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Table 1 General characteristics of 25 interventions reported in 45 articles included in the review

From: Is it time to RE-AIM? A systematic review of economic empowerment as HIV prevention intervention for adolescent girls and young women in sub-Saharan Africa using the RE-AIM framework

Study, location Design Description Outcome of interest RE-AIM dimension
Reach Adoption Implementation Efficacy/effectiveness Maintenance
Abdool Karim et al. (2015) [68]; Humphries et al. (2017) [69], South Africa Cluster RCT to evaluate the impact of a cash-incentivized prevention intervention to reduce HIV infection
Intervention:
Cash-incentivized prevention intervention to reduce HIV infection
To increase HIV testing, reduce incidence of HIV Study participants: 3217 adolescents; 53% females (1705)
Age range, 13–24 for females (median: 16 years).
Non-participants: characteristics of non-participants were not reported
Program delivered by trained field staff Cash incentives of up to US$175 over 2 years, conditional on their participation in a life skills program, passing grades in 6 months of academic exams, and acceptance of an HIV test After 2 years, CCTs reduced HSV-2 incidence by 30% (p = 0.007). Among boys, those in the incentive group had a 40% lower incidence of HSV-2 than controls (p = 0.042), while girls had a 24% lower incidence of HSV-2 compared to controls (p = 0.035). The reduction in HSV-2 infection was greater the higher the CCT amount. The number of HIV infections (75) was too small to detect a difference between intervention and control. Individual level:
Follow-up at 12 and 24 months to assess individual behavior change participants)
Program level:
Indicators of program level maintenance were not reported
Adoho et al. (2014) [70], Liberia RCT comparing economic, empowerment, and health outcomes between participants and controls
Intervention:
Empowerment of Adolescent Girls and Young Women (EPAG) part of a larger Adolescent Girls Initiative (AGI) administered by the World Bank with support from the Nike Foundation and the Governments of Australia, the UK, Norway, Denmark, and Sweden. The intervention provided 6 months of livelihoods and life skills training (in either a Job Skills or Business Development Services track) and 6 months of follow-up support to facilitate self or wage employment for young girls (16–27 years) in Liberia
Promote safe sexual behavior Study participants: 2042 females; Age range, 16–27 (mean, 23 years) not enrolled in school.
Non-participants: Reasons for not participating in the program included (1) they were back in school, (2) they had moved to a distant location, (3) they were seriously ill, (4) they had found full-time work, (5) they were not interested or able to make such a big-time commitment, or (6) they could not be located despite numerous efforts.
Program delivered by four NGOs selected by the Liberian Ministry of Gender and Development Empowerment of Adolescent Girls and Young Women (EPAG) provided 6 months of livelihoods and life skills training (in either a Job Skills or Business Development Services track) and 6 months of follow-up support to facilitate self or wage employment. Among participants, there was no significant reduction in the number of sexual partners or increase in condom use as a result of the intervention. There was also no difference in these outcomes between the treatment and intervention arms.
Attrition rate: 20% at 6-months follow-up
Cost: $1200 for the Business Skills Track; $1650 for the Job Skills Track
Individual level: follow-up at 6 months to assess individual behavior change (sexual behavior)
Program level: indicators of program level maintenance were not reported
Austrian and Muthengi (2014) [71]; Muthengi (2014) [72], Uganda Cluster RCT to assess the impact of Adolescent Girls Empowerment Program on demographic, reproductive and health outcomes
Intervention:
Adolescent Girls Empowerment Program that includes safe space, health vouchers and savings account
Improve sexual and reproductive health outcomes (HIV knowledge, HIV testing, and knowledge of contraceptives) and increase in economic assets Study participants: 4661 adolescent girls; age range, 10–19
Non-participants: characteristics of non-participants were not reported
Program implemented in partnership with key stakeholders: safe spaces with YWCA Zambia; Health Vouchers with Ministry of Community Development, Mother and Child and Savings Program with National Savings and Credit Bank and Making Cents International.
Program uptake participants: 30% attended 52+ meetings
There were 3 arms: arm 1: safe spaces only; arm 2: safe spaces and health voucher; and arm 3: safe spaces, health vouchers, and savings account. No difference between program and control with social safety nets, gender norms at 24 months. AGEP also had no impact on HIV prevalence or incidence. AGEP however improved sexual and reproductive health knowledge, improved self-efficacy, improved saving behaviors, and decreased transactional sex (for girls who were sexually active at the start).
