RESEARCHARTICLE

Interventionstoaddressunequalgendera
nd powerrelationsandimproveself-efficacyand empowermentforsexualandreproductive healthdecision-makingforwomenlivingwith

HIV:Asystematicreview

JenniferL.Robinson1,ManjulaaNarasimhan2,AvniAmin2,SophieMorse3,Lau
ra
a1111111111 K.Beres1,PingTeresaYeh1,CaitlinElizabethKennedy1*
a1111111111
a1111111111 1 DepartmentofInternationalHealth,JohnsHopkinsBloombergSchoolofPublicHealth,Baltimore,
a1111111111 Maryland,UnitedStatesofAmerica, 2 DepartmentofReproductiveHealthandResearch,WorldHealth
Organization,Geneva,Switzerland, 3
DepartmentofHealthPolicyandManagement,JohnsHopkins
a1111111111 BloombergSchoolofPublicHealth,Baltimore,Maryland,UnitedStatesofAmerica
caitlinkennedy@jhu.edu

OPEN ACCESS Abstract

Citation: RobinsonJL,NarasimhanM,AminA,
MorseS,BeresLK,YehPT,etal.(2017)
Interventionstoaddressunequalgenderand
powerrelationsandimproveself-efficacyand Background
empowermentforsexualandreproductivehealth
decision-makingforwomenlivingwithHIV:A
ManywomenlivingwithHIVexperiencegenderedpowerinequalities,particularlyintheir
systematicreview.PLoSONE12(8):e0180699.
intimaterelationships,thatpreventthemfromachievingoptimalsexualandreproductive
https://doi.org/10.1371/journal.pone.0180699
health(SRH)andexercisingtheirrights.Weassessedtheeffectivenessofinterventionsto
Editor: PeterANewman,UniversityofToronto,improveself-
efficacyandempowermentofwomenlivingwithHIVtomakeSRHdecisions
CANADA throughasystematicreview.
Received: February2,2017
Accepted: June20,2017
Published: August24,2017 Methodsandfindings
Copyright: 2017Robinsonetal.Thisisanopen Weincludedpeer-
reviewedarticlesindexedinPubMed,PsycINFO,CINAHL,Embase,and
accessarticledistributedunderthetermsofthe ScopuspublishedthroughJanuary3,2017,presentingmulti-armorpre-
postintervention
CreativeCommonsAttributionLicense ,which evaluationsmeasuringoneofthefollowingoutcomes:(1)self-
efficacy,empowerment,or
permitsunrestricteduse,distribution,and measuresofSRHdecision-makingability,
(2)SRHbehaviors(e.g.,condomuse,contracep-
reproductioninanymedium,providedtheoriginal
authorandsourcearecredited. tiveuse),or(3)SRHoutcomes(e.g.,sexuallytransmittedinfections[STIs]).Twenty-
one
DataAvailabilityStatement: Allrelevantdataare
studiesevaluating11interventionapproachesmettheinclusioncriteria.Allwereconducted
withinthepaperanditsSupportingInformation intheUnitedStatesorsub-SaharanAfrica.Twohigh-
qualityrandomizedcontrolledtrials
files. (RCTs)showedsignificantdecreasesinincidentgonorrheaandchlamydia.Sixteenstudies
Funding: ThisstudywasfundedbytheWorld
measuringcondomusegenerallyfoundmoderateincreasesassociatedwiththeinterven-
tion,includinginhigher-
HealthOrganization,DepartmentofReproductive
qualityRCTs.Findingsoncontraceptiveuse,condomself-efficacy,
HealthandResearch.WHOcommissionedthis
andotherempowermentmeasures(e.g.,sexualcommunication,equitablerelationship
reviewtoinformupdatedWHOguidelineson
sexualandreproductivehealthandrightsof
power)weremixed.Studieswerelimitedbysmallsamplesizes,highlosstofollow-up,and
highreportedbaselinecondomuse.
womenlivingwithHIV.Thefundercontributedto

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 Self-
efficacyandempowermentreview

thestudydesign,datacollection,analysis, Conclusions
interpretation,andwritingofthereview.
Whilemoreresearchisneeded,thelimitedexistingevidencesuggeststhatthesei
nterven-
Competinginterests: Theauthorshavedeclared
tionsmayhelpsupporttheSRHandrightsofwomenlivingwithHIV.Thisreviewparticularly
thatnocompetinginterestsexist.
highlightstheimportanceoftheseinterventionsforpreventingSTIs,whichpres
entasignifi-
canthealthburdenforwomenlivingwithHIVthatisrarelyaddressedholistically.
Empower- ment-
basedinterventionsshouldbeconsideredaspartofacomprehensivepackageo
fSTI andotherSRHservicesforwomenlivingwithHIV.

Introduction
Anincreasingbodyofevidencedemonstratesthewaysunequallevelsofpower
betweenmen
andwomeninintimaterelationshipspreventwomen,includingwomenlivingwi
thHIV,from
makingdecisionsregardingtheirsexualandreproductivehealth(SRH)[ 1
5 ].Genderrefers
tothesetofroles,behaviors,andnormsthataredesignatedasappropriateforwo
menand
menbysociety[ 6
].Gendercanbethecause,consequence,and/ormechanismofunequalor
hierarchicalpowerrelationsthatis,howpowerandcontrolaredistributed(un
equallyor
hierarchically)inintimaterelationships,withinthehousehold,inthecommunit
y,andin
widersocietalinstitutionsincludingallthewaytothehighestlevelsofpoliticald
ecision-mak-
ing[ 6
].Inthispaper,wefocusprimarilyonthedistributionofpowerinintimaterelatio
nships
betweenwomenandmenandwithinthehousehold.Frequently,unequalcontr
oloverand
accesstoeconomicresources,unequalrelationshippower,andlimitedabilityt
omakesexual
decisions(includingwhether,when,howoften,andwithwhomtohavesex;and
negotiating
condomuse,contraceptiveorotherprotectivepractices)makewomenvulner
abletoSRH
risks[ 7 , 8
].Genderinequalitiesandpowerimbalancesrestricttheabilityofmanywome
nliving
withHIVtomeettheirSRHneedsandexercisetheirrights[ 9 ].
Oneapproachtoaddressgenderinequalitiesisimplementinginterventionstha
 tseekto
empowerwomenlivingwithHIV.Empowermenthasbeendefinedastheproces
sofenhanc-
ingthecapacityofindividualsorgroupstomakechoicesandtotransformthosec
hoicesinto
desiredactionsandoutcomes[ 10
].Suchinterventionsaredesignedtoincreasewomen'sself-
efficacy,autonomy,oragency,and,hence,improvetheirsexualandreproducti
vedecision-
makingandrelatedhealthoutcomes.However,althoughsomeinterventionsh
avebeenevalu-
atedonanindividualbasis,theeffectivenessofsuchinterventionsasawholehas
notbeensys- tematicallyassessedthroughmeta-
analysesorsystematicreviews.
Weconductedasystematicreviewtoexaminetheeffectivenessofintervention
sthataimto
addressunequalgenderpowerrelations,empowerwomenlivingwithHIV,andi
ncreasetheir self-efficacytomakeSRHdecisions.

Methods
ThissystematicreviewwasconductedtoinformWorldHealthOrganizationguid
elinesonthe
sexualandreproductivehealthandrightsofwomenlivingwithHIV,followingPRI
SMA
reportingguidelines[ 11 ];thereviewprotocolisavailableuponrequest[
12 ].

Eligibilitycriteria
Studieswereeligibleforinclusioniftheymetthefollowingcriteria:

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 Self-
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1.Examinedoneormoreinterventionsdesignedtoaddressunequalgenderpo
werrelations, increaseself-
efficacy,and/orincreaseempowermentaroundsafersexandreproductive
decision-makingforwomenlivingwithHIV,
2.ComparedwomenlivingwithHIVwhoreceivedtheinterventiontothosew
hodidnot throughapre/postormulti-armdesign,
3.Measuredatleastoneofthefollowingoutcomes:(a)Self-
efficacy,empowerment,orother
measureofabilitytomakeowndecisionsaroundcondomuse,pregnancytermi
nation, birthspacing,childbearing,andotheraspectsofSRH,
(b)SRHbehaviors(suchascondom
use,contraceptiveuse,disclosureofHIVserostatustopartner)or(c)SRHoutco
mes(such asSTIs,pregnancy).
4.Publishedinapeer-reviewedjournalpriortothesearchdate.
WeincludedstudiesamongallpopulationsofwomenlivingwithHIV,includinga
doles-
cents(1019years),youngpeople(2024years),adults(25+years),andwom
enofanyage
whoweremembersofkeypopulations(includingfemalesexworkers,womenw
housedrugs,
womeninprisonsorotherclosedsettings,andtransgenderwomen)[ 13
].Givenourfocuson
SRHdecision-
making,weexcludedstudieswithchildrenundertenyearsofage.Ifastudy
evaluatedaninterventionforbothmenandwomen,orforbothwomenlivingwith
HIVand HIV-
negativewomen,itwasincludedonlyifoutcomedataweredisaggregatedforwo
menliv- ingwithHIV.Wedidnotincludeself-
efficacyforcopingwithHIVstatus;self-efficacyfor
adherencetomedications;orgeneralmeasuresofself-efficacy,self-
esteem,agency,orwellness
notdirectlylinkedwithSRHbehaviorsandoutcomes.Articlesfromallcountriesa
ndwritten inalllanguageswereeligibleforinclusion.

