PRB

(June 2011) What Works for Women and Girls: Evidence for HIV and AIDS Interventions synthesizes the vast research literature on program interventions (through the end of 2009) to provide clear evidence of what works and what seems most promising for women and girls that improve a range of HIV outcomes. Intended for policymakers, program managers, civil society, implementing partners, and donors, the website www.whatworksforwomen.org includes searchable findings from over 450 interventions in 90 countries and is also available as a downloadable document. What Works for Women and Girls is currently a project of the Public Health Institute. In a PRB Discuss Online, website authors Karen Hardee, Visiting Senior Fellow, PRB; Jill Gay, President, J. Gay Associates; and Melanie Croce-Galis, President, Global Artemis Consulting answered questions from participants about interventions related to HIV and AIDS programming and the evidence base needed for those designing policies and programs for women and girls.

June 28, 2011 1 pm (EDT)

Transcript of Questions and Answers

Richard Cincotta: Given the difficulties encountered developing a safe anti-HIV vaginal microbicide, and the impracticability of the female condom in societies where women have limited ability to negotiate barrier methods, what options will public health programs in sub-Saharan Africa focus on, among female clients, to reduce the risks of HIV infection?
Jill Gay: Actually, we’ve made remarkable progress on developing a safe anti-HIV vaginal microbicide, thanks to Quarraisha Abdool Karim, the South African scientist. While we do not yet have a vaginal microbicide product, huge progress has been made. And female condoms are vastly underprogrammed. Studies have shown that having access to female condoms increases condom use and that women who have access to female condoms are in a better position to negotiate condom use. We’ve found several overarching themes related to what works for women and girls, particularly that women are diverse and that programming works best when it is targeted to the specific needs of the women in question. Overall, however, we’ve found that integrating HIV programming with reproductive health services (and vice versa) or with children’s immunization/health services can be effective. Importantly, interventions that strengthen an enabling environment for women (transforming gender norms, legal norms, reducing violence, etc.) can also be effective in providing women with more agency to protect themselves from HIV infection and we have documented a number of interventions that can affect these proximate determinants.

Jeanne Humble: What is the correlation between infibulation and/or excision and the transmission of HIV and AIDS?
Jill Gay: We have not found any studies that show any correlation. However, cuts with blood that transfers blood from a person living with HIV to an HIV-negative person will bring increased risk of HIV transmission.

Maria de Bruyn: What measures would you suggest be taken to ensure that counseling on family planning/contraception that are linked to HIV services also address options in case of failed contraception? And what would you suggest the content of those messages/that information should be in different settings?
Jill Gay: Maria de Bruyn, you have done the pioneering work in this field. Our work highlights the need to meet the sexual and reproductive needs of women living with HIV as an important component for what works. This includes preventing unintended pregnancy and pre-conception counseling for women living with HIV who desire a pregnancy. It is important to note that hormonal contraception and IUDs can be effectively used by women living with HIV (provided they have access to medical care). We did find a number of gaps regarding counseling for women about emergency contraception, abortion services (where legal) and post-abortion care services (where illegal). The content of the messaging will depend on legality of emergency contraception and abortion services.

santosh kumar: The Zulu women and girls are genitally mutilated in high percentage, yet they are worst hit community by HIV infection. How genital mutilation and circumscion works in preventing from HIV spread among women and girls?
Jill Gay: Genital mutilation does not correlate with HIV transmission or acquisition unless blood is exchanged between a woman or girl who is HIV positive and a woman or girl who is HIV negative. However, genital mutilation carries grave health risks for women and girls, including sepsis, hemorrhage and death.

Trilochan Pokharel: In one of my studies, I have found that the impact of HIV and AIDS on female and children’s survival is influenced by education level of mother. This indicates several implications of social model of HIV and AIDS. How can gender power balance be integrated into HIV and AIDS intervention programme in countries where communities are not gender friendly?
Jill Gay: A number of studies have shown education to be a protective factor for women and girls. We’ve also dedicated a large section of www.whatworksforwomen.org to strengthening the enabling environment for women and girls. Some of the interventions that work best to transform gender norms are programs that encourage/facilitate peer and partner discussions as well as community education campaigns. Programs such as One Man Can in South Africa, or Program H in Brazil, or Somos Differentes, Somos Iguales in Nicaragua address gender equity through programs for men and couples have shown to be effective in enhancing couple communication and increasing HIV protective behaviors such as condom use. Even when communities do not promote gender equity, programs have shown to have an impact both on reducing HIV acquisition and transmission and to increase gender-equitable attitudes.