Attrition rate, 18%
Individual level: follow-up at 12 months and 24 months to assess individual behavior change among participants
Program level: indicators of program level maintenance were not reported
Baird et al. (2012) [73]; Baird et al. (2013) [74], Malawi Cluster RCT comparing conditional cash transfers (CCT) recipients versus unconditional cash transfer (UCT) recipients and non-recipients
Intervention:
Conditional cash transfers (CCT)
Decrease prevalence/incidence of HIV and herpes simplex virus 2 (HSV-2) Study participants: 1706 never married young women; age range, 13–22 (schoolgirls and school dropouts)
Non-participants: individuals who did not want to get tested for HIV
A local NGO implemented the CCT program CCT (based on at least 80% school attendance) and UCT participants received some money from 1–5/month and their parents received some money from 4–10/month for 2 years Overall, 2 years after the program ended, among school girls, neither CCTs nor UCTs had any long-term effect on HIV prevalence, onset of sexual activity, risky sexual behaviors such as having older partners or use of condoms, and the following sexual behaviors: sexual debut, age at first sex, number of sexual partners, condom use, and age of sexual partners. Among school dropouts, CCTs initially delayed the onset of sexual activity, but 2 years after the end of the program, 97% of this cohort is sexually active. CCTs did not lead to long-term changes in condom use or age at first sex among baseline dropouts.
Attrition: 15.7% among school dropouts and 12.5% among school girls.
Individual level: follow-up at 6 months, 12 months, 24 months to assess individual level change
Program level: indicators of program level maintenance were not reported
Bandiera et al. (2012) [75]; Bandiera et al. (2018) [76], Uganda Cluster RCT to evaluate the effects of the Empowerment and Livelihoods for Adolescents (ELA) program
Intervention: empowerment and Livelihoods for Adolescents (ELA) program
To increase HIV- and pregnancy-related knowledge and condom use Study participants: 4800 adolescent girls. Age range, 14–20 years. Mean age, 16 years
Non-participants: not explicitly stated. However, authors explain that distance to program location may have impacted participation.
Program implemented by NGO, BRAC Uganda by trained mentors or professional staff.
Program uptake by participants, 21%
ELA combined the provision of life skills to reduce risk behaviors and vocational skills training to start small income-generating activities After 2 years, among those sexually active, routine condom use increased by 25% (p < 0.05) and the number of girls reporting having sex unwillingly dropped from 21% at baseline to under 4% (p < 0.01). The intervention group also had a 26% lower rate of fertility over 2 years (p < 0.05).
Attrition rate: 18% at 24 months’ follow-up
Program costs: year 1: US$365,690; year 2: US$232,240
Individual participant cost: $17.9
Individual level: follow-up at 12 and 24 months to assess individual level behavior change
Program level: authors alluded to the continuation of the program beyond study timeline. The program was expanded to include a microfinance component that provides financial support for microenterprise
Bazika (2007) [77], Congo Cross-sectional survey and FGDs to understand how involvement in IGAs is associated with HIV risk
Intervention: income-generating activities related to trade and craft apprenticeships
Increase condom use Study participants: 372 young people; age range, 15–24
Non-participants: characteristics of non-participants were not reported
Implemented by local authorities
Program uptake by participants: not stated
IGAs consisting mostly of “trade and craft apprenticeships” Approximately 25% of the youth were involved in IGAs; 5% of all participants reported sexual intercourse with a new partner without a condom, which was significantly lower among those currently involved in IGAs (p < 0.01); however, higher levels of unprotected sex were reported by youth involved in agriculture. Individuals level: follow-up at 4 years after intervention implementation to assess individual level change.
Program level: the program was discontinued 3 months after implementation
Cho et al. (2018) [78], Kenya Cluster RCT to test whether keeping orphan adolescents in school reduces HIV risk
Intervention: involved providing school fees, school uniforms, and nurse’s visits to monitor absenteeism
Reduction in HIV and herpes simplex virus 2 (HSV-2) incidence Study participants: 835 orphaned adolescents; age range, 11–20; mean age, 15 years; 48% were adolescent girls (401)
Non-participants: one individual was not interested in the study. However, more details on characteristic of non-participants were not provided
Program implemented by trained research staff. The intervention arm received payment of school fees, school uniforms, and nurse’s visits to monitor absenteeism After 3 years, school support reduced the med-likelihood of engaging in transactional sex. High (AOR = 0.49, p = 0.03) and increased VMMC among males (AOR = 1.66, p = 0.04), but no differences were seen in sexual debut, age at first sex, number of sexual partners, or condom use between intervention and control participants. The study was underpowered to detect a difference on HIV or HSV-2 incidence between arms.