Datasources
ThefollowingelectronicdatabasesweresearchedforarticlesthroughJanuar
y3,2017:
PubMed,CINAHL,Embase,PsycINFO,andScopus.Wedevelopedsearchter
msforHIV,
women,studydesign,andSRHtoidentifyarticlesinPubMed( S1Appendix
),thenadapted
thesearchforotherdatabases.Secondaryreferencesearchingwasconducte
donallincluded articles.

Dataanalysis
InitialscreeningoftitlesandabstractswasconductedbyJRandSM.Potentiallyrel
evantcita-
tionswerethenindependentlyscreenedinduplicatebyJRandSMandresolvedth
 roughdis- cussionwithCK.Full-
textarticleswerereviewedforfinaleligibilitydecisions.
JRandSMindependentlyextracteddatainduplicateusingstandardizedforms.D
ifferences
indataextractionwereresolvedthroughdiscussionandconsensus.Thefollowin
ginformation
wasgatheredfromeachincludedstudy:objectives,location,populationcharact
eristics,inter- ventiondescription,studydesign,samplesize,follow-
upperiods,loss-to-follow-up,analytic
approach,outcomemeasures,comparisongroups,effectsizes,confidenceinte
rvals,signifi-
cancelevels,conclusions,andlimitations.JRandCKassessedstudyrigorusingt
heEvidence
Project'stoolforevaluatingmultiplestudydesignsinHIVbehavioralinterventio
nresearch
[
14],includingassessmentofcomparisongroups,randomassignmentandsel
ection,follow-
uprate,equivalencyofcomparisongroups,andcontrolforpotentialconfound
ers.
DataweredescriptivelyanalyzedbycodingcategoriesandSRHoutcomes.We
didnot meta-
analyzeduetodifferencesininterventiondesignandoutcomemeasurement
across

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 Self-
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studies.However,wegroupedsimilarmeasures(e.g.,condomuseself-
efficacy)acrossstudies andsummarizedfindingsbyoutcome.

Results
Databasesearchesproducedatotalof3,351hits;2,087citationsremainedafterr
emoving
duplicates( Fig1
).Afterinitialscreening,151citationswerereviewedbytwoauthorsindupli-
cate,ofwhich73wereexcludedfornotmeetingtheinclusioncriteria(e.g.,qualit
ativestudies,
studieswithoutrelevantoutcomes,orstudieswithoutfindingsforwomenliving
withHIV). Seventy-eightarticleswerepulledforfull-
textreview,and57wereexcluded.Ultimately,21
studieswereincludedinthereviewcovering11specificinterventionapproaches
( Table1 ).

Studydescriptions
Location. ThirteenstudieswerelocatedintheUnitedStates(US)[
15 27 ],whileeight
wereadaptedfromUS-
basedinterventionstoanAfricancontext,includingfourinSouth
 Fig1.Dispositionsofcitationsthroughthesearchandscreeningprocess.
https://doi.org/10.1371/journal.pone.0180699.g001

