Kristien Michielsen PhD Thesis_website.pdf - International Centre ...

HIV PREVENTION FOR YOUNG PEOPLE IN
SUB-SAHARAN AFRICA: EFFECTIVENESS OF
INTERVENTIONS AND AREAS FOR IMPROVEMENT.
EVIDENCE FROM RWANDA
Kristien Michielsen
Doctoral Thesis Submitted to the Faculty of Medicine and Health Sciences
Ghent University
PhD Supervisor: Prof. dr. Marleen Temmerman
Department of Obstetrics and Gynaecology, Ghent University
PhD Co-Supervisor: Prof. dr. Ronan Van Rossem
Department of Sociology, Ghent University
November 2012
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Bedankt
Dominiek
voor het creëren van de omstandigheden
Juliette
voor de dagelijkse portie relativering (en kussengevechten)
HIV Prevention for Young People in Sub-Saharan Africa: Effectiveness of Interventions
and Areas for Improvement. Evidence from Rwanda.
Kristien Michielsen
Doctoral thesis submitted to the Faculty of Medicine and Health Sciences, Ghent
University, Belgium.
2012
This title has been published in the series “ICRH Monographs.”
ISBN 9789078128250
International Centre for Reproductive Health (ICRH)
Ghent University
De Pintelaan 185P3
B-9000 Ghent (Belgium)
www.icrh.org
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Supervisor: Prof. dr. Marleen Temmerman
Department of Obstetrics and Gynaecology
Faculty of Medicine and Health Sciences
Ghent University, Belgium
Co-supervisor: Prof. dr. Ronan Van Rossem
Department of Sociology
Faculty of Political and Social Sciences
Ghent University, Belgium
Members of the jury: Prof. dr. Steven Callens
Department of Internal Medicine,
Ghent University, Belgium
dr. Olivier Degomme
International Centre for Reproductive Health,
Department of Obstetrics and Gynaecology,
Ghent University, Belgium
Prof. dr. Lea Maes
Department of Public Health,
Ghent University, Belgium
Prof. dr. Dominique Meekers
Department of Global Health Systems and Development,
Tulane University
New Orleans, USA
dr. Christiana Nöstlinger
Institute for Tropical Medicine, Antwerp
Prof. dr. Geert Van Hove
Department of Special Education,
Ghent University, Belgium
Prof. dr. Steven Weyers
Department of Obstetrics and Gynaecology,
Ghent University, Belgium
Chairperson of the jury: Prof. dr. Johan Vande Walle
Department of Pediatrics and Medical Genetics,
Ghent University, Belgium
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TABLE OF CONTENTS
LIST OF FIGURES ................................................................................................................ vii
LEXICON AND LIST OF ABBREVIATIONS .................................................................... viii
1. INTRODUCTION ............................................................................................................. 1
1.1. HIV/AIDS: History, Transmision and Stages ............................................................................ 2
1.2. The HIV Epidemic ................................................................................................................................ 3
1.2.1. Worldwide ................................................................................................................................. 3
1.2.2. Sub-Saharan Africa ................................................................................................................ 4
1.3. HIV in Young People in Sub-Saharan Africa ............................................................................. 7
1.3.1. Focus on Young People ......................................................................................................... 7
1.3.2. Being Young in Sub-Saharan Africa ................................................................................ 8
1.3.3. HIV Prevention Interventions for Young People ....................................................... 9
1.4. Conclusion ............................................................................................................................................. 11
2. OBJECTIVES .................................................................................................................... 13
2.1. General Objective ................................................................................................................................ 14
14
2.3. Presentation of Publications ........................................................................................................... 18
3. STUDY SITES AND POPULATION .............................................................................. 21
3.1. Study Setting: The District of Bugesera in the East Province of Rwanda .................... 22
3.1.1. Young People ............................................................................................................................ 23
3.1.2. School Life in Rwanda .......................................................................................................... 24
3.2. The Intervention: The Peer Education Intervention of Rwandan Red Cross ............. 25
3.2.1. Short History ............................................................................................................................ 25
3.2.2. Objectives and Design .......................................................................................................... 25
4. METHODOLOGY ............................................................................................................
4.1. Study Design ..........................................................................................................................................
4.1.1. Sytematic Literature Reviews: Objective 1, 3.b and 3.c ..........................................
(Paper 1: Meta-Analysis, Paper 5: Out-of-school Youth, and
Paper 6: Theory Review)
4.1.2. Qualitative Research: Objectives 2 and 3.a (Paper 2: Rwandan .........................
Intervention and Paper 4: Self -selection)
4.1.3. Qualitative Study: Objective 3.b (Paper 4: Mailbox Technique) .........................
4.2. Research Ethics .....................................................................................................................................
4.2.1. Ethical Approval ......................................................................................................................
4.2.3. Exemption for Parental Consent ......................................................................................
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27
27
27
29
31
33
33
33
33

5. RESULTS ....................................................................................................................... 35
5.1. Outline .............................................................................................................................................. 36
5.2. To Assess the Overall Effectiveness of HIV Prevention Interventions .................. 36
for Young People in Sub-Saharan Africa (Objective 1)
5.3. To Assess the Effectiveness of a Peer-led School-based HIV Prevention ............ 50
Intervention in Rwanda (Objective 2)
5.4. To Identify and Study Possible Reasons for the Observed Limited ....................... 72
Effectiveness of HIV Prevention Interventions for Young People in
Sub-Saharan Africa (Objective 3)
5.4.1. To Assess Young People’s Participation in HIV Prevention ........................ 72
Interventions (Objective 3.a)
5.4.2. To Study The Vulnerability of Young People for Poor Sexual and ............ 90
Reproductive Health (Objective 3.b)
5.4.3. To Assess the Theoretical Assumptions used to Change Sexual ............... 123
Behaviour in HIV Prevention Interventions for Young People
in Sub-Saharan Africa (Objective 3.c)
6. DISCUSSION ................................................................................................................
6.1. Failure to Demonstrate the Effectiveness of HIV Prevention .....................................
Interventions
6.2. Reasons for the Observed Limited Effectiveness of HIV Prevention .......................
Interventions
6.3. Limitations .......................................................................................................................................
6.4. Conclusions, Recommendations and Directions for Further Resaerch .................
SUMMARY ......................................................................................................................... 169
SAMENVATTING .............................................................................................................. 173
REFERENCES .................................................................................................................... 178
ANNEX ................................................................................................................................
Paper 7: Kenyan Intervention ..............................................................................................................
Paper 8: Globalisation and Education ..............................................................................................
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143
144
146
160
162
195
195
205

LIST OF FIGURES
Figure 1.1: Evolution of HIV Infection [23] .........................................................................................
Figure 1.2: Reproduction of the HIV Virus [24] ................................................................................
Figure 1.3: Evolution of the number of people living with HIV (left) and of HIV ...............
incidence (bleu, right) and AIDS-related deaths (grey, right) [25]
Figure 1.4: Number of people living with HIV by region [27] ....................................................
Figure 1.5: Evolution of HIV prevalence in sub-Saharan Africa among the adult ..............
population (15-49 years), 1990-2009 [26]
Figure 1.6: Aspects of the HIV epidemic addressed in this doctoral research ....................
Figure 2.1: Overview of doctoral research objectives ....................................................................
Figure 3.1: Map of Rwanda (left) and the district of Bugesera in the East ...........................
Province of Rwanda (right)
Figure 3.2: Rwandan national (red, middle), urban (blue, upper), and rural ......................
(green, lower) HIV prevalence curves [105]
Figure 3.3:
Figure 4.1: Quality assessment of articles included in paper 6 .................................................
Figure 6.1: Theoretical intervention sequence of HIV prevention interventions for .......
young people in sub-Saharan Africa
Figure 6.2: Practical interpretation of intervention sequence ...................................................
Figure 6.3:
this doctoral research study
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3
3
4
4
5
8
17
22
23
23
29
146
147
151

LEXICON AND LIST OF ABBREVIATIONS
Adolescents People aged 10 to 19 years
BSS Behavioural Surveillance Survey
Children People aged under 18 years
CSE Comprehensive Sexuality Education
CNLS Comité Nationale de Lutte contre le Sida / National AIDS Commission
DHS Demographic and Health Survey
HSV-2 Herpes Simplex Virus type 2
ICRH International Centre for Reproductive Health
IPPF International Planned Parenthood Federation
RRC Rwandan Red Cross
SRH(R) Sexual and Reproductive Health (and Rights)
(c)RCT (clustered) Randomized Controlled Trials
STI Sexually Transmitted Infection
UNAIDS Joint United Nations Programme on HIV/AIDS
UNDP United Nations Development Programme
UNFPA United Nations Population Fund
UNGASS United Nations General Assembly Special Session on HIV and AIDS
UNICEF United Nations Children’s Fund
WHO World Health Organization
Young people People aged 10 to 24 years
Youth People aged 15 to 24 years
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INTRODUCTION
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1. Introduction
1.1. HIV/AIDS: History, Transmission and Stages
The HIV epidemic exploded in the early eighties. In the United States of America an
increasing number of persons presented with an aggressive form of the rare skin cancer
Kaposi Sarcoma [1]. Around the same period physicians noticed a stark increase in a
severe lung infection Pneumocystis carinii pneumonia [2]. While these diseases where
initially mainly observed in homosexual men, it rapidly became clear that also other
population groups were affected. In 1982, while reports of similar diseases came from
ciency
Syndrome. Two years later, in 1984, French and American scientists succeeded in
isolating a virus that was thought to be the cause of AIDS [3, 4], which would be named
receiving a blood transfusion from an infected source, the chance of being infected is
90% [5]. Second, HIV can be transmitted through needles: intravenous needles use has a
0.7% [95% CI 0-10.2] chance of transmitting HIV [6-9], while needle sticks through the
skin have a 0.3% chance [10]. Third, HIV can be transmitted from mother to child during
pregnancy, childbirth and breastfeeding. Without treatment for the HIV-positive mother,
the chance of transmitting the virus to her child is 25% to 40% [11, 12]. Finally, HIV can
be transmitted through sexual intercourse. The risk of being infected with HIV through
sexual intercourse depends on the type of sexual contact. It ranges from an estimated
0.005% (man being fellated) [13] over 0.1% (receptive penile-vaginal intercourse)
[14] to 1.7% [95% CI 0.3-8.9] (receptive anal intercourse) [6, 15]. Worldwide, the most
common transmission route is heterosexual sexual intercourse [16-18]: it is estimated
to account for about 70% of HIV infections [19, 20]. In some nations or regions, other
transmission routes dominate, e.g. injecting drug use in Russia [21] or homosexual sexual
intercourse among Belgians [22]. HIV infection can be prevented by screening donor
blood for HIV, providing prophylaxis treatment to HIV positive pregnant women and
their newborn babies, treating HIV positive persons 1 , making clean needles and syringes
available, circumcising men, and having protected sexual intercourse. Currently, there is
no vaccine or cure for HIV/AIDS.
HIV infection has three main stages: acute infection, the latent phase, and AIDS (Figure
1.1). Upon infection, when entering the blood stream, HIV rapidly multiplies. It attaches
itself to CD4-cells, white blood cells playing a central role in the body’s immune response,
and uses these cells to reproduce itself (Figure 1.2). This phase of acute infection is characterized
by a rapid increase in HIV viral load and a stark decrease in CD4-cells. HIV viral
load reaches its peak around six weeks after infection.
1 ing
HIV positive people is an effective prevention strategy.
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Then the immune systems responds and reduces the number of viral particles in the
blood. The infection enters into the latent phase, which can last between two and twenty
years. Within this phase, we distinguish between asymptomatic and symptomatic HIV infection.
The asymptomatic phase lasts on average ten years in which the infected person
is free of major symptoms. In the symptomatic phase, symptoms start to appear because
of the weakened immune system. Without treatment, gradually, the number of CD4-cells
reduces. When it reaches the critical level of 200 cells per µL, the immune system is so
weak that a number of opportunistic infections begin to show. To be diagnosed with
AIDS, a person needs to be diagnosed with one or more severe opportunistic infections
or cancers (as Pneumocystis carinii pneumonia, or Kaposi sarcoma).
Figure 1.1: Evolution of HIV infection [23] Figure 1.2: Reproduction of the HIV virus [24]
1.2 The HIV Epidemic
1.2.1. Worldwide
increased at a staggering rate. The peak of new infections occurred in the mid-nineties
with 3.5 million [3.2 million – 3.8 million] new infections. Since then, the number of newly
infected people has been decreasing slowly. Since the peak in HIV deaths in 2004 (2.2
million [1.9 million – 2.6 million]), due to the widespread introduction of anti-retroviral
treatment, also the number of AIDS-related deaths started to decrease (Figure 1.3).
The continued large number of infections and a longer life expectancy of HIV-positive
people, has resulted in an ever increasing number of HIV-positive persons worldwide. Recent
UNAIDS data show that an estimated 34 million people [31.6 million–35.2 million]
were living with HIV worldwide in 2010. This means that about 1% of the adult world
population is infected with the virus. In 2010, an estimated 1.8 million [1.6 million – 1.9
million] people died of an AIDS-related cause and 2.7 million [2.4 million – 2.9 million]
new infections occurred [25].
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Figure 1.3: Evolution of the number of people living with HIV (left) and of HIV incidence
(blue, right) and AIDS-related deaths (grey, right) [25]
1.2.2. Sub-Saharan Africa
Figure 1.4 and Figure 1.5 show that one region is particularly touched by the HIV epidemic.
In 2010, 70% of the new HIV infections occurred in sub-Saharan Africa. This part
of the world hosts two thirds of all HIV-positive people, while it is home to only 12% of
e.g. Mauritania with an HIV prevalence of the adult population (15 to 49 years) of 0.7%
[0.6%-0.9%], Cameroon with 5.3% [4.9%-5.8%] and Swaziland with 25.9% [24.9%-
27.0%] [26]. While these data might be subject to reporting or measurement biases, the
large differences between the countries indicate the existence of important differences
within the sub-Saharan African region. Not neglecting this great variety, we cannot ignore
that one part is highly affected: East and Southern Africa. Most countries in this subregion
have an adult HIV prevalence of over 5%, some even exceed 20%. South Africa has
more people with HIV than any other country in the world (5.6 million), while Botswana,
Swaziland and Lesotho have the highest prevalence rates in the world.
Figure 1.4: Number of people living with HIV by region [27]
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There is no straightforward reason that explains why HIV prevalence is so high in this
region. A combination of factors lies at the base. We touch on a non-exhaustive number of
possible reasons, for the purpose of illustrating the complexity of the problem: interact-
First, there are biological factors that account for part of this discrepancy. Communities
with high prevalence of male circumcision are generally less affected by the HIV pandemic
[31-34]. Also, the HIV subtype seems to play a role. Each HIV subtype has its preferred
way of transmission. HIV-1 subtype C is most dominant in Southern Africa and fuels
heterosexual epidemics, while subtype B, most prevalent in Europe and North America, is
more easily transmitted through homosexual contact and intravenous drug use [35].
Figure 1.5: Evolution of HIV prevalence in sub-Saharan Africa among the adult population
(15-49 years), 1990-2009 [26]
Second, behavioural factors, such as condom use and the type of sexual partnerships,
partly explain this difference. In East and Southern Africa there is a high prevalence of
concurrent sexual partnerships [36-38]. Such overlapping relationships create a complex
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and interlinked sexual network that, given the high chances of HIV transmission in the
1.1), serves as a highway for HIV transmission [39-42]. Especially in Southern Africa
between self-reported symptoms of sexually transmitted infections and having had a
partner who engaged in concurrency. Helleringer and Kohler [44] mapped the sexual
network of the general population of young adults on Likoma Island in Malawi: even
though the number of sexual partners was not high (on average 2.6 for men and 2.2 for
women in the last three years), about half of the respondents were connected to each
cantly
higher than in the smaller networks. In a survey among 3,500 young people in
the Cape Town area in South-Africa, Mah [45] found that 13% reported a concurrent
partnership during their last sexual relationship; men and so-called Black youth reported
higher levels. Also in South Africa, in a household survey including 1,144 respondents
between the ages of 15 and 24 years, 38% of sexually active men and 19% of sexually
active women reported having had an overlapping second partner during their last
relation [46]. In the same study, 40% of women said their partner had another partner.