Attrition rate: 10%
Individual level: follow-up at 12, 24, and 36 months to assess individual level change
Program level: indicators of program level maintenance were not mentioned
Cluver et al. (2016) [79], South Africa Prospective observational study with random sampling to assess the relationship between receipt of social services (“cash,” “cash plus care,” or “no support”) and HIV risk behaviors
Intervention:
Intervention provided “cash” defined as household receipt of a child support grant or foster care grant, school feeding, and/or food gardens; “cash plus care” adds receipt of teacher social support and/or positive parenting
Reduction in HIV incidence Study participants: 2668 adolescent boys and girls; age range, 12–18; mean age, 14 years; 56% were adolescent girls (1494)
Non-participants: characteristics of non-participants were not reported
Program implemented by trained research staff “Cash” defined as household receipt of a child support grant or foster care grant, school feeding, and/or food gardens; “cash plus care” adds receipt of teacher social support and/or positive parenting. Child-focused grants, free schooling, school feeding, teacher support, and parental monitoring were independently associated with reduced HIV-risk behavior incidence (OR 0.10–0.69). For example, girls predicted past-year incidence of economically driven sex dropped from 11% with no interventions to 2% amongst those with a child grant, free school, and good parental monitoring. Similarly, girls’ incidence of unprotected/casual sex or multiple partners dropped from 15% with no interventions to 10% with either parental monitoring or school feeding and to 7% with both interventions.
Attrition rate: 3%
Individual level: follow-up at 12 months to assess individual level change
Program level: indicators of program level maintenance were not reported
de Walque et al. (2012) [80]; de Walque et al. (2014) [81], Tanzania RESPECT RCT to assess the effectiveness of Conditional Cash Transfers (CCTs) on prevention of STIs
Intervention: RESPECT-provided conditional cash transfers
Reduction in risky sexual behaviors, reduce incidence of HIV, herpes simplex virus 2, and syphilis Study participants: 2399 males and females; age range, 18–30; mean age range, 27 years;females, 50% (1199)
Non-participants: the authors noted that some participants explicitly refused to participant in the study and some declined. However, detailed reasons and characteristic of these non-participants were not stated.
Program implemented by trained research staff. CCTs of US$10 (low-value) or US$20 (high-value) per testing round conditioned on testing negative for 4 curable STIs every 4 months (3 testing rounds in 12 months) At 12 months, the high-value CCT arm had a lower risk of combined prevalence of any of the four STIs compared to controls (aRR = 0.73, p < 0.05) and compared to the low-value arm (aRR = 0.69, p < 0.05). At end line, the combination of syphilis prevalence and new cases of HIV and HSV2 were not different between study arms.
One year after the end of the intervention, both the high and low value CCTs lowered the risk of testing positive for any one of the 7 STIs (0.799 and 0.818, respectively, p < 0.05). Only the low-value arm significantly lowered the prevalence when looking only at the 4 STIs on which the CCT was conditioned (RR = 0.766, p < 0.05), and only the high-value arm significantly reduced the prevalence when looking at HIV/HSV/syphilis. Results were sustained 12 months post-intervention for males, but not females. There were no significant differences in self-reported sexual risk behavior at 24 months.
Attrition rate: 6.4% attrition at 12 months and 9.3% attrition at 24 months
Individual level: follow-up at 12 and 24 months to assess individual level change
Program level: conditional cash transfer and other components of the intervention were discontinued after 1 year of implementation
Dunbar et al. (2010) [82]; Dunbar et al. (2014) [83], Zimbabwe Individual RCT to compare the effects of the Shaping the Health of Adolescents in Zimbabwe (SHAZ!) intervention on structural factors and sexual risk behaviors
Intervention:
Shaping the Health of Adolescents in Zimbabwe (SHAZ!) intervention on structural factors and sexual risk behaviors
Increase correct HIV knowledge, increase condom use Study participants: 315 HIV- female, out of school orphans; age range, 16–19; mean age, 18 years
Non-participants: individuals who did not return for enrollment. However, the authors did provide additional details on the characteristic of these individuals. Participants who returned to school, relocated or where influenced by partners to not participate in the study.
Program implemented by trained research staff SHAZ! Intervention consisted of (1) reproductive health services; (2) life skills, gender, and HIV education; (3) financial literacy education and a choice of 6-month vocational training course; and (4) integrated social support and adult mentoring. The control arm received components 1 and 2 only. After 2 years, within the intervention arm, there Med- were statistically significant reductions in high transactional sex (IOR = 0.64, p < 0.05), and increases in condom use with current partners (IOR = 1.79, p < 0.05) compared to baseline, but these were not significantly different from the results in the control group. Sexual debut also did not differ between arms. Unintended pregnancy was marginally significantly lower in intervention arm (AHR = 0.61, p = 0.06). Intervention participants also had a greater reduction in the experience of violence over time (AHR = 0.10, p = 0.06). The study was not powered to detect differences in HIV and HSV-2 incidence.
