 pe

r si

te),

pos

t-in

terv

entio

n =

300

0(1

000

per

site

)

Red

uctio

n in

vul

nera

bilit

y•

Pos

itive

ass

ocia

tion

betw

een

cam

paig

nex

posu

re a

nd b

elie

fs a

bout

impo

rtan

ce o

fus

ing

cond

oms,

dis

cuss

ing

HIV

with

ase

xual

par

tner

, and

get

ting

test

ed fo

r HIV

• A

ssoc

iatio

n be

twee

n ex

posu

re a

ndeg

alita

rian

gend

er n

orm

s –

mix

ed r

esul

ts

Red

uctio

n in

HIV

pre

vale

nce

• Num

ber o

f diff

eren

t typ

es o

f peo

ple

talk

edto

in th

e pa

st m

onth

abo

ut H

IV/A

IDS

–si

gnifi

cant

Wea

k ev

iden

ce fo

r im

prov

emen

ts in

soc

ial

norm

s

Str

ong

evid

ence

for

incr

ease

s in

inte

rper

sona

l com

mun

icat

ion

O (

22)

Des

ign:

bas

elin

e es

tabl

ishe

d by

pro

xyus

ing

data

from

DH

S D

emog

raph

ic a

ndH

ealth

Sur

vey

and

the

Gha

na Y

outh

Sur

vey;

mid

-ter

m a

sses

smen

t use

d da

tafr

om th

e G

hana

Rep

rodu

ctiv

e H

ealth

and

Chi

ld S

urvi

val S

urve

y

Sam

ple

size

: Pre

-you

th s

urve

y =

135

5,po

st-y

outh

sur

vey

= 1

161

Sta

tistic

al a

djus

tmen

ts m

ade

for

diffe

renc

es in

age

, edu

catio

n, m

arita

lst

atus

, reg

ion,

urb

an v

sru

ral r

esid

ence

,re

ligio

n an

d m

edia

acc

ess

Ski

lls•

Sel

f-ef

ficac

y to

use

con

dom

s fo

r th

ose

expo

sed

with

hig

h ex

posu

re to

cam

paig

n–

sign

ifica

nt

Red

uctio

n in

vul

nera

bilit

y•

Per

ceiv

ed p

eer

appr

oval

for

abst

inen

cean

d co

ndom

use

– s

igni

fican

t

Red

uctio

n in

HIV

pre

vale

nce

• M

edia

n ag

e of

firs

t sex

– n

ot s

igni

fican

t

Wea

k ev

iden

ce fo

r in

crea

ses

in s

elf-

effic

acy

in te

rms

of a

bstin

ence

and

inab

stin

ence

and

par

tner

-red

uctio

nbe

havi

ours

Mod

erat

e ev

iden

ce fo

r in

crea

ses

in s

elf-

effic

acy

in th

e us

e of

con

dom

s

Str

ong

evid

ence

for i

ncre

ases

in p

erce

ived

peer

app

rova

l for

abs

tinen

ce a

nd c

ondo

mus

e, a

s w

ell a

s im

prov

emen

ts in

con

dom

use

and

inte

rper

sona

l com

mun

icat

ion

221

92-4-120938-0_CH07_221

Stu

dy

Des

ign

an

d s

amp

le s

ize

Eva

luat

ion

res

ult

sS

tren

gth

of

evid

ence

fo

r ef

fect

• N

umbe

r of

sex

ually

act

ive

resp

onde

nts

havi

ng s

ex w

ith m

ore

than

one

par

tner

in th

e pa

st 1

2m

onth

s –

not s

igni

fican

t•

Con

dom

use

at l

ast s

ex –

sig

nific

ant

• T

alki

ng a

bout

usi

ng c

ondo

ms

–si

gnifi

cant

• T

alki

ng a

bout

avo

idin

g or

del

ayin

gse

x in

the

past

yea

r –

sign

ifica

nt

a S

TI =

sex

ually

tran

smitt

ed in

fect

ion.

b T

he s

econ

d st

udy

liste

d fo

r th

e S

oul C

ity c

ampa

ign

(8)

eval

uate

s si

x ty

pes

of o

ngoi

ng H

IV p

reve

ntio

n ac

tiviti

es in

this

reg

ion

of S

outh

Afr

ica,

one

of w

hich

was

the

mas

s m

edia

cam

paig

n re

late

d to

Sou

l City

. The

aut

hors

trac

k ch

ange

s in

a s

erie

s of

out

com

e va

riabl

es o

ver

time,

to w

hich

the

six

type

s of

inte

rven

tions

colle

ctiv

ely

cont

ribut

ed. T

hus,

it is

not

pos

sibl

e to

iden

tify

the

exte

nt to

whi

ch a

giv

en in

terv

entio

n co

ntrib

uted

to th

e ob

serv

ed c

hang

e. T

he a

utho

rs c

reat

edin

dice

s fo

r kno

wle

dge

and

cons

iste

nt c

ondo

m u

se. M

ultip

le re

gres

sion

ana

lysi

s de

mon

stra

ted

that

exp

osur

e to

radi

o m

essa

ges

and

to th

e S

oul C

ity ra

dio

dram

aw

ere

posi

tivel

y lin

ked

to th

e co

nsis

tent

con

dom

use

inde

x bu

t not

to th

e A

IDS

kno

wle

dge

inde

x. S

ince

the

mul

tivar

iate

asp

ect o

f the

ana

lysi

s w

as th

e on

ly p

art

of th

e an

alys

is th

at a

llow

ed fo

r an

ass

essm

ent o

f the

effe

cts

of S

oul C

ity o

n th

e ou

tcom

es o

f int

eres

t, w

e re

port

onl

y th

ose

here

.

222

92-4-120938-0_CH07_222

The literature review for this paper took three forms. First, the authors par-ticipated in the mass media-intervention component of a WHO initiativeknown as “synthesizing intervention effectiveness”, which included an effortto locate all research published between 1990 and 2004 on the effects of massmedia interventions on HIV/AIDS-related behaviours (3). Another compo-nent summarized the findings of those papers that met certain criteria formethodological rigor. Studies were evaluated according to eight quality cri-teria (3) and were included in the review if they used either a pre-test versuspost-test design or a treatment versus comparison design. Of 25 studies thatperformed rigorous evaluations, four targeted young people and met the in-clusion criteria; these form part of the current review (5, 7, 10, 19).

Second, the Center for Communication Programs at Johns HopkinsBloomberg School of Public Health has conducted at least four studies on theimpact of mass media programmes on HIV/AIDS-related behaviours amongyoung people. All have been submitted for publication, but do not appear inthe previous WHO review because they were not published by 2004.

Third, we followed references from other published reviews (23, 24) andconsulted POPLINE, Medline, and the Communication Initiative web site(http://www.comminit.com) in an attempt to identify additional studies.

We included studies that evaluated the effectiveness of mass media cam-paigns in a developing country and that had the main objective of providingeducation on HIV/AIDS or sexual health. To be eligible for inclusion, studieshad to use a pre-intervention versus post-intervention design or an interven-tion versus control design or analyse cross-sectional data comparing thosewho had been exposed to the campaign with those who had not been exposed.They also had to comprehensively report quantitative and statistical data formost outcomes being studied (Table 7.1). We defined an interventioneffect as:

a significant change occurring from pre-intervention to post-intervention

a significant difference between the intervention and control groups, or

a significant association between exposure to a mass media campaign andthe outcome.

These types of studies yield results that allow “plausibility statements” to bemade when using the classification of scientific inference offered by Victoraet al. (25). Not surprisingly, we did not find any randomized controlled trialsthat randomized individuals because of the virtual impossibility of randomlyallocating participants to intervention and control groups in cases in whichthere is full coverage of a mass media intervention; one study did randomizeat the village level (7).

223

92-4-120938-0_CH07_223

There are several limitations to this study. The primary studies reviewed herevaried substantially in their rigor; several compared intervention and controlgroups without addressing baseline differences between groups. However,because they all met a minimum level of rigor, we did not attempt any furtherweighting of the evidence. Almost all of the studies relied on self-reportedmeasures of campaign exposure and outcomes; self-reporting is subject tostrong bias, especially in relation to sexual behaviour. Another limitationis the measurement of exposure to a given mass media intervention. Peoplealready performing a certain behaviour (for example, using condoms) may bemore likely to attend to and recall messages about condoms than those whoare not engaging in that behaviour. In addition, a given intervention classifi-cation (for example, television) may cover a wide range of highly variedprogramming and content – from a 30 second public service announcementto an hour long soap opera. Finally, most of the interventions that were studiedwere conducted in the context of multicomponent programmes offeringhealth services, peer counselling or other educational elements; however, theevaluations are largely unable to differentiate the effects of mass media fromthose of the other components of the intervention. These limitations are byno means trivial, nor are they unique to this set of evaluations of mass mediainterventions.

Additionally, few studies considered the costs and cost effectiveness of massmedia interventions, limiting donors’ ability to select programmes that offerthe most cost-effective interventions. Whereas mass media programming of-ten requires substantial investment in both production and diffusion, the costper person reached can be surprisingly low, as we know from evaluations ofprogrammes in other health sectors (26, 27). Further research examining thecost effectiveness of behaviour-change communication programmes is in thepipeline.

7.2.1 Outcomes of interest

We were interested in identifying outcomes that directly affect the globalgoals for preventing HIV/AIDS among young people as outlined in the Dec-laration of Commitment of the UN General Assembly Special Session onAIDS (28). To this end, we focused on the following outcomes as indicatorsof progress on the global goals:

increase awareness and knowledge of information on how to avoid HIVinfection, measured as

changes in knowledge (about modes of transmission, methods of pre-vention, how to tell if someone has HIV/AIDS);

increase access to the skills needed to avoid HIV infection, measured as

224

92-4-120938-0_CH07_224

self-efficacy (in abstinence, condom use);

increase access to the health services needed to avoid HIV infection, mea-sured as

awareness and utilization of health products and services;

decrease young people’s vulnerability to HIV, measured as

more accurate perceptions of personal riskchanges in social norms (friends’ approval of use of condoms orabstinence);

decrease HIV prevalence, measured by its proximate behavioural deter-minants, such as

abstinence (both intention and behaviour)a decrease in the number of sexual partners (intention and behaviour)the use of condoms (intention and behaviour)improvements in mediating factors, such as interpersonal communica-tion (about sexual health, HIV/AIDS, condoms).

The evaluations of most mass media campaigns do not measure directly thegoal of decreasing HIV prevalence but rather they measure its proximatedeterminants. The exception in this review is the “loveLife” campaign inSouth Africa, which did measure HIV prevalence (14). Interventions that aimto change behaviour are rarely subject to long-term evaluations of outcomes(such as prevalence) because change may be difficult to measure during thelife of the intervention, and factors outside the intervention may have a pow-erful influence on long-term outcomes. In the case of HIV/AIDS, a thirdfactor also comes into play: the logistical and ethical difficulty of measuringHIV prevalence as part of a programme evaluation. For these reasons, preva-lence is generally measured indirectly through reported behavioural deter-minants instead of directly through biological markers.

Within each of the outcome areas outlined above, the interventions underreview often measured a given concept in different ways (for example, con-dom use may have been measured as whether a participant ever used acondom, used one the last time he or she had sex or used one with a casualpartner). In this review, we combined different operational definitions into asingle category (for example, condom use). The lack of standardization ofindicators of outcome seriously limits the potential to perform a meta-analysison this topic.

225

92-4-120938-0_CH07_225

7.3 Findings

We found rigorous evaluation data for 15 mass media interventions address-ing HIV-related behaviours among young people: 11 examined interventionsin Africa, 2 in Latin America, 1 in Asia, and 1 examined a programme thattook place in 44 countries (Table 7.3). No studies of print-only materials metthe inclusion criteria. Intervention designs are summarized in Table 7.3. Onestudy evaluated a radio-only campaign (which we have designated a type 1intervention) (5). Six of the studies evaluated interventions using radio withother supporting media (for example, written materials, videos, posters, the-atre performances, school workshops); these are designated type 2 interven-tions (6–11). The remaining eight interventions involved television and radiowith other supporting media; these are designated type 3 interventions (12–22). One intervention (“Soul City” in South Africa) was evaluated in twostudies (17–19). All studies are described in detail on the web.

7.3.1 Additional outcomes

Additional outcomes are summarized in Table 7.4 and described below.

7.3.1.1 Access to information: changes in knowledge

Of the nine studies reporting data on knowledge of HIV transmission andprevention, four measured increased knowledge of modes of HIV/AIDStransmission. In China, study C (7) showed large, significant differences –measured both before and after the intervention – in knowledge of modes oftransmission, including sexual intercourse (77% before versus 95% after),having multiple sexual partners (69% before versus 93% after) and sharingneedles for drug use (67% before versus 95% after). Similarly large differ-ences were found for rejecting incorrect modes of transmission, and allknowledge measures were significantly different from the control group. The“Tsa Banana” campaign in Botswana (study G) (11) showed mixed resultson the item, “sexually active people risk getting infected with HIV,” withmales showing significant improvements in knowledge (adjusted oddsratio = 3.2) and females showing no significant improvement. In Guinea,study E (9) reported levels of knowledge of transmission of 90–96% amongthe control groups, leaving little room for improvement in the interventiongroup. One study of HIV programmes in South Africa (study L) (19) reporteda positive association between a low score on an AIDS knowledge index andexposure to “Soul Buddyz” (a programme within the Soul City interventionaimed at children aged 8–12 years) in South Africa.

The one study measuring knowledge of abstinence as a prevention technique,the “HEART” campaign in Zambia (study I) (13), showed significantlyhigher knowledge among those who had the seen the campaign compared

226

92-4-120938-0_CH07_226

with those who had not (66% of males exposed to the campaign versus53% of males not exposed; 65% for females exposed versus 55% forfemales not exposed). Three of the five studies measuring knowledge ofcondoms as a prevention method showed large and significant differencesbetween intervention and comparison groups (studies B, C and M) (6, 7, 20).The Soweto Adolescent Reproductive Health Programme (study M) (20)reported a significant jump in the knowledge that condoms can prevent HIVtransmission, from 60% pre-intervention to 85% post-intervention; study C(7), “HIV Prevention and Education in Rural China” also found a substantialimprovement in this type of knowledge (a change from 46% to 94% in theintervention group versus 44% to 49% for the control group) .

The one study measuring a response to the statement “there is a cure forAIDS” (study L in South Africa) (17) found significant increases indisagreement with the statement post-intervention (change from 79%pre-intervention to 89% post-intervention). Of five studies reporting on re-sponses to the statement that “you can tell someone has HIV/AIDS by theway that they look,” only study C (7) in China showed a significant improve-ment between intervention and control groups from pre-intervention topost-intervention.

7.3.1.2 Access to skills: self-efficacy to pursue preventive behaviours

Two evaluations measured young women’s self-efficacy in pursuing absti-nence or refusing to have sex with someone who offered gifts. Study K (16)in Côte d’Ivoire showed significant differences in self-efficacy across thosewith low levels of exposure to the campaign compared with those who hadhigh levels of exposure, while study O (22) in Ghana did not detect significantdifferences across levels of exposure. However, all four studies investigatingself-efficacy in using condoms or convincing a sexual partner to use condomsshowed significant differences between the intervention and comparisongroups (7, 13, 16, 22). Those who were highly exposed to the “Stop AIDSLove Life” campaign in Ghana (study O) (22) had significantly higher scoreson a scale of 1–6 measuring condom-related self-efficacy than those whowere not exposed to the campaign (3.9 for males exposed to the campaignversus 2.9 for males not exposed; 3.0 for females exposed versus 1.6 forfemales not exposed). Similarly, those who were exposed to a campaign inCôte d’Ivoire (study K) (16) were significantly more likely to report self-efficacy in terms of consistent condom use than those who were not exposed(58% of those with no exposure used condoms consistently versus 70% ofthose with low exposure versus 75% of those with high exposure). In studyC in China (7), both the intervention and the control groups showed increasesin their confidence about their abilities to convince sexual partners to usecondoms, but the increase for the intervention group was significantly larger

227

92-4-120938-0_CH07_227

(83% to 92% among the intervention group versus 78% to 84% among thecontrol group).

7.3.1.3 Access to health services: awareness and utilization

All four campaigns that measured awareness of a health product or serviceshowed significant positive differences between interventions and controls.Variables measured included awareness of an AIDS hotline in study A (5) inSaint Vincent and the Grenadines (91% of the intervention group versus 75%of the controls), and in study I (13) in Zambia the availability of voluntarycounselling and testing (79% for males in the intervention group versus 67%for male controls; 84% for females in the intervention group versus 64% forfemale controls) and places where condoms could be purchased (81% inter-vention versus 72% controls). Other variables measured included the locationof condom vendors in study E in Guinea (9) (86% for males in the interventiongroup versus 57% for male controls; 59% for females in the interventiongroup versus 22% for female controls). However, awareness did not neces-sarily translate into utilization; no significant differences were found in theuse of the AIDS hotline in Saint Vincent and the Grenadines (5), and studyD in Cameroon (8) reported no significant differences in visits to health cen-tres between the intervention and control groups. In Zimbabwe, study F(10) reported that members of intervention groups were significantly morelikely to attend health centres than controls (28% versus 10%) and more likelyto attend youth services (11% versus 2%). In South Africa, study J (14) re-ported that those exposed to the loveLife campaign were significantly morelikely than those who had not been exposed to have ever been tested for HIV(16% versus 10%).

7.3.1.4 Decreasing vulnerability

Perception of personal risk

None of the four evaluations reporting data on the perception of personal riskof HIV/AIDS showed a consistent and significant difference (studies D, E,H, I) (8, 9, 12, 13).

Social norms

Eight of the 15 studies reported measures of social norms; these measureswere highlighted especially by data for the broad-based media efforts of SoulCity in South Africa (study L) (17) and the global Staying Alive campaign(study N) (21). Evaluation of the Soul City programme (study L) (17, 18)found significant desirable changes in all norms tested before and after thecampaign, including disagreement with the expectation that a woman wouldhave sex with a man without using a condom (59% disagreed with the

228

92-4-120938-0_CH07_228

statement pre-intervention and 65% disagreed post-intervention). The Soulcity evaluation also found that participants disagreed with the idea that boysor men have the right to have sex with their girlfriends if they buy them gifts(65% pre-intervention versus 73% post-intervention) (17). The global Stay-ing Alive campaign reported more varied results; positive associations withcampaign exposure were shown for the importance of using a condom, dis-cussing HIV with a sexual partner and getting tested for HIV. However,norms regarding tolerance toward people living with HIV/AIDS did not showsimilar positive associations (21).

After the PRISM media campaign in Guinea, young people, parents, healthworkers, community leaders, religious leaders and members of establishedsocial networks were significantly more likely to report that their communitywas open to discussing young people’s reproductive health questions than theyear before campaign (study E) (9). In Cameroon, study D (8) reported thatthe proportion of youths that often discussed sexuality or contraceptives wassignificantly higher among the intervention group (0.897 versus 0.774). StudyK in Côte d’Ivoire (16) reported significantly higher perceptions of peer sup-port for abstinence among those who were highly exposed to the campaigncompared with those who were not exposed (62% versus 53%).

In study O in Ghana (22), the percentage of youths who believed that theirfriends approved of avoiding or delaying sexual activity decreased signifi-cantly from before the intervention to after the intervention (60% versus 42%for males; 61% versus 36% for females); however, those who had higherexposure to the Ghana Stop AIDS Love Life campaign were significantlymore likely to believe that their friends approved of delaying or avoiding sexthan those with no exposure (52% of males with high exposure versus 27%of males with no exposure; 47% of females with high exposure versus 26%of females with no exposure).

In study A (5) in Saint Vincent and the Grenadines, some measures of socialnorms showed improvement after a radio campaign while others did not.Although campaign listeners and non-listeners were equally likely to reportthat their friends, parents or most people important to them thought that theyshould use condoms, campaign listeners were significantly more likely thannon-listeners to report that their friends used condoms (46% for listenersversus 22% for non-listeners).

229

92-4-120938-0_CH07_229

7.3.1.5 Decreasing prevalence as measured by proximate behavioural determinants

Abstinence

The age of sexual debut or current or continued abstinence was evaluated forsix programmes. Two showed significant effects (10, 13); two did not (20,22); and two showed mixed results (8, 12). Study F (10) in Zimbabwe foundthat 53% of those in the intervention sites “said no to sex” compared with32% in the comparison sites; however no differences were found for partic-ipants’ responses to “stopped having sex due to the campaign”.

Number of sexual partners

Of the five studies reporting on whether the number of sexual partners wasreduced, four showed equivocal or null results (7, 8, 12, 22). However, studyF in Zimbabwe (10) showed a marked change, with 20% of respondents inthe intervention group reporting that they had had only one partner during therecall period compared with 2% of the control group.

Condom use

Twelve programmes reported on condom use, with eight reporting on condomuse during last sexual episode. Of these eight, five showed significant dif-ferences between intervention and comparison groups (7, 9, 12, 13, 22). Thelargest effects were reported by study O (22) in Ghana, which found that thosewho were highly exposed to the campaign were several times more likelythan those who were not exposed to report using a condom during the lasttime they had sex (males: 34% versus 10%; females: 22% versus 4%). StudyE (9) found similarly strong effects (males: 48% versus 24%; females: 27%versus 3%).

Of the five programmes reporting on whether condoms had ever been used,three found significant increases (8, 9, 13). Two separate evaluations of SoulCity in South Africa (study L) showed an association between consistentcondom use and exposure to the programme (17-19).

Mediating factors: interpersonal communication

Nine studies reported data on whether young people discussed HIV, absti-nence or condom use with peers, parents or partners. Study F (10) inZimbabwe showed a significant difference between intervention and controlgroups in participants having discussions with anyone about sexually trans-mitted infections or AIDS (78% of intervention group versus 67% of controlgroup). Significantly more youths who were exposed to the loveLife cam-paign in South Africa reported ever talking to their parents about HIV/AIDSthan youths who were not exposed to the campaign (90% versus 81%) (15).

230

92-4-120938-0_CH07_230

The Soul City campaign in South Africa (study L) also reported significantlymore frequent discussions with “someone close” among those with accessto more sources of Soul City media than among those with fewer sources(18, 19). The multicountry Staying Alive campaign (study N) calculated anetwork score, ranging from 0 to 6, for which respondents were assigned onepoint for each type of individual (parent, sibling, teacher or counsellor, doctoror nurse, sexual partner, friend or schoolmate) with whom they talked aboutHIV/AIDS during the previous month (21). In each of the three Staying Aliveevaluation sites, those exposed to the campaign scored significantly higherthan those who were unexposed (in Kathmandu: 2.26 points versus 1.30; inSao Paulo: 0.96 versus 0.65; in Dakar 1.48 versus 1.04).

In Zambia, abstinent youths who were exposed to the HEART campaign(study I) spoke to significantly more people about abstinence than those whowere not exposed (males: 2.9 for those exposed versus 2.3 for those not ex-posed; females: 3.8 for those exposed versus 2.2 for those not exposed)(13). Single females highly exposed to the “PL.U.S.” campaign in Côted’Ivoire (study K) were significantly more likely to discuss sexual abstinencewith a parent during the previous 12 months than those who were not (33%versus 15%) (16). The PL.U.S. campaign also showed significant gains indiscussions about condoms for both single males and single females: 90% ofsingle females who were highly exposed to the campaign encouraged some-one to use condoms during the previous 12 months compared with 56% ofthose who were not exposed to the campaign (16).

The PRISM campaign in Guinea (study E) and the Stop AIDS Love Lifecampaign in Ghana (study O) also showed significantly higher levels of dis-cussion about condoms among participants in the intervention group thanamong the control group. Those in the PRISM intervention group wereroughly twice as likely as controls to recommend condom use to someoneelse (males: 70% versus 31%; females: 31% versus 16%) (9). Study O, theStop AIDS Love Life campaign, also reported large and significant differ-ences between the proportion of participants who were highly exposed to thecampaign and the proportion of those who were not exposed in terms of dis-cussing the use of condoms to avoid AIDS and other sexually transmittedinfections during the past year (males: 57% versus 16%; females: 55% versus18%) (22). However, a radio campaign in Saint Vincent and the Grenadines(study A) did not show improvements in the proportion of adolescents andparents who discussed the use of condoms (5). Less than 2% of the sexuallyexperienced participants in the Zimbabwe study (study F) asked a partner touse a condom as a result of the campaign (10).

231

92-4-120938-0_CH07_231

HIV prevalence

Only one of the 15 studies recorded HIV prevalence (study J). The evaluationof study J in South Africa found that overall young people who participatedin the programme had an adjusted odds of being HIV positive of approxi-mately 0.60 compared with those who had not participated (15).

7.3.2 Summary of studies of effectiveness

The evidence supports the effectiveness of mass media interventions inincreasing the knowledge of HIV transmission and prevention, improvingself-efficacy in terms of condom use, influencing social norms about the ac-ceptability of young people discussing reproductive health, increasing inter-personal communication about HIV and prevention behaviours, increasingthe use of condoms, and boosting awareness of health providers. The studiesreviewed in this article did not tend to show significant effects with regard tocreating awareness that healthy looking people may have HIV/AIDS or im-proving self-efficacy in terms of abstinence. They also did not show signifi-cant effects in terms of increasing the proportion of adolescents who delaytheir first sexual experience or decreasing the number of sexual partners.

7.3.3 Relative effectiveness of different types of interventions

This section summarizes findings by intervention type (Table 7.5 and Table7.6). Although we highlight the results of the five goals of the UN Declarationand nine possible outcomes (see section 7.2.1), a given study usually reportedon only three or four of these outcomes. The summary below is based on thestudies that reported findings for the relevant variables.

7.3.3.1 Radio only

The one radio-only campaign (study A) showed mixed results: significantimprovements were achieved in awareness of an AIDS hotline but there wereno improvements in social norms, interpersonal communication about HIV/AIDS or in different measures of condom use (5).

7.3.3.2 Radio with other supporting media

There were six interventions of this type (6-11). All of the studies reportedsome measure of knowledge gain. With the notable exception of study C inChina (7), most results tended not to be significant. In contrast, more studiesthan not showed positive effects on skills, knowledge about health servicesand social norms.

232

92-4-120938-0_CH07_232

Tab

le 7

.5S

tren

gth

of e

vid

ence

of e

ffec

tive

nes

s fo

r eac

h in

terv

enti

on

typ

e b

y g

oal

as

ou

tlin

ed b

y th

e D

ecla

rati

on

of C

om

mit

men

t of t

he

UN

Gen

eral

Ass

emb

ly S

pec

ial S

essi

on

on

AID

S (

14)

Inte

rven

tio

n t

ype

and

stu

dy

des

ign

aIn

crea

sekn

ow

led

ge

Imp

rove

ski

llsIn

crea

se a

cces

s to

an

daw

aren

ess

of

hea

lth

serv

ices

Red

uce

vu

lner

abili

tyR

edu

ce H

IVp

reva

len

ce

Sb

Mix

edc

NS

dS

Mix

edN

SS

Mix

edN

SS

Mix

edN

SS

Mix

edN

S

Typ

e 1

(rad

io o

nly

)C

ross

-sec

tiona

lA

AA

Bef

ore–

afte

rIn

terv

entio

nvs

cont

rol

RC

Te

Typ

e 2

(rad

io w

ith

oth

er m

edia

)C

ross

-sec

tiona

lE

BE

E, F

EE

, FB

Bef

ore–

afte

rG

GIn

terv

entio

nvs

cont

rol

FD

DD

D, F

RC

TC

CC

Typ

e 3

(rad

io a

nd

tel

evis

ion

wit

h o

ther

med

ia)

Cro

ss-s

ectio

nal

KO

K, O

NK

OB

efor

e–af

ter

LL

LIn

terv

entio

nvs

cont

rol

MI

HI,

JH

, II,

JH

, MR

CT

a S

tudi

es a

re c

lass

ified

acc

ordi

ng to

the

type

of d

ata

they

rep

ort;

for

exam

ple,

a b

efor

e–af

ter

stud

y th

at u

ses

cros

s-se

ctio

nal d

ata

anal

ysis

may

app

ear

eith

er in

the

row

for

cros

s-se

ctio

nal s

tudy

or

the

row

for

befo

re–a

fter,

dep

endi

ng o

n w

hich

par

t of t

he s

tudy

the

findi

ngs

cam

e fr

om.

b S

= s

igni

fican

tc F

indi

ngs

are

desi

gnat

ed a

s “m

ixed

” if

they

wer

e si

gnifi

cant

for

som

e m

easu

res

but n

ot o

ther

s or

sig

nific

ant f

or o

ne s

ex b

ut n

ot th

e ot

her.

d N

S =

not

sig

nific

ant.

e R

CT

= r

ando

miz

ed c

ontr

olle

d tr

ial.

233

92-4-120938-0_CH07_233

Tab

le 7

.6R

eco

mm

end

atio

ns

on

th

e st

ren

gth

of

the

evid

ence

Inte

rven

tio

nty

pe

Co

ncl

usi

on

C

om

men

ts

1. R

adio

onl

yS

tead

y•

Impr

ove

know

ledg

e an

d sk

ills

– no

evi

denc

e (n

ot r

epor

ted)

• Im

prov

e ac

cess

to h

ealth

ser

vice

s –

stro

ng e

vide

nce

for

a sm

all i

ncre

ase

in a

war

enes

s of

ser

vice

s (A

IDS

hot

line)

but

only

wea

k ev

iden

ce fo

r in

crea

sing

rep

orte

d at

tend

ance

at t

hese

ser

vice

s•

Red

uce

vuln

erab

ility

–no

evi

denc

e of

impr

oved

per

cept

ions

in s

ocia

l nor

ms

• M

itiga

te v

ulne

rabi

lity/

risk

– no

evi

denc

e (n

ot r

epor

ted)

• R

educ

e H

IV p

reva

lenc

e (s

urro

gate

mea

sure

: con

dom

-use

beh

avio

urs)

– n

o ev

iden

ce o

f im

prov

emen

ts in

con

dom

use

• M

edia

ting

fact

ors

(inte

rper

sona

l com

mun

icat

ion

abou

t and

atti

tude

s to

war

ds c

ondo

ms)

– n

o ev

iden

ce o

f im

prov

emen

ts2.

Rad

iow

ith o

ther

med

ia

Go

• Im

prov

e kn

owle

dge

– w

eak

evid

ence

of i

mpr

oved

kno

wle

dge

• Im

prov

e sk

ills

– th

e tw

o st

udie

s re

port

ing

on th

is o

utco

me

show

ed s

tron

g ev

iden

ce fo

r in

crea

sed

self-

effic

acy

in u

sing

cond

oms

and

know

ledg

e of

how

to u

se c

ondo

ms

• Inc

reas

e us

e an

d aw

aren

ess

of h

ealth

ser

vice

s –

the

thre

e st

udie

s re

port

ing

on th

is o

utco

me

show

ed m

oder

ate

evid

ence

for

incr

ease

s in

thes

e va

riabl

es•

Red

uce

vuln

erab

ility

– 1

/1 s

tudy

foun

d im

prov

ed s

ocia

l nor

ms

• M

itiga

te v

ulne

rabi

lity/

risk

– no

evi

denc

e (n

ot r

epor

ted)

• R

educ

e H

IV p

reva

lenc

e –

Mod

erat

e to

str

ong

impr

ovem

ents

in A

BC

beh

avio

urs

(Abs

tain

, Be

faith

ful,

use

Con

dom

s)•

Med

iatin

g fa

ctor

s –

mod

erat

e to

str

ong

impr

ovem

ents

in in

terp

erso

nal c

omm

unic

atio

n an

d at

titud

es to

war

ds th

e A

BC

beha

viou

rs3.

Rad

ioan

dte

levi

sion

with

othe

r m

edia

Go

• Im

prov

e kn

owle

dge

– m

oder

ate-

to-s

tron

g ev

iden

ce, e

spec

ially

reg

ardi

ng c

ondo

ms

• Im

prov

e sk

ills

– m

oder

ate-

to-s

tron

g ev

iden

ce o

f im

prov

ed s

elf-

effic

acy

for

prev

entiv

e be

havi

ours

• In

crea

se a

war

enes

s of

hea

lth s

ervi

ces

– m

oder

ate-

to-s

tron

g ev

iden

ce fo

r in

crea

ses

• R

educ

e vu

lner

abili

ty –

no

evid

ence

to w

eak

evid

ence

of i

mpr

ovem

ents

in p

erce

ived

per

sona

l ris

k; m

oder

ate

evid

ence

of im

prov

ed s

ocia

l nor

ms

rega

rdin

g th

e A

BC

beh

avio

urs

• M

itiga

te v

ulne

rabi

lity/

risk

– no

evi

denc

e (n

ot r

epor

ted)

• Red

uce

HIV

pre

vale

nce

(sur

roga

te m

easu

re: A

BC

beh

avio

urs)

– w

eak

evid

ence

of i

ncre

ases

in a

bstin

ence

and

redu

ctio

nin

the

num

ber

of p

artn

ers;

str

ong

evid

ence

for i

mpr

ovem

ents

in c

ondo

m u

se. T

he o

ne s

tudy

mea

surin

g H

IV p

reva

lenc

efo

und

stro

ng e

vide

nce

of p

reva

lenc

e re

duct

ion

asso

ciat

ed w

ith p

artic

ipat

ion

in th

e in

terv

entio

n•

Med

iatin

g fa

ctor

s (in

terp

erso

nal c

omm

unic

atio

n) –

str

ong

evid

ence

of i

mpr

ovem

ent

234

92-4-120938-0_CH07_234

In terms of sexual behaviour, the findings were split fairly evenly betweensignificant and non-significant results related to abstinence and delay ofsexual debut. There was little evidence that interventions reduced partici-pants’ number of sexual partners. However, the weight of the evidence acrossstudies reporting condom use was strongly positive, and this type of pro-gramme had favourable effects on increasing interpersonal communicationwith others about HIV/AIDS. None of the studies of radio with supportingmedia included HIV prevalence as an outcome measure.

7.3.3.3 Television and radio with other supporting media

There were eight interventions of this type (12-22). Evaluations of this typeof intervention generally showed improvements in knowledge and skills re-lated to HIV/AIDS as well as knowledge about health services. The resultstended to be positive for social norms.

Evidence from the evaluations that measured abstinence or delay of sexualdebut varied but leaned towards having no effect. The findings of the fewstudies reporting a reduction in the number of sexual partners were also splitbut tended towards no effect. In contrast, data on different measures of con-dom use showed positive effects in the majority of studies. The only study toreport HIV prevalence (study J) (14, 15) found that programme participationwas associated with lower HIV prevalence. Finally, all studies reported apositive effect on interpersonal communication regarding HIV/AIDS.

7.3.4 Dose–response relationship

Dose–response theory suggests that if a campaign causes changes in an out-come, then higher levels of campaign exposure should yield larger changes(27). Four of the fifteen studies examined the dose–response question(10, 16, 17, 22); all four studies found significant differences between thosewith low exposure and those with high exposure to the campaigns, whensocioeconomic factors and access to media were controlled for.

In the programme in Ghana for example (study O), a dose–response rela-tionship was evident for 6 of 11 variables (22). In the intervention in Côted’Ivoire (study K), the proportion of single females who perceived that theyhad peer support to abstain from sex and the proportion of young people ofboth sexes who encouraged someone else to use condoms were significantlygreater among those with high exposure to the campaign (study K) thanamong those with low or no exposure (16). In the project in Zimbabwe (studyF), 9 out of 10 outcomes showed evidence of significant dose–response ef-fects. The likelihood of having had discussions with others about sexuallytransmitted infections or AIDS or of having sought care at a health centre or

235

92-4-120938-0_CH07_235

youth centre was significantly greater among those who had been exposed to5–8 components of the campaign than among those who had been exposedto 1–2 or 3–4 components (10). And in South Africa, study L reported thatthe frequency of talking to someone close about HIV/AIDS and always usinga condom were positively associated with exposure to more sources of thecampaign (17, 18).

7.4 Discussion

The purpose of this review was to identify methodologically rigorous studiesthat examined the effects of mass media interventions on HIV/AIDS-relatedbehaviours among young people in developing countries and to determinethe extent to which the evidence would justify future widespread implemen-tation of three types of mass media programmes (Box 7.1). Radio-onlyprogramming and radio programming with other media require a moderatethreshold of evidence to justify their expansion. In contrast, despite the factthat television and radio programming used with other media have the po-tential to reach millions of people it is a less feasible intervention primarilybecause of the financial and human resources needed to produce and broad-cast high quality programmes. Thus, the threshold of evidence needed torecommend future expansion of a comprehensive radio and television inter-vention with other media is high.

The lack of evidence for radio-only interventions indicates that most projectshave now moved beyond this single channel to offer more comprehensiveservices. Because we identified only one study of this intervention type, wecannot generalize about its effectiveness. The mixed results of that one studylead to our classifying this type of intervention as “Steady”.

