Behavioural Interventions for HIV Positive Prevention in Developing

Research

Behavioural interventions for HIV positive prevention in developing countries: a systematic review and meta-analysis Caitlin E Kennedy,a Amy M Medley,a Michael D Sweatb & Kevin R O’Reillyc

Objective To assess the evidence for a differential effect of positive prevention interventions among individuals infected and not infected with human immunodeficiency virus (HIV) in developing countries, and to assess the effectiveness of interventions targeted specifically at people living with HIV. Methods We conducted a systematic review and meta-analysis of papers on positive prevention behavioural interventions in developing countries published between January 1990 and December 2006. Standardized methods of searching and data abstraction were used. Pooled effect sizes were calculated using random effects models. Findings Nineteen studies met the inclusion criteria. In meta-analysis, behavioural interventions had a stronger impact on condom use among HIV-positive (HIV+) individuals (odds ratio, OR: 3.61; 95% confidence interval, CI: 2.61–4.99) than among HIV-negative individuals (OR: 1.32; 95% CI: 0.77–2.26). Interventions specifically targeting HIV+ individuals also showed a positive effect on condom use (OR: 7.84; 95% CI: 2.82–21.79), which was particularly strong among HIV-serodiscordant couples (OR: 67.38; 95% CI: 36.17–125.52). Interventions included in this review were limited both in scope (most were HIV counselling and testing interventions) and in target populations (most were conducted among heterosexual adults or HIV-serodiscordant couples). Conclusion Current evidence suggests that interventions targeting people living with HIV in developing countries increase condom use, especially among HIV-serodiscordant couples. Comprehensive positive prevention interventions targeting diverse populations and covering a range of intervention modalities are needed to keep HIV+ individuals physically and mentally healthy, prevent transmission of HIV infection and increase the agency and involvement of people living with HIV.

الرتجمة العربية لهذه الخالصة يف نهاية النص الكامل لهذه املقالة. .Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español

Introduction and prevention.12 There is no clear consensus on what positive prevention entails, but it generally includes activities centred Historically, efforts to prevent human immunodeficiency virus on four main goals: (i) keeping HIV+ individuals physically (HIV) infection have focused on reducing HIV infection risk healthy; (ii) keeping such persons mentally healthy; (iii) prevent- among individuals with HIV-negative (HIV−) or unknown se- ing further transmission of HIV; and (iv) involving people living rostatus. Initially, this reflected concerns over stigmatization and with HIV in prevention activities, leadership and advocacy.4,13 discrimination associated with interventions targeting HIV-infected Fig. 1 outlines a conceptual framework that shows how posi- (HIV+) individuals and limited availability of HIV testing services.1 tive prevention goals are related to selected interventions and Recently, however, there has been a dramatic scale-up of HIV test- outcomes. The framework is broad and includes biomedical as ing, antiretroviral therapy (ART) availability and associated care well as behavioural interventions. The scope of our review was worldwide. Consequently, many more people living with HIV limited to behavioural interventions, which allowed for a more now know their serostatus and are living longer and healthier lives.2 focused examination of one aspect of positive prevention. Three previous reviews have examined behavioural interven- Today, programme planners recognize that continued reli- 14–16 ance on general HIV prevention messages may limit the effective- tions targeting people living with HIV. However, almost all ness and sophistication of prevention strategies.3 It may be more the included studies had been conducted in the United States efficient to change behaviour among fewer HIV+ individuals of America. There have been no similar reviews of positive pre- than many HIV− individuals.4 Recent data show that in many vention interventions in developing country settings. Given the sub-Saharan African countries, most new cases of HIV infection scale-up of HIV testing and treatment in developing countries occur in HIV-serodiscordant couples, and rates of HIV disclo- and the unique social, economic and epidemiologic features of sure and condom use in such couples remain low.4,5 Focusing these settings, the purpose of this paper was to assess the efficacy attention on HIV-serodiscordant couples may therefore be one of HIV prevention interventions with HIV+ individuals in of the most effective ways of reducing HIV transmission. Efforts developing country settings. to reduce stigma have alleviated some of the concerns regarding prevention programmes aimed at HIV-infected persons.4 As a Methods result, HIV prevention activities increasingly target individuals who know that they are HIV+.6 This strategy is known as positive Objectives prevention, although it has also been called prevention for, by or This review is part of a larger series of systematic reviews of with positives,1,7–11 and, most recently, positive health, dignity HIV-related behavioural interventions in developing coun-

a Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street (E5033), Baltimore, MD, 21205-1996, United States of America. b Medical University of South Carolina, Charleston, USA. c Department of HIV and AIDS, World Health Organization, Geneva, Switzerland. (Submitted: 2 June 2009 – Revised version received: 27 December 2009 – Accepted: 6 January 2010 – Published online: 28 May 2010 )

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Fig. 1. Conceptual framework showing goals, selected interventions and outcomes of positive preventiona

POSITIVE PREVENTION

Keep people living with Keep people living with Prevent HIV Increase the agency GOALS HIV HIV transmission of people living with physically healthy mentally healthy to other people HIV

Provision of ART Support groups Prevention counselling Training of people living with Prevention of Substance abuse (e.g. HIV disclosure, HIV in advocacy methods INTERVENTIONS opportunistic infections treatment programmes sexual risk reduction, Encouragement and Adherence counselling Opioid substitution therapy alcohol reduction) support for formation and support Medical management Partner/family HIV of advocacy groups by STI diagnosis/treatment of depression testing programmes people living with HIV Distribution of bednets Psychosocial counselling Family planning Participation of people education/counselling Clean water programmes and support programmes living with HIV on Programmes for country-level technical Nutritional education prevention of mother- and support working groups and to-child transmission other policy Needle/syringe development groups exchange programmes Condom distribution Mass media programmes

Improve coping, prevent Increase visibility/ Prevent illness depression, and Reduce risk behaviour/ OUTCOMES and infection unintended pregnancies participation of people reduce risk behaviour living with HIV

Reduced morbidity and mortality related to HIV/AIDS Reduced HIV incidence Reduced stigma

AIDS, acquired immunodeficiency syndrome; ART, antiretroviral therapy; HIV, human immunodeficiency virus; STI, sexually transmitted infection. a “Positive prevention” denotes preventive interventions that target HIV+ individuals.

