Effectiveness of HIV Prevention for Youth in Sub-Saharan Africa: Systematic Review and Meta-Analysis of Randomized and Nonrandomized Trials

"We undertook a systematic review, and a meta-analysis when appropriate, to assess effectiveness of interventions to reduce sexual risk behaviours, and consequent HIV infection, among young people (10-25 years) in sub-Saharan Africa."

This study attempted to assess the effectiveness of HIV-prevention interventions in changing sexual behaviour of young people through a review of randomised and nonrandomised trials of interventions in sub-Saharan Africa aiming to reduce risk behaviour. [Footnotes are removed throughout by the editor.]

Of the 28 studies included, most interventions were set in schools (12 in secondary, 3 in primary, and 1 in both primary and secondary schools). Four interventions combined school and community-level activities, whereas eight were community-based only. The majority were in urban areas (15) or in a combination of urban and rural settings (10). Duration of an intervention ranged from an hour-long reading of an illustrated book to intensive sexual health education over 3 years, combining teacher-peer activities in school with community activities and provision of youth-friendly health services. Seventeen contained elements of peer education, of which five relied solely on peer workers. In 12 interventions, teachers were included, and they were responsible for delivering all components of the intervention in six studies. Seven used media to transfer messages. "Difficulties with implementing planned activities were reportedly common and differential exposure to intervention was high."

The authors report little commonality in study design and interventions and little evidence of linear building of interventions from results of analysis. "In addition, no two studies used the same methods of analysing or reporting data, and outcome indicators very markedly diverse." As stated here, attempts to standardise indicators are available ("e.g. by the Centre for HIV Identification, Prevention and Treatment Services") but infrequently used. "The development of standardized methods and indicators does not guarantee the use thereof, and therefore organizations and evaluators should be informed and sensitized on the importance of using standardized indicators and scales."

"It is encouraging to note that taken together the evidence indicates that sex education and condom promotion activities among youth does not increase sexual activity, nor promote risky sexual behaviour. However, we could not observe large positive changes either. Youth did not significantly reduce sexual activity, and condom use at last sex only increased notably among males....This finding corresponds with other reviews, who find significant changes in knowledge and attitudes, but a small degree of risk reduction."

The cause of limited effectiveness is cited by the various studies as being poor implementation, including such factors as: reluctance of teachers and health professionals to discuss condom use with youth, as well as resource constraints and general disorganisation in schools that hamper implementation of the planned activities. "Limited effectiveness might also stem from flaws in the assumptions underlying HIV risk reduction interventions. Although the interventions varied markedly in the setting and delivery strategies they adopted, they predominantly focused on HIV/AIDS as a means of changing sexual risk behaviour. However, the existence of a direct causal link between sexual behaviour and HIV infection does not mean that the converse is true. From an ecological perspective, HIV/AIDS is only one factor among a great number of interacting factors which operate on different levels to influence sexual behaviour. Seen from an ecological viewpoint, it is quite logical that interventions focusing on knowledge or attitudes to HIV/AIDS can only result in relatively small changes in sexual behaviour."

Some studies showed higher impact on males, possibly indicating a lack of agency of females in negotiating precautions. Some studies showed that higher exposure to interventions led to higher impact on youth. "Furthermore, differences in impact according to sexual history were present in several evaluations: participants who were virgins at the time of exposure to the intervention reported higher rates of abstinence after the intervention, less sexual intercourse in the past months and higher intentions to use a condom. This highlights the importance of HIV prevention interventions for children and early adolescents."