The comparison of interest is between interventions that use radio togetherwith other media and those that use radio and television together with othermedia. For most outcomes, the two types of interventions showed a surpris-ingly similar pattern. First, both had positive effects on knowledge, skills,awareness and use of health services, use of condoms and interpersonal com-munication with others. Second, the two types of interventions yielded similarresults on social norms: they were generally positive though split or mixedwhen disaggregated by sex of the participant. The evidence was too limitedto make a comparison on mitigation of vulnerability or risk or on the preva-lence of HIV. Because of the consistently strong effects on multiple out-comes, we categorize both radio with other media and radio and televisionwith other media as interventions as “Go”. Although we required a higherlevel of evidence for radio and television than for radio alone with othermedia, we believe that both merit the endorsement of “Go” for the followingreason: the strong evidence of dose effect (that is, the greater the exposure

236

92-4-120938-0_CH07_236

via multiple channels, the stronger the effect) favours the use of a wider rangeof media, especially where access to television is high.

Box 7.1

Recommendations for mass media campaigns

For policy-makers

Mass media have the potential to reach millions of people with life-saving messages that can change behaviour.

Large-scale campaigns must be closely coordinated with other inter-ventions (such as those that are school-based or clinic-based) to max-imize their effects.

For programme development and delivery staff

To achieve large-scale effects, mass media programmes should be de-veloped and implemented through multiple channels with mutually re-inforcing messages.

Mass media interventions should be tailored for young people, andcampaign materials should be pre-tested among young people.

For researchers

Focus scarce evaluation resources on large-scale comprehensive com-munication programmes that have the potential to achieve population-based effects (rather than pilot studies or “boutique” programmes).

Recognize that randomized controlled trials are not the method of choicefor evaluating full-coverage mass media programmes. Instead, usestrong quasi-experimental designs and analytic approaches that build acase for inferring causality.

Work towards standardizing outcome indicators.

Conduct cost-effectiveness analyses for mass media programmes todetermine the cost per unit of effect.

It might be tempting to conclude that radio used with other media can producethe same results as radio and television used with other media. However, thispresupposes that the settings for the different mass media programmes arecomparable; this is a tenuous assumption. Our review of the findings providesprogramme developers and staff with a justification for using either type ofintervention. Given that television is generally more costly than radio – interms of both production and broadcast – this finding suggests that radio used

237

92-4-120938-0_CH07_237

with other media may be a valuable means of reaching young people whenbudgets are constrained. Another important factor in deciding between thetwo interventions relates to the intended audience. Radio without televisionmay work well where access to television is limited. However, among a pop-ulation where there is high access to television, it may be more difficult forradio-based interventions to capture the necessary attention. Thus, our find-ings do not lead to a hard and fast recommendation of one over the other.Rather, they point to the value of both, depending on the media habits andpreferences of the intended audience and the costs involved in programming.

7.4.1 Features of the most effective interventions

Given the nature of peer-reviewed journals, researchers often provide littledetail regarding the components of the communication intervention or theprocess of its development and monitoring. Thus we have relatively littleinformation on the interventions themselves even from published studies.Since this area of exploration is still in its infancy, it is premature to look tothe published literature to answer questions about which features of a cam-paign enhance its effectiveness.

7.4.2 Factors that facilitate or obstruct effective interventions

Although a list of all factors would be too lengthy to elaborate here, multiplefactors affect the development of effective media campaigns. Many are com-mon to other types of interventions: political will and adequate funding andpersonnel, among others. Two factors are particularly relevant to communi-cation programmes. They are described below.

7.4.2.1 Cultural sensitivities

Sexual behaviour is a taboo subject in many cultures, yet it lies at the heartof efforts to prevent the spread of HIV. Communicators must find ways to beas explicit as possible without crossing the fine line of cultural sensibility.

7.4.2.2 Availability of local talent

The use of “entertainment and education” together is one of the fastest grow-ing means of communication used to teach people about HIV/AIDS; it is alsopotentially one of the most effective because this type of programme engagesthe audience in compelling dramas about the lives of people to whom theycan relate. Maibach and Holtgrave dubbed entertainment and education pro-grammes “fun with a purpose” (29). However, for education and entertain-ment programmes on HIV/AIDS to compete with commercial programmes,they must have the same professional polish. Because many developingcountries do not have a sufficiently large pool of local talent experienced in

238

92-4-120938-0_CH07_238

scripting and producing this genre, communicators are faced with the specialchallenge of developing and producing materials. Nonetheless, a number ofhighly entertaining soap operas that touch on HIV/AIDS have emerged indeveloping countries (30).

7.4.3 Conclusions

Despite the millions of dollars that have been invested in communicationprogrammes to prevent the spread of HIV and AIDS, the number of pro-grammes that have undergone rigorous evaluation is limited. Results fromthe 15 studies reviewed here suggest that communication programmes canand do influence HIV-related outcomes among young people, although notfor every variable or in every campaign. The strongest evidence points tochanges in knowledge, interpersonal communication and condom use. How-ever, we need to continue to build the evidence base for the effectiveness ofmass media campaigns among youths and focus especially on comprehensiveprogrammes that go to scale with a combination of television, radio and othersupporting media.

Acknowledgements

The authors thank Michael Sweat, Kevin O’Reilly, and Julie Denison forinviting them to participate in the “synthesizing intervention effectiveness”initiative and for their assistance in identifying some of the articles used inthis review as part of that initiative.

References

1. World Health Organization. HIV/AIDS and adolescents. Child and AdolescentHealth and Development, WHO, Geneva, 200–2004 (http://www.who.int/child-adolescent-health/HIV/HIV_adolescents.htm, accessed 4 May 2004).

2. Scalway T, Deane J. Critical challenges in HIV communication. London, PanosInstitute, 2002.

3. Bertrand JT et al. Systematic review of the effectiveness of masscommunication programmes to change HIV/AIDS-related behaviors. HealthEducation and Behavior, 2006. In press.

4. McKee N, Bertrand JT, Becker-Benton A. Strategic communication in the HIV/AIDS epidemic. New Delhi, Sage Publications, 2004.

5. Middlestadt S et al. Evaluating the impact of a national AIDS prevention radiocampaign in St. Vincent and the Grenadines. Journal of Applied SocialPsychology, 1995, 25:21-34.

6. Magnani RJ et al. Impact of a health communications programme on adolescentreproductive health knowledge, attitudes and behaviors in three cities inParaguay. Washington, DC, Pathfinder International, 2001 (Focus on YoungAdults (FOCUS) Program Working Paper).

239

92-4-120938-0_CH07_239

7. Xiaoming S et al. Integrating HIV prevention education into existing familyplanning services: results of a controlled trial of a community-level interventionfor young adults in rural China. AIDS and Behavior, 2000, 4:103-110.

8. Van Rossem R, Meekers D. (1999b) An evaluation of the effectiveness oftargeted social marketing to promote adolescent reproductive health inCameroon. Washington, DC, Population Services International, ResearchDivision, 1999 (Working Paper No. 19).

9. Fonseca-Becker et al. HIV/AIDS prevention among youth in upper Guinea:impact evaluation report of a behavior change and community mobilizationcampaign. Baltimore, MD, Johns Hopkins University Bloomberg School ofPublic Health, Center for Communication Programs, 2003.

10. Kim et al. Promoting sexual responsibility among young people in Zimbabwe.International Family Planning Perspectives, 2001, 27:11-19.

11. Meekers D, Stallworthy G, Harris J. Changing adolescents’ beliefs aboutprotective sexual behavior: the Bostwana Tsa Banana programme.Washington, DC, Population Services International, Research Division, 1997(Working Paper No. 3).

12. Van Rossem R, Meekers D. (1999a). An evaluation of the effectiveness oftargeted social marketing to promote adolescent reproductive health inGuinea. Washington, DC, Population Services International, ResearchDivision, 1999 (Working Paper No. 23).

13. Underwood C et al. Reducing the risk of HIV transmission among adolescentsin Zambia: psychosocial and behavioural correlates of viewing a risk-reductionmedia campaign. Journal of Adolescent Health, 2006, 38:55e1-55e13(available from http://dx.doi.org/10.1016/j.jadohealth.2004.09.022).

14. Pettifor AE et al. Young people’s sexual health in South Africa: HIV prevalenceand sexual behaviors from a nationally representative household survey.AIDS, 2005, 19:1525-1534.

15. Pettifor AE et al. HIV and sexual behaviour among young South Africans: anational survey of 15-24 year olds. Johannesburg, Reproductive HealthResearch Unit, University of the Witwatersrand, 2004.

16. Babalola S, Ouedraogo D, Vondrasek C. Motivation for late sexual debut in Coted’Ivoire and Burkina Faso: a positive deviance inquiry. Journal of HIV/AIDSPrevention Education for Adolescents and Children, 2006. In press.

17. Goldstein S et al. Communicating HIV and AIDS, what works? A report on theimpact evaluation of Soul City’s fourth series. Journal of Health Communication,2005, 10:465-483.

18. Scheepers E et al. Evaluating health communication – a holistic overview of theimpact of Soul City IV. Australian Journal of Health Promotion, 2004,15:121-133.

19. Peltzer PT, Seoka P. Evaluation of HIV/AIDS prevention intervention messageson a rural sample of South African youths’ knowledge, attitudes, beliefs andbehaviours over a period of 15 months. Journal of Child and AdolescentMental Health 2004,16:93-102.

20. Meekers D. The effectiveness of targeted social marketing to promoteadolescent reproductive health: the case of Soweto, South Africa. Journal ofHIV/AIDS Prevention and Education for Adolescents and Children, 2000,3:73-92.

240

92-4-120938-0_CH07_240

21. Geary CW et al. Using global media to reach youth: the 2002 MTV Staying Alivecampaign. Arlington, VA, Family Health International, 2004.

22. Tweedie IM et al. Ghana Stop AIDS Love Life campaign, phase 1: February2000-June 2001 Evaluation Report. Baltimore, MD, Johns Hopkins University,Center for Communication Programs, 2002 (Technical Report).

23. Speizer IS, Magnani RJ, Colvin CE. The effectiveness of adolescentreproductive health interventions in developing countries: a review of theevidence. Journal of Adolescent Health, 2002, 33:324-348.

24. Family Health International. Intervention strategies that work for youth:summary of FOCUS on young adults: end of programme report. Arlington, VA,Family Health International, YouthNet Program, (2002).

25. Victora CG, Habicht JP, Bryce J. Evidence-based public health: moving beyondrandomized trials. American Journal of Public Health, 2004, 94:400-405.

26. Kincaid DL et al. Impact of a mass media vasectomy promotion campaign inBrazil. International Family Planning Perspectives, 1996, 4:169-175.

27. Piotrow PT et al. Health communication: lessons from family planning andreproductive health. Westport, CT, Praeger, 1997.

28. United Nations. Declaration of commitment on HIV/AIDS. United NationsGeneral Assembly Special Session on HIV/AIDS, 2001 (http://www.un.org/ga/aids/coverage/FinalDeclarationHIVAIDS.html, accessed 6 August 2004).

29. Maibach E, Holtgrave DR. Advances in public health communication. AnnualReview of Public Health, 1995, 16:219-238.

30. Piotrow PT, de Fossard E. Entertainment-education as a public healthintervention. In: Singhal A et al, eds. Entertainment-education and socialchange: history, research, and practice. Mahway, NJ, 2003.

241

92-4-120938-0_CH07_241

92-4-120938-0_CH07_242

8. The effectiveness of communityinterventions targeting HIV and AIDSprevention at young people indeveloping countriesEleanor Maticka-Tyndalea & Chris Brouillard-Coylea

Objective To identify successful HIV/AIDS prevention interventionstargeting youths and delivered in geographically bounded communities (forexample, rural villages, urban settlements or neighbourhoods) in developingcountries.

Methods A systematic review and synthesis of studies evaluating interven-tions that were published between January 1990 and December 2004 wasconducted. Using predetermined criteria, all interventions were summarizedinto multiple tables to facilitate comparison. Results of the evaluations ofeach of four types of intervention were reviewed using predetermined thresh-olds of evidence. The four types of interventions were classified as follows.Type 1 interventions were those targeting youths and delivered throughexisting organizations or centres that served youths. Type 2 were those tar-geting youths but not affiliated with existing organizations or centres. Type3 were those targeting all community members and delivered through tradi-tional kinship networks. Type 4 were those targeting communities as a wholeand delivered through community-wide events.

Findings Evaluations of 22 interventions were reviewed. Type 1 interven-tions produced primarily positive results at the required threshold of evidence.They are recommended for use in scaling-up projects but should be subjectto continued rigorous evaluations. Studies of all other intervention types pro-duced primarily positive results, but the evaluations were less rigorous soclear conclusions could not be drawn about their effectiveness. It is recom-mended that these interventions be continued and that priority should be givento implementing rigorous evaluations of these interventions.

Conclusions Considerable creativity, ingenuity and commitment is demon-strated in designing and delivering HIV interventions but there is a paucityof adequate evidence of their effectiveness. This precludes identification ofthe types of interventions that actually produce the targeted changes. It is

a Department of Sociology and Anthropology, University of Windsor, 401 Sunset Ave, Windsor,Ontario N9B 3P4, Canada. Correspondence should be sent to Dr Maticka-Tyndale(email: maticka@uwindsor.ca).

243

92-4-120938-0_CH08_243

essential that governments and donor agencies invest in high quality processand outcome evaluations and cost–benefit analyses so that effective inter-ventions can be identified and promoted.

8.1 Introduction

There is increasing recognition that young people are at the centre of the AIDSpandemic regardless of whether they are living in countries with generalizedor concentrated epidemics. Not only are they carrying a disproportionatelyhigh burden of infection but they also consistently face conditions and cir-cumstances that make them vulnerable to new infection (see chapter 2). TheUnited Nations General Assembly Special Session on HIV/AIDS (UNGASS)(1) acknowledged the need to focus attention on young people by specifyinggoals for interventions targeting youths (see Paragraph 53). Reaching thesegoals requires that governments, organizations working with youth and donoragencies ensure that young people (those aged 15–24 years) have access toinformation about HIV and health services, to interventions that help thembuild skills to avoid becoming infected with HIV, and that the vulnerabilityto and prevalence of HIV infection among young people is decreased. Therehas been international acceptance of these goals. What remains is to identifythe best ways of achieving them.

Our objective is to strengthen the evidence base for interventions targetingyoung people in developing countries, particularly those interventions thatare delivered in geographically bounded communities. These communitiesmay be rural villages, urban settlements or neighbourhoods. What distin-guishes them in this case is that they are where young people live regardlessof whether they are in school or out of school, married or unmarried, em-ployed or unemployed. As such, interventions in these settings have thepotential to reach large numbers of people. The focus of this paper is onidentifying the types of interventions delivered in geographically boundedcommunities that have demonstrated success in achieving at least one of theUNGASS goals.

8.2 Methods

A systematic review of the literature was undertaken to locate interventionsdelivered in geographically bounded communities. We searched the follow-ing electronic databases: PsycINFO, AIDSLINE, Medline, POPLINE, ERIC,Sociological Abstracts, Social Sciences Abstracts and the Leeds HealthEducation Effectiveness Database. We also searched the reference sectionsof articles retrieved, conference proceedings, issues of journals that had pub-lished articles evaluating interventions and the web sites of organizationsinvolved in AIDS-related programmes and research (AEGiS, AVERT, the

244

92-4-120938-0_CH08_244

CORE Initiative, CAPS – the Center for AIDS Prevention Studies, Devel-opment Gateway, the United Kingdom Department for InternationalDevelopment, Europeer, Family Health International, the Pan AmericanHealth Organization, UNAIDS, UNFPA, UNESCO, UNICEF, WHO). Wealso sent requests to individuals knowledgeable about HIV prevention orworking for organizations involved in HIV prevention. Publications appear-ing in both peer-reviewed journals and grey literature were retrieved, andauthors or sponsoring organizations were contacted by email if additionalinformation was needed.

Inclusion criteria were set in consultation with the editors of this report.Articles and reports were reviewed by both authors to determine whether theymet the inclusion criteria outlined in Table 8.1. Studies that met the inclusioncriteria were summarized and put into a chart for comparison. Further detailon the studies is available on the web (www.who.int/child-adolescent-health).An iterative process of discussion and re-reading of documents was used toachieve consensus on categorizing the interventions.

Information on the shared characteristics of interventions was reviewed and,based on discussions with colleagues experienced in intervention research orprogramme delivery, interventions were divided into four types, whichdiffered in their target population and their mode of delivery. Type 1 inter-ventions and type 2 interventions target only young people (aged 15–24 years)and focus on providing information, building skills and changing behaviours.Type 1 interventions are affiliated with existing organizations or centres thatserve youths. Through this affiliation, the organization or centre’s acceptancewithin the community as well as their mechanisms for reaching young people,their infrastructure and mode of sustainability become available to the inter-vention. However, a suitable host organization must be found for theseinterventions and a working relationship with, placement of, and support forthe intervention must be negotiated; additionally, sensitive topics must beincluded in the intervention without challenging the position of the organi-zation in the community. Type 2 interventions create their own mechanismand infrastructure to deliver the intervention. While negotiating with anexisting organization is not necessary, this type of intervention must establishacceptance with gatekeepers, develop a mechanism to reach young people,as well as a sustainable method of delivery. A suitable location must also befound and infrastructure for delivering the intervention must be developed.

Type 3 interventions and type 4 interventions are delivered to the communityas a whole. Type 3 interventions use traditional kinship networks to deliverinterventions that have been designed to fit in with local traditions andcustoms for communicating about health and sexuality. These interventionsuse repeated one-on-one discussions or small, often family-based, group

245

92-4-120938-0_CH08_245

discussions in which a relationship is built among those delivering and thosereceiving the intervention. Since delivery of this type of intervention proceedsone individual or family at a time, these are the most labour-intensive type,and attention must be paid to the mechanism of delivery if large numbers of

Table 8.1Inclusion and exclusion criteria used to identify studies for review

Inclusion criteria Exclusion criteria

Some of the intervention content deals withHIV/AIDS

Intervention delivered exclusively to adults(aged > 24 years) or children (aged < 15years)

Youths (aged 15–24 years) included inpopulation targeted by intervention

Intervention delivered primarily throughschool, health facility or media

Description of intervention availableIntervention designed to be delivered ingeographically bounded community

Intervention targets youths living ininstitutional settings

Primary objectives are statedIntervention delivered in a developingcountry

Intervention delivered only in a developedcountry

One or more of the following outcomes isreported for youth: knowledge of HIV/AIDS,skills related to preventing sexualtransmission of HIV, behaviour related topreventing sexual transmission of HIV, HIVprevalence/incidence or outcomes relatedto community awareness of circumstancesand conditions contributing to youthvulnerability

Evaluation study has insufficient evidencefrom which to draw conclusions

Evaluation method described and includesjudgements based on project records orqualitative interviews with participants,cross-sectional surveys with or withoutcomparison groups, surveys conductedbefore and after the intervention with orwithout comparison groups, or randomizedcontrolled trials

No information about design of evaluationprovided

Results reported for youths aged 15–24years

No results reported for youths aged 15–24years

Report published between January 1990and December 2004

Intervention targets youths identified as“especially vulnerable” (for example,intravenous drug users, refugees, sexworkers)

Results published in English, French orSpanish

Results published only in a language otherthan English, French or Spanish

246

92-4-120938-0_CH08_246

people are to be reached. Type 4 interventions deliver their messages throughlarge-scale community activities, such as festivals, community theatre eventsor competitions. They have a broad reach and deliver a uniform message, butthere is little, if any, accommodation or response to individual concerns orcircumstances.

We identified 22 evaluated interventions that met the inclusion criteria. Theirdistribution across intervention types is shown in Figure 1.

8.3 Findings

8.3.1 Intervention types and threshold of evidence

Evidence-based decision-making typically requires the application of rigor-ous evaluation standards to support recommendations. However, as Ross etal. discuss in chapter 4, applying such standards is fraught with difficultywhen interventions targeting behaviour change and community norms arebeing evaluated. Thus, an alternative framework, based on establishing dif-ferent thresholds of evidence, is used here. The evidence required at eachthreshold is based on the typology presented by Habicht et al. (2) and de-scribed by Ross et al. In this framework, a threshold of evidence is set foreach type of intervention. This threshold takes into consideration the feasi-bility of delivering the intervention on a large scale, the acceptability of theintervention to participants and those who are implementing it, its risk ofproducing adverse outcomes, the potential size of the effect, and the presenceof other health and social benefits associated with delivery of the intervention.

Table 8.2 provides information on the criteria and threshold of evidenceneeded to recommend an intervention for each of the four intervention types

Fig. 1.Types of interventions

Intervention Types

In Geographical

Communities

Targeting

Youth

N=17

Targeting Entire

Communities

N=5

TYPE 1

Delivered using

existing

centres

N=11

TYPE 2

Created own system

and structure

for delivery

N=6

TYPE 3

Delivered through

traditional

networks

N=3

TYPE 4

Delivered through

community-

wide activities

N=2

247

92-4-120938-0_CH08_247

Tab

le 8

.2T

hre

sho

ld o

f ev

iden

ce n

eed

ed t

o r

eco

mm

end

wid

esp

read

imp

lem

enta

tio

n o

f ea

ch t

ype

of

inte

rven

tio

na

Inte

rven

tio

n

ty

pe

Fea

sib

ility

Lac

k o

fp

ote

nti

alfo

r ad

vers

eo

utc

om

es

Acc

epta

bili

tyP

ote

nti

alsi

ze o

fef

fect

Oth

erh

ealt

h o

rso

cial

ben

efit

s

Ove

rall

thre

sho

ldC

om

men

ts

1. T

arge

ts y

outh

s an

d is

deliv

ered

usi

ng e

xist

ing

orga

niza

tions

or

cent

res

serv

ing

yout

h

+ +

+-

-+

+ +

+ +

+ +

Mod

erat

eR

equi

res

an e

xist

ing

orga

niza

tion

or c

entr

e th

at is

acce

pted

by

the

com

mun

ity w

ithin

fras

truc

ture

to s

uppo

rtpr

ogra

mm

e. T

he e

ffect

siz

ede

pend

s on

the

reac

h of

the

orga

niza

tion

or c

entr

e2.

Tar

gets

you

ths

and

crea

tes

its o

wn

syst

em a

ndst

ruct

ure

for

deliv

ery

+-

++

+H

igh

Mus

t cre

ate

a sy

stem

of d

eliv

ery

acce

ptab

le to

the

com

mun

ity a

ndth

at a

dequ

atel

y pe

netr

ates

targ

etpo

pula

tion

3. C

omm

unity

-wid

ein

terv

entio

n de

liver

edth

roug

h ex

istin

gtr

aditi

onal

kin

ship

net

wor

ks

+ +

-+

++

++

+M

oder

ate

Mus

t add

ress

soc

ial n

orm

sas

soci

ated

with

com

mun

icat

ing

abou

t sex

ual m

atte

rs w

ithin

the

iden

tifie

d ne

twor

ks4.

Com

mun

ity-w

ide

inte

rven

tion

deliv

ered

thro

ugh

com

mun

ityw

ide

activ

ities

, (eg

. fes

tival

s)

+ +

+-

+ +

+ +

+ +

Mod

erat

eC

omm

unity

act

iviti

es p

rovi

de w

ide

reac

h if

the

appr

oach

isac

cept

able

and

mea

ning

ful t

oco

mm

unity

mem

bers

a D

egre

e of

des

irabi

lity

is in

dica

ted

with

a m

axim

um o

f 3 “

+”

sign

s. D

egre

e of

und

esira

bilit

y is

indi

cate

d w

ith a

max

imum

of 3

“-”

sig

ns.

248

92-4-120938-0_CH08_248

studied. All types of interventions must address the challenges posed by thepotential delivery of misinformation and community backlash. For example,misinformation may result from personal interpretation, lack of comprehen-sion, errors in recall or cultural norms associated with the information or itscommunication. Cultural resistance to the advocacy of condoms in much ofsub-Saharan Africa, for example, has at times resulted in schoolteachers,government officials, community leaders or religious leaders presenting in-formation about condoms in ways intended to discourage their use (3–5).Community backlash may occur if the content of an intervention is consideredinappropriate for young people (most typically this happens with interven-tions aimed at girls). While the challenge posed by misinformation andbacklash is evident, less obvious is the opportunity that these mishaps affordto open discussions of a community’s beliefs and norms and the potential forshifting such norms. This was the case for three interventions reviewed here(denoted as I, S and T in Table 8.3) (6–9). The threat posed by backlash andmisinformation are acknowledged in the negative rating given for potentialadverse effects for all intervention types. The greater potential for damageposed by a backlash to type 1 interventions, where it may threaten the ongoingwork of the host organization, is acknowledged in the more negative ratinggiven to this type of intervention.

Also common across intervention types is the possibility of producing otherhealth and social benefits by engaging participants in conscious considerationof their health, the possibility of changing their behaviour to protect theirhealth, and the adoption of attitudes favouring delayed gratification in orderto experience long-term health benefits. Each of these could extend beyondHIV to other areas of health and social life. As a result, all types of interven-tions received at least a small positive rating in the category assessing otherhealth and social benefits.

When considering the remaining threshold criteria, type 1 and type 4 inter-ventions benefit from their connection with existing community organiza-tions and events. The feasibility of the interventions as well as theiracceptability and reach may be enhanced by their association with and use ofthe infrastructures, facilities and delivery mechanisms of their host organi-zations. In addition, there is a potential synergy between the social benefitsand the health benefits provided by the host organization or event and theHIV interventions. Since type 4 interventions are delivered to an entire com-munity, their reach is especially wide; however, the personal relevance andspecificity of their message is limited, potentially weakening their effect.Based on these characteristics, intervention types 1 and 4 are judged to requirea moderate threshold of evidence before they can be recommended forinvestment and scaling-up – that is, evidence is needed at the level of plau-sibility. (See description of levels of evidence in chapter 4 and in Glossary).

249

92-4-120938-0_CH08_249

Tab

le 8

.3D

escr

ipti

on

of

the

inte

rven

tio

ns

by

stu

dy

Stu

dy,

loca

tio

n a

nd

dat

esT

arg

et p

op

ula

tio

n a

nd

pri

mar

y o

bje

ctiv

esD

escr

ipti

on

Inte

rven

tio

n t

ype

1 (t

arg

etin

g y

ou

ths

and

del

iver

ed u

sin

g e

xist

ing

yo

uth

org

aniz

atio

ns

or

cen

tres

)A

– C

amer

oon:

Nko

ngsa

mba

, 199

7–19

98 (

15)

• Y

outh

s ag

ed 1

2–25

yea

rs•

Incr

ease

con

trac

eptiv

e us

e•

Red

uce

inci

denc

e of

ST

Is,a

HIV

and

unin

tend

ed p

regn

anci

es

Car

eful

ly s

elec

ted

peer

edu

cato

rs w

ere

give

n1

wee

k of

trai

ning

(w

ith q

uart

erly

ret

rain

ing)

;th

ey h

ave

a hi

gh in

vest

men

t in

the

proj

ect a

ndde

liver

one

-on-

one

and

grou

p ac

tiviti

es th

atin

clud

e re

prod

uctiv

e he

alth

info

rmat

ion,

refe

rral

s an

d pr

omot

iona

l mat

eria

lsB

– C

amer

oon:

Mok

olo

neig

hbou

rhoo

d of

Yao

undé

(16

, 17)

• A

dole

scen

ts•

Impr

ove

repr

oduc

tive

heal

th k

now

ledg

eP

rom

ote

beha

viou

r ch

ange

usi

ng tr

aine

d pe

ered

ucat

ors

and

info

rmat

ion,

edu

catio

n an

dco

mm

unic

atio

n pu

blic

atio

ns

Car

eful

ly s

elec

ted

and

supe

rvis

ed p

eer

educ

ator

s de

liver

info

rmal

talk

s, o

ne-o

n-on

ese

ssio

ns, c

onfe

renc

es, r

ound

tabl

edi

scus

sion

s, c

ultu

ral a

nd a

thle

tic a

ctiv

ities

, as

wel

l as

a m

agaz

ine

cont

aini

ng r

epro

duct

ive

heal

th in

form

atio

nC

– N

iger

ia a

nd G

hana

,19

94–1

997

(28)

• Y

outh

s ag

ed 1

2–24

yea

rs, b

oth

in a

nd o

ut o

fsc

hool

• Im

prov

e kn

owle

dge

of s

exua

lity

and

repr

oduc

tive

heal

th is

sues

• P

rom

ote

safe

r se

x an

d co

ntra

cept

ive

use

amon

g th

ose

who

are

sex

ually

act

ive

8 yo

uth-

serv

ice

orga

niza

tions

in N

iger

ia, 2

inG

hana

trai

ned

staf

f to

deve

lop

prog

ram

me;

staf

f tra

ined

pee

r ed

ucat

ors

to d

eliv

er o

ne-o

n-on

e di

scus

sion

s an

d gr

oup

activ

ities

, to

dist

ribut

e m

ater

ial c

onta

inin

g ed

ucat

ion

abou

tan

d co

unse

lling

on

sexu

al a

nd r

epro

duct

ive

heal

th, r

efer

rals

to o

ther

ser

vice

sD

– B

ali:

Kut

a, U

bud,

Can

dida

sa a

nd L

ovin

a19

95–1

996

(13)

• B

ali a

ge-m

ate

(cul

tura

lly d

efin

ed c

ohor

ts)

grou

p m

embe

rs•

Util

ize

esta

blis

hed

Bal

ines

e yo

uth

grou

ps to

prov

ide

info

rmat

ion

on H

IV p

reve

ntio

n

Pee

r ed

ucat

ors

from

exi

stin

g ag

e-m

ate

(cul

tura

lly d

efin

ed c

ohor

t) g

roup

s to

whi

ch a

llyo

uth

belo

ng fr

om p

uber

ty to

mar

riage

rece

ived

3-d

ay tr

aini

ng to

del

iver

a s

ingl

e7-

hour

ses

sion

to a

ge-m

ate

grou

p co

ntai

ning

info

rmat

ion

on H

IV r

isk,

tran

smis

sion

and

prev

entio

n

250

92-4-120938-0_CH08_250

E –

Gha

na:

Fou

r pr

ojec

t are

as c

onne

cted

with

NG

Osb

begi

nnin

g in

199

8; m

ultic

ount

ry in

itiat

ive

(18)

• A

dole

scen

ts•

Rea

ch y

outh

s bo

th in

and

out

of s

choo

l with

info

rmat

ion

abou

t rep

rodu

ctiv

e he

alth

Pee

r ed

ucat

ors

trai

ned

peer

pro

mot

ers

who

recr

uit p

eer

cont

acts

and

del

iver

cou

nsel

ling,

disc

ussi

on g

roup

s, w

orks

hops

, dra

ma

and

mus

ic fo

cusi

ng o

n re

prod

uctiv

e he

alth

info

rmat

ion

and

serv

ices

, as

wel

l as

prov

idin

gno

n-pr

escr

iptio

n fa

mily

pla

nnin

g m

etho

dsF

– Z

ambi

a:4

NG

O-b

ased

pro

ject

s(d

ate

not r

epor

ted)

(19

)

• Y

outh

s ag

ed 1

4–25

yea

rs a

nd g

atek

eepe

rs•

Incr

ease

kno

wle

dge

of H

IV•

Pro

mot

e sa

fer

beha

viou

r• B

uild

cap

acity

to re

spon

d to

and

cop

e w

ith H

IV/

AID

S

Pee

r ed

ucat

or p

rogr

amm

es w

ere

part

of

over

all r

each

; pee

r ed

ucat

ors

with

reg

ular

lyup

date

d tr

aini

ng m

ater

ials

del

iver

dra

ma,

gam

es a

nd m

usic

that

focu

s on

ser

vice

s fo

ryo

uths

and

wom

en, c

ondo

m d

istr

ibut

ion,

life

-sk

ills

trai

ning

, gen

der

awar

enes

s an

dse

nsiti

zatio

nG

– M

alaw

i:m

id-1

997

to D

ec. 2

000

(12)

• Y

outh

s ag

ed 5

–20

year

s•

Com

pete

nce

and

life

skill

s to

pro

mot

esu

stai

ned

HIV

pre

vent

ion

amon

g ch

ildre

nag

ed 5

–14

year

s•

Red

uce

leve

ls o

f HIV

in y

outh

s ag

ed 1

5–20

year

s

You

th te

chni

cal s

ubco

mm

ittee

s tr

ain

club

mat

rons

and

pat

rons

, lin

k w

ith U

NIC

EF

, and

guid

e de

liver

y of

ser

vice

s th

at in

clud

e an

ti-A

IDS

clu

bs a

nd li

fe s

kills

edu

catio

n fo

r ou

t-of

-sc

hool

you

ths,

focu

sing

on

repr

oduc

tive

heal

thin

form

atio

n, s

ervi

ces

and

prom

otio

nal

mat

eria

lsH

– Z

ambi

a:tw

o pr

ovin

ces

in n

orth

ern

Zam

bia,

(da

te n

otre

port

ed)

(26)

• Y

outh

s in

sch

ool a

nd c

omm

unity

ant

i-AID

Scl

ubs

• T

rain

you

ths

to c

are

for

peop

le li

ving

with

HIV

/A

IDS

and

orp

hans

and

vul

nera

ble

child

ren

inho

pe o

f ins

pirin

g sa

fe b

ehav

iour

Hea

lth p

rofe

ssio

nals

trai

ned

yout

h ca

regi

vers

,w

ith fo

llow

up

afte

r 2

mon

ths

and

ongo

ing

trai

ning

eve

ry 3

mon

ths;

trai

ned

yout

hs p

rovi

deca

re to

peo

ple

livin

g w

ith H

IV/A

IDS

and

orph

ans

and

vuln

erab

le c

hild

ren;

pro

vide

repr

oduc

tive

heal

th in

form

atio

n, m

ater

ials

and

supp

ort

I – K

enya

:M

atha

re s

lum

, Nai

robi

,19

87, e

xpan

ded

in 1

992

to in

clud

e gi

rls (

6)

• A

dole

scen

ts a

ged

9–18

yea

rs•

Cre

ate

oppo

rtun

ities

for

yout

h de

velo

pmen

t•

Impa

rt H

IV/A

IDS

info

rmat

ion

as w

ell a

sm

otiv

atio

n to

sta

y sa

fe

Dev

elop

s lif

e sk

ills

thro

ugh

socc

er p

layi

ng,

com

mun

ity s

ervi

ces

and

info

rmal

conv

ersa

tions

am

ong

yout

hs; p

rogr

amm

e al

soof

fers

fina

ncia

l ass

ista

nce

for

educ

atio

n an

dH

IV in

form

atio

n pr

ovid

ed v

ia p

eer

educ

ator

s

251

92-4-120938-0_CH08_251

Stu

dy,

loca

tio

n a

nd

dat

esT

arg

et p

op

ula

tio

n a

nd

pri

mar

y o

bje

ctiv

esD

escr

ipti

on

J –

Nep

al:

Ter

ai d

istr

ict o

f Naw

alpa

rasi

and

Kaw

asot

i and

sub

urbs

of K

athm

andu

,(d

ate

not r

epor

ted)

(23

)

• A

dole

scen

ts a

nd a

dults

• U

se e

xist

ing

yout

h co

mm

unic

atio

n ne

twor

ks to

incr

ease

rep

rodu

ctiv

e he

alth

kno

wle

dge

Act

iviti

es d

esig

ned

and

impl

emen

ted

by lo

cal

yout

hs w

ho d

eliv

er a

dole

scen

t-fr

iend

ly h

ealth

serv

ices

and

pro

vide

a s

uppo

rt n

etw

ork

for

heal

th p

rofe

ssio

nals

; pee

r ed

ucat

ion

and

coun

selli

ng a

re a

lso

offe

red

as w

ell a

s ad

ult

educ

atio

n an

d dr

ama

addr

essi

ng H

IVin

form

atio

n an

d so

cial

nor

ms

K –

Ken

ya:

Nye

ri, 1

997–

2001

(24

)•

Unm

arrie

d yo

uths

age

d 10

–24

year

s an

din

fluen

tial a

dults

• D

elay

ons

et o

f sex

ual a

ctiv

ity•

Pre

vent

thos

e w

ho a

re s

exua

lly a

ctiv

e fr

omsu

fferin

g ne

gativ

e co

nseq

uenc

es o

f act

ivity

Car

eful

ly s

elec

ted

youn

g pa

rent

s de

liver

eded

ucat

iona

l act

iviti

es (

via

grou

p di

scus

sion

s,dr

ama

and

lect

ures

), c

ouns

ellin

g, r

efer

rals

for

heal

th s

ervi

ces

and

sens

itiza

tion

of a

dults

to th

esi

tuat

ions

and

nee

ds o

f you

ths

with

a fo

cus

onre

prod

uctiv

e he

alth

info

rmat

ion

Inte

rven

tio

n t

ype

2 (t

arg

etin

g y

ou

ths

and

cre

atin

g o

wn

sys

tem

an

d s

tru

ctu

re f

or

del

iver

y)L

– G

hana

:12

dis

tric

ts in

upp

er e

aste

rn a

nd n

orth

ern

Gha

na, 1

996

(29)

