Empowering Women with HIV Should Be Part of Comprehensive HIV Care

Empowerment interventions for women living with HIV can help decrease acquisition of other sexually transmitted infections (STIs), and improve condom use, according to the first systematic review on the topic.¹

Results suggest that empowerment around safer sex and reproductive decision-making should be part of comprehensive care plans for women living with HIV.

The study was published online on August 24, 2017 in PLoS One.

“All women living with HIV must be supported in their voluntary choices around sexual relationships and be given information and resources to engage in safe, enjoyable sexual experiences, or to not engage in sex based on their personal preference, with counselling and support tailored to their decision-making, desires and needs,” wrote first author Jennifer Robinson, MD, MPH, of the Johns Hopkins Bloomberg School of Public Health (Baltimore, MD), and colleagues.

Women living with HIV often experience gender power inequalities that can interfere with their ability to have their needs met regarding sexual and reproductive health (SRH). Unequal control over and access to economic resources, unequal relationship power, and limited ability to make sexual decisions may increase risks to women’s SRH.

Interventions designed to improve self-efficacy, autonomy, and empowerment of women living with HIV may improve their SRH, but how well they work as a whole remains an open question.

To evaluate the issue, researchers searched five databases from inception through January 2017, for studies that assessed the effectiveness of interventions designed to improve self-efficacy, empowerment, SRH decision-making ability, SRH behaviors (condom use, contraceptive use), and SRH outcomes (STI acquisition) among women with HIV. The analysis included 21 studies (including 16 RCTs) that evaluated 11 interventions, all of which took place in the US (n=13) or sub-Saharan Africa (n=8). Studies included women aged 10-25+ years, as well as high risk populations like female sex workers, women who use drugs, women in prisons, and transgender women.

Interventions were often delivered in small groups or one-on-one, and commonly included motivational interviewing, or cognitive behavioral components.

Key Results:

• Decreased incidence of STIs: Two high quality RCTs showed significantly decreased incidence of gonorrhea and chlamydia
• Moderately improved condom use: 16 studies (12 RCTs, 4 other designs) suggested moderately increased condom use
• Mixed results on contraceptive use, condom self-efficacy, and other empowerment measures (sexual communication, equitable relationship power)

The authors highlighted results suggesting empowerment interventions may increase condom use and decrease incident STIs. This is important because certain STIs may facilitate transmission of HIV and/or increase the risk of some cancers, they stressed.

They also emphasized the need for larger changes to cultural norms, laws and institutions that maintain gender inequalities. Promoting environments in which women can exercise more control over their own SRH is likely to be challenging, but such changes may have significant impact, they wrote.

“Supporting women living with HIV in all their diversity to achieve their sexual and reproductive health and rights in all epidemic contexts requires overcoming major barriers to service uptake such as social exclusion and marginalization, criminalization, stigma, and gender inequality. Addressing unequal gender and power relations and empowering women living with HIV may be one part of a comprehensive approach to achieve these goals,” the authors stressed.

They noted several limitations. Studies had small sample sizes, high loss to followup and high reported baseline condom use. Only a few studies assessed SRH outcomes, empowerment and self-efficacy, making it difficult to know the impact of empowerment interventions on these variables. Moreover, studies on condom use had a wide range of methods, precluding meta-analysis. Many studies did not include transgender women.

Take Home Points

• Empowerment interventions for women living with HIV can help decrease acquisition of other sexually transmitted infections (STIs), and improve condom use, according to the first systematic review on the topic
• Empowerment around safer sex and reproductive decision-making should be part of comprehensive care plans for women living with HIV
• Interventions are need that promote larger change, build environments in which women can exercise more control over their own SRH, and alter cultural norms, laws and institutions that maintain gender inequalities

References:

Robinson JL, Narasimhan M, Amin A, et al. Interventions to address unequal gender and power relations and improve self-efficacy and empowerment for sexual and reproductive health decision-making for women living with HIV: A systematic review. PLoS One. 2017 Aug 24;12(8):e0180699. doi: 10.1371/journal.pone.0180699. eCollection 2017