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Table1.Descriptionsofincludedstudies.
AuthorYear SexualandReproductiveHealthand StudyDesign InterventionProvider TheoreticalFramework
StudyOutcomes*
Location RightsEmpowermentIntervention
SISTAAdaptations(WiLLOW,PURSE)
Wingood,etal.,
2004
Atlanta,GA; WiLLOW :`Womeninvolvedinlife RCT,individual Trainedfemalehealth Socialcognitivetheory;Theory
Unprotectedvaginal
Birmingham,AL, learningfromotherwomen' N=366 educator,co-facilitatedby ofgenderandpower;designed intercourse
USA 4,4-hourinteractivegroupsessions Follow-UpTime:12 HIV-positivefemalepeer forwomenlivingwithHIV Proportionnever
implementedoverconsecutiveweeks months educator usedcondoms
with810groupparticipants. IncidentSTDs
TopicsCovered:Genderpride; CondomSelf-
supportivesocialnetworkuseand Efficacy
maintenance;HIVtransmissionrisk
behaviors,communicationandsafe
sexnegotiation,condomuse,
managingabusiverelationships
PrimaryObjective:Reduce
unprotectedvaginalsex
Saleh-Onoya
etal.,2009
WesternCape, WiLLOWAdaptation RCT,individual Black,isiXhosaspeaking, Socialcognitivetheory;Theory Self-
efficacyfor
SouthAfrica 4,4-hourgroupsessionsimplemented N=120 femalehealtheducatorand ofgenderandpower;designed negotiatingcondom
overconsecutiveweekswith810 Follow-UpTime:3 ablackisiX-hosaspeaking forwomenlivingwithHIV use
groupparticipants months HIV-positivewomanco- Self-efficacyfor
TopicsCovered:sexualriskreduction facilitator correctcondomuse
andcopingtraining(e.g.,ethnicand Controlin
genderpride,self-esteem,support relationships
networks,communication,HIVrisk Condomuseatlast
behaviors,etc.) sex
PrimaryObjective:Enhancecoping STIIncidence
skillsandconsistentcondomuse
Kleinetal.,2013
SouthernUSA MultimediaWiLLOW RCT,individual Interactivecomputer Socialcognitivetheory;Theory CondomUse
2,1-hourinteractivecomputersession N=175 moduleswithfemale ofgenderpower,builtfrom Partnersexual
separatedinto28minuteactivity Follow-UpTime:3 AfricanAmericannarrator eachpieceofWiLLOW
communication
modules months meetings Communication
Topicscovered:pride,values,goals, self-efficacy
usingsocialsupport,stress
management,riskreduction,condom
management,buildinghealthy
relationships,HIVre-
infection,STIs,
partnercommunication,disclosure,
condomself-efficacy,computeruse
instructions
PrimaryObjective:Increaseprotective
sexualbehaviorsandpsychoso
cial mediatorsassociatedwithHIVrisk
reduction
Sarnquistetal.,
2014
Chitungwiza, PURSE :`PeersUndertaking Non-randomizedtrial NurseswithenhancedFP Sociallearningtheory,Theory
Relationshippower
Zimbabwe ReproductiveandSexualHealth N=98 training ofgenderandpower Controlover
Education' Follow-UpTime:3 condomuse
3,90-minutegroupsessions monthspostpartum Long-acting
Topicscovered:sexualnegotiation reversible
skillsandempowerment,information contraception
aboutHIV,PMTCT,andFP,and (LARC)use
communicationskillsrelatedtosex
andFP.
PrimaryObjective:Achievedesir
ed familysizeandspacing;maximize
maternalandchildhealth
(Continue
d)
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Table1. (Continued)
AuthorYear SexualandReproductiveHealthand StudyDesign InterventionProvider TheoreticalFramework
StudyOutcomes*
Location RightsEmpowermentIntervention
SWP`SMART/ESTWomen'sProject';NOW/NOW2;ThePartnerProject
Jonesetal.,
2001
Miami,FL; NOW :`NewOpportunitiesforWomen' Non-randomizedtrial Psychologist Hierarchicalapproach
UseofN-9
Newark,NJ;New 3,120-minutesessionsover3months withmatched spermicides
York,NY,USA TopicsCovered:HIV/STD controls
transmission,hierarchicalcounseling, N=178
skilltraining,reactionstobarriers, Follow-UpTime:9
cognitivereframing,andsexual months
negotiation
PrimaryObjective:Increasesexual
barrieruse
Jonesetal.,
2005
Lusaka,Zambia ThePartnerProject (NOW RCT,individual Trainedgender-congruent Theoryofreasonedaction/
Protectedsex
Adaptation) N=332(180women counselors plannedbehavior
4groupinterventionsessions;male livingwithHIV)
partnersattended1or4separate Follow-UpTime:12
sessions months
Topicscovered:HIV/sexually
transmitteddiseasepreventionand
transmission,reproductivechoiceand
mothertochildtransmission,
communication,conflictresolution,
sexualnegotiation
PrimaryObjective:Reducesexualrisk
behavior
Jonesetal.,
2006
Lusaka,Zambia NOW2 (NOWAdaptation) RCT,individual Registeredandlicensed Theoryofreasonedaction/
Sexualbarrieruse
2-hourgroupsessionslimitedto10 N=240 practicalnursesand plannedbehavior Malecondomuse
women Follow-UpTime:12 healthcarestafftrainedin Femalecondomuse
Topicscovered:(1)HIV/STDs,safer months interventionadministration
sex,barrieruse,reproductivechoice,
HIVre-infection,transmissionand
infectionwithotherSTDsand
hierarchicalmethodsofsexualbarrier
use(2)Vaginallubricants,gelsand
suppositories
PrimaryObjective:Increasesexual
barrieruse
Jonesetal.,
2007
Miami,FL,USA NOW `NewOpportunitiesforWomen' Randomizedtrial Facilitatorsweregender Theoryofreasonedaction/
Riskbehavior
3,120-minutesessionsover3months withoutcontrol matchedRNs,LPNsand plannedbehavior
limitedto10participants (randomizedto healthcarestafftrainedin
Topicscovered:sexualbarrier individualorgroup theadministrationofeach
products,sexualriskreduction sessions) condition
strategies,sexualnegotiation N=187
PrimaryObjective:Increasesexual Follow-UpTime:12
barrieruse months
Weissetal.,
2011
(Continue
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Table1. (Continued)
AuthorYear SexualandReproductiveHealthand StudyDesign InterventionProvider TheoreticalFramework
StudyOutcomes*
Location RightsEmpowermentIntervention
Miami,FL; SWPIandII`SMART/ESTWomen's RCT,individual Psychologist Cognitivebehavioralstress Unprotectedsex
Newark,NJ;New Program'+GroupHealthyLiving N=933 management(CBSM)plus Vaginalsexual
York,NY,USA Component Follow-UpTime:24 expressivesupportivetherapy barriers
10weekly2-hourgroupcognitive months framework(CBSM+)
behavioralstressmanagement/
expressivesupportivetherapy
framework(CBSM+)
6additional2-hourgrouphealthyliving
sessions
Topicscovered:medication
adherence,nutrition,safers
ex, substanceabusereduction,and
physicalactivity.
PrimaryObjective:Optimizehea
lth statusofpoorwomenofcolorliving
withHIV
Jonesetal.,
2013
Miami,FL; SWP`SMART/ESTWomen's Non-randomizedtrial Health-careproviders, Cognitivebehavioralstress
Numberofsexual
Newark,NJ;New Program'CommunityHealthCenter N=428 counselors,socialworkers, management(CBSM)plus partners
York,NY,USA Adaptation Follow-UpTime:12 andhealtheducators expressivesupportivetherapy
10weekly2-hourgroupcognitive months framework(CBSM+),
behavioralstressmanagement/ Glasgow'sRE-AIMmodel
expressivesupportivetherapy
framework(CBSM+)
6additional2-hourgrouphealthyliving
sessions
Topicscovered:medication
adherence,nutrition,physicalacti
vity, sexualriskbehavior,andalcoholand
druguse
PrimaryObjective:Optimizehea
lth statusofwomenlivingwithHIVina
communityhealthsetting
M2M`Mothers2Mothers';Mamekhaya
Futtermanetal.,
2010
Peri-urbanCape Mamekhaya,basedonM2M Non-randomized M2Mmentormothers Cognitivebehavioral Partnertesting
Town,South `Mothers2Mothers' trial,group (womenlivingwithHIV) interventions,empowerment Abstinence/condom
Africa 8session,smallgroupsofpregnant N=160 trainedinCBI andsupportmodel use
women Follow-UpTime:6
TopicsCovered:HealthyLiving- monthspost-delivery
stayingincare,dealingwith
symptoms,HIV,ARVs,family
planning,condoms;FeelingHap
py& Strong-disclosure,stigma,support,
hope,negativeemotions,domestic
violence,substanceabuse;Partnering
&PreventingTransmission:infa
nt feeding,partnertesting,safersex;
Parenting:feeding,immunizations,
infanttesting,custody,attachme
nt;in allsessions:music,meditation,active
learning
PrimaryObjective:PMTCTand
maternalwell-being
Richteretal.,
2014
(Continue
d)
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Table1. (Continued)
AuthorYear SexualandReproductiveHealthand StudyDesign InterventionProvider TheoreticalFramework
StudyOutcomes*
Location RightsEmpowermentIntervention
KwaZulu-Natal, Mothers2MothersAdaptation RCT,group Peermentors Empowermentandsupport
Askingpartnerto
SouthAfrica 8individualmentorsessions:4 N=1,200 model testforHIV
antenatal,4postnatal Follow-UpTime:1.5
Topicscovered:destigmatizingHIV, monthspost-birth
PMTCTtasks,exclusivefeeding,
abstainingfromtraditionalmedici
nes, healthydailyroutines,obtainingachild
grant,maintainingstrongso
cial network,couples'HIVtesting,
disclosure,condomuse
PrimaryObjective:Maternalandinfant
well-being
KHARMA`KeepingHealthyandActivewithRiskReductionandMedicationAdherence'
Holstadetal.,
2011
Alarge KHARMA `KeepingHealthyandActive RCT,individual Trainednurses Motivationalinterviewingtheory Abstinence
southeastern withRiskReductionandMedication N=203 UseofProtection
metropolitancity, Adherence' Follow-UpTime:9
USA 8groupsessions months
Topicscovered:ARTadherence,risk
behavior,HIVstatusdisclosure
PrimaryObjective:Promotionof
adherencetoantiretroviral
medicationsandriskreduction
behaviors
Holstadetal.,
2012
Lagos,Nigeria KHARMAAdaptation RCT,individual Trainednurses Motivationalinterviewing Numberofsexual
8groupsessions N=60 theory;Socialcognitivetheory partners
Topicscovered:ARTadherence,self- Follow-UpTime:6 Useofcondoms/
efficacyforcondomskillsand months protection
knowledge,condomnegotiation,HIV Drug/alcoholuse
statusdisclosure priortosex
PrimaryObjective:Promotionof
adherencetoantiretroviral
medicationsandriskreduction
behaviors
HR`HealthyRelationships'
Marhefkaetal.,
2014
Florida,USA HR-VG `HealthyRelationships RCT,individual 2womenlivingwithHIV(1 Socialcognitivetheory
Unprotectedsex
VideoconferencingGroups'(HR N=71 socialworker,1community
Adaptation) Follow-UpTime:6 member)
6,2-hourvideoconferencesessions months
Topicscovered:HIVstatus,disclosure
decision-makingandsafersexual
behaviors
PrimaryObjective:Reducingsexual
riskbehavior
ProjectROADMAP`ReeducatingOlderAdultsinMaintainingAIDSPrevention '
Echeniqueetal.,
2013
(Continue
d)
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Table1. (Continued)
AuthorYear SexualandReproductiveHealthand StudyDesign InterventionProvider TheoreticalFramework
StudyOutcomes*
Location RightsEmpowermentIntervention
Miami,FLUSA ROADMAP `ReeducatingOlderAdults RCT,individual Peereducators Information-motivation-
Condomuse
inMaintainingAIDSPrevention' N=300 behavioralskills(IMBmodel)of
4weeklypsycho-educationalgroup Follow-UpTime:6 AIDSriskbehaviorchange;
sessionsforolderwomen,2-hours months principlesofself-efficacytheory
each
Topicscovered:HIV,harmreduction,
effectsofHIVonsexualbehaviors,
assertivecommunicationwith
partners,condomnegotiation,de-
escalatingnegativepartnerreacti
ons, reviewoflessonslearned,self-reward
formaintainingsaferbehavior
PrimaryObjective:Reducehighrisk
sexualbehavior
WDIP`WomenandInfantsDemonstrationProject'
Fogartyetal.,
2001
Baltimore,MD, WDIP `WomenandInfants RCT,individual TrainedpeermentorsStagesofchangetheory Condomuseself-
USA DemonstrationProject' N=322 efficacy
Unlimitedindividualsessionsover6 Follow-UpTime:18 Condomuse
monthperiod months Contraceptiveuse
Topicscovered:condomand
contraceptiveuse,condomnegotiation
PrimaryObjective:condomand
contraceptiveuse
ProtectandRespect
Tetietal.,2010
Philadelphia,PA, ProtectandRespect RCT,individual Healthcareprofessionals, Transtheoreticalmodelofthe Condomuse
USA 5consecutive,weekly,1.5hourgroup N=184 healtheducators,andpeer stagesofchange;Modified
interventionsessionsandpeer-led Follow-UpTime:18 educatorsAIDSriskreductionmodel;
supportgroups months Theoryofgenderandpower;
Topicscovered:sexualriskreduction formativeresearch
educationandskill-building;women's
challengesandopportunities;HIV/
AIDSandSTIfacts;maleandfemal
e condomuseandcondomnegotiation;
triggerstounsafesex;HIVstatus
disclosure;problemsolving;healthy
relationships;socialsupport;andgoal
setting.
PrimaryObjective:increaseHIVstatus
disclosureandcondomuse
WHC`Women'sHealthCoOp'
Wechsbergetal.,
2010
Pretoria,South WHC-Pretoria `Women'sHealth RCT,individual Trainedinterventionist Genderandempowerment
Condomuse
Africa CoOp'(WHCAdaptation) N=214 theories
2individual1-hoursessionsheldwithin Follow-UpTime:6
a2-weekperiod months
Topicscovered:substanceabuse
, HIV/STIs,HIVrisk,behavioralskills
trainingwithcondoms,violence
prevention,sexualnegotiationand
communication
PrimaryObjective:reducesexualrisk,
substanceuse,andvictimiza
tion amongat-riskandunderserved
women
ESHI`EnhancedSexualHealthIntervention'
Wyattetal.,2004
(Continue
d)
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Table1. (Continued)
AuthorYear SexualandReproductiveHealthand StudyDesign InterventionProvider TheoreticalFramework
StudyOutcomes*
Location RightsEmpowermentIntervention
LosAngeles,CA, ESHI `EnhancedSexualHealth RCT,individual Trainedgroupfacilitator Cognitive-behavioral
Condomuse
USA Intervention' N=147 andpeermentorlivingwith approachestoriskreduction
11weekly2.5-hourpsycho- Follow-UpTime:6 HIVwithahistoryofCSA andcultural-andgender-
educationalsessions months specificconcepts
Topicscovered:HIVriskbehaviors,
interpersonalandhealthbehaviors,
andpsychologicalsymptoms
PrimaryObjective:reducesexualrisks
andincreaseHIVmedication
adherenceforHIV-positivewomen
withchildsexualabuse(CSA)histories
EVOLUTION
Brothersetal.,
2016
Baltimore,MD; EVOLUTION :YoungWomenTaking RCT,individual Trainedgroupfacilitator
Theoryofgenderandpower Sexualactivityand
Chicago,IL; ChargeandGrowingStronger N=43 sexualrisk
Tampa,FL,USA 9(7group,2individual)weekly23 Follow-UpTime:3 questionnaire
hoursessionswith68womenper months Self-efficacyfor
group limitingHIVrisk
Topicscovered:HIVriskreduction behavior
educationandsexualnegotiation Self-efficacyfor
skills,forgiveness,emotional sexualdiscussion
regulation,communication, Condomuseself-
relationships efficacy
PrimaryObjective:Decreasesexual Sexualbeliefs
risk;empoweryoungwomenliving
withHIVthroughknowledgeandskills