• Y

outh

s ag

ed 1

5–25

yea

rs•

Pro

mot

e H

IV/A

IDS

aw

aren

ess

and

know

ledg

ean

d sa

fer

sex

prac

tices

thro

ugh

peer

-to-

peer

educ

atio

n

You

th to

You

th is

one

of m

any

proj

ects

bei

ngru

n by

diff

eren

t loc

al o

rgan

izat

ions

; car

eful

lyse

lect

ed p

eer

educ

ator

s ar

e gi

ven

5-da

ytr

aini

ng, 3

-day

ref

resh

er c

ours

es, y

early

revi

ewm

eetin

g an

d tr

aini

ng o

f tra

iner

s w

orks

hop;

they

deliv

er w

eekl

y pe

er e

duca

tion

sess

ions

, gro

upac

tiviti

es c

onta

inin

g re

prod

uctiv

e he

alth

info

rmat

ion

and

cond

om d

emon

stra

tions

M –

Sri

Lank

a:lo

w in

com

e ur

ban

area

of K

andy

and

the

Uni

vers

ity o

f Per

aden

iya

(30)

(da

te n

otre

port

ed)

• U

rban

you

ths

aged

17–

27 y

ears

• Le

arn

sexu

al n

egot

iatio

n an

d de

cisi

on-m

akin

gsk

ills

nece

ssar

y to

avo

id r

isk,

suc

h as

saf

e se

xpr

actic

es

Pee

r ed

ucat

ors

recr

uite

d, s

uper

vise

d an

dte

chni

cally

ass

iste

d to

faci

litat

e gr

oup

sess

ions

that

incl

ude

fact

ual p

rese

ntat

ions

, writ

ten

activ

ities

, gro

up d

iscu

ssio

n an

d pr

oble

m-

solv

ing

arou

nd r

elat

ions

hips

, sex

ualit

y an

din

form

atio

n on

ST

Is, H

IV a

nd A

IDS

N –

Indi

a:G

ujar

at, 1

998

(20)

• Y

oung

men

age

d 15

–30

year

sO

utre

ach

wor

kers

trai

n pe

er e

duca

tors

and

wor

ker

educ

ator

s to

run

gro

up d

iscu

ssio

ns

252

92-4-120938-0_CH08_252

• Eng

age

mal

es in

repr

oduc

tive

heal

th e

duca

tion,

sexu

al ri

sk re

duct

ion

and

early

trea

tmen

t of H

IVan

d S

TIs

usin

g na

rrat

ive

inte

rven

tion

mod

el w

ithac

tiviti

es o

n se

men

loss

con

cern

s in

tegr

ated

into

HIV

and

ST

I edu

catio

n; th

is p

rogr

amm

eal

so in

clud

ed in

com

e ge

nera

tion,

sel

f-he

lpgr

oups

for

thos

e in

the

illeg

al li

quor

trad

e,co

uple

s’ c

lubs

and

3-d

ay h

ealth

fairs

how

ever

,th

ese

aspe

cts

of th

e pr

ogra

mm

e do

not

fall

with

in th

e sc

ope

of th

is p

aper

O–

Indi

a:14

/261

urb

an s

lum

s in

Luck

now

(25

) (d

ate

not r

epor

ted)

• A

dole

scen

t mal

es•

Incr

ease

aw

aren

ess

of S

TI r

isk

• E

xpan

d se

x ed

ucat

ion

to in

clud

e fo

rms

ofse

xual

ity o

ther

than

coi

tus

Ret

ired

psyc

hiat

rist a

nd 3

mal

e as

sist

ants

deliv

er p

rogr

amm

e in

clud

ing

a se

cure

box

for

anon

ymou

s qu

estio

ns fr

om p

artic

ipan

ts, t

aped

educ

atio

nal m

essa

ges,

lect

ures

and

ans

wer

ques

tions

focu

sing

on

repr

oduc

tive

heal

thin

form

atio

nP

– G

hana

:G

a M

ashi

e ar

ea o

f Acc

ra,

1998

(29

)

• Y

outh

s•

Pro

mot

e at

titud

inal

and

beh

avio

ural

cha

nges

rela

ted

to H

IV/A

IDS

and

oth

er S

TIs

am

ong

yout

hs b

oth

in a

nd o

ut o

f sch

ool

Sup

ervi

sed

peer

edu

cato

rs g

iven

5-d

ay tr

aini

ng(w

ith r

efre

sher

trai

ning

6 m

onth

s la

ter)

to r

ungr

oup

disc

ussi

ons,

rol

e pl

ay, d

ebat

es a

ndga

mes

with

rep

rodu

ctiv

e he

alth

info

rmat

ion;

prov

ide

acce

ss to

con

dom

s, h

ealth

ser

vice

san

d co

unse

lling

and

chi

ldca

re s

uppo

rt s

ervi

ces;

linke

d to

pro

gram

mes

run

by

othe

r N

GO

sta

rget

ing

yout

hs w

ho w

ere

in s

choo

l or

out o

fsc

hool

thes

e ar

e ot

her

aspe

cts

of th

epr

ogra

mm

e w

hich

are

not

par

t of t

he s

cope

of

this

pap

erQ

–N

epal

:T

him

i and

Bal

kot (

27)

(dat

e no

tre

port

ed)

• Y

outh

15-

24•

Ena

ble

beha

viou

ral c

hang

e to

pre

vent

HIV

/A

IDS

and

ST

I•

Incr

ease

acc

ess

to y

outh

-frie

ndly

hea

lth c

are

You

th A

ctio

n G

roup

s de

liver

trai

ning

in s

tree

tdr

ama,

lead

ersh

ip, H

IV in

form

atio

n, b

asic

coun

selli

ng a

nd tr

aini

ng-o

f-tr

aine

rs, w

ith fo

cus

on re

prod

uctiv

e he

alth

info

rmat

ion

and

serv

ices

Inte

rven

tio

n t

ype

3 (c

om

mu

nit

y-w

ide

inte

rven

tio

n d

eliv

ered

th

rou

gh

fam

ily n

etw

ork

s)R

–U

gand

a:2

Bag

anda

com

mun

ities

in r

ural

• A

dole

scen

t girl

s ag

ed 1

3–19

yea

rs w

ere

the

prim

ary

focu

s, b

ut “s

enga

s” a

cces

sibl

e to

ent

ire“S

enga

s” a

re g

iven

7 d

ays’

trai

ning

, mon

thly

mee

tings

and

6-m

onth

ly w

orks

hops

; the

y

253

92-4-120938-0_CH08_253

Stu

dy,

loca

tio

n a

nd

dat

esT

arg

et p

op

ula

tio

n a

nd

pri

mar

y o

bje

ctiv

esD

escr

ipti

on

Uga

nda

(21,

22)

(da

tes

and

exac

t loc

atio

nsno

t rep

orte

d)• c

omm

unity

(tra

ditio

nally

the

“sen

ga” o

r “fa

ther

’ssi

ster

” is

a c

hann

el o

f com

mun

icat

ion

abou

tse

xual

beh

avio

ur fo

r ad

oles

cent

girl

s)•

Use

trai

ned

“sen

gas”

to p

rovi

de a

dole

scen

tgi

rls w

ith in

form

atio

n on

rep

rodu

ctiv

e he

alth

deliv

er c

omm

unity

sup

port

ed o

ne-o

n-on

eac

tiviti

es a

nd d

istr

ibut

e co

ndom

s

S–

Bur

kina

Fas

o:4

villa

ges,

200

3 (7

)•

Mar

ried

and

unm

arrie

d ad

oles

cent

s•

Pro

vide

rep

rodu

ctiv

e he

alth

info

rmat

ion,

acce

ss to

birt

h co

ntro

l and

con

dom

s•

Wor

k to

influ

ence

com

mun

ity g

ende

r no

rms

30 m

arrie

d, a

dole

scen

t mot

hers

trai

ned

as p

eer

educ

ator

s pr

ovid

ed e

duca

tiona

l sup

port

kits

for

hom

e vi

sits

and

focu

sed

on o

ne-t

o-on

eco

unse

lling

and

pro

vidi

ng r

epro

duct

ive

heal

than

d H

IV p

reve

ntio

n in

form

atio

nT

–U

gand

a:M

pigi

and

Igan

ga, 1

992–

1994

(8, 9

)

• M

uslim

fam

ilies

in c

omm

unity

• U

se M

uslim

rel

igio

us s

truc

ture

to in

crea

sekn

owle

dge

of A

IDS

• Id

entif

y an

d m

odify

ris

ky p

ract

ices

Tra

ined

imam

s an

d fa

mily

AID

S w

orke

rs;

imam

s in

trod

uced

and

sup

port

ed A

IDS

wor

kers

in h

ouse

hold

-bas

ed e

duca

tion

focu

sing

on

HIV

and

AID

SIn

terv

enti

on

typ

e 4

(co

mm

un

ity-

wid

e in

terv

enti

on

del

iver

ed t

hro

ug

h c

om

mu

nit

y-b

ased

act

ivit

ies)

U–

Tha

iland

:A

ll 77

vill

ages

in S

uwan

naku

hadi

stric

t, N

ongb

ua L

amph

u pr

ovin

ce, n

orth

ern

Tha

iland

, Jul

y 19

95 (

14)

• C

omm

unity

mem

bers

age

d 15

–35

year

s•

Incr

ease

sel

f-ef

ficac

y, s

kills

and

con

fiden

ce in

cond

om u

se a

nd d

iscu

ssio

ns w

ith p

artn

er

Use

d tr

aini

ng-o

f-tr

aine

rs a

ppro

ach;

rec

ruite

dvi

llage

lead

ers

to p

artic

ipat

e in

con

dom

rel

ayra

ces

at v

illag

e, s

ubdi

stric

t and

dis

tric

t lev

el;

incl

uded

con

dom

dem

onst

ratio

ns a

nd a

focu

son

the

deve

lopm

ent o

f sel

f effi

cacy

inac

cess

ing,

dis

cuss

ing

and

usin

g co

ndom

sV

–U

nite

d R

epub

lic o

f Tan

zani

a:K

isar

awe,

Mus

oma,

Mas

asi,

Bag

amoy

odi

stric

ts (

10, 1

1) (

date

not

rep

orte

d)

• O

ut-o

f-sc

hool

you

ths

and

othe

r co

mm

unity

mem

bers

• E

nabl

e yo

uths

to r

educ

e th

eir

risk

of H

IVin

fect

ion

thro

ugh

popu

lar

thea

tre

You

ng a

rtis

ts tr

aine

d in

pop

ular

thea

tre

and

fact

s ab

out H

IV/A

IDS

del

iver

cas

cade

trai

ning

,au

dien

ce-d

irect

ed d

ram

as w

ith d

iscu

ssio

nsan

d w

orks

hops

focu

sing

on

HIV

/AID

Sin

form

atio

n an

d ex

plor

atio

n of

loca

l situ

atio

nsth

at m

ay in

crea

se th

e ris

k of

HIV

tran

smis

sion

a S

TIs

= s

exua

lly tr

ansm

itted

infe

ctio

ns.

b N

GO

s =

non

gove

rnm

enta

l org

aniz

atio

ns.

254

92-4-120938-0_CH08_254

Type 3 interventions, which work through traditional kinship networks, alsorequire a moderate threshold of evidence. Their feasibility and the potentialsize of their effect are weaker than for types 1 and 4 because they rely on alarger number of intervention leaders and are delivered on a one-on-one basisor on a family or household basis, thus they require greater effort to reach alarge number of community members. However, this intervention type has astronger potential to produce other social and health benefits because thepersonalized nature of the delivery makes it possible to incorporate otherbeneficial messages.

Intervention type 2 is judged to require a high threshold of evidence. Inter-ventions of this type must build their own delivery mechanism and infras-tructure, find a location for delivery and address issues of acceptabilitywithout forming an alliance with other already accepted community activitiesor organizations. This added effort and cost limits their feasibility, accept-ability and potential effect size as well as their ability to bring about otherhealth and social benefits.

None of the studies reviewed here provided any costing information. At most,there were comments about costs. For example, a participatory theatreapproach in the United Republic of Tanzania found that the cost of usingvideos of their productions to extend the reach of the intervention was pro-hibitive (study V in Table 8.3) (10, 11); in study G, the activities of anti-AIDSclubs that relied on sports and audiovisual equipment could not be sustainedbecause of the cost of maintaining, repairing and replacing damaged andstolen equipment (12). Without further information, the effect of costs on thefeasibility of interventions could not be judged for any of the interventiontypes.

8.3.2 Description of interventions

Table 8.3 briefly summarizes information about each intervention’s location,target population and primary objectives as well as giving a brief descriptionof the study. (Additional details are available on the web.)

8.3.2.1 Theoretical frameworks

Only three studies explicitly articulated a theoretical framework of behaviourchange. These frameworks included social influence theory (study D) (13),social learning theory (study U) (14), and theatre for change (study V) (10,11). Some type 1 and 2 studies commented on the assumptions on whichthey were based, with the most common set of assumptions those of theknowledge, attitudes and behaviour model – that is, that changes in knowl-edge and attitudes are necessary and potentially sufficient to change be-haviour (type 1:A, B, E, F; type 2: N) (15–20). However, not all of the

255

92-4-120938-0_CH08_255

knowledge, attitude and behaviour elements were necessarily measured inthe evaluations of these interventions, and no evaluations tested the associa-tion among knowledge, attitudes and behaviour. Some interventions sup-ported their use of peer educators with the claim that peers were better ableto effect change than adults (type 1: A, B, E) (15–18). However, only onestudy compared the difference in programme delivery between peers andadults (type 3: R) (21, 22), and none of the studies articulated a theory of howpeers influenced each other. Several intervention studies focused specificallyon cultural appropriateness either in the content or method of delivery (type1: F, J, K; type 2: N, O; type 3: R, T; type 4: U, V) (8–11, 14, 19–25). In thesestudies, cultural appropriateness was described as either a contributor toeffecting change or as being necessary to effect change. Mention was madeof the importance of building self-esteem and peer bonding around positivesocial behaviours (type 1: I) (6); in two studies there was also mention ofincreasing the perception among young people that “AIDS is real” byinvolving them in caring for people with HIV (type 1: H) (26). In the 10remaining studies, no mention was made of a theoretical framework or theassumptions on which a model of behaviour change was built.

Models of programme delivery were even less likely to be articulated. Threepeer-led interventions described the use of a cascade or step-down model ofdelivery in which training programmes were delivered through an everwidening circle of peer leaders as those who were originally trained went onto train others (type 1: E, F; type 2: Q) (18, 19, 27). One other study specif-ically described a model that linked organizations that were delivering theintervention with other organizations such as health centres that could providecounselling, testing and healthcare support (type 1: H) (26). Other interven-tion studies described methods used to train leaders and deliver programmesbut did not articulate the specific models or theoretical frameworks on whichthese were built.

8.3.2.2 Objectives

The objectives of most interventions were to convey information, build skillsneeded to establish or change targeted behaviours, and change sexualbehaviours that put young people at risk. In addition, most type 3 and 4interventions shared the objectives of raising awareness and changing com-munity norms that contributed to vulnerability. The objectives of the evalu-ations of two type 1 interventions also included testing the dispersal ofinformation from those directly involved in the intervention to all youth inthe community (studies C and G) (12, 28). Two others (studies E and J) (18,23) tested different forms of programme organization.

256

92-4-120938-0_CH08_256

8.3.2.3 Content

The most common information provided in all interventions was about thetransmission and prevention of HIV. In 14 of the 22 interventions this wasdone within the context of reproductive health (studies A, B, C, E, G, H, J,K, L, O, P, Q, R and S) (7, 12, 15–18, 21–29 ). Interventions that targetedskill building included both general life skills (studies C, D, J, Q, R, S) (7,13, 21–23, 27, 28,) and skills specific to avoiding HIV infection (studies C,D, L, P, R, U, V) (10, 11, 13, 14, 21, 22, 28, 29). Skills specific to preventingHIV were often restricted to locating and accessing condoms, condom self-efficacy and the proper use of condoms (studies D, L, P, U) (13, 14, 29). Skillsin communicating with partners were taught in four interventions (D, J, K,R) (13, 21– 24), and in two studies (T, V) (8–11) participants learnt to identifylocal situations and practices where there were heightened risks of becominginfected with HIV.

8.3.2.4 Providers and delivery

Interventions of all types (but not all interventions) were delivered by com-munity members. Thirteen of the 17 type 1 and 2 interventions used “peereducators”, “peer supporters” or “peer leaders” to deliver programmes.(There was no consistency in the terminology used or the definitions of theseroles.) The remaining four type 1 and 2 interventions used adult communitymembers as intervention leaders, but expected the youth who were partici-pating to become informal educators and role models for their peers (G, H,I, K) (6, 12, 24, 26). Two each of type 3 and 4 interventions used peer edu-cators either exclusively (S, V) (7, 10, 11) or with adult leaders (R, U) (14,21, 22 ). The remaining type 3 intervention (T) (8, 9) used trained adultcommunity members to deliver the programme.

8.3.3 Quality of the evidence

Only 9 of the 22 evaluations used experimental designs – that is,. designs thatmet the requirements for a moderate or high threshold of evidence. Threefrom type 1 used some form of random allocation to intervention and controlgroups (A, C, H) (15, 26, 28), and six from types 1, 2 and 3 used non-randomized comparisons (B, J, K, O, R, T) (8, 9, 16, 17, 21–25). Of theremaining studies, two each from types 1 and 2 and one from type 4 coulddemonstrate adequacy of the intervention either by using data collected beforeand after the intervention or by tracking the effects of the intervention usingproject records, field notes, interviews and materials produced by interven-tion participants (D, G, M, N, U) (12–14, 20, 30). The remaining eight (threetype 1, three type 2 and one each of types 3 and 4) provided evidence basedon the informed judgement of those responsible for the intervention (E, F, I,L, P, Q, S, V) (6, 7, 10, 11, 18, 19, 27, 29).

257

92-4-120938-0_CH08_257

Among the 9 evaluations that used experimental designs, the net changefound before and after the interventions were tested in only two, both of whichwere type 1 interventions (A, H) (15, 26). Only one study with a non-randomized comparison (type 1: J) (23) controlled for potential confoundersother than sex of the participant; and only 8 of the 22 studies disaggregatedresults by the sex of the participant (A, B, H, J, K, M, T, U) (8, 9, 14–17,23, 24, 26, 30). All but one of these studies (study H) (26) found that resultswere conditional on the sex of the participant, raising the question of whetherresults in the remainder of studies would have been different had they beendisaggregated by the sex of the participant. None of the three evaluations thatused randomized cluster sampling took this into account in their data analysis(A, C, H) (15, 26, 28).

The generally poor quality of the design and data analyses must be consideredwhen weighing the evaluation outcomes.

8.3.4 Outcome measures

Four of the UNGASS goals were commonly set as objectives for the inter-ventions included here: increasing knowledge related to HIV, building skillsrelated to preventing HIV transmission or acquisition, decreasing vulnera-bility to HIV, and reducing the prevalence of HIV. Changing sexual be-haviour and increasing the use of condoms, which may be consideredantecedents to reducing prevalence, were also set as objectives in severalinterventions. Table 8.4 provides information on the design and outcomes ofthe evaluations. (More details about each intervention are available on theweb.) The results presented here are based primarily on evidence reported atthe 0.05 level of statistical significance and obtained in evaluations usingexperimental designs required for the probability (randomized comparisontrials) or plausibility (non-randomized comparison trials) levels of evidence.Results based on adequacy levels of evidence (produced by designs that in-cluded pre-intervention and post-intervention components with no controlcomparisons) or informed judgement (produced by qualitative assessmentwithout formal pre-intervention and post-intervention measures) are usedonly when they provide useful information, and they are identified as comingfrom less rigorously designed evaluations. When the net changes before andafter an intervention were not reported, results are considered to reflect gainsthat may be attributed to the intervention if there is a net gain of at least 10percentage points from baseline to post-intervention in the intervention groupwhen compared with the control group. The acceptance of the 0.05 level ofsignificance or a net change of 10 percentage points are liberal criteria thaterr on the side of inflating the chance of an alpha error in favour of reducingthe chance of a beta error. We felt this was justified since there is considerableurgency to identify interventions that might by useful.

258

92-4-120938-0_CH08_258

Tab

le 8

.4D

escr

ipti

on

of

ou

tco

me

eval

uat

ion

s b

y st

ud

ya

Stu

dy

and

loca

tio

nD

esig

n

Ou

tco

mes

mea

sure

dM

ales

All

Fem

ales

Str

eng

th o

fev

iden

ce

Inte

rven

tio

n t

ype

1 (t

arg

etin

g y

ou

ths

and

del

iver

ed u

sin

g e

xist

ing

yo

uth

org

aniz

atio

ns

or

cen

tres

)A

– C

amer

oon

(15)

Des

ign:

Clu

ster

ran

dom

ized

tria

l usi

ngho

useh

old

clus

ters

;1

inte

rven

tion,

1 c

ontr

ol s

ite.

Pos

t-in

terv

entio

n da

ta c

olle

ctio

n to

ok p

lace

3m

onth

s af

ter

inte

rven

tion

com

plet

ion,

17

mon

ths

afte

r pr

e-in

terv

entio

n da

ta c

olle

ctio

nN

o. o

f par

ticip

ants

pre

-inte

rven

tion:

inte

rven

tion

grou

p =

402

, con

trol

= 4

00N

o. o

f par

ticip

ants

pos

t-in

terv

entio

n:in

terv

entio

n gr

oup

= 4

03, c

ontr

ol =

413

Lim

itatio

n: D

ata

anal

ysis

did

not

take

into

acco

unt c

lust

ered

sam

plin

g

Kno

wle

dge

• S

pont

aneo

us k

now

ledg

e of

ST

Isoc

curr

ing

in w

omen

Beh

avio

ur•

Eve

r ha

d se

x•

Had

sex

in la

st 3

mon

ths

• C

ondo

m u

sed

durin

g la

st s

exua

lep

isod

e (r

ecen

t sex

onl

y)

+N

Sb

+ +

+ -

Str

ong

evid

ence

for

gain

s in

know

ledg

e an

dse

xual

beh

avio

uran

d co

ndom

use

B –

Cam

eroo

n(1

6, 1

7)D

esig

n: N

on-r

ando

miz

ed tr

ial;

1 in

terv

entio

nan

d 1

cont

rol g

roup

sel

ecte

d us

ing

2-st

age

prob

abili

ty s

ampl

ing

Par

ticip

ants

: Maj

ority

wer

e se

cond

ary

scho

olst

uden

ts a

ged

15–1

9 ye

ars

No.

of p

artic

ipan

ts p

re-in

terv

entio

n:in

terv

entio

n gr

oup

= 1

248

(mal

es: 6

32;

fem

ales

: 616

), c

ontr

ol g

roup

= 1

256

(mal

es:

634;

fem

ales

: 622

)

Kno

wle

dge

• G

ener

al k

now

ledg

e of

HIV

/AID

S

Beh

avio

ur•

Sex

dur

ing

past

12

mon

ths

• 1

part

ner

durin

g pa

st 1

2 m

onth

s•

Rep

orte

d ab

stin

ence

• U

sed

cond

om d

urin

g la

st s

ex w

ithre

gula

r pa

rtne

r

NS

NS

NS

NS

+

NS + + NS

Str

ong

evid

ence

of n

o ga

ins

inkn

owle

dge

and

no g

ains

in y

oung

men

’s b

ehav

iour

but s

ome

gain

sfo

r yo

ung

wom

en’s

sex

ual

beha

viou

r

259

92-4-120938-0_CH08_259

260

Stu

dy

and

loca

tio

nD

esig

n

Ou

tco

mes

mea

sure

dM

ales

All

Fem

ales

Str

eng

th o

fev

iden

ce

No.

of p

artic

ipan

ts p

ost-

inte

rven

tion:

inte

rven

tion

grou

p =

123

8 (m

ales

: 604

;fe

mal

es: 6

34),

con

trol

= 1

226

(mal

es: 6

15;

fem

ales

: 611

)

Lim

itatio

n: A

noth

er s

imul

tane

ous

inte

rven

tion,

know

n as

“10

0% y

outh

” m

ay h

ave

influ

ence

dre

sults

• S

TI s

ympt

oms

durin

g pa

st 1

2m

onth

sN

SN

S

C –

Gha

naan

d N

iger

ia (

28)

Des

ign:

Clu

ster

ran

dom

ized

tria

l; 10

inte

rven

tion,

10

cont

rol s

ites;

dat

a co

llect

ion

also

incl

uded

in-d

epth

inte

rvie

ws,

focu

s gr

oup

disc

ussi

ons

and

proj

ect m

onito

ring

over

18

mon

ths

No.

of p

artic

ipan

ts p

re-in

terv

entio

n:in

terv

entio

n gr

oup

= 9

11, c

ontr

ol =

873

No.

of p

artic

ipan

ts p

ost-

inte

rven

tion:

inte

rven

tion

grou

p =

908

, con

trol

= 8

93

Lim

itatio

n: R

esul

ts fo

r ent

ire c

omm

unity

with

out

cont

rol f

or p

rogr

amm

e pa

rtic

ipat

ion

Kno

wle

dge

• O

vera

ll kn

owle

dge

ofre

prod

uctiv

e he

alth

(ou

t-of

scho

ol y

outh

s)

Ski

lls (

mea

sure

d am

ong

out-

of-s

choo

l you

ths)

• C

ontr

acep

tive

self-

effic

acy

• W

illin

gnes

s to

buy

con

dom

s

Beh

avio

ur•

Sex

in p

ast 3

mon

ths

(all

yout

h)•

Use

of m

oder

nco

ntra

cept

ives

(out

-of-

scho

olyo

uth)

NS

NS

NS

NS

NS

Str

ong

evid

ence

for

lack

of s

prea

dfr

om ta

rget

edyo

uth

to y

outh

inge

nera

lco

mm

unity

92-4-120938-0_CH08_260

D –

Bal

i (13

)D

esig

n: B

efor

e an

d af

ter

surv

ey w

ith n

oco

ntro

l with

a to

tal o

f 12

“ban

jars

”, 3

sel

ecte

dfr

om e

ach

of 4

are

as; d

ata

colle

ctio

nin

clud

ed s

urve

ys, 6

focu

s gr

oup

disc

ussi

ons

No.

of p

artic

ipan

ts p

re-in

terv

entio

n: 3

75vo

lunt

eers

(m

ale:

218

; fem

ale:

157

)

No.

of p

artic

ipan

ts p

ost-

inte

rven

tion:

97

part

icip

ants

(at

3 s

ites)

Lim

itatio

n: P

ost-

inte

rven

tion

surv

ey h

eld

durin

g to

uris

t sea

son

with

sub

stan

tial l

oss

ofpa

rtic

ipan

ts, r

educ

ing

stat

istic

al p

ower

Kno

wle

dge

• M

easu

red

onkn

owle

dge

scal

e

Ski

lls•

Tal

king

with

frie

nds/

adul

ts•

Per

ceiv

ed b

arrie

rs to

cond

om u

se•

Con

dom

sel

f-ef

ficac

y

+ + + +

Mod

erat

eev

iden

ce fo

rga

ins

inkn

owle

dge

and

skill

s

E –

Gha

na (

18)

Des

ign:

Qua

litat

ive

com

paris

on o

fst

ruct

ured

and

uns

truc

ture

d m

odel

s of

prog

ram

me

deliv

ery,

no

cont

rol g

roup

s; d

ata

colle

ctio

n fr

om s

urve

ys, f

ocus

gro

ups,

obse

rvat

ion

guid

es fo

r pe

er e

duca

tors

, and

in-d

epth

inte

rvie

ws

with

opi

nion

lead

ers

Str

uctu

red

mod

el: 8

7 pe

er e

duca

tors

(40

%tr

aine

d), 5

24 p

eer

prom

oter

s (5

8% tr

aine

d)

Uns

truc

ture

d m

odel

: 83

peer

edu

cato

rs(4

0% tr

aine

d), 3

78 p

eer

prom

oter

s (4

2%tr

aine

d)

Lim

itatio

ns: F

ield

wor

k co

inci

ded

with

firs

tna

tiona

l cen

sus;

res

pond

ents

not

alw

ays

coop

erat

ive

Kno

wle

dge

• P

rote

ctio

n ag

ains

tH

IV•

Ove

rall

know

ledg

eab

out H

IV•

Con

dom

use

know

ledg

e

Str

uct

ure

dp

rog

ram

me

+ + +

Un

stru

ctu

red

pro

gra

mm

e

+ NS

NS

Wea

k ev

iden

cefo

r ga

ins

inst

ruct

ured

inte

rven

tion

com

pare

dw

ith u

n-st

ruct

ured

261

92-4-120938-0_CH08_261

Stu

dy

and

loca

tio

nD

esig

n

Ou

tco

mes

mea

sure

dM

ales

All

Fem

ales

Str

eng

th o

fev

iden

ce

F –

Zam

bia

(19)

Des

ign:

Qua

litat

ive

case

stu

dy w

ith v

aria

ble-

by-

varia

ble,

cro

ss-c

ase

anal

ysis

of o

pera

tiona

lizat

ion

ofpr

ojec

ts a

nd a

ctiv

ities

. Dat

a co

llect

ion

incl

uded

docu

men

t rev

iew

s, s

emi-s

truc

ture

d in

terv

iew

s an

dno

n-st

ruct

ured

inte

rvie

ws

with

key

info

rman

ts a

s w

ell

as o

n-si

te v

isits

to o

bser

ve p

eer

activ

ities

.

The

re w

as a

n im

pres

sion

istic

ass

essm

ent o

f pos

sibl

eim

pact

but

attr

ibut

able

cau

sal l

inks

cou

ld n

ot b

epr

oven

giv

en ti

me

cons

trai

nts

Kno

wle

dge

• G

ener

al k

now

ledg

e of

HIV

and

sym

ptom

s•

Mod

es o

f tra

nsm

issi

on

Beh

avio

ur•

Som

e ch

ange

of

beha

viou

r•

Red

uced

num

ber

ofpa

rtne

rs

+ + + NS

Wea

k ev

iden

ce fo

rga

ins

in k

now

ledg

ean

d so

me

beha

viou

r ch

ange

;no

cha

nge

innu

mbe

r of

par

tner

s

G –

Mal

awi (

12)

Des

ign:

Bef

ore

and

afte

r sur

vey

with

no

cont

rol g

roup

.D

ata

colle

ctio

n in

clud

ed n

arra

tive

rese

arch

and

annu

al fo

cus

grou

p di

scus

sion

s w

ith ta

rget

gro

ups,

info

rmat

ion

on S

TI a

nd H

IV p

reva

lenc

e, d

ocum

ent

revi

ews

and

site

vis

its.

Lim

itatio

ns: T

he g

roup

s m

easu

red

in th

e pr

e-kn

owle

dge,

atti

tude

s an

d be

havi

ours

stu

dy d

id n

otco

rres

pond

to th

e ta

rget

age

gro

up s

o co

uld

not b

eus

ed fo

r co

mpa

rison

Kno

wle

dge

• G

ener

al k

now

ledg

e an

daw

aren

ess

Tra

nsm

issi

on:

• S

entin

el s

urve

y

+ –

Wea

k ev

iden

ce fo

rga

ins

in k

now

ledg

ean

d so

me

evid

ence

for

nega

tive

effe

cton

HIV

inci

denc

e

H –

Zam

bia

(26)

Des

ign:

Clu

ster

ran

dom

ized

tria

l with

> 6

clu

ster

s; 1

6of

30

club

s se

lect

ed a

t ran

dom

in o

ne in

terv

entio

n,on

e co

mpa

rison

site

. Dat

a co

llect

ion

also

incl

uded

focu

s gr

oups

and

in-d

epth

inte

rvie

ws

with

car

egiv

ers,

patr

on o

r m

atro

ns, p

eopl

e liv

ing

with

AID

S a

nd th

eir

fam

ily m

embe

rs

Beh

avio

ur•

Eve

r ha

d se

x•

Had

sex

in th

e pa

st 3

mon

ths

• E

ver

used

a c

ondo

m:

• U

sed

cond

om d

urin

g la

stse

x

+ NS + NS

+ NS + NS

Str

ong

evid

ence

for

impr

ovem

ents

inso

me

sexu

albe

havi

ours

and

cond

om u

se

262

92-4-120938-0_CH08_262

No.

of p

artic

ipan

ts p

re-in

terv

entio

n: in

terv

entio

ngr

oup

mal

e =

200

, fem

ale

=16

5; c

ontr

ol g

roup

mal

e =

209

, fem

ale

= 2

22

No.

of p

artic

ipan

ts p

ost-

inte

rven

tion:

inte

rven

tion

grou

p m

ale

= 2

80, f

emal

e =

216

; con

trol

gro

upm

ale

= 2

69, f

emal

e =

218

I – K

enya

(6)

Des

ign:

Ane

cdot

al r

epor

ts o

f pro

gram

me

activ

ities

Kno

wle

dge

• G

ener

al A

IDS

and

prev

entio

n

Ski

lls•

Abl

e to

del

iver

pee

red

ucat

ion

on H

IV/A

IDS

+

+

Wea

k ev

iden

ce fo

r ga

ins

inkn

owle

dge

and

skill

s

J –

Nep

al (

23)

Des

ign:

Non

-ran

dom

ized

tria

l; 2

inte

rven

tion

grou

ps w

ith m

atch

ed c

ontr

ol s

ites

(1 e

ach

urba

nan

d ru

ral);

sur

veys

and

qua

litat

ive

data

col

lect

ed;

part

icip

ator

y ap

proa

ch w

ith 9

act

iviti

es w

ith 4

–5gr

oups

eac

h in

pre

-inte

rven

tion,

and

5 a

ctiv

ities

with

20

grou

ps in

eac

h po

st-in

terv

entio

n.

