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A review of HIV interventions for at-risk women |
Exner T M, Seal D W, Ehrhardt A A |
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Authors' objectives To critically review the scientific literature on primary AIDS prevention efforts aimed at high-risk women, in order to attempt to evaluate their impact and efficacy.
Searching Electronic searches of AIDSLINE (from 1980 to December 1995), PsycLIT (from January 1987 to November 1995), and MEDLINE (from 1980 to December 1995) were carried out. The keywords 'HIV' and 'AIDS' merged with the subheadings 'prevention and control', 'education', 'evaluation', 'intervention', and 'risk reduction', were used to identify relevant articles and abstracts (further search terms were provided). The search was limited to English language publications. Additional articles and abstracts were identified by handsearching Current Contents (Social and Behavioral Sciences) for the years 1995 and 1996 using the category HIV and AIDS. When both a published article and abstract described the same study, only the article was considered for the review. In one case where two published reports described the identical study and follow-up period, both were reviewed; the report, which provided greater detail, was used as the primary citation.
Study selection Study designs of evaluations included in the reviewRandomised controlled trials (RCTs), controlled trials, quasi-RCTs, cohort studies and retrospective studies were included in the review. The study follow-up periods ranged from 2 weeks to 18 months.
Specific interventions included in the reviewPrimary prevention programmes with a psychological, behavioural or educational component that focused on reducing sexual risk behaviour for human immunodeficiency virus (HIV) among adult women. The specific interventions included were: informational interventions; condom and spermicide skills; relational skills; HIV counselling and testing; individual risk counselling; and community interventions. Interventions targeting reductions in needle-sharing and/or drug use, changes in AIDS-related knowledge and attitudes, and prenatal HIV transmission to infants, were excluded.
Participants included in the reviewThe review included high-risk adult women from a variety of ethnic backgrounds (White, Latino, African American, Hispanic), socioeconomic backgrounds (college students, single pregnant women, inner city or low-income women, incarcerated women) and risk groups (intravenous drug users or partners of, partners of HIV-positive individuals, patients with sexually-transmitted diseases, sex workers), who lived in the USA, Canada or Peurto Rico.
Outcomes assessed in the reviewThe primary outcome was the change in risky sexual behaviour. The secondary outcomes included condom usage and intention to undergo HIV testing.
How were decisions on the relevance of primary studies made?The authors do not state how the papers were selected for the review, or how many of the authors performed the selection.
Assessment of study quality The validity of the studies was judged using the following criteria:
the use of randomised control groups, or comparison groups demonstrated to be comparable to experimental groups on sociodemographic and outcome variables;
the presentation of data on the numbers of participants recruited to each condition;
the presentation of attrition rates, where applicable;
the presentation of pre- and post-intervention data; and
the reporting of the analytic approach used and tests for significance. Two reviewers evaluated the validity of each report.
Data extraction The authors do not state how the data were extracted for the review, or how many of the authors performed the data extraction.
Methods of synthesis How were the studies combined?The studies were combined using a descriptive narrative, according to whether the interventions were interpersonal or community-based. The interpersonal studies were further subdivided into the specific type of intervention used (informational, condom or spermicide skills, relational skills, HIV counselling and testing, individual risk counselling) and the population studied.
How were differences between studies investigated?Differences between the studies were discussed descriptively in the summary of results.
Results of the review Forty-seven studies were included: 23 RCTs, 5 controlled trials, 6 quasi-experimental, 11 cohort studies, 1 serial cross-sectional study, and 1 retrospective study. However, the review focused mainly on 16 reports (11 RCTs, 4 quasi-RCTs and 1 cohort study), which were judged to meet the authors' minimum standards for methodological rigor. Thirty-nine studies examined interpersonal interventions, whilst 8 examined the effectiveness of community interventions.