Onlyoutcomesrelevanttoself-efficacyandempowermentaroundsexualandreproductivehealthareincluded.
https://doi.org/10.1371/journal.pone.0180699.t001

Africa[ 28 31 ],twoinZambia[ 32 , 33
],oneinZimbabwe[ 34 ],andoneinNigeria[ 35 ].The
US-
basedstudieswerelargelyimplementedinurbanareas.Twostudiesdidnotspe
cifythe
exactstudylocation,butwerelocatedinasouthernstatewithahighHIVpreval
enceanda
largesoutheasternmetropolitancityrespectively[ 16 , 20 ].
Populationcharacteristics.
AllstudiesincludedwomenlivingwithHIV,perourinclu-
sioncriteria.Severalstudiesfocusedonwomenfromvulnerableorkeypopulatio
ns,suchas
womenwithhighratesofalcoholandotherdruguse[ 19 , 31
],femalesexworkers[ 31 ],preg-
nantwomen[ 28 , 29 , 34 ],olderadults[ 15
],youngwomen[ 27 ],andwomenwithhistoriesof
childsexualabuse[ 26 ].TheUS-
basedstudiesincludedprimarilyAfrican-AmericanandHis-
panicwomen[ 15 26
].Acrossstudies,agesrangedfrom1670yearsold.
Studydesign. Tables 1 and 2
presentinformationonstudydesignandqualityassessment.
Sixteenstudieswererandomizedcontrolledtrials(RCTs)withrandomizationatei
therthe
 individualorgroup(facility/community)level[ 15 17 ,
21 27 , 29 33 , 35
],whilefivestudies
employedotherstudydesigns,includingnon-
randomizedtrialsandarandomizedtrialwith
nocontrol(participantsrandomizedtogrouporindividualintervention)[
18 20 , 28 , 34 ].Sam-
plesizesatbaselinerangedfrom43to1,200;severalofthesmallerstudieswere
describedas feasibilityorpilotstudies.Follow-
uptimerangedfrom324months.Tenstudieshadfollow-
upratesof75%ormore.
Theoreticalbases.
Allprogramshadanunderlyingtheoreticalbasis.Theoriesused
includedsociallearningtheory/socialcognitivetheory[ 15 , 21 ,
22 , 25 , 30 , 34 , 35
],thetheoryof
genderandpower[ 21 , 23 , 25 , 27 ,
30 , 31 , 34
],theempowermentandsupportmodel[ 28 , 29 ],the
theoryofreasonedactionandtheoryofplannedbehavior[ 19 ,
32 , 33 ],stagesofchangetheory
[ 16, 23 ],andtheAIDSriskreductionmodel[ 23 ].

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 Self-
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Table2.Qualityassessmentofincludedstudies.
Author, CohortControlor Pre/post Random Random Follow- Comparison Comparison
Controlfor
Year comparison intervention assignmentof selectionof uprate groups groups potential
group data participantsto participants of75% equivalent equivalentat
confounders
the for ormore socio- baselineon
intervention assessment demographics outcome
measure
SISTAAdaptations(WiLLOW,PURSE)
WingoodYes Yes Yes Yes No Yes Yes Yes Yes
etal.,2004
Saleh- Yes Yes Yes Yes No Yes Yes No Yes
Onoya
etal.,2009
Kleinetal., Yes Yes Yes Yes No Yes Yes Yes Yes
2013
Sarnquist Yes Yes Yes No No Yes Yes Yes Unclear
etal.,2014
SWP`SMART/ESTWomen'sProject';NOW/NOW2;ThePartnerProject
Jonesetal., Yes Yes Yes No No No Yes Yes No
2001
Jonesetal., Yes Yes Yes Yes No Unclear Unclear Unclear No
2005
Jonesetal., Yes Yes Yes Yes No No Yes Yes No
2006
Jonesetal., Yes Yes Yes Yes No Unclear Unclear Unclear No
2007
Weissetal., Yes Yes Yes Yes No Unclear Unclear Unclear No
2011
Jonesetal., Yes Yes Yes Unclear No Yes No No No
2013
M2M`Mothers2Mothers';Mamekhaya
Futterman Yes Yes No No No No No Unclear Yes
etal.,2010
Richter Yes Yes Yes Yes No No Yes Yes Unclear
etal.,2014
KHARMA`KeepingHealthyandActivewithRiskReductionandMedicationAdherence'
Holstad Yes Yes Yes Yes No Yes No Unclear Yes
etal.,2011
Holstad Yes Yes No Yes No Yes No Unclear Unclear
etal.,2012
HR`HealthyRelationships'
Marhefka Yes Yes Yes Yes No Yes Yes Yes Yes
etal.,2014
ProjectROADMAP`ReeducatingOlderAdultsinMaintainingAIDSPrevention '
Echenique Yes Yes Yes Yes No No Yes Yes No
etal.,2013
WDIP`WomenandInfantsDemonstrationProject'
Fogarty Yes Yes Yes Yes No No Unclear Unclear Unclear
etal.,2001
ProtectandRespect
Tetietal., Yes Yes Yes Yes No No Yes Yes Yes
2010
WHC`Women'sHealthCoOp'
Wechsberg Yes Yes Yes Yes No No Unclear Unclear Yes
etal.,2010
(Continue
d)
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 Self-
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Table2. (Continued)
Author, CohortControlor Pre/post Random Random Follow- Comparison Comparison
Controlfor
Year comparison intervention assignmentof selectionof uprate groups groups potential
group data participantsto participants of75% equivalent equivalentat
confounders
the for ormore socio- baselineon
intervention assessment demographics outcome
measure
ESHI`EnhancedSexualHealthIntervention'
Wyattetal., Yes Yes Yes Yes No Yes Yes Yes Yes
2004
EVOLUTION
Brothers Yes Yes Yes Yes No Yes Yes Yes Yes
etal.,2016
https://doi.org/10.1371/journal.pone.0180699.t002

Interventiondescriptions.
The21includedstudiescovered11specificinterventions
(
Table1).Someinterventionsincludedmultipleadaptationstodifferentgeograph
iccontext.
Inoneinstance,anin-personinterventionwaslateradaptedformultimedia[
21 ].Severalwere
consideredeffectivebehavioralinterventionsbytheU.S.CentersforDisea
seControland Prevention.
Interventionsweregenerallydeliveredinsmallgrouporone-on-
onesessions.Several interventionsincorporatedcognitive-
behavioralcomponents,includingcognitive-behavioral
stressmanagement/expressive-supportivetherapyandcognitive-
behavioralskilltraining
[ 18, 24 , 26 , 28
].Motivationalinterviewingwasalsocommon[ 15 , 17 ,
35 , 36 ].