No.

of p

artic

ipan

ts p

re-in

terv

entio

n: a

dole

scen

ts =

724,

adu

lts =

752

, ser

vice

pro

vide

rs =

59

No.

of p

artic

ipan

ts p

ost-

inte

rven

tion:

ado

lesc

ents

=97

9, a

dults

= 6

54, s

ervi

ce p

rovi

ders

= 6

2; k

eyin

form

ant i

nter

view

s =

3; 1

4 in

-dep

th in

terv

iew

s; 1

0fo

cus

grou

ps; 2

31 fa

cilit

ator

rep

orts

; 48

mys

tery

clie

nt s

urve

ys; 6

7 co

mm

unity

gro

up a

sses

smen

tsat

mid

poin

t and

pos

t-in

terv

entio

n

Kno

wle

dge

• M

odes

of t

rans

mis

sion

(urb

an p

artic

ipan

ts)

• M

odes

of t

rans

mis

sion

(rur

al p

artic

ipan

ts)

Beh

avio

ur•

Eve

r ha

d se

x (u

nmar

ried

urba

n m

en o

nly)

• E

ver

had

sex

(unm

arrie

dru

ral m

en o

nly)

-

NS

- +

+

+

Str

ong

evid

ence

for g

ains

inyo

ung

wom

en’s

kno

wle

dge

and

redu

ctio

ns in

sex

ual

activ

ity a

mon

g ru

ral y

oung

men

Mod

erat

e ev

iden

ce fo

rne

gativ

e ef

fect

on

know

ledg

e of

rur

al y

oung

men

and

sex

ual b

ehav

iour

of u

rban

you

ng m

en

263

92-4-120938-0_CH08_263

Stu

dy

and

loca

tio

nD

esig

n

Ou

tco

mes

mea

sure

dM

ales

All

Fem

ales

Str

eng

th o

fev

iden

ce

K –

Ken

ya (

24)

Des

ign:

Non

-ran

dom

ized

tria

l; 1

inte

rven

tion

and

1 co

ntro

l. D

ata

colle

ctio

n in

clud

edin

terv

iew

er-a

dmin

iste

red

and

self-

adm

inis

tere

d qu

estio

nnai

res

No.

of p

artic

ipan

ts p

re-in

terv

entio

n:in

terv

entio

n gr

oup

mal

e =

573

, fem

ale

= 5

23;

cont

rol g

roup

mal

e =

219

, fem

ale

= 2

29

No.

of p

artic

ipan

ts p

ost-

inte

rven

tion:

inte

rven

tion

grou

p m

ale

= 7

11, f

emal

e =

697

;co

ntro

l gro

up m

ale

= 2

14, f

emal

e =

243

Ski

lls•

Com

mun

icat

ion

with

par

ent

Beh

avio

ur•

Sec

onda

ry a

bstin

ence

• >

3 p

artn

ers

durin

g pa

st 3

year

s•

Use

d co

ndom

last

tim

e ha

dse

x

+ NS

NS +

+ + + +

Str

ong

evid

ence

for

gain

s in

com

mun

i-ca

tion

with

pare

nts,

cha

nge

inco

ndom

use

and

in s

exua

lbe

havi

our

ofyo

ung

wom

en (n

otyo

ung

men

)

Inte

rven

tio

n t

ype

2 (t

arg

etin

g y

ou

ths

and

cre

atin

g o

wn

sys

tem

an

d s

tru

ctu

re f

or

del

iver

y)L

– G

hana

(29

)D

esig

n: Q

ualit

ativ

e st

udy;

pre

-inte

rven

tion

and

post

-inte

rven

tion

exer

cise

with

part

icip

ants

in p

eer

educ

atio

n se

ssio

ns; s

itevi

sits

; fee

dbac

k w

orks

hops

with

pee

red

ucat

ors,

out

reac

h st

aff a

nd m

anag

emen

tco

mm

ittee

. Dat

a co

llect

ion

incl

uded

obse

rvat

ions

, in-

dept

h in

terv

iew

s, fo

cus

grou

ps, r

evie

w o

f doc

umen

tatio

n an

d re

port

s,an

d vi

sits

to p

harm

acie

s. E

valu

atio

nsi

mul

tane

ous

with

stu

dy P

(18

)

Kno

wle

dge

• M

odes

of t

rans

mis

sion

and

AB

C p

rogr

amm

e (A

bsta

in,

Be

faith

ful,

use

Con

dom

s)as

pre

vent

ion

• S

TI k

now

ledg

e

Ski

lls•

Cou

ld d

emon

stra

te h

ow to

use

a co

ndom

Beh

avio

ur•

Abs

tain

• U

se c

ondo

ms

corr

ectly

and

cons

iste

ntly

+ - +

Som

e+S

ome+

Wea

k ev

iden

ce fo

rga

ins

in s

ome

know

ledg

e,co

ndom

use

ski

llsan

d se

xual

beha

viou

r an

dco

ndom

use

beha

viou

r

264

92-4-120938-0_CH08_264

M –

Sri

Lank

a (3

0)D

esig

n: B

efor

e an

d af

ter

inte

rven

tion,

no

cont

rol

No.

of p

artic

ipan

ts p

re-in

terv

entio

n an

d po

st-

inte

rven

tion:

615

you

ths

inte

rvie

wed

for

ethn

ogra

phic

rese

arch

; app

roxi

mat

ely

one

half

wer

e lo

w in

com

e, o

neha

lf w

ere

univ

ersi

ty s

tude

nts,

rou

ghly

sam

e nu

mbe

r of

mal

es a

nd fe

mal

es

Kno

wle

dge

• A

IDS

• C

ondo

ms

• S

exua

l ter

ms

NS

NS

NS

NS + +

Wea

k ev

iden

ce fo

r gai

nsin

kno

wle

dge

amon

gyo

ung

wom

en b

ut n

oef

fect

on

youn

g m

en

N –

Indi

a (2

0)D

esig

n: Q

ualit

ativ

e in

terv

entio

n w

ith p

re-in

terv

entio

nan

d po

st-in

terv

entio

n co

mpa

rison

of f

low

char

tspr

oduc

ed b

y pr

ogra

mm

e pa

rtic

ipan

ts. D

ata

also

colle

cted

thro

ugh

info

rmal

gro

ups

of m

en d

iscu

ssin

gm

astu

rbat

ion

and

noct

urna

l em

issi

ons

Flo

wch

arts

ana

lyse

d: p

re-in

terv

entio

n =

35,

pos

t-in

terv

entio

n =

16

No.

of p

artic

ipan

ts: 5

0 si

ngle

men

incl

udin

g 22

vill

ager

s,16

mig

rant

wor

kers

, 12

pris

on in

mat

es

Kno

wle

dge

• M

astu

rbat

ion

is s

afe

sex

Atti

tude

s• M

astu

rbat

ion

acce

ptab

le a

ndha

s po

sitiv

e co

nseq

uenc

es

+ +

Wea

k ev

iden

ce fo

r gai

nsin

kno

wle

dge

and

attit

ude

chan

ges

amon

gyo

ung

men

O –

Indi

a (2

5)D

esig

n: N

on-r

ando

miz

ed tr

ial;

14 in

terv

entio

n si

tes,

14

mat

ched

con

trol

site

s. D

ata

colle

cted

thro

ugh

surv

eys

and

part

icip

ator

y di

ssem

inat

ion

wor

ksho

ps

No.

of p

artic

ipan

ts p

re-in

terv

entio

n: in

terv

entio

n gr

oup

= 3

77, c

ontr

ol =

343

No.

of p

artic

ipan

ts p

ost-

inte

rven

tion:

inte

rven

tion

grou

p=

363

, con

trol

= 3

43

Kno

wle

dge

• T

ime

to s

ympt

oms

of H

IV•

Mul

tiple

pre

vent

ion

met

hods

+ +

Str

ong

evid

ence

for

gain

s in

kno

wle

dge

for

youn

g m

en

265

92-4-120938-0_CH08_265

Stu

dy

and

loca

tio

nD

esig

n

Ou

tco

mes

mea

sure

dM

ales

All

Fem

ales

Str

eng

th o

fev

iden

ce

P –

Gha

na (

29)

Des

ign:

Ane

cdot

al e

vide

nce.

Dat

a co

llect

edfr

om s

ite v

isits

; fee

dbac

k w

orks

hops

and

repo

rts

from

pee

r ed

ucat

ors,

out

reac

h st

aff

and

man

agem

ent;

info

rmal

dis

cuss

ions

and

mee

tings

; in-

dept

h in

terv

iew

s an

d fo

cus

grou

ps w

ith p

eer

educ

ator

s an

d ta

rget

gro

upm

embe

rs. P

re-s

urve

y da

ta c

olle

cted

but

not

anal

ysed

unt

il 2

year

s la

ter.

Dat

a ev

alua

ted

sim

ulta

neou

sly

with

that

col

lect

ed in

stu

dy L

18

Kno

wle

dge

• K

now

s ab

out 2

or

mor

em

odes

of t

rans

mis

sion

and

prev

entio

n•

Info

rmat

ion

abou

t ST

Is

Ski

lls• D

emon

stra

te c

orre

ct c

ondo

mus

e (o

ut-o

f-sc

hool

you

th)

Beh

avio

ur•

Dem

and

for

cond

oms

and

cond

om u

se•

Fem

ale

cond

oms

purc

hase

d

+ - + + +

Wea

k ev

iden

ce fo

rga

ins

in s

ome

know

ledg

e, s

kills

,an

d co

ndom

acqu

isiti

on.

Q –

Nep

al (

27)

Des

ign:

Qua

litat

ive

stud

y. D

ata

colle

cted

from

disc

ussi

ons,

par

ticip

ator

y m

etho

ds a

nd 3

cas

est

udie

s; p

roje

ct d

ocum

ents

and

oth

er r

elev

ant

mat

eria

ls r

evie

wed

;

No.

of p

artic

ipan

ts: 1

62 m

embe

rs o

f 18

yout

hac

tion

grou

ps

Kno

wle

dge

• G

ener

al k

now

ledg

e of

HIV

/A

IDS

, ST

Is a

nd s

exua

lhe

alth

Ski

lls•

You

th h

ave

“sen

se o

f soc

ial

resp

onsi

bilit

y”

+W

eak

evid

ence

for

gain

s in

kno

wle

dge,

sens

e of

res

pons

i-bi

lity

and

sexu

albe

havi

ours

266

92-4-120938-0_CH08_266

Lim

itatio

ns: F

ew a

ctio

n gr

oup

mem

bers

or

loca

l rep

rese

ntat

ives

inte

rvie

wed

. How

ever

, all

actio

n gr

oup

coor

dina

tors

inte

rvie

wed

and

part

icip

ated

in d

ata

colle

ctio

n an

d an

alys

is

Beh

avio

ur•

Saf

er s

exua

l beh

avio

urs

• R

educ

ed p

erso

nal

vuln

erab

ility

+ + +In

terv

enti

on

typ

e 3

(co

mm

un

ity-

wid

e in

terv

enti

on

del

iver

ed t

hro

ug

h f

amily

net

wo

rks)

R –

Uga

nda

(21,

22)

Des

ign:

Non

-ran

dom

ized

tria

l; 2

inte

rven

tion,

1co

ntro

l com

mun

ity. I

nclu

ded

only

girl

s w

hopa

rtic

ipat

ed in

stu

dy fo

r fu

ll 12

mon

ths;

inte

rven

tion

grou

p w

as s

elf-

sele

cted

(83

girl

sliv

ed in

inte

rven

tion

com

mun

ities

, 30

inco

ntro

l); 8

focu

s gr

oups

(4 g

roup

s of

mal

es a

nd4

of fe

mal

es),

60

in-d

epth

inte

rvie

ws

with

adul

ts (

30 w

ith m

ales

and

30

with

fem

ales

).D

ata

colle

cted

from

wor

ksho

ps, c

omm

unity

focu

s gr

oups

and

in-d

epth

inte

rvie

ws

with

non

-ta

rget

adu

lts w

ho h

ad v

isite

d “s

enga

s” (w

omen

trai

ned

to p

rovi

de s

exua

l hea

lth in

form

atio

n in

the

man

ner

appr

opria

te to

trad

ition

al k

insh

ipne

twor

ks)

No.

of p

artic

ipan

ts: i

nter

vent

ion

grou

p =

71,

cont

rol =

24

Kno

wle

dge

• M

odes

of H

IV tr

ansm

issi

on

Ski

llsIf

sexu

ally

act

ive

• C

omm

unic

ate

with

par

tner

• C

omm

unic

ate

with

oth

erpe

ople

Beh

avio

ur (

amon

g se

xual

lyac

tive

girls

)•

Had

sym

ptom

s of

an

ST

I•

Rep

ort c

onsi

sten

t con

dom

use

+ NS

NS + +

Wea

k ev

iden

ce fo

rga

ins

in k

now

ledg

ean

d be

havi

our

chan

ge a

mon

gyo

ung

wom

en b

ut n

och

ange

in c

om-

mun

icat

ion

skill

s

267

92-4-120938-0_CH08_267

Stu

dy

and

loca

tio

nD

esig

n

Ou

tco

mes

mea

sure

dM

ales

All

Fem

ales

Str

eng

th o

fev

iden

ce

S –

Bur

kina

Fas

o(7

)D

esig

n: Q

ualit

ativ

e st

udy.

Dat

a co

llect

ion

incl

uded

61

in-d

epth

inte

rvie

ws

with

pee

red

ucat

ors,

lead

ers,

spo

uses

c and

chi

efm

edic

al o

ffice

r; 1

7 fo

cus

grou

ps w

ith p

eer

educ

ator

s, m

othe

rs-in

-law

, mar

ried

adol

esce

nts

who

wer

e no

t pee

r ed

ucat

ors,

othe

r pr

ogra

mm

e be

nefic

iarie

s an

d m

embe

rsof

org

aniz

ing

com

mitt

ee. T

here

was

als

o a

revi

ew o

f pro

ject

doc

umen

tatio

n an

d 6

case

stud

ies

Kno

wle

dge

• O

f rep

rodu

ctiv

e he

alth

in th

eco

mm

unity

and

am

ong

peer

educ

ator

s

Beh

avio

ur•

Con

trac

eptiv

e us

e•

Cha

nge

in c

omm

unity

nor

ms

rela

ted

to w

omen

(fo

rex

ampl

e, m

ovem

ent a

bout

the

com

mun

ity, a

bilit

y to

talk

with

oth

ers

abou

t sex

ual

heal

th is

sues

, etc

)

+

Som

e+

+

Wea

k ev

iden

ce fo

rga

ins

in k

now

ledg

e,co

ntra

cept

ive

use

and

chan

ge in

com

mun

ity n

orm

sre

late

d to

you

ngw

omen

T –

Uga

nda

(8, 9

)D

esig

n: N

on-r

ando

miz

ed tr

ial;

2 co

mm

uniti

es.

Pre

-inte

rven

tion

part

icip

ants

div

ided

into

expo

sed

and

non-

expo

sed

grou

ps fo

r pr

e-in

terv

entio

n vs

–pos

t-in

terv

entio

n an

alys

is.

Non

-exp

osed

act

ed a

s co

ntro

l gro

up. D

ata

colle

ctio

n in

clud

ed s

urve

ys, f

ocus

gro

ups

(9w

ith a

bout

75

part

icip

ants

) an

d 25

inte

rvie

ws

with

key

info

rman

ts (

fam

ily A

IDS

wor

kers

,im

ams,

imam

’s a

ssis

tant

s, s

heik

hs)

No.

of p

artic

ipan

ts p

re-in

terv

entio

n: 1

907

Kno

wle

dge

• M

odes

of t

rans

mis

sion

and

prev

entio

n•

Ris

k pe

rcep

tion

Beh

avio

ur•

Dec

reas

e nu

mbe

r of

sex

ual

part

ners

• E

ver

use

cond

om (

Urb

anyo

uth:

+; R

ural

: NS

)+

+ +

+

Str

ong

evid

ence

of

gain

s in

kno

wle

dge

and

sexu

albe

havi

our

(am

ong

both

you

ng m

en a

ndw

omen

)

268

92-4-120938-0_CH08_268

No.

of p

artic

ipan

ts p

ost-

inte

rven

tion:

exp

osed

(inte

rven

tion

grou

p) =

126

0, n

on-e

xpos

ed(c

ontr

ol g

roup

) =

566

Lim

itatio

ns: n

atio

nal p

rogr

amm

es e

xist

, whi

chco

nfou

nd r

esul

ts; s

ampl

es in

clud

e w

ider

age

rang

e th

an “

yout

h”

Inte

rven

tio

n t

ype

4 (c

om

mu

nit

y-w

ide

inte

rven

tio

n d

eliv

ered

th

rou

gh

co

mm

un

ity-

bas

ed a

ctiv

itie

s)U

– T

haila

nd(1

4)D

esig

n: B

efor

e an

d af

ter

stud

y w

ith n

o co

ntro

lgr

oup;

sur

veye

d im

med

iate

ly b

efor

eco

mm

unity

-wid

e ra

ce, i

mm

edia

tely

afte

r ra

cean

d 6

wee

ks p

ost-

race

with

con

veni

ence

sam

ple;

29

villa

ges

used

in e

valu

atio

n

No.

of p

artic

ipan

ts p

re-r

ace

and

post

rac

e:w

omen

= 8

7, m

en =

77(

mem

bers

of f

irst t

eam

sfo

rmed

)

No.

of p

artic

ipan

ts in

con

veni

ence

cro

ss-s

ectio

n6

wee

ks a

fter

race

: men

= 7

9, w

omen

= 8

1

Lim

itatio

ns: H

ighl

y m

obile

targ

et g

roup

prec

lude

s m

easu

rem

ent o

f lon

g-te

rm e

ffect

Kno

wle

dge

• P

rope

r co

ndom

used

Ski

lls•

Con

dom

sel

f-ef

ficac

yd

Beh

avio

ur•

Pro

port

ion

acce

ssin

gco

ndom

s (p

ost-

inte

rven

tion

only

)

+ +

28%

+ +

Wea

k ev

iden

ce o

f gai

nsin

kno

wle

dge

and

skill

sre

late

d to

con

dom

use

V –

Uni

ted

Rep

ublic

of

Tan

zani

a(1

0, 1

1)

Des

ign:

Qua

litat

ive

data

col

lect

ion

by a

team

of

artis

ts w

ho k

ept n

oteb

ooks

of d

aily

obse

rvat

ions

; com

mun

ity m

embe

rs a

nd a

rtis

tsca

talo

gued

eco

nom

ic, s

ocia

l and

hea

lthpr

oble

ms

that

faci

litat

e th

e sp

read

of H

IV;

repo

rts

wer

e de

velo

ped

from

not

eboo

ks o

f the

grou

ps u

sed

to p

repa

re fo

r ne

xt p

hase

of

prog

ram

me

(tra

inin

g pe

er e

duca

tors

)

Kno

wle

dge

• C

ultu

ral p

ract

ices

cont

ribut

ing

toH

IV s

prea

d

+W

eak

evid

ence

of g

ains

in k

now

ledg

e an

d sk

ills,

chan

ges

in c

omm

unity

norm

s an

d co

mm

unity

taki

ng a

ctio

n

269

92-4-120938-0_CH08_269

Stu

dy

and

loca

tio

nD

esig

n

Ou

tco

mes

mea

sure

dM

ales

All

Fem

ales

Str

eng

th o

fev

iden

ce

Ski

lls•

Abl

e to

iden

tify

dang

erou

spr

actic

es u

npro

mpt

ed

Beh

avio

urs

• C

hang

es in

com

mun

ityno

rms

Com

mun

ity a

ctio

n•

Act

ion

take

n to

pro

tect

yout

h

+ + +

A “

+”

indi

cate

s th

at a

res

ult i

s st

atis

tical

ly s

igni

fican

t at l

east

at P

0.0

5 an

d in

the

desi

red

dire

ctio

n (f

or e

xam

ple,

an

incr

ease

in k

now

ledg

e, a

dec

reas

e in

sex

ual

activ

ity, o

r an

incr

ease

in c

ondo

m u

se).

A “-

” sig

n in

dica

tes

that

a re

sult

is s

tatis

tical

ly s

igni

fican

t at l

east

at P

0.0

5 an

d in

an

unde

sira

ble

dire

ctio

n (f

or e

xam

ple,

a de

crea

se in

kno

wle

dge,

an

incr

ease

in s

exua

l act

ivity

or

a de

crea

se in

con

dom

use

). F

or c

ases

in w

hich

no

appr

opria

te te

sts

of s

tatis

tical

sig

nific

ance

wer

eco

nduc

ted,

res

ults

are

rat

ed +

or

– if

the

net d

iffer

ence

betw

een

the

pre-

inte

rven

tion

and

post

-inte

rven

tion

resu

lts is

10

perc

enta

ge p

oint

s w

hen

com

pare

dw

ith c

ontr

ols.

For

stu

dies

that

use

d on

ly in

terv

entio

n gr

oups

, the

net

diff

eren

ce is

cal

cula

ted

betw

een

pre-

inte

rven

tion

and

post

-inte

rven

tion

cont

rols

and

mus

tbe

> 1

0 pe

rcen

tage

poi

nts.

For

qua

litat

ive

stud

ies,

resu

lts a

re ra

ted

+ o

r – b

ased

on

the

repo

rt; t

hese

are

iden

tifie

d as

wea

k re

sults

in th

e in

str

engt

h of

evi

denc

eco

lum

n.b

NS

= n

ot s

igni

fican

t.c W

ithin

this

cul

tura

l set

ting,

it w

as n

eces

sary

to g

et s

pous

al c

onfir

mat

ion

of in

form

atio

n pr

ovid

ed b

y fe

mal

e pe

er e

duca

tors

.d

Res

ults

dis

aggr

egat

ed b

y se

x pr

ovid

ed b

y th

e au

thor

s (O

ctob

er 2

005)

.

270

92-4-120938-0_CH08_270

8.3.4.1 Knowledge outcomes

Altogether, 20 of the 22 studies, representing all four intervention types,evaluated gains in knowledge related to HIV transmission and prevention.Seven produced evidence at the level of probability (type 1: A, C) (15, 28)or plausibility (type 1: B, J; type 2: O; type 3: R, T) (8, 9, 16, 17, 21–23,25). All but two of these found at least some gains in knowledge. Both of theinterventions that found no gains in knowledge were type 1 (B, C) (16, 17,28). However, one evaluation (study C) (28) tested the dispersal of an inter-vention from a sample of “out-of-school youths” to whom it was deliveredto all “out-of-school youths” in the community rather than the effect of theintervention on participating youths. Two of the three intervention studiesthat disaggregated knowledge effects by the sex of the participant demon-strated knowledge gains only for young women (type 1: J; type 2: M) (23, 30).

Specific gains were reported in knowledge related to modes of HIV trans-mission, including some distinctive cultural practices such as ablution of thedead or genital excision (type 3: T) (8, 9). Gains were also reported in knowl-edge of prevention behaviours, such as abstinence or condom use (type 2: A,B; type 3: T) (8, 9, 15–17), as well as in scores on summative knowledgescales (type 1: A, D; type 2: M; type 3: R) (13, 15, 21, 22, 30). Knowledgegains related to distinctive cultural practices were most often reported onlyat the level of adequacy or based on informed judgement. These included therecognition in a type 2 study that “semen loss” was not detrimental to healthand that masturbation could be used as an alternative to more risky sexualactivities (study N) (20) or that a variety of local practices increased vulner-ability to HIV infection (type 3: V) (10, 11).

8.3.4.2 Skills outcomes

Three interventions specifically taught skills in using condoms. The evalua-tion of a type 4 intervention (study U) (14) produced evidence at the level ofadequacy of gains in skills for both young men and women, with type 2intervention studies (L, P) (29) providing the informed judgement of inter-vention leaders that more young people demonstrated proper use of condoms.The evaluation of a type 1 intervention included measures of self-efficacy inusing condoms (study D) (13). Only the evaluation study of a type 4 interven-tion (study U) disaggregated results for skills by the sex of the participant (14).

Improvements in communication about sexuality and HIV/AIDS with peers,adults or sexual partners were assessed in three studies of type 1 interventions(studies D, J, K) (13, 23, 24) and one study of a type 3 intervention (study R)(21, 22). The three evaluations that provided plausibility evidence (type 1: J,K; type 3: R) (21–24) all demonstrated significant gains, although the onlyevaluation that tested for potential confounding effects found that commu-nication improved only among rural males and urban females (type 1: J)

271

92-4-120938-0_CH08_271

(23). Intervention leaders and case notes from several studies provided evi-dence at the level of informed judgement that girls had been empowered tospeak about sexual matters as a result of participating in the intervention (forexample, type 1: I; type 3: S) (6, 7).

8.3.4.3 Community norms, attitudes and actions

Interventions of all types provided evidence of increased awareness andpotential changes in community norms that could contribute to reducing vul-nerability to HIV. None, however, evaluated these outcomes above the levelof adequacy or extended their evaluations over a long enough period to drawconclusions about whether the changes had been realized.

Three interventions targeted local norms that made girls more vulnerable toHIV infection (type 1: I; type 3: S; type 4: V) (6, 7, 10, 11). Three targetedlocal beliefs and practices that contributed to HIV transmission or createdbarriers to preventing transmission (type 2: N; type 3: T; type 4: V) (8–11,20). Three targeted local communication norms that created barriers to pro-viding information about HIV to youths or to communication betweenpartners about risk and prevention (type 3: S; type 4: U, V) (7, 10, 11, 14).The evaluation studies documented ways in which communities were re-sponding to heightened awareness, including the actions being taken tochange local practices. For interventions targeting youths, some evaluationsalso documented shifts in personal norms and attitudes, but in only one eval-uation were data presented that suggested these may have led to less riskysexual behaviour (type 4: V) (10, 11).

8.3.4.4 HIV incidence

Changes in HIV incidence were used in only one evaluation (type 1: G)(12) This intervention included initiation of anti-AIDS clubs across Malawifollowing a national media campaign. Sentinel surveillance data demon-strated an increase in incidence over the period of this intervention. However,in the absence of an experimental design, it is not possible to determinewhether the change in HIV incidence was related to the intervention orwhether the intervention merely lacked the power to reverse the existing na-tional trend.

8.3.4.5 Sexual activity

Seven evaluations used experimental designs producing plausibility-level orprobability-level evidence to assess changes in sexual intercourse. Six weretype 1 interventions (studies A, B, C, H, J, K) (15–17, 23, 24, 26, 28) and onewas type 3 (study T) (8, 9).

272

92-4-120938-0_CH08_272

All evaluations of type 1 interventions found reductions in the proportion ofboth males and females reporting that they ever had sexual intercourse.Young women made positive gains in both of the studies that disaggregatedresults by sex (type 1: B, H) (16, 17, 26); young men made positive gainsonly in one (type 1: study H) (26). The other studies produced non-significantresults. However, reports of recent sexual activity (for example, occurringduring the past 3 months or past year) generally did not show statisticallysignificant changes, with the exception of two evaluations of type 1 inter-ventions. In young women, one found a decrease in reports of recent sexualactivity (type 1: B) (16, 17) and one an increase (type 1: A) (15); there wereno significant changes in young men’s reports. Women were more likely toreport a reduction in the number of partners (type 1: B, K; type 3: T) (8, 9,16, 17, 24). Only one study (type 3: T) (8, 9) found a decrease in the numberof partners for young men; two type 1 studies showed no change for youngmen (studies B, K) (16, 17, 24).

8.3.4.6 Condom use

Condom use was assessed using a variety of questions including whether acondom had ever been used (type 1: C; type 3: T) (8, 9, 28), had been usedduring the last sexual encounter (type 1: A, B, H, K) (15–17, 24, 26) andwhether condoms were used consistently (type 3: R) (21, 22). One study alsoasked about condom use with different types of partners (type 1: B) (16,17). All seven of these evaluations produced evidence at the level of plausi-bility or probability; four of them demonstrated gains in condom use. In thetwo studies that disaggregated results by sex of the participant (studies H andK) (24, 26) the gains were the same for both sexes. Both type 1 and type 3interventions demonstrated gains, with the level of evidence meeting or ex-ceeding the threshold requirement in each case.

8.3.4.7 Overview of outcomes

As is shown in Table 8.5, none of the studies produced strong, unequivocalevidence of positive effects. Most provided either mixed results or were eval-uated using designs that could produce conclusions only at the level ofplausibility or lower. However, in Table 8.4, when specific results are re-viewed relative to the threshold of evidence required for each interventiontype (see Table 8.2), it is evident that intervention types 1, 3 and 4 provideevidence at or above the required threshold for at least one, and most oftenseveral, of the UNGASS goals. The goal of reducing HIV prevalence, how-ever, was not met in the intervention in which incidence data were evaluated(12). In addition, the results suggest that changes in sexual behaviour, asantecedent conditions to reducing HIV prevalence, may require interventionsthat specifically target young people (type 1 interventions) or, if delivered toa broader age range in the community, may require delivery within a tradi-tional or family setting (type 3).

273

92-4-120938-0_CH08_273

Tab

le 8

.5S

tren

gth

of

evid

ence

of

effe

ctiv

enes

s fo

r ea

ch in

terv

enti

on

typ

e an

d r

eco

mm

end

atio

ns

for

pro

gra

mm

esa

Stu

dy

des

ign

Po

siti

ve e

ffec

tN

o s

ign

ific

ant

effe

ctN

egat

ive

effe

ctS

tren

gth

of

evid

ence

Sta

tist

ical

lysi

gn

ific

ant

Sta

tist

ical

sig

nif

ican

cen

ot

kno

wn

Sta

tist

ical

lysi

gn

ific

ant

Inte

rven

tio

n t

ype

1 (t

arg

etin

g y

ou

ths

and

del

iver

ed u

sin

g e

xist

ing

yo

uth

org

aniz

atio

ns

or

cen

tres

)A

necd

otal

IE

quiv

ocal

Qua

litat

ive

E,F

Cro

ss-s

ectio

nal (

no c

ompa

rison

gro

up)

Bef

ore-

afte

r (n

o co

mpa

rison

gro

up)

D,G

GQ

uasi

-exp

erim

enta

l ( 1

com

paris

on g

roup

)B

,J,K

aB

,J,K

RC

Tb

(< 6

clu

ster

s)R

CT

( 6

clu

ster

s)A

,HC

,HIn

terv

enti

on

typ

e 2

(tar

get

ing

yo

uth

s an

d c

reat

ing

ow

n s

yste

m a

nd

str

uct

ure

fo

r d

eliv

ery)

Ane

cdot

alP

Wea

kQ

ualit

ativ

eL,

N,Q

Cro

ss-s

ectio

nal (

no c

ompa

rison

gro

up)

Bef

ore-

afte

r (n

o co

mpa

rison

gro

up)

MQ

uasi

-exp

erim

enta

l ( 1

com

paris

on g

roup

)O

RC

T (

<6

clus

ters

)R

CT

( 6

clu

ster

s)In

terv

enti

on

typ

e 3

(co

mm

un

ity-

wid

e in

terv

enti

on

del

iver

ed t

hro

ug

h f

amily

net

wo

rks)

Ane

cdot

alE

quiv

ocal

Qua

litat

ive

SC

ross

-sec

tiona

l (no

com

paris

on g

roup

)B

efor

e-af

ter

(no

com

paris

on g

roup

)Q

uasi

-exp

erim

enta

l ( 1

com

paris

on g

roup

)R

,TR

RC

T (

< 6

clu

ster

s)

274

92-4-120938-0_CH08_274

RC

T (

6 c

lust

ers)

Inte

rven

tio

n t

ype

4 (c

om

mu

nit

y-w

ide

inte

rven

tio

n d

eliv

ered

th

rou

gh

co

mm

un

ity-

bas

ed a

ctiv

itie

s)A

necd

otal

Wea

kQ

ualit

ativ

eV

Cro

ss-s

ectio

nal (

no c

ompa

rison

gro

up)

Bef

ore-

Afte

r (n

o co

mpa

rison

gro

up)

UQ

uasi

-exp

erim

enta

l ( 1

com

paris

on g

roup

)R

CT

(<

6 cl

uste

rs)

RC

T (

6 c

lust

ers)

a In

terv

entio

ns a

ppea

r in

mor

e th

an o

ne c

olum

n w

hen

they

had

mix

ed r

esul

ts. S

ee ta

ble

4 fo

r de

tails

.b

RC

T =

ran

dom

ized

con

trol

led

tria

l.

275

92-4-120938-0_CH08_275

8.4 Go, ready, steady, do not go

Table 8.6 presents recommendations for donors, governments and organiza-tions that work with or are concerned about youths based on the evidencereviewed in this paper. The criteria used for making these recommendationsare reviewed in chapter 4.

8.4.1 Go

The relatively weak study designs and incomplete information preclude giv-ing a “Go” recommendation to any of the intervention types.

8.4.2 Ready

Five of the 10 type 1 interventions were evaluated using designs that producedplausibility or probability evidence sufficient to meet the moderate thresholdset for this type. All of the studies that evaluated the effect of the interventionon knowledge, skills, age of sexual debut or condom use demonstrated sig-nificant gains. Gains were generally not obtained in changing the incidenceor frequency of recent sexual activity or number of partners. Given the di-versity within this type of intervention and the lack of adequate monitoringor process data that would provide a clear picture of the content or deliveryof these interventions, this type is not rated as “Go”, but is considered“Ready” for delivery on a large scale when this is accompanied by continuedevaluations of impact, particularly in different settings, and among differentpopulation subgroups; and with comprehensive monitoring of processes.

8.4.3 Steady

The remaining intervention types fall into the “Steady” category. While theygenerally produced positive results, the evaluation designs were too weak,conducted over too few interventions and over too short a time to support astronger recommendation. Only three of the 11 studies of types 2, 3 and 4interventions produced evidence at the level of plausibility (studies O, R, T)(8, 9, 21, 22, 25); the remainder had evidence either at the level of adequacy(studies M, U) (14, 30) or informed judgement (studies L, N, P, Q, S, V) (7,10, 11, 20, 27, 29). Each intervention type did, however, have unique char-acteristics that are likely to have contributed to their success. Type 2 inter-ventions often addressed unique local and cultural issues, and type 3 usedtraditional kinship networks of communication to convey information aboutmatters of sexuality. While the two type 4 interventions had the widest reachand involved large numbers of community members in participatory activitiesthat raised awareness and mobilized communities, the small number of in-terventions of this type and the weak study designs point to a need for furthertesting and verification of the results. Because of the generally positive results

276

92-4-120938-0_CH08_276

Tab

le 8

.6R

eco

mm

end

atio

ns

on

th

e st

ren

gth

of

the

evid

ence

by

inte

rven

tio

n t

ype

Inte

rven

tio

n t

ype

Key

ch

arac

teri

stic

sC

on

clu

sio

nC

om

men

ts

1. T

arge

ts y

outh

s an

dis

del

iver

ed u

sing

exi

stin

gor

gani

zatio

ns o

r ce

ntre

sth

at s

erve

you

ths

• Y

outh

org

aniz

atio

ns o

r ce

ntre

s al

read

y ac

cept

ed b

yco

mm

unity

; int

erve

ntio

n is

sus

tain

able

and

has

capa

city

to m

ove

into

HIV

/AID

S p

rogr

amm

ing

• S

ucce

ssfu

l neg

otia

tion

of e

ntra

nce

into

org

aniz

atio

n•

HIV

/AID

S e

duca

tion

mus

t hav

e lo

gica

l fit

with

orga

niza

tion

• P

eer

educ

ator

s sh

ould

be

chos

en u

sing

spe

cific

,re

leva

nt s

elec

tion

crite

ria; m

onito

ring

and

supp

ort

shou

ld b

e pr

ovid

ed

Rea

dyT

hese

inte

rven

tions

wer

e m

ost l

ikel

y to

have

dem

onst

rate

d su

stai

nabi

lity,

to h

ave

a st

rong

eva

luat

ion

desi

gn a

nd p

ositi

vere

sults

2. T

arge

ts y

outh

s an

dcr

eate

s its

ow

n sy

stem

and

stru

ctur

e

• S

ucce

ssfu

l neg

otia

tion

of e

ntra

nce

into

com

mun

ity•

Pre

limin

ary

cont

ext a

nd n

eeds

ass

essm

ent s

houl

d be

used

as

foun

datio

n fo

r th

e in

terv

entio

n•

Sen

sitiz

atio

n of

com

mun

ity a

nd/o

r ga

teke

eper

isne

cess

ary

• P

eer

educ

ator

s sh

ould

be

chos

en u

sing

spe

cific

,re

leva

nt s

elec

tion

crite

ria; m

onito

ring

and

supp

ort

shou

ld b

e pr

ovid

ed

Ste

ady

orD

o no

t go

All

eval

uatio

ns o

f the

se in

terv

entio

ns h

adw

eak

desi

gns

The

stu

dies

wer

e as

like

ly n

ot to

dem

onst

rate

sus

tain

abili

ty b

eyon

d th

ein

itial

test

pha

se a

s th

ey w

ere

tode

mon

stra

te s

usta

inab

ility

Spe

cific

pro

blem

s w

ith s

ome

inte

rven

tions

are

add

ress

ed in

the

disc

ussi

on o

f the

“D

o no

t go”

cat

egor

y3.

Com

mun

ity-w

ide

inte

rven

tion

deliv

ered

thro

ugh

exis

ting

trad

ition

alki

nshi

p ne

twor

ks

• S

ucce

ssfu

l neg

otia

tion

of e

ntra

nce

into

com

mun

ity•

Pre

limin

ary

cont

ext a

nd n

eeds

ass

essm

ent a

ndas

sess

men

t of m

ost a

ccep

tabl

e pe

er e

duca

tors

sho

uld

be u

sed

to b

uild

inte

rven

tion

• S

ensi

tizat

ion

of c

omm

unity

and

/or

gate

keep

er is

nece

ssar

y

Ste

ady

Onc

e th

e sy

stem

for

deliv

erin

g th

ein

terv

entio

n is

est

ablis

hed,

this

type

dem

onst

rate

d an

abi

lity

to c

over

a w

ide

rang

e of

issu

es; h

owev

er, f

ew o

f the

sein

terv

entio

ns w

ere

eval

uate

d

277

92-4-120938-0_CH08_277

Inte

rven

tio

n t

ype

Key

ch

arac

teri

stic

sC

on

clu

sio

nC

om

men

ts

• P

eer

educ

ator

s sh

ould

be

chos

en u

sing

spe

cific

,re

leva

nt s

elec

tion

crite

ria; m

onito

ring

and

supp

ort

shou

ld b

e pr

ovid

ed4.

Com

mun

ity-w

ide

inte

rven

tion

deliv

ered

thro

ugh

activ

ities

, suc

has

fest

ival

s

• Suc

cess

ful n

egot

iatio

n of

ent

ranc

e in

to c

omm

unity

• Pre

limin

ary

cont

ext a

nd n

eeds

ass

essm

ent s

houl

dbe

use

d as

a fo

unda

tion

for

the

inte

rven

tion

• S

ensi

tizat

ion

of c

omm

unity

and

/or

gate

keep

er is

nece

ssar

y• A

ppro

pria

te c

omm

unity

act

iviti

es m

ust b

e id

entif

ied

• P

eer

educ

ator

s sh

ould

be

chos

en u

sing

spe

cific

,re

leva

nt s

elec

tion

crite

ria; m

onito

ring

and

supp

ort

shou

ld b

e pr

ovid

ed

Ste

ady

The

se in

terv

entio

ns h

ave

the

wid

est r

each

and

are

mos

t suc

cess

ful i

n ad

dres

sing

com

mun

ity n

orm

san

d pr

oduc

ing

com

mun

ity-w

ide

resp

onse

s

The

stu

dies

eva

luat

ing

thes

e in

terv

entio

ns h

adw

eak

desi

gns

Diff

icul

t to

eval

uate

com

mun

ity-w

ide

resp

onse

s

278

92-4-120938-0_CH08_278

and the unique characteristics of many of these interventions, it is recom-mended that interventions of these types that are already in place shouldcontinue, but no new ones should be implemented until evaluations demon-strate their effectiveness at least at the level of plausibility.

One type 1 intervention has also been categorized as “Steady” (rather than“Ready”) based on promising results but a weak study design. The KenyanMathare Youth Sports Association’s intervention (study I) (6) is a type 1intervention that has received international awards for its work with youth.Its reach extends to thousands of youth, and its programming includes aninnovative approach to challenging the gender norms that heighten the vul-nerability of young girls. Education about HIV risks and risk avoidance isincorporated into small group activities. Considering the broader social ben-efits that this programme has brought to the community, it should continueto be supported at its current level but an evaluation to assess its effects onHIV-related knowledge, skills and behaviours should be undertaken.

8.4.4 Do not go

While no intervention type has been categorized as “Do not go”, lessons werelearnt from several interventions that led to the identification of approachesthat should be avoided. The evaluation of a type 2 programme in Nepaldemonstrated the need to monitor activities at all sites in multisite interven-tions to ensure the intervention is actually delivered and that the design isfeasible (study Q) (27) Multisite interventions that lack these characteristicsdo not warrant the financial investment of donor agencies or governments.

