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

BackgroundMany 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.Methods and findingsWe 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.ConclusionsWhile 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.

研究背景：许多艾滋病病毒（HIV）感染者女性面临基于性别的权力不平等，尤其是在亲密伴侣关系中，这阻碍她们获得最佳性与生殖健康（Sexual and Reproductive Health, SRH）以及行使自身权利。本研究通过系统综述，评估了旨在提升HIV感染者女性的自我效能与赋权水平、使其能够自主做出性与生殖健康相关决策的各类干预措施的有效性。研究方法与结果：本研究纳入了2017年1月3日及之前发表、收录于PubMed、PsycINFO、CINAHL、Embase及Scopus数据库的同行评议论文，这些研究需开展多臂干预或前后对照干预评估，且至少测量以下一类结局指标：(1)自我效能、赋权，或性与生殖健康决策能力相关指标；(2)性与生殖健康行为（如安全套使用、避孕措施使用）；(3)性与生殖健康结局（如性传播感染[Sexually Transmitted Infections, STIs]）。最终共有21项评估11种干预方式的研究符合纳入标准，所有研究均在美国或撒哈拉以南非洲地区开展。2项高质量随机对照试验（Randomized Controlled Trial, RCTs）显示，干预后新发淋病与衣原体感染率显著下降。16项针对安全套使用情况的研究普遍发现，干预措施与安全套使用量的适度提升相关，该结果在高质量随机对照试验中同样成立。关于避孕措施使用、安全套使用自我效能，以及其他赋权指标（如性沟通、伴侣关系间权力平等）的研究结果则存在分歧。现有研究存在样本量偏小、失访率高，以及报告的基线安全套使用率偏高等局限性。研究结论：尽管仍需开展更多研究，但现有有限证据表明，此类干预措施或有助于保障HIV感染者女性的性与生殖健康及相关权利。本综述特别强调了此类干预措施在预防性传播感染方面的重要性——性传播感染给HIV感染者女性带来了沉重的健康负担，且此类负担极少得到全面的应对。对于HIV感染者女性，基于赋权的干预措施应被纳入性传播感染及其他性与生殖健康综合服务包中。