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 female community health worker demonstrates condom usage to a group of women in a Maasai community, Kenya.

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

Key Findings

Empowerment interventions might help support the sexual and reproductive health (SRH) and rights of women living with HIV, particularly by preventing STIs. The evidence in this review shows a potential to increase condom use and reduce incident STIs in women living with HIV through these interventions. Evidence for other outcomes such as contraceptive use, self-efficacy, and psychosocial metrics was mixed and limited by the small number of studies measuring impact on empowerment, self-efficacy, or other SRH outcomes.

This review also showed some interventions were effective and feasible when adapted from the United States to Sub-Saharan Africa (SSA).

Evidence included in this review

Twenty-one studies evaluating eleven intervention approaches met this review’s inclusion criteria. All were in the USA (thirteen) or SSA (eight). The eight SSA approaches were adapted from US intervention strategies. Sixteen of the studies were high-quality randomized controlled trial and five were trials that were either non-random or did not include a control group.

Further research

The impacts of empowerment and self-efficacy interventions need further research across a broader range of SRH and rights outcomes, measuring changes in empowerment and self-efficacy as well as the impact on distal health outcomes. Involving women living with HIV in these future studies will allow for a clearer interpretation of results to make more useful conclusions on how empowerment and self-efficacy interventions can improve their SRH. Future research should also cover structural-level interventions creating an enabling environment for women living with HIV.


Article

 

Robinson JL, Narasimhan M, Amin A, Morse S, Beres LK, Yeh PT, 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;12(8):e0180699. doi:10.1371/journal.pone.0180699

http://doi.org/10.1371/journal.pone.0180699

Abstract

Background: Many women living with HIV experience gendered power inequalities, particularly in their intimate relationships, that prevent them from achieving optimal sexual and reproductive health (SRH) and exercising their rights. We assessed the effectiveness of interventions to improve self-efficacy and empowerment of women living with HIV to make SRH decisions through a systematic review.

Methods and findings: We included peer-reviewed articles indexed in PubMed, PsycINFO, CINAHL, Embase, and Scopus published through January 3, 2017, presenting multi-arm or pre-post intervention evaluations measuring one of the following outcomes: (1) self-efficacy, empowerment, or measures of SRH decision-making ability, (2) SRH behaviors (e.g., condom use, contraceptive use), or (3) SRH outcomes (e.g., sexually transmitted infections [STIs]). Twenty-one studies evaluating 11 intervention approaches met the inclusion criteria. All were conducted in the United States or sub-Saharan Africa. Two high-quality randomized controlled trials (RCTs) showed significant decreases in incident gonorrhea and chlamydia. Sixteen studies measuring condom use generally found moderate increases associated with the intervention, including in higher-quality RCTs. Findings on contraceptive use, condom self-efficacy, and other empowerment measures (e.g., sexual communication, equitable relationship power) were mixed. Studies were limited by small sample sizes, high loss to follow-up, and high reported baseline condom use.

Conclusion: While more research is needed, the limited existing evidence suggests that these interventions may help support the SRH and rights of women living with HIV. This review particularly highlights the importance of these interventions for preventing STIs, which present a significant health burden for women living with HIV that is rarely addressed holistically. Empowerment-based interventions should be considered as part of a comprehensive package of STI and other SRH services for women living with HIV.