Studyoutcomes
Table3 presentsstudyoutcomes.TwostudiesmeasuredSTIincidence[
25 , 30 ].Eighteenofthe
21studiesmeasuredsexualandreproductivehealthbehaviors:16measuredco
ndomuse[ 15
17, 21 28 , 30 33 , 35
]whiletwomeasuredcontraceptiveuse[ 16 , 34
].Sixstudiesmeasuredself-
efficacyandpsychosocialoutcomes[ 16 , 21 , 25 ,
27 , 30 , 34 ].Nostudiesmeasuredreproductive
healthdecision-
makingaroundpregnancytermination,birthspacing,orchildbearing.
Sexuallytransmittedinfections.
TwostudiesmeasuredSTIincidence:theoriginalWiL-
LOWinterventioninthesouthernUSAanditsSouthAfricanadaptation.Both
werehigh-
qualityRCTs,althoughtheSouthAfricanadaptationhadashorterfollow-
 uptime(3vs.12
months)andsmallersamplesize(102vs.321participants)[ 25 ,
30 ].Bothstudiesshowedsignif-
icantdecreasesinSTIincidence.TheoriginalWiLLOWinterventionfoundasignifi
cant
reductioninincidenceofbacterialSTIs( Chlamydiatrachomatis
andgonorrhea)over12-
monthfollow-
upininterventionversuscontrolparticipants(OR=0.20,95%CI=0.100.60).
However,therewasnosignificantchangein Trichomonasvaginalis [
25 ].IntheSouthAfrican
adaptation,theinterventiongroupsimilarlyshowedasignificantreductionininci
denceof
Chlamydiatrachomatis
(OR=0.21,95%CI=0.070.59)andgonorrhea(OR=0.10,95%
CI=0.020.49)comparedtothecontrolgroup.TheSouthAfricanadaptationfurt
hershowed
asignificantdecreaseinincidenceof Trichomonasvaginalis
(OR=0.06,CI=0.010.46),but
nodifferenceinincidenceofbacterialvaginosis[ 30 ].
Condomuse. Sixteenstudies(11interventions)measuredcondomuse[
15 17 , 21 28 , 30
33, 35
];however,studiesusedawiderangeofmeasures,precludingmeta-
analysis.Thesestud-
ies(12RCTsandfourotherdesigns)showedmixedresults.Althoughmoststudie
sfoundsig-
nificantincreasesincondomuse,othersfoundnochangeandincreaseswereoft
enmoderate, oftenaffectedbyhighbackgroundratesofcondomuse.

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Table3.Sexualandreproductivehealthfindingsfromincludedstudies.
AuthorYear StudyFindings*
SISTAAdaptations(WiLLOW,PURSE)
Wingoodetal., Condomuseself-efficacy: Proportionneverusedcondoms,past30days:
2004 %relativechangecomparinginterventiontocontrol:8.1 OR=0.3(95%CI0.1,0.7),p=0.008
(95%CI1.1,15.0),p=0.001 IncidentbacterialSTD(chlamydiaorgonorrhea):
Adjustedmeandifference:1.0(95%CI0.2,1.9)OR=0.2(95%CI0.1,0.6),p=0.006
Numberofactsofunprotectedvaginalsex,past30days:IncidentbacterialTrichomonasinfection:
%relativechangecomparinginterventiontocontrol:-28.0 Nodifferencesobserved,nodatareported
(95%CI-69.3,-13.4),p=0.022
Adjustedmeandifference:-0.7(95%CI-1.8,-0.4)
Saleh-Onoyaetal., Condomuseself-efficacy: Incidentbacterialvaginosis:
2009 F=1.65,p=0.20 OR=1.23(95%CI0.53,2.85)
Self-efficacyfornegotiatingcondomuse: Incidenttrichomonasvaginalis:
F=0.47,p=0.50 OR=0.06(95%CI0.01,0.46)
Relationshippower: Incidentgonorrhea:
F=0.77,p=0.38 OR=0.10(95%CI0.02,0.49)
Condomuseatlastsex: Incidentchlamydia:
OR=0.48(95%CI0.09,2.54),p=0.39 OR=0.21(95%CI0.07,0.59)
Kleinetal.,2013 Sexualcommunicationself-efficacy: 100%condomuse:
%relativechangecomparinginterventiontocontrol:9.70 OR=9.67(95%CI1.25,74.97),p=0.30
(95%CI2.08,21.77),p=0.004 Numberofunprotectedvaginalandanalsexacts,past30days:
Adjustedmeandifference:3.40(95%CI1.12,5.65) %relativechangecomparinginterventiontocontrol:-133.67
Condom-protectedvaginalandanalsexacts,past30days:(95%CI-190.20,-41.71),p=0.002
%relativechangecomparinginterventiontocontrol:45.21 Adjustedmeandifference:-3.41(95%CI-5.54,-1.29)
(95%CI17.67,71.36),p=0.002
Adjustedmeandifference:0.33(95%CI0.13,0.52)
Sarnquistetal., Relationshippower: DisclosureofHIVserostatus,womantopartner:
2014 Intervention:2.5%,Control:2.1%,p=0.01 Intervention:98.4%,Control:87.5,p=0.04
Controlovercondomuse: DisclosureofHIVserostatus,partnertowoman:
Intervention:67.2%,Control:34.4%,p=0.002 Intervention:75.8%,Control:55.2%,p=0.04
Useoflong-actingreversiblecontraception:
Intervention:87.1%,Control:81.8%,p=0.34
SWP`SMART/ESTWomen'sProject';NOW/NOW2;ThePartnerProject
Jonesetal.,2001 UseofN-9spermicides:
Intervention:83%,Control:9%,p <0.05
Jonesetal.,2005 Protectedsex,6monthsafterbaseline: Protectedsex,12monthsafterbaseline:
X=4.90,t(1,70)=-.67,p <0.001 X=4.83,t(1,30)=-3.20,p=0.003
Jonesetal.,2006 Malecondomuse,6monthsafterbaseline: Sexualbarrieruse,6monthsafterbaseline:
Groupvsindividualintervention:F=13.5,p <0.001 Groupvsindividualintervention:F=4.6,p <0.05
Malecondomuse,12monthsafterbaseline: Sexualbarrieruse,12monthsafterbaseline:
Groupvsindividualintervention:F=0.24,p=0.62 Groupvsindividualintervention:F=0.5,p=0.05
Jonesetal.,2007 Sexualriskbehavior:
Groupvsindividualintervention:F=1.31,p=0.27
Weissetal.,2011 Unprotectedsex:
DecreasedORfrom0.16to0.095,F=0.04,p=0.038
Jonesetal.,2013 Numberofsexpartners:
OR=0.6(95%CI0.40.9)
M2M`Mothers2Mothers';Mamekhaya
Futtermanetal., Abstinentoralwaysusescondom:
2010 Coefficient:0.24,SE:1.44,p >0.05
(Continue
d)

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 Self-
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Table3. (Continued)
AuthorYear StudyFindings*
Richteretal.,2014 AskingpartnerstotestforHIV:
OR=1.84,p=0.014
KHARMA`KeepingHealthyandActivewithRiskReductionandMedicationAdherence'
Holstadetal.,2011 Alwaysusescondoms,past3months:
Z=2.10,p=0.036
Holstadetal.,2012 Alwaysusescondoms,past3months: Condomuseatlastsexualencounter:
Intervention:84.6%,Control:43.8%,p=0.014 Intervention:88.9%,Control:52.6%,p=0.015
HR`HealthyRelationships'
Marhefkaetal., Proportionreportingnounprotectedsex,past3months: Differenceinfrequencyofunprotectedsex,past3months:
2014 OR=0.92(95%CI0.24,3.56) Difference=6.89(95%CI5.43,8.73)
ProjectROADMAP`ReeducatingOlderAdultsinMaintainingAIDSPrevention '
Echeniqueetal., Inconsistentcondomusewithallpartners: InconsistentcondomusewithHIV-positivepartners:
2013 Intervention:20%atbaseline;9.2%at6-months,p= <0.05 Intervention:7.7%atbaseline;6.2%at6-months,p >0.99
Comparison:12.2%atbaseline;9.8%at6-months,p=0.42 Comparison:9.8%atbaseline;9.8%at6-months,p
>0.99
InconsistentcondomusewithHIV-negative/unknownserostatus
partners:
Intervention:12.3%atbaseline;3.1%at6-months,p <0.10
Comparison:2.4%atbaseline;4.9%at6-months,p=0.51
WDIP`WomenandInfantsDemonstrationProject'
Fogartyetal.,2001 Self-efficacyforcondomusewithmainpartner: Progress inuseofcontraceptives:
OR=2.01,p=0.01 OR=2.07,p=0.08
Progress inuseofcondomswithmainpartner: Relapseinuseofcontraceptives:
OR=2.30,p=0.02 OR=0.43,p=0.03
ProgressintermsofStagesofChangetheory:movingupastageorstayinginmaintenance
ProtectandRespect
Tetietal.,2010 Proportionofsexactswherecondomsused:
DifferenceinOR=270.04(95%CI:24.53,2971.94),p <0.01
WHC`Women'sHealthCoOp'
Wechsbergetal., Condomuseatlastsexact:
2010 OR=7.27(95%CI1.64,32.23),p <0.05
ESHI`EnhancedSexualHealthIntervention'
Wyattetal.,2004 Condomusewithmainpartner,past3months:
OR=2.96,p=0.039
EVOLUTION
Brothersetal., Numberofmalepartners,past3months: Self-efficacyforsexualdiscussion
2016 RR=1.11(95%CI0.72,1.70),p=0.648 Adjustedmeandifference:-0.16(95%CI-0.36,0.04),p=0.110
Anyunprotectedvaginaloranalintercourse,past3months: Condomuseself-efficacy
AdjustedOR=0.26(95%CI0.05,1.51),p=0.135 Adjustedmeandifference:0.14(95%CI-0.10,0.37),p=0.250
Self-efficacyforlimitingHIVriskbehavior Sexualbeliefs
Adjustedmeandifference:0.04(95%CI-0.14,0.21), Adjustedmeandifference:0.05(95%CI-0.15,0.24),p=0.631
p=0.667