Attrition: 19% at 24 months
Individual level: follow-up at 6, 12, 18 and 24 months to assess individual level change
Program level: indicators of program level maintenance were not reported
Erulkar and Chong (2005) [84]; Hall et al. (2006) [85], Kenya Longitudinal (pre-post intervention) study of Tap and Reposition Youth (TRY) participants and matched controls to assess changes in vulnerabilities and risk behaviors
Intervention:
Tap and Reposition Youth (TRY) - combined training on business management and reproductive health, group savings, and formal microcredit to individual group members’ contingent on other members’ timely repayment
Increase condom use and sexual and reproductive health/HIV knowledge, increase ability to negotiate issues related to sexual behavior, increase economic assets (earning, savings, household assets) Study participants: 444 out-of-school adolescent females; age range, 16–22
Non-participants: characteristics of non-participants were not reported
Program delivered by project officers and mentors The TRY intervention combined training on business management and reproductive health, group savings, and formal microcredit to individual group members contingent on other members’ timely repayment At program exit (after < 1 year to 3 years), 80.3% High of TRY participants were able to refuse sex with their partner, compared to 71.6% of controls (p < 0.05), though TRY girls were significantly more likely to insist on condom use compared to controls (61.7% vs. 49.3%, p < 0.01). There was no significant difference in the likelihood of having used a condom at last sex between the two groups, though both arms experienced a decrease from baseline levels.
Attrition rate: 32% at end line (36 months follow-up)
Individual level: follow-up at 12, 24 and 36 months to assess individual level change
Program level: indicators of program level maintenance were not reported
Goodman et al. (2014) [86], Kenya Stratified-random, cross-sectional survey to assess differences among three program cohorts (those involved for 4 months, over 1 year, and over 2 years) in a range of outcomes, including sexual practices. Some families received cash transfers. Some families received cash transfers
Intervention:
The intervention provided vocational training, group income-generating activities (IGAs), and provision of business start-up kits
Increase condom use, increase financial literacy, increase economic assets (earnings, savings) Study participants: 707 OVC-headed households (aged 13 to 25); mean age 19 years; 66% females (467)
Non-participants: characteristics of non-participants were not reported
Program implemented by community stakeholders and trained social workers Three-year intervention grouping 20–40 families together for vocational training, group income-generating activities (IGAs), and provision of business start-up kits. They also received weekly group trainings on business, health, hygiene, and agriculture. Some families received cash transfers. Among females, those in higher cohorts had fewer sex partners (p = 0.03) and greater condom use at last sexual encounter (p = 0.015). Among males there was no significant difference in number of sexual partners or condom use.
Attrition rate: figure not reported
Individual level: follow-up at 12, 24, and 36 months to assess individual level change
Program level: authors alluded to the continuation of the program and implementation in four other sub-Saharan African countries
Hallfors et al. (2011) [22]; Hallfors et al. (2015) [23]; Luseno et al. (2015) [87], Zimbabwe Cluster RCT to assess the effects of the school subsidies (school fees, uniforms, schools’ supplies, and school helpers) on HIV risk behaviors
Intervention:
The intervention provided payment of school fees, uniforms, supplies, and a school-based female teacher to serve as a helper to assist with attendance monitoring and assist with attendance problems
Reduce school drop-outs, reduce unintended pregnancy, decrease age of sexual debut, and promote gender equity Study participants: 328 orphan girls (aged 14–21 years); mean age, 12 years.
Non-participants: characteristics of non-participants were not reported
Not clearly stated, but can be inferred to be members of the research team Payment of school fees, uniforms, supplies, and a school-based female teacher to serve as a helper to assist with attendance monitoring and assist with attendance problems At 5 years, no differences for either HIV or HSV-2 were found by study condition. Prevalence was similar, by condition, among the never married, with a trend toward higher HIV and HSV-2 infection among the married comprehensive intervention group compared with the delayed partial intervention group. Also, fewer girls among the comprehensive intervention group reported sexual debut, marriage, or pregnancy compared with the delayed partial intervention group.
Attrition rate: 3% at 12 months follow-up; 12% at 24 months follow-up
Follow up at 12, 24, 36 and 60 months.
Program level: the intervention lasted for 5 years. The duration of the research trial. Program level continuation in the setting was not reported
Handa et al. (2014) [88]; Rosenberg et al. (2014) [89], Kenya Cross-sectional data from cluster RCT participants, comparing adolescent sexual debut in households receiving the transfer and those in control households
Intervention:
Unconditional Cash Transfer (CT) Program for orphans and vulnerable children through the Kenyan government
Reduce age of sexual debut, increase condom use, decrease number of sexual partners and decrease engaging in transactional sex Study participants: 1433 females (out of a total sample of 2210 Orphans and Vulnerable Children (OVC)); age range, 15–25 years
Non-participants: characteristics of non-participants were not reported
Program delivered by the Children’s Department of the Ministry of Gender, Children and Social Development of the Government of Kenya Government of Kenya’s unconditional Cash Transfer (CT) Program for OVC (KES 1500 or US$20 per month per household) paid to OVC caregivers.