tries. Other interventions reviewed was implemented; (ii) the interven- Search strategy 17 include mass media interventions, tion was conducted in a developing First, we reviewed all articles included in 18 psychosocial support, treatment as country, defined on the basis of The the larger series of systematic reviews of 19 prevention, voluntary counselling World Bank categories of low-income, HIV-related behavioural interventions 20 21 and testing and peer education. We lower-middle income or upper-middle in developing countries to determine used standardized methods across all income economies23; (iii) the evalua- whether they met the criteria for positive reviews and report results according tion design compared post-intervention prevention. Our review encompassed to the Preferred Reporting Items for outcomes using either a pre/post or articles previously published and reviews Systematic Reviews and Meta-Analyses multi-arm study design (including post- of interventions currently in progress, in- (PRISMA) Statement.22 only exposure analysis); (iv) behavioural, cluding condom social marketing, partner People living with HIV may be psychological, social, care or biological notification, free condom distribution, reached by interventions that target a abstinence-based interventions, com- broad audience of both HIV+ and HIV− outcome(s) related to HIV prevention were presented; (v) pre-post or multi- prehensive sex education interventions, individuals or by interventions that target needle/syringe programmes, family plan- them specifically. Our review therefore arm outcomes of interest were stratified by known or clinically suspected HIV ning for HIV+ women and behavioural had two objectives. The first was to assess counselling. serostatus of the participants (objec- the evidence for a differential effect of -in Second, we searched electronic data- tive 1), or the intervention specifically terventions by serostatus. In other words, bases specifically for positive prevention do interventions that target both HIV+ targeted HIV+ individuals (objective 2); articles. A standard set of search terms and HIV− individuals work differently and (vi) the article was published in a (available at: http://www.jhsph.edu/ in these two groups? The second was to peer-reviewed journal between January dept/ih/globalhealthresearch/HIVposi- assess the effectiveness of interventions 1990 and December 2006. No language tiveprevention.pdf ) was generated and targeted specifically at HIV+ individuals. restrictions were applied; English trans- entered into five electronic databases, lations were obtained when necessary. If all of which covered the full range of Inclusion criteria two articles presented data for the same included dates: the United States Na- Studies were included in the review if project and target population, the article tional Library of Medicine’s Gateway they met the following criteria: (i) an with the longest follow-up was retained system (including Medline), PsycINFO, HIV-specific behavioural intervention for analysis. Sociological Abstracts, Excerpta Medica

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Database (EMBASE) and the Cumula- standardized effect size estimates24 and (available at: http://www.who.int/bul- tive Index to Nursing and Allied Health used Comprehensive Meta-Analysis V.2.2 letin/volumes/88/8/09-068213) provide Literature (CINAHL). Links to medical (Biostat, Inc., Englewood, United States further information on individual study subject heading terms and explosion of of America) to conduct statistical analy- characteristics and rigour scores. On aver- terms were used where available. ses. For each outcome, we entered odds age, studies received 3.9 out of 8 possible Third, we hand-searched the tables ratios (ORs) directly into the program points for study design and rigour. There of contents of four journals: AIDS, or calculated ORs from data reported in was no clear association between study AIDS and Behaviour, AIDS Care and articles. ORs were pooled using random rigour and results, most likely owing to AIDS Education and Prevention. We also effects models. We attempted to contact multiple sources of heterogeneity across examined the reference lists of included authors when published articles provided studies (in setting, target population, articles to identify articles we might have insufficient information to make these intervention and comparison groups) and missed. This process was iterated until no calculations. to differences in study quality. new articles were found. Meta-analysis was conducted for outcomes reported in at least three stud- Differential effect of interventions Study selection ies. For both study objectives, the only by serostatus outcome that met this criterion was male Initial inclusion/exclusion of studies was Nine studies addressed our first objec- condom use. Condom use was defined in based on title and abstract review by a tive.25–32 Seven were conducted with terms of the dichotomous proportion of member of the study staff. Remaining heterosexual adults, 1 with pregnant respondents who either: (i) did or did not citations were then screened by two senior women and 1 with female commercial use condoms, or (ii) did or did not have study staff on the basis of the inclusion sex workers. Eight evaluated HIV coun- unprotected sex. When articles presented criteria above. The results were merged selling and testing interventions and 1 multiple measures of condom use (e.g. for comparison, and discrepancies were evaluated a family planning education condom use at last sexual encounter, con- discussed to establish consensus. Final in- programme. Most interventions also sistent condom use in the last 3 months, clusion/exclusion of studies was based on included condom distribution. For this condom use with primary/non-primary objective, 2 outcomes were measured a thorough reading of the full-text article. partners), we calculated an average effect across multiple studies: condom use and size across measures within each study Data extraction contraceptive use. and used the average effect size estimate in Each article meeting the inclusion criteria cross-study meta-analysis. When articles Condom use underwent data extraction by two inde- presented multiple follow-up times, we pendent reviewers. Data were entered into used the comparison with the longest Four studies with a combined study popu- a systematic coding form that included follow-up. We also summarize results for lation of 4322 generated 6 discrete effect detailed questions on intervention, study outcomes that were common across two sizes for condom use among HIV+ and 26,27,32 design, methods and outcomes. The two studies, although data from these studies HIV− individuals. Among HIV+ completed coding forms were compared were not meta-analysed: contraceptive individuals (n = 889), pooled data suggest and discrepancies were resolved by a third use, multiple sex partners and HIV se- that interventions had a positive effect on reviewer. rostatus disclosure. condom use (OR: 3.61; 95% confidence interval, CI: 2.61–4.99) (Fig. 3). The Rigour score Results Q statistic of 2.82 showed no statistically significant heterogeneity (P = 0.73; The rigour of the study design for included From over 9000 articles identified in the I2 = 0.000). Among HIV− individuals articles was assessed by means of an eight- initial search, 230 were determined to from these same studies (n = 3433), point scale, with one point awarded for be potentially relevant and 18 ultimately pooled data show no statistically sig- each of the following items: (i) prospec- met our inclusion criteria (Fig. 2).25–42 nificant intervention effect on condom tive cohort; (ii) control or comparison These 18 articles reported on 19 studies, use (OR: 1.32; 95% CI: 0.77–2.26) group; (iii) pre-/post-intervention data; as one article described both an individual (Fig. 4). The Q statistic of 33.14 showed (iv) random assignment of participants and a couples-based intervention.32 Of statistically significant heterogeneity to the intervention; (v) random selection 2 the studies included in the review, 15 (P = 0.0001; I = 84.92). Meta-analysis of subjects for assessment, or assessment were conducted in sub-Saharan African results for HIV+ and HIV− individuals of all subjects who participated in the countries, 1 in Asia (China), 1 in South differed significantlyP ( = 0.002). intervention; (vi) follow-up rate of 80% America (Brazil), and 2 (reported in The 4 studies that stratified con- or more; (vii) comparison groups equiva- one article) in three countries (Kenya, dom use outcomes by serostatus were lent on socio-demographic measures; and United Republic of Tanzania and Trini- all evaluations of HIV counselling and (viii) comparison groups equivalent at dad and Tobago). Target populations testing interventions, and all included baseline on outcome measures. included heterosexual adults in 12 stud- comparisons of couples versus individual ies; HIV-serodiscordant couples in 5; counselling. Therefore, we conducted Meta-analysis pregnant women in 1, and commercial meta-analysis comparing couples versus We converted effect size estimates to the sex workers in 1. Most studies (n = 14) individual counselling for both HIV+ common metric of an odds ratio, since were conducted in a clinic setting, 2 in and HIV− individuals. Meta-analysis all studies compared two groups and re- participants’ homes and 2 in both clinic results showed no difference between ported dichotomous outcomes. We used and home settings. One study did not couples and individual counselling with standard meta-analytic methods to derive report the setting. Table 1 and Table 2 respect to condom use among either