Also unsuitable for funding are interventions that have high resource needsand lack a mechanism to ensure their ongoing provision as well as interven-tions that do not provide training, structure, monitoring or support for peerleaders. The former is seen in an example of anti-AIDS clubs in Malawi (type1 intervention) that relied on videos, video equipment and sports equipment(study G) (12) The equipment was stolen or broken within 1–2 years, thuslimiting the ongoing activities of the clubs. In contrast, anti-AIDS clubs inZambia (also type 1 interventions) were able to replenish supplies in home-based care kits every 3 months by maintaining relationships with nongovern-mental organizations (NGOs) and health services (study H) (26) Theproblems of providing inadequate training, structure, monitoring or supportfor peer leaders is evidenced in the type 2 intervention in Nepal (study Q)(27) as well as the type 1 intervention in Ghana (study E) (18) that comparedresults of a structured intervention with those of an unstructured interventioninvolving peer leaders. Clearly, interventions that depend on a continuingsupply of materials and that do not have a long-term and sustainable sourceof supplies, or those that rely on peer leaders but do not provide them with

279

92-4-120938-0_CH08_279

the training, structure and support they need to do their job, should be cate-gorized as “Do not go”.

8.4.5 Requirements for success

From reviewing the materials brought together here, it is possible to identifykey characteristics that are required for interventions to succeed. It is essentialthat all types of interventions provide the following for the leaders of theinterventions, especially peer leaders.

A screening procedure should be used to select peer leaders to ensure theyare motivated and capable of taking on the required tasks.

Comprehensive training and refresher sessions in programme content andthe skills required for delivery should be provided.

Leaders should be assigned specific tasks and objectives, and their workmust be monitored and supported.

In addition, all intervention types should:

focus on gaining entry into the community and on developing strategies todeal with adverse reactions to programme components;

focus on participatory learning activities;

ensure there is a sustainable means of obtaining required programmesupplies;

build links between components of complex interventions (for example,referral systems and activities should operate across components).

Beyond the requirements common to all interventions, each type of inter-vention has its own requirements.

Those implementing type 1 interventions should:

ensure the intervention is incorporated into the activities of an existingorganization or centre that has demonstrated an ability to reach a largenumber of youths and also ensure it is sustainable and accepted by thecommunity;

ensure that the organization’s activities attract both males and females.

Those implementing intervention types 2, 3 or 4 need to develop a system ofoutreach to the target population that is sustainable and acceptable to com-munity members. Those implementing type 2 interventions need to developan infrastructure that can sustain the intervention over the long term.

Those implementing type 3 interventions need to:

280

92-4-120938-0_CH08_280

hold discussions with community leaders and gatekeepers to identify theappropriate traditional networks for delivering an intervention that dealswith sexual behaviour and to determine the best type of leaders to deliverthe intervention;

develop a method to ensure that appropriate material support and resourcesare available to programme leaders to compensate them for the sizablecommitment of time and to ensure they can reach the target population.

Those implementing type 4 interventions should:

identify activities that have wide community appeal;

choose the timing and location of the intervention to maximize its reachand community participation;

advertise the activities in a way that make them accessible to communitymembers.

Although using an established theoretical model of behaviour change hasoften been cited as a requirement for success (31), this conclusion is not sup-ported by the studies reviewed here. Few interventions were explicitly basedon a theoretical model, and neither the number nor the strength of outcomeswas influenced by the presence or absence of a theoretical framework. Thisfinding parallels that of Gallant and Maticka-Tyndale in their review ofschool-based programmes in sub-Saharan Africa (5).

8.5 Conclusions

In drawing conclusions about interventions implemented in specific geo-graphically bounded communities, the weakness of the study designs and dataanalyses and the paucity of evaluations for several intervention types cannotbe ignored. It is evident that the attention of NGOs involved in designing andimplementing interventions has most often been on the intervention itself andnot on its evaluation. This is understandable given the urgency of the AIDSepidemic and the mission of NGOs. Recognizing these priorities, this reporthas used a more liberal interpretation of the adequacy of the study designneeded to demonstrate the effectiveness of an intervention.

The most encouraging results in terms of outcomes and programme reach arefor intervention types 1, 3 and 4 in which AIDS programmes were linkedto existing youth-focused organizations, to traditional kinship networks orwere part of community-wide events. The stronger study designs and suc-cesses noted for type 1 interventions present a particular contrast with thoseassessing type 2 interventions, which differ from type 1 interventions only intheir lack of connection to existing organizations. Of the interventions tar-geting entire communities, type 3 interventions, which also used existing

281

92-4-120938-0_CH08_281

infrastructure, were most successful in demonstrating gains in knowledge andskills as well as behaviour change; they also provided some evidence of shiftsin community norms. Finally, while few in number, the success of the twotype 4 interventions in raising awareness and mobilizing communities to planaction that could reduce the vulnerability of young people suggests that type4 interventions are promising and more of them should be evaluated. Thechallenges encountered by type 2 interventions suggest that it may be easierto achieve success when attention can be focused on developing and deliv-ering the content of the intervention rather than also focusing attention ondeveloping an infrastructure for delivery.

While the publications reviewed for this paper provided evidence of a con-siderable amount of innovation and creativity, and there are several inter-ventions that may make substantial contributions to achieving the UNGASSgoals, it is clear that more attention needs to be paid and funding applied tothe evaluation of both processes and outcomes and particularly to the speci-fication of the conditionality of the effects of the intervention. Attention mustalso be paid to cost–benefit analyses or at least to the costing of interventions.Continued delivery of the best of these interventions is important. However,good quality evaluations of processes and outcomes that test the efficacy andeffectiveness of interventions and provide information on cost are essentialto providing the evidence base needed for future decision-making. To thisend, a summary of recommendations to guide the development, evaluationand delivery are contained in Box 8.1.

Box 8.1

Recommendations for interventions targeting youths that are delivered ingeographically defined communities

For policy-makers

There is a sufficiently strong evidence base to support widespreadimplementation of interventions to prevent HIV that are deliveredwithin the framework of existing youth-service organizations oryouth centres. However, these interventions should only be imple-mented if they are carefully evaluated.

In addition, there is also a sufficiently strong evidence base to sup-port the continued delivery of similar interventions when they arenot connected to existing youth-oriented organizations and to sup-port the continued delivery of interventions targeting both adultsand youths when they are delivered through traditional or familynetworks or when they are delivered through community-wide

282

92-4-120938-0_CH08_282

events, such as theatrical performances, health fairs or festivals andcompetitions. However, expansion of such interventions should nottake place until they have been more carefully evaluated.

For programme development and delivery staff

Interventions delivered within existing youth-oriented organiza-tions, centres or infrastructures (for example, through faith-basedorganizations, families or existing community festivals) are able tofocus greater attention on elements necessary for success than areinterventions that must also build their own infrastructure to supportdelivery. Attention should be paid to working with gatekeepers en-sure ongoing acceptance of and support for interventions; thereshould be careful selection, training and supervision of programmeleaders; the tasks and duties of intervention leaders should be iden-tified; mechanisms must be found to provide the necessary ongoingresources for intervention delivery; participatory learning activitiesshould be used; links should be established between institutions andorganizations involved in the delivery and support of multifacetedinterventions; and culturally appropriate leaders, content and deliv-ery methods should be identified.

For researchers

Evaluation and operations research should be core elements of anyintervention targeting either young people or communities as awhole for the purpose of increasing young people’s knowledge andskills and changing their behaviours related to HIV transmissionand infection. In particular, evaluation results should pay attentionto analyses that identify specific conditions for different levels ofsuccess (for example, gender differences, and differences betweenrural and urban areas) and should include an evaluation of the costof the intervention.

References

1. United National General Assembly Special Session on HIV/AIDS. Declarationof commitment on HIV/AIDS. Geneva: United Nations, 2001.

2. Habicht J, Victora C, Baughan J. Evaluation designs for adequacy, plausibilityand probability of public health programme performance and impact.International Journal of Epidemiology, 1999, 28:10–18.

3. Caldwell J. Rethinking the African AIDS epidemic. Population and DevelopmentReview, 2000, 26:117–135.

283

92-4-120938-0_CH08_283

4. Green E. Rethinking AIDS prevention. Westport, CT, Praeger, 2003.

5. Gallant, M., Maticka-Tyndale, E. School-based HIV prevention programmes forAfrican youth. Social Science and Medicine, 1994, 58:1337–1351.

6. Brady M, Bunu Khan A. Letting girls play: the Mathare Youth SportsAssociation’s football program for girls. New York, Population Council, 2002.

7. UNFPA. Rapport evaluation thematique du projet UNFPA: mobilisationcommunautaire, participation et renforcement de l’autonomie desadolescent(e)s [Thematic evaluation report of UNFPA project: communitymobilization, participation and empowerment of adolescents]. Burkina Faso,UNFPA, 2004.

8. Kagimu M, Marum E, Serwadda D. Planning and evaluating strategies for AIDShealth education interventions in the Muslim community in Uganda. AIDSEducation and Prevention, 1995, 7:10–21.

9. Kagimu M et al. Evaluation of the effectiveness of AIDS health educationinterventions in the Muslim community in Uganda. AIDS Education andPrevention, 1998, 10:215–228.

10. Bagamoyo College of Arts et al Participatory action research on HIV/AIDSthrough a popular theatre approach in Tanzania. Evaluation and ProgramPlanning, 2002, 25:333–339.

11. Bagamoyo College of Arts. Report on participatory action research on HIV/AIDSthrough popular theatre approach in Temeke district. Dar Es Salaam, UnitedRepublic of Tanzania, UNICEF, 2001.

12. Reijer P, Chalimba M, Nakwagala A. Malawi goes to scale with anti-AIDS clubsand popular media. Evaluation and Program Planning, 2002, 25:357–363.

13. Merati TP et al. Traditional Balinese youth groups as a venue for prevention ofAIDS and other sexually transmitted diseases. AIDS, 1997, 11 Suppl1:S111–119.

14. Elkins D et al. Relaying the message of safer sex. Health EducationResearch, 1998, 13:357–370.

15. Speizer I, Oleko Tambashe B, Tegang SP. An Evaluation of the “Entre NousJeunes” peer educator program for adolescents in Cameroon. Studies in FamilyPlanning, 2001, 32:339–351.

16. Institut de Recherche et des Etudes des Comportements (IRESCO) [Instituteof Research and Studies of Behaviour].. Peer education as a strategy toincrease contraceptive prevalence and reduce the rate of STIs/HIV amongadolescents in Cameroon. Washington, DC, Population Council, 2002.(Frontiers Final Report.)

17. Population Council, Frontiers in Reproductive Health. Cameroon: peereducation and youth-friendly media reduce risky sexual behaviour. Washington,DC, Population Council, 2003. (Summary No. 37.)

18. Centre for Development and Population Activities (CEDPA). Using PEs toimprove adolescent reproductive health in Ghana. Washington, DC, CEDPA,2000.

19. Hughes-d’Aeth A. Evaluation of HIV/AIDS peer education projects in Zambia.Evaluation and Program Planning, 2002, 25:397–407.

20. Lakhani A, Ketan G, Collumbien M. Addressing semen loss concerns.Reproductive Health Matters, 2001, 9:49–59.

284

92-4-120938-0_CH08_284

21. Muyinda H et al. Traditional sex counselling and STI/HIV among young womenin rural Uganda. Culture, Health and Sexuality, 2001, 3:353–361.

22. Muyinda H et al. Harnessing the senga institution of adolescent sex educationfor the control of HIV and STDs in rural Uganda. AIDS Care, 2003, 15:159–167.

23. Mathur S, Malhotra A, Mehta M. Youth reproductive health in Nepal: isparticipation the answer? Washington, DC, International Centre for Researchon Women (ICRW) , EngenderHealth, 2001.

24. Erulkar A et al. Behaviour change evaluation of a culturally consistentreproductive health program for young Kenyans. International Family PlanningPerspectives, 2004, 30:58–67.

25. Awasthi S, Nichter M, Pande V. Developing an interactive STD-preventionprogramme for youth: lessons from a north Indian slum. Studies in FamilyPlanning, 2000, 31:138–150.

26. Esu-Williams E et al. Involving young people in the care and support of peopleliving with HIV and AIDS in Zambia. Washington, DC, Population Council, 2004.(Horizons Final Report.)

27. Sharma M. Youth for Each Other programme: rapid impact assessment. NepalRed Cross Society Junior/Youth Department HIV/AIDS PreventionProgramme. Nepal, Centre for Development and Population Activities, 2002.

28. Brieger W et al. West African Youth Initiative: outcome of a reproductive healtheducation program. Journal of Adolescent Health, 2001, 29:436–446.

29. UNICEF, Ghana. Evaluation of HIV/AIDS prevention through peer education,counselling, health care, training and urban refuges in Ghana. Evaluation andProgram Planning, 2002, 25:409–420.

30. Nastasi B et al. Community-based sexual risk prevention programme for SriLankan youth: influencing sexual-risk decision making. International Quarterlyof Community Health Education, 1998, 18:139–155.

31. Kirby D. Emerging answers: research findings on programs to reduce teenpregnancy. Washington, DC, National Campaign to Prevent Teen Pregnancy,2001.

285

92-4-120938-0_CH08_285

92-4-120938-0_CH08_286

9. Achieving the global goals on HIVamong young people most at risk indeveloping countries: young sexworkers, injecting drug users andmen who have sex with menOliver Hoffmann,a Tania Boler,a & Bruce Dickb

Objective To review evaluations of interventions in developing countriestargeting three groups most at risk of becoming infected with HIV: young sexworkers, young injecting drug users and young men who have sex with men.

Methods A systematic literature review was undertaken to identify pro-grammes in developing countries targeting young people in the three selectedgroups most at risk from HIV. We also identified programmes directed atyoung people in developed countries as well as programmes in developingcountries that targeted these three population groups but that did not differ-entiate between young people and adults.

Findings Young people 10 to 24 years of age represent a large proportion ofthe population most at risk of becoming infected with HIV in developingcountries. Despite this fact, well documented evaluations of interventions thattarget these groups are scarce. However, there is evidence of effectivenessfor programmes that are facility-based and use outreach to provide informa-tion and services to at-risk young people.

Conclusion There is growing evidence from developing countries of suc-cessful interventions that target groups most at risk from HIV, and theseprogrammes should be widely implemented provided that they are carefullyplanned and monitored and have a strong evaluation component. However,there is an urgent need to disaggregate data by age in order to determine howeffective these programmes are in reaching young people and to better un-derstand the specific needs of at-risk young people as opposed to older agegroups.

a Department of Epidemiology and Population Health, London School of Hygiene and TropicalMedicine, Keppel Street, London WC1E 7HT, England. Correspondence should be sent to DrHoffmann (email: oliver.hoffmann@lshtm.ac.uk).

b Department of Child and Adolescent Health and Development, Family and Community Health,World Health Organization, Geneva, Switzerland.

287

92-4-120938-0_CH09_287

9.1 Introduction

Since the beginning of the AIDS pandemic it has been clear that not everyoneis equally at risk of becoming infected with HIV. This remains true in gen-eralized epidemics, concentrated epidemics and low-level epidemics. Pre-venting transmission of HIV to and from individuals and groups who are mostat risk will be crucial if governments are to contain the epidemic and achievethe Millennium Development Goal on AIDS. In low-level and concentratedepidemics, groups with an increased risk of becoming infected include in-jecting drug users, sex workers, men who have sex with men, and people whoare incarcerated or live in institutions. In addition, in generalized epidemics,young girls, men who have many sexual partners and the women who aremarried to them, mobile groups and groups living in relative poverty mayalso be particularly at risk.

With the exception of injecting drug use, the virus is transmitted the sameway among the groups most at risk and other groups in the population. Forthose most at risk, however, there are many factors that increase their chancesof becoming infected, and underlying these factors are structural determi-nants, such as inequity and discrimination, exploitation and abuse. Interven-tions that aim to change these determinants of vulnerability are outside thescope of this chapter.

Many young people are particularly at risk of becoming infected with HIVbecause of the situations in which they live, learn and earn and as a result ofbehaviours they adopt, or are forced to adopt, as a result of social, culturaland economic factors. The ultimate long-term challenge is to decrease thesecauses of vulnerability. In the short term, however, the groups most at risk ofHIV are particularly in need of the interventions outlined in the United Na-tions General Assembly Special Session on HIV/AIDS (UNGASS) goals andtargets for young people, notably the goals of providing them with access toinformation, skills and services. Achieving these goals will mitigate theirvulnerability and decrease their risk of HIV infection.

During the process of developing this series of papers that review the evidencefor policies and programmes to achieve the global goals on HIV and youngpeople, it was felt important to review the evidence for achieving these targetsamong young people aged 15–24 years who are most at risk of becominginfected. Many of these young people live on the fringes of society, and theyare unlikely to be reached by the majority of interventions outlined in thisseries, such as those implemented through schools, health services or themedia. To complicate matters, these groups frequently suffer from discrim-ination and marginalization, and their behaviours – such as drug use or sexwork – are often illegal, making it even harder for interventions deliveredthrough mainstream settings to reach them.

288

92-4-120938-0_CH09_288

What then do we know about the evidence for reaching the global goals onyoung people who are most at risk and most in need of the interventions thatgovernments endorsed during UNGASS? Clearly it is important to preventHIV infection in these groups, and national responses need to focus stronglyon these groups. They also need to receive explicit attention because it wouldbe possible for countries to achieve the UNGASS targets without ensuringcoverage of these groups, who are at the centre of the HIV epidemic.

This is not to imply that young injecting drug users necessarily require sep-arate or parallel services from those provided to adult drug users. And this isthe same for young sex workers, young men who have sex with men, youngprisoners or other groups of young people at high risk from HIV. It is likelyto be neither necessary nor practicable to provide separate services. However,it is clear that any assessment of interventions designed to achieve the globalgoals must not ignore these groups. It is important to review what we knowabout reaching these groups through the interventions outlined in the globalgoals. It is also important to clarify whether young people most at risk havespecific needs relative to older age groups and whether these needs requireexplicit attention from policies and programmes.

9.2 Methods

9.2.1 A focus for this paper

It was clearly not possible to include all groups of young people who mightbe at particular risk in all epidemic scenarios. It was therefore decided to focuson groups most at risk in areas of low-level and concentrated epidemics, sincemany of the groups of young people most at risk in generalized epidemicsare likely to have some access to information, skills and services throughexisting channels. Within low-level and concentrated epidemics it was de-cided to focus on young injecting drug users, young sex workers and youngmen who have sex with men, since data are more likely to be available forthese groups than other at-risk groups, such as mobile populations or prison-ers. However, it needs to be emphasized that there is significant overlapamong these groups. For example, young men who have sex with men maybe sex workers, and sex workers may be injecting drug users.

In addition to selecting specific groups for inclusion in this review, it wasalso necessary to have a process for assessing the evidence for the effective-ness of interventions. An initial search for studies focusing on at-risk youngpeople in developing countries indicated that there were relatively few data,either in the published literature or the grey literature. It was thereforedecided also to review studies of interventions directed at young people indeveloped countries as well as studies that had been undertaken within

289

92-4-120938-0_CH09_289

general populations of sex workers, injecting drug users and men who havesex with men in developing countries but that had not disaggregated their databy age.

This chapter therefore reviews studies and reports that:

1. quantify the number of young people most at risk of HIV and assesstheir specific needs compared with older age groups of at-risk populations;

2. focus on young people most at risk of HIV in developing countries;

3. focus on young people most at risk of HIV in developed countries;

4. focus on people most at risk of HIV in developing countries that do notdisaggregate data by age.

9.2.2 Inclusion and exclusion criteria

Inclusion and exclusion criteria are outlined in Table 9.1.

The main focus of this series is to review the evidence for policies and pro-grammes aiming to achieve the global goals and targets on HIV and youngpeople in developing countries. The inclusion and exclusion criteria for thisspecific component of the chapter have therefore been tighter and morealigned with other chapters in this series than the inclusion and exclusioncriteria for studies that have been included for the last two categories above(studies in developed countries and studies in developing countries that havenot disaggregated their data by age). These categories have been includedonly to provide a broader evidence context for assessing the effectiveness ofinterventions directed towards the groups who are the primary focus of theseries.

A systematic literature review was undertaken, including searches indatabases (PubMed, POPLINE, CAB Direct, Cochrane Library and Educa-tional Research Abstracts Online), recent issues of journals focusing onyoung people’s health and HIV prevention activities (AIDS, AIDS and Be-havior, AIDS Care, AIDS Education and Prevention, Archives of Pediatricsand Adolescent Medicine, Behavior Modification, Journal of AdolescentHealth, Journal of Adolescent Research, Journal of HIV/AIDS Preventionand Education for Adolescents and Children, Journal of Sex Education andTherapy), and finally on relevant web sites, such as WHO, UNAIDS,UNICEF, UNESCO, the United Kingdom Department for InternationalDevelopment (including the Safe Passages to Adulthood research pro-gramme), German Technical Cooperation (GTZ), Family Health Interna-tional (including YouthNet), Population Council, Pathfinder International,AIDS Education Global Information System (AEGiS), International Centre

290

92-4-120938-0_CH09_290

Table 9.1Inclusion and exclusion criteria used to identify studies for review. (Numbers inparentheses refer to categories listed in section 9.2.1)

Inclusion criteria Exclusion criteria

Interventions designed to mitigatevulnerability to HIV infection throughproviding increased access to information,skills and services (categories 1–4)

Interventions that aim to decreasevulnerability to HIV, such as structuralinterventions

Interventions implemented in developingcountries that aim to reduce the risk of HIVtransmission among injecting drug users,sex workers and men who have sex withmen by providing increased access toinformation, skills and services for HIVprevention (categories 1 and 4)Interventions in developing countries wereaimed at reducing the risk of HIVtransmission among young people aged 10–24 who are injecting drug users, sex workersor men who have sex with men by providingincreased access to information, skills andservices for HIV prevention (categories 1and 2)Interventions in developed countries thataimed to reduce the risk of HIV transmissionin young (10-24 years) injecting drug users,sex workers, and men who have sex withmen by providing increased access toinformation, skills and services for HIVprevention (category 3)Study provides a description of theintervention that enables a judgement to bemade about what was done (category 2)

Study provides inadequate descriptions ofthe content of the intervention, the design ofthe study or how data were collected andanalysed (category 2)

Study provides a description of theevaluation design and there were sufficientdata to make a judgement about the level ofevidence of effectiveness (category 2)Research and reports were publishedbetween 1990 and 2004

for Reproductive Health (ICRH), International Center for Research onWomen (ICRW), KIT (Royal Tropical Institute of the Netherlands) librarycatalogue, International Council on Management of Population Programmes(ICOMP), Johns Hopkins Bloomberg School of Public Health Center for

291

92-4-120938-0_CH09_291

Communication Programs, CAPS – the Center for AIDS Prevention Studies,Streetkids–SRH.org, and the Network of Sex Work Projects.

A number of review articles on HIV prevention interventions that focused onyoung people (1–6) and developing countries (7) were scanned for relevantstudies. All reference sections of peer-reviewed papers identified during thisliterature search were checked for additional articles of interest. Finally, 12experts working in the field were contacted to identify unpublished research.

A less extensive search was made for studies assessing the effectiveness ofinterventions in developing countries directed towards injecting drug users,sex workers and men who have sex with men but that did not disaggregatethe data by age and for studies of interventions targeted at young people mostat risk of HIV in developed countries, predominantly the United States.

No systematic search for studies reported in languages other than English wasundertaken.

9.2.3 Developing a typology

From the initial review of the literature it was clear that interventions aimedat groups considered to be most at risk included some mix of facility-basedinterventions with or without outreach and the provision of information withor without additional services. The typology that was developed was basedon these programme elements, and the interventions were categorized intothe following types.

Type 1: these interventions only provided information through an outreachprogramme.

Type 2: these interventions provided information and services through anoutreach programme.

Type 3: these interventions provided information and services through afacility-based programme.

Type 4: these interventions provided information and services through afacility-based programme that also included an outreach component.

Apart from distinguishing the place where the intervention was based, thistypology also differentiates between those programmes that only provide in-formation and those that also include services. A range of services wereprovided in the studies reviewed, including treatment for sexually transmittedinfections (STIs), strategies to reduce harm by providing needle exchange orsubstitution therapy, or both, as well as condoms, counselling and support.

292

92-4-120938-0_CH09_292

9.2.4 Threshold of evidence required to recommend widespreadimplementation

As with the other papers in this series, once the typology had been defined itwas necessary to determine the threshold of evidence that would be requiredto recommend widespread implementation of different types of interventions –that is, to allocate them to the “Steady”, “Ready”, “Go” and “Do not go”categories. Table 9.2 provides an overview of the threshold of evidence re-quired to recommend the four types of interventions. As the complexity ofthe interventions increases – for example, offering information plus services,or outreach plus facilities – the levels of evidence required become highersince the interventions become increasingly difficult to develop and sustain,even though they are likely to have a greater impact.

9.3 Findings

9.3.1 Studies quantifying the number of at-risk young people and assessingtheir needs

The literature indicates that people who are younger than 25 years representa significant proportion of the groups most at risk of HIV (see chapter 2). Inseveral south-east Asian countries, for example, the proportion of womenyounger than 25 who are working in high-risk environments, such as brothels,has been estimated to vary between 41% in Indonesia (8) and 76% in the LaoPeople’s Democratic Republic (9).

In Africa, a large proportion of female sex workers are young. For example,37% of 622 female sex workers in a study from Zambia were younger than20 (10), and in one region in the United Republic of Tanzania, womenyounger than 20 accounted for 23% of 983 women working in bars and similarestablishments (11).

Two longitudinal studies from west Africa indicate possible trends towardsyounger people becoming involved in sex work. In Benin, the number offemale sex workers younger than 25 rose from 17% in 1993 to 34% in 1998–1999, despite an ongoing HIV intervention directed towards female sexworkers (12). In Côte d’Ivoire, the median age of female sex workers attend-ing an STI clinic declined from 30 years in 1992 to 23 years in 1998 (13).

In Central Asia and eastern Europe, areas that are experiencing some of thefastest growing HIV epidemics in the world, the impact of economic andsocial transition has led to unparalleled proportions of young people injectingdrugs, which is the main mode of HIV transmission in those regions (14). Itis estimated that the average age of young people using injected drugs for thefirst time is between 16 years and 19 years (15), and 70% of all people in-jecting drugs are younger than 25 (14). A study in Irkutsk, Russia, showed

293

92-4-120938-0_CH09_293

Tab

le 9

.2T

hre

sho

ld o

f ev

iden

ce n

eed

ed t

o r

eco

mm

end

wid

esp

read

imp

lem

enta

tio

n o

f ea

ch t

ype

of

inte

rven

tio

na

Inte

rven

tio

nty

pe

Fea

sib

ility

Lac

k o

fp

ote

nti

alfo

rad

vers

eo

utc

om

es

Acc

epta

bili

tyfo

r ta

rget

gro

up

Acc

epta

bili

tyfo

rco

mm

un

ity

and

po

licy-

mak

ers

Po

ten

tial

size

of

effe

ct

Oth

erh

ealt

h o

rso

cial

ben

efit

s

Ove

rall

thre

sho

ldC

om

men

tsb

1. In

form

atio

non

ly p

rovi

ded

thro

ugh

outr

each

++

++

++

++

++

++

Low

Rel

ativ

ely

easy

to o

rgan

ize

and

impl

emen

t but

leas

t lik

ely

to h

ave

any

long

-last

ing

posi

tive

effe

cton

the

targ

et g

roup

2. In

form

atio

nan

d se

rvic

espr

ovid

edth

roug

hou

trea

ch

++

++

++

++

++

Mod

erat

eS

ervi

ces

are

mor

e lik

ely

toha

ve a

n ef

fect

than

info

rmat

ion

alon

e bu

t thi

s ty

pe m

ay b

edi

fficu

lt to

org

aniz

e, e

spec

ially

the

outr

each

com

pone

nt3.

Fac

ility

-ba

sed

info

rmat

ion

and

serv

ices

++

++

++

++

++

++

++

Low

Like

ly to

be

effe

ctiv

e on

ly if

the

targ

et g

roup

vis

its th

e fa

cilit

y bu

tot

herw

ise

easi

er to

org

aniz

eth

an o

utre

ach

4. O

utre

ach

and

faci

lity-

base

din

form

atio

nan

d se

rvic

es

++

++

++

++

++

++

Mod

erat

eM

ost d

iffic

ult t

o es

tabl

ish

and

sust

ain

but a

lso

mos

t lik

ely

to b

eef

fect

ive,

esp

ecia

lly if

out

reac

hen

cour

ages

the

targ

et g

roup

tom

ake

use

of th

e fa

cilit

ies

a D

egre

e of

des

irabi

lity

is in

dica

ted

with

a m

axim

um o

f 3 “

+”

sign

s. D

egre

e of

und

esira

bilit

y is

indi

cate

d w

ith a

max

imum

of 3

“-”

sig

ns.

b A

ll in

terv

entio

ns n

eed

to o

verc

ome

stig

mat

izat

ion

of th

e ta

rget

gro

up a

nd th

e ill

egal

ity o

f the

beh

avio

urs

in o

rder

to b

e su

cces

sful

294

92-4-120938-0_CH09_294

that 90% of injecting drug users were younger than 20 years, and 65% ofyoung people living on the street who were also injecting drugs were HIVpositive (16).

Not only do young people make up a significant proportion of injecting drugusers, but as this study from Irkutsk indicates they may also be particularlyvulnerable. In Bangladesh, sex workers who are younger than 25 were almosttwice as likely to report having been beaten or raped when compared withtheir older peers (17); in Myanmar national surveillance reports show thatsex workers and injecting drug users who are younger than 25 have a higherprevalence of infection with HIV than other age groups (18). A cross-sectional study from India found a significantly higher prevalence of HIVinfection among female sex workers who were younger than 20 comparedwith the prevalence among older age groups (P = 0.002, odds ratio [OR] =2.4, 95% confidence interval [CI] = 1.3–4.4) (19). A high prevalence of HIVamong young women was also reported from a cohort of female sex workersin the United Republic of Tanzania that reviewed HIV prevalence amongwomen aged 16–39 years: 46% of those who were younger than 20 were HIVpositive; 72% of women aged 20–24 were HIV positive; and 68% of thoseaged 25 years or older were HIV positive (20).

Not only do the data indicate that young people represent a significant pro-portion of the population most at risk of becoming infected, and that they maybe particularly vulnerable, but there is also some evidence that their needsdiffer from older people in at-risk groups.

For example, Tawil (21) cited a Moroccan programme targeting men whohave sex with men. This programme’s baseline survey found that only 28%of males aged 15–24 years reported using condoms regularly, while 57%of those aged 25 years or older reported using condoms regularly. Similarly,a Bolivian study conducted among female sex workers reported an increasedrisk of gonorrhoea, trichomoniasis and genital ulcer among those aged24 years or younger, without indicating behavioural reasons for this disparity(22). A study that compared drug users who were younger than 26 with olderdrug users found significant differences in risk-taking behaviours betweenthe two groups (23). Although younger drug users were less likely to injecttheir drugs compared with older drug users, the age at which users startedtaking drugs had dropped significantly among the younger drug users(16.2 years for younger users versus 17.9 years for older users, P < 0.001),and younger users were also less likely to be aware of their HIV status (41.8%for younger users versus 64.9% for older users, P < 0.001).

295

92-4-120938-0_CH09_295

9.3.2 Studies focusing on young people most at risk in developing countries

While there is a wealth of information from cross-sectional studies conductedamong at-risk young people, there are few published evaluations of inter-ventions targeting these groups in developing countries. No studies werefound in peer-reviewed journals, and the 11 studies that were identified wereall in programme reports or other grey literature. Three of these were fromAfrica, two from Asia and six were from Latin America. Target groups in-cluded sex workers (5 studies), men who have sex with men (1 study),injecting drug users (3 studies) and youths living on the street (2 studies).Unfortunately, only four of these studies met the inclusion criteria (Table 9.1).The studies that met the inclusion criteria came from Africa (1 study) andfrom Latin America (3 studies). One of the Latin American studies examinedinterventions directed to sex workers; one examined interventions targeted atmen who have sex with men; and two examined interventions targeted atstreet youths.

9.3.2.1 Sex workers

Interventions targeting young sex workers were identified in Brazil, Ethiopiaand Nicaragua (24). The Ethiopian programme, run by the Organisation forSocial Services for AIDS, and the Brazilian “Sidewalk Girls” programmeboth used older peer educators who met with younger sex workers in an at-tempt to teach them how to reduce their risk of becoming infected. Unfortu-nately, no evaluations of these interventions were found. A secondintervention by the Instituto Centroamericano de la Salud in Nicaragua pro-vided all sex workers in Managua with vouchers that entitled them to receivea standardized package of free sexual and reproductive health treatment(study D) (24, 25). The project started in 1996 and for eight years afterwardsdistributed more than 30 000 vouchers and provided more than 12 000 con-sultations, during which a large number of STIs were treated among femalesex workers (25). A substudy among 114 sex workers who also sniffed glueshowed decreases in the prevalence of gonorrhoea (13.7% to 8.6%, not sig-nificant), syphilis (15.6% to 8.0%, not significant) and trichomoniasis (22.1%to 12.4%, P < 0.01) (24).

9.3.2.2 Injecting drug users

Interventions for young injecting drug users were identified in Argentina,India and Kenya (24). The Kenyan centre trained 54 volunteers in counsellingand HIV prevention, and it provided counselling and detoxification servicesfor 20 young injecting drug users. In Argentina, HIV testing, safer sex work-shops and a drug users’ network were provided; in India a drop-in centreprovided counselling and HIV testing as well as support groups for more than

296

92-4-120938-0_CH09_296

4 000 drug users. Unfortunately, none of these interventions provided eval-uation data.

9.3.2.3 Men who have sex with men

Only one project was identified that specifically targeted men who have sexwith men who were also sex workers. “El Salon” in Costa Rica provided asafe place in the form of a home at which young male sex workers couldaccess counselling, education and support (study B) (24). The evaluation ofthe intervention showed an increased use of condoms and the formation ofsupport groups among the target group (24).

9.3.2.4 Street youths

Evaluations of interventions targeting youths living on the street were alsoincluded because this group frequently becomes involved in sex work anddrug use. Studies of interventions were identified in Brazil and Uganda (26,27). In Uganda, services provided information and counselling and increasedaccess to condoms (147 000 condoms distributed) and STI treatment (29 000adolescents treated for STIs from April 2002 to March 2004). Unfortunatelyno denominators were available (study C) (26). In Brazil, the interventionaimed to increase knowledge about HIV prevention through the use of videos,comic books and drama groups (study A) (27). Cross-sectional surveysamong 400 young people carried out before and after the interventionsdemonstrated significant changes, with the interventions resulting in in-creased levels of knowledge about HIV transmission and decreased levels ofmisconceptions about HIV/AIDS.

Table 9.3 summarizes the studies that met the inclusion criteria according totypology (whether the interventions were outreach-based and/or clinic-basedand whether they included information and/or services). Only one project thatmet the inclusion criteria was identified as a type 1 intervention (providingonly information through an outreach programme). No studies of type 2 in-terventions (information and services provided through an outreach pro-gramme) had sufficient details on either the content or the evaluation. Forinterventions based only in facilities, (type 3 interventions), one programmefor male sex workers was identified. Two studies of type 4 interventions wereidentified; these provided facility-based services as well as outreach activi-ties. One worked with street children and sex workers and the other workedonly with sex workers.

Table 9.3, Table 9.4 and Table 9.5 include studies focusing on the main targetgroup of this review, namely young people in developing countries who aremost at risk of becoming infected with HIV. Table 9.4 describes the evalua-tion designs for each of the studies, and Table 9.5 summarizes the studiesaccording to the level of evidence of effectiveness that could be derived fromthe studies.