Several qualitative studies have shown that people categorize their relationships as
‘main’/‘regular’/‘primary’ and ‘nonprimary’/‘other’ [47-50].
nature. For example, poverty can been seen as an important factor [52-54]; it can lead
to a lack of health care and treatment for HIV positive persons, but also to transactional
sex – i.e. sex in exchange for money and/or goods – during which condom negotiation is
demic,
since they had access to paid sex and were mobile [55]. Another contextual factor
is education. While one study show that HIV risk decreases with 7% for each additional
year of educational attainment [56], another claims that this impact differs regionally,
depending on the level of globalization [57]. Another example of social factors are laws
discriminating against men who have sex with men, pushing them into the margins, and
hence increasing their risk for unprotected sex. This shows that political leadership is essential
in the response to HIV. While Uganda’s initial response to the epidemic, focussing
on each individual’s responsibility to combat the epidemic, is put forward as a success
story, South Africa’s leaders have received criticism for their HIV denialism. Socio-cultural
issues, like gender inequality and taboos surrounding sexuality, are equally important.
Only recently more positive news was reported. The latest UNAIDS report indicated that
in 22 sub-Saharan African countries, HIV incidence declined by more than 25% between
2001 and 2009, including in some of the world’s largest epidemics like Ethiopia, Nigeria,
South Africa, Zambia and Zimbabwe. But, even though the epidemic seems to be leveling
off, with an HIV incidence of 1.9 million [1.7 million–2.1 million], it remains at an unacceptably
high level. [25]
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1.3. HIV in Young People in Sub-Saharan Africa
“Nothing should be more important than a major focus on young people” [58]
1.3.1. Focus on Young People
The changes in HIV incidence are most marked among young people. HIV incidence
declined among young people aged 15 to 24 years in 16 of the 21 countries most affected
by HIV. These declines have occurred amid signs of changes in sexual behaviour. The
percentage of young men with multiple partners in the past 12 months decreased sig-
of 14 countries. Among young men who had multiple partners in the last 12 months, the
in 7 of 16 countries, respectively. [59, 60]
Nevertheless, HIV incidence in young people aged 15 to 24 years remains worrying. Half
of the new HIV infections occurs in this age group. Worldwide, on average, over 2,500
young people get infected with HIV every day; almost 80% of these infections takes place
in sub-Saharan Africa, resulting in a regional HIV prevalence of 1.4% [1.1%-1.8%] in
young men and 3.3% [2.7%-4.2%] in young women [25]. Changing sexual behaviour in
this group is crucial in tackling the pandemic [58, 61].
In many sub-Saharan African countries, young people aged 15 to 24 years make up over
one third of the population. This means that in this region a large number of people are
about to start their sexual lives or have just started it [62]. These young people are particularly
vulnerable to HIV infection and poor sexual and reproductive health; due to the
combination of universal risk-taking behaviours that emerge during adolescence, such
as alcohol consumption, sexual initiation, and several individual, social and structural
factors, including limited knowledge and skills with regard to sexual and reproductive
health issues, poverty and gender imbalance [63]. The World Health Organization (WHO)
estimated that nearly two thirds of premature deaths and one third of the total disease
burden in adults are associated with conditions or behaviours that began in youth, such
as drinking, unprotected sex or exposure to violence [64].
Girls and young women are most vulnerable in this respect. They are more prone to HIV
infection, due to several factors, including biological susceptibility to HIV, economic dependence
on men, sexual relationships with older men and less access to education. The
number: globally, young women make up more than 60% of all young people living with
HIV; in sub-Saharan Africa their share jumps to 72% [65].
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This study will focus on prevention of sexual transmission of HIV in young people in
sub-Saharan Africa. Figure 1.6 indicates that focusing on prevention of sexual transmission
of HIV among young people is only one of the many ways of managing the HIV/AIDS
epidemic.
Treatment of HIV
positive persons
Care and support
for people infected
with and affected
by HIV
Prevention of sexual transmission
Biomedical ( male
circumcision,
microbicides, treatment
as prevention,
General population Young people
Ways of managing the HIV epidemic
Influence policy
Ways of preventing HIV infection
Prevention through blood (blood
transfusion and needle sharing)
Figure 1.6: Aspects of the HIV epidemic addressed in this doctoral research
1.3.2. Being Young in Sub-Saharan Africa
Young people in sub-Saharan Africa live in a complex world, characterized by rapid
social change. Factors as increased school enrollment, globalization and increasing trade,
democratization of political systems, and instantaneous global communication expose
8
Reduce the impact
of HIV on society
(education sector,
health sector,
Ways of preventing sexual transmission of HIV
Behavioural (increase
condom use, reduce
number of sex partners,
increase age of sexual
debut, reduce
concurrent
partnerships, reducing
the age gap between
partners, HIV
)
Structural (education,
Target groups of HIV prevention through sexual transmission
Men who have sex
with men
Prevention of HIV
Prevention of vertical transmission
(mother-to-child transmission)
Combination prevention
Sex workers Mobile populations
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young people to information, challenges, and possibilities that threaten their customs
and values [66]. Furthermore, with an increase in the age of marriage and schooling, a
distinct period of adolescence was created in African societies; a period characterized by
boy-girl friendships, likely to include sexual relationships [67-70].
For many young people in developing countries, this transitory life stage is further
complicated by the clashes between the many forces of westernization, and the stricter
traditional values of their societies [69]. The relatively new life phase of adolescence and
concept of companionate heterosexual relations before and during marriage, as well as
increased access to pornographic movies, is of great importance in shaping young people’s
ideas and behaviours [68, 71-74]. As Maticka-Tyndale [75] puts it, young people are
confronted with “a complex mix of traditional beliefs, norms and expectations, western
values, ideas and modes of interaction, and a changing set of social expectations”. Luke
[76] adds that “the cultural ideals for adolescent behaviour are being replaced by peers’
concerns for status and material goods and pressures to begin sexual relations”. Strong
gender roles, norms and values concerning relationships coincide with differing religious
and western views.
The disintegration of traditional methods of sex education, such as rites of passage and
elder’s narratives, and the lack of comprehensive sexuality education in school has created
a void of knowledge on sexual and reproductive health matters for adolescents. On
or incomplete [76-78] and peer pressure and norms can be counteractive [79, 80]. On
the other hand, many governments, non-governmental organizations and international
organizations are investing in HIV prevention interventions for young people.
1.3.3. HIV Prevention Interventions for Young People
In order to prevent sexual transmission of HIV, a number of strategies can be adopted:
biomedical prevention (e.g. male circumcision, microbicides or treatment as prevention),
individual behaviour change strategies and structural interventions. Our study
focuses on the latter two. Behaviour change interventions promote actions as: abstinence
the number of sexual partners. Additionally, they aim to increase knowledge, change
attitudes, improve access to services and to reduce stigma or address other mediators
attempt to motivate behavioural change within individuals and social units by use of a
range of educational, motivational, peer-group, skills-building approaches, and community
normative approaches”. Structural approaches to HIV prevention, on their turn, “seek
to change social, economic, political, or environmental factors determining HIV risk and
vulnerability” [51]. In practice, structural interventions might address factors as gender
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inequality [83], the economic situation of young people [84] or stimulating young people
to go to school [85].
Over a decade ago, Merson [86] concluded a review on the effectiveness of HIV prevention
interventions by stating that there is a dearth of evaluated prevention interventions
for young people. Since, the number of evaluations and literature reviews is increasing.
tings,
such as schools [87, 88], or with particular tools like mass media [89]. Others have
[86, 91-95], and even others have focused on types of outcomes, e.g. including only evaluations
that report on biological outcomes [96].
Gallant [87] studied the effectiveness of 11 school-based HIV prevention interventions
in sub-Saharan Africa. Studies that assessed the effectiveness on HIV knowledge and attitudes
reported positive results, respectively in 10 of 11 and 7 of 7 studies. Sexual debut
was delayed in only 1 of 3 studies, and only for a subgroup of the population. Condom use
increased in 1 of 2 studies. Some years later Paul-Ebhohimhen [88] published a review
on the same topic: knowledge (12 of 13 measures) and attitudes (11/13) were changed
in almost all studies measuring these items. Intention to use a condom, was only changed
in 1 of 5 studies, and also condom use and abstinence increased in 1 of 5 studies. Bertrand
[89] measured effectiveness of HIV prevention interventions for young people using
media worldwide. Of the 9 studies reporting data on knowledge of HIV transmission
and prevention, 4 measured an increase. As for sexual behaviour, abstinence increased in
2 of 6 interventions, the number of partners reduced in 1 of 5 studies and 5 of 12 reported
an increase in condom use.
Speizer [91], Magnussen [93] and Kirby [92] reviewed the effectiveness of HIV prevention
and reproductive health interventions for young people in developing countries
worldwide. The studies demonstrated relatively little effectiveness on sexual behaviour
outcomes: for most indicators only one fourth to one third showed positive changes. Ross
[96] assessed the impact of behavioural interventions on HIV incidence using random-
incidence.
Three common messages dominate these reviews. Firstly, there is a paucity of evaluated
of sub-Saharan Africa. Secondly, the quality of evaluation designs is relatively low, hence
the level of evidence is questionable. Thirdly, the current evidence paints a mixed picture:
while interventions generally succeed in increasing knowledge and, to a lesser extent,
changing attitudes, the effectiveness on self-reported behaviour is more ambiguous and
effectiveness to reduce HIV incidence has not been shown. Given the focus of these reviews
(thematically, geographically or methodologically), none of these reviews focused
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1.4. Conclusion
In the past three decades HIV has had devastating effects on people’s lives. Especially
young people in sub-Saharan Africa remain at the centre of the epidemic. Recently the
ing
visible in surveillance studies on national levels. However, in order to reverse the
epidemic, a continuous focus on HIV prevention in young people is essential. Literature
reviews on aspects of HIV prevention interventions for young people (e.g. media
interventions and suggest limited effectiveness of these interventions in changing young
people’s sexual behaviour and HIV incidence.
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13
OBJECTIVES
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2. Objectives
2.1. General Objective
Given that young people remain at the centre of the HIV epidemic, the general objective
of this study was to improve the effectiveness of HIV prevention interventions for young
people in sub-Saharan Africa.
1. To assess the overall effectiveness of HIV prevention interventions for
young people in sub-Saharan Africa
Research question: what is the overall effectiveness of HIV prevention
interventions in changing sexual behaviour of young people in sub-Saharan
Africa?
Literature reviews on aspects of HIV prevention interventions for young people
(e.g. media interventions, school-based interventions) suggest a limited
effectiveness of these interventions in changing sexual behaviour and
reducing HIV incidence. However, a literature review and meta-analysis on the
young people in sub-Saharan Africa, that allows drawing overall conclusions on
their effectiveness, was missing. Studying evaluations of HIV prevention
interventions for young people also gives insights in potential reasons for their
success/failure.
2. To assess the effectiveness of a peer-led school-based HIV prevention
intervention in Rwanda
Research question: What is the effectiveness of a peer-led HIV prevention
intervention for young people in Rwanda?
Peer education is a popular approach in HIV prevention for young people. It
makes use of existing social processes, and actively involves young people in
the intervention [97, 98]. In Rwanda, peer education has been adopted as a
strategy to prevent HIV infection among in-school youth [99], but has not yet
be thoroughly evaluated.
To get a better understanding of how HIV prevention interventions for young
people in sub-Saharan Africa are developed, implemented and evaluated, an
evaluation of a peer-led intervention was set up. Besides contributing to the
HIV prevention interventions and gain insights in the conditions for their
success/failure.
14
Kristein.indd 14 10/25/2012 8:36:13 PM

Additionally, we participated in the evaluation of a peer-led sports-based HIV
prevention intervention in Kenya, which can be found in annex.
3. To identify and study possible reasons for the observed limited
effectiveness of HIV prevention interventions for young people in
sub-Saharan Africa
Results from the previous objectives indicated a limited effectiveness of HIV
prevention interventions on young people’s sexual behaviour and HIV
reasons for this observed lack of effectiveness. Firstly, interventions might
intervention. Secondly, it could be that HIV prevention interventions do not
address the right topics to make young people change their sexual behaviour.
Most HIV prevention interventions talk about ways of transmission and
prevention of HIV, in order to make young people change their behaviour.
But it is likely that sexual behaviour is based on more than knowledge on and
attitudes towards HIV. Therefore, it is important to understand how young
people think about sexuality and relationships and to study factors that
determine their vulnerability to HIV. Thirdly, the observed limited
reduction interventions, on how to change young people’s sexual behaviour.
Finally, many HIV prevention interventions for young people have to deal with
study.
a. To assess young people’s participation in HIV prevention interventions
Research question: To what extent do young people participate in a
peer-led school-based HIV prevention intervention in Rwanda and what is
Participation in most HIV prevention interventions is voluntary. Several
studies have shown that young people with high exposure to the
intervention are more likely to change their behaviour. However, these
would provide more insight in the mechanisms of participation and would
allow designing interventions that are attractive to all young people. Using
data from the evaluation study of the peer-led school-based intervention in
Rwanda, we analyzed participation in the intervention and developed
15
Kristein.indd 15 10/25/2012 8:36:13 PM

. To study determinants of young people’s vulnerability for HIV infection
Research question: What factors contribute to the vulnerability of young
people to HIV infection?
Sexual intercourse is the main transmission route for HIV. However, this does
behaviour. In order to develop effective interventions that succeed in changing
sexual risk behaviour of young people, we should be aware of the important
structural level, using a qualitative technique (the mailbox technique) and a
systematic literature review.
c. To assess the theoretical assumptions used to change behaviour in HIV
prevention interventions for young people in sub-Saharan Africa
Research question: On which theoretical assumptions are HIV prevention
interventions for young people in sub-Saharan Africa based?
In setting up and implementing interventions, programme planners - explicitly
or implicitly - make assumptions on how sexual behaviour can be changed.
Using a systematic literature review, we will study the assumptions used in HIV
prevention interventions for young people in sub-Saharan Africa, identify their
strengths and weaknesses and analyze if theory-based interventions are more
effective than non-theory-based interventions.
4. To formulate recommendations to improve the effectiveness of HIV
prevention for young people
16
Kristein.indd 16 10/25/2012 8:36:13 PM

Figure 2.1: Overview of doctoral research objectives
17
1. Assess the overall
effectiveness of HIV
prevention interventions
(paper 1)
2. Assess the effectiveness of
a peer-led school-based
HIV prevention
intervention in Rwanda
(paper 2)
Observed
limited
effectiveness
3. Identify and study possible reasons for
observed limited effectiveness
a. participation in intervention (paper 3)
b. intervention content: determinants of
vulnerability (papers 4, 5)
c. intervention theoretical assumptions
(paper 6)
Identify other reasons
4. Formulate recommendations
to improve the effectiveness
of HIV prevention
interventions for young
people in sub-Saharan Africa
Kristein.indd 17 10/25/2012 8:36:14 PM

2.3. Presentation of Publications
This thesis is based on a number of papers that have been published or are under review
in international peer-reviewed journals. The manuscripts are presented in full in the
Results section (primary papers) or in annex (secondary papers):
Primary papers:
1. Michielsen K., Chersich MF., Luchters S., De Koker P., Van Rossem R., Temmerman M.
(2010). Effectiveness of HIV prevention for youth in sub-Saharan Africa: systematic re
view and meta-analysis of randomized and nonrandomized trials. AIDS 24(8):1193–
202. Type: A1, IF: 6.348 (further referred to as “Paper 1: meta-analysis”)
2. Michielsen K., Chersich M., Luchters S., Van Rossem R., Temmerman M. (2010).
Concurrency and the limited effectiveness of behavioural interventions on sexual risk
behaviour of youth in sub- Saharan Africa. AIDS 24(13):2140-2. Type: A1
(correspondence), IF: 6.348
3. Michielsen K., Beauclair R., Delva W., Van Rossem R., Temmerman M. (2012) The
impact of a peer-led HIV prevention intervention in secondary schools in Rwanda:
results from a cohort study with repeated measures and control group. BMC Public
Health 12:729 Type: A1, IF: 2.0 (“Paper 2: Rwandan intervention”)
4. Michielsen K., Celis H., Jingwa B., Degomme O., Van Rossem R., Temmerman M. Selfselection
in a HIV prevention intervention: who is participating? Results from a peer
education programme in secondary schools in Rwanda. Submitted to AIDS Education
and Prevention (13/2/2012 – under review). Type: A1, IF: 1.59 (“Paper 3: selfselection”)
5. Michielsen K., Remes P., Van Rossem R., Temmerman M. “I Think AIDS Is Raging
among Teenagers Because of Their Passion for Possessions”. Rwandan Adolescents’
Perceptions on Sexual and Reproductive Health Vulnerability Using the ‘Mailbox
technique’. Submitted to SAHARA (4/1/2012 – under review). Type: A1, IF: 0.741
(“Paper 4: mailbox technique”)
6. Stroeken K., Remes P., De Koker P., Michielsen K., Van Vossole A., Temmerman M.
(2011). HIV among out-of-school youth in Eastern and Southern Africa: a review. AIDS
Care 2012;24(2):186-94. Type: A1, IF: 1.603 (“Paper 5: out-of-school youth”)
7. Michielsen K., Chersich M., Dooms T., Temmerman M., Van Rossem R.. Nothing as
practical as a good theory? The theoretical basis of HIV prevention interventions for
young people in sub-Saharan Africa. AIDS Research and Treatment. 2012:345327.