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HIV+ or HIV− individuals (HIV+ Fig. 2. Disposition of citations during the search and screening process in systematic pooled effect size: OR: 1.78; 95% CI: review of positive preventiona interventions in developing countries 0.48–6.54; Q = 29.15; P = 0.0.0001; I2 = 89.71; HIV− pooled effect size: OR: 0.63; 95% CI: 0.15–2.62; Q = 35.09; Articles in database of Citations identified Citations identified = 0.0001; 2 = 91.45). Meta-analysis other systematic through online database through secondary and P I reviews (n = 83) searches (n = 9626) hand searches (n = 0) results for couples versus individual counselling among HIV+ and HIV− individuals were not significantly different (P = 0.29). Citations excluded after One study27 is an outlier (Fig. 4) initial screening (n = 9479) with an OR below 1, indicating reduced condom use, probably because of the Citations retained nature of the comparison group. While for double screening (n = 230) other studies employed before–after or Citations excluded after intervention–control comparisons, this double screening (n = 154) because: study compared individuals who received Not a developing country (n = 25) Not an intervention (n = 75) couples counselling with those who Not a behavioural intervention (n = 14) received individual counselling. Among No pre/post or multi-arm comparisons (n = 13) HIV− individuals, couples counselling re- Serostatus of participants not reported (n = 15) HIV-negative participants only (n = 6) sulted in decreased condom use compared Results not stratified by serostatus (n = 5) with individual counselling, likely because Full text article not available (n = 1) couples where both partners tested nega- Full-text articles retrieved for more detailed evaluation tive felt safe foregoing condom use. (n = 76) Articles excluded after Contraceptive use full-text review (n = 44) because: 25,26 Not a developing country (n = 3) Two studies examined the effect of Not an intervention (n = 5) HIV counselling and testing on contra- Not a behavioural intervention (n = 1) ceptive use, stratified by serostatus. Both No pre/post or multi-arm comparisons (n = 24) HIV-negative participants only (n = 3) studies were conducted by the same re- Results not stratified by serostatus (n = 8) search team among women attending antenatal and paediatric clinics in Rwanda. Both showed a limited effect of HIV test- Articles retained and coded ing on contraceptive use. In the first study, as background material (n = 14) HIV+ women showed less hormonal Articles included in review (n = 18); contraceptive use over time from baseline Studies reported in those articles (n = 19) to the 12-month follow-up assessment, while HIV− women showed no change in HIV, human immunodeficiency virus. hormonal contraceptive use over time.25 a “Positive prevention” denotes preventive interventions that target HIV+ individuals. In the second study, HIV+ women were significantly more likely to be using sper- crete effect sizes for condom use.34,36–40,42 studies (n = 312) show a very strong and micides than HIV− women.26 Pooled, these data show a strong and highly significant intervention effect on significant effect on condom use (OR: condom use (OR: 67.38; 95% CI: 36.17– Interventions targeting HIV+ 7.84; 95% CI: 2.82–21.79) (Fig. 5). The 125.52). The Q statistic of 0.96 showed individuals Q statistic of 141.45 showed statistically no statistically significant heterogeneity significant heterogeneity (P = 0.0001; (P = 0.62; I2 = 0.000) across these three Ten studies addressed our second objec- 2 I = 95.76). studies. Meta-analysis results for condom tive: 5 with HIV+ heterosexual adults Condom use results were also strati- and 5 with HIV-serodiscordant cou- use across these two population groups 33–42 fied by target population. Four studies were significantly different P( = 0.002). ples. All of the latter studies evaluated measured condom use following counsel- HIV counselling and testing interven- ling and group education among HIV+ Multiple sex partners tions. Studies with HIV+ heterosexual heterosexual adults.36–38,40 Pooled data adults all evaluated counselling and group Two studies examined the effect of educa- from these studies (n = 1489) show a education interventions, although 2 also tion and counselling among HIV+ het- 36,40 trend towards increased condom use as- included HIV care and treatment. sociated with the intervention, but this erosexual adults on the outcome “multiple For this objective, three outcomes were trend did not reach significance (OR: sex partners”, and both suggested a positive 38,40 measured across multiple studies: con- 2.08; 95% CI: 0.93–4.62; P = 0.074). The although modest intervention effect. dom use, multiple sex partners and HIV Q statistic of 40.56 showed statistically In Zambia, the percentage of participants disclosure. significant heterogeneity (P = 0.0001; reporting sexual activity with non-primary I2 = 92.60). Three studies measured partners decreased from 2% at baseline Condom use condom use following HIV counselling to 0.04% at 6- and 12-month follow-up Seven studies with a combined study and testing among HIV-serodiscordant assessments (significance not reported).38 population of 1801 generated seven dis- couples.34,39,42 Pooled data from these In the United Republic of Tanzania, the