297

92-4-120938-0_CH09_297

Tab

le 9

.3D

escr

ipti

on

of

the

inte

rven

tio

ns

by

stu

dy

Stu

dy

and

loca

tio

nT

arg

et p

op

ula

tio

n a

nd

pri

mar

y o

bje

ctiv

esD

escr

ipti

on

Inte

rven

tio

n t

ype

1 (i

nfo

rmat

ion

on

ly p

rovi

ded

th

rou

gh

ou

trea

ch p

rog

ram

me)

A –

Bra

zil (

27)

• P

rimar

y ob

ject

ives

: to

prev

ent H

IV/A

IDS

tran

smis

sion

in th

e ta

rget

gro

up•

Tar

get g

roup

s: Y

oung

wom

en v

ulne

rabl

e to

sexu

al v

iole

nce,

you

ths

livin

g on

the

stre

et

• M

ultic

ompo

nent

pro

gram

me

cons

istin

g of

edu

catio

n ab

out

sexu

ality

and

HIV

/AID

S; t

rain

ing

in H

IV/A

IDS

pre

vent

ion

skill

s;se

nsiti

zatio

n of

edu

cato

rs a

nd in

stitu

tiona

l dire

ctor

s to

the

need

tosu

ppor

t vul

nera

ble

yout

hs• A

fter f

orm

ativ

e re

sear

ch, e

duca

tors

wer

e tr

aine

d w

ith a

man

ual a

ndth

roug

h m

eetin

gs. T

he in

terv

entio

n pr

oduc

ed a

vid

eo a

nd a

com

icbo

ok th

at w

ere

dist

ribut

ed a

mon

g th

e ta

rget

gro

up a

nd s

tage

dgr

oup

disc

ussi

ons,

role

-pla

ys a

nd th

eatr

e ac

tiviti

es. S

essi

ons

wer

eco

nduc

ted

in 1

0 in

stitu

tiona

l set

tings

and

125

out

reac

h ac

tiviti

esw

ere

impl

emen

ted

• S

cale

of p

roje

ct: i

nfor

mat

ion

not a

vaila

ble

Inte

rven

tio

n t

ype

2 (i

nfo

rmat

ion

an

d s

ervi

ces

pro

vid

ed t

hro

ug

h a

n o

utr

each

pro

gra

mm

e)N

o st

udy

met

the

incl

usio

n cr

iteria

Inte

rven

tio

n t

ype

3 (f

acili

ty-b

ased

info

rmat

ion

an

d s

ervi

ces)

B –

Cos

ta R

ica

(24)

• P

rimar

y ob

ject

ive:

not

sta

ted

• T

arge

t gro

ups:

you

ng p

eopl

e in

volv

ed in

sex

wor

k, in

ject

ing

drug

use

and

/or

youn

g m

ale

sex

wor

kers

livi

ng o

n th

e st

reet

• M

ultic

ompo

nent

pro

gram

me

cons

istin

g of

a s

afe

plac

e to

spe

ndtim

e of

f the

str

eets

in p

roje

ct h

ouse

and

edu

catio

n ab

out H

IV/A

IDS

prev

entio

n•

Cou

nsel

ling

and

supp

ort p

rovi

ded

for

alco

hol-r

elat

ed a

nd d

rug-

rela

ted

prob

lem

s•

Thi

s in

terv

entio

n st

arte

d w

ith a

thor

ough

situ

atio

n an

alys

is•

Em

phas

is p

lace

d on

cre

atin

g a

safe

spa

ce fo

r vu

lner

able

you

ths

298

92-4-120938-0_CH09_298

• A

ppro

ach

is c

onfin

ed to

the

loca

lity

of th

e ce

ntre

• S

cale

of p

roje

ct: 1

hou

seIn

terv

enti

on

typ

e 4

(fac

ility

-bas

ed in

form

atio

n a

nd

ser

vice

s w

ith

an

ou

trea

ch c

om

po

nen

t)C

– U

gand

a (2

6)•

Prim

ary

obje

ctiv

e: to

red

uce

prev

alen

ce o

fS

TIs

a an

d H

IV a

mon

g vu

lner

able

you

ths;

toin

crea

se a

cces

s to

you

th-f

riend

ly h

ealth

serv

ices

• T

arge

t gro

ups:

chi

ldre

n an

d ad

oles

cent

s liv

ing

on th

e st

reet

s an

d se

x w

orke

rs

• M

ultic

ompo

nent

pro

gram

me

cons

istin

g of

dro

p-in

hea

lth c

entr

esan

d m

obile

clin

ics

for

yout

h fo

r tr

eatm

ent a

nd c

ouns

ellin

g an

dte

stin

g; tr

aini

ng o

f pee

r pr

ovid

ers

for

soci

ally

mar

kete

dco

ntra

cept

ives

and

ST

I kits

; tra

inin

g of

hea

lth-c

are

prov

ider

s in

yout

h-fr

iend

ly s

ervi

ces;

clo

se in

volv

emen

t of c

omm

unity

lead

ers

• A

fter

dete

rmin

ing

the

size

of t

he ta

rget

gro

up a

nd in

form

ing

com

mun

ity le

ader

s ab

out t

he p

rogr

amm

e, 5

you

th-f

riend

ly d

rop-

incl

inic

s an

d 17

mob

ile c

linic

out

reac

h po

sts

wer

e op

ened

aro

und

Kam

pala

• 10

0 pe

er p

rovi

ders

wer

e tr

aine

d to

dis

trib

ute

soci

ally

mar

kete

dco

ndom

s an

d S

TI k

its•

Dra

ma

and

film

sho

ws

prov

ided

info

rmat

ion

to th

e ta

rget

gro

up•

Sca

le o

f int

erve

ntio

n: th

roug

hout

cap

ital c

ityD

– N

icar

agua

(24

, 25)

• P

rimar

y ob

ject

ive:

to p

rovi

de S

TI s

ervi

ces

for

youn

g fe

mal

e se

x w

orke

rs•

Tar

get g

roup

s: A

ll se

x w

orke

rs a

nd th

eir

clie

nts

• N

ot a

mul

ticom

pone

nt in

terv

entio

n•

Tre

atm

ent v

ouch

ers

dist

ribut

ed to

be

used

at v

ario

us h

ealth

-car

epr

ovid

ers

(pub

lic, n

ongo

vern

men

tal a

nd p

rivat

e se

ctor

)•

Pro

vide

rs c

ontr

acte

d on

a c

ompe

titiv

e ba

sis

• E

ach

vouc

her

prov

ided

trea

tmen

t for

ST

Is, s

afe

sex

coun

selli

ngan

d ed

ucat

iona

l mat

eria

l•

Tar

get g

roup

invo

lved

in d

esig

ning

trea

tmen

t vou

cher

s an

dac

com

pany

ing

hand

book

s th

at w

ere

dist

ribut

ed a

mon

g fe

mal

e se

xw

orke

rs, t

heir

clie

nts

and

youn

g pe

ople

who

sni

ffed

glue

• S

ervi

ce p

rovi

ders

wer

e gi

ven

an u

pdat

ed S

TI t

reat

men

t pla

n an

din

trod

uced

to th

e pr

ogra

mm

e•

Sca

le o

f int

erve

ntio

n: th

roug

hout

cap

ital c

ity

a S

TIs

= s

exua

lly tr

ansm

itted

infe

ctio

ns.

299

92-4-120938-0_CH09_299

Tab

le 9

.4D

escr

ipti

on

of

ou

tco

me

eval

uat

ion

s b

y st

ud

y

Stu

dy

Des

ign

an

d s

amp

le s

ize

Eva

luat

ion

res

ult

sS

tren

gth

of

evid

ence

fo

r ef

fect

Inte

rven

tio

n t

ype

1 (i

nfo

rmat

ion

pro

vid

ed o

nly

th

rou

gh

ou

trea

ch p

rog

ram

me)

A (

27)

Des

ign:

pre

-tes

t and

pos

t-te

stev

alua

tion;

no

com

paris

on g

roup

Sam

ple

size

: ran

dom

sam

ple

of 4

00 y

outh

sin

terv

iew

ed 1

0 m

onth

s ap

art

“Sig

nific

ant”

cha

nges

bot

h in

incr

ease

d le

vels

of

know

ledg

e ab

out H

IV tr

ansm

issi

on a

s w

ell a

s in

decr

ease

d le

vels

of m

isco

ncep

tions

Wea

kLi

mita

tions

: tes

ts fo

r st

atis

tical

sign

ifica

nce

not a

vaila

ble

Inte

rven

tio

n t

ype

2 (i

nfo

rmat

ion

an

d s

ervi

ces

pro

vid

ed t

hro

ug

h a

n o

utr

each

pro

gra

mm

e)N

o st

udy

met

the

incl

usio

n cr

iteria

Non

eIn

terv

enti

on

typ

e 3

(fac

ility

-bas

ed in

form

atio

n a

nd

ser

vice

s)B

(24

)D

esig

n: p

re-in

terv

entio

n an

d po

st-

inte

rven

tion

eval

uatio

n•

Incr

ease

in r

epor

ted

use

of c

ondo

ms

amon

gm

ale

sex

wor

kers

• In

crea

se in

num

ber

of s

uppo

rt g

roup

s

Wea

kLi

mita

tions

: no

com

paris

on g

roup

; no

deno

min

ator

Inte

rven

tio

n t

ype

4 (f

acili

ty-b

ased

info

rmat

ion

an

d s

ervi

ces

wit

h a

n o

utr

each

co

mp

on

ent)

C (

26)

Des

ign:

ser

vice

util

izat

ion

stat

istic

s•

29 5

64 tr

eatm

ents

pro

vide

d in

1½

yea

rs a

t6

369

drop

-in c

entr

es a

nd 2

3 19

5 ou

trea

ch s

ites

• 1

291

refe

rral

s (m

ainl

y fo

r bl

ood

test

s fo

rse

xual

ly tr

ansm

itted

infe

ctio

ns)

• 21

5 co

unse

lling

ses

sion

s pl

us te

stin

g pr

ovid

ed•

21 6

64 y

oung

peo

ple

rece

ived

con

dom

s(1

0 07

9 fe

mal

es a

nd 1

1 58

5 m

ales

)

Wea

kLi

mita

tions

: no

deno

min

ator

s pr

ovid

ed

D (

24, 2

5)D

esig

n: p

re-t

est a

nd p

ost-

test

eva

luat

ion

ina

subs

ampl

e of

targ

et p

opul

atio

n (f

emal

esw

ho s

niff

glue

)

• 15

000

vou

cher

s di

strib

uted

in 8

yea

rs, 4

0%le

adin

g to

med

ical

con

sulta

tions

• Gon

orrh

oea

prev

alen

ce re

duce

d fr

om 1

3.7%

to8.

6%•

Syp

hilis

pre

vale

nce

redu

ced

from

15.

6% to

8.0%

• T

richo

mon

iasi

s pr

eval

ence

red

uced

from

22.1

% to

12%

Wea

kLi

mita

tions

: no

com

paris

on g

roup

300

92-4-120938-0_CH09_300

Tab

le 9

.5S

tren

gth

of

evid

ence

of

effe

ctiv

enes

s fo

r ea

ch in

terv

enti

on

typ

e

Inte

rven

tio

n t

ype

and

stu

dy

des

ign

Po

siti

ve e

ffec

tN

osi

gn

ific

ant

effe

ct

Neg

ativ

e ef

fect

Evi

den

ce

Sta

tist

ical

lysi

gn

ific

ant

Sta

tist

ical

sig

nif

ican

cen

ot

kno

wn

Sta

tist

ical

lysi

gn

ific

ant

Sta

tist

ical

sig

nif

ican

cen

ot

kno

wn

Typ

e 1

(in

form

atio

n o

nly

pro

vid

ed t

hro

ug

h o

utr

each

)(1

eva

luat

ion)

Wea

k

Bef

ore–

afte

r (n

o co

mpa

rison

gro

up)

AT

ype

2 (i

nfo

rmat

ion

an

d s

ervi

ces

pro

vid

ed t

hro

ug

ho

utr

each

) (0

eva

luat

ions

)N

one

Typ

e 3

(fac

ility

bas

ed in

form

atio

n a

nd

ser

vice

s)(1

eva

luat

ion)

Wea

k

Bef

ore–

afte

r (n

o co

mpa

rison

gro

up)

BT

ype

4 (o

utr

each

an

d f

acili

ty-b

ased

info

rmat

ion

an

dse

rvic

es)

(2 e

valu

atio

ns)

Wea

k

Des

crip

tive

(ser

vice

sta

tistic

s)C

Bef

ore–

afte

r (n

o co

mpa

rison

gro

up)

D

301

92-4-120938-0_CH09_301

9.3.3 Studies focusing on at-risk young people in developed countries

Four evaluation studies from developed countries were reviewed to determinewhether they corroborated the findings from studies in developing countries.Two of these studies focused on interventions directed towards young menwho have sex with men (28, 29), and two focused on young injecting drugusers (30, 31). No studies of interventions directed towards young sex work-ers were identified.

Studies in Bulgaria and the Russian Federation targeted the leaders of previ-ously identified social networks of men who have sex with men and trainedthem as peer educators (28, 29). Risk surveys were administered to membersof their network and to members of a control network. Among members ofthe network in the intervention group, the frequency of unprotected inter-course dropped significantly as did the proportion of men engaging inunprotected intercourse with multiple partners (29).

A study in San Francisco (31) evaluated a needle and syringe exchange pro-gramme that targeted 15–25-year-old injecting drug users. The programmewas run by peers and targeted homeless injecting drug users, providing sterileinjecting equipment and educational materials. There was a significant re-duction in reported sharing and reusing of syringes among young peopleparticipating in the programme when compared with those in a control group.

9.3.4 Studies of interventions for at-risk populations in developing countriesthat did not disaggregate data by age

Thirty studies were identified that examined interventions directed towardsgeneral populations most at risk of becoming infected with HIV, of which 21were interventions directed towards sex workers, 5 towards injecting drugusers and 4 towards men who have sex with men. There were 16 studies fromAsia, 8 from Africa, and 6 from Latin America.

9.3.4.1 Sex workers

Studies of interventions with sex workers included several peer-reviewedarticles with data measured both pre-intervention and post-intervention, withor without control groups. Studies from the Asia–Pacific region included in-terventions in China (32), India (33–35), Indonesia (36–38), Papua NewGuinea (39) and Thailand (40–42). In Africa, studies from Benin (12), Côted’Ivoire (43), Ghana (44), Kenya (45, 46), Sierra Leone (47) and the Demo-cratic Republic of the Congo (48) were identified. In Latin America, threestudies were identified, one each from Bolivia, Honduras and Peru (22, 49,50). In addition, projects in Bangladesh, India and Papua New Guinea were

302

92-4-120938-0_CH09_302

documented in the UNAIDS case study Female sex worker HIV preventionprojects (51).

All of the interventions had information and education components, and mostoffered services either by providing free condoms (12 studies) or free STItreatment (6 studies). The majority of programmes were type 4 interventions.They operated in specially designed facilities (either STI clinics or commu-nity centres) where the education sessions or STI treatment took place, andthey engaged in outreach activities to attract clients to their facilities. A fewof the interventions had only outreach activities, although these sometimesincluded training peer educators at their workplaces.

The best documented intervention to reduce HIV transmission among sexworkers is the Thai government’s “100% condom” programme (40). Afterproving successful in Thailand, a similar approach was adopted by severalother Asian countries. Additional strategies have been tested in different lo-cations, mainly in Asia , including peer education, outreach education, groupeducation and the involvement of employers. Other measures tested widelyincluded distributing condoms and providing HIV counselling and testingand STI treatment. All programmes used more than one method to reduceHIV incidence, and therefore it was not possible to tease out the impact ofspecific interventions.

Other evaluation studies of interventions targeting sex workers in Asiancountries that showed positive changes in behaviour and knowledge included:peer education (increased AIDS and STI knowledge and decreased preva-lence of gonorrhoea, P = 0.05) (37) and combined educational activities andSTI treatment (increased knowledge about AIDS and STIs, P < 0.001;increased condom use, P = 0.01; and decreased prevalence of trichomoniasis,P < 0.001) (38).

In Côte d’Ivoire a randomized controlled trial among female sex workers wasconducted with 542 women who were given either a basic or intensive inter-vention (more frequent visits) consisting of information and education, freecondoms and STI treatment (type 4 interventions). Outcomes were measuredfor 225 women (42%) through self-reported behaviour and testing for STIs.When baseline data were compared with post-intervention data, the inter-vention was found to be significantly associated with increases in condomuse (from 40% to 82%) and decreases in the prevalence of gonorrhoea (from14% to 5%) and trichomoniasis (from 24% to 11%). In terms of HIV inci-dence, rates were lower among those who participated in the intensiveprogramme than among those in the basic programme, although these dif-ferences were not statistically significant (43).

303

92-4-120938-0_CH09_303

A longitudinal study of an intervention in the United Republic of Tanzaniainvolving 600 women at increased risk of becoming infected provided infor-mation sessions every 3 months on HIV and STIs and reproductive health,voluntary HIV counselling and testing, and clinical health check-ups includ-ing syndromic management of STIs. This intervention reduced HIV incidencefrom 13.9/100 person–years to 5.0/100 person–years over three consecutive9-month periods; the reduction was attributed to the combination of infor-mation and services, which describe a type 4 intervention (52).

Although the study in the United Republic of Tanzania demonstrated thatinterventions aimed at improving STI treatment can be successful in reducingHIV incidence among sex workers, monthly oral administration of 1g ofazithromycin among Kenyan sex workers in a randomized placebo-controlledtrial did not have this effect (46). Two studies – in Benin and Bolivia – triedto assess the impact of interventions through serial cross-sectional surveys(12, 22). Although both studies reported significant reductions in STI preva-lence that were achieved through treatment and educational activities, theresearch design is severely limited because it does not provide informationon any of the outcome measures for consecutive visits made by the sameperson, only for the group of sex workers as a whole. It also failed to documentthe level of participation in the programmes. The findings can at most, there-fore, show time trends for STI prevalence among a group of sex workers.

9.3.4.2 Injecting drug users

The vast majority of interventions for injecting drug users concentrate onmaking drug injecting safer (that is, they use a harm reduction approach). Akey component of this approach is needle and syringe exchange programmes,in which sterile injecting equipment is provided or exchanged for used equip-ment. Two evaluations of type 4 intervention exchange programmes werefound in Asia. An evaluation in Nepal interviewed 586 clients of a programmeduring a 4-year period and found that the median number of times participantsshared needles decreased from 14 to 2, and the median number of people theyshared injecting equipment with was reduced from 2 to 1 (53). An evaluationof an exchange intervention in Thailand reported significant reductions inrisk-taking behaviours, despite difficulties encountered by young injectingdrug users in accessing the programme (54).

Two type 2 outreach education interventions for adult injecting drug userswere also identified. The first was based in Chennai, India, and targeted menaged 18 years and older. An outreach team recruited injecting drug users andprovided various interventions at street level, including the distribution ofbleach. These combined interventions brought about safer injecting be-haviours (P = 0.01) without affecting sexual risk behaviour (55). The second

304

92-4-120938-0_CH09_304

intervention took place in Puerto Rico where outreach workers provided in-formation on HIV prevention to indigenous adults who were injecting drugusers. This intervention was associated with significant improvements inknowledge of HIV and a reduction in risky injecting behaviours (56).

A WHO multisite study that looked at injecting drug users and took place intwo cities in Brazil and one city in Thailand as well as nine cities in developedcountries (57), showed that the behavioural changes that occurred were sim-ilar in Bangkok and the cities in developed countries but different from thosein the Brazilian cities. The frequency of consistent condom use with casualpartners was lowest in Rio de Janeiro, whereas in Bangkok it was reported tobe higher than in most of the cities in developed countries. This highlightsthe challenge of comparing results from studies conducted in different de-veloping countries and between developed and developing countries.

In addition to the data from developing countries, evidence of successful HIVinterventions aimed at injecting drug users is available from a number ofliterature reviews (58). Consecutive HIV prevalence data from injecting drugusers in cities in the United States with and without needle-exchange pro-grammes were reviewed (59); there was significant evidence of a 5.8%decrease in seroprevalence among injecting drug users in the 29 cities thathad needle-exchange programmes compared with a 5.9% increase amongdrug users in the 52 cities without such programmes (P = 0.004) (59). ACochrane systematic review assessed the effect of oral substitution treatmentfor opioid-dependent injecting drug users on rates of HIV infection and high-risk behaviours and found significant associations between treatment andreductions in illicit opioid use, injecting use and the sharing of injectingequipment. Reductions in risk behaviours related to drug use also translatedinto reductions in the prevalence of HIV infection (60). In general, these weretype 4 interventions.

9.3.4.3 Men who have sex with men

Four interventions targeting men who have sex with men were identified fromBrazil (61), India and Morocco (both mentioned in Tawil) (21) and PuertoRico (62). The intervention in Morocco included 600 men and the interven-tion in India included 3 000 men reached through peer outreach programmesfocusing on safer sex messages, condom distribution and providing STI careat a drop-in centre (a type 4 intervention). Increased safer sex practices werereported in post-intervention analyses at both sites, with these effects beingstatistically significant in India but not in Morocco. The two interventions inLatin America identified participants though peer referral and focused on peereducation. The study in Brazil had a pre-intervention versus post-interventiondesign and included 227 men who have sex with men, who had a mean age

305

92-4-120938-0_CH09_305

of 29 years; in this study men were assigned either to an intensive series ofsafer sex workshops or a series of health education lectures. There were nosignificant differences in health outcomes between the two interventions, al-though comparisons between baseline and post-intervention surveys showedstatistically significant increases in knowledge and awareness and decreasesin self-reported risk behaviours. These differences were found to have beensustained at a 6-month follow-up survey.

In addition to these studies from developing countries, a meta-analysis of HIVbehavioural interventions aimed at reducing sexual risk behaviour among thisgroup of men included 33 studies from different parts of the world (63). Itdescribed significant decreases in the prevalence of unprotected anal inter-course (OR = 0.8, 95% CI = 0.7–0.9) and number of sexual partners (OR =0.85, 95% CI = 0.6–0.9) as well as a significant increase in condom use duringanal intercourse (OR = 1.6, 95% CI = 1.2–2.2). In this meta-analysis, suc-cessful programmes were those that were based on a theoretical model,included training in interpersonal skills, incorporated several delivery meth-ods and were delivered over multiple sessions spanning a minimum of 3weeks (63), thus providing evidence for the effectiveness of type 4interventions.

9.4 Discussion

The authors of the original papers that were commissioned for the meetingin Talloires in March 2004 that initiated the “Steady, Ready, Go!” processwere asked to give special consideration to young people who are most at riskof becoming infected with HIV. When the papers were reviewed during themeeting, participants recommended that a specific chapter be written focus-ing on these groups of young people. This is important for two reasons. First,interventions for young sex workers, men who have sex with men, and in-jecting drug users are likely to be key to decreasing the transmission of HIVin low-level and concentrated epidemics. Second, having the evidence of ef-fectiveness for these interventions is important because they are usuallysurrounded by controversy, the behaviours that this group participates in areoften illegal, and the groups themselves are marginalized and exposed todiscrimination.

However, there was uncertainty about whether enough data would be avail-able to allow the interventions to be analysed in the same manner used forother chapters in this series. There was also concern that the evidence foreffectiveness would be weak since programmes for groups most at risk oftenfocus more on taking action than finding out whether an action works. Thisproblem has already been described by Myers and colleagues (64) whosuggested that part of the reason for the difficulty in finding evaluations of

306

92-4-120938-0_CH09_306

interventions targeting these three groups is the fact that much of the literaturehas been produced by practitioners rather than researchers. While some ofthe reservations about writing this chapter were clearly justified, our reviewhas nonetheless enabled us to draw some conclusions and allowed us to iden-tify some important issues that require further attention.

This review set out to assess the level of evidence of effectiveness needed torecommend implementation of interventions targeting at-risk young peoplein developing countries, in order to achieve the global goals on preventingthe spread of HIV. Prior to reviewing the evidence, it was necessary to es-tablish whether young people were actually an important proportion of thegroup most at risk of becoming infected. Our findings support the conclusionsof Monasch and Mahy in chapter 2 that young people make up a significantproportion of the population most at risk from HIV. In addition, data indicatethat younger injecting drug users, sex workers and men who have sex withmen may be particularly vulnerable.

However, little is known about the specific needs of young people in thesegroups as opposed to older people. This issue needs to be emphasized in futureresearch, given the fact that a large number of the people most at risk areyoung, and it will be important to ensure that their needs are adequately metby any programmes that are implemented.

As anticipated, few studies were identified that explicitly focused on at-riskyoung people in developing countries. However, the fact that so few studieswere identified in either the published or the grey literature was surprising inview of the evidence from other areas of programming that young peoplerequire specific attention from policies and programmes, and that they maybe particularly vulnerable and have specific needs.

Not only was it difficult to identify relevant studies, but those that were iden-tified often did not provide adequate information to allow for comparisonamong studies or assessments of the studies themselves. In general, studiesdid not provide sufficient details about the interventions, did not clearly de-fine or measure expected outcomes, lacked information about the impact ofthe interventions and failed to provide adequate pre-test and post-test evalu-ations or control groups. Given that young people are at the centre of theepidemic in many developing countries, the lack of well evaluated interven-tions targeting them is a cause for concern.

Despite the comprehensive strategy used to identify relevant studies for thisreview, it is possible that studies may have been missed, for example if theywere reported only in conference abstracts or in internal programme reportsor other project documents. Furthermore, it must be recognized thatconducting research with these groups is challenging. Not only do many

307

92-4-120938-0_CH09_307

interventions not consider the specific needs of young people but data col-lected by studies are often not disaggregated by age. Additionally, research-ing and evaluating interventions for such marginalized groups may bedifficult for both methodological and ethical reasons.

In this review, we did not attempt to identify or analyse studies conductedamong the general population of people most at risk and that did not disag-gregate data by age with the same systematic rigour that had been used forstudies of interventions targeting young people. However, the studies we re-viewed provide consistently supportive evidence for the effectiveness ofinterventions targeting at-risk populations in developing countries in termsof changing knowledge and reported behaviours and even biological out-comes, such as reducing the prevalence of STIs.

Because of the lack of studies, this review did not really benefit from theoverall methodology that had been developed for chapters in this series. Inaddition, while the typology is likely to have some resonance with programmedevelopment and delivery staff, it is questionable whether these groups aresufficiently similar enough to warrant being combined, even if there is some-times overlap between them. It is therefore unrealistic to draw strong con-clusions from Table 9.5.

However, as indicated in Table 9.6, this does not mean that we do not haveevidence from which to recommend action. What it demonstrates is the needto see the evidence for young people in developing countries within the widercontext of evidence for the effectiveness of interventions in developing coun-tries that have been directed at adults and young people (where the data arenot disaggregated by age). When the evidence for effectiveness among youngpeople in developing countries is combined with the evidence for general at-risk populations in developing countries and the data from young people indeveloped countries, it becomes reasonable to move type 4 interventions from“Steady” to “Ready” or even to “Go”. The studies that focused on youngpeople in developed countries additionally demonstrate that good researchon at-risk young people is possible.

Young people who are at the centre of concentrated epidemics require inter-ventions urgently. Such interventions should be based on good practice (5)and should include facility and outreach components as well as a focus oninformation and services (Box 9.1); thus, they should be type 4 interventions.However, in recommending the widespread implementation of such inter-ventions it is important to include the caveat that they also should be carefullyplanned, monitored and evaluated and that an operations research componentshould be included to provide a better understanding of the mechanismsof action and the interactions between different parts of each intervention.

308

92-4-120938-0_CH09_308

Tab

le 9

.6.

Rec

om

men

dat

ion

s o

n t

he

stre

ng

th o

f th

e ev

iden

ce f

or

effe

ctiv

enes

s b

y in

terv

enti

on

typ

e

Inte

rven

tio

n t

ype

Key

ch

arac

teri

stic

sC

on

clu

sio

nC

om

men

ts

1. In

form

atio

n on

lypr

ovid

ed th

roug

hou

trea

ch

Tar

get g

roup

nee

ds to

be

iden

tifie

dan

d re

ache

d w

ith th

e in

form

atio

nS

tead

y•

Thi

s ty

pe o

f int

erve

ntio

n is

use

d w

idel

y an

d ai

ms

at im

prov

ing

info

rmat

ion

and

skill

s•

No

thor

ough

eva

luat

ions

hav

e be

en fo

und

• It

is q

uest

iona

ble

whe

ther

edu

catio

nal a

ctiv

ities

alo

ne c

an b

esu

cces

sful

in c

hang

ing

risk

beha

viou

r am

ong

vuln

erab

le g

roup

sw

ithou

t inc

ludi

ng s

ervi

ces

that

pro

vide

cond

oms,

ST

Ia tr

eatm

ent a

nd h

arm

-red

uctio

n in

terv

entio

ns2.

Info

rmat

ion

and

serv

ices

pro

vide

dth

roug

h ou

trea

ch

No

stud

y m

et th

e in

clus

ion

crite

riaN

one

• N

o in

terv

entio

n of

this

type

was

rev

iew

ed in

a s

tudy

that

met

the

incl

usio

n cr

iteria

3. F

acili

ty-b

ased

info

rmat

ion

and

serv

ices

Tar

get g

roup

mus

t kno

w a

bout

and

wan

t to

use

the

faci

lity,

whi

ch m

ust

be a

cces

sibl

e an

d pr

ovid

e a

conf

iden

tial s

ervi

ce

Ste

ady

• A

ll U

NG

AS

S g

oals

are

add

ress

ed b

y th

is in

terv

entio

n ty

pe:

info

rmat

ion,

ski

lls a

nd s

ervi

ces

are

prov

ided

in a

n at

tem

pt to

decr

ease

ris

k an

d ul

timat

ely

HIV

pre

vale

nce

• P

ossi

ble

stig

mat

izat

ion

mus

t be

over

com

e if

the

faci

lity-

base

dap

proa

ch is

to w

ork

• T

he o

ne s

tudy

cite

d pr

imar

ily p

rovi

des

safe

pla

ces

for

youn

g pe

ople

mos

t at r

isk

of H

IV, b

ut it

doe

s no

t inc

lude

spe

cific

ser

vice

s ai

med

at r

educ

ing

HIV

tran

smis

sion

(fo

r ex

ampl

e ne

edle

exc

hang

e)4.

Out

reac

h an

dfa

cilit

y-ba

sed

info

rmat

ion

and

serv

ices

Goo

d in

tegr

atio

n of

ser

vice

s in

outr

each

and

faci

lity-

base

d ac

tiviti

esne

cess

ary

Info

rmat

ion

abou

t ser

vice

s m

ust b

eco

nsis

tent

All

mem

bers

of t

arge

t gro

up m

ust

have

equ

al a

cces

s to

the

inte

rven

tion

Rea

dyb

• A

ll U

NG

AS

S g

oals

are

add

ress

ed b

y th

is in

terv

entio

n ty

pe:

info

rmat

ion,

ski

lls a

nd s

ervi

ces

are

prov

ided

in a

n at

tem

pt to

decr

ease

ris

k an

d ul

timat

ely

HIV

pre

vale

nce

• T

he o

utre

ach

com

pone

nt is

a c

ruci

al a

spec

t, he

lpin

g to

info

rm th

eta

rget

gro

up a

bout

faci

lity-

base

d se

rvic

es•

Bot

h st

udie

s in

this

cat

egor

y w

ere

succ

essf

ul in

incr

easi

ng k

now

l-ed

ge, i

mpr

ovin

g se

rvic

e ut

iliza

tion

and

redu

cing

pre

vale

nce

ST

Is

a S

TI =

sex

ually

tran

smitt

ed in

fect

ion.

b W

hen

taki

ng th

e ev

iden

ce fr

om a

dult

prog

ram

mes

in d

evel

opin

g co

untr

ies

into

acc

ount

.

309

92-4-120938-0_CH09_309

Box 9.1

Recommendations for interventions targeting young people most at risk

For policy-makers

Specific attention needs to be given to young people who are most atrisk from HIV, including young injecting drug users, sex workers andmen who have sex with men.

Urgent action must be taken if these young people are to benefit fromstrategies to meet the global goals on HIV/AIDS and the Millennium De-velopment Goal on AIDS.

Interventions should be widely implemented for these groups of youngpeople and more emphasis needs to be placed on identifying the specificneeds of young people compared with those of adults.

Interventions should include strong monitoring and evaluation compo-nents (an important message for donors as well).

Interventions to mitigate the vulnerability of young people need to beseen within the broader context of structural interventions being madeto decrease their vulnerability.

For programme development and delivery staff

When developing interventions for sex workers, injecting drug users,men who have sex with men and other groups at high risk from HIV, itis important to ensure that the specific needs of young people are givenadequate attention and that data are disaggregated by age and sex.

If the global goals on HIV and young people are to be achieved, at-riskyoung people will need to receive information, skills and servicesthrough facilities and outreach strategies.

Practitioners working with at-risk young people should monitor their in-terventions and collaborate more closely with researchers from the initialstages of project design in order to better assess the impact of theirprogrammes.

Researchers

There is an urgent need to strengthen the evaluation component of in-terventions for young people most at risk, in order to determine theimpact of the intervention and the mechanisms of action.

There is also a need to be clear about key indicators for monitoring andevaluating programmes to achieve the global goals on HIV among at-risk young people.

More research is needed to identify the special needs of young peoplemost at risk, compared with the needs of at-risk adults.

310

92-4-120938-0_CH09_310

Planning, monitoring and evaluating interventions will not only ensure thatthe evidence base for their effectiveness will be strengthened but it will alsocontribute to the collective ability to track the achievement of the global goalson HIV among these groups of at-risk young people.

Finally, it needs to be emphasized that stopping the spread of HIV among at-risk young people will depend on interventions that decrease their vulnera-bility to HIV not those that merely mitigate this vulnerability. Suchinterventions were beyond the scope of this review, although several studiesthat attempted to do this were identified (65, 66, 67). Unfortunately theirimpact is often difficult to assess.

Acknowledgements:

We would like to acknowledge the following people who contributed to theidentification of studies and reports of interventions directed to young peo-ple most at risk of HIV: Peter Aggleton, Andrew Ball, Gary Barker,Stacia Burnham, Catherine Campbell, John Howard, Carol Jenkins, RafaelMazin, Gabriele Riedner, Mary Jane Rotheram, Meindert Schaap andRichard Steen.

References:

1. Speizer IS, Magnani RJ, Colvin CE. The effectiveness of adolescentreproductive health interventions in developing countries: a review of theevidence. Journal of Adolescent Health, 2003, 33:324-348.

2. Robin L et al. Behavioral interventions to reduce incidence of HIV, STD, andpregnancy among adolescents: a decade in review. Journal of AdolescentHealth, 2004, 34:3-26.

3. Pedlow CT, Carey MP. HIV sexual risk-reduction interventions for youth: areview and methodological critique of randomized controlled trials. BehaviorModification, 2003, 27:135-190.

4. Rivers K, Aggleton P. Adolescent sexuality, gender and the HIV epidemic. NewYork, United Nations Development Programme, 1999.

5. Aggleton P, Rivers K. Interventions for adolescents. In: Gibney L, DiClementeD, Vermund S, eds. Preventing HIV in developing countries: biomedical andbehavioral approaches. New York, Plenum Publications, 1999:231-255.

6. Kim N et al. Effectiveness of the 40 adolescent AIDS-risk reductioninterventions: a quantitative review. Journal of Adolescent Health, 1997,20:204-215.

7. Merson MH, Dayton JM, O’Reilly K. Effectiveness of HIV preventioninterventions in developing countries. AIDS, 2000, 14 Suppl 2:S68-84.

8. Indonesia Ministry of Health. Behavioural surveillance among populations atrisk for HIV. Jakarta, Directorate of Communicable Disease Control andEnvironmental Health, Ministry of Health and Central Bureau of Statistics, 2002.

311

92-4-120938-0_CH09_311

9. Lao People’s Democratic Republic, National Committee for the Control of AIDSBureau, Family Health International. Behavioural surveillance survey in LaoPeople’s Democratic Republic, 2000-2001. Lao PDR, 2003.

10. National AIDS Council, Ministry of Health, Zambia, Family Health International.Behavioral and biologic surveillance survey: Zambia female sex workers.Zambia, Family Health International, 2004:67.

11. Hoffmann O et al. Methodological lessons from a cohort study of high riskwomen in Tanzania. Sexually Transmitted Infections, 2004, 80 Suppl 2:S69-73.

12. Alary M et al. Decline in the prevalence of HIV and sexually transmitted diseasesamong female sex workers in Cotonou, Benin, 1993-1999. AIDS, 2002,16:463-470.

13. Ghys PD et al. Increase in condom use and decline in HIV and sexuallytransmitted diseases among female sex workers in Abidjan, Cote d’Ivoire,1991-1998. AIDS, 2002, 16:251-258.

14. UNAIDS. 2004 report on the global HIV/AIDS epidemic: 4th global report.Geneva, UNAIDS, 2004.

15. Rhodes T et al. Drug injecting and sexual safety: cross-national comparisonsamong cocaine and opiod injectors. In: Stimson GV, Des Jarlais DC, Ball A,eds. Drug injecting and HIV infection: global dimensions and local responses.London, UCL Press, 1998.

16. Rhodes T. HIV transmission and HIV prevention asssociated with injecting druguse in the Russian Federation. International Journal of Drug Policy, 2004,15:1-15.

17. Bangladesh National AIDS/STD Programme. National HIV and behaviouralsurveillance 1999–2003. Bangladesh, Directorate General of Health Services,Ministry of Health and Family Welfare, 2004.

18. Myanmar AIDS Prevention and Control Project, Department of Health. Sentinelsurveillance data for 1989- 2003. Yangon, AIDS Prevention and Control Project,2004.

19. Sarkar K et al. Young age is a risk factor for HIV among female sex workers:an experience from India. Journal of Infection, 2005, Dec 26 [Epub ahead ofprint].

20. Riedner G et al. Baseline survey of sexually transmitted infections in a cohortof female bar workers in Mbeya Region, Tanzania. Sexually TransmittedInfections, 2003, 79:382-387.

21. Tawil O et al. HIV prevention among vulnerable populations: outreach in thedeveloping world. AIDS, 1999, 13 Suppl A:S239-247.

22. Levine WC et al. Decline in sexually transmitted disease prevalence in femaleBolivian sex workers: impact of an HIV prevention project. AIDS, 1998,12:1899-1906.