Eligible households received monthly CTs. There was no condition placed on receiving the CTs; however, beneficiaries were told that they were expected to use the money for the care and development of the OVC resident in the household
Frequency: cash was paid bimonthly to participants’ caregivers
Duration: 4 years (2007–2011)
The rate of sexual debut was 38% in the CT group vs. 44% in the control (p = 0.001); the reduction in odds of sexual debut for CT recipients was 31%. The effect size was larger for females (AOR = 0.58) than males (AOR = 0.74), but not significantly so. Other sexual risk behaviors (engaging in transactional sex) were not statistically significantly different between the study arms.
Attrition rate: 17% (between baseline assessment and first follow-up in 2009 (24 months follow-up)), 5% (between 2008–2011 (48 months follow-up))
Cost: the program budget for FY 2011/22 is KES 3.5 billion, of which 31% were from general tax revenues, 37% from development loans, and 31% from foreign aid donations.
Individual level: first follow-up at 2 years and 4 years to assess individual level change
Program level: indicators of program level maintenance were not reported
Jewkes et al. (2014) [90], South Africa Shortened interrupted time-series study to assess the effects of the intervention on HIV risk, IPV, economic, and social outcomes
Intervention:
Stepping Stones—the intervention provided training on livelihood strengthening through finding work or establishing a business, combined with HIV, gender, and violence prevention training
Increase household assets and promote safe sex negotiation Study participants: 122 out-of-school young women (from a total of 232 out-of-school young people mostly under 30 years)
Age range, 17–34 years
Non-participants: characteristics of non-participants were not reported
Program delivered by trained facilitators from an NGO called Project Empower Training on livelihood strengthening through finding work or establishing a business, combined with HIV, gender, and violence prevention training
Intervention group: frequency—10 sessions of Stepping Stones and 11 sessions of Creating Futures
Duration: 3 h bi-weekly for 12 weeks
After 58 weeks, for women there was a significant reduction in the experience of sexual IPV from 9.8% at baseline to 3.6% (p = 0.033), though for men there was no change in perpetration of sexual IPV. For women, there were positive but not statistically significant changes in condom use at last sex and engagement in transactional sex, while there was no change in these metrics for men
Attrition rate: acknowledged but figure was not reported
Individual level: 28 weeks post-baseline and second follow-up 58 weeks post-baseline to assess individual level change
Program level: indicators of program level maintenance were not reported
Khoza et al. (2018) [91], South Africa Qualitative data collection with a sub-sample of participants in a pilot RCT (N = 120 adolescents) of 3 CT strategies to explore the consequences of CTs on adolescents
Intervention:
CHANGE Study—monthly cash transfers provided to participants to promote uptake of sexual risk reduction services in clinics
To promote visits to clinics for sexual reproductive health education, services related to family planning and contraception, HIV counseling and testing, HIV risk assessment, and HIV risk reduction counseling Study participants: 49 adolescents
Age range, 16–18 years
Non-participants: characteristics of non-participants were not reported
This was not specified The 3 CT strategies: (1) unconditional monthly payments of 280 ZAR (US$20) for 6 months; (2) monthly payments of 280 ZAR for 6 months, conditional on 80% school attendance; and (3) and a single payment of 280 ZAR conditional on a once-off clinic visit involving sexual reproductive health education, services related to family planning and contraception, HIV counseling and testing, HIV risk assessment, and HIV risk reduction counseling. In interviews 6 months after the receipt of CTs and up to 12 months after the end of the intervention, some girls mentioned that CTs were protective against transactional sexual relationships.
Attrition rate: not reported. May not be applicable for the qualitative study
Individual level: follow-up 6 and 12 months to assess individual level change
Program level: indicators of program level maintenance were not reported
Kim et al. (2009) [92]; Pronyk et al. (2006) [93]; Kim et al. (2007) [94] ; Pronyk et al. (2008) [95], South Africa Cross-sectional study of randomly selected matched clusters to compare associations between IPV, sexual risk behaviors, economic well-being, and empowerment between three clusters: villages exposed to IMAGE (group-based microfinance with 12-month gender and HIV training curriculum), villages exposed to microfinance (MF) only, and control villages
Intervention: IMAGE—intervention with microfinance fir AIDS and gender equity. Combined intervention of group-based microfinance with gender and HIV training curriculum, Sisters for Life
Condom use, household communication about sex, communication with intimate partner about sexual matters Study participants: 1409 female participants; 1835 people age 14–35 living with those women; and 3881 people age 14–35 living in intervention and control villages
Age: 18 years and over
Non-participants: authors stated that some individuals refused to participate in the study. However, the characteristic of these individuals was not reported
The microfinance component was implemented by an NGO called Small Enterprise Foundation MF-component: groups of 5 women served as guarantors for each loan, and all 5 must repay their loans before they qualify for more credits. The loan centers met fortnightly to repay loans, apply for additional loan credit, and discuss business plan.