Boldindicatessignificantdifferencebetweeninterventionandcomparisongroups.
Oddsratiosrepresentoddsintheinterventiongroupcomparedtothecontrolgroup.
https://doi.org/10.1371/journal.pone.0180699.t003

OfthethreeSISTAadaptationRCTsthatmeasuredcondomuse,twoshowedsig
nificant
increases[ 21 , 25
],whiletheSouthAfricanadaptationdidnot[ 30 ].Mostotherhigh-
quality
RCTsalsofoundsignificantpositiveimpactsoncondomusebyvariousmeasurem
ents
[ 17, 24 , 26 , 31 33 , 35
].WDIPfoundprogress(throughstagesofchange)incondomusewith
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 Self-
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mainpartner[ 16 ].Threestudieswithhighlosstofollow-
uprates(3044%retentionatfollow-
up)foundmixedresultsoncondomuse[ 15 , 23 , 28 ].
Contraceptiveuse.
Twostudiesmeasuredcontraceptiveuse.WDIP,anRCT,foundthat
interventionparticipantsweremorelikelytoshowprogress(OR=2.07,p=0.08)
andsignifi-
cantlylesslikelytorelapse(OR=0.43,p=0.03)incontraceptiveusecomparedto
thecompar-
isongroup[ 16 ].PURSE,anon-
randomizedtrialwith98participantsandhighratesoffollow-
up,foundthatuptakeoflong-
actingreversiblecontraceptionincreasedinbothintervention
andcontrolgroupsthreemonthsafterdelivery,buttherewasnosignificantdiffe
renceacross
groups(I:87%,C:81.8%,p=0.34).Theauthorssuggestedthiswasduetobothgr
oupshaving
accesstonurseswithtraininginenhancedfamilyplanning[ 34 ].
Self-efficacyandpsychosocialmeasures.
FourRCTs(theoriginalWiLLOW,itsSouth
Africanadaptation,WDIP,andEVOLUTION)andonenon-
randomizedtrial(PURSE)mea- suredcondomuseself-
efficacy.TheoriginalWiLLOWprogramfoundthatinterventionpar-
ticipantshadhighercondomuseself-efficacyover12monthsoffollow-
up(13.6vs.12.6;
p=0.001)[ 25 ].PURSEalsofoundsignificantincreasesinself-
reportedcontrolovercondom
use(67.2%vs.34.4%,p=0.002)[ 34
],andWDIPinterventionparticipantsshowedhigherself-
efficacyforcondomusewithamainpartnerthancontrolparticipants(OR=2.01,p
=0.01)
[
16].However,neitherthesmallEVOLUTIONpilotstudynortheSouthAfricanWi
LLOW
adaptationfoundasignificantdifferencebetweeninterventionandcontrolgro
upsincondom
useself-efficacy[ 30 ].
Otherpsychosocialoutcomesalsoshowedmixedresults.ThemultimediaWiLL
OWadap- tationreportedimprovementinsexualcommunicationself-
efficacy(meandifference=3.40,
p=0.004)[ 21 ],whileEVOLUTIONfoundnosignificantimpactsonself-
efficacyforsexual
discussionorself-efficacyforlimitingHIVriskbehavior[ 27
].PURSEfoundsignificant
increasesinrelationshippower(2.5vs.2.1,p=0.01)[ 34
],whereastheSouthAfricanWiL-
LOWadaptationfoundnosignificantresultsforrelationshipcontrolorcondomne
gotiation
[
30].Finally,PURSEinterventionparticipantsweremorelikelytoreportdisclosing
theirHIV
 statustoapartner(98.4%vs.87.5%,p=0.04)andviceversa(75.8%vs.55.2%,p=
0.04)[ 34 ].

Discussion
AllwomenlivingwithHIVmustbesupportedintheirvoluntarychoicesaroundsex
ualrela-
tionshipsandbegiveninformationandresourcestoengageinsafe,enjoyablese
xualexperi-
ences,ortonotengageinsexbasedontheirpersonalpreference,withcounsellin
gandsupport tailoredtotheirdecision-
making,desiresandneeds.SupportingwomenlivingwithHIVinall
theirdiversitytoachievetheirsexualandreproductivehealthandrightsinallepi
demiccon-
textsrequiresovercomingmajorbarrierstoserviceuptakesuchassocialexclusi
onandmar-
ginalization,criminalization,stigma,andgenderinequality[ 37
].Addressingunequalgender
andpowerrelationsandempoweringwomenlivingwithHIVmaybeonepartof
acompre- hensiveapproachtoachievethesegoals.
Thissystematicreviewhighlightsthepotentialforincreasingcondomuseandre
ducing
incidentSTIsthroughempowermentinterventionsforwomenlivingwithHIV.STI
scontinue
tobeanimportantpublichealthissuethatcanfacilitatesexualtransmissionofHI
Vandtrigger
somecancers.AsstatedintheWHOGlobalHealthSectorStrategyonSexuallyTra
nsmitted
Infections,20162021,theburdenofmorbidityandmortalityworldwideresult
ingfromsexu-
allytransmittedpathogenscompromisesqualityoflife,aswellassexualandrepr
oductive
health[ 37 ].WomenlivingwithHIVhavehighratesofSTIco-
infection,withameanSTI
prevalenceof15.8%
(standarddeviation:9.9)acrossstudiesinarecentglobalsystematic
review[ 38
].AlthoughSTIscreeningandtreatmentarearecommendedpartofthepackag
eof

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 Self-
efficacyandempowermentreview