Epub 2012 Aug 1. Type: A2 (“Paper 6: theory review”)
Secondary papers (in annex):
1. Delva W., Michielsen K., Meulders B., Groeninck S., Wasonga E., Ajwang P.,
Temmerman M., Vanreusel B. (2010), HIV prevention through sport: the case of the
Mathare Youth Sport Association in Kenya, AIDS Care 22(8):1012-20. Type: A1, IF:
1.684 (“Paper 7: Kenyan intervention”)
18
Kristein.indd 18 10/25/2012 8:36:14 PM

2. Stroeken K., Michielsen K., Remes P., Meeuwis M. The region-sensitive effect of
globalization on HIV in Eastern and Southern Africa: The dual role of education.
Submitted to AIDS & Behavior (08/2012 – under review). Type: A1, IF: 3.494 (“Paper
8: globalization and education”)
19
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20
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STUDY SITES AND
POPULATION
21
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3. Study Sites and Population
As an introduction to the results, we present some background into the setting in which
our studies took place, i.e. the Republic of Rwanda.
3.1. Study setting: the district of Bugesera in the East Province of
Rwanda
Rwanda is a small landlocked country situated at the centre of the African continent. It
has a surface of 26,338 square kilometres, slightly smaller than Belgium, and a population
of almost 11.7 million [100], making it the most densely populated country in Africa.
Rwanda has a very young population, the median age being 18.7 years, with a strong
population growth (fertility rate: 5.4 children per woman) [101]. Rwanda has known
a recent history of extreme violence. Since the Hutu ethnic group overthrew the Tutsi
ruling king in 1959, there have been regular killings of Tutsis and moderate Hutus. This
violence culminated in the 1994 genocide, where in the course of a month an estimated
one million Tutsis and moderate Hutus were killed. Rwanda occupies rank 166 on the
Human Development Index list [102], slightly below the sub-Saharan African average
Figure 3.1: Map of Rwanda (left) and the district of Bugesera in the East Province of Rwanda
(right)
only a few years later a national HIV prevalence of 17.8% in urban areas and 1.3% in
rural areas was registered. After the extreme violence and high number of sexual assaults
during the genocide, the prevalence peaked in 1996 with an estimated 27% HIV-infected
persons in urban areas and 6.9% in rural populations. While these data were mainly
collected among pregnant women in antenatal care centres and patients from sexually
transmitted infections (STI) clinics, more precise sentinel data were collected in 2002,
22
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that found that prevalence varied between 2.6% and 3.6% in rural areas and between
7.0% and 8.5% in urban areas. More recent surveys (2005 and 2010) established the
adult HIV prevalence at 3% (4% in women and 2% in men). Urban areas remain most
affected with a prevalence of 7.1%, compared to 2.3% in rural areas [103, 104].
The Rwandan government puts HIV high
on the agenda. Over 110 million dollar
was spent on HIV related activities
in 2008 (mostly coming from external
donors). A considerable part of this
budget (26% or 29 million in 2008) is
allocated to prevention. The Rwandan
Government published an ambitious
3-year National Strategic Plan on HIV/
AIDS (2009-2012) in which it aims
to reduce the incidence of HIV in the
general population by half. Concerning
behavioural prevention, the Rwandan
Government uses the EABC approach:
education, abstinence, being faithful and
condom use. [99]
Our study takes place in the East Province
of Rwanda, in the neighbouring districts
of Bugesera (intervention district)
and Rwamagana (control district). This
province is characterized by low levels
of knowledge on HIV, early sexual debut,
high levels of risky sexual behaviour, and
low uptake of HIV prevention related
services [99]. It is a rural province, with few urban centres.
3.1.1. Young People
43.5% of the Rwandan population is under the age of 15 years, 53% are under the age
of 20 years [107]. In Rwanda, HIV prevalence among young people aged 15-24 years is
1.9% for women and 1.3% for men. Especially young women aged 20-24 years are affected:
the HIV prevalence rises from 0.8% among those aged 15-19 years to 2.4% among
those aged 20-24 years [103]. 6.6% of young people had sex before the age of 15 years
[108]. Modern contraceptive use 2 among young women is 30.6% for women aged 15-19
years and 42.1% for those aged 20-24 years. 11% of young people aged 15-24 years had
comprehensive knowledge of HIV/AIDS [110].
2 “Modern methods of contraception include the pill, female and male sterilization, IUD [intrauterine device], injectables, implants, male and female
condom, diaphragm, and emergency contraception. Traditional methods include periodic abstinence, withdrawal and folk methods” [109. Family
Planning [http://www.measuredhs.com/topics/Family-Planning.cfm]
23
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In the National Strategic Plan on HIV [99] young people get a prominent place; halving
the HIV prevalence among young people is one of the key indicators. This should be
reached by delaying the onset of sexual activity, expanding youth-friendly HIV prevention
and reproductive health services, and integrating sexual and reproductive health and HIV
prevention in the school curricula (p. 53). School-based sexual health and anti-AIDS clubs
will be used to reach young people (p. 54); a total of 2.5 million dollar (2% of the total
budget) is dedicated for HIV related activities among secondary school students. Young
The overall coordination of the National Strategic Plan on HIV is done by the National
AIDS Control Commission (CNLS). The implementation is divided into 12 sectors (according
to the sector in which it takes place), under the responsibility of the corresponding
ministry. Other partners in implementation are civil society organizations, the private
sector, regional and international programmes, and national reference institutions [99].
3.1.2. School life in Rwanda
The secondary education system in Rwanda is divided into two parts. In lower secondary,
dents
in secondary education ranges from 12 up to 30 years and even older.
The gross enrolment rate (number of pupils enrolled in a given level of education related
education is 143, which drastically reduces for lower secondary education (43) and higher
secondary education (32 3 ) [111]. The gross graduation ratio is 53 for primary school,
19 for lower secondary education [111] and 10 for higher secondary education [112].
The majority of secondary school students reside in boarding schools and only return
home for holidays two or three times a year. In most schools, boarding school students
‘clubs’ operate in the schools, giving the students the opportunity to engage in free time
activities, such as football clubs, music clubs, or religious clubs. In each school, the Rwandan
Government installed a mandatory ‘anti-AIDS club’. This club is tasked with motivating
students to take preventive efforts against HIV infection.
3 This means that, for each 100 young people that are, given their age, expected to be in higher secondary education, 32 are actually enrolled.
24
Kristein.indd 24 10/25/2012 8:36:14 PM

3.2. The intervention: the Peer Education intervention of the
Rwandan Red Cross
3.2.1. Short History
beginning of the nineties. After the genocide, however, the programme stopped for sev-
living with HIV/AIDS and prevention activities for youth, in the former provinces of
Gikongoro and Gisenyi and later in Kibungo and Kibuye. In 2003, the Red Cross Belgium
Flanders injected additional funds enabling the Rwandan Red Cross to set up an HIV prevention
programme in secondary schools in the former province of Gitarama.
The Gitarama programme was evaluated in the framework of a policy study for the Bel-
es
and points for improvement, a process was put in place to strengthen it and implement
an improved new intervention in the district of Bugesera. A joint effort by the RRC,
the Belgian Red Cross Flanders, Sensoa (the expert centre for sexual health in Flanders)
and the International Centre for Reproductive Health (ICRH) was set up. Workshops were
organized in Spring and Autumn 2008, to develop clear goals and objectives for the intervention,
and to elaborate a monitoring and follow-up plan. Red Cross staff was trained in
HIV/AIDS and sexual and reproductive health issues and in educational tools by Sensoa,
who also developed a training for the peer educators. The intervention was funded by the
Belgian Red Cross Flanders.
3.2.2. Objectives and Design
The main objective of the Peer Education intervention was to reduce sexual risk behaviour
and to promote sexual and reproductive health in the secondary school community.
- to increase knowledge of the students regarding HIV/AIDS and sexual and reproductive
health;
- to reduce discrimination and stigmatization of HIV positive people in the secondary
schools and in the community;
- to promote responsible sexuality;
- to reduce sexual risk behaviours for STI/HIV and unplanned pregnancies;
- to promote voluntary HIV/STI counseling and testing.
were selected and given a 6-day training. The training consisted of information on the
Red Cross and its main principles, HIV/AIDS, sexually transmitted diseases, family planning
and pregnancies, the role of the peer educator (what is expected of a peer educator
25
Kristein.indd 25 10/25/2012 8:36:14 PM

and what is the deontology of a peer educator?) and teaching methods (how to best approach
students and how to transmit messages and counsel?). The peer educators were
selected by the disciplinary teacher, who lives in the school and knows the students well,
teacher per school (‘encadreur’) equally received a training in order to be able to support
the peer educators in their activities. School principals attended a half day information
session on the intervention. Two-yearly follow-up trainings (‘recyclage’) and trimestral
activities took place. Each trimester the peer educators handed in an activity report. The
District Red Cross Coordinator paid regular visits to the schools and was available for
questions at any time.
The activities of the peer educators primarily focused on sensitizing their fellow students
for adopting positive and responsible behaviours towards HIV/AIDS. This was done
through group and individual counseling, theatres, songs and other interactive methods.
The intervention started in August 2009 and ended in October 2010. It was implemented
in all (15) secondary schools in the district of Bugesera.
26
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METHODOLOGY
27
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4. Methodology
To reach the aforementioned objectives, several study designs were chosen: systematic
literature reviews and a meta-analysis (objectives 1, 3.b and 3.c), quantitative (objectives
2 and 3.a) and qualitative designs (objective 3.b). The advantage of combining several research
methods is that they can counteract each other’s weaknesses while taking advantage
of the particular strengths of each method; combining research methods most likely
results in a more complete picture of the topic under study. The study designs will be
discussed in detail in the papers presented in Chapter 5; hereafter a general description
of the most important methodologies used throughout the doctoral study is presented.
The chapter concludes by discussing the research ethics.
4.1. Study Designs
4.1.1. Systematic literature reviews: objectives 1, 3.b and 3.c (paper 1:
meta- analysis, paper 5: out-of-school youth, and paper 6: theory
review)
Systematic literature reviews are used to identify and interpret all available relevant
of the knowledge on a given topic, but equally allow to identify research gaps.
Based on the PRISMA-and QUOROM-statement [114, 115], we performed two systematic
literature reviews, one including a meta-analysis. These reviews resulted in three
in sub-Saharan Africa (paper 1: meta-analysis), on the HIV and sexual and reproductive
health status of out-of-school youth compared to in-school youth (paper 5: out-of-school
youth) and on the theoretical basis of HIV prevention interventions for young people in
sub-Saharan Africa (paper 6: theory review).
Before the studies were effectuated, a study protocol was developed, which included procedures
for the literature search strategy, the inclusion criteria, the data to be extracted,
the extraction procedure and the data analysis methods. Both literature searches included
academic and grey literature. Paper 5 included an assessment of the overall quality
of the articles, based on Taylor [116] (Figure 4.1). The quality of the articles included in
papers 1 and 6 was guaranteed by the use of inclusion criteria on methodological soundness.
Inclusion criteria were developed. Inclusion was decided by two independent researchers
(paper 5: out-of-school youth) and by one researcher performing the literature
study twice with a six month time lapse in between (paper 1: meta-analysis and paper 6:
theory review). For both reviews, an electronic data extraction sheet was piloted by the
-
discussion between the pair of reviewers.
28
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Study Type
Qualitative Quantitative
Description of the sampling
(inadequate=0; adequate=1)
How was data collected?
(inadequate=0; adequate=1)
Independent inspection of data (1
rater=0; >1 rater=1)
Was there a clear description of data
analysis? (no=0; yes=1)
Use of supportive quantitative
methods? (no=0; yes=1)
Figure 4.1: Quality assessment of articles included in paper 6
4.1.2. Quantitative research: objectives 2 and 3.a (paper 2: Rwandan
intervention and paper 4: self-selection)
In order to study the effectiveness of a peer-led HIV prevention intervention for young
people in secondary schools in Rwanda (paper 2: Rwandan intervention), and to assess
undertook a longitudinal non-randomized controlled trial. Such methodology allows to
quantify the effectiveness of and participation in the intervention, to compare between
intervention and control groups and between participants and non-participants. If collected
properly, quantitative data also allow generalizations to a broader population.
Study design: Longitudinal Nonrandomized Controlled Trial: Studies 2 and 4
We undertook a longitudinal non-randomized controlled trial including 8 intervention
and 6 control schools. The study assessed students’ knowledge, attitudes and behaviours
3 times over a period of 18 months: March 2009 (Baseline), March 2010 (T1) and Sep-
baseline and T1 surveys were used, assessing if respondents’ characteristics at baseline
could predict participation in the intervention at T1.
Since the study was already planned to take place in all 15 secondary schools in the
district of Bugesera over a certain period of time, it was not possible to randomly allocate
schools, let alone, students, to the intervention or control condition. In the district
of Bugesera 8 out of 15 schools were selected on a purposive basis. We aimed to include
the greatest variety of schools in the study and applied several selection criteria: location
(urban/rural), funding (public/private), number of students (small/large), religious
background, and education offered (lower/higher secondary education). Control schools
29
Population size ( 1000=3)
Design: clear question/hypothesis
(no=0; yes=1)
Design: Type of study (other=1;
cross-sectional=2; casecontrol=3;cohort=4;
RCT=5; review
& meta-analysis=6)
Data analysis
Clear analysis plan (no=0;
yes=1)
Reporting on all participants
(no=0; yes=1)
Clear results (no=0; yes=1)
Kristein.indd 29 10/25/2012 8:36:15 PM

in the neighbouring district of Rwamagana were selected using the same criteria. The
chance of still being in school at the end of the survey. Drop-out rates are highest after
year. Since no roads directly connect intervention and control sites, cross-site contamination
was unlikely.
enced
sexual behaviour (condom use and recent history of sexual intercourse), sample
size calculations were based on Wald tests for the odds ratio associated with the interaction
term in regression models with two binary variables (intervention/control and T0/
T1 or T0/T2) and their interaction. For logistic regression models, a minimum of 1,241
observations are required to detect an adjusted odds ratio of 2 or more with 80% power
lence
of the outcome variable and no changes over time in the control group [117]. For
linear regression models, a minimum of 348 observations are required to detect a small
[118, 119]. Further, we assumed a design effect of 2, due to possibly strong correlation
of repeated measurements from the same participant (T0/T1/T2), resulting in a minimum
of 2,482 observations required from 1,241 participants. Anticipating a 25% loss to
follow-up, we increased the target sample size to 1,655 participants.
Data Collection
The data were collected using paper-based self-administered questionnaires with closed
ended questions. The questionnaire was developed in French, translated in Kinyarwanda
and back translated in French. The questionnaires were developed using existing,
validated questions and scales both for Rwanda [120-123] and Kenya [124-129] and
were pretested among a small group of young people. In Rwanda, the questionnaires
were administered in classrooms or refectories. The data-entry was done electronically
was done by or under supervision of the main researcher and consistency checks with
the paper versions were done by the main researcher.
Statistical Analysis
Three statistical packages were used to analyse our data: Stata version 11 (Stata Corporation,
College Station, TX) (papers 2 and 4), R version 2.9.0 (Ihaka & Gentleman, 1996;
R Development Core Team, 2005) (paper 3), and SAS version 9.2 (SAS Institute Inc., Cary,
North Carolina). The latter was used to test if answers from students within one school
were correlated. Since this was not the case, it was decided not to include schools as a
dures
that were used to analyse our data.
