What Works for Women and Girls

Table 2.1Gray Scale of the Strength of EvidenceTypeIIIIIIIVVStrength of evidenceStrong evidence from at least one systematic review of multiple well designed, randomized controlled trials.Strong evidence from at least one properly designed, randomized controlled trial of appropriate size.Evidence from well-designed trials without randomization: single, group, pre-post, cohort, time series, or matchedcase-control studies.Evidence from well-designed, non-experimental studies from more than one center or research group.Opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees.In the case of abstracts from the latest International AIDS Conference (2008) or fromrelevant conferences in 2009 or 2010, the Gray Scale was not included since it was not alwayspossible to ascertain the appropriate Gray Scale rating from the abstract. All printed abstractsfrom the XVII International AIDS Conference in Mexico City, Mexico, August 2008 werereviewed and included if they met the criteria for inclusion. The 2008 XVII InternationalAIDS Conference abstracts were searched online (www.iasociety.org for the 2008 conference)using keywords such as “breastfeed” and “malaria.” Some authors of 2008 abstracts wereemailed in 2009 to see if particularly promising data had been published. Where possible,the published articles were included, with the appropriate Gray Scale included. In addition,abstracts from the International Family Planning Conference (www.fpconference2009.org),held in Kampala, Uganda in November 2009, were included.One weakness of the Gray scale is prioritizing randomized controlled trials, as randomizedcontrolled trials are “primarily a vehicle for evaluating biomedical interventions, ratherthan strategies to change human behavior. Altering the norms and behaviors of social groupscan sometimes take considerable time….” (Global HIV Prevention Working Group, 2008:12). Much of the evidence cited in this document falls in strength levels IV and V; however,many studies fall in strength level III, with growing numbers of systematic reviews (level I)and randomized control trials (level II). Not all of the interventions listed here have the sameweight and those that are promising but require further evaluation are identified. It must alsobe noted that randomized controlled trials—the gold standard of the Gray ratings—are notalways ethical or appropriate for certain HIV interventions and therefore should not be theonly factor in judging the relative weight of any particular study. Furthermore, many HIVprevention programs that address key issues in novel, context-specific ways are often not rigorouslyevaluated (Gupta et al., 2008a).In cases where a majority of the evidence, and particularly strong evidence, exists for anintervention, this was listed in each section as “what works.” Criteria set for “what works” and“promising” were:What Works: strongly rated studies (Gray I, II or III) for at least two countries and/or fiveweaker studies across multiple settings.Promising: studies that were strongly rated but in only one setting or a number of weakerstudies in only one country.WHAT WORKS FOR WOMEN AND GIRLS39