careforpeoplelivingwithHIVbytheWHO[ 39 , 40
]andPEPFAR[ 41 ],acomprehensive,
rights-
basedapproachtoaddressingSTIsandotherSRHissuesisneededtofacilitateS
TIpre- ventionaswellastreatmentforwomenlivingwithHIV.
Findingsfromourreviewweremoremixed,however,forotheroutcomes,includi
ngcon- traceptiveuse,self-
efficacy,andpsychosocialmeasures.Whiletheseinterventionsholdprom-
ise,furtherworkisneededtodeterminewhichcomponentsofinterventionsma
kethem successful,forwhichpopulations,andonwhichoutcomes.
Conclusionsfromthisreviewarelimitedbythenatureoftheevidencebase.Thera
ngeof
outcomesmeasuredbytheincludedstudieswasnarrow,withthemajoritymeas
uringcondom
use.OnlyafewstudiesmeasuredotherSRHoutcomes,ormoreproximaloutcom
essuchas empowermentandself-
efficacy.Consequently,itisdifficulttoassesstheimpactoftheinter-
ventionsonwomen'sself-
efficacyorempowerment,andtounderstandtheassociation
betweenempowermentandSRHoutcomes.Notmeasuringotheroutcomeslimi
tstheevi-
denceforpathwaystoimprovedhealthforwomenlivingwithHIVandtheirpartne
rs.Addi-
tionally,studiesusedawiderangeofmeasuresforcondomusethataffectedoura
bilityto compareacrossinterventionsandprecludedusfromconductingmeta-
analysis.Condomuse
reportedinthesestudieswasaffectedbyhighratesofinitialreporteduse,creatin
gaceilingfor measuringinterventionimpact.Manymeasureswerealsoself-
reported,introducingthepossi-
bilityofrecallandsocialdesirabilitybias.Finally,theincludedstudieswereofmix
edquality, withmanylimitedbysmallsamplesizeandlowfollow-
uprates.Theevidencebaseisfurther
limitedingeographicandpopulationscope.Manyimportantpopulationsofwom
enliving
withHIV,suchastransgenderwomen,werenotincludedinanystudies.Mostincl
udedstud-
ieswereconductedintheUSAorwereadaptationsofinterventionsoriginallyimp
lemented
there.Nevertheless,someinterventionsweredeterminedtobeeffectivewhena
daptedtomul-
tiplecontextsandfeasibleacrosssettings.Finally,wedidnotincludeunpublishe
d(grey)lit-
eratureorqualitativestudiesinourinclusioncriteria;thesestudiesmayhavepro
vided additionalinsightsintotheeffectivenessandoutcomesofinterventions.
Althoughthisreviewfocusedoninterventionswithwomen,interventionswithm
enthat
seektoaddressunequalgenderandpowerrelationsarealsoessentialtoempow
erwomenin theirSRHdecisions.Recentevidencesuggeststhatgender-
transformativeinterventionsto
engagingmeninHIV[ 42 ]andgender-basedviolence[ 43
]holdpromise;suchprograms
 seektodirectlydiscussandreconfiguregenderrolesinthedirectionofmoregend
erequita-
blerelationships[ 44
].Additionally,manygenderinequalitiesexistatastructurallevel
throughculturalnorms,laws,andinstitutions.Futureresearchshouldalsoseekt
oimple- mentstructural-
levelinterventionssothatwomenmayliveinenvironmentsthatbetterfacil-
itatetheircontrolovertheirownsexualandreproductivehealth.Thoughstructur
al-level
interventionscanbechallengingbothtoimplementandevaluate,theycanhave
significant
impact[ 45 ].
Thisisthefirstsystematicreviewofinterventionstoimproveself-
efficacyandempower- mentaroundsafersexandreproductivehealthdecision-
makingforwomenlivingwithHIV.
Thelimitationsoftheexistingevidenceindicateaneedforfurtherresearchtodet
erminethe impactofempowermentandself-
efficacyinterventions.Futurestudiesshouldincludemea-
surementofawiderrangeofsexualandreproductivehealthandrightsoutcomes
,including
bothproximalempowermentandmoredistalhealthoutcomemeasures.Studie
sshouldensure
themeaningfulparticipationofthecommunityofwomenlivingwithHIVinstudyd
esign.
Interventionsshouldalsobeexplicitabouthowtheircontentaddressesunequal
genderpower
relations.Suchstudieswouldallowforclearconclusionsonhowthesetypesofint
erventions mayimprovetheSRHofwomenlivingwithHIV.

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 Self-
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Supportinginformation
S1Appendix.FullsearchstrategyforPubMed.
(DOCX)
S1Checklist.PRISMAchecklist.
(DOCX)

Acknowledgments
WewishtoacknowledgeDonnaHesson,PublicHealthInformationistattheWel
chMedical LibraryofJohnsHopkinsUniversity.

AuthorContributions
Conceptualization: CEKMNAA.
Datacuration: JLRSMLKBPTY.
Fundingacquisition: MNAA.
Investigation: JLRSMLKBPTYCEK.
Methodology: CEKMNAA.
Projectadministration: CEK.
Supervision: CEK.
Visualization: JLRSMPTY.
Writingoriginaldraft: JLR.
Writingreview&editing: JLRMNAASMLKBPTYCEK.

References
1.
WellingsK,CollumbienM,SlaymakerE,SinghS,HodgesZ,PatelD,etal.SexualBehaviourinCon-
text:AGlobalPerspective.Lancet.2006;368(9548):170628.
https://doi.org/10.1016/S0140-6736(06)
69479-8 PMID: 17098090
2.

OrzaL,BewleyS,ChungC,CroneET,NagadyaH,VazquezM,etal."Violence.EnoughAlready":
FindingsfromaGlobalParticipatorySurveyamongWomenLivingwithHIV.JIntAIDSSoc.2015;18

(Suppl5):20285. https://doi.org/10.7448/IAS.18.6.20285 PMID: 26643458

3. LangenTT.GenderPowerImbalanceonWomen'sCapacitytoNegotiateSelf-
ProtectionagainstHIV/
AIDSinBotswanaandSouthAfrica.AfrHealthSci.2005;5(3):18897.PMID: 16245988
4.
SenarathU,GunawardenaNS.Women'sAutonomyinDecisionMakingforHealthCareinSouthAsia.
AsiaPacJPublicHealth.2009;21(2):13743. https://doi.org/10.1177/1010539509331590
PMID:
19190000
5.
AtterayaMS,KimmH,SongIH.Women'sAutonomyinNegotiatingSaferSextoPreventHIV:Findings
fromthe2011NepalDemographicandHealthSurvey.AIDSEducPrev.2014;26(1):112.
https://doi.
org/10.1521/aeap.2014.26.1.1 PMID: 24450274
6.
KoesterD.DLPConceptBrief04:Gender&Power.Birmingham,UK:DevelopmentalLeadershipPro-
gram,2015.

7.

JewkesRK,DunkleK,NdunaM,ShaiN.IntimatePartnerViolence,RelationshipPowerInequity,an
d IncidenceofHIVInfectioninYoungWomeninSouthAfrica:ACohortStudy.Lancet.2010;376
 (9734):418. https://doi.org/10.1016/S0140-6736(10)60548-X PMID: 20557928
8. CalvertC,RonsmansC.TheContributionofHivtoPregnancy-
RelatedMortality:ASystematicReview
andMeta-Analysis.Aids.2013;27(10):16319.
https://doi.org/10.1097/QAD.0b013e32835fd940
PMID: 23435296

PLOSONE| https://doi.org/10.1371/journal.pone.0180699 August24,2017 17/19

 Self-
efficacyandempowermentreview

9.
AminA.Addressinggenderinequalitiestoimprovethesexualandreproductivehealthandwellbeing
of
womenlivingwithHIV.JIntAIDSSoc.2015;18(6Suppl5):20302.
https://doi.org/10.7448/IAS.18.6.
20302 PMID: 26643464
10.

WorldBank.PovertyReductionandEquity:EmpowermentOverview2016.http://web.worldbank.
org/ WBSITE/EXTERNAL/TOPICS/EXTPOVERTY/EXTEMPOWERMENT/0,contentMDK:20244572~
pagePK:210058~piPK:210062~theSitePK:486411,00.html .
11.

MoherD,ShamseerL,ClarkeM,GhersiD,LiberatiA,PetticrewM,etal.Preferredreportingitemsfor
systematicreviewandmeta-analysisprotocols(PRISMA-P)2015statement.SystematicReviews.

2015;4(1):1. https://doi.org/10.1186/2046-4053-4-1 PMID: 25554246

12.
WorldHealthOrganization.Consolidatedguidelineonsexualandreproductivehealthandrightsof
womenlivingwithHIV.Webannex:GRADEtablesandsystematicreviewsearchstrategies.Geneva, Switzerland:WHO,2017.

13.

WorldHealthOrganization.ConsolidatedGuidelinesonHIVPrevention,Diagnosis,Treatmenta
nd CareforKeyPopulations.Geneva,Switzerland:WHO,2014.
14.
DenisonJA,O'ReillyKR,SchmidGP,KennedyCE,SweatMD.HIVVoluntaryCounselingandTesting
andBehavioralRiskReductioninDevelopingCountries:AMeta-Analysis,19902005.AIDSBehav.

2008;12(3):36373. https://doi.org/10.1007/s10461-007-9349-x PMID: 18161018

15. EcheniqueM,IllaL,Saint-JeanG,AvellanedaVB,Sanchez-
MartinezM,EisdorferC.ImpactofaSec- ondaryPreventionInterventionamongHIV-
PositiveOlderWomen.AIDSCare.AIDSCare.2013;25

(4):4436. https://doi.org/10.1080/09540121.2012.712666 PMID: 22866876

16. FogartyLA,HeiligCM,ArmstrongK,CabralR,GalavottiC,GielenAC,etal.Long-
TermEffectiveness ofaPeer-BasedInterventiontoPromoteCondomandContraceptiveUseamongHIV-PositiveandAt-
RiskWomen.PublicHealthRep.2001;116(Suppl1):10319.

17.
HolstadMM,DiIorioC,KelleyME,ResnicowK,SharmaS.GroupMotivationalInterviewingtoPromote
AdherencetoAntiretroviralMedicationsandRiskReductionBehaviorsinHIVInfectedWomen.AIDS

Behav.2011;15(5):88596. https://doi.org/10.1007/s10461-010-9865-y PMID:

21165692
18. JonesDL,LopezM,SimonsH,Diaz-
GlosterM,TobinJN,WeissSM.TranslationofaComprehensive
HealthBehaviorInterventionforWomenLivingwithHiv:TheSMART/ESTWomen'sProgram.Transl

BehavMed.2013;3(4):41625. https://doi.org/10.1007/s13142-013-0213-4 PMID:

24294330
19.
JonesDL,WeissSM,ChitaluN,VillarO,KumarM,BwalyaV,etal.SexualRiskInterventioninMultieth-
nicDrugandAlcoholUsers.AmJInfectDis.2007;3(4):16976.PMID: 18629378
20.

