HIV Prevention in Young People in Sub-Saharan Africa: A Systematic Review

This 103-page report examines the use of a methodology known as the Steady, Ready, Go! approach, wherein different types of HIV interventions for young people in different settings are systematically reviewed alongside each other and graded for their effectiveness. The overall goal of this report is to demonstrate how Steady, Ready, Go! has been used to systematically review and update the evidence for the effectiveness of HIV/AIDS prevention interventions in young people in sub-Saharan Africa (SSA).

As detailed here, from 2004-2006, the Department of Child and Adolescent Health and Development of the World Health Organization (WHO) collaborated with the London School of Hygiene & Tropical Medicine to lead a series of systematic reviews of interventions to prevent HIV among young people in developing countries that were completed or published between 1990 and June 2005. These reviews used Steady, Ready, Go!, the major focus of which is to use the implications of the results to generate clear recommendations for policies and programming. This report presents an update of the first Steady, Ready, Go! review, adding evaluations of interventions in SSA in schools, health services, or geographically defined communities with results released between January 2005 and December 2008.

An initial screening of nearly 1,200 citations resulted in 23 studies which met the criteria for inclusion. According to the evaluators, this relatively large number of studies reported in the recent 4-year period reflects an increasing recognition of the importance of HIV prevention among young people, and the need for studies to assess the effectiveness of interventions that aim to achieve that.

In short, a systematic review of evidence (1990-2008) on the effectiveness of interventions in SSA to reduce risky sexual behaviours and pregnancy, HIV, and other STIs among youth found that, despite 19 years of research, there is still insufficient evidence to recommend widescale implementation of the majority of the types of interventions that have been considered:

• Go: Sufficient evidence exists to recommend widespread large-scale implementation of in-school interventions that are adult-led and curriculum-based.
• Ready: Evidence exists to suggest that the following interventions are effective, but that large-scale implementation must be accompanied by further monitoring and evaluation: i) interventions in health facilities that train service providers and take actions to make the facility more youth-friendly, coupled with activities in the community (with or without involvement of other sectors to link or refer young people to health services); and ii) community interventions involving the whole community, using either traditional networks or community-wide activities for intervention delivery.
• Steady: More research and development is still needed for in-school interventions that are peer-led and non-curriculum based, health facility interventions that do not also involve actions in the clinic and activities in the community, and community interventions that reach out to youth only.

More specifically,

• Interventions in schools were largely successful at demonstrating improvements in reported sexual risk behaviours and other mediating factors. Overall, in-school interventions are a logical and promising means to impart necessary information and skills to schoolgoing young people. However, evidence from the 2 recent trials that included an assessment of the impact of schools-based interventions on biological outcomes suggests that such interventions may not be sufficient to reduce the risk of HIV, other sexually transmitted infections (STIs), or early pregnancies. Evaluators recommend curriculum-based, adult-led interventions that include the "Kirby characteristics" (see Appendix B), with or without the involvement of peers.
• Evidence on the most appropriate way to deliver health care to young people in order to maximise their access to, and appropriate use of, such services remains incomplete. Evaluators recommend that interventions in health facilities include interventions which train service providers and take actions to make the facility more youth-friendly, coupled with activities in the community, with or without involvement of other sectors to link or refer young people to health services.
• Interventions in geographically defined communities are generally the most difficult to evaluate. "Interestingly, the results of the recently reported studies in this setting tended to differ from those of the earlier studies reviewed in the 2006 Steady, Ready, Go! series. Our updated review demonstrated that intervention types which target the community as a whole, rather than just young people, were more effective at improving reported sexual risk behaviour and impacting biological outcomes, which suggests that it may be important to explore interventions to change the social and sexual norms within the wider community. This highlights the difficulty in disentangling the important elements of community-based interventions and the possibility that the exact nature of the interventions used and the context may be particularly important for interventions in this setting." Evaluators recommend interventions that reach out to the community using either traditional networks or community-wide activities for intervention delivery.
• Five interventions used biologically measured outcomes to assess HIV, STIs, and/or pregnancy; they are described here. In short, studies with biological outcomes, especially HIV itself, are described here as particularly important for several reasons. First, the primary objective of most of these interventions (and of this review) was HIV prevention, so it is important to evaluate that as a primary outcome. Second, many studies have demonstrated that reporting of sexual behaviour is problematic and potentially unreliable/invalid, especially among young people. "Evidence from this review reinforces the widely held belief that knowledge alone is not enough to facilitate behaviour change, and reported sexual behaviour is an unreliable proxy for HIV and other STIs. It is therefore recommended that in future research, whenever possible, HIV or at the least other biological markers of sexual activity be measured."

The evaluators assert that "a one-size-fits-all intervention is unlikely to be the most effective approach, and careful evaluation of local risk factors and context is necessary to determine the optimal intervention. There is a growing consensus that to achieve HIV prevention in young people it is necessary to provide a range of tools and address a number of barriers, and to accomplish this it is necessary to implement interventions in different settings simultaneously, and thus have the capacity to promote change using different approaches on a number of levels."