Frequency: loan center meetings every 2 weeks
Duration: individual borrowing and repayment of loans over 10 or 20-week cycle
IMAGE incorporated a participatory gender-focused learning program called Sisters-for-Life into the MF-component.
Frequency of the Sisters-for-Life component: phase 1 consisted of ten 1-h trainings and the phase 2 was where participants engaged youths and men in the community through community mobilization.
Duration: 12–15 months
At 24 months, participants in MF-only group showed an improvement in all nine indicators of economic well-being, including household asset value, ability to repay debts, and ability to meet basic household needs compared to the control group.
Likewise, compared to the control group, participants in the IMAGE group showed improved all indicators of economic well-being, as well as in empowerment (e.g., greater self-confidence, autonomy in decision-making), IPV (including reduction in past-year experience of IPV) and HIV risk behavior (including increased condom use).
There was no difference between MF-only and IMAGE in improving economic well-being among participants. However, IMAGE showed great effects on improving empowerment, IPV and HIV risk behaviors among participants.
After 2 years, participants in the intervention group experienced significantly less IPV in the previous 12 months compared to controls (RR = 0.45, p < 0.05). The intervention had no effect on the rate of unprotected sexual intercourse at last occurrence with a non-spousal partner for young people in the households of participants, or for young people living in participant villages. There was also no difference in HIV incidence among young people in intervention and comparison villages
Attrition rate: 20% at 2 years follow-up; 40% at 3 years follow-up
Individual level: follow-up at 24 months and 36 months to assess individual level change
Program level: the intervention was completed at the 3-year study period. However, sustainment of intervention beyond study period was not reported.
Kohler and Thornton (2012) [96], Malawi RCT to assess the effects of two levels of CCTs on sexual risk behaviors
CCTs of K500 or K2000 (USD 4 or 16) for individuals or K2000 or K4000 (USD 16 or 32) for couples were given conditional on maintaining HIV status (positive or negative) throughout the intervention period
Intervention: The Malawi Incentives Project—the intervention builds upon the Malawi Diffusion and Ideational Change Project (MDICP) where participants were offered free door-to-door HIV testing and randomly assigned to cash incentives group. The Malawi Incentive projects provided conditional cash transfers in addition to the components of MDICP
Reduce HIV incidence, promote safe sex (condom use), HIV testing Study participants: 1307 participants (55% females)
Age range, 14–49 years
Mean age, 36 years
Non-participants: characteristics of non-participants were not reported
The Incentives were delivered by the organizers of the Malawi Incentives Project. This was not explicitly stated The Malawi Incentives Project builds upon the Malawi Diffusion and Ideational Change Project (MDICP), where participants were offered free door-to-door HIV testing and randomly assigned to cash incentives groups.
Frequency: participants received cash incentives at the end of the year if they maintained negative HIV status
There was no effect of the offered incentives on participants’ HIV status or self-reported reported sexual behaviors. Compared to male participants, female participants who received CCTs were 6.7% points less likely to engage in risky sex. Among the male participants, receipt of CCTs showed an increased likelihood of risky sex.
Attrition rates: 17% among the entire sample; 16% among HIV negative participants
Individual level: follow-up at 2 years to assess individual level change
Program level: indicators of program level maintenance were not reported
Nyqvist et al. (2015) [97]; Nyqvist et al.(2018) [98], Lesotho Parallel 3—group RCT to examine the impact of a financial incentive lottery program on HIV incidence
Intervention:
A financial incentive lottery program to reduce HIV incidence
Reduction in HIV and other STI incidence Study participants: 3029 females and males
Number of females not specified
Age range, 18–32
Non-participants: characteristics of non-participants were not reported
Program was delivered by an NGO 3 groups: (1) control arm, (2) intervention arms: Lottery incentive program separated into low-value lottery (individuals were eligible to win lottery prizes worth 500 malotis equivalent to US$50 every 4 months) and high-value lottery (individuals were eligible to win lottery prizes worth 1000 malotis equivalent to US$100 every 4 months). Participants’ eligibility for the lotteries organized every fourth month was conditioned on participants testing negative for syphilis and trichomoniasis vaginalis (2 curable STIs) a week prior to lottery draw
Frequency: the lottery draws were conducted every 4 months for 2 years
Over 2 years, in the pooled intervention Med- group, HIV incidence was 21.4% lower high compared to the control (p < .05). In the high-prize arm only, HIV incidence was 28% lower compared to the control (p < 0.05); the low-prize arm was not significantly lower than the control. Effects of the intervention on HIV incidence were greater for women. The number of high-risk sexual acts was significantly reduced in the pooled intervention group compared to the control.