JonesDL,WeissSM,MalowR,IshiiM,DevieuxJ,StanleyH,etal.ABriefSexualBarrierIntervention
forWomenLivingwithAIDS:Acceptability,Use,andEthnicity.JUrbanHealth.2001;78(4):593604.

https://doi.org/10.1093/jurban/78.4.593 PMID: 11796806

21. KleinCH,LomonacoCG,PavlescakR,CardJJ.WiLLOW:ReachingHIV-PositiveAfrican-
American
WomenthroughaComputer-DeliveredIntervention.AIDSBehav.2013;17(9):301323.
https://doi.org/
10.1007/s10461-013-0479-z PMID: 23625384
22.

MarhefkaSL,BuhiER,BaldwinJ,ChenH,JohnsonA,LynnV,etal.EffectivenessofHealthyRelation-
shipsVideo-GroupaVideoconferencingGroupInterventionforWomenLivingwithHIV:Preliminary

FindingsfromaRandomizedControlledTrial.TelemedJEHealth.2014;20(2):12834.
https://doi.org/
10.1089/tmj.2013.0072 PMID: 24237482
23.
TetiM,BowlegL,ColeR,LloydL,RubinsteinS,SpencerS,etal.AMixedMethodsEvaluationofthe
EffectoftheProtectandRespectInterventionontheCondomUseandDisclosurePracticesofWomen

LivingwithHIV/AIDS.AIDSBehav.2010;14(3):56779.
https://doi.org/10.1007/s10461-009-9562-x
 PMID: 19357943
24.

WeissSM,TobinJN,AntoniM,IronsonG,IshiiM,VaughnA,etal.EnhancingtheHealthofWomenLiv-
ingwithHIV:TheSMART/ESTwomen'sproject.IntJWomensHealth.2011;3(1):6377.

25.
WingoodGM,DiClementeRJ,MikhailI,LangDL,McCreeDH,DaviesSL,etal.ARandomizedCon-
trolledTrialtoReduceHIVTransmissionRiskBehaviorsandSexuallyTransmittedDiseasesamong
WomenLivingwithHIV:TheWiLLOWProgram.JAcquirImmuneDeficSyndr.2004;37Suppl2:S58 67.

26.

WyattGE,LongshoreD,ChinD,CarmonaJV,LoebTB,MyersHF,etal.TheEfficacyofanIntegrated
RiskReductionInterventionforHIV-PositiveWomenwithChildSexualAbuseHistories.AIDSBehav.

2004;8(4):45362. https://doi.org/10.1007/s10461-004-7329-y PMID: 15690118

27.

BrothersJ,HottonAL,HosekSG,HarperGW,FernandezMI.YoungWomenLivingwithHIV:Out-
comesfromaTargetedSecondaryPreventionEmpowermentPilotTrial.AIDSPatientCareandSTDs.

2016;30(5):22935. https://doi.org/10.1089/apc.2015.0294 PMID: 27158851

28.

FuttermanD,SheaJ,BesserM,StaffordS,DesmondK,ComuladaWS,etal.Mamekhaya:APilot
StudyCombiningaCognitive-BehavioralInterventionandMentorMotherswithPMTCTServicesin

PLOSONE| https://doi.org/10.1371/journal.pone.0180699 August24,2017 18/19

 Self-
efficacyandempowermentreview

SouthAfrica.AIDSCare.2010;22(9):1093100.
https://doi.org/10.1080/09540121003600352 PMID:
20824562
29. RichterL,Rotheram-
BorusMJ,VanHeerdenA,SteinA,TomlinsonM,HarwoodJM,etal.Pregnant
WomenLivingwithHIV(WLH)SupportedatClinicsbyPeerWLH:AClusterRandomizedControlled

Trial.AIDSBehav.2014;18(4):70615. https://doi.org/10.1007/s10461-014-0694-2
PMID: 24469222
30. Saleh-
OnoyaD,ReddyPS,RuiterRA,SifundaS,WingoodG,vandenBorneB.CondomUsePromo-
tionamongisiXhosaSpeakingWomenLivingwithHIVintheWesternCapeProvince,SouthAfrica:A

PilotStudy.AIDSCare.2009;21(7):81725. https://doi.org/10.1080/09540120802537823
PMID:
20024738
31.

WechsbergWM,LusenoWK,KlineTL,BrowneFA,ZuleWA.PreliminaryFindingsofanAdaptedEvi-
dence-BasedWoman-FocusedHIVInterventiononCondomUseandNegotiationamongAt-Risk

WomeninPretoria,SouthAfrica.JPrevIntervCommunity.2010;38(2):13246.
https://doi.org/10.
1080/10852351003640799 PMID: 20391060
32.
JonesDL,RossD,WeissSM,BhatG,ChitaluN.InfluenceofPartnerParticipationonSexualRisk
BehaviorReductionamongHIV-PositiveZambianWomen.JUrbanHealth.2005;82(3Suppl4):iv92

100. https://doi.org/10.1093/jurban/jti111PMID: 16107445

33. JonesDL,WeissSM,BhatGJ,BwalyaV.InfluencingSexualPracticesamongHIV-
PositiveZambian
Women.AIDSCare.2006;18(6):62934. https://doi.org/10.1080/09540120500415371
PMID:
16831792
34. SarnquistCC,MoyoP,Stranix-
ChibandaL,ChipatoT,KangJL,MaldonadoYA.IntegratingFamily
PlanningandPreventionofMothertoChildHIVTransmissioninZimbabwe.Contraception.2014;89

(3):20914. https://doi.org/10.1016/j.contraception.2013.11.003 PMID: 24332254

35.
HolstadMM,EssienJE,EkongE,HigginsM,TeplinskiyI,AdewuyiMF.MotivationalGroupsSupport
AdherencetoAntiretroviralTherapyandUseofRiskReductionBehaviorsinHIVPositiveNigerian

Women:APilotStudy.AfrJReprodHealth.2012;16(3):1427.PMID: 23437496
36.
AidalaHA.TheInvisibleEpidemicContinues:SexualityConcernsamongWomenLivingwithHIV
/ AIDS.US:ProQuestInformation&Learning;2002.
37.

WorldHealthOrganization.GlobalHealthSectorStrategyonSexuallyTransmittedInfections201
6 2021.Geneva,Switzerland:WHO/RHR,2016.
38. KalichmanSC,PellowskiJ,TurnerC.Prevalenceofsexuallytransmittedco-
infectionsinpeopleliving withHIV/AIDS:systematicreviewwithimplicationsforusingHIVtreatmentsforprevention.Sexually
transmittedinfections.2011;87(3):18390.
https://doi.org/10.1136/sti.2010.047514 PMID: 21330572
39.
OrganizationWH.EssentialPreventionandCareInterventionsforAdultsandAdolescentsLivingwi
th HIVinResource-LimitedSettings.Geneva:WorldHealthOrganization.Geneva:2008.
40.

OrganizationWH.ConsolidatedGuidelinesontheUseofAntiretroviralDrugsforTreatingandPreven
t- ingHIVInfection2nded.Geneva:2016.
41.
President'sEmergencyPlanforAIDSRelief(PEPFAR).Guidanceforthepreventionofsexuallytrans-
mittedHIVinfections.WashingtonD.C.:2011.

42. DworkinSL,Treves-KaganS,LippmanSA.Gender-
transformativeinterventionstoreduceHIVrisks andviolencewithheterosexually-
activemen:areviewoftheglobalevidence.AIDSBehav.2013;17

(9):284563. https://doi.org/10.1007/s10461-013-0565-2 PMID: 23934267

43.

CaseyE,CarlsonJ,TwoBullsS,YagerA.GenderTransformativeApproachestoEngagingMenin Gender-
BasedViolencePrevention:AReviewandConceptualModel.TraumaViolenceAbuse.2016.

https://doi.org/10.1177/1524838016650191 PMID: 27197533

44.
 GuptaGR.Gender,Sexuality,andHIV/AIDS:theWhat,theWhy,andtheHow.13thInternationalAIDS
Conference;July12,2000;Durban,SouthAfrica:InternationalCenterforResearchonWomen.

45.
O'ReillyKR,d'AquilaE,FonnerV,KennedyC,SweatM.CanPolicyInterventionsAffectHIV-Related
Behaviors?ASystematicReviewoftheEvidencefromLow-andMiddle-IncomeCountries.AIDS

Behav.2017;21(3):62642. https://doi.org/10.1007/s10461-016-1615-3 PMID:

27864626

PLOSONE| https://doi.org/10.1371/journal.pone.0180699 August24,2017 19/19

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