Stephen: What effectiveness studies on male involvement in PMTCT are available in LMIC?
Jill Gay: We know that in some societies, men are encouraged to have multiple partners while their wife/partner is pregnant, thus increasing the risk of HIV transmission. Yet in 2007, only 5% of male partners of women attending antenatal care were counseled and tested for HIV. One study in India found that involving partners, with women’s consent at ANC clinics, increased testing and disclosure, as did couple counseling in Zambia. PMTCT-Plus, or family-focused care increased the numbers of women and their male partners who access testing and treatment. Sperm washing and being on effective antiretroviral treatment can be important aspects of pre-conception planning. Numerous gaps exist on how to effectively involve men in PMTCT programs, including post-partum.

Dr. Satyajeet Nanda: A quick research methodological concern I have is “when we say what ‘works’, whom do we refer to—actually affected, expert’s or service provider’s point of view”. Since they may differ from their perspective and generalisation could be wrong.
Jill Gay: That’s a great question. Our ideal goal was to identify interventions that actually reduced HIV among women and girls and we worked closely with an advisory committee to determine what interventions qualified for “what works,” what were “promising,” and where the gaps were. www.whatworksforwomen.org; has a section on methodology explaining what we did and the reviewers and also listed in the acknowledgments. While we were looking for changes in HIV prevalence or incidence, those are not the only outcomes of interest for HIV programming, for example, for programming related to care and support. We focused on interventions that effected a behavior change (as opposed to a change in knowledge or attitudes). So for example, in prevention we identified interventions that demonstrated behavior change such as (self-reported) partner reduction or increased condom use that we know can reduce one’s risk for HIV infection. We also included outcomes for providers, for example, decreased stigma and discrimination against patients living with HIV due to provider training). Methodologically-speaking, it’s also important to note that this review looked for interventions with demonstrated effect and created the intervention list from there, based on a full review of the evidence. We did not do the reverse and identify a number of interventions and then seek studies to back them up. Therefore, we can say that these interventions “work” because they have had a demonstrated effect on behavior change in a number of countries/populations. We’ve also identified a number of “promising” interventions t hat have shown evidence of effect, but perhaps in fewer geographic regions or through studies that were less robust. When we talk about What Works we are referring to specific outcomes – but these can be outcomes for those affected (lower incidence of HIV; increased ability to negotiate safer sex) or providers (decreased stigma and discrimination against patients living with HIV due to provider training). When “promising” includes expert opinion, this is noted with a Gray V – based on expert opinion.

Sizarina Hamisi: What really works for women and girls in Kenya and Tanzania in regards to HIV/AIDS intervention?
Jill Gay: While you can search www.whatworksforwomen.orgfor studies specifically conducted with women in Kenya and Tanzania, many of the interventions apply to women in Kenya and Tanzania – from protecting property rights to changing gender norms to Safe Motherhood. However, we found 28 “what works” and 15 “promising” studies in Kenya and for Tanzania 17 “what works” and 13 “promising,” all on a variety of topics.

Dr. Yasmin Siddiqua: In Bangladesh, HIV interventions includes information dissemination to general population and condom promotion for high risk group. Women and girls, in Bangladesh, having low negotiation skill, and lack of empowerment, are not the decision maker of thier own health and well being. Many surveys have found high level of awareness regarding HIV related issues, yet, low level of practice due to their low status in the family and limited spousal communication. Combined with different myths and misbeliefs, it might be difficult in Bangladesh to empower women with knowledge and practice in a short time span. Based on the review of different intervention, please share with us the best practice in reaching women and girls, in a conservative society, to transfer their knowledge into practice. If condom can be made widely available, even then proper way of using condom can be a barrier for HIV prevention. Please shed light in this regard also.
Jill Gay: Changing the enabling environment to increase gender equality, establish legal rights for women, reduce violence against women, increase women’s opportunities to earn a livelihood or access income, and increasing educational opportunities for girls are all critical to “transfering knowledge into practice.” In addition, access to female condoms so that when men refuse to use male condoms has been shown to increase the numbers of protected sex acts. Community, peer and partner discussions have helped women to be more empowered. In terms of condom negotiation skills, a number of training programs are useful, for example, Stepping Stones (available on the Strategies for Hope website) and ISOFI (available on www.icrw.org). These interventions can be implemented at different paces within different contexts.