Propensity score matching (paper 2: Rwandan intervention)
The allocation of schools to the intervention and control group in the Rwandan study was
30
Kristein.indd 30 10/25/2012 8:36:15 PM

not randomized. Therefore we had to consider the possibility of selection bias. We evalu-
in the intervention and control groups, which appeared to be the case. To control for this
imbalance we calculated propensity scores. A propensity score is the probability of a unit
being assigned to a particular condition in a study given a set of known covariates [130].
Participants with propensity scores outside of the area of common support ([0.17, 0.98])
were excluded from subsequent analyses [131]. The propensity scores were also included
as a covariate in the multivariate effectiveness analysis.
Generalized estimation equations (paper 2: Rwandan intervention)
Given the longitudinal nature of the Rwanda study (each respondent participated three
times in the study), we needed to take into account the possibility of correlation between
averaged linear regression models to correlated data [132]. Parameter estimates from
In the Rwandan effectiveness study, marginal linear and logistic regression analyses, using
GEE, were conducted to determine the likelihood of experiencing different outcomes
based on which group the participant belonged to, while accommodating for repeated,
binomial or Gaussian distribution depending on which dependent variable was analysed.
Ordinal, multinomial and linear regression techniques (paper 3: self-selection)
To study determinants of binary and categorical dependent variables, we used binary,
ordinal and multinomial logistic regression. When studying determinants of a linear variable
we used linear regression models with backward variable selection technique. The
effects in a step-wise manner. At each step, the independent predictor with the least contribution
to the total variability was deleted. Akaike Information Criterion (AIC) was used
where -2Log Likelihood is twice the difference in the log Likelihood of the full model and
the alternative model [135] and k is twice the number of estimated parameters in the
model (number of variables and the intercept). For linear regression, competing models
related to the independent predictors (link function). Fitting models with different possible
distributions and link functions is an integral part of model selection by goodness of
4.1.3 Qualitative study: objective 3.b (paper 4: mailbox technique)
One of the hypotheses of the observed limited effectiveness of HIV prevention interventions
for young people in sub-Saharan Africa, and in Rwanda in particular, is that HIV
prevention interventions do not address the right topics to make young people change
their sexual behaviour. Hence, a study into the factors that determine this sexual behav-
31
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iour is advisable, but complex and sensitive. The main objective of this study was to gain
a thorough understanding of young Rwandans perceptions on sex and relationships.
sexual and reproductive health and 2) to formulate recommendations for interventions
that more directly address young people’s needs. Given the exploratory nature of such a
study, we opted for a qualitative approach. This allows to uncover hidden and underlying
ing
of the perspectives of the study population.
Study Design
There were several concerns for collecting data among in-school Rwandan youth on the
sensitive topic of sexuality and relationships using traditional qualitative methodologies.
Interviews and focus group discussions would likely not generate useful information,
because of the taboo on the topic and social desirability bias. Since the majority of the
students live in boarding schools, without privacy, using a diary method was not appropriate
because of the lack of safe storage spaces. An essay method, asking young people
to write an essay on a particular subject would have the downside that students would
only be able to express their ideas on one particular (imposed) moment. We sought a
way in which young people could freely and voluntarily express their ideas on paper
without having to store their written documents in an unsafe place. The idea of a mailbox
emerged, which offered the advantages of anonymity and spontaneity.
Data Collection
Six secondary schools, selected on a purposive basis, were given a mailbox in March
2009 and asked to install it in a place with a large passage of students, away from signs
by the principal investigator. Instructions were attached to the mailbox and the students
received detailed information on the objectives of the study in a school assembly. While
ated
in September 2009.
Almost half of the relevant letters came from one (rural, lower secondary) school, even
though all schools were given similar levels of information about the project. School
administration and teachers of this school were asked if they had undertaken actions to
motivate their students to write the letters, which was not the case. The reason for this
difference between schools is not clear.
Data Analysis
In total, 186 letters were collected. Analysis was done in QSR NVivo 9 (QSR International
reproductive health or relationship issues were excluded from the analysis. Second, a
closed coding system was applied, using the theoretical framework of Delor and Hu-
32
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ert [137] as a guideline. The coding was done twice by the same researcher with four
months between each coding.
4.2. Research Ethics
4.2.1 Ethical Approval
The study was approved by the Ethics Commission of the Ghent University Hospital
(2008/485), on the condition that approval was obtained from a local Ethics Commission.
The Rwanda National Ethical Committee (42/RNEC/2009), the Rwandan Institute
for Statistics (130/2009/INSR) and the Rwandan National AIDS Commission (0135/
CNLS/2009/S.E) also approved the study.
Participants in the survey were explained the objectives of the study and the principles
informed consent form prior to participation. Since it was a longitudinal study, we used
a coding system guaranteeing anonymity to link answers of the same respondent over
time.
Participation in the mailbox study was voluntary. Students were gathered and explained
the objectives of the study. Then, once the mailboxes were installed, students could
themselves take the initiative to participate. Providing their name, sex, age or any other
personal information was not required. When provided, this information was treated
All school authorities were explained the objectives of the study and asked to sign a form
consenting to use their school as a study setting. Collaborators in the study were asked to
read and consent to the ethics code of the American Sociological Association [138].
4.2.3. Exemption for Parental Consent
Even though the legal age of majority is 21 years in Rwanda, and our study included
submission of our research project to the Rwandan National Ethical Committee was not
approved for that reason. Argumentation in the second submission convinced the Committee
members that parental consent was not necessary. Two main arguments were
given. First, practical considerations: most students live in boarding schools and return
home only two or three times a year. Parents rarely come to the school. The school does
not possess all addresses or phone numbers of the parents, making it impossible to visit
them or contact them by letter or phone. Low literacy rates and a low number of phone
ownership was an additional problem. Second, we argued for a more developmental
approach to adolescence and adulthood and stressed the importance of collecting data
directly from adolescents. Based on guidelines from the World Health Organization [139],
33
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the Society for Adolescent Medicine [140], the American Sociological Association [141]
standing
studies and have the cognitive capacity to take decision concerning participation
and that the generally accepted age limit for this capacity is 14 years.
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35
RESULTS
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5. Results
5.1. Outline
The results section is divided into three parts, following the objectives of the study.
Firstly, we will elaborate on the overall effectiveness of HIV prevention interventions for
young people in sub-Saharan Africa, by presenting the results of a literature review and
meta-analysis (objective 1, paper 1: meta-analysis).
Secondly, we will present the results of the evaluations of a peer-led school-based HIV
prevention interventions for young people in Rwanda (objective 2, paper 2: Rwandan intervention).
Both the meta-analysis and the Rwanda study demonstrate that HIV prevention
interventions for young people do not result in large changes in sexual behaviour.
Thirdly, we will analyse the possible reasons for this observed limited effectiveness
(objective 3): participation in the intervention (paper 3: self-selection), determinants
of young people’s vulnerability (paper 4: mailbox technique and paper 5: out-of-school
youth) and the theoretical assumptions used in these interventions (paper 6: theory
review).
5.2. To assess the overall effectiveness of HIV prevention
interventions for young people in sub-Saharan Africa
(objective 1)
Introduction
Literature reviews on the effectiveness of particular types of HIV prevention interventions
for young people and other populations in sub-Saharan Africa and other regions,
suggest a limited effectiveness of such interventions in changing sexual behaviour and
reducing HIV incidence. However, a literature study and meta-analysis on the effective-
Saharan Africa, that allows drawing overall conclusions on their effectiveness, was missing.
Studying evaluations of HIV prevention interventions for young people also provides
insights in possible reasons for their success/failure.
Papers
Michielsen K., Chersich MF., Luchters S., De Koker P., Van Rossem R., Temmerman M.
(2010). Effectiveness of HIV prevention for youth in sub-Saharan Africa: systematic review
and meta-analysis of randomized and nonrandomized trials. AIDS 24(8):1193–202.
Michielsen K., Chersich M., Luchters S., Van Rossem R., Temmerman M. (2010). Concurrency
and the limited effectiveness of behavioural interventions on sexual risk behaviour
of youth in sub- Saharan Africa. AIDS 24(13):2140-2 (correspondence).
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37
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38
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39
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40
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41
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42
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43
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44
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47
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48
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49
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5.3. To assess the effectiveness of a peer-led school-based HIV
prevention intervention in Rwanda (objective 2)
Introduction
The literature review and meta-analysis indicated a rather limited effectiveness of HIV
prevention interventions in sub-Saharan Africa in changing young people’s sexual behaviour
or HIV incidence. To get a better understanding of how HIV prevention interventions
for young people in sub-Saharan Africa are developed, implemented and evaluated, we
set up an evaluation study of a peer-led school-based intervention in Rwanda. Given the
limited number of evaluated HIV prevention interventions for young people in sub-Saha-
more,
studying the intervention in detail provides more insights into the possible reasons
for success or failure of interventions in general.
Furthermore, we collaborated in the evaluation of a peer-led sports-based HIV prevention
intervention for young people in Kenya. The paper presenting the results of this
effectiveness evaluation can be found in annex to this thesis (Delva W., Michielsen K.,
Meulders B., Groeninck S., Wasonga E., Ajwang P., Temmerman M., Vanreusel B (2010),
HIV prevention through sport: the case of the Mathare Youth Sport Association in Kenya,
AIDS Care, Aug;22(8):1012-20).
Papers
Michielsen K., Beauclair R., Delva W., Van Rossem R., Temmerman M. (2012) The impact
of a peer-led HIV prevention intervention in secondary schools in Rwanda: results from a
cohort study with repeated measures and control group. BMC Public Health, 12:729.
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51
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52
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53
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54
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55
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56
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57
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58
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59
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62
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63
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65
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5.4. To identify and study possible reasons for the observed limited
effectiveness of HIV prevention interventions for young people
in sub-Saharan Africa (objective 3)
Both the literature review and evaluations of peer-led HIV prevention interventions
showed that such interventions do not seem to live up to their goal of reducing sexual
reasons that might explain this observed lack of effectiveness: interventions do not succeed
in reaching their target population, interventions do not address the crucial factors
to reduce young people’s vulnerability to HIV, and interventions start from the wrong
assumptions to change sexual behaviour of young people.
5.4.1. To assess young people’s participation in HIV prevention interventions
(objective 3.a)
Introduction
One of the conclusions of the literature review and meta-analysis was that there was a
differential effectiveness of HIV prevention interventions; studies that compared young
people highly exposed to interventions with those who had less exposure report more
active participants was rarely further elaborated upon.
Paper 2 (Rwandan intervention) showed that participation in the intervention was very
low, with a large proportion of the target population not participating in the intervention.
This was equally the case for the Kenyan intervention presented in annex. In the Rwandan
intervention, over 40% of the respondents had not participated in any of the intervention
activities. In the Kenyan intervention, about one in six never participated.
Using the data from the Rwandan study we analysed if pre-intervention characteristics
in the intervention, participation in group discussions and participation in individual
advice.
Paper
Michielsen K., Celis H., Jingwa B., Degomme O., Van Rossem R., Temmerman M. Selfselection
in an HIV prevention intervention: who is participating? Results from a peer
education programme in secondary schools in Rwanda. Submitted to AIDS Education and
Prevention.
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73
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74
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75
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76
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78
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79
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81
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83
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5.4.2. To study the vulnerability of young people for poor sexual and
reproductive health (objective 3.b)
Introduction
A possible explanation of the limited effectiveness of HIV prevention interventions could
be that the interventions do not address the right topics to make young people change
their behaviour. Since sexuality and sexual relationships are inherently embedded in a
social context, a thorough contextualized understanding of young people’s perceptions
on sex and relationships is essential for formulating effective SRH promotion interventions.
However, few studies on sexuality of youth in Africa go beyond describing HIV risk
related behaviours. We undertook two studies on determinants of young people’s sexual
health, focussing on different levels.
Firstly, we aimed to gain a thorough understanding of young Rwandans’ perceptions
on sexuality and relationships, by analysing the stories they spontaneously write about
sexuality and relationships. This allowed to identify factors that young people themselves
indicate to be important in their sexual decision making and allows to analyse their particular
vulnerability for HIV infection and poor sexual and reproductive health.
Secondly, focussing on the environmental level, we assessed the link between being
out-of-school on the one hand and HIV status and risky sexual behaviour on the other
hand, thereby uncovering the protective/hazardous effect of schooling for young people.
This study aims to demonstrate the important role of structural level factors on young
people’s HIV status, sexual and reproductive health and sexual behaviour. To this end, we
undertook a literature review of descriptive studies in East and Southern Africa.
Furthermore, we lifted the education factor to the highest level and studied its impact as
a structural factor on HIV prevalence. The starting hypothesis was that the link between
of globalization. Analysing data from the Demographic Health Survey and other datasets,
we tried to uncover, qualify and contextualize this link. This study is presented in annex
to this thesis (Stroeken K., Michielsen K., Meeuwis M., Remes P. The region-sensitive
effect of globalization on HIV in Eastern and Southern Africa: The dual role of education.
Submitted to AIDS & Behavior).
Papers
Michielsen K., Remes P., Van Rossem R., Temmerman M. “I Think AIDS Is Raging among
Teenagers Because of Their Passion for Possessions”. Rwandan Adolescents’ Perceptions
on Sexual and Reproductive Health Vulnerability Using the ‘Mailbox technique’. Submitted
to SAHARA.
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Stroeken K., Remes P., De Koker P., Michielsen K., Van Vossole A., Temmerman M., (2011).
HIV among out-of-school youth in Eastern and Southern Africa: a review. AIDS Care
2012;24(2):186-94.
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92
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93
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95
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96
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97
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108
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111
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116
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117
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118
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5.4.3. To assess the theoretical assumptions used to change sexual behaviour in
HIV prevention interventions for young people in sub-Saharan Africa
(objective 3.c)
Introduction
One of the conclusions of our literature review and meta-analysis was that the observed
reduction interventions. We undertook a study assessing the theoretical underpinnings
of HIV prevention interventions for young people in sub-Saharan Africa. This section
assesses the extent to which these interventions are grounded in theory, how these
theories are used and if theory-based interventions are more effective in changing sexual
behaviour than interventions not based on theory. We discuss the gaps in the theoretical
basis of HIV prevention interventions for young people in sub-Saharan Africa.
Papers
Michielsen K., Chersich M., Dooms T., Temmerman M., Van Rossem R.. Nothing as practical
as a good theory? The theoretical basis of HIV prevention interventions for young
people in sub-Saharan Africa. AIDS Research and Treatment. 2012: 345327. Epub 2012
Aug 1,
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124
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126
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129
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132
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133
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134
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135
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136
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137
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138
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139
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140
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141
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142
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143
DISCUSSION
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6. Discussion
Given the high burden of HIV on young people in sub-Saharan Africa, the main objective
of this study was to improve the effectiveness of HIV prevention interventions for young
people in this region. To that end, we assessed the overall effectiveness of such interven-
improvement.
This discussion is divided in four parts. Firstly, we discuss the effectiveness of HIV prevention
interventions for reducing sexual risk behaviour of and HIV incidence in young
most important reasons for this observed limited effectiveness is presented, suggesting
study. Finally, recommendations, conclusions, and suggestions for further research are
formulated.
6.1. Failure to demonstrate the effectiveness of HIV prevention
interventions
The literature review and meta-analysis (paper 1) showed limited effectiveness of HIV
prevention interventions for young people in sub-Saharan Africa. Young people did
condom use only increased notably among males, but remained at a low level. Further-
changes in knowledge and attitudes, but only small changes in sexual behaviour [88-91,
93, 163]. None of the interventions included in the meta-analysis had an overall positive
meta-analysis. Mavedzenge [164] systematically reviewed evidence on the effectiveness
of youth HIV/AIDS prevention interventions in sub-Saharan Africa and made evidence-
evaluations that were not overall positive (e.g. [165-167]). For all other types of interventions
the evidence was too weak to advice scale-up. A review of Ross [96], including
randomized controlled trials (RCTs) of HIV prevention interventions with biological end-
of which none measured a reduction in HIV incidence.
remains a mismatch between the number of evaluated HIV prevention interventions for
young people in sub-Saharan Africa and the burden of the HIV epidemic for youth in this
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egion. In 2010, young people aged 15 to 24 years accounted for 42% of new HIV infections
[25]. These numbers justify an important focus on young people in HIV prevention
efforts and contrast sharply with the fact that we could only identify 34 relatively wellevaluated
interventions in sub-Saharan Africa that aim to reduce young people’s sexual
risk behaviour, over a period of over two decades (paper 1: meta-analysis and paper 6:
theory review).