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trolled trials. Instead, we employed broad Fig. 3. Meta-analysis of condom use among HIV positive individuals following a behavioural intervention study design criteria to capture a range of effectiveness data. Given the lack of rigorous trials conducted in developing coun- Study name Odds ratio and 95% CI Odds Lower Upper tries, this strategy allowed us to include ratio limit limit more available intervention evaluation Allen, Serufilira et al. 1992 4.800 2.822 8.164 data. However, this approach also in- Farquhar et al. 2004 6.500 0.769 54.935 creases the risk of bias. In particular, self- VCT Efficacy Group 2000 - Individual men 2.480 1.068 5.758 VCT Efficacy Group 2000 - Individual women 3.031 1.854 4.955 selection bias and self-reporting bias may VCT Efficacy Group 2000 - Couple men 5.541 0.455 67.491 have compromised results, as only four VCT Efficacy Group 2000 - Couple women 5.323 0.237 119.479 studies randomly assigned participants Combined estimate (random effects) 3.608 2.612 4.985 to the intervention, and most outcomes 0.01 0.1 1 10 100 Decreased Increased were based on self-reporting. Studies condom use condom use scored an average of only 3.9 out of 8 CI, confidence interval; VCT, voluntary counselling and testing. possible points for study design rigour. Limitations of the available evidence percent of participants reporting sexual adults. Combined, these interventions base suggest that future research should activity with non-primary partners de- showed a positive effect on condom use, use more rigorous designs and measure creased from 31.8% at baseline to 21.4% but this effect was strikingly larger among biological outcomes when appropriate. at the 3-month and 18.2% at the 6-month serodiscordant couples. Together, these Nevertheless, although we employed follow-up assessment (baseline to 3-month findings suggest that positive prevention broad study design inclusion criteria, we follow-up, not significant; baseline to interventions are effective at changing still required studies to be published in 6-month follow-up, P = 0.05).40 behaviour in developing country settings peer-reviewed journals. While our experi- and should be expanded. ence has shown that unpublished studies HIV status disclosure These results are consistent with and programme reports tend to be of Two studies examined disclosure of HIV those found in the broader literature from lower methodological quality, there may status as an outcome.40,42 Both evaluated both developing and developed country be innovative or well designed studies in counselling and education interventions settings. Several previous systematic re- the grey literature that were not included with HIV+ heterosexual adults, and both views of voluntary HIV counselling and as evidence in this review. measured disclosure before and after the testing also suggest that such interven- We were also limited by the lack of intervention. Both found a significant in- tions have the strongest impact on behav- consistency of outcome measures across crease in HIV status disclosure following iour change among HIV+ individuals and studies and were only able to meta-analyse the intervention. In the United Republic serodiscordant couples.20,43–45 Our finding results for condom use, which is only one of Tanzania, HIV status disclosure to that interventions targeting people liv- of many behaviours for the prevention of anyone increased from 18.8% at baseline ing with HIV in developing countries HIV infection. In addition, our condom to 84.4% at the 12-month follow-up are generally effective is consistent with use measure does not fully capture the (P < 0.05).40 In China, HIV status dis- findings from three previous systematic variety of sexual behaviours, such as oral closure to spouses increased from 3.6% at reviews covering interventions conducted sex and mutual masturbation, which may 14–16 baseline to 11.9% at follow-up (P = 0.04), primarily in the United States. pose significantly less risk when engaged but rates remained low.42 The results of this review should be in without a condom. Although meta- viewed in the light of its limitations. Un- analysis provides a succinct summary Discussion like other systematic reviews of positive of results from diverse studies, the need prevention interventions based almost to standardize outcome measures can Of the 19 studies included in our review, entirely in the United States,14,16 we chose obscure nuances in actual levels of risk 9 targeted both HIV+ and HIV− indi- not to limit our inclusion criteria to con- across studies and respondents. viduals and stratified results by serostatus. Almost all were HIV counselling and Fig. 4. Meta-analysis of condom use among HIV negative individuals following a testing interventions which can more behavioural intervention easily report results by serostatus than

other behavioral interventions. Meta- Study name Odds ratio and 95% CI analysis, though based on limited data, Odds Lower Upper suggests that such interventions may ratio limit limit have a stronger impact on condom use Allen, Serufilira et al. 1992 2.400 1.623 3.550 Farquhar et al. 2004 0.200 0.091 0.437 among HIV+ participants than among VCT Efficacy Group 2000 - Individual men 1.940 1.322 2.848 HIV− participants. The remaining 10 VCT Efficacy Group 2000 - Individual women 1.930 1.166 3.195 studies evaluated behavioural interven- VCT Efficacy Group 2000 - Couple men 1.457 0.683 3.108 tions specifically targeting people living VCT Efficacy Group 2000 - Couple women 1.387 0.854 2.253 Combined estimate (random effects) 1.321 0.771 2.262 with HIV, which were evenly divided 0.01 0.1 1 10 100 between HIV counselling and testing for Decreased Increased HIV-serodiscordant couples and group condom use condom use counselling and education for HIV+ CI, confidence interval; VCT, voluntary counselling and testing.

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tries, routine medical visits will provide Fig. 5. Meta-analysis of condom use in studies of positive preventiona interventions one practical setting for prevention among such individuals, as they have con- Study name Odds ratio and 95% CI sistent contact with providers. However, Odds Lower Upper ratio limit limit in most developing country settings, ART Allen, Tice et al. 1992 37.923 8.468 169.827 is not initiated until a patient’s CD4+ Bunnell et al. 2006 2.424 1.962 2.995 lymphocyte count drops below 200 cells/ da Silveira et al. 2006 0.999 0.633 1.579 46 Jones et al. 2006 0.789 0.224 2.783 µl. A large number of HIV+ individuals Kamenga et al. 1991 67.500 29.959 152.081 do not meet this criterion and therefore MacNeil et al. 1999 6.590 4.388 9.899 have minimal interaction with the health Yang et al. 2001 101.106 28.482 358.907 system during the infection’s long latency Combined estimate (random effects) 7.838 2.820 21.786 period. Community-based interventions 0.01 0.1 1 10 100 Decreased Increased are needed to reach HIV+ individuals condom use condom use in developing countries who know their CI, confidence interval. serostatus but are not regularly accessing a “Positive prevention” denotes preventive interventions that target HIV+ individuals. medical care. Such interventions also offer the opportunity for involvement The studies included in our review the studies in our database either did not and leadership by people living with were conducted among a relatively nar- target HIV+ individuals or did not assess HIV. Although current interventions are row range of target populations. Almost the serostatus of participants. promising they have the potential to be all targeted general adult populations, Our conceptual model for positive much more effective if designed and led HIV-serodiscordant couples or general prevention is comprehensive; it covers a by people living with HIV themselves. populations of HIV+ adults; only one broad range of interventions designed to This review included interventions con- study was conducted with commercial keep people living with HIV physically ducted in community settings, but few sex workers. Because we had limited or and mentally healthy, prevent HIV trans- such interventions were identified; the no data on high-risk populations such as mission to other people and increase the lack of existing literature in this area lim- commercial sex workers, injection drug involvement of HIV+ individuals in pre- its the usefulness of the review findings. users and men who have sex with men, we vention activities. Previous World Health Finally, although great strides have been were unable to stratify our results by these Organization (WHO) guidelines for es- made in increasing access to HIV testing, important populations, and it is unclear to sential prevention and care interventions the majority of people living with HIV what extent the results can be generalized for HIV+ individuals in resource-limited in developing countries remain untested to them. Further research into positive settings have been similarly comprehen- and unaware of their serostatus. Interven- preventive interventions with such popu- sive, although focused on interventions tions must continue to encourage HIV lations is warranted for both ethical and in the health sector.13 While recognizing testing and counselling, especially within epidemiological reasons. First, they are of- that not all interventions will be needed couples, as HIV serodiscordance is com- ten at highest risk for both HIV infection or equally appropriate in all countries, mon4 and rates of HIV status disclosure and its negative health consequences in the WHO guidelines recommend 13 to sexual partners are low.5 both generalized and concentrated HIV biomedical and behavioural interven- In conclusion, behavioural interven- epidemics, and they are often underserved tions seen as low in cost and of particular tions targeting HIV+ individuals in de- by HIV prevention interventions. In ad- importance for people living with HIV.13 veloping countries appear to be effective, dition, sex workers can easily be infected The behavioural interventions identified especially among HIV-serodiscordant with HIV by clients and then transmit in this review did not cover the full spec- couples. These findings have several pub- it to their partners, offspring and other trum of possible behavioural interven- lic health implications. First, the global clients. Similarly, injection drug users can tions for the prevention of HIV infection, expansion of HIV testing and treatment transmit HIV infection to both sex and and they were rarely linked with biomedi- programmes provides a mechanism for drug-sharing partners. cal interventions such as the provision of both identifying such individuals and In addition, the 19 studies included ART.More comprehensive programming providing HIV prevention messages and in this review represent a relatively nar- will be necessary to reduce the spread services targeted towards them. Efforts row range of interventions: 14 HIV of HIV and achieve the WHO/Joint should be made to integrate HIV preven- counselling and testing interventions United Nations Programme on HIV/ tion messages and services into HIV care and 5 group education and counselling AIDS (UNAIDS) goal of universal ac- and treatment settings as well as HIV interventions for HIV+ individuals. We cess to comprehensive HIV prevention, testing and counselling programmes. found no articles – even in our larger treatment , care and support for people Moreover, because many HIV+ individu- database of 84 articles from previous living with HIV by 2010.13 als have limited contact with health care systematic reviews of HIV behavioural in- Behavioural and biomedical inter- settings, community-based programmes terventions in developing countries – that ventions for HIV+ prevention can be should also provide HIV prevention mes- evaluated interventions such as needle/ conducted either as part of routine HIV sages and services to them. Community syringe exchange programmes, condom care and treatment in medical settings or and clinic-based programmes should be social marketing, peer education or mass in community-based settings. As ART linked to provide comprehensive care to media campaigns or other environmen- treatment for HIV+ individuals becomes people living with HIV. Comprehensive tal/structural interventions. In general, increasingly available in developing coun- positive prevention programmes should

