Behavioral interventions to promote condom use among women living with HIV

Behavioral interventions to promote condom use and/or to modify HIV sexual risk behaviours include individual counseling, skills training, coping strategies, peer education, and social and educational support. This systematic review of randomized controlled trials assessed the effects of behavioral interventions on promoting condom use among women living with HIV, a population at higher risk to other sexually transmitted infections (STIs). Based on five eligible studies, we found that behavioral interventions promoting consistent condom use in HIV-positive women did not have a significant impact on outcomes, when compared to standard care or minimal HIV-related support. However, these findings should be used with caution since they are based on a few small trials that were targeted specifically towards HIV-positive women.  New research is needed to assess the potential personal and public health gains that could arise from a combination of interventions that promote safe sexual behavior and adopt a harm reduction approach, particularly in developing countries, where HIV infection rates among women remain high.

Authors' conclusions: 

Meta-analysis shows that behavioral interventions have little effect on increasing condom use among HIV-positive women. However, these findings should be used with caution since results were based on a few small trials that were targeted specifically towards HIV-positive women. To decrease sexual transmission of HIV among this population, we recommend interventions that combine condom promotion, family planning provision and counselling, and efforts to reduce viral loads among HIV-positive women and their partners (e.g., HAART treatment provision). New research is needed to address the needs of HIV-positive women, including an assessment of the impact of interventions that combine safer sexual behavior and harm reduction approaches.

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Background: 

High rates of HIV infection among women of reproductive age have dramatic consequences for personal and public health. Prophylaxis during sexual intercourse in the form of condoms has been the most effective way to prevent both STI and HIV transmission among people living with HIV.

Objectives: 

To investigate the effectiveness of behavioral interventions in promoting condom use among women living with HIV.

Search strategy: 

We conducted a comprehensive literature search in several scientific databases, clinical trials databases, conference proceedings, and conference websites to identify studies produced between 1980 and May 2010 that met our selection criteria.

Selection criteria: 

Studies were included in the analysis if they conducted a randomized controlled trial that examined the effects of behavioral interventions on condom use among HIV-positive women; considered at least one HIV-related behavioral outcome (e.g., reported protected anal, vaginal, or oral sex) or biological outcome (e.g., acquisition of STIs); and one follow-up assessment three months or more after the intervention. Studies were assessed irregardless of language or publication status.

Data collection and analysis: 

We used random effects models to summarize odds ratios (ORs) that compared intervention and control groups with respect to a dichotomous outcome (consistent versus inconsistent condom use). We used funnel plots to examine publication bias and a χ2 statistic to test for heterogeneity. The methodological and evidence quality was evaluated through risk of bias criteria and the GRADE system, respectively.

Main results: 

Five primary studies that collectively researched a total of 725 women living with HIV were analysed. When compared to standard care or minimal HIV support intervention, meta-analysis showed that behavioral interventions had no effect on increasing condom use among HIV-positive women. This finding was consistent at 3 (OR= 0.72; 95% CI 0.43-1.20; p=0.21), 6 (OR= 0.96; 95% CI 0.66-1.40; p=0.83) and 12-months follow-up meetings (OR= 0.75; 95% CI 0.51-1.11; p=0.15). Only one study presented adequate data to analyze the relationship between behavioral interventions and STI incidence. Studies included in this analysis demonstrated low risk of bias based on the risk of bias criteria. However, sample size was considered inadequate across all studies.

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