Africa is dominated by behavioural interventions using educational and sensitising
tools to achieve behaviour change. This is generally called the “Information, Education,
Communication” (IEC) approach. Even though our literature study allowed to include
sexual behaviour applying a structural approach: using cash transfers, the intervention
aimed to stimulate girls to stay in school and to reduce their economic dependence on
than the control group, though the absence of HIV baseline data warrants caution. Also
recently, the Population Council published the results of the Siyakha Nentsha Programme
to school-aged boys and girls. The evaluation showed that young men had reduced onset
of sexual activity and fewer partners [168].
evaluations and reviews on related topics have found: interventions aiming to reduce
sexual risk behaviour of and HIV incidence in young people using IEC approaches generally
do not live up to their goal. The peer-led school-based intervention in Rwanda (paper
2) did succeed in increasing young people’s perception that AIDS is a serious disease and
differences between the intervention and control group when it came to self-reported
sexual behaviour including condom use. Participants in the peer-led sports-based intervention
in Kenya (paper 7, annex) reported more condom use, but this remained at a low
level and the effect disappeared in the multivariate analysis. In addition, the intervention
group reported higher behavioural control. There were no differences between the intervention
and control groups concerning attitudes, sexual activity, concurrent partnerships
and number of partners.
Three decades of developing, implementing and evaluating HIV prevention programmes
for young people in sub-Saharan Africa has not resulted in a ‘gold standard’ intervention.
Both on the macro-level (meta-analysis) and the micro-level (peer-led interventions) no
convincing evidence was found of the effectiveness of these interventions in reducing
sexual risk behaviour of and HIV incidence in the target population.
On the other hand, UNAIDS reports that HIV incidence declined among young people in
21 countries with generalized epidemics between 2001 and 2009 and that these reduc-
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tions occurred amid signs of changes in sexual behaviour (later sexual debut, reduction
of multiple partnerships and increase of condom use at last sex) [59, 60]. This means that
young people are changing their behaviour, but that these changes are hardly observed as
the results of HIV prevention interventions. In the next section, we will elaborate on the
possible reasons for the observed limited effectiveness of HIV prevention interventions
on sexual risk behaviour of young people in sub-Saharan Africa.
6.2. Reasons for the observed limited effectiveness of HIV
prevention interventions
The observed limited effectiveness of HIV prevention interventions in sub-Saharan Africa
in changing young people’s sexual behaviour and reducing HIV incidence cannot be at-
of possible mechanisms:
- factors related to the intervention (6.2.1.): intervention design (content and objec -
tives) and intervention implementation (participation and approach);
- factors related to the evaluation (6.2.2.): evaluation design and evaluation outcomes.
6.2.1. Intervention related factors
In assessing evaluations of HIV prevention interventions, much attention goes to the
quality of the evaluation design, to avoid Type I (false positives) and Type II (false negatives)
errors [135], but less consideration is given to what Green [169] calls Type III errors:
the adequacy of the intervention itself. In this section, we will discuss the intervention
design (content and objectives) and implementation (participation and approach).
6.2.1.1. Intervention design
The ultimate objective of most HIV prevention interventions, including those studied in
this thesis, is to reduce HIV incidence in young people. By trying to do so, interventions
aim to reduce sexual risk behaviour resulting in the following logical sequence (Figure
6.1):
HIV prevention
intervention
Figure 6.1: Theoretical intervention sequence of HIV prevention interventions for young
people in sub-Saharan Africa
Sexual risk behaviour
Despite the simplicity of this sequence, the practical interpretation seems less straightforward;
interventions focus on cognitions to increase condom use and reduce unsafe
sexual activity, which on its turn should result in a reduced HIV incidence (Figure 6.2).
146
HIV incidence
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the intervention content - which is traditionally focused on increasing HIV related knowledge,
adopting HIV related positive attitudes and learning HIV related skills - and the
interventions’ objectives, i.e. changing sexual behaviour. The second problem concerns
the choice of the interventions’ behavioural outcomes and strength of association with
HIV incidence.
Traditional interventions:
ABC, IEC, skills building,
stigma reduction, risk
perception
Intervention outcome
objectives: increase
condom use, reduce
sexual activity
Figure 6.2: Practical interpretation of intervention sequence
Intervention content
The objectives of HIV prevention interventions for young people in sub-Saharan Africa
are broad. The Rwandan intervention aimed to reduce sexual risk behaviour and to promote
sexual and reproductive health and the Kenyan intervention had as a main objective
to promote sexual behavioural change among the youth of the Mathare Valley community.
To achieve this, the interventions educated participants on HIV transmission routes
and protection modes through traditional and interactive learning methods. These are no
exceptions; many other (peer education) interventions have similar objectives and use
comparable methods (e.g. [124, 170-173]).
Looking at their theoretical basis, we found that HIV prevention interventions are based
on cognitive behavioural models, that explain sexual behaviour through a number of
cognitions as intentions, attitudes, beliefs and expectations (paper 6). By focussing on
cognitive constructs of behaviour, the interventions start from the assumption that cogni-
The discrepancy between knowledge and behaviour may also be related to adolescent
brain development: since the prefrontal cortex, which is associated with risk-taking and
decision-making, is among the last regions of the brain to gain maturity [175, 176], it is
are prone to impulsive behavior [177].
critical determinants of sexual behaviour, forming a complex multi-layered and interde-
four levels:
- personal factors: characteristics of the individual;
- interpersonal factors: direct relationships between the young person and another
person;
- environmental factors: organizational or institutional factors that shape the direct,
proximate environment;
- social and cultural factors: factors that shape the society and context on a higher, distal
level.
147
Ultimate objective:
reduce HIV
incidence
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Personal level
Adolescents go through a period of physical and emotional maturation on their way to
adulthood, constructing their adult identity by exploring and experimenting, including
sexually. They might not yet have stable internalized values and norms concerning
relationship. Their limited experience makes them vulnerable to peer pressure and unhealthy
decisions (paper 4: mailbox technique).
Although the level of HIV knowledge of young people in Rwanda was high - after the
Rwandan intervention the median score for knowledge of HIV transmission routes was
10/11 (paper 2) - the questions posted in the mailboxes (paper 4) demonstrated a low
understanding of the biological mechanisms of HIV and human reproduction. It seemed
that young people in our study can replicate the prevention messages they hear (abstain,
be faithful, use a condom), but might lack understanding of the reasons for proposing
these behaviours.
Interpersonal level
Young people engage in different types of sexual relationships, putting them differently
at risk for HIV infection. Age-disparate relationships are more risky because they expose
the younger person (mostly a girl) to a partner who is more likely to be sexually
experienced and hence more likely to be HIV positive [36, 180-182]. Overlapping sexual
partnerships or concurrent relationships create a highly connected sexual network that
serves as a highway for HIV transmission [40-42].
Among young people in Rwanda, both types of relationships exist, driven by an underlying
phenomenon: transactional sex, in which money or gifts are given in exchange for
sexual intercourse (paper 4: mailbox technique). The “desire to lead a modern life”, as it
is called by Remes [183], is a driving factor in engaging in transactional sex, on its turn
encouraging multiple partners and relationships with older partners to increase material
gain. The letters written by Rwandan students indicated that peer pressure is a driving
factor in these types of relationships. Also, it is clear from their letters that young people
are curious and experiment with sex, or wish to do so. These experimental sexual interactions
are driven by factors as curiosity and sexual desire, and occur among same-age
youth. Given their ad hoc nature, these interactions often taken place unprepared and
unprotected.
Different types of sexual relationships are motivated by different factors, and put young
people differently at risk. While experimental sex puts young people at risk because of
the ad hoc nature and unavailability of condoms, the lack of condom use in transactional
sex is often the result of a negotiation process. In steady, long-term relationships, young
people can be at risk because proposing condoms might be seen as a lack of trust. Hence,
these different types of partnership should be recognized and dealt with differently in
HIV prevention interventions. In the evaluation studies included in our literature review
and meta-analysis (paper 1), most researchers dichotomize sexual relationships either
with a ‘steady’ or ‘casual’ partner, the latter being portrayed as considerably more risky
prevention efforts; it risks conveying that long-term steady partnerships are safe, while
in reality they might well be most hazardous [40-42].
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The interpersonal level not only concerns peers and partners, but also other important
teachers fail to inform them on sexual health topics (paper 4: mailbox technique).
Environmental level
The situation in which the Rwandan study participants live – boarding schools with
relatively limited supervision - allows for much contact between boys and girls, but
few opportunities for planned sexual intercourse. Paper 5 (out-of-school youth) found
that in-school youth have a lower HIV prevalence and less risky sexual behaviour than
out-of-school youth. Although it cannot be ignored that this is partly because of other
background difference between these two groups, the study suggests that schools may
be relatively isolated communities where risky sexual behaviour might be less problematic
than in the open network. On the other hand, schools can also be a risky place:
several letters written by Rwandan students (paper 4: mailbox technique) mentioned the
phenomenon of (male) teachers having sex with (female) students in exchange for school
is commonly mentioned.
Social and cultural factors
Norms. Sex between young people is taboo and considered morally and legally (under 18
itive
aspects of relations, sex and sexuality. In the letters written by Rwandan students
(paper 4: mailbox technique), a positive discourse on adolescent sexuality and relationships
is almost completely absent. While young Rwandans do have sex for pleasure, the
values attributed to adolescent sexuality are negative and sinful.
Gender. Girls are usually seen as the provokers of sexual desire in boys; in experimental
sex because of their provocative clothing and in transactional sex because of their desire
for gifts. Boys are seen as only to act upon their physical needs. Nevertheless, girls are
supposed to say ‘no’ to every attempt for intimacy, thereby devaluating the meaning of a
‘real no’ (paper 4: mailbox technique). Paper 3 (self-selection) found that being a boy or
girl was a dominant predictor of participation in the peer-led intervention. Those who
are more outgoing and at ease with their sexuality are more likely to participate in group
activities. In general, in Rwandan culture, while it can be considered a sign of masculinity
to have sex, openly talking about sex is taboo for girls [161].
technique). Young people in Rwanda, especially girls, have sex in exchange for money and
ence
sexual decisions, in the sense that youth need money to buy less essential goods as
telephones and body lotion that others may have. The less urgent need for these products
in comparison to survival sex surely might put young people in a stronger negotiation
position. However, they seem to use this power to negotiate more goods, instead of safer
sex.
Future perspective. In resource-limited societies with limited tangible opportunities and
might win over the fear of possibly getting infected with a disease that will affect one
-
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pation in the peer-led intervention in Rwanda depended, among others, on the future
perspective of the students: students who never had sex were more likely to participate
when they have a more positive future perspective.
Education and globalization. Paper 8 (globalization and education, in annex) found that
literacy and a secluded or safer sex network, outweigh the risks of education, such as
increase of mobility and of the reach and/or density of social (hence sexual) networks.
This tipping point regionally differs because it relates to the level of globalization, itself
determining the extent to which secondary education is common in a region and thus
no longer a comparatively strong booster of the sexual network. Education therefore
reduces prevalence and saves lives mostly in regions that have reached a certain level of
globalization and thus passed the tipping point. In the less globalized regions, education
should be prevented from creating a cultural vacuum, alienating pupils, or creating social
division, as in the formation of elites with the means of engaging in much partner concurrency.
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Policy
Gender norms
Family
Teachers
Parents
Globalization
Peers
HIV related cognitions:
knowledge, attitudes
151
Education
Sexual and
reproductive health
services
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Partner characteristics
Socio-demographic
characteristics
sexual
behaviour
HIV
incidence
Future
perspective
Access to
condoms
Type of relationship
Individual factors
Life stage: adolescence
Economic factors
School
Interpersonal factors
Environmental factors
Norms
Social and
cultural factors

Gaps in intervention content
indication of the complexity of young people’s sexual behaviour. The combination of
studies suggests that sexual behaviour is determined by more than cognitive predictors
as HIV related knowledge, attitudes and skills. Sexual decisions depend on interlinked
personal factors, partner characteristics, type of relationship, the proximate context (e.g.
school, family) and the more distal social and cultural context (e.g. norms, gender, poverty)
(Figure 6.3). Seen from an ecological viewpoint, it is clear that interventions mainly
focusing on personal HIV knowledge, attitudes and skills can only have limited effects
on sexual behaviour. Recognizing the complexity and heterogeneity of sexual behaviour,
theory could provide guidance in simplifying this complex behaviour and in identifying
key determinants. However, the implicit assumptions made by many HIV prevention
interventions might simplify sexual behaviour too much. They generally do not account
for inter-personal, environmental, social and cultural factors related to the complexity
of sex, the experience of youth and disparities in social, cultural and economic realities
of young people in sub-Saharan Africa. As Mason-Jones [184] explained after evaluating
the lack of effectiveness of a peer education programme: “It may be that social factors are
changes”. It is possible that interventions are doomed from the outset, simply because it
munity
norms and structural factors. Ross [96] and Hayes [185] even stated that such
interventions may be “inherently ineffective”.
The vulnerability model [137] and the socio-ecological approach [178] may be good alternative
frameworks to guide interventions. While the vulnerability model puts a strong
emphasis on the interaction (sexual relationship), the socio-ecological model stresses the
importance of both proximate and distal determinants of behaviour. Nevertheless, since
young people are not a homogenous population and contexts differ, the most important
part of developing an effective intervention is understanding the behaviour that one is
trying to change, and using a thorough situation analysis and needs assessment to identify
the determinants of this behaviour and causal pathways through which these deter-
Interventions’ outcome objectives
Interventions aim to reduce HIV incidence and, to that end, focus on reducing sexual risk
behaviours. However, several studies have failed to demonstrate a consistent link between
certain sexual behaviours and HIV incidence/prevalence. Buvé [186] looked at the
difference in HIV prevalence between four cities in four different countries. The observed
differences could not be explained by differences in sexual behaviour (even though
ence
HIV transmission, i.e. male circumcision and HSV-2 infection. Also Chapman [187]
compared HIV prevalence and sexual behaviours in four countries and concluded that socalled
sexual risk behaviours were higher in low prevalence populations. Pettifor [188]
compared two nationally representative surveys of young people, one in South Africa and
one in the USA. While HIV prevalence in South African young people is ten times higher
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partners, and practiced safer sex. There are several possible explanations: South African
young girls are more likely to have older sexual partners, male circumcision levels are
lower, STI prevalence is higher, and the South African society is more characterized by
gender power imbalances, poverty, coerced sex and rape, lack of youth friendly services,
studied the role of education and demonstrated that HIV prevalence can be linked to
structural factors as education and globalization and that this relationship differs regionally,
nationally and sub-nationally.
Reducing sexual risk behaviour among young people is essential in reducing HIV inci-
in HIV incidence also depends upon relational and contextual factors. Otherwise put, the
same behaviour does not result in the same risk for HIV infection in every relationship
or context. In order to have a high impact, interventions should focus on the most risky
behaviour(s) of their target population, and its dominant predictors, and should consider
the position of the target population within the dynamic sexual network through which
HIV is spread [189].
The Rwandan and Kenyan interventions described in this review were not based on a
thorough assessment of dominant sexual behaviours and relationships, or on a contextual
study. Therefore, it is possible that the interventions were targeting the wrong behav-
Rwanda (paper 4) demonstrated that young people do have sex and that transactional
sex, often with older partners, is one of the dominant forms of sexual relationships.
young people on how to deal with this. Neither did it provide a positive approach to
young people’s sexual relationships, which would allow discussion on how to integrate
protective measures in such transactional relationships.
comes.
The behavioural objectives mostly aimed at are increased condom use (at last
number of sexual partners, recent sexual activity). While protective sexual intercourse
through condom use is unambiguously a positive measure against HIV infection, sexual
activity is an outcome of a different sort. Many interventions attribute a positive connotation
to postponing sexual debut and to reducing sexual activity and sexual partners,
hence dividing sexual behaviours into ‘good’ and ‘bad’ behaviours. While manuals for
setting up HIV prevention interventions for young people prioritize a non-judgemental
(unconsciously) implies a moralistic judgement on young people’s sexual behaviour. We
argue that HIV prevention interventions should question the utility of these behavioural
outcomes and should more consciously choose how to reach their ultimate objective
(reducing HIV incidence). A promising, alternative outcome was developed by Wellings
[193]: sexual competence, which stimulates young people to be sexually responsible,
making sure sexual intercourse is characterised by absence of coercion and regret, autonomy
of decision, and use of a reliable method of contraception. While currently used
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desired outcomes impose judgment on young people’s sexual behavioural choices, the
latter approaches young people as responsible persons who can make conscious decisions,
while at the same time acknowledging the importance of safe sexual behaviour.