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focus not only on preventing transmission Acknowledgements States National Institute of Mental of HIV but also on maintaining the physi- The authors thank Sidney Callahan, Lisa Health. The content is solely the re- cal and mental health and the dignity Fiol Powers, Alexandra Melby, Marta sponsibility of the authors and does not of the individual. Although this review Mulawa, Erica Rosser and Lauren Tingey necessarily represent the official views of focused on behavioural interventions, for their assistance with coding and Elena the National Institute of Mental Health a full set of behavioural and biomedical Tuerk for her coordination of the project. or the National Institutes of Health. interventions should be implemented to stem the spread of HIV and improve Funding: The project described here was Competing interests: None declared. the health and quality of life of HIV+ supported by WHO and by award num- individuals in developing countries. ■ ber R01MH071204 from the United

امللخص فعالية التدخالت السلوكية الوقائية اإليجابية الخاصة بفريوس العوز املناعي البرشي )فريوس اإليدز( يف البلدان النامية: مراجعة منهجية وتحليل تلوي الغرض تقييم ّالبينات الخاصة بفروق تأثري التدخالت الوقائية اإليجابية بني )نسبة األرجحية 7.84؛ فاصلة الثقة %95 2.82 – 21.79(، وكان التأثري أقوى املصابني وغري املصابني بفريوس اإليدز يف البلدان النامية، وتقييم فعالية عىلوجه الخصوص بني الزوجني املختلفني يف الحالة املصلية )نسبة األرجحية: التدخالت التي استهدفت املعايشني لفريوس اإليدز. 67.38؛ فاصلة الثقة %95: 36.17 – 125.52(. وكانت التدخالت املدرجة الطريقة أجرى الباحثون مراجعة منهجية ًوتحليال تلوياً للبحوث الخاصة يف هذه املراجعة محصورة النطاق )أكرثها كانت التدخالت الخاصة مبشورة بالتدخالت السلوكية الوقائية اإليجابية يف البلدان النامية والتي ُنرشت خالل واختبار فريوس اإليدز( ومحصورة يف الفئات السكانية املستهدفة )أكرثها الفرتة من كانون الثاين/يناير 1990 وكانون األول/ديسمرب 2006. واستخدم أجريت بني البالغني املشتهني للجنس املغاير أو األزواج املختلفني يف الحالة الباحثون طرقا ًمعيارية للبحث واستخالص املعطيات، وحسبوا أحجام التأثري املصلية(. الجامعي باستخدام مناذج التأثريات املعشاة. االستنتاج تشري ّالبينات الحالية إىل أن التدخالت التي تستهدف املعايشني املوجودات تالءمت تسع عرشة دراسة مع خصائص اإلدراج يف املراجعة. ويف لفريوس اإليدز يف البلدان النامية أدت إىل زيادة استخدام العازل الذكري، التحليل التلوي كان للتدخالت السلوكية تأثري أقوى عىل استخدام العازل والسيام بني األزواج املختلفني يف الحالة املصلية. وهناك حاجة إىل التدخالت الذكري بني اإليجابيني لفريوس اإليدز )نسبة األرجحية: 3.61؛ وفاصلة الثقة الوقائية اإليجابية الشاملة التي تستهدف مختلف الفئات السكانية وتغطي %95: 2.61 – 4.99( مقارنة بالسلبيني لفريوس اإليدز )نسبة األرجحية: 1.32؛ ًمجاالمن األمناط الوقائية للحفاظ عىل الصحة البدنية والنفسية لإليجابيني فاصلة الثقة %95: 0.77 – 2.26(. كام أظهرت التدخالت التي استهدفت عىل لفريوس اإليدز، ومنع انتقال العدوى بالفريوس، وزيادة نشاط ومشاركة وجه الخصوص اإليجابيني للفريوس تأثرياً إيجابيا ًعىل استخدام العازل الذكري املعايشني للفريوس.