Attrition rate: 5.4% at 16 months follow-up; 4.6% at 24 months follow-up
Individual level: follow-up at 16, 20, and 24 months to assess individual level change
Program level: indicators of program level maintenance were not reported
O’Neill Berry et al. (2013) [99], Lesotho Cross-sectional survey of participants in the Girls Empowerment program
Intervention: Girls Empowerment program—provided entrepreneurial training to develop concrete, feasible, and bankable ideas to start their own small businesses as well as HIV/AIDS risk reduction and prevention, life skills
Increase knowledge on income-generating activities, reduce transactional sex, and promote HIV testing Study participants: 40 girls aged 17–22
Non-participants: characteristics of non-participants were not reported
Program delivered by trained staff Girls Empowerment Program (GEP) camp focused on providing entrepreneurial training to develop concrete, feasible, and bankable ideas to start their own small businesses as well as HIV/AIDS risk reduction and prevention, life skills. Findings show considerable improvement in the girls’ knowledge about income-generating activities. In addition, almost half of the camp attendees participated in further entrepreneurial training and about half of these girls went on to develop small businesses. Individual level: follow-up at 6 months and 12 months to report on participants’ businesses
Program level: indicators of program level maintenance were not reported
Pettifor et al. (2016) [18]; Pettifor et al. (2016b) [100], South Africa Individually randomized controlled trial to evaluate the efficacy of a CCT conditional on school attendance on HIV incidence compared to a control group
Intervention:
Conditional cash transfers to promote school attendance
Reduce HIV and herpes simplex virus 2 (HSV-2) incidence Study participants: 2448 HIV negative females in high school
Median age, 15 years
Age range, 13–20 years
Non-participants: characteristics of non-participants were not reported
Not specified Young women and their parent/guardian received a monthly cash transfer of ZAR 100 (US$10) and ZAR 200 (US$20), respectively, conditional on 80% school attendance
Intervention group received CCTs once a month.
Duration: participants were eligible for CCTs up to a maximum of 3 years
Conditional cash transfer on school attendance did not reduce HIV incidence among study participants. There was no statistically significant difference in HIV incidence between participants who received cash transfer (1.94% per person-years) and those who did not (1.70% per person-years; hazard ratio 1.17, 95% CI 0.80–1.72, p = 0.42). School attendance however was found to reduce HIV acquisition, irrespective of study groups.
Attrition rate: 9% at 36 months follow-up
Individual level: follow-up at 12, 24, and 36 months until study completion to assess individual level change
Program level: not reported
Rotheram-Borus et al. (2012) [101], Uganda Pilot pre- and post-intervention assessment of HIV risk behaviors among those receiving HIV education plus vocational training compared to those with HIV education only; cohort study of effects of combined intervention over time.
Study participants were randomized to an immediate vocational training or delayed vocational training (4 months delay). The vocational training included hairdressing, catering, tailoring, mechanics, electronics, carpentry, cell phone repair, and welding. All participants in the two groups received an adapted Street-Smart HIV prevention program at the same time
Intervention:
The intervention provided HIV education (adapted Street-Smart HIV prevention program) plus vocational training. The vocational training included hairdressing, catering, tailoring, mechanics, electronics, carpentry, cell phone repair, and welding
Increase in condom use, reduction in number of sexual partners, economic assets (employment type and length) Study participants: 100 youth
Females not specified
Age range, 13–23 years
Non-participants: characteristics of non-participants were not reported
The project was delivered by an NGO—The Ugandan Youth Development league. The vocational training component was delivered by local artisans within the NGO Frequency and duration: 10 session of the adapted HIV education session (Street Smart) over 10 weeks; 4–8 h, 5 days a week of vocational training. At 4-month follow-up, there were no significant differences between the arms in average number of sexual partners, or in abstinence or 100% condom use. After 24 months, the combined intervention groups showed decreases from baseline in the average number of sex partners (2.12 to 1.12, p = 0.013) and increases in abstinence or 100% condom use (45% to 71%, p = 0.003).
Attrition rate:15% at 4 months and 26% at 24 months
Individual level: follow-up at 4 and 24 months to assess individual level change
Program level: indicators of program level maintenance were not reported
Ssewamala et al., (2009) [39]; Ssewamala et al. (2010) [102]; Ssewamala et al. (2010b) [26]; Ismayilova et al. (2012) [103], Uganda Longitudinal RCT (pre-Suubi intervention (wave 1) and 10–12 months post-Suubi intervention (wave 2)) to examine the influence of Suubi Project on educational outcomes
Intervention:
Suubi Project—the intervention provided orphaned children with 3 component programs
Attitudes toward engaging in sexual risk-taking behavior, increase economic assets (savings), enhance educational plans and aspirations, reduce sexual risk-taking behaviors and attitudes Study participants: 161 adolescent girls (out of 286 orphaned adolescents from 15 primary schools).