6.2.1.2. Intervention implementation
A second reason why HIV prevention interventions for young people in sub-Saharan
Africa fail to demonstrate success is that they are confronted with implementation problems.
Studying the implementation of interventions is an essential condition for improving
interventions’ effectiveness. It allows us to not only answer the question ‘Does the
intervention work?’, but also questions as ‘How does it work?’ and ‘What components are
essential to its success?’ [169, 194]. An extensive literature review by Durlak [195] provided
strong evidence that effective implementation is associated with better outcomes
in promotion and prevention interventions.
Studies included in our literature review and meta-analysis partially ascribed the limited
impact of interventions to poor implementation of the intervention [129, 149, 150, 196-
198]. A process analysis of the Rwandan intervention was done by master student Hanne
Celis in two intervention schools [199]. She found that practical problems hampered the
implementation of the intervention. Firstly, because of internal organisational issues the
intervention was cut off funding for a certain period. Fortunately, this happened during
the second part of the intervention, when the peer educators were already trained and
could continue their activities. However, they missed out on the follow-up trainings. Secondly,
peer educators complained that not enough time and space was allocated to their
activities. Thirdly, several aspects of the planned intervention, e.g. the development of a
booklet for the peer educators, were not implemented [199].
The observed limited effectiveness of HIV prevention interventions for young people in
sub-Saharan Africa is not responded to by extensive (published) process evaluations.
Little is known about the implementation quality of interventions; in evaluation studies,
ing
uniquely on the implementation of interventions are even rarer; it seems that only
large trials and study groups can afford to invest extensively in evaluating the process
of developing and implementing HIV prevention interventions [83, 200-205]. Further-
science for health interventions, a large number of journals are interested in outcome
evaluations of health interventions. The limited word count that applies to most journals
hinders that both evaluation types are presented together.
prevention interventions, but represent a more general problem with intervention planning,
budgeting and monitoring that exists in many other sectors. Therefore, we will not
elaborate on this, and focus on less recognized implementation issues: participation and
approach.
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Participation
HIV prevention interventions for young people often do not succeed in reaching the
complete target population. In Rwanda, about 40% of potential participants did not participate
in any intervention activity (paper 2: Rwandan intervention). In Kenya, one in six
respondents said to have never participated (paper 7: Kenyan intervention, in annex).
In Rwanda, we found that group activities are attended by three types of students. Firstly,
we see that those who are at ease with their sexuality are more likely to participate.
Secondly, practical considerations play their part in participation in group activities:
students living in boarding schools tend to participate more. Thirdly, we identify a group
of students that very consciously participates in the group activities: those who were
recently sexually active, those who feel susceptible to HIV infection, those who were ever
tested for HIV and those who are consciously abstaining from sexual intercourse. For in-
lack of dominant predictors could equally mean that participation in individual advice is
not greatly determined by pre-intervention characteristics, but by other factors occurring
during the period of the intervention.
This study showed that the type of activity chosen by the intervention planners has an
impact on the type of participants. Therefore, in a homogenous group it is essential to be
aware of the preferred activity type of the target population. In a heterogeneous group it
is critical to offer a variety of activities in order to appeal to all young people involved.
Another point of interest is the gender difference in participation. It seems that boys
were more likely to participate in group activities, thereby suggesting the need for girlsonly
spaces or activities on HIV prevention, encouraging young girls to openly discuss
these topics. Since a positive sexual self-concept contributed to participation in the intervention,
we recommend to include the general well-being of young people into interven-
feelings, and to engage in healthy and respectful relationships. Finally, structural factors
play an important role in intervention effectiveness: if the context where young people
live in does not provide much perspective or support, implementing healthy behaviours
is hampered.
Approach: peer education
The interventions we evaluated in Rwanda and Kenya used peer educators to transfer
HIV prevention messages. Peer education is a popular approach: 17 of the 28 interventions
in our literature review and meta-analysis used this approach (paper 1). Since
many Rwandan school-going youth stay in a boarding school and only return to their
families two or three times a year, they have no other option than to rely on peers or
teachers for HIV/SRH information. Therefore, intuitively, peer education seems like a
good strategy. However, the fact that young people need to rely on peers for information
on HIV/SRH does not mean they want to rely on them. In our study, students were asked
to indicate the two main channels through which they would prefer to receive information
on HIV. Friends ranked sixth as a preferred source of information, preceded by radio,
countries [206-209].
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Not disregarding the capacities young people have, it is a very tall order to expect a young
person – possibly discovering his/her sexuality him/herself - to act as an expert and
guide, counsel, teach and advise peers on a personal, sensitive and complex issue as sexu-
to young people, the notion of ‘peer’ oftentimes refers to someone of the same age. This
is a very simplistic notion: even though they might be of approximately the same age, this
does not mean they have a similar background, similar experiences, similar values and
norms [180]. Besides personal characteristics, a peer educator’s credibility is determined
by their own behaviour and by how they transmit messages [210].
Peer education is an attractive tool for HIV prevention and SRH promotion, because it
makes use of existing social processes and actively involves young people in the intervention.
However, given its limited effectiveness, it might be necessary to re-evaluate the use
and role of the peer educators. Firstly, in the Rwanda study we received reports of peer
educators feeling superior to their peers. It seemed that peer education created some
sort of hierarchy among the students. In personal communication with programme managers
of other peer education interventions, the same issue was mentioned. The choice
of peer educators, the support they receive and the monitoring of their work is essential
to counteract this, and for the overall success of such interventions. Secondly, programme
planners and evaluators must set realistic expectations for peer education. Peer education
based on information sharing will never on its own change sexual behavior to a
large extent. Yet, it can however be valuable in creating an open, positive climate around
sexuality and in breaking taboos and have a long-term effect on sexual behaviour. Thirdly,
while peer educators are now the centre of the intervention, informing, counseling and
as focal points: beside spreading information on HIV/SRH through theatre, songs and
discussions, they could be the ones who are aware of key specialists and services to
which they can refer. Peer education should not be a stand-alone intervention and should
be embedded in a larger strategy. Finally, peer education interventions seemingly actively
involve young people in prevention efforts. However, only involving them in the implementation
phase of an already developed intervention is not very participatory. True
involvement goes further; young people can be involved in the needs assessment, in the
set-up of the intervention, in the monitoring and in the evaluation. Their input in these
phases might proof to be more valuable than in the actual implementation.
6.2.2. Evaluation related factors
explain the observed limited effectiveness of HIV prevention interventions for young
people in sub-Saharan Africa, UNAIDS data report that “young people are leading the HIV
prevention revolution” and that reductions in HIV prevalence coincide with changes in
sexual behaviour among young people. Therefore, we cannot exclude that interventions
do have an effect on young people’s sexual behaviour, but that evaluations do not succeed
in demonstrating this effect.
An overview of evaluations of HIV prevention interventions for young people in sub-Sa-
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haran Africa (paper 1: meta-analysis) demonstrates few commonalities in study design,
perhaps suggesting that there is little consensus on the optimal approach and that few
studies have built upon previous knowledge in a linear way. No two studies use the same
methods of analysing or reporting data, and outcome indicators are markedly diverse.
analysis was far from universal. Other problems that surfaced concerned implementation
of the intervention (as a result of which the evaluation does not measure the effectiveness
of the intervention), comparativity of the control population, indicators used
in participant retention). As Mavedzenge [164] compared a recent review on papers
published between 2005 and 2008 with a review of papers published before 2005, she
argues that the quality of recent studies was generally higher, “however, high quality was
not universal, and this review was still hindered by poor study design and lack of analytical
rigor in some evaluations.” The same observation has been made by other reviews on
comparable topics [87, 91, 93, 94].
This chapter deals with issues in evaluation design quality and outcome measures used
to evaluate interventions.
6.2.2.1. Evaluation design
Evaluators mostly try to use or approximate to (clustered) randomized controlled trials
(cRCT), which are considered the gold standard for demonstrating cause-and-effect relation
between an intervention and an outcome. In total, worldwide, nine behavioural or
structural HIV prevention interventions for all populations have been evaluated using a
well-developed randomized controlled trial [84, 96, 202, 211-218]. Their use to evaluate
complex, multicomponent, multilevel interventions has been questioned for several years
[51, 194, 219-222].
When applied to evaluate complex prevention approaches as behavioural prevention
of HIV, several essential conditions of (c)RCTs are regularly compromised [221]. Firstly,
study participants themselves should remain ignorant of the study arm they are attributed
to. In most evaluations of HIV prevention interventions study participants are aware
and generate reporting bias. Randomisation might also be compromised by the fact that,
in the end, participants often decide themselves to what extent they participate in the
intervention (paper 3: self-selection). Secondly, the large number of interventions and
campaigns being implemented in many sub-Saharan African countries and of which it
cannot always be controlled if they reach both intervention and control arm equally, even
further complicates this. The condition of having a ‘naïve’ control group can rarely be ful-
results from (c)RCTs may not be easily transferable, hence their utility is questionable
[51, 194]. Furthermore, many evaluations seem to measure effectiveness on a relatively
short term. Only one intervention was evaluated on a longer term (8 years) [223], while
other evaluations did not exceed 3 years and often even did not measure effectiveness
after 1 year. This observation is especially relevant given the long pathway targeted in
public health interventions (increasing knowledge, changing attitudes, improving skills,
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generating behavioural intention and then changing sexual behaviour and HIV incidence).
Changes in sexual behaviour after interventions might pass through social and
institutional changes or follow long causal pathways before they succeed in changing
sexual behaviour and HIV incidence might not be observed on the short term, they may
still occur in a later stage.
An additional challenge of evaluation studies, not only (c)RCTs, is making sure the evalu-
and 30% loss to follow-up (based on an incidence rate of 1.6%) [211]. It is possible that
the intervention did reduce HIV incidence, but by less than 50%, making it not possible
reduction of 25% in HIV incidence would already be of great value to public health, this
would require an even larger sample size. For example, a decrease in HIV incidence
from 0.5% to 0.4% would require 72,307 persons in each study arm [225]. Especially in
dence
requires an enormous sample size, and many trials are underpowered because of
estimation or recruitment problems [96, 185]. Behavioural outcomes are more prevalent
and require smaller, but still considerable, sample sizes: in our evaluation of the Rwanda
intervention (paper 2) we calculated that for logistic regression models, a minimum of
1,241 observations are required to detect an adjusted odds ratio of 2 or more with 80%
prevalence of the outcome variable and no changes over time in the control group.
Problems with the correct use of evaluation designs might lead to false conclusions,
effects. Even though (c)RCTs are still considered by many to be “the cornerstone of the
evidence needed to support implementation of HIV prevention programmes” [185] and
“will remain the most rigorous and convincing intervention study design” [96], we follow
Laga [194] when she “advocates for realism and pragmatism when it comes to generating
more convincing evidence to guide prevention programming” and proposes “plausibility
designs” as an alternative, an approach followed by the latest meeting of the UNAIDS
Programme Coordinating Board (June 2012). Such designs rely on a number of information
sources from mixed methods - including monitoring, process evaluation, qualitative
methods, modeling, population based surveys, quasi-experimental designs – to build a
plausible case for intervention effectiveness.
6.2.2.2. Outcome measures
To measure the effectiveness of HIV prevention interventions, studies rely on two main
types of outcome indicators: biological and behavioural endpoints. Since the ultimate
objective of HIV prevention interventions is to reduce incidence of HIV, this seems to be
the best outcome to use.
The use of such a biological endpoint is rare. In our meta-analysis (paper 1), two studies
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were included that measured HIV status [211, 212]. Since then three additional studies
were published: one evaluated a multicomponent HIV prevention intervention for young
people in Zimbabwe [226], one updated the evaluation of Ross [96] with a long-term
impact study [223] and one presented results of a cash transfer intervention for school
girls [84]. We are aware of one other trial in South Africa and Tanzania that assesses the
impact of a multicomponent behaviour change intervention for young people, but of
which the results of the biological endpoint are not yet published [227, 228].
Of the ones studied, no IEC intervention, even though well designed and implemented,
succeeded in causally linking a reduction of HIV incidence to the intervention (paper 1:
-
incidence. Doyle [223] hypothesized that the impact of the intervention on biological
endpoints would increase over time, but an evaluation eight years post-intervention did
As the previous section demonstrated, using such biological outcomes requires very
large sample sizes, making it complex and expensive. Sometimes, other STIs are used as
substitutes for HIV incidence. However, a good biological substitute would have to share
characteristics as prevalence level, stage of the epidemic, risk groups and behaviour and
probability of transmission with HIV which is rarely the case [229, 230].
As an alternative, many evaluations rely on self-reports of sexual behaviour. Using this
strategy many studies have been confronted with discrepancies between reported sexual
Shiri trial is that none of the four girls who were pregnant reported that they had sex
in the questionnaire [202]. In a study in the UK, more than 10% of young adults with a
in the 12 months before STI testing [231]. Sison [232] found that women with genitourinary
symptoms may over-recall frequency of sexual behaviour compared to women
without these symptoms. In a study among Zimbabwean women, 12% of the participants
that tested positive for recent semen exposure reported no sex in the previous two days
[233]. These discrepancies are caused by recall bias and social desirability bias, depending
on the timeframe studied (e.g. lifetime recall versus last month recall), the interview
mode (e.g. face-to-face, self-administered, computer-assisted) and the study population
[234, 235]. These problems have been extensively studied and documented [236-240],
and will not be discussed here.
A more overlooked problem to evaluation research, is the choice and interpretation of
outcome measures. In our and many other evaluation studies, internationally recognized
indicators are used and interpreted as follows: ‘condom use at last sex’ (if this increases,
the intervention is considered successful), ‘recent sexual activity’ (if this decreases,
the intervention is considered successful), or ‘number of sexual partners in the last 6
months’ (if this reduces, the intervention is considered successful). In using these indica-
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use, abstinence, other STIs) and D is the duration of infectiousness (stage of HIV infection,
treatment). This formula clearly shows that it is the combination of these aspects
that determines the risk of infection, and not each aspect in itself. Measuring the use of
condoms or the number of sexual partners separately does not give a good indication of
the risk for HIV infection. This could explain why studies trying to predict HIV/STI infection
by using individual indicators, e.g. condom use, show weak correlations [211, 212,
242-246]. Furthermore, the indicators mostly used, measure proportions of behaviour,
ignoring differences in absolute numbers. Someone who reports to use condoms ‘most
of the time’ and has had 10 sexual encounters is at less risk than someone who uses condoms
‘most of the time’ during 100 sexual encounters. Neither do these indicators take
into account the position of the individual in the sexual network [229].
For example, the indicator ‘condom use at last sex’ might hide an increase in young
people having equal, respectful relationships who decided not to use a condom after a
negative HIV test. Or why would having a large number of sexual partners be negative
for one’s sexual health if the sexual intercourse were consensual and protected? It is
likely that people make risk assessments and adapt their behaviour accordingly. This
may result in high condom use with perceived high risk partners and in low condom use
with perceived low risk partners. Hence, using a condom use indicator or a sexual activ-
alcohol use and sexual self-concept, but not for relational and contextual characteristics.
exclude the possibility that interventions do have an effect, but that this effect is not accurately
measured in the evaluation. Understanding the HIV risk of young people necessitates
that their risk behaviours are conceptualized as mutually dependent, and are measured
as such [225]. While this was a topic for discussion in the beginning of this century
[229, 237, 247], it faded to the background of methodological debate in recent years. The
recent focus on sexual networks and types of sexual relationships (particularly concur-
248]. We suggest two alternatives for the currently used indicators. Firstly, giving preference
to scales instead of dichotomous variables, allowing for more nuanced reporting on
risks. Secondly, developing composite risk scores, including exposure, transmission and
infectiousness for measuring real risk for HIV infection among young people [247].
6.3. Limitations
Here we will discuss limitations related to the overall study set-up.
school (often boarding school) students. School attendance in Rwanda is low. The gross
enrolment rate (number of pupils enrolled in a given level of education related to the age
-
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tion is 143, which drastically reduces for lower secondary education (43) and higher
secondary education (32 4 ) [111, 112]. In a study among 285 students of the last year
of secondary education in a selection of four schools in the same Rwandan district (not
presented in this thesis), we found that, compared to the general population, more respondents
have running water at home or in the community (55.4% vs. 35.6% in general
indicates that overall this group is better off than the average Rwandan youth [249].
in sub-Saharan Africa. Nevertheless, we found some striking similarities in intervention
validity of our studies.