23. Welp E et al. HIV prevalence and risk behaviour in young drug users inAmsterdam. AIDS, 2002, 16:1279-1284.

24. Shaw C, Aggleton P. Preventing HIV/AIDS and promoting sexual health amongespecially vulnerable young people. Southampton, England, University ofSouthampton, Centre for Sexual Health Research, 2002.

25. World Bank. A guide to competitive vouchers in health. Washington, DC, WorldBank, 2004.

312

92-4-120938-0_CH09_312

26. Kasirye R. Empowering street and slum young people to prevent HIV/AIDS inKawempe division-Kampala city: a case study of Uganda youth developmentlink (UYDEL). Kampala, UYDEL, 2004:26.

27. Johns Hopkins Bloomberg School of Public Health. Reaching young peopleworldwide: reproductive health communication activities to date, 1986-1995.Baltimore, MD, Johns Hopkins Bloomberg School of Public Health, Center forCommunication Programs, 1995:110.

28. Kegeles SM, Hays RB, Coates TJ. The Mpowerment Project: a community-levelHIV prevention intervention for young gay men. American Journal of PublicHealth, 1996, 86:1129-1136.

29. Amirkhanian YA et al. A randomized social network HIV prevention trial withyoung men who have sex with men in Russia and Bulgaria. AIDS, 2005,19:1897-1905.

30. Gleghorn A et al. The impact of intensive outreach on HIV prevention activitiesof homeless, runaway, and street youth in San Francisco: the AIDS Evaluationof Street Outreach Project (AESOP). AIDS and Behavior, 1997, 1:261-271.

31. Sears C et al. Investigation of a secondary syring exchange programme forhomeless young adult injection drug users in San Francisco, California, USA.Journal of Acquired Immune Deficiency Syndromes, 2001, 27:193-201.

32. Ma S et al. Decreasing STD incidence and increasing condom use amongChinese sex workers following a short term intervention: a prospective cohortstudy. Sexually Transmitted Infections, 2002, 78:110-114.

33. Jana S et al. The Sonagachi project: a sustainable community interventionprogram. AIDS Education and Prevention, 2004, 16:405-414.

34. Bhave G et al. Impact of an intervention on HIV, sexually transmitted diseases,and condom use among sex workers in Bombay, India. AIDS, 1995, 9 Suppl1:S21-30.

35. Singh YN, Malaviya AN. Experience of HIV prevention interventions amongfemale sex workers in Delhi, India. International Journal of STD and AIDS, 1994,5:56-57.

36. Ford K et al. Behavioral interventions for reduction of sexually transmitteddisease/HIV transmission among female commercial sex workers and clientsin Bali, Indonesia. AIDS, 1996, 10:213-222.

37. Ford K et al. Evaluation of a peer education programme for female sex workersin Bali, Indonesia. International Journal of STD and AIDS, 2000, 11:731-733.

38. Ford K et al. The Bali STD/AIDS study: evaluation of an intervention for sexworkers. Sexually Transmitted Diseases, 2002, 29:50-58.

39. Elly J et al. Papua New Guinea: an innovative strategy to raise self-esteem ofsex workers in Port Moresby, Papua New Guinea, and to promote safer sexpractices with clients. Pacific AIDS Alert Bulletin, 2000, 19:17.

40. Hanenberg RS et al. Impact of Thailand’s HIV-control programme as indicatedby the decline of sexually transmitted diseases. Lancet, 1994, 344:243-5.

41. Van Griensven GJ et al. Evaluation of a targeted HIV prevention programmeamong female commercial sex workers in the south of Thailand. SexuallyTransmitted Infections, 1998, 74:54-58.

313

92-4-120938-0_CH09_313

42. Ford NJ, Koetsawang S. Narrative explorations and self-esteem: research,intervention and policy for HIV prevention in the sex industry in Thailand.International Journal of Population Geography, 1999, 5:213-233.

43. Ghys PD et al. Effect of interventions to control sexually transmitted disease onthe incidence of HIV infection in female sex workers. AIDS, 2001,15:1421-1431.

44. Asamoah-Adu A et al. Evaluation of a targeted AIDS prevention intervention toincrease condom use among prostitutes in Ghana. AIDS, 1994, 8:239-246.

45. Ngugi EN et al. Prevention of transmission of human immunodeficiency virusin Africa: effectiveness of condom promotion and health education amongprostitutes. Lancet, 1988, 2:887-890.

46. Kaul R et al. Monthly antibiotic chemoprophylaxis and incidence of sexuallytransmitted infections and HIV-1 infection in Kenyan sex workers. Journal of theAmerican Medical Association, 2004, 291:2555-2562.

47. Larsen MM et al. Changes in HIV/AIDS/STI knowledge, attitudes and practicesamong commercial sex workers and military forces in Port Loko, Sierra Leone.Disasters, 2004, 28:239-254.

48. Laga M et al. Condom promotion, sexually transmitted diseases treatment, anddeclining incidence of HIV-1 infection in female Zairian sex workers. Lancet,344:246-248.

49. Sanchez J et al. Prevention of sexually transmitted diseases (STDs) in femalesex workers: prospective evaluation of condom promotion and strengthenedSTD services. Sexually Transmitted Diseases, 2003, 30:273-279.

50. Fox LJ et al. Condom use among high-risk women in Honduras: evaluation ofan AIDS prevention program. AIDS Education and Prevention, 1993, 5:1-10.

51. UNAIDS. Female sex worker HIV prevention projects: lessons learnt fromPapua New Guinea, India and Bangladesh. Geneva, UNAIDS, 2000:127.

52. Riedner G et al. Decline in sexually transmitted infection prevalence and HIVincidence in female barworkers attending prevention and care services inMbeya Region, Tanzania. AIDS, 2006, 20:609-615.

53. Peak A et al. Declining risk for HIV among injecting drug users in Kathmandu,Nepal: the impact of a harm reduction programme. AIDS, 1995, 9:1067-1070.

54. Gray J. Harm reduction in the hills of northern Thailand. Journal of SubstanceUse and Misuse, 1998, 33:1075-1091.

55. Kumar MS, Mudaliar S, Daniels D. Community-based outreach HIV interventionfor street-recruited drug users in Madras, India. Public Health Reports, 1998,113 Suppl 1:S58-66.

56. Birkel RC et al. Findings from the Horizontes Acquired Immune DeficiencySyndrome Education Project: the impact of indigenous outreach workers aschange agents for injection drug users. Health Education Quarterly, 1993,20:523-538.

57. Stimson GV, Des Jarlais DC, Ball A. Drug injecting and HIV infection: globaldimensions and local responses. London, UCL Press, 1998.

58. Dolan KA and Niven H. A review of HIV prevention among young injecting drugusers: A guide for researchers. Harm Reduction Journal, 2005, 2:5

314

92-4-120938-0_CH09_314

59. Hurley SF, Jolley DJ, Kaldor JM. Effectiveness of needle-exchangeprogrammes for prevention of HIV infection. Lancet, 1997, 349:1797-1800.

60. Gowing L et al. Substitution treatment of injecting opioid users for prevention ofHIV infection. Cochrane Database of Systematic Reviews, 2004 (4):CD004145.

61. Sampaio M et al. Reducing AIDS risk among men who have sex with men inSalvador, Brazil. AIDS and Behavior, 2002, 6:173-181.

62. Toro-Alfonso J, Varas-Diaz N, Andujar-Bello I. Evaluation of an HIV/AIDSprevention intervention targeting Latino gay men and men who have sex withmen in Puerto Rico. AIDS Education and Prevention, 2002, 14:445-456.

63. Herbst JH et al. A meta-analytic review of HIV behavioral interventions forreducing sexual risk behavior of men who have sex with men. Journal ofAcquired Immune Deficiency Syndromes, 2005, 39:228-41. (HIV/AIDSPrevention Research Synthesis Team.)

64. Myers T, Aggleton P, Kippax S. Perspectives on harm reduction: editorialintroduction. Critical Public Health, 2004, 14:325-328.

65. UNAIDS. Reducing girls’ vulnerability to HIV/AIDS: the Thai approach. Geneva,UNAIDS, 1999:57.

66. UNAIDS. Innovative approaches to HIV prevention: selected case studies.Geneva, UNAIDS, 2000:15.

67. UNAIDS. Summary booklet of best practices. Issue 1. Geneva, UNAIDS,1999:221.

315

92-4-120938-0_CH09_315

92-4-120938-0_CH09_316

Conclusions and recommendations Jane Ferguson,a Bruce Dick,a & David A Rossb

10.1 Introduction

An estimated 40 million people were living with HIV at the end of 2005 (1).More than one quarter of this total are young people aged 15–24 years, andabout 2 million young people are newly infected each year. Almost 25 yearsafter the first cases of AIDS were recognized, the HIV pandemic continuesto pose unprecedented challenges to individuals, families, communities andgovernments around the world, especially in developing countries, whichbear the greatest burden. Young people are particularly affected in terms oftransmission, vulnerability and impact. (see chapter 2).

In addition to HIV being a focus of the Millennium Development Goals,global goals were also endorsed during the UN General Assembly SpecialSession on HIV/AIDS. Some of the goals and targets that were agreed areexplicitly directed towards young people (see chapter 1). Achieving thesetargets will require national governments, civil society and funding agenciesto expend far greater resources and make stronger efforts to prevent HIVamong young people. There are many programmes and activities competingfor limited HIV resources in all countries, including the growing demand foreffective treatment. In terms of the resources that are directed towards pre-venting infection among young people, it is not just a question of increasingthe resources but also of ensuring that the resources are used effectively. Soit is important not only to be able to make a compelling case for focusing onyoung people but also to be clear about what needs to be done. Although thereis broad consensus about the key interventions necessary to prevent HIVamong young people in developing countries (2–4) and there have been re-views of the effectiveness of several of these (5, 6), no systematic review ofa comprehensive set of interventions for young people has been undertaken,although one other effort is in development (7).

a Department of Child and Adolescent Health and Development, WHO, Geneva, Switzerland.Correspondence should be sent to Jane Ferguson (email: fergusonj@who.int).

b Infectious Disease Epidemiology Unit, London School of Hygiene and Tropical Medicine,London, England.

317

10.

92-4-120938-0_CH10_317

Encouragingly, there has recently been an increase in the spending allocatedto tackling the epidemic (1, 8), and additional resources are likely to be gen-erated by recent calls for universal access to prevention, treatment and care(9). It has been estimated that US$ 6.1 billion was available for AIDS activ-ities from all sources in 2004. For 2005, 2006 and 2007, projections havebeen made, based on past trends and known pledges and commitments, thatamount to US$ 8.3 billion, US$ 8.9 billion and US$ 10 billion, respectively.Unfortunately, much of this spending has not been allocated according to theevidence of effectiveness. Many factors influence which programmes arefunded and implemented, and there is rarely a simple linear progression fromresearch evidence to policy and practice (10). Decision-makers are morelikely to make evidence-informed choices about the use of resources if theyare provided with evidence that has been synthesized and is presented in areadily understandable way that facilitates the transformation of informationto knowledge.

The authors of the chapters in this report have reviewed the evidence for theeffectiveness of interventions to achieve the global goals on preventing HIV/AIDS among young people in developing countries. They have explicitlyendeavoured to do this in ways that will be useful not only to researchers andother specialists in the field but also to programme managers and policy-makers. While the authors have applied rigorous research methods to sys-tematically review the evidence, they have also aimed to directly address thekey choices that policy-makers and programme managers in developingcountries need to make when deciding how to allocate funds for HIV pre-vention among young people.

Based on the major settings through which interventions are provided toyoung people (schools, health services, mass media, geographically-definedcommunities, and outreach to young people who are most at risk), the chaptershave teased out the different types of interventions provided in each setting.The interventions aimed to achieve a variety of outcomes (Box 10.1). Clearguidance has been provided about which types of interventions are suitablefor wide implementation, based on the evidence, in order to make the bestuse of resources to achieve the global goals and targets.

This chapter summarizes the main findings of the systematic reviews. Itdraws overall conclusions and makes recommendations from the whole seriesin terms of the “Do not go, Steady, Ready, Go” continuum (Box 10.2 andchapter 4). It has benefited from a meeting that was held in June 2005 inChavannes, Switzerland, that involved a number of external experts fromdifferent geographical regions who reviewed earlier versions of the chaptersand assisted the editors in identifying key conclusions and recommendationsfrom the papers.

318

92-4-120938-0_CH10_318

10.2 The road to “Steady, Ready, Go”

Although the scope of this report has been limited to a review of the evidenceon the effectiveness of interventions that have aimed to prevent HIV amongyoung people in developing countries, the task has not been easy. It has en-compassed different types of interventions of varying complexity and scalethat have taken place among different population groups, settings and con-texts and that have used a range of study designs. The iterative process bywhich the chapters in this report were written and revised has been describedin chapter 1. While this process has been relatively time consuming, it hasensured that all chapters have been extensively reviewed and revised in thelight of comments from a range of researchers, programme managers andpolicy-makers. It has also helped to ensure that the five reviews – despitespanning evidence from different types of interventions implemented in dif-ferent settings – all used the same methods and have the same structure. Thishas allowed the strength of the evidence for each type of intervention in eachsetting to be evaluated on a level playing field. The five systematic reviews

Box 10.1

Summary of intervention outcomes

Intervention setting Outcomes measuredSchools Knowledge, skills (personal values,

perceptions of peer norms, communicationabout sex), sexual behaviour (sexualinitiation, condom use, number of partners,use of contraceptives)

Health services Increased utilization of health servicesMass media Knowledge, skills (self-efficacy in terms of

abstinence or condom use), sexualbehaviour (condom use, numbers ofpartners, abstinence), communication(parents, others), social norms, awarenessand use of health services

Communities Knowledge, skills (communication withpeers, parents, partners, condom use),sexual behaviour (ever having sex,number of partners), community norms

Young people most at risk Increased access to information andservices (harm reduction interventions andSTIa treatment)

a STI = sexually transmitted infection.

319

92-4-120938-0_CH10_319

included in this technical report each followed the same seven key steps out-lined in Box 10.3 and described in greater detail in chapter 4.

The typologies that have been developed for the interventions used in differ-ent settings aimed to reflect the key choices that decision-makers need tomake when selecting, developing and implementing interventions. Beingclear about these different types of interventions makes the results of thereviews more transparent and useful to policy-makers and programme man-agers. For example, within the health services setting, rather than simplydiscussing “youth-friendly health services” the authors have discussed dif-ferent types of interventions that were defined according to their specificcomponents, such as training service providers and other clinic staff, chang-ing the structure or functioning of the health facility itself, providing outreachfrom the facility to the community and involving other sectors.

Some systematic reviews exclude evidence from studies that are not ran-domized controlled trials. A key concept in this report is that different typesof interventions require different strengths of evidence in order for them tobe recommended for widespread implementation. The strength of evidence

Box 10.2

The “Steady, Ready, Go” continuum for recommending interventions

Recommendation CriteriaGo Evidence threshold met

Sufficient evidence to recommend widespreadimplementation on large scale now, ideally withcareful monitoring of coverage, quality and cost,and operations research to better understand themechanisms of action

Ready Evidence threshold partially metEvidence suggests interventions are effective butlarge-scale implementation must be accompaniedby further evaluation and operations research toclarify impact and mechanisms of action

Steady Evidence threshold not metSome of the evidence is promising but furtherdevelopment, pilot-testing and evaluation ofprocesses and outcomes are needed before it canbe determined whether these interventions shouldmove into the “Ready” category or “Do not go”

Do not go Strong enough evidence of lack of effectivenessor of harmNot the way to go

320

92-4-120938-0_CH10_320

required depends on the feasibility of the intervention (including its likelycost), its potential risk of adverse outcomes, its acceptability, the potentialeffect size and the time needed for that effect to be achieved, as well as itspotential to bring about other benefits (see chapter 4). Where appropriate,therefore, the reviews have included evidence on effectiveness from quasi-experimental study designs, designs that included before-intervention andafter-intervention measurements, and other observational studies.

A key aim of the process used in these reviews was transparency. So althoughreaders may not necessarily agree with the conclusions reached by the authorsof each of the chapters, the transparency of the methods used make it easierto see where the disagreement lies. The authors have inevitably had to makevalue judgements in assessing the evidence, but the standardized method usedenables readers to be clear about the judgements that have been made. Thisstandard method includes creating a typology for the interventions, assigningthe threshold of evidence required to recommend widespread implementa-tion, weighing the strength of evidence from the different studies for eachintervention type and finally, making recommendations using the “Do NotGo, Steady, Ready, Go” continuum.

Box 10.3

Steps followed in the systematic reviews in this report

Step Description1. Define the key types of interventions that policy-makers need to

choose between in the setting under consideration2. Define the strength of evidence that would be needed to justify

widespread implementation of the intervention3. Develop explicit inclusion and exclusion criteria for the studies

under review4. Critically review all eligible studies and their findings, by

intervention type5. Summarize the strength of the evidence on the effectiveness of

each type of intervention6. Compare the strength of the evidence provided by the studies

against the threshold of evidence needed to recommendwidespread implementation

7. From this comparison, derive evidence-basedrecommendations related to the implementation of each type ofintervention in the setting or population group

321

92-4-120938-0_CH10_321

10.3 Results

Chapter 2 clearly demonstrates that young people (those aged 10–24 years)are at the centre of the HIV epidemic in developing countries, and it assertsthat they should be at the centre of prevention efforts. They are the age groupwith the highest incidence of HIV and they are disproportionately representedamong the population subgroups most at risk of becoming infected. Fortu-nately, they are also the age group where HIV prevention interventions mayhave the greatest potential for reversing the epidemic (11). Unless HIV is keptfrom spreading among young people, and especially among young womenliving in areas with generalized epidemics, future generations will be con-demned to suffer not only from HIV itself but also from the enormouseconomic and social costs of sustained HIV treatment and care services.

Chapter 3 provides an overview of the public health interventions that havebeen used to prevent HIV transmission. These include interventions aimed atchanging behaviours, including those that attempt to reduce sexual risk be-haviours and injecting drug use; biomedical interventions, such as managingsexually transmitted infections (STIs), providing antiretroviral treatment andcircumcision; and social or environmental interventions, including increasingaccess to sterile syringes and needles for those who inject drugs and usingmicrofinance initiatives aimed at women. This chapter does not specificallyfocus on young people but it clearly shows that there is a range of interven-tions, and that they have widely differing costs and logistical and humanresource implications, as well as varying evidence of their effectiveness. Thechapter concludes that there is a large and expanding armamentarium of pre-vention interventions available to policy-makers and programme managers,but it also cautions against confusing a lack of implementation with a lack ofefficacy (12, 13).

The key results of the systematic reviews of the different types of inter-ventions in the five settings – presented in chapters 5 to 9 – are shown inTable 10.1. This table summarizes the number of studies of each type ofintervention that met the inclusion criteria, the threshold of evidence neededto recommend widespread implementation, the strength of evidence for apositive impact provided by the studies reviewed and, finally, the overallrecommendation.

Altogether, 23 different types of interventions were defined, and a total of 85studies were identified that could be used to assess their effectiveness. Fiveof these studies contributed evidence to two intervention settings (14–18).

322

92-4-120938-0_CH10_322

323

Tab

le 1

0.1

Su

mm

ary

of f

ind

ing

s an

d r

eco

mm

end

atio

ns

fro

m th

e sy

stem

atic

rev

iew

s o

f in

terv

enti

on

s to

ach

ieve

the

glo

bal

go

als

on

HIV

an

d y

ou

ng

peo

ple

in f

ive

del

iver

y se

ttin

gs

Set

tin

gT

ype

of

inte

rven

tio

nN

o. o

fst

ud

ies

mee

tin

gin

clu

sio

ncr

iter

ia

Th

resh

old

of

evid

ence

nee

ded

to r

eco

mm

end

wid

esp

read

imp

lem

enta

tio

n

Str

eng

tho

fev

iden

cefo

r a

ben

efic

ial

imp

act

Rec

om

men

dat

ion

Sch

oo

lsC

urric

ulum

-bas

ed in

terv

entio

ns w

ith c

hara

cter

istic

sth

at h

ave

been

foun

d to

be

effe

ctiv

e in

dev

elop

edco

untr

ies

and

are

led

by a

dults

13Lo

wV

ery

stro

ngG

o

Cur

ricul

um-b

ased

with

cha

ract

eris

tics

foun

d to

be

effe

ctiv

e in

dev

elop

ed c

ount

ries

and

that

are

led

bype

ers

1Lo

wW

eak

Ste

ady

Cur

ricul

um-b

ased

with

out t

he c

hara

cter

istic

s fo

und

tobe

effe

ctiv

e in

dev

elop

ed c

ount

ries

and

that

are

led

byad

ults

2Lo

wW

eak

Ste

ady

Cur

ricul

um-b

ased

with

out t

he c

hara

cter

istic

s fo

und

to b

e ef

fect

ive

in d

evel

oped

cou

ntrie

s an

d le

d by

pee

rs1

Low

Wea

kS

tead

y

Non

-cur

ricul

um b

ased

with

out c

hara

cter

istic

s fo

und

tobe

effe

ctiv

e in

dev

elop

ed c

ount

ries

and

led

by a

dults

4Lo

wW

eak

Ste

ady

Non

-cur

ricul

um b

ased

with

out c

hara

cter

istic

s fo

und

tobe

effe

ctiv

e in

dev

elop

ed c

ount

ries

and

led

by p

eers

1Lo

wE

quiv

ocal

Ste

ady

Hea

lth

ser

vice

sIn

terv

entio

ns w

ith s

ervi

ce p

rovi

ders

and

in th

eco

mm

unity

1Lo

wE

quiv

ocal

Ste

ady

(or

Do

not

go)

Inte

rven

tions

with

ser

vice

pro

vide

rs a

nd in

faci

litie

s an

dth

e co

mm

unity

4Lo

wW

eak

Go

Inte

rven

tions

with

ser

vice

pro

vide

rs a

nd in

volv

ing

othe

rse

ctor

s1

Mod

erat

eE

quiv

ocal

Ste

ady

(or

Do

not

go)

92-4-120938-0_CH10_323

324

Set

tin

gT

ype

of

inte

rven

tio

nN

o. o

fst

ud

ies

mee

tin

gin

clu

sio

ncr

iter

ia

Th

resh

old

of

evid

ence

nee

ded

to r

eco

mm

end

wid

esp

read

imp

lem

enta

tio

n

Str

eng

tho

fev

iden

cefo

r a

ben

efic

ial

imp

act

Rec

om

men

dat

ion

Inte

rven

tions

with

ser

vice

pro

vide

rs a

nd in

faci

litie

s an

din

volv

ing

othe

r se

ctor

s0

Mod

erat

eN

o da

taN

o da

ta

Inte

rven

tions

with

ser

vice

pro

vide

rs a

nd in

the

com

mun

ity a

nd in

volv

ing

othe

r se

ctor

s2

Mod

erat

eE

quiv

ocal

Ste

ady

(or

Do

not

go)

Inte

rven

tions

with

ser

vice

pro

vide

rs a

nd in

faci

litie

s an

dth

e co

mm

unity

and

invo

lvin

g ot

her

sect

ors

8M

oder

ate

Wea

kR

eady

Mas

s m

edia

Rad

io o

nly

1M

oder

ate

Equ

ivoc

alS

tead

yR

adio

with

oth

er m

edia

(ex

clud

ing

tele

visi

on)

6M

oder

ate

Med

ium

Go

Rad

io a

nd te

levi

sion

with

oth

er m

edia

8H

igh

Str

ong

Go

Geo

gra

ph

ical

lyd

efin

ed c

om

mu

nit

ies

Tar

getin

g yo

uths

thro

ugh

exis

ting

yout

hs-s

ervi

ceor

gani

zatio

ns11

Mod

erat

eE

quiv

ocal

Rea

dy

Tar

getin

g yo

uths

thro

ugh

new

str

uctu

res

6H

igh

Wea

kS

tead

y (o

r D

o no

tgo

)T

arge

ting

the

com

mun

ity th

roug

h tr

aditi

onal

net

wor

ks3

Mod

erat

eE

quiv

ocal

Ste

ady

Tar

getin

g th

e co

mm

unity

thro

ugh

com

mun

ity e

vent

s2

Mod

erat

eW

eak

Ste

ady

Yo

un

g p

eop

le m

ost

at r

isk

Info

rmat

ion

only

pro

vide

d th

roug

h ou

trea

ch1

Mod

erat

eW

eak

Ste

ady

Info

rmat

ion

and

serv

ices

pro

vide

d th

roug

h ou

trea

ch0

Hig

hN

o da

taN

o da

taF

acili

ty-b

ased

info

rmat

ion

and

serv

ices

1Lo

wW

eak

Ste

ady

Out

reac

h an

d fa

cilit

y -

base

d in

form

atio

n an

d se

rvic

es2

Mod

erat

eW

eak

Ste

ady

(but

Rea

dyif

evid

ence

from

deve

lopi

ngco

untr

ies

amon

gal

l age

sco

nsid

ered

)

92-4-120938-0_CH10_324

There were six types of school-based interventions. These were classifiedon the basis of the content and quality of the interventions, whether theywere curriculum based and according to who delivered the intervention(teachers or peers).

There were also six types of health service interventions. These were clas-sified according to whether they provided training to clinic staff with orwithout implementing changes in the structure or functioning of the facilityitself and whether there were also information and sensitization activitiesheld in the community with or without the involvement of other sectors.

The three types of mass media interventions were classified according todistinctions between the delivery channels used to target young people:radio only, or some combination of radio, television and other media (suchas print).

Interventions in geographically defined communities were divided intofour types. The first distinction made was whether the target group wasyoung people or the entire community. The youth-only interventions werefurther subdivided according to whether they were delivered through a pre-existing youth-service organization or a new institutional structure; theinterventions targeting the entire community were subdivided accordingto the delivery channels used, namely traditional networks or communityevents.

The four types of interventions targeting young people most at risk of be-coming infected with HIV were classified based on the site of delivery ofthe interventions (within facilities, through outreach, or both) and the con-tent of the intervention (provision of information only or both informationand services).

The thresholds of evidence needed to recommend widespread implementa-tion of different interventions varied (Table 10.1). Nine types of interventionswere judged to require only weak evidence (a low threshold) (that is, therehad to be at least some evidence from adequacy studies and plausibility stud-ies), 11 to require at least moderately strong evidence (that is, at least someevidence from strong plausibility studies), and 3 to require strong evidence(a high threshold) (that is, substantial evidence from strong plausibility orprobability studies or both) (19). Interventions deemed to require a highthreshold of evidence were placed in that category because there were chal-lenges inherent in the feasibility of implementation that related to the com-plexity and likely costs of delivery.

Despite the fact that many of the studies included in the reviews had un-clear descriptions of the interventions and weak study designs, 23 of the 80studies were considered to show strong evidence of effectiveness or lack of

325

92-4-120938-0_CH10_325

effectiveness. These were distributed across the settings, with the exceptionof interventions targeting young people who were most at risk, for which theevidence was consistently weak.

Overall, however, the evidence for most intervention types was not strong(Table 10.1). Studies related to 11 types of interventions were considered tohave weak evidence (4 in schools, 2 in health services, 2 in geographicallydefined communities, 3 targeting the most at-risk young people). Studies ofan additional 7 intervention types were judged to have only equivocal evi-dence of effectiveness (1 in schools, 3 in health services, 1 in the mass media,2 in geographically defined communities). Authors used the term “equivocal”to describe those studies for which the quality of the evidence or the results,or both, made it difficult to definitively assess the impact of the intervention.The studies considered under one type of intervention type (mass media) wereconsidered to have moderately strong evidence. Only studies included underone of the intervention types for schools and one intervention type for massmedia were thought to have strong evidence.

All authors sought out studies of interventions that would lead towards achiev-ing the global goals – that is, by increasing access to information, skills andservices; reducing vulnerability to HIV infection and reducing HIV preva-lence. In the schools, mass media and communities settings (chapters 5, 7and 8), there was evidence of changes in knowledge as well as in reported atti-tudes, behaviours and skills, indicating that interventions delivered in thesesettings offer opportunities to increase access to information and skills. The ev-idence on the effectiveness of interventions in health services focused almostexclusively on their impact in increasing young people’s access to and use ofthe services themselves (chapter 6). The studies reviewed did not examinethe degree to which the health services could become a venue for providingeffective information or for improving skills, with the notable exception ofself-efficacy for condom use. Similarly, the focus of studies on interventionsfor the young people most at risk of HIV was on increasing access to infor-mation and services. Overall, there were few studies that provided evidenceon the prevalence of HIV or other biological outcomes, such as other STIs orpregnancy. And there were not many studies that addressed vulnerability.

The recommendations made for the different interventions are describedbelow.

“Go” – There were four types of interventions for which the authors con-cluded that the evidence threshold had been met. Thus there was sufficientpositive evidence to be able to recommend widespread implementation ofthese interventions on a large scale as long as coverage and quality weremonitored: there was one intervention in schools, one in health services andtwo in the mass media (Box 10.4).

326

92-4-120938-0_CH10_326

“Ready” – There were three types of interventions for which it was concludedthat the evidence threshold had been partially met. Thus there was sufficientlystrong positive evidence to recommend large-scale implementation but onlyif this were to be accompanied by further outcome evaluations and operationsresearch to clarify the impact of the intervention and the mechanisms of ac-tion. This applied to one intervention type in health services, one in geo-graphically defined communities, and one implemented among young peopleconsidered to be most at risk (but only when the evidence from interven-tions in developing countries targeting all ages was also taken into account)(Box 10.5).

“Steady” – The remaining interventions (14 in total) were given a “Steady”recommendation. There were five types of interventions in schools, three inhealth services, three in geographically defined communities, two interven-tion types targeting young people most at risk and one delivered through themass media (Box 10.6). For these types of interventions, some of the evidenceis promising but further development, pilot-testing and evaluation are neededbefore it can be determined whether they should move into the “Ready” cat-egory or the “Do not go” category.

Box 10.4

Interventions recommended to “Go” (widespread implementation now)

Setting Intervention typeSchools Curriculum-based interventions with

characteristics that have been found tobe effective in developed countries andare led by adults

Health services Interventions with service providers thatinclude making changes either to thestructure or functioning of the facilitiesthemselves and are linked tointerventions in the community topromote the health services for youngpeople

Mass media Interventions with messages deliveredthrough the radio and other media(forexample, print media), except televisionInterventions with messages deliveredthrough the radio and television andother media (for example, print media)

Geographically definedcommunities

No interventions met the criteria

Young people most at risk No interventions met the criteria

327

92-4-120938-0_CH10_327

“Do not go” – In four of the “Steady” interventions, the authors consideredthat there was some evidence, at least under certain circumstances, that thistype of intervention might have no beneficial impact on preventing the spreadof HIV. These four types of interventions included three in the health services(the types that did not include making any changes to facilities) and one ingeographically defined communities (interventions that used new deliverystructures).

10.4 Discussion

The choices that face policy-makers and programme managers are complex.Not only do they need to consider different settings and population groups,but also within each of these settings they need to choose between severaldifferent types of interventions. It is hoped that these reviews will go someway towards facilitating these difficult decisions.

We know that there is no magic bullet that will decrease HIV prevalenceamong young people, so programmes need to include a range of interventions.Fortunately, the global goals themselves assist with such decisions, since theyhelp us move beyond a simplistic focus linking specific interventions withdecreases in HIV prevalence towards a more realistic approach that linksspecific interventions with intermediate outcomes that are points on the pathto decreasing prevalence: these outcomes are to increase knowledge andskills, increase access to services and to decrease vulnerability.

Although we consider that the reviews included in this report will make animportant contribution to making decisions about the allocation of resources

Box 10.5

Interventions recommended as “Ready” (widespread implementation accom-panied by further evaluation and operations research)

Setting Intervention typeSchools No interventions met this criteriaHealth services Interventions with service providers and

in health facilities and in the communitythat involve other sectors

Mass media No interventions met the criteriaGeographically definedcommunities

Interventions targeting youths usingexisting youth-service organizations

Young people most at risk Facility based programmes that alsohave outreach and provide informationand services

328

92-4-120938-0_CH10_328

to different interventions, there were several important limitations. First, notall interventions for all groups of young people in all delivery settings havebeen included. Three groups of young people who are most at risk of HIVwere the focus of the studies included in chapter 9, namely young sex workers,young injecting drug users and young men who have sex with men. However,there are obviously other groups of young people who are also vulnerable and

Box 10.6

Interventions recommended as “Steady” (interventions that require further de-velopment, pilot-testing and evaluation before widespread implementation canbe recommended)

Setting Intervention typeSchools Curriculum-based with characteristics found

to be effective in developed countries and thatare led by peersCurriculum-based without the characteristicsfound to be effective in developed countriesand that are led by adultsCurriculum-based without the characteristicsfound to be effective in developed countriesand led by peersNon-curriculum based without characteristicsfound to be effective in developed countriesand led by adultsNon-curriculum based without characteristicsfound to be effective in developed countriesand led by peers

Health services Interventions with service providers and in thecommunityInterventions with service providers andinvolving other sectorsInterventions with service providers and infacilities and involving other sectorsInterventions with service providers and in thecommunity and involving other sectors

Mass media Radio onlyGeographicallydefined communities

Interventions targeting youths through newstructuresInterventions targeting the entire communitythrough traditional networksInterventions targeting the entire communitythrough community events

Young people mostat risk

Outreach only interventions providinginformation and services

329

92-4-120938-0_CH10_329

at increased risk, such as young migrant workers, young prisoners, and youngpeople in the uniformed services. For practical reasons these groups werenot included in order to limit the scope of the reviews and because data onthe effectiveness of interventions directed towards these groups are scarce.In addition to the absence of some groups from this review, some interven-tions have “fallen between the cracks” of the settings that were defined. Forexample, folk media, such as traditional theatre, songs and puppetry, fall be-tween interventions delivered through the media and those delivered throughthe community, and the social marketing of condoms falls among interven-tions delivered through the media, health services and the community.

Second, there was no attempt to review the evidence for the effectiveness ofinterventions directed towards underlying determinants of behaviour (some-times known as “upstream”, “structural” or “environmental” factors), suchas decreasing poverty, improving education or providing vocational training.In general, the focus of these chapters has been on mitigating vulnerabilityrather than preventing it. The decision not to include interventions directedtowards decreasing vulnerability was taken in order to limit the scope of thereview and because an initial search of the literature identified few studiesthat were likely to meet the inclusion criteria or would be amenable tothe methods that were used for reviewing evidence. As noted in chapter 3,evaluating such interventions remains a major challenge. However, the factthat such interventions were not included should not in any way be seen asimplying that they are unimportant. Clearly, changing these underlying de-terminants will be central to any long-term response to HIV and AIDS.Mitigating young people’s vulnerability is, however, likely to make importantcontributions in the short term, as will greater commitments to, and compli-ance with, the obligations of governments outlined in the Convention on therights of the child and other human rights instruments.

Third, none of the chapters has explicitly reviewed interventions in the po-litical environment that may contribute to achieving the global goals. (Thepolitical environment includes a number of different components, such aspolitical leadership, activism, policies and legislation. Policies and legislationare often a reflection of the other two components, since they are tangibleevidence of political commitment, providing both vision and the means forachieving specific outcomes). Such interventions have an impact both di-rectly – because they influence budget allocations and expressed prioritiesfor action – and indirectly – because they provide the basis for policies andlegislation, which subsequently facilitate or impede the implementation ofinterventions provided through other settings, such as schools and healthservices.

330

92-4-120938-0_CH10_330

Efforts were made at the start of this process to develop a chapter that wouldreview the evidence for a range of interventions in the political environmenton specific outcome measures related to HIV prevention (20). These effortsincluded exploring the links between political commitment and HIV/AIDSprevention, examining case studies on adolescent sexual and reproductivehealth policies in developing countries (case studies from 11 countries wereidentified) (21, 22), and conducting a preliminary analysis of the YouthNetdatabase on sexual and reproductive health policies for adolescents in 40countries that explicitly promoted behaviour-change communication or ac-tion to reduce STIs among adolescents (23). Preliminary conclusions fromthese efforts supported the likely relationship between the policy environmentand HIV interventions for young people, but it was not possible to apply themethods that had been used to assess the evidence for interventions in othersettings because there was insufficient information on the interventions. Al-ternative forms of analysis were beyond the scope of this project.

Some of the evidence that emerged from this initial review emphasized thepolitical nature of policy-making, the importance of credible data and re-search evidence to be used for advocacy and the value of assessing the“political palatability” of interventions – that is, whether they are technicallyfeasible, cost effective, simple to understand and pose minimal threats topolitical positions or yield political dividends. These issues are reflected inthe judgements made by the authors of the settings papers (chapters 5 to 9)when they established the thresholds of evidence that would be needed inorder to recommend widespread implementation.

In addition to developing specific policies and laws, there are a number ofother activities that are important in creating a supportive environment foreffective responses to HIV prevention; these are frequently included in “bestpractice” publications but often have not been systematically evaluated. Suchinterventions are particularly important when considering interventions di-rected towards young people’s sexuality and interventions targeting groupsthat are already subject to marginalization and discrimination, such as in-jecting drug users. The fact that we often do not have rigorous evaluations ofsuch activities is likely to be more a reflection of the difficulties of evaluatingthem than a lack of effectiveness.