Résumé Interventions comportementales pour la prévention du VIH dans les pays en développement : révision systématique et méta-analyse Objectif Évaluer les éléments probatoires d’un effet différentiel des également montré un effet positif sur l’utilisation du préservatif (RC: 7,84; interventions de prévention efficaces chez les sujets infectés et non IC à 95 %: 2,82- 21,79), particulièrement élevé parmi les couples infectés par le virus de l’immunodéficience humaine (VIH) dans les pays sérodifférents (RC: 67,38; IC à 95 %: 36,17-125,52). Les interventions en développement, et évaluer l’efficacité des interventions s’adressant comprises dans cette analyse étaient limitées à la fois dans leur but (la de manière spécifique aux personnes vivant avec le VIH. plupart étaient des interventions de conseil et de dépistage du VIH) et Méthodes Nous avons conduit une révision systématique et une méta- dans leurs populations cibles (la plupart ont été réalisées auprès d’adultes analyse des articles scientifiques sur les interventions comportementales hétérosexuels ou de couples sérodifférents). de prévention efficaces dans les pays en développement publiés entre Conclusion Les preuves dont nous disposons actuellement suggèrent janvier 1990 et décembre 2006. Des méthodes standardisées de que les interventions ciblant les personnes vivant avec le VIH dans les recherche et d’abstraction de données ont été utilisées. La taille des pays en développement augmentent l’utilisation du préservatif, notamment effets globalisés a été calculée en utilisant des modèles à effets aléatoires. chez les couples sérodifférents. Des interventions de prévention positives Résultats Dix-neuf études présentaient les critères d’inclusion. D’après la complètes, ciblant des populations diverses et couvrant un éventail de méta-analyse, les interventions comportementales ont eu une plus forte modalités d’intervention, sont nécessaires pour maintenir les individus incidence sur l’utilisation du préservatif chez les individus séropositifs VIH+ en bonne santé physique et mentale, prévenir la transmission de (VIH+) (rapport de cotes, RC: 3,61 ; intervalle de confiance à 95 %, IC: l’infection à VIH et augmenter l’action et l’implication des personnes 2,61-4,99) que chez les individus séronégatifs (RC: 1,32; IC à 95 %: vivant avec le VIH. 0,77-2,26). Les interventions ciblant spécifiquement les individus VIH+ ont

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Resumen Intervenciones conductuales para la prevención del VIH en los países desarrollados: revisión sistemática y metanálisis Objetivo Evaluar los datos relacionados con el efecto diferencial de las a los individuos VIH+ también tuvieron un efecto positivo en el uso del intervenciones favorables en prevención entre individuos infectados y preservativo (OR: 7,84; CI del 95%: 2,82 - 21,79) y, en especial, entre las no infectados por el virus de la inmunodeficiencia humana (VIH) en los parejas serodiscordantes al VIH (OR: 67,38; CI del 95%: 36,17 - 125,52). países en desarrollo y evaluar la eficacia de las intervenciones dirigidas Las intervenciones incluidas en esta revisión estuvieron limitadas específicamente a las personas que conviven con el VIH. tanto por el alcance de las mismas (la mayoría eran intervenciones Métodos Se llevó a cabo una revisión sistemática y un metanálisis de de asesoramiento y pruebas del VIH) como por las poblaciones diana artículos sobre intervenciones conductuales para la prevención positiva en (la mayoría se llevaron a cabo entre adultos heterosexuales o parejas países en desarrollo, publicados entre enero de 1990 y diciembre de 2006. discordantes al VIH). Se emplearon métodos estandarizados de búsqueda y de extracción de Conclusión Los datos actuales sugieren que las intervenciones dirigidas datos. Las magnitudes de los efectos agrupados se calcularon mediante a las personas que conviven con el VIH en los países en desarrollo la utilización de modelos de efectos aleatorios. incrementan el uso del preservativo, especialmente entre parejas Resultados Diecinueve estudios cumplían los criterios de inclusión. Por serodiscordantes al VIH. Las intervenciones exhaustivas de prevención lo que respecta al metanálisis, las intervenciones conductuales tuvieron positiva dirigidas a distintas poblaciones y que abarcan varios tipos de un mayor impacto sobre el uso del preservativo entre los individuos VIH- intervenciones son necesarias para mantener la salud física y psíquica positivos (VIH+) (oportunidad relativa, OR: 3,61; intervalo de confianza de las personas VIH+, prevenir la transmisión de la infección por el VIH del 95%, CI: 2,61 - 4,99) que entre los individuos VIH-negativos (OR: y aumentar la capacidad de actuación y de implicación de las personas 1,32; CI del 95%: 0,77 - 2,26). Las intervenciones específicas dirigidas que conviven con el VIH.

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n 254) and 1 =

n 630). In addition, In addition, 630). 1 104) and at 2 =

2 n =

n Study design not reported). Unit of analysis: Unit of analysis: not reported). 414) and after intervention =

2 458), at 12 months ( 458), n =

1 502) and after intervention ( n = =

n n week (VCT, at 1 week (VCT, 836), 2060). Mean follow-up time per subject was 2060). 2 =

n Time series, no comparison arm. Assessments at no comparison arm. series, Time baseline ( at 24 months ( Participants not randomly selected. individual. comparing women who were tested Cross-sectional, for HIV individually with those tested their Participants not individual. Unit of analysis: partners. randomly selected. no comparison arm. Prospective cohort, Assessments at baseline (group education, n weeks (follow-up counselling, Unit 122 HIV+ women returned 1 week postpartum. Participants not randomly individual. of analysis: selected. Assessments at no comparison arm. series, Time baseline ( follow-up time differed by participant and Average Participants not individual. Unit of analysis: outcome. randomly selected. Assessments no comparison arm. series, Time at baseline ( ( Participants individual. Unit of analysis: 1.2 years. not randomly selected. Description 35-minute educational video and group discussion led by HIV test results and counselling physician and social worker. male sex partners At request of study subjects, 3 weeks later. attend group sessions and be tested invited to watch video, Couples could choose to receive test results together. for HIV. Condoms and spermicide distributed free. with encouragement Group education about HIV transmission, Return in 1 week, VCT. to inform male partners about HIV counselling on VCT, for optional alone or with partner, and free safe sex during pregnancy and on breastfeeding, if HIV−, condoms; return in 2 weeks for more counselling: other infant feeding breastfeeding recommended; if HIV+, along with nevirapine for both mother and options given, More counselling infant and counselling on its use at delivery. and optional infant HIV testing offered 3 6 months symptoms treated and with HIV-related Women postpartum. referred to local clinics. 35-minute educational video and group discussion led by HIV test results and counselling physician and social worker. male sex partners At request of study subjects, 3 weeks later. attend group sessions and be tested invited to watch video, Couples could choose to receive test results together. for HIV. Condoms and spermicide distributed free. 15-minute educational video in Kinyarwanda on contraceptive Oral methods and group discussion led by nurse. injectable progestins and Norplant provided contraceptives, Other contraceptive free to women enrolled in programme. methods made available to women and their partners condoms (both before and after were intrauterine devices, tubal ligation and vasectomy. intervention), Pre-test counselling in factories; subjects encouraged to visit project clinic for HIV test results and counselling 2 weeks Free STD diagnostic and treatment services after blood draw. Video on and condoms also available at project clinic. preventing HIV infection shown at all times in waiting area of project clinic.