Overall, the findings demonstrated that HIV prevention programmes can be effective in reducing risky sexual behaviour among at-risk women. Thirty of the 47 studies identified showed some impact on sexual risk behaviour, although only 20 reported statistical significance. The effectiveness of the interventions varied depending on the type, number of sessions, and whether the studies included women alone or both men and women. Eight of the 12 studies targeting only women had a significant impact on risk behaviour, whereas only 1 of the 4 studies involving both men and women reported significant behavioural changes for women. Four of the 5 studies with interventions lasting for at least 5 sessions reported significant effects, compared with only 4 of the 9 single-session studies.
Informational interventions (5 studies): at-risk, inner-city, or low-income women, were targeted in these studies using a single-session intervention or a short follow-up period. These interventions were shown to have a limited impact in terms of behavioural changes.
Condom and spermicide skills interventions (2 studies): only one of the two single-session intervention studies met the authors' methodological criteria. The paucity of research did not allow any firm conclusions to be drawn as to the effectiveness of this intervention.
Relational skills interventions (20 studies): 8 of the studies met the authors' methodological criteria. Overall, skills interventions of longer duration (at least 5 sessions), which were specifically targeted to women, appeared to be more successful than informational approaches at producing short-term sexual behaviour change.
HIV counselling and testing (10 studies): 5 studies examined the use of 'standard' HIV counselling interventions and 5 examined 'enhanced' counselling, where the counselling was augmented by additional training in condom or relational skills. No overall conclusions could be drawn as the only study that met the methodological criteria failed to find significant changes in condom usage. No firm conclusions could be drawn from the enhanced counselling studies as they lacked a no-treatment control group.
Individual risk counselling (2 studies): neither of the two studies met the methodological criteria set by the authors.
Community interventions (8 studies): 2 studies met the minimum methodological criteria used by the authors. However, interpretation of the efficacy of the interventions was problematic due to the small number of studies, and the limited methodological and statistical information provided. Five of the reports were preliminary and only appeared in abstract form. Six of the 8 studies, however, showed an increase in condom usage.
Authors' conclusions Overall, the findings of this review demonstrated that HIV prevention programmes can be effective in reducing risky sexual behaviour among at-risk women. Programme effectiveness varied according to the intervention type, session duration, and whether the studies included women alone or both men and women. The most efficacious HIV prevention programmes were specifically directed toward women, focused on relationship and negotiation skills, and involved multiple sustained contacts. There was evidence to suggest that community-level interventions hold promise.
CRD commentary In general, this was a thorough, and clearly presented review. The literature search appears to have been extensive. However, by limiting the retrieval to only English language articles, relevant evidence may have been excluded. The authors discussed how they assessed the validity of the studies, but they failed to state how initial decisions on the eligibility of the studies were made. Evidence from the more methodologically rigorous studies was highlighted and a number of issues regarding study design were discussed. The evidence presented in the review appears to uphold the authors' concluding statements and their recommendations that more rigorously-designed studies should be performed.
Implications of the review for practice and research The authors state the following.
1. A national AIDS risk-reduction strategy is needed, which addresses not only specific individual behaviour but also the environmental conditions that impede behavioural change.
2. Gender- and culturally-specific interventions are needed. These appear to be most effective when they are skills-based.
3. Current gaps in the literature must be addressed, particularly regarding community-level interventions, issues of long-term maintenance, and dissemination or technology transfer.
4. A better understanding and definition of realistic and acceptable long-term sexual behaviour change, within the context of women's sexuality and relationships, is needed.
5. Future interventions should adhere to minimum standards in the peer-refereed description of the study design and analysis, to enable a clearer interpretation of the findings.
Funding NIMH/NIDA, grant number 5P50 MH-43520; NIMH Training, grant number T32-MH19139.
Bibliographic details Exner T M, Seal D W, Ehrhardt A A. A review of HIV interventions for at-risk women. AIDS and Behavior 1997; 1(2): 93-124 Indexing Status Subject indexing assigned by CRD MeSH Female; HIV Seroprevalence; Sexually Transmitted Diseases; Women's Health AccessionNumber 11998005223 Date bibliographic record published 31/08/1999 Date abstract record published 31/08/1999 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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