Fourth, the reviews focused on HIV prevention and did not include treatment,care or support for young people living with HIV and AIDS, nor did theyprovide an explicit focus on “positive prevention”. This should in no way beseen as implying that these are unimportant components of national responsesto preventing the spread of HIV among young people. Although many clinicaldecisions are likely to be similar for adolescents and children or adults, andthe basic preventive interventions are likely to be the same whether or not a

331

92-4-120938-0_CH10_331

person is infected with HIV, there are a range of issues related to care andsupport that are likely to be of particular importance to young people livingwith HIV and AIDS; these include issues of sexuality, fertility, disclosure,living with a chronic disease, adhering to treatment regimens and dealing withstigma and discrimination. Testing, treatment and care are likely to provideimportant entry points for preventing HIV among young people.

With the growing focus on universal access, and as experiences are gainedin providing care and support for young people living with HIV and AIDS,a similar review may be warranted to assess the evidence for the effectivenessof interventions that aim to provide care and support. At the same time, asaccess to HIV testing and treatment expands it will be important to carefullymonitor the resources allocated to prevention and treatment. It will also beimportant to monitor and evaluate the impact of greater awareness about theavailability of treatment and greater community knowledge about the extentof HIV infection in the community on young people’s behaviours and on thecommunity’s values and norms, including stigma and discrimination.

In addition to the limitations that result from what we did not plan to include,there are also a number of limitations relating to the interventions and studiesthat actually were reviewed. First, although the authors of the five systematicreviews made every effort to ensure that all studies that met their inclusioncriteria were included, inevitably some will have been missed. For example,while computerized searches can locate the majority of articles appearing inpeer-reviewed journals, they do not identify books or chapters in books orgrey literature, such as unpublished project reports. There was also a languagebias towards English in the search criteria of most of the chapters. In addition,there are likely to be biases in the kind of evaluations that are published. Abias towards publishing positive results has been well documented as has thefact that expensive interventions are more likely to be evaluated more thor-oughly than less costly interventions (24, 25); this may reflect positively onmedia interventions but negatively on interventions delivered through com-munity settings.

Second, with the exception of the review of mass media approaches, the ma-jority of the studies reviewed were of local interventions and so they shedlimited light on the likely effectiveness of interventions implemented on alarger scale. It is possible that the effectiveness (and cost effectiveness) mightbe greater because of the economies of scale and the potential for changingsocial norms to the degree where a tipping point is reached. On the other hand,the quality and intensity of an intervention may be lower when it is imple-mented on a large scale.

Third, with a few notable exceptions, such as the “MEMA kwa Vijana”project in the United Republic of Tanzania (26), little data could be found on

332

92-4-120938-0_CH10_332

the costs of the interventions. Yet given that per capita annual spending onall health care in the least developed countries was estimated at US$ 11.00in 2000 (27), cost will obviously be a key factor in deciding which interven-tions to choose.

Fourth, few studies provided adequate information about the contextual fea-tures that were probably necessary to achieve the documented outcomes(28). The importance of context cannot be underestimated, and although thefocus of this review was on developing countries it is clear that there is a widerange of contexts within this broad categorization. For example, the effec-tiveness of interventions may well differ between Asia, Latin America andAfrica and between middle-income and low-income countries within one re-gion. Furthermore, the evidence for the effectiveness of interventions indeveloping countries needs to be viewed within the wider evidence base fromdeveloped countries. This wider evidence base informed the authors’ thinkingand is referred to in the reviews. As interventions classified as “Go” and“Ready” are introduced in new contexts it will be important to conduct carefulevaluations to ensure that they remain effective.

Fifth, there are well known measurement problems inherent in the reportingof attitudes and behaviours (29), and these may well be greater among youngpeople (30). For example, interventions may well bias reported behaviourstowards more socially desirable behaviours. However, few studies in anysetting included biological outcomes, and most relied on reported behavioursas surrogates for changes in HIV incidence or prevalence.

Sixth, a key finding of this series of reviews was that there are other seriouslimitations to many of the studies that provided the evidence. A number ofstudies that were initially identified did not meet even the minimum levels ofintervention specification required for inclusion. Furthermore, many of thereports of the interventions that did meet these minimum criteria were farfrom ideal in terms of the information they provided; at least some of the timethis reflected poor underlying design of the intervention and the evaluation,poor implementation, or some combination of these. Frequently, the specificsof the intervention were not described in detail, and this problem was oftencompounded either by a lack of evaluation of the process or the results notbeing reported. Many of the studies did not report the methods used in suf-ficient detail, and this often made assessing the quality of the evaluationdifficult.

In general, there was much more detail in studies of interventions conductedin schools and through the mass media than in the other settings. This reflectsthe greater effort that has gone into defining interventions in these settings,and makes it much easier to be clear about the characteristics of interventionsthat are related to their effectiveness in achieving health outcomes. Defining

333

92-4-120938-0_CH10_333

these characteristics remains a challenge in other settings, such as in the healthservices and for interventions in geographically defined communities andamong young people who are most at risk.

This had a number of implications for the programmatic recommendationsthat were made for different interventions by comparing evaluation data withthe predefined threshold of evidence needed to recommend widespread im-plementation. A number of value judgements had to be made by the authorsbased on their assessment of the quality of the intervention and of its evalu-ation in each study; less weight was placed on evidence from studies whereeither of these were poor. The benefits of the methods adopted for this revieware that the facts on which such judgements were based are summarized inthe tables in the printed version of the report and can be found in greater detailin the web versions of each of the five systematic reviews (www.who.int/child-adolescent-health/). Readers may not agree with all the judgementsmade, but the aim was to ensure that the basis for these judgements was asclear as possible, thus guaranteeing that they can act as a point of departurefor further debate and dialogue.

A final challenge in interpreting the data was the fact that a number of thestudies included multiple interventions, and it was difficult or often impos-sible to tease out the relative contributions of the different components. Giventhe importance of combining interventions in multiple settings, it is criticalto know which individual interventions should be included in a multicom-ponent package. It is also important to have a better understanding of howthe relative and absolute contributions of each component might differ if theyare used in different combinations.

Despite these many qualifications, this overview of the evidence does lead toa set of clear recommendations for policy-makers, programme developersand researchers. Some of the caveats arise because of the pragmatic natureof this endeavour. As many as 5 000–6 000 young people become infectedwith HIV every day, and governments, donors and nongovernmental orga-nizations are already allocating large amounts of money to prevent the spreadof HIV among young people. Even though the evidence is not perfect it isimportant that these funds are spent on interventions that are likely to haveas much impact as possible and that decisions are influenced by the evidenceon effectiveness. There would have been fewer caveats had the evidence beenmore rigorously reviewed – for example, if it had been restricted to random-ized controlled trials and, perhaps, quasi-experimental studies. However, thiswould likely have led to the conclusion that the data are not sufficient to makeany recommendations, which would neither help advocates for this importantaspect of national responses nor help policy-makers and programme man-agers move beyond such generic questions as “does prevention work?” It

334

92-4-120938-0_CH10_334

would also not have ensured that funds are spent on those interventions thathave the best evidence, even if it is incomplete.

There is clearly a great deal to do. The evidence is much clearer after thisreview but so are the challenges. First, interventions categorized as “Go” mustbe widely implemented on a large scale together with adequate monitoringand operations research. From this review, it is clear that these interventionsare effective in contributing to the global goals for increasing knowledge andskills and access to health services, and they will ultimately contribute toreducing the prevalence of HIV among young people. Second, interventionscategorized as “Ready” should be implemented together with adequate out-come and process evaluations to establish whether they should move into the“Go” category. Third, improvements in intervention design and piloting andevaluation should be accelerated for interventions in the “Steady” categoryto determine whether they should be moved into the “Ready” or the “Do notgo” categories.

Accomplishing all this will be a challenge for intervention developers andevaluators and for those who support and fund programmes. It should be ofconcern that 25 years into the epidemic we do not have enough evidence torecommend as “Go” any interventions targeting the young people who aremost at risk or any community interventions.

10.5 Recommendations

The key recommendations are summarized in Box 10.7, Box 10.8 andBox 10.9. As can be seen from these boxes, this series of reviews providesnumerous challenges for policy-makers, people responsible for programmedevelopment and delivery, and researchers. Policy-makers and programmemanagers should make every effort to ensure that “Go” interventions arewidely implemented now: requests for additional reviews and synthesis ofthe evidence for these types of interventions risk becoming an apology for alack of action and thus a form of denial, in the face of the challenge posed bythe need to ensure that we can demonstrate effectiveness and impact by takingsuch interventions to scale and ensuring their quality. Of course there will bean ongoing need to better understand different strategies for implementingthese interventions, for operations research and for more detailed informationabout costs and cost effectiveness. But this should not prevent us from actingnow to implement “Go” recommendations.

335

92-4-120938-0_CH10_335

Box

10.

7

Rec

om

men

dat

ion

s fo

r p

olic

y-m

aker

s

Set

tin

gR

eco

mm

end

atio

ns

Gen

eral

• Y

oung

peo

ple

are

at th

e ce

ntre

of t

he H

IV p

ande

mic

and

ther

e ar

e a

rang

e of

inte

rven

tions

that

hav

ean

ade

quat

e ev

iden

ce b

ase

to r

ecom

men

d th

em to

be

wid

ely

impl

emen

ted

to a

chie

ve th

e gl

obal

goa

lson

HIV

and

you

ng p

eopl

e as

long

as

ther

e is

car

eful

mon

itorin

g, e

valu

atio

n an

d op

erat

ions

res

earc

h•

Pre

vent

ion

can

wor

kS

cho

ols

• S

choo

l-bas

ed in

terv

entio

ns th

at in

corp

orat

e ch

arac

teris

tics

prev

ious

ly s

how

n to

be

rela

ted

toef

fect

iven

ess

in d

evel

oped

cou

ntrie

s an

d th

at a

re le

d by

adu

lts c

an r

educ

e se

xual

ris

k be

havi

our

and

incr

ease

kno

wle

dge

Hea

lth

ser

vice

s•

Tra

inin

g he

alth

-car

e pr

ovid

ers,

mak

ing

chan

ges

in fa

cilit

ies

and

unde

rtak

ing

activ

ities

to o

btai

nco

mm

unity

sup

port

can

incr

ease

you

ng p

eopl

e’s

use

of h

ealth

ser

vice

s th

at p

rovi

de tr

eatm

ent f

orS

TIs

a , c

ouns

ellin

g, te

stin

g an

d co

ndom

s•

Acc

ess

to h

ealth

ser

vice

s w

ill b

e en

hanc

ed b

y in

terv

entio

ns in

oth

er s

ecto

rs d

irect

ed a

t you

ng p

eopl

e’s

know

ledg

e, s

kills

, atti

tude

s an

d be

havi

ours

Mas

s m

edia

• M

ass

med

ia p

rogr

amm

es, p

artic

ular

ly w

hen

coor

dina

ted

with

inte

rven

tions

in o

ther

sec

tors

, can

rea

chm

any

youn

g pe

ople

with

impo

rtan

t pre

vent

ion

info

rmat

ion

on H

IV/A

IDS

as

wel

l as

help

to r

educ

ere

port

ed s

exua

l ris

k be

havi

our

Geo

gra

ph

ical

lyd

efin

ed c

om

mu

nit

ies

• E

stab

lishe

d co

mm

unity

org

aniz

atio

ns s

ervi

ng y

oung

peo

ple

can

influ

ence

thei

r kn

owle

dge,

atti

tude

san

d re

port

ed s

exua

l beh

avio

urs

to h

elp

prev

ent t

he s

prea

d of

HIV

Yo

un

g p

eop

lem

ost

at

risk

• Y

oung

peo

ple

who

are

mos

t at r

isk

of H

IV (

in th

is r

evie

w th

e gr

oups

con

side

red

wer

e in

ject

ing

drug

user

s, s

ex w

orke

rs, a

nd m

en w

ho h

ave

sex

with

men

) re

quire

urg

ent a

ctio

n•

Gre

ater

atte

ntio

n to

spe

cify

ing

the

need

s of

you

ng p

eopl

e in

ord

er to

tailo

r in

terv

entio

ns k

now

n to

be

effe

ctiv

e to

them

is r

equi

red

a S

TIs

= s

exua

lly tr

ansm

itted

infe

ctio

ns.

336

92-4-120938-0_CH10_336

337

Box

10.

8

Rec

om

men

dat

ion

s fo

r p

rog

ram

me

dev

elo

pm

ent

and

del

iver

y st

aff

Set

tin

gR

eco

mm

end

atio

ns

Gen

eral

• In

terv

entio

ns, a

nd th

eir

repo

rts,

sho

uld

be c

lear

abo

ut w

hat i

s be

ing

done

and

wha

t the

exp

ecte

dou

tcom

es a

re•

The

y sh

ould

als

o pr

ovid

e re

sults

dis

aggr

egat

ed b

y ag

e an

d se

x of

the

part

icip

ants

• The

impl

emen

tatio

n of

all

inte

rven

tions

sho

uld

be a

ccom

pani

ed b

y ca

refu

l mon

itorin

g an

d by

eva

luat

ion

appr

opria

te to

the

leve

l of e

xist

ing

evid

ence

• G

reat

er c

olla

bora

tion

is n

eede

d be

twee

n pr

ogra

mm

e m

anag

ers

and

rese

arch

ers

to fa

cilit

ate

effe

ctiv

em

onito

ring

and

eval

uatio

n de

sign

Sch

oo

ls•

Pro

gram

mes

sho

uld

be c

urric

ulum

-bas

ed a

nd d

esig

ned

and

impl

emen

ted

usin

g th

e ch

arac

teris

tics

show

n to

be

asso

ciat

ed w

ith e

ffect

iven

ess

Hea

lth

ser

vice

s•

In o

rder

to in

crea

se y

oung

peo

ple’

s us

e of

ser

vice

s it

is n

eces

sary

to tr

ain

serv

ice

prov

ider

s an

d ot

her

clin

ic s

taff

in h

ow to

pro

vide

hig

h qu

ality

hea

lth s

ervi

ces

for

youn

g pe

ople

• F

acili

ties

shou

ld b

e m

ade

mor

e ac

cess

ible

and

acc

epta

ble

to y

oung

peo

ple

• Wor

k al

so n

eeds

to b

e do

ne in

the

com

mun

ity to

gen

erat

e de

man

d an

d su

ppor

t for

the

serv

ices

targ

etin

gyo

ung

peop

le•

Oth

er s

ecto

rs, i

n pa

rtic

ular

sch

ools

and

the

med

ia, c

an a

ssis

t in

crea

ting

dem

and

by im

prov

ing

youn

gpe

ople

’s o

vera

ll kn

owle

dge

abou

t HIV

/AID

S a

nd e

ncou

ragi

ng h

ealth

-see

king

beh

avio

urs

Mas

s m

edia

• T

o ac

hiev

e th

e be

st r

esul

ts, m

ass

med

ia p

rogr

amm

es m

ust b

e ta

ilore

d sp

ecifi

cally

to y

oung

peo

ple

• T

hey

need

to p

rovi

de m

utua

lly r

einf

orci

ng m

essa

ges

thro

ugh

mul

tiple

cha

nnel

sG

eog

rap

hic

ally

def

ined

co

mm

un

itie

s•

Initi

ativ

es s

houl

d la

rgel

y fo

cus

on w

orki

ng w

ith e

xist

ing

yout

h-se

rvic

e or

gani

zatio

ns, w

here

car

eful

atte

ntio

n sh

ould

be

paid

to s

elec

ting,

trai

ning

and

spe

cify

ing

cultu

rally

app

ropr

iate

inte

rven

tions

and

task

s fo

r pr

ogra

mm

e st

aff

• S

taff

shou

ld b

enef

it fr

om o

ngoi

ng s

uper

visi

on•

Org

aniz

atio

n le

ader

s ne

ed to

be

vigi

lant

in m

aint

aini

ng o

vera

ll co

mm

unity

sup

port

and

res

ourc

em

obili

zatio

nY

ou

ng

peo

ple

mo

st a

t ri

sk•

The

se y

oung

peo

ple

shou

ld b

e pr

ovid

ed w

ith in

form

atio

n, s

kills

and

ser

vice

s th

roug

h fa

cilit

ies

and

thro

ugh

outr

each

str

ateg

ies

• T

heir

spec

ific

need

s sh

ould

be

give

n in

crea

sed

atte

ntio

n.•

Car

eful

eva

luat

ion

of th

e im

pact

and

pro

cess

es o

f int

erve

ntio

ns is

ess

entia

l to

incr

ease

kno

wle

dge

ofw

hat i

s ef

fect

ive

amon

g th

is g

roup

of y

oung

peo

ple

92-4-120938-0_CH10_337

338

Box

10.

9

Rec

om

men

dat

ion

s fo

r re

sear

cher

s

Set

tin

gR

eco

mm

end

atio

ns

Gen

eral

• T

here

is a

crit

ical

nee

d to

str

engt

hen

rese

arch

and

pro

gram

me

mon

itorin

g an

d ev

alua

tion

capa

city

inde

velo

ping

cou

ntrie

s•

Hig

h-qu

ality

eva

luat

ions

and

mon

itorin

g of

the

impa

ct o

f HIV

pre

vent

ion

inte

rven

tions

am

ong

youn

gpe

ople

in d

evel

opin

g co

untr

ies

are

urge

ntly

requ

ired

for i

nter

vent

ions

cla

ssed

as

“Rea

dy” a

nd “S

tead

y”•

Ope

ratio

ns r

esea

rch

is n

eede

d to

bet

ter

unde

rsta

nd th

e m

echa

nism

s of

act

ion

of in

terv

entio

ns• C

larit

y is

nee

ded

abou

t the

spe

cific

vul

nera

bilit

ies

of y

oung

peo

ple,

incl

udin

g yo

ung

inje

ctin

g dr

ug u

sers

,yo

ung

sex

wor

kers

and

you

ng m

en w

ho h

ave

sex

with

men

, to

guid

e pr

ogra

mm

e m

anag

ers

• S

tand

ardi

zatio

n of

out

com

e in

dica

tors

wou

ld g

reat

ly fa

cilit

ate

com

paris

ons

of r

esul

ts a

cros

s st

udie

s•

Cos

ting

and

cost

–effe

ctiv

enes

s st

udie

s sh

ould

be

built

into

eva

luat

ion

stud

ies

• R

esea

rch

is n

eede

d to

bet

ter

unde

rsta

nd th

e re

latio

nshi

p be

twee

n re

port

ed e

ffect

s on

beh

avio

urs

and

biom

edic

al im

pact

sS

cho

ols

• W

hene

ver

poss

ible

, fut

ure

eval

uatio

ns o

f sch

ool-b

ased

inte

rven

tions

sho

uld

use

rand

omiz

ed d

esig

nsw

ith s

uffic

ient

ly la

rge

sam

ples

• T

hey

shou

ld a

lso

mea

sure

the

impa

ct o

n S

TIs

a an

d H

IV a

s w

ell a

s kn

owle

dge

and

self-

repo

rted

attit

udes

, sel

f-ef

ficac

y an

d se

xual

ris

k be

havi

ours

Hea

lth

ser

vice

s•

Eva

luat

ion

and

oper

atio

ns r

esea

rch

shou

ld b

e co

re e

lem

ents

of a

ny in

terv

entio

ns to

incr

ease

you

ngpe

ople

’s u

se o

f hea

lth s

ervi

ces

Mas

s m

edia

• E

valu

atio

ns o

f mas

s m

edia

pro

gram

mes

sho

uld

focu

s on

thos

e th

at a

re c

ompr

ehen

sive

, hav

e th

epo

tent

ial f

or a

chie

ving

pop

ulat

ion

effe

cts

and

use

stro

ng q

uasi

-exp

erim

enta

l des

igns

to b

uild

a c

ase

for

infe

rrin

g ca

usal

ityG

eog

rap

hic

ally

def

ined

co

mm

un

itie

s•

Eva

luat

ion

and

oper

atio

ns r

esea

rch

need

to b

e co

re e

lem

ents

of p

rogr

amm

es ta

rget

ing

youn

g pe

ople

and

the

com

mun

ity a

t lar

ge•

Thi

s re

sear

ch s

houl

d pa

y pa

rtic

ular

atte

ntio

n to

iden

tifyi

ng c

ondi

tions

for

effe

ctiv

enes

s am

ong

vario

uspo

pula

tions

(su

ch a

s, y

oung

men

and

you

ng w

omen

) an

d lo

catio

ns (

such

as

rura

l or

urba

n ar

eas)

Yo

un

g p

eop

lem

ost

at

risk

• R

esea

rch

is n

eede

d to

iden

tify

the

spec

ial n

eeds

of t

hese

you

ng p

eopl

e in

con

tras

t to

thos

e of

adu

ltsin

ord

er to

impr

ove

indi

cato

rs th

at c

an b

e us

ed fo

r m

onito

ring

and

eval

uatio

na

ST

Is =

sex

ually

tran

smitt

ed in

fect

ions

.

92-4-120938-0_CH10_338

Interventions classified as “Ready” also need to be widely implemented butat the same time supported by carefully conducted evaluations and monitor-ing, and operations research. Programme developers and researchers need towork together to achieve these aims, and this collaboration will ensure thatyoung people benefit from these interventions and, at the same time, that theirimplementation contributes to the evidence base so that others can learn fromthese experiences. For interventions classified as “Go” and “Ready” the re-views in this series have emphasized the need for much greater clarity aboutexpected outcomes and about what is being done and how it is being done.However, the challenge is to accelerate action towards the global goals, andincreased resources are only likely to become available if there is wide con-sensus about what needs to be done and if collectively we can demonstratethat it is doable on a large scale in a sustainable way.

The future research agenda is substantial. However, many of the priorityquestions that need to be answered are now much clearer. Our hope is that ifa similar exercise were to be conducted in 5 years’ time, a much greaternumber of interventions would either be in the “Go” or “Do not go” cate-gories. This would provide implementers with clearer evidence-based guid-ance to inform their decisions, and would also ensure that resources availablefor prevention are used effectively.

Acting on the recommendations of this review will have a significant impacton preventing the transmission of HIV among young people, which in turnwill have wide-ranging implications for the health and development of indi-viduals, families, communities and countries around the world.

Acknowledgements

We would particularly like to thank Danny Wight for his helpful commentson an earlier draft of this paper, and to thank him and the other participantsof the June 2005 Chavannes meeting for their contributions to identifying andrefining the conclusions and recommendations from the reviews included inthis report. Those people are: Carlos Cáceres, Michel Carael, Kim Dickson,Ashok Dylachand, Mahesh Mahalingam, Elizabeth Mason, Jotham Musin-guzi, Zhenzhen Zheng.

References

1. UNAIDS. AIDS epidemic update 2005. Geneva, UNAIDS, WHO, 2005.

2. UNICEF, UNAIDS, WHO. Young people and HIV/AIDS – opportunity in crisis.New York, UNICEF, 2002.

3. National Research Council, Institute of Medicine. Growing up global: thechanging transitions to adulthood in developing countries. Washington, DC,National Academy Press, 2005.

339

92-4-120938-0_CH10_339

4. Aggleton P, Rivers K. Preventing HIV: behavioural interventions with youngpeople, 1997 (http://www.id21.org/insights/insights22/insights-iss22-art05.html).

5. Kirby D, Laris BA, Rolleri L. Impact of sex and HIV education programs onsexual behavior in developed and developing countries. Research TrianglePark, NC, Family Health International YouthNet Program, 2005. (YouthResearch Working Paper No. 2.)

6. WHO, UNFPA, UNAIDS. Achieving the global goals: access to services., 2003(http://www.who.int/child-adolescent-health/publications/ADH/ISBN_92_4_159132_3.htm)

7. Peersman G, Grimley Evans J. Interventions for preventing HIV infection inyoung people in developing countries. Cochrane Database of SystematicReviews, 2002, (2):CD003649. (Protocol.)

8. UNAIDS. Resource needs for an expanded response to AIDS in low- andmiddle-income countries, 2005 (http://data.unaids.org/Publications/IRC-pub06/ResourceNeedsReport_en.pdf).

9. UNAIDS. The road towards universal access (http://www.unaids.org/en/Coordination/Initiatives/default.asp).

10. Weiss C. Research and policy-making: a limited partnership. In: Heller F, ed.The use and abuse of social science. London, Sage, 1986.

11. Gregson S et al. HIV decline associated with behavior change in easternZimbabwe. Science, 2006, 311:664-666.

12. Global Campaign for Education. Deadly inertia: a cross-country study ofeducational responses to HIV/AIDS, 2005 (http://www.campaignforeducation.org/resources/Nov2005/ENGLISHdeadlyinertia.pdf).

13. Global HIV Prevention Working Group. Access to HIV prevention: closing thegap, 2003 (http://www.gatesfoundation.org/nr/downloads/globalhealth/aids/PWGFundingReport.pdf).

14. Hayes RJ et al. The MEMA kwa Vijana project: design of a community-randomised trial of an innovative adolescent sexual health intervention in ruralTanzania. Contemporary Clinical Trials, 2005, 26:430-442.

15. Okonofua FE et al. Impact of an intervention to improve treatment-seekingbehavior and prevent sexually transmitted diseases among Nigerian youths.International Journal of Infectious Diseases, 2003, 7:61-73.

16. Kim YM et al. Promoting sexual responsibility among young people inZimbabwe. International Family Planning Perspectives, 2001, 27:11-19.

17. loveLife. loveLife 2004: report on activities and progress. Cape Town,Parklands, loveLife, 2004.

18. Brieger W et al. West African Youth Initiative: outcome of a reproductive healtheducation program. Journal of Adolescent Health, 2001, 29:436-446.

19. Habicht JP et al Evaluation designs for adequacy, plausibility and probability ofpublic health programme performance and impact. International Journal ofEpidemiology, 1999, 28:10-18

20. Buse K. Political environment, policies and outcomes related to HIV/AIDS andyoung people, 2005 (unpublished data presented at the Evidence for Policiesand Programmes to Achieve the Global Goals on HIV/AIDS and Young People

340

92-4-120938-0_CH10_340

meeting: 8-11 March 2005), available from WHO Department of Child andAdolescent Health and Development.

21. Greene ME, Houvras I. Policy development supporting adolescent and youthsexual and reproductive health: nine countries’ experiences and collaborationswith UNFPA, 2004. (Unpublished document). (Available fromyouth@unfpa.org.)

22. Rosen JE. Formulating and implementing national youth policy: lessons fromBolivia and Dominican Republic. Washington, DC, Focus on Young Adults,2000.

23. Youth-policy.com. Youth reproductive health policy database (http://www.youth-policy.com/compendium.cfm).

24. Schulz K et al. Empirical evidence of bias dimensions of methodological qualityassociated with estimates of treatment effects in controlled trials. Journal of theAmerican Medical Association, 1995, 273:408-412.

25. Guyatt GH et al. Randomized trials versus observational studies in adolescentpregnancy prevention. Journal of Clinical Epidemiology, 2000, 53:167-174.

26. Terris-Prestholt F et al. From trial intervention to scale-up: costs of anadolescent sexual health program in Mwanza, Tanzania. Sexually TransmittedDiseases (in press).

27. Organisation for Economic Co-operation and Development. Policy brief:poverty and health in developing countries: key actions, 2003 (http://www.oecd.org/LongAbstract/0,2546,en_2649_201185_18514160_1_1_1_1,00.html).

28. Pawson R, Tilley N. Realistic evaluation. London, Sage, 1997.

29. Catania JA et al. Methodological problems in AIDS behavioral research:influences on measurement error and participation bias in studies of sexualbehavior. Psychological Bulletin, 1990, 108:339-362.

30. Plummer ML et al. “A bit more truthful”: the validity of adolescent sexualbehaviour data collected in rural northern Tanzania using five methods.Sexually Transmitted Infections, 2004, 80 Suppl 2:S49-56.

341

92-4-120938-0_CH10_341

92-4-120938-0_CH10_342

Glossary

Adolescents10-19 year olds.

Before-after studyAn intervention study design in which one or more outcomes of interest aremeasured in a population before and after the introduction of an interven-tion. This intervention study design does not include a control populationwho do not receive the intervention.

Case-Control StudyAn observational study design that starts with the identification of individ-uals with the outcome of interest, such as a disease (cases), and individualswithout the outcome of interest (controls). The frequencies of exposures topotential risk or protective factors for the outcome of interest are comparedin cases and controls.

Cluster randomized trial (CRT)A specific type of randomized controlled trial in which groups of individ-uals, such as whole communities, are randomly allocated to the interven-tion and comparison (control) arms of the trial.

Cohort studyAn observational study in which individuals who do not have the outcomeof interest are identified as either being exposed or not being exposed to apossible risk or protective factor for the outcome of interest, and are thenfollowed up over time to measure the incidence of the outcome of interest,such as the development of a disease.

Cross-sectional studyAn observational study in which the frequency of one or more outcomes ofinterest (and/or exposures) is measured in a population at one point in time.

InterventionA defined set of activities that are implemented to achieve specified outcomesin a target population. Examples could include trained teachers delivering aseries of classes on sexual and reproductive heath to students, or a series of

343

92-4-120938-0_GLOSSARY_343

television “spots” to promote abstinence and/or condom use among youngpeople.

Intervention studyA study in which an intervention is assigned to individuals or to clusters ofindividuals and the frequency of the outcome(s) of interest is measured toassess the effect of the intervention. Examples of intervention study designsinclude before-after, time series, quasi-experimental, and randomizedcontrolled trials (including cluster randomized trials)

Intervention typeA group of interventions sharing common characteristics. In the systematicreviews in this report, similar interventions have been grouped into these“intervention types” based on key choices that policy makers and programmemanagers need to make. Examples include:

1. Curriculum-based interventions in schools, with characteristics thathave been found to be effective in developed country settings, and thatwere adult-led

2. Mass media interventions with messages delivered through the radio,television and through other media (eg. print media)

Observational studyA study design in which the distribution of both exposures and outcomes ofinterest are measured without the investigator attempting to influence them.

ProgrammeA set of interventions implemented on a large scale, such as a national ado-lescent health programme or a national AIDS control programme.

ProjectThe implementation of a particular intervention or interventions in a specificlocal setting.

Quasi-experimental studyAn intervention study design in which an intervention is assigned to someindividuals or clusters of individuals (intervention group) and not to others(comparison or control group) in a non-random manner. The frequency of theoutcome(s) of interest is measured in both intervention and control groups inorder to assess the effect of the intervention. Quasi-experimental studies in-clude studies where data are collected after an intervention has been imple-mented, before and after an intervention has been introduced, or at severalpoints in time after an intervention has been introduced. The key issue is thatsimilar data on the outcome(s) of interest are collected in both interventionand control groups, but that the individuals or clusters of individuals have

344

92-4-120938-0_GLOSSARY_344

been assigned to either receive or not receive the intervention in a non-randommanner.

Randomized controlled trial (RCT)An intervention study design in which individuals or groups of individuals(see cluster randomized trial) are randomly allocated either to receive(intervention arm) or not to receive (control or comparison arm) the inter-vention(s) under evaluation.

SettingThe situation in or through which the intervention is delivered, such as inschools, health services, geographically-defined communities, through massmedia, or among groups most at risk of HIV.

Strength of evidenceEach study of the effectiveness of an intervention contributes evidence. Inthis report, the strength of evidence that a study contributes has been definedas depending on a combination of the quality of the intervention, the evalu-ation design and its implementation. The evaluation designs have beenweighted, with increasing weight being assigned to study designs on a hier-archy from adequacy, to plausibility and probability.

Structural interventionAn intervention that aims to change underlying determinants of risk, vul-nerability or disease, such as interventions that aim to decrease poverty,improve education, or increase employment. Such interventions are some-times known as ‘upstream’, or ‘environmental’ interventions.

Time series studyAn intervention study design in which one or more outcomes of interest aremeasured at several points in time in a population receiving an interven-tion. This design of intervention study does not include a control populationwho do not receive the intervention.

Threshold of evidence for widespread implementationThe minimum strength of evidence needed to be able to recommendwidespread implementation of a specific intervention type within a partic-ular intervention setting. The threshold of evidence depends on the feasibility(including cost), potential for adverse outcomes, acceptability, potential sizeof effect and potential for other health or social benefits of that interventiontype.

Young people10-24 year-olds.

Youth15-24 year-olds.

345

92-4-120938-0_GLOSSARY_345

92-4-120938-0_GLOSSARY_346

ACKNOWLEDGEMENTS:

The authors of the chapters in this report have acknowledged those peoplewho made specific contributions to their respective chapters. In addition theeditors would like to thank the following people who, along with the authorsof specific chapters, have contributed to this report by reviewing and com-menting on drafts of the chapters, providing ideas and support for the overallSteady, Ready, GO project, or participating in the preparatory meetings(Talloires, France, May 2004; Gex, France, March 2005; Chavannes,Switzerland, June 2005): Professor Peter Aggleton, University of London,United Kingdom; Dr John D. Berman, AIDSMark, Population Services In-ternational, USA; Dr Ann Biddlecom, The Alan Guttmacher Institute, USA;Dr Anthony Bloome, Leadership Program in AIDS, World Bank, USA;Dr Katherine Bond, The Rockefeller Foundation, Thailand; Dr HeatherBoonstra, The Alan Guttmacher Institute, USA; Dr Kent Buse, LSHTM,United Kingdom; Dr Carlos F. Cáceres, Universidad Peruana CayetanoHeredia, Peru; Dr Ward Cates, Family Health International, USA; Ms ShantiConly, U.S. Agency for International Development, USA; Dr FrancesCowan, University of Zimbabwe, Zimbabwe; Dr Siobhan Crowley, WHO,Switzerland; Dr Mehboob Dada, UNESCO, France; Mr Paul de Lay,UNAIDS, Switzerland; Dr Kim Eva Dickson, WHO, Switzerland; Dr A.Dyalchand, Institute of Health Management Pachod (IHMP), India; Mr BillFinger, Family Health International, USA; Dr Annette Gabriel, GTZ,Germany; Dr Anna C. Gorter, Instituto CentroAmericano de la Salud,Nicaragua; Dr Catherine Hankins, UNAIDS, Switzerland; Mr DavidHarrison, loveLife, South Africa; Dr. John Howard, Ted Noffs Foundation,Australia; Dr Myat Htoo Razak, WHO, Thailand; Professor Anne M.Johnson, University College London, United Kingdom; Professor Knut-IngeKlepp, University of Oslo, Norway; Dr Marie Laga, Institute of TropicalMedicine, Belgium; Dr Erma Manoncourt, UNICEF, Egypt; Mr MaheshMahalingam, UNAIDS, Switzerland; Dr Rafael Mazin, PAHO, USA;Dr Kristin Mmari, Johns Hopkins University, USA; Ms Claire Mulanga,ILO, Switzerland; Dr Joanna Nerquaye-Tetteh, Planned ParenthoodAssociation of Ghana, Ghana; Mr Rick Olson, UNICEF, USA; Dr JulittaOnabanjo, UNFPA, USA; Dr Audrey Pettifor, University of North Carolina,

347

92-4-120938-0_ACKNOWLEDGEMENT_347

USA; Dr Arletty Pinel, UNFPA, USA; Dr Elizabeth Pisani, LSHTM, UnitedKingdom; Dr Leah Robin, CDC, USA; Professor John Santelli, ColumbiaUniversity, USA; Ms Sharifah Tahir, YouthNet/FHI, USA; Dr RichardSteen, WHO, Switzerland; Dr C. Johannes van Dam, Population Council,USA; Professor Cesar G Victora, Universidade Federal de Pelotas, Brazil;Dr Merlin L Wilcox, Liverpool School of Tropical Medicine, UnitedKingdom; Professor Zhenzhen Zheng, Chinese Academy of Social Sciences,China.

The editors would like to make special mention of the following people whomade substantial intellectual contributions throughout the preparation ofthis report: Professor Michel Carael, Free University of Brussels, Belgium;Professor Richard Hayes, LSHTM, United Kingdom; Ms Jane Hughes, ThePopulation Council, Vietnam; Ms Aurorita Mendoza, UNAIDS, Nepal;Dr Jotham Musinguzi, Ministry of Finance, Planning & Economic Develop-ment, Uganda; Dr Danny Wight, Medical Research Council Social & PublicHealth Sciences Unit, Scotland.

The work would not have been accomplished without the conscientious ad-ministrative assistance of Ms Anita Blavo of the Department of Child andAdolescent Health and Development (CAH), World Health Organization,and the support of Dr Hans Troedsson and Dr Elizabeth Mason of CAH.

Special thanks to colleagues in the Department of Knowledge Managementand Sharing (KMS), WHO: Dr Laragh Gollogly, Ms Kaylene Selleck andMr David Bramley who made the final arrangements for this report possible,and to Ms Miriam Pinchuk for her careful technical editing of the manuscripts.

Grateful acknowledgment is given to the UNAIDS Inter-agency Task Teamon HIV/AIDS and Young People for initiating the preparation of this report,and to the financial contributions from the Canadian International Develop-ment Agency, UNAIDS, UNFPA, UNICEF, and the United States Agencyfor International Development, as well as core support provided by WHO.

348

92-4-120938-0_ACKNOWLEDGEMENT_348