Research Article: Interventions to address unequal gender and power relations and improve self-efficacy and empowerment for sexual and reproductive health decision-making for women living with HIV: A systematic review

Date Published: August 24, 2017

Publisher: Public Library of Science

Author(s): Jennifer L. Robinson, Manjulaa Narasimhan, Avni Amin, Sophie Morse, Laura K. Beres, Ping Teresa Yeh, Caitlin Elizabeth Kennedy, Peter A Newman.


Many women living with HIV experience gendered power inequalities, particularly in their intimate relationships, that prevent them from achieving optimal sexual and reproductive health (SRH) and exercising their rights. We assessed the effectiveness of interventions to improve self-efficacy and empowerment of women living with HIV to make SRH decisions through a systematic review.

We included peer-reviewed articles indexed in PubMed, PsycINFO, CINAHL, Embase, and Scopus published through January 3, 2017, presenting multi-arm or pre-post intervention evaluations measuring one of the following outcomes: (1) self-efficacy, empowerment, or measures of SRH decision-making ability, (2) SRH behaviors (e.g., condom use, contraceptive use), or (3) SRH outcomes (e.g., sexually transmitted infections [STIs]). Twenty-one studies evaluating 11 intervention approaches met the inclusion criteria. All were conducted in the United States or sub-Saharan Africa. Two high-quality randomized controlled trials (RCTs) showed significant decreases in incident gonorrhea and chlamydia. Sixteen studies measuring condom use generally found moderate increases associated with the intervention, including in higher-quality RCTs. Findings on contraceptive use, condom self-efficacy, and other empowerment measures (e.g., sexual communication, equitable relationship power) were mixed. Studies were limited by small sample sizes, high loss to follow-up, and high reported baseline condom use.

While more research is needed, the limited existing evidence suggests that these interventions may help support the SRH and rights of women living with HIV. This review particularly highlights the importance of these interventions for preventing STIs, which present a significant health burden for women living with HIV that is rarely addressed holistically. Empowerment-based interventions should be considered as part of a comprehensive package of STI and other SRH services for women living with HIV.

Partial Text

An increasing body of evidence demonstrates the ways unequal levels of power between men and women in intimate relationships prevent women, including women living with HIV, from making decisions regarding their sexual and reproductive health (SRH) [1–5]. Gender refers to the set of roles, behaviors, and norms that are designated as appropriate for women and men by society [6]. Gender can be the cause, consequence, and/or mechanism of unequal or hierarchical power relations—that is, how power and control are distributed (unequally or hierarchically) in intimate relationships, within the household, in the community, and in wider societal institutions including all the way to the highest levels of political decision-making [6]. In this paper, we focus primarily on the distribution of power in intimate relationships between women and men and within the household. Frequently, unequal control over and access to economic resources, unequal relationship power, and limited ability to make sexual decisions (including whether, when, how often, and with whom to have sex; and negotiating condom use, contraceptive or other protective practices) make women vulnerable to SRH risks [7,8]. Gender inequalities and power imbalances restrict the ability of many women living with HIV to meet their SRH needs and exercise their rights [9].

This systematic review was conducted to inform World Health Organization guidelines on the sexual and reproductive health and rights of women living with HIV, following PRISMA reporting guidelines [11]; the review protocol is available upon request [12].

Database searches produced a total of 3,351 hits; 2,087 citations remained after removing duplicates (Fig 1). After initial screening, 151 citations were reviewed by two authors in duplicate, of which 73 were excluded for not meeting the inclusion criteria (e.g., qualitative studies, studies without relevant outcomes, or studies without findings for women living with HIV). Seventy-eight articles were pulled for full-text review, and 57 were excluded. Ultimately, 21 studies were included in the review covering 11 specific intervention approaches (Table 1).

All women living with HIV must be supported in their voluntary choices around sexual relationships and be given information and resources to engage in safe, enjoyable sexual experiences, or to not engage in sex based on their personal preference, with counselling and support tailored to their decision-making, desires and needs. Supporting women living with HIV in all their diversity to achieve their sexual and reproductive health and rights in all epidemic contexts requires overcoming major barriers to service uptake such as social exclusion and marginalization, criminalization, stigma, and gender inequality [37]. Addressing unequal gender and power relations and empowering women living with HIV may be one part of a comprehensive approach to achieve these goals.




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