Dr. Yasmin Siddiqua: I have another question. Whom are we considering girls in this discussion? Are they early adolescents, late adolescents, young girls, married or unmaried, in school or out of school? For each such segment, the intervention supposed to be different. Please discuss little on this.
Jill Gay: What Works discusses effective interventions for married and unmarried girls, girls in and out of school, young adolescents and older adolescents. For very young children, sexuality education is also important but will have a different content than for sexually active married or unmarried adolescents. Sexuality education is effective for all girls, boys and adolescents. Another important segment of young girls are orphans and vulnerable children. Young girl orphans are more likely to be sexually active and have other risk factors for acquisition of HIV and need to be a focus of effective interventions.

Dr. Anima Sharma: Dear Coordinators, The issue of Gender is deeply embedded with the surrounding issue of HIV/AIDS, especially in the countries where women are treated as the subordinates and where socio-cultural milieu does not provide enough protection to them. Though, in the case of HIV/AIDS stigma attached with the disease does not spare the males too but the girls and women face more adversicties because of the family and local power system. Hence, I suggest that multi-pronged intervention taking into account all the dimensions. My personal experience has been that by provicative methods we are not going to achieve anything rather we should adopt passive and silent methods. I am saying this because more we advocate for the empowerment of women, more anti- women cells (or cells for men) start emerging up and it creates a war like situation…and I am sure nobody wants to live and grow their children in an antoginistic home environment. Hence. medical intervention, counselling, advocacy and mild campaigns involving men too should go on simultaneously. Please correct me wherever you find discrepencies in my write-up. Thanks.
Jill Gay: The evidence has shown that carefully designed programs to increase gender equity, such as Progam H in Brazil by Promundo and PATH, and the One Man Can Campaign by Sonke Gender Justice in South Africa can both increase gender equity and increase the numbers of people practicing safer sex and reduce HIV acquisition. You will find these studies on www.whatworksforwomen.org and then find their materials on their websites and decide for yourself if you think they are provocative or if these materials could be adapted for your context.

Meskerem Bekele, Ethiopia: I think there is more improvement in women’s and girl’s life today than yesterday. Especially when we talk about HIV/AIDS. But still there is a gap. I think women couldn’t protect themselves from each societal influence. Many of them couldn’t say “no” for unsafe sex. I discussed with many women and girls who have doubt about their husband or boyfriend who has affair with other women and girls. But they couldn’t say “no sex’ or “we must use condom” How can the law protect these kinds of women or girls? Yes, some men involve in women’s and girl’s life to improve them in every aspect of their life. But sometimes most of them consider themselves as though they are almighty and could nothing happen without their permission and their mercy. How can balance and show it is their responsibility and obligation to work with women and girls?
Jill Gay: Yes, there have been some improvements in women’s lives related to HIV, although much remains to still accomplish. Empowering women legally can have a positive effect in reducing HIV transmission. For example, ensuring that widows have access to property rights will reduce the risk that widows are forced to engage in survival sex. Some programs have been shown to be very effective in working with male partners, such as the One Man Can Campaign of Sonke Gender Justice and Program H in Brazil. In addition, access to female condoms will increase the total number of protected sex acts, as access to female condoms can be one tool for condom negotiation for safer sex.

Ryan: AIDS and HIV have been in the local news in Washington, DC a lot recently because of a rise in the number of those infected here. Can you talk about AIDS and HIV rates in other cities and whether funding and treatment programs have begun to decline in recent years?
Jill Gay: Our work is focused on developing countries, where funding levels for HIV vary by country. Certainly the topic of global funding for AIDS is at the forefront. Kaiser has done a study recently for the US which is on their website that provides all the details on both US funding levels and global funding levels.

Tanya Medrano: What does the existing evidence tell us about the gender-related vulnerabilities of orphans and other vulnerable children (OVC) and the best approaches for addressing those vulnerabilities in the context of community-based Care and Support programs?
Jill Gay: Yes, boys and girls do face diffirent physical and psychological vulnerabilities, and share some in common. Both physical and psychosocial support is critical and OVC need programming that responds to their needs as children, adolescents and teen. Girls and boys often received differentiated care based on gender norms favoring boys. Girls are at particular risk of HIV acquistion, including through early sexual activity. While treatment for adults can reduce the number of OVC, support for caregivers is critical and women need additional support to provide care for orphans. Interventions should start early. Family counseling and psychosocial counseling could provide needed support. There are a number of gaps in programming for OVC, ranging from enhancing male envolvement in OVC care, keeping girls in school, and helping OVC who are living with HIV to access needed treatment and access to sexual and reproductive health services.