Mean age, 13.5 years
Non-participants: adolescents whose parents were skeptical of some aspects of the program, specifically the component of a matched savings account, which they said was too good to be true.
The workshops were delivered by students from Makerere University in Uganda. University students were trained by the research team Suubi Project provides orphaned children with 3 component programs: (1) workshops focused on financial education, asset building, and career building; (2) mentorship from peers to reinforce learning; (3) a joint Conditional Development Accounts (CDAs) in both the child’s and caregiver’s name Between wave 1 and wave 2, girls in the intervention group reported a 33% increase in positive educational plans while 27% of girls in the control group reported increase in positive education plans. In wave 2, girls in the intervention group reported statistically significant more positive educations plans than those in the control group (t (154) = 2.94, p < 0.01).
Between wave 1 and wave 2, there was a 31% increase in the number of girls in the intervention group reporting more optimistic and higher level of confidence in achieving their educational plans, while in the control group, there was only 10% increase in these outcomes. In wave 2, girls in the intervention group reported statistically significant more confidence in achieving their educational plans than those in the control group (t (122) = 4.70, p < 0.00).
Attrition rate: 9.1% at 10 months
Individual level: follow-up at 10 months to assess individual level change
Program level: indicators of program level maintenance were not reported
Stark et al. (2018) [41]; Falb et al. (2016) [104], Ethiopia RCT to assess the effectiveness of Child Development Accounts (CDAs) versus control condition on sexual risk-taking intentions
Intervention:
COMPASS program—the intervention provided (1) twelve 1-to-2-h workshops on assets building and financial planning for 10 months; (2) monthly mentorship program for adolescents with peer mentors on future planning; and (3) Child Development Accounts (CDAs) to reduce sexual risk-taking intentions
Increase school attendance, earnings, and reduce transactional sex exploitation Study participants: 919 girls
Age range, 13–19 years
Non-participants: characteristics of non-participants were not reported
The program was implemented by the International Rescue Committee (IRC) and program sessions were delivered by young female mentors (from their late teens to 30 years) The core component of the COMPASS program was to provide opportunities for girls to build assets to protect against and respond to violence and establish a foundation for a healthy transition to adulthood. COMPASS program frequency/duration: (1) twelve 1 to 2 h workshops on assets building and financial planning for 10 months; (2) monthly mentorship program for adolescents with peer mentors on future planning.
The CDAs were matched savings account with a match rate of 2:1 as an incentive for participants to save, but with a limit (“cap”) on the maximum savings that could be matched (the match cap, in this case, was equivalent to US$10 a month). Each control condition adolescent received the usual care for orphaned children, which consisted of counseling and educational-related supplies (including textbooks).
The intervention did no impact economic and education outcomes measured in the study. Participants in the intervention group did not differ from those in the control group in school attendance or engaging in transactional sexual exploitation. Individual level: follow-up at 10 months to assess individual level change
Program level: indicators of program level maintenance were not reported
Visser et al. (2015) [105]; Visser et al. (2018) [106], South Africa Mixed methods quasi-experimental design investigating differences in HIV risk behavior and other outcomes between former ISIBINDI participants and a control group
Intervention:
ISIBINDI—the program involves home visits to promote orphans and vulnerable children’s wellbeing. This includes optional components of career guidance, job empowerment, food gardens, and income-generating activities
Reduce HIV risk, reduce number of sexual partners, and to promote consistent condom use Study participants: 604 (55% female) OVC
Age range, 18–25
Non-participants: characteristics of non-participants were not reported
The program was developed by the National Association of Child Care Workers, then was implemented by community-based organizations The core of the ISIBINDI model is home visits to promote OVC wellbeing and includes optional components of career guidance, job empowerment, food gardens, and IGAs. The ISIBINDI model develops the capacity of child and youth (CYCWs) care workers to respond directly to the needs of vulnerable children, youth, and families, particularly those affected by HIV/AIDS and poverty. CYCWs training modules comprise of 14 sessions of 6–30 h over a 2–3-year period. 12.9% of ex-participants of ISIBINDI reported HIV risk behavior compared to 19.7% of controls (p = 0.012).
The percentage of participants that received food aid was not reported.
Attrition rate: not reported
Individual level: follow-up duration not reported (there was post-intervention assessment)
Program level: indicators of program level maintenance were not reported