: 18–35 : : 20–40 : : 29 : Population characteristics Population

: 100% female : 100% female : 100% female : 100% female : 100% male : range a NR : Female paediatric and antenatal care clients Gender Age Female paediatric and antenatal care clients Gender Mean age Age range attending antenatal care and their Women partners Gender Mean age (SD) 23.7 (4.4) women tested individually: women whose partners were tested; results 24.1 (4.6) received individually: women whose partners were tested; results 23.8 (4.4) received as couple: HIV+ and HIV− urban women Gender Age distribution 20–24 (4.4%) 25–29 (28.7%) 30–34 (36.7%) 35–39 (25.7%) 40–44 (4.6%) Male factory workers Gender Age Setting Kigali, Rwanda Kigali, Rwanda Kigali, Kenya Nairobi, Rwanda Kigali, Zimbabwe Harare, 29 27 25 26 28

− Studies included in systematic review of the literature on behavioural interventions for HIV positive prevention in developing countries Studies included

Table 1. Table Author and year Interventions targeting HIV+ and HIV individuals 1993 Allen et al., 1992 Allen et al., 2004 Farquhar et al., 1995 King et al., 1998 Machekano et al.,

Bull World Health Organ 2010;88:615–623 | doi:10.2471/BLT.09.068213 A

174), 174), n 1 890). 890). = =

n n 29) and at =

n 550) and at 14 20). Unit of analysis: Unit of analysis: 20). 2 =

n n Study design 31). Unit of analysis: individual. individual. Unit of analysis: 31). 001) and at 14months ( 31), at 1 month ( 31), 684 couples) and at 12 months 818 couples) and at 12 months =

1 196). Unit of analysis: individual. individual. Unit of analysis: 196). = = = n

60 couples) and at 12 months ( = 2

n n n = n

n n 120), at 7 months ( 120), 684 couples). Unit of analysis: individual and Unit of analysis: 684 couples). 3 couple. Unit of analysis: 584 couples). 20) and at 6 months ( = = = =

n n n n Time series, no comparison group. Assessments no comparison group. series, Time at baseline ( 2–5 months ( Participants not randomly selected. Assessments no comparison arm. Before/after, at baseline ( ( Participants not randomly selected. couple. Randomized controlled trial with 1 intervention Assessments at baseline and 1 control group. ( months ( Participants not randomly selected. Randomized controlled trial with 1 intervention and 1 Assessments at baseline ( control group. 7-months ( Participants not randomly individual. Unit of analysis: selected. Assessments no comparison arm. Before/after, at baseline ( ( Participants not randomly selected. Assessments at no comparison arm. Before/after, baseline ( Participants not couple. Unit of analysis: couples). randomly selected. Assessments at baseline Randomized controlled trial. ( Participants not randomly selected. individual. Description Sex workers examined, treated for existing STDs and tested Sex workers examined, Given test results and counselled in subsequent for HIV. All given free condoms and told to return clinic for visit. Free condoms treatment or condoms whenever necessary. also distributed daily in all bars included study. Male-focused counselling programme with educational video During and small group discussion. “Responsibility” entitled trained counsellor gave men their HIV test results return visit, in individual counselling session and encouraged them to share them with partners; all female partners had already been tested for HIV. VCT VCT or health information. Individuals randomized to HIV client-centred counselling (personalized risk assessment arm: role plays and condom use and risk-reduction plan, demonstrations); test results available 2 weeks after blood 15-minute video and group Health information arm: draw. discussion about HIV and condom use. VCT VCT or health information. Couples randomized to HIV client-centred counselling (personalized risk assessment arm: role plays and condom use and risk-reduction plan, demonstrations); test results available 2 weeks after blood 15-minute video and group Health information arm: draw. VCT offered at first discussion about HIV and condom use; follow-up. with free diagnosis and VCT service, Same-day couples’ condom skills training and free condoms. treatment of STDs, More counselling provided on request at 3-month intervals and when sexual contacts without protection were reported. Educational video and group discussion led by social At post-test Free condoms and spermicides offered. worker. project counsellor confidentially distributed HIV counselling, but couples encouraged to receive test results individually, them together. group counselling sessions for 6 months to initiate Weekly and sustain behaviour change provide psychological Sessions based on unified HIV/AIDS counselling support. psychoanalytical and theory combining behavioural, humanistic axioms.

: :

: 31.9 : :

Population characteristics Population : 100% female : 50% female 50% male, : 50.8% females 49.2% males, : 50% females 50% males, : 50% female 50% male, : 50% female 50% male, : NR : : NR : NR : NR : Female commercial sex workers Gender Mean age Heterosexual males in cohabitating union Gender Mean age 39 males: 32 females: individuals General population: Gender Mean age (SD) 28.9 (9.7) intervention males: 28.6 (8.6) intervention females: 28.1 (9.1) control males: 28.5 (8.8) control females: couples General population: Gender Mean age (SD) 31.5 (8.4) intervention males: 25.9 (6.6) intervention females: 32.1 (32.1) control males: 26.7 (7.4) control females: HIV serodiscordant couples Gender Age HIV serodiscordant couples Gender Age HIV+ individuals Gender Age Setting The Gambia Rwanda Kigali, Kenya; Nairobi, Dar es Salaam, United Republic of Port of Tanzania; and Trinidad Spain, Tobago Kenya; Nairobi, Dar es Salaam, United Republic of and Port Tanzania; Trinidad of Spain, Tobago and Zambia Lusaka, Rwanda Kigali, Kenya Nairobi, 30 35 33 34 31 32 32 Author and year 1993 Pickering et al., 2001 Roth et al., 2000 VCT Efficacy Group, Individuals 2000 VCT Efficacy Group, Couples Interventions targeting HIV+ individuals only 2003 Allen et al., 1992 Allen et al., 1994 Balmer et al.,

B Bull World Health Organ 2010;88:615–623 | doi:10.2471/BLT.09.068213

167 n 149 = =

= n n

n 815). Unit of 815). 335). Unit 335). =

n =

n 140 couples). Unit of 140 couples). Unit 139 couples). = = 154) and at 6 months

n n =

233) and at 12 months n =

n Study design 926) and at 6 months ( at 6 months ( 168 couples), at 18 months ( 178 couples), 90 couples) and at 12 months ( 332) and at 60 days ( = = = = =

n n n n n 240), at 6 months ( 240), Participants not individual. Unit of analysis: 166). Participants not individual. Unit of analysis: 144). = = =