Second, while a process evaluation was undertaken by a master student in two Rwandan
process analyses as a weakness of HIV prevention interventions, and as a possible explanation
of why interventions do not seem to learn from each other [250].
Third, one of the main points of critique on HIV prevention interventions for young people
in sub-Saharan Africa is that the content is too much focussed on HIV, while sexual behaviour
is determined by many other factors. These factors and their causal pathways to
mailbox study (paper 4) did unveil several critical factors, additional qualitative research
would have been able to identify more factors and to qualify their causal pathways.
Furthermore, qualitative research could also have been used for other aspects of the
doctoral study, such as the process of implementation of the intervention, narratives of
students’ conversations or thematic analysis of drama plays and songs of peer educators.
Hence, we acknowledge that the evidence-base of the conclusions and recommendations
of this doctoral thesis mainly consists of quantitative effectiveness studies, while a
broader evidence-base would have been preferable.
Fourth, while this could also be considered a strength, we want to discuss the multicultural
aspect of our research in the limitations section. Working mainly in Rwanda with
Rwandan researchers and students has proven enriching, but at the same time, challeng-
development: we used a standardized questionnaire that was developed in French,
translated into Kinyarwanda, back translated and tested among a group of students. Nev-
Rwandan young people. Second, we collected data using multiple choice, often with 5- or
7-point Likert scales. We found that the great majority of students always entered the extreme
values (completely disagree or completely agree). Possibly, more nuanced answers
are considered unclear or vague, and a clear opinion is preferred. Third, while a Rwandan
4 For each 100 young people that are, given their age, expected to be in higher secondary education, 32 are actually enrolled.
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esearcher did verify our analysis and interpretation of the results, we cannot exclude
that we analysed and interpreted the results from a western point of view, overlooking
6.4. Conclusions, recommendations and directions for further
research
HIV prevention interventions for young people in sub-Saharan Africa show disappointing
results in reducing sexual risk behaviour and HIV incidence. Even though recent UNAIDS
data indicate a decreasing HIV incidence among young people in a number of highly
affected countries, it remains high and effective interventions are an urgent priority.
Research should continue to focus on how to develop, implement and evaluate effective
observed limited effectiveness: interventions might be inherently ineffective (intervention
design), they might be poorly implemented (participation, approach) or the evaluation
may not be capable of measuring the actual effectiveness (design, power, outcome
measures).
enced
by countless interacting factors on different levels - interventionists and evaluators
are, as Delor [137] puts it, prone to two pitfalls: “retreating into vagueness under the
pretext of complexity and, on the contrary, making a conquest at the expense of causal
reduction” (i.e. aiming to contribute a phenomenon to one cause while, in fact, is has several
causes). In the interventions included in our literature review and the interventions
we evaluated, we found evidence of such causal reductionism both in the intervention
design (interventions focused on HIV knowledge, attitudes and skills and largely ignored
inter-personal, environmental and social and cultural factors) and in intervention out-
of young people, is a complex issue, and requires complex interventions and complex
evaluations.
timately,
we cannot indicate which factor is most likely to be responsible for the observed
limited intervention effect on sexual behaviour and HIV incidence: comparing different
intervention designs is only useful when the interventions are well implemented and a
good evaluation strategy is applied, while an effectiveness evaluation is only meaningful
if the intervention is well designed and implemented. We recommend further research
on three levels.
the intervention. Given the (often complex) causal pathway that interventions aim to
measure and attribute to an intervention. It could, for example, be possible that the
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ecently observed reduction in HIV incidence in young people is a result of two decades
of implementing HIV prevention interventions in the severely affected countries, but cur-
searchers
should invest in developing alternative, innovative, evaluation approaches that
tion
should not be limited to outcome effectiveness, but should parallel the intervention
process, including the essential phases of intervention development and implementation.
interventions’ effectiveness requires a creative combination of alternative approaches
(“combination evaluation”), studying plausibility of effectiveness, rather than probability:
process analysis and monitoring should be triangulated with (quasi-)experimental
designs and other information sources as e.g. population-based surveys and statistical
modeling [194]. The latter can also assist programme developers and evaluators in understanding
the expected effect of the intervention on HIV incidence.
Since the use of biological endpoints is costly and not always appropriate, many evaluations
will continue to rely on self-reported sexual behaviour to measure intervention
effectiveness. Too often, these sexual behaviours are extracted from their context and
measured in single variables. Complementing these indicators with newly developed
contextualized, composite sexual behaviour measures is essential to measure the real
risks young people are taking, and hence, the true effectiveness of interventions. Composite
indicators should include three aspects: exposure (relationship and partner
characteristics), transmission (type of sex and protective measures) and infectiousness
(HIV infection and stage of infection of the partners). Such indicators can be developed
in relatively small-scale studies, informed by qualitative research, measuring both sexual
behaviour and HIV/STI status. The use of existing datasets including all three aspects of
risk for HIV infection can be used to test if combined indicators better predict HIV/STI
status.
Research into structural evolutions might shed light into the long-term effectiveness of
HIV prevention interventions. These evolutions include changes in HIV treatment and
societal changes as gender empowerment, poverty alleviation, globalization and technological
evolutions [251]. Societal changes and changes in the natural evolution of the HIV
epidemic might interact with the intervention effect. A study by Bajos [252] about the
evolution of sexual behaviour in France indicated how much this evolution is determined
by changes in nuptiality and broader social and structural factors, more than by public
health interventions. For example, changes observed in HIV incidence and sexual behaviour
of young people in sub-Saharan Africa can be a long-term result of HIV prevention
intervention and awareness campaigns, but might also be linked to the natural evolution
of the epidemic or to societal changes, such as women’s emancipation. Given that the
HIV epidemic has been present for three decades and that there are a large number of
interesting data sources available (e.g. DHS, DSS, globalization indicators,…), it might be
feasible to link societal changes to changes in HIV prevalence and estimate the relative
effect of public health interventions.
Secondly, the intervention: young people’s vulnerability is determined by different fac-
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tions.
Existing data should be used, and new information needs to be collected, on what
determines sexual behaviour of young people and how. Correcting what Bertozzi [250]
ability
in a single behavioural intervention, research into the importance of the factors
people’s sexual behaviour and HIV prevalence. This is essential both for intervention
development (what are the determining factors of risky sexual behaviour and how can
mediate
determinants of sexual behaviour). As Laga [194] puts is: “the goal of a better
articulation of [the programme’s] impact pathways is to assist planners and evaluators
in simplifying the complex reality without becoming simplistic”. By studying these causal
pathways, it is possible that shifts in paradigms might occur, for example from an individual-focused
approach to a more community-centered approach.
Making these pathways explicit also relates to the use of theory in HIV prevention interventions.
While many interventions report the use of behavioural theories to guide the
intervention or evaluation, few reports are made on why a particular theory was chosen,
how it was used and what the added value of this theory was. More research should be
done into the practical use of behavioural theories for HIV prevention interventions for
young people, taking into account the complexity of sexual behaviour (including determinants
on different levels). Only this way, knowledge can be cumulated and intervention
effectiveness can increase.
tervention
deserves a central place in HIV prevention – e.g. start with a situation analysis
intervention including key stakeholders [253], and taking into account past, ongoing and
planned interventions. The interventions included in our literature review and metaanalysis
did not seem to take extensive time to optimize their intervention before it was
implemented and tested. The interventions presented in this study are dominated by the
IEC approach, spreading information and sensitizing young people, sometimes complemented
with service provision, to come to behaviour change, and hence HIV incidence
reduction. Project-based IEC approaches are just one of many possible interventions, and
researchers and intervention managers should experiment with alternative approaches.
Piot [254] expresses as follows: “Any explanation based on a single risk factor for this
very high HIV endemicity ignores the realities of complex societies and human behaviour.
A complex and diffuse epidemic should be addressed by an equally nuanced and
multipronged response”. It is possible that such complex interventions are already taking
The intermediate and ultimate objectives of interventions should be clear and neutral.
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Ultimately, interventions want to reduce HIV incidence. If they plan to do this through
the intermediary objective of sexual behaviour change, they must be sure to focus on the
most relevant behaviours. If awareness raising is the intermediary objective, the pathway
to HIV incidence reduction is longer, and no immediate effects on sexual behaviour
abstinence, or the reduction of the number of partners, intervention planners might be
(unconsciously) sending messages to young people with a moralizing tone. Therefore we
would argue to study the use of an alternative, less judgmental, and more empowering,
intervention outcome in HIV prevention interventions for young people in sub-Saharan
Africa: making young people sexually competent, stimulating them to be sexually responsible,
making sure sexual intercourse is characterised by absence of coercion and
regret, autonomy of decision, and use of a reliable protection method [193]. A factor that
deserves particular attention is gender equality, since gender norms and roles strongly
cial
in all phases of the intervention. Essential in this process is uncovering and questioning
the prevailing gender norms of the study population, and the importance of striving
for mutually respectful (sexual) relationships.
Young people in the same type of relationship with the same type of partner might take
different decisions concerning protective measures. A possible confounding factor in
the association between individual behaviour (e.g. condom use) and type of relationship
is personality. Risk taking is deeply rooted in an individual’s personality – varying
from consistent risk seeking to consistent risk avoiding - with sensation-seeking as a key
helps explain how decisions are made concerning young people’s sexual health.
Thirdly, the implementation: interventions should be regularly monitored and adjusted if
necessary, as an integral part of the implementation and evaluation process. A large number
of interventions report implementation problems. When such implementation errors
occur, the evaluation does not longer measure if the designed intervention is effective
and is no longer valuable. Reports on implementation, and how to overcome implemen-
Interventions do not seem to reach the complete target population, because of their
choice for a certain implementation approach (e.g. peer education) and certain activities
(e.g. group activities). In the preparatory phase of the intervention, intervention planners
should study the preferred information sources and activities of the target population
and adapt the intervention accordingly. The choice of an intervention strategy should be
done in concordance with other activities taking place in the region.
In order to increase collaboration between and among intervention planners, researchers
and evaluators [51, 194, 250], we propose the development of a central online
repository that gathers information on interventions (e.g. content, set-up), monitoring
and process evaluations (e.g. implementation issues and solutions) and effectiveness
evaluations (e.g. evaluation designs, outcome measures) [258]. This would increase comparability
of interventions and would allow people to build upon previous experiences.
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Hence, such repository would have a dual functionality: collect evidence on effective HIV
prevention interventions and guide intervention planners and evaluators in their work
towards more quality, uniformity and comparability. Several organizations tried to address
some of these aspects, such as UNAIDS’s minimum quality standards for or their
trol’s
compendium of USA-based HIV prevention interventions with evidence of effective-
[262], and USAID’s handbook of indicators for HIV programmes [263] or their database
on US international aid [264]. However, to our knowledge a comprehensive repository,
encompassing evidence on and guidelines for the full intervention process (from design
to evaluation) does not yet exist for young people’s HIV or sexual health related interventions
in sub-Saharan Africa. To be comprehensive, such repository should also not be
evidence collected by non-governmental organizations, which form a large part of existing
evidence in developing countries. Initiatives as Programme Science, that try to close
aged
[265-268].
While such repository might help in making implementation information more easily
available, researchers should be encouraged to effectively set-up, implement and report
more process evaluations. Therefore, funding needs to be made available and donors
have to be convinced that this is an integral part of intervention research. Furthermore,
aging
qualitative publications of this particular type of research. Alternatively, by in-
intervention, the implementation and the effectiveness in one manuscript, which would
be a large step forward.
-
of a vaccine or a cure, the focus remains on preventing HIV transmission. By analysing
existing data on the determinants of the complex sexual behaviour of young people and
their causal pathways, and by gathering additional information, researchers should make
unprecedented efforts to develop alternative and more effective interventions. Accepting
the complexity of sexual behaviour of young people, also means dealing with a consider-
evaluation are to be considered inseparable: results of effectiveness evaluations should
be considered of little use if no information is provided on the intervention or its implementation
and vice versa. Since the evaluation should be an integral part of the intervention,
intervention managers and evaluators need to work in close collaboration, without
suspicion. Donors have to accept that a complex intervention cannot be designed beforehand,
but requires a process approach that maps risky behaviours, dominant predictors,
causal pathways and key stakeholders. This pre-intervention research should be considered
a fundamental part of the intervention and donors should be aware that effectiveness
depends on this phase, hence funding should be made available. In this process,
reality, and not morality, should be at the forefront: young people should be approached
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as responsible individuals who are able to make their own decisions and need to be
made competent to ensure their choice to (not) have sexual intercourse is made autonomous,
without coercion or regret and with the necessary in-depth knowledge of risks.
This requires a change in attitudes of all stakeholders involved. A complex intervention
approach also means that the intervention is monitored and can be changed during its
responsibility to make innovative approaches public, even though they might not be
reports on intervention development and implementation. We are convinced this can be
done if all parties remain conscious of the ultimate objective; eradicating HIV among the
important and vulnerable population of young people.
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Key recommendations for establishing more effective HIV prevention
interventions:
- accept the complexity of HIV and sexual and reproductive health of
young people: investment in a thorough baseline and needs assessment
for the development of population- and context specific interventions is
crucial;
- map the causal pathways through which the intervention aims to reach
its outcomes;
- beware of a (implicit, unconscious) moralizing tone in prevention
messages when focusing on specific risk behaviours;
- align the intervention with past, existing and future
activities/campaigns/interventions in the same field;
- allow for flexibility in intervention design, implementation and
evaluation based on regular monitoring of the intervention;
- consider the intervention development, implementation and evaluation
as an inseparable whole;
- combine different evaluation methods to study the probability and
plausibility of effectiveness, as well as the process of development and
implementation of the intervention.
Additionally, in order to contribute to more effective interventions, researchers
should study:
- the development of more appropriate, contextualized indicators to
adequately assess sexual risk taking;
- factors determining vulnerability to HIV infection among young people
and their inclusion in applicable theoretical frameworks;
- societal evolutions influencing sexuality on a large scale.
These recommendations can only be implemented, or even considered, if the
context in which interventions are planned, implemented, evaluated and studied
changes as well. This means that the funding climate should be sensitized about
the importance of pre-intervention research, close monitoring and evaluation,
and the necessity of flexible planning and evaluation. Researchers should get
more opportunities to publish implementation research, preferable in
combination with research on intervention development and effectiveness.
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Summary
Introduction
Worldwide, on average, 2,500 young people (15-24 years) get infected with HIV every
in a regional HIV prevalence of 1.4% in young men and 3.3% in young women. Since
no cure or vaccine is available, reducing sexual risk behaviour in this group is crucial in
tackling the epidemic.
Objectives and methods
The general objective of this doctoral study was to improve the effectiveness of HIV
-
the population of young people in sub-Saharan Africa, given that there were indications
that they were not very effective. This was done through a systematic literature review
and meta-analysis. A study protocol described procedures for the literature search strategy,
the inclusion criteria, the data to be extracted, the extraction procedure and the data
analysis methods.
Secondly, we aimed to evaluate a peer-led school-based HIV prevention intervention in
Rwanda, to get more hands-on insight into how such interventions are developed, implemented
and evaluated. We used a nonrandomized controlled trial. In fourteen schools
(eight intervention and six control schools) 1,950 students completed a standardized
questionnaire at baseline. We undertook two additional measurements, six and twelve
months in the intervention. Statistical analyses were done in Stata, SPSS and SAS, using
propensity score matching, generalized estimation equations and multivariate regression
analysis.
objective aimed to identify and study more in-depth the possible reasons for this limited
effectiveness of HIV prevention interventions for young people in sub-Saharan Africa.
This objective mainly relied on studies taking place in Rwanda. First, participation in the
intervention was assessed by identifying baseline characteristics of respondents that
could possibly predict participation in the intervention. To that end, we applied multinomial
and linear regression models with backward variable selection in Stata to the longitudinal
data collected for the effectiveness evaluation. Second, we studied determinants
of young people’s sexual behaviour. To that end, we used a qualitative ‘mailbox study’
that assessed determinants of young people’s sexual risk behaviour. This study assessed
the spontaneous thoughts of Rwandan adolescents on sexuality, allowing us to identify
schools in Rwanda and students were invited to write about their ideas, secrets, wishes,
desires and fears on sexuality and relationships. Analysis was done in NVivo9. Further-
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literature review that compared HIV status and sexual behaviour of out-of-school and
in-school youth. Third, using a systematic literature, we assessed the theoretical underpinnings
of existing HIV prevention interventions for young people in sub-Saharan Africa.