n n n Before/after, no comparison arm. Assessments at no comparison arm. Before/after, baseline ( couple and aggregated cohort. individual, analysis: Participants not randomly selected. Non-randomized trial with 1 intervention group and Assessments at baseline ( 1 control group. 30 days ( Participants not randomly individual. of analysis: selected. Assessments at baseline Randomized controlled trial. ( ( randomly selected. Assessments at no comparison arm. series, Time baseline ( couples) and at 18 months ( Participants not randomly selected. couple. analysis: Randomized control trial comparing enhanced programme with standard health services. Assessments at baseline ( ( randomly selected. Assessments at no comparison arm. series, Time baseline ( couples) and at 30 months ( Participants not individual and couple. of analysis: randomly selected. Assessments at no comparison arm. Before/after, baseline ( individual and couple. Unit of analysis: couples). Participants not randomly selected. Description ART delivered weekly at home, with referral as needed for delivered weekly at home, ART Behavioural intervention free medical and psychological care. testing of at enrolment, ART with group education on VCT and cohabitating partners through home-based family counselling on risk reduction strategies to protect HIV− Free condoms partners or those with unknown HIV status. provided on request. Educational programme with four educational modules on general health-care measures and condom use HIV infection, delivered by physician during routine medical consultation. Use of flipcharts with graphic displays to reinforce Patients could request as many main contents. intervention’s free condoms as they wished from clinic pharmacy after consultation. Three-session group educational and skills-building intervention with videos and role playing to illustrate sexual risk reduction and sexual negotiation barrier products, participants given1-month supply At each visit, strategies. of male and female condoms vaginal lubricants screened and treated for STDs vaginal infections. HIV serodiscordant couples invited to special clinic where Each couple was subsequently serostatus confirmed. first individually by counsellor of informed of HIV test results, the same sex and then together as couple by both members Couples then counselled about of the counselling team. HIV infection and condom use; followed monthly at STDs, counselling centre and given condoms a sexual activity calendar at each visit. enhanced care and support consisting At least once a month, of ongoing counselling HIV+ person on prevention and condom education of other family members, problem-solving, referral for treatment. when necessary, provision and, individually first results of informed and HIV for tested Couples by counsellor of the same sex and then together as couple; condom use and HIV-associated counselled on safe sex, and followed by monthly counselling sessions to identify risks, difficulties faced and develop corrective strategies. Couples educated at home on HIV and condom use every Emphasis on importance of other month for 12 months. consistent condom use; free condoms distributed.

: males: 41; females: 37 41; females: males: :

: 20–49 : : 29 : : 31.9 : : Population characteristics Population : 25.4% male, 74.6% female 25.4% male, : 100% female : 100% women : 50% female 50% male, : 66% female 34% male, : 50% female 50% male, : 50% female 50% male, : 50 (5.9%) HIV+ adults initiating ART HIV+ adults initiating Gender HIV+ women attending HIV outpatient clinic Gender Sexually active HIV+ women Gender HIV serodiscordant couples Gender Sexually active HIV+ adults Gender HIV serodiscordant couples Gender HIV+ individuals and their spouses Gender Median age Age distribution 15–19 (5.6%); 20–29 (41.5%); 30–39 (29.4%); 40–49 (17.6%) ≥ Mean age Mean age 32.0 39.8; females: males: F− couples: M+, 30.7 37.9; females: males: F+ couples: M−, Mean age Mean age 25.4 40.7; females: males: F− couples: M+, 31.0 38.7; females: males: F+ couples: M−, Age range Setting Tororo, Uganda Tororo, Brazil Pelotas, Zambia Lusaka, Kinshasa, Republic Democratic of the Congo United Republic of Tanzania Kinshasa, Republic Democratic of the Congo China Fuyang City, 37 39 40 36 38 41 42 Age throughout the table is expressed in years.

a AIDS, acquired immunodeficiency syndrome; ART, antiretroviral therapy; HIV, human immunodeficiency virus; NR, not reported; SD, standard deviation; STD, sexually-transmitted disease; VCT, voluntary counselling and testing. VCT, sexually-transmitted disease; standard deviation; STD, not reported; SD, human immunodeficiency virus; NR, antiretroviral therapy; HIV, ART, acquired immunodeficiency syndrome; AIDS, Author and year 2006 Bunnell et al., 2006 Da Silveira et al., 2006 Jones et al., 1991 Kamenga et al., 1999 MacNeil et al., 2000 Ryder et al., 2001 et al., Yang

Bull World Health Organ 2010;88:615–623 | doi:10.2471/BLT.09.068213 C

XSL Version: xslver | JobID: JobID | Title: journal-title | Copyright Year 2 | Volume 87 | | Issue issue | pub-date pub-date XSL Version: xslver | JobID: 09.075424 | Title: journal-title | Copyright Year 2 | Volume 87 | | Issue issue | pub-date pub-date Research HIV positive prevention: a systematic review Caitlin E Kennedy et al. 3 1 3 3 4 2 2 8 7 2 3 6 3 5 7 4 8 3 3 Final score - 1 0 1 1 1 1 NA NA NR NA NA NA NA NA NA NA NA NA NA measure on outcome Comparison groups equiva lent at baseline - 0 0 1 1 0 1 1 NA NA NA NA NA NA NA NR NA NA NA NA Comparison lent on socio- demographics groups equiva 1 0 1 0 1 1 0 1 1 1 1 1 1 1 0 1 NA NR NR 80% ≥ Follow-up - b - 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 1 1 1 0 tion of par ticipants for assessment Random selec - 0 0 0 0 0 0 1 1 0 0 1 0 0 1 0 1 0 0 NR signment of intervention Random as participants to - 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 vention data Pre/post inter - 1 1 0 0 0 0 1 1 0 1 0 1 1 0 1 0 0 0 0 Control/com parison group 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Cohort of studies included in systematic review of the literature on behavioural interventions for HIV positive prevention in developing countries of studies included a 29 37 39 30 27 40 36 35 38 41 26 25 33 42 31 28 34 individuals − 32 Quality scoring 32

individuals receiving the intervention was used for assessment, a “1” is also in the column. If a non-probability sample was used, a “0” is in the column. “0” a If a non-probability sample was used, is also in the column. “1” a individuals receiving the intervention was used for assessment, A score of 1 indicates that the article met the criterion; a score of 0 indicates that it did not. However, studies with mixed designs have been given 1 point in this table. However, A score of 1 indicates that the article met criterion; a 0 it did not. If a probability sample was used to select participants, a “1” is in the column. Similarly, if a mixed sampling strategy was used but randomization was conducted in at least one sampling frame, a “1” is in the column. If a census sample of all is in the column. “1” a if a mixed sampling strategy was used but randomization conducted in at least one frame, Similarly, is in the column. “1” a If a probability sample was used to select participants,

a b Table 2. Table NA, not applicable; NR, not reported; VCT, voluntary counselling and testing. VCT, not reported; not applicable; NR, NA, Author and year Interventions both targeting HIV+ and HIV 1993 Allen et al., 1992 Allen et al., 2004 Farquhar et al., 1995 King et al., Machekano et al.,1998 1993 Pickering et al., 2001 Roth et al., VCT Efficacy Group 2000 (individuals) VCT Efficacy Group 2000 (couples) Interventions only targeting HIV+ individuals 2003 Allen et al., Allen et al.,1992 1994 Balmer et al., 2006 Bunnell et al., 2006 Da Silveira et al., 2006 Jones et al., 1991 Kamenga et al., 1999 MacNeil et al., 2000 Ryder et al., 2001 et al., Yang

D Bull World Health Organ 2010;88:615–623 | doi:10.2471/BLT.09.068213