Results
The literature review and meta-analysis showed limited effectiveness of HIV prevention
reduce sexual activity, and condom use only increased notably among males, but remained
at a low level. Furthermore, this study demonstrated a paucity in evaluated HIV
prevention interventions for young people in sub-Saharan Africa. The evaluation study in
vention
did succeed in increasing young people’s perception that AIDS is a serious disease
and reduced self-reported enacted stigma. However, multivariate analyses showed
no changes in sexual behaviour of the intervention group in neither country. Dose-effect
analyses found that active participants did not change their behaviour more than passive
participants.
large number of potential participants never participated in intervention activities: in the
Rwandan intervention, over 40% did not participate in any of the intervention activi-
at ease with their sexuality, those consciously seeking information, and those who seek
to pass time, were more likely to participate in the intervention. For participation in an
occurring during the intervention and not pre-intervention characteristics are crucial.
Secondly, the intervention might not deal with the right issues. Letters written by Rwandan
young people in the qualitative mailbox technique, revealed a large number of determinants
of sexual behaviour, ranging from personal factors (e.g. puberty, knowledge)
over inter-personal factors (e.g. type of sexual relationships) and environmental factors
(e.g. school) to social and cultural factors (e.g. norms, economic factors, gender), demonstrating
the complexity of sexual behaviour of young people. The letters found a dominance
of two types of sexual relationships: experimental sex taking place unprepared
among same-age youth and driven by sexual desire, and transactional sex, where young
people have sex with an (often older) partner in exchange for money or goods and driven
by peer pressure to possess the right material goods. While these types of relationships
and contextual factors put young people at risk for HIV infection, they were not dealt
with in the intervention. The important role of structural factors is further shown in the
study on the role of education. We found that in-school youth have less HIV and demonstrated
less risky sexual behaviour than out-of-school youth. However, school attendance,
especially in less globalized regions, can also alienate pupils, or create social division, as
in the formation of elites with the means of engaging in much partner concurrency.
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Thirdly, three behavioural theories were found to be at the basis of most interventions:
social cognitive theory, theory of reasoned action/planned behaviour and health belief
model. While such theories could provide guidance in simplifying this complex behaviour
and in identifying key determinants, their focus remains on individual cognitions, such as
HIV related knowledge and attitudes, simplifying sexual behaviour too much. To face the
complexity of young people’s sexual behaviour, interventions often resort to causal reductionism
and simple, often (unconsciously) moralising messages. Thereby they ignore
behaviour.
Discussion and conclusion
Our studies observed little effectiveness of HIV prevention interventions for young
people in sub-Saharan Africa. We discuss two groups of factors that may be accountable
too much on cognitions on the individual level, ignoring other determinants of sexual
behaviour, making it possible that they are doomed from the outset, simply because it is
munity
norms and social and cultural factors. Furthermore, interventions often (unconsciously)
send moralizing messages, sometimes ignoring the reality of young people’s
sexual behaviour and hence, ignoring to focus on their most risky sexual behaviours.
Interventions are also confronted with implementation issues, resulting in problems to
reach the target population and in maladapted intervention approaches.
The second group of factors is situated on the level of the evaluation. Randomized controlled
trials are considered the gold standard for determining cause-and-effect relationships.
However, their use in measuring the effectiveness of HIV prevention interventions
on sexual behaviour is often compromised by the complexity of the real life situation
in which these interventions take place. The long causal pathway in changing sexual
changes to the intervention. While the ultimate objective of the interventions is to reduce
necessary to measure changes in HIV incidence. Therefore, evaluators often rely on selfreported
sexual behaviour. We argue that the indicators currently used to measure this
the context of the relationship and network in which they take place. It is possible that
interventions do change sexual behaviour, but that these changes are not observed due to
We recommend further research on three levels. Firstly, the evaluation: alternative
evaluation designs should be formulated, combining different evaluation approaches
mirroring the intervention process (“combination evaluation”), and studying plausibility
of effectiveness, rather than probability. In order to adequately measure sexual risk,
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composite contextualized indicators have to be developed combining aspects of transmission
(including relational characteristics), exposure and infectiousness. Secondly, the
intervention: by analysing existing data on the determinants of this complex behaviour
and their pathways, and by gathering additional information, researchers should make
unprecedented efforts to develop more effective interventions. Interventions should be
vention
planning: the situation analysis and needs assessment. Thirdly, the implementation:
monitoring interventions is essential in understanding their effectiveness. Evalu-
importance of making the processes of intervention development and implementation
publicly accessible, in order for others to learn from successes and failures.
In conclusion, we can state that complex problems require complex interventions and
complex evaluations. Accepting this complexity means dealing with a considerable de-
and implementation is feasible if all parties involved (researchers, intervention manag-
and remain conscious of the ultimate objective; eradicating HIV among the important
and vulnerable population of young people in sub-Saharan Africa.
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Samenvatting
Inleiding
Wereldwijd worden dagelijks 2500 jongeren (15-24 jaar) besmet met hiv; bijna 80% van
deze infecties vindt plaats in sub-Sahara Afrika. Dit weerspiegelt zich in een regionale
hiv-prevalentie van 1,4% bij jonge mannen en 3,3% bij jonge vrouwen. Omdat er op korte
termijn geen effectief vaccin of geneesmiddel verwacht wordt, blijft het voorkomen van
besmetting essentieel. Verminderen van seksueel risicogedrag bij jongeren staat hierbij
centraal.
Doelstellingen en onderzoeksmethoden
De algemene doelstelling van dit doctoraatsonderzoek was het verhogen van de effectiviteit
van hiv-preventie-interventies voor jongeren in sub-Sahara Afrika. Daartoe formu-
van deze interventies voor jongeren in sub-Sahara Afrika bestuderen; dit omdat er
aanwijzingen waren dat ze slechts beperkt effectief zijn. We ontwikkelden een studieprotocol
voor een systematische literatuurstudie en meta-analyse waarin zoekstrategie,
inclusiecriteria, te extraheren gegevens, extractieprocedure en de methode voor dataanalyse
beschreven werden.
Ten tweede evalueerden we een hiv-preventie-interventie in secundaire scholen in
Rwanda, om een concreter inzicht te krijgen in hoe zulke interventies worden ontwikkeld,
geïmplementeerd en geëvalueerd. Beide interventies maakten gebruik van ‘peer
educatie’. De effectiviteit werd gemeten via een niet-gerandomiseerde longitudinale gecontroleerde
studie: Voor de start van de interventie vulden 1950 leerlingen in veertien
secondaire scholen (acht interventie- en zes controlescholen) een vragenlijst in. Tijdens
de interventie, op zes en twaalf maanden, werden nogmaals vragenlijsten afgenomen.
Analyse werd gedaan in Stata, SPSS en SAS.
Terwijl de vorige doelstellingen de beperkte effectiviteit van de interventies aantoon-
redenen hiervoor. Het bereik van de Rwandese interventie werd bestudeerd door te
onderzoeken of bepaalde factoren een deelname konden voorspellen. Hiervoor werden
in Stata multinomiale en lineaire regressiemodellen toegepast op de longitudinale data
verzameld voor het evaluatieonderzoek. Vervolgens keken we naar de determinanten
van seksueel gedrag van jongeren. Een kwalitatieve ‘brievenbusstudie’, waarbij Rwandese
jongeren in vijf secondaire scholen werden gevraagd om spontaan verhalen te
schrijven, vragen te stellen en gedachten te delen over seksualiteit en relaties, maakte
structurele factor: onderwijs. Een literatuuronderzoek vergeleek de hiv-status en het seksueel
gedrag van schoolgaande en niet-schoolgaande jeugd in Oost- en Zuidelijk Afrika.
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Tenslotte onderzochten we de theoretische onderbouw van hiv-preventieprogramma’s
voor jongeren in sub-Sahara Afrika, gebruik makend van de bestaande literatuur.
Resultaten
De literatuurstudie en meta-analyse toonden aan dat hiv-preventie-interventies het
seksueel gedrag (leeftijd bij eerste seksueel contact, aantal partners en recente sek-
hiv-incidentie niet daalt. Enkel condoomgebruik bij mannen lijkt toe te nemen, hoewel
het onvoldoende blijft. Verder toonden de studies aan dat er een duidelijk gebrek is aan
kwaliteitsvolle evaluaties van hiv-preventie-interventies.
Ook de evaluatiestudie in Rwanda bevestigde dat het verminderen van seksueel risicogedrag
bij jongeren uiterst moeilijk is. Hoewel de Rwandese interventie ervoor zorgde
dat meer jongeren aids als een ernstige ziekte gingen beschouwen en dat gerapporteerd
stigma daalde, bleek uit de multivariate analyse dat het seksueel gedrag niet veranderd
was. Bijkomende analyses die actieve deelnemers vergeleken met passievere deelnemers
veranderden de conclusies niet.
Mogelijke redenen voor deze waargenomen beperkte effectiviteit werden onderzocht.
Ten eerste, stelden we vast dat een groot aantal potentiële deelnemers nooit deelnam aan
de interventieactiviteiten: in Rwanda nam meer dan 40% van de potentiële deelnemers
jongeren die comfortabel kunnen communiceren over (hun) seksualiteit, jongeren die
bewust zoeken naar informatie, en jongeren die proberen de tijd te doden. Zij die beant-
opgesteld worden, wat aangeeft dat factoren die zich tijdens de interventie voordoen en
dus niet pre-interventie kenmerken van belang zijn.
In de tweede plaats onderzochten we de inhoud van de interventies. Brieven geschreven
door Rwandese jongeren in de kwalitatieve ‘brievenbusstudie’, legden een groot aantal
determinanten van seksueel gedrag bloot, gaande van persoonlijke factoren (b.v. puberteit,
kennis) over interpersoonlijke factoren (b.v. type van seksuele relaties) en omgevingsfactoren
(b.v. school) tot sociale en culturele factoren (b.v. normen, economische
factoren, gender). Dit toont aan hoe complex het seksueel gedrag van jongeren is. Verder
maakten de brieven duidelijk dat jongeren voornamelijk twee soorten seksuele relaties
aangaan: experimentele seks, die vaak onvoorbereid plaatsvindt tussen jongeren van
dezelfde leeftijd en gedreven wordt door seksueel verlangen en nieuwsgierigheid, en
transactionele seks, waarbij jongeren seks hebben met een (vaak oudere) partner in ruil
voor geld of materiële zaken, gedreven door groepsdruk om de juiste zaken te bezitten.
Hoewel deze types relaties en contextuele factoren jongeren kwetsbaar maken voor hiv-
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infectie, werden ze niet betrokken in de interventie. De belangrijke rol van structurele
factoren werd verder aangetoond in een studie over de rol van onderwijs. We vonden dat
onder schoolgaande jeugd t.o.v. niet-schoolgaande jeugd minder hiv voorkomt en dat er
minder risicovol seksueel gedrag wordt vertoond. Echter, onderwijs kan ook een ander
effect hebben, zoals het vergroten van de sociale kloof door de vorming van elites die de
middelen hebben om meerdere seksuele partners te onderhouden, wat meer risico’s met
zich meebrengt.
Tenslotte, de gedragstheorieën die aan de basis liggen van de meeste interventies – social
cognitive theory, theory of reasoned action/planned behaviour en health belief model
– worden in interventies zodanig ingevuld dat de focus grotendeels ligt op cognities
op het individueel niveau, zoals hiv-gerelateerde kennis en houdingen. Om te kunnen
omgaan met de complexiteit van seksueel gedrag, nemen hiv-preventie-interventies voor
jongeren vaak hun toevlucht tot reductionisme en eenvoudige, vaak (onbewust) moraliserende
boodschappen. Daarbij negeren ze de realiteit en de grote hoeveelheid andere
factoren die vanop verschillende niveaus een impact hebben op seksueel gedrag.
Discussie en conclusie
Evaluaties van hiv-preventie-interventies tonen een beperkte effectiviteit in het verminderen
van seksueel risicogedrag van en hiv-incidentie bij jongeren in sub-Sahara
mogelijk verantwoordelijk zijn. Een eerste groep betreft de interventie zelf. Onze studies
wezen uit dat interventies zich voornamelijk richten op hiv-gerelateerde cognities op het
individuele niveau terwijl we eveneens aantoonden dat heel wat andere factoren een rol
spelen in het nemen van seksuele beslissingen. Daarom is het mogelijk dat de interventies
van bij aanvang gedoemd zijn om te mislukken, gegeven de moeilijkheid om individueel
seksueel gedrag te veranderen in de aanwezigheid van statische sociale normen en
culturele factoren. Bovendien doen interventies vaak (onbewust) beroep op moraliserende
boodschappen over seksueel gedrag, waarbij ze niet steeds uitgaan van de realiteit
en veronachtzamen zich te concentreren op het meest risicovol seksueel gedrag. Verder
worden interventies ook geconfronteerd met implementatieproblemen.
De tweede groep factoren ligt op het niveau van de evaluatie. Gerandomiseerde gecontroleerde
studies worden beschouwd als de gouden standaard voor het bepalen van
oorzaak-gevolgrelaties. Het correct toepassen van de regels van zulke designs botst
echter vaak met de complexiteit van hiv-preventie-interventies voor jongeren. De lange
weg die gevolgd moet worden om seksueel gedrag en hiv-incidentie te wijzigen, in combinatie
met de hoeveelheid contextuele factoren die dit kan beïnvloeden, maakt het extra
moeilijk om waargenomen veranderingen toe te wijzen aan de interventies. Bovendien
moeten dus beroep doen op zelf-gerapporteerd seksueel gedrag. Echter, we stelden
vast dat de indicatoren die momenteel gebruikt worden voor het bepalen van seksueel
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isicogedrag geen juiste afspiegeling zijn van de risico’s die jongeren daadwerkelijk nemen:
ze worden immers gemeten buiten de context van de relatie en het netwerk waarin
ze plaatsvinden. Het is dus mogelijk dat interventies er in slagen om seksueel gedrag te
veranderen, maar dat de evaluaties niet in staat zijn om deze veranderingen te meten.
Om de effectiviteit van hiv-preventie-interventies voor jongeren in sub-Sahara Afrika
te verhogen, formuleren wij aanbevelingen op drie vlakken. Ten eerste, de evaluatie:
het gebruik van alternatieve evaluatiedesigns, waarbij verschillende methodes worden
gecombineerd doorheen het volledige interventieproces (“combinatie-evaluatie”), en
waarbij onderzoek naar de plausibiliteit van effectiviteit, eerder dan de probabiliteit,
centraal staat. Om adequaat seksueel risicogedrag te meten, raden wij de ontwikkeling
van samengestelde, contextuele indicatoren aan. Zulke indicatoren combineren aspecten
van transmissie (inbegrepen relationele kenmerken), blootstelling en besmettelijkheid.
Ten tweede, de interventie: door het bestuderen van de determinanten van seksueel gedrag
en hoe ze dit gedrag beïnvloeden, en het verzamelen van nieuwe gegevens, moeten
onderzoekers het mogelijk maken om effectievere interventies te ontwikkelen. Zulke
voor de eerste fase van de interventieplanning vraagt: de situatie- en behoefteanalyse.
Ten derde, de uitvoering: het monitoren van interventies is essentieel in het begrijpen
176
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van hun effectiviteit. Evaluatoren, interventiemanagers en uitgevers van wetenschappelijke
tijdschriften moeten zich bewust worden van het belang van het publiceren van
ontwikkelings- en implementatieprocessen van interventies, zodat anderen kunnen leren
van successen/mislukkingen.
Samenvattend kunnen we stellen dat, om complexe problemen op te lossen, er complexe
interventies en complexe evaluaties nodig zijn. Het accepteren van deze complexiteit
eit
toelaten in de interventie, implementatie en evaluatie is haalbaar als alle betrokken
wetenschappelijke tijdschriften) bereid zijn op een open manier samen te werken en zich
bewust blijven van het uiteindelijke doel; hiv elimineren bij de belangrijke en kwetsbare
bevolkingsgroep van jongeren in sub-Sahara Afrika.
177
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Annex
Paper 7
Delva, W., Michielsen, K., Meulders, B., Groeninck, S., Wasonga, E., Ajwang, P., Temmerman,
M., Vanreusel, B. (2010), HIV prevention through sport: the case of the Mathare
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Paper 8
Stroeken, K., Michielsen, K., Remes, P.,Meeuwis, M. The region-sensitive effect of globalization
on HIV in Eastern and Southern Africa: The dual role of education. Submitted to
AIDS & Behavior (08/2012)
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