Among the estimated 35.3 million people living with HIV and AIDS the vast majority reside in low- and middle- income countries. The capacity for mounting prevention and care for HIV in these settings in recent years has become strained, with ever increasing demand for services coupled with neutral or reduced levels of funding. This is putting enormous pressure on HIV prevention and care programs to spend these limited funds wisely and efficiently through use of evidence-based guidance. Despite the vast and ever growing scientific literature on the efficacy of interventions, interpreting the scientific literatre is challenging since identifying relevant studies is time intensive; the quality of research from published reports requires careful analysis; there are conflicting findings across studies; metrics and study designs used across studies are typically inconsistent; and pooling results across studies requires advanced statistical techniques. The state of the art strategy to address these challenges is to use systematic reviews and meta-analyses to analyze and interpret the effects of interventions evidenced with research across multiple studies. In this renewal of our current project we will conduct systematic reviews and meta-analyses on 20 key behavioral interventions on HIV HIV-related outcomes conducted in low/middle-income countries. Cultural and contextual factors will be assessed with the input from collaborators from low- and middle- income country colleagues. We will also now expand our strategy to incorporate behavioral interventions linked biomedical interventions based on their emergence and widespread implementation, and the critical role human behavior plays in the success of biomedical strategies. In addition, the study will now also give critical attention to co-occurring (Multivalet / Combination) interventions across the large array of studies examined, and will conduct stratified meta-analyses, meta- regression, and network meta-analyses to identify how co-intervention affects the strength of intervention outcomes. The outcomes of the study, especially with regard to missing systematic reviews on behavioral interventions linked to biomedical programs and combination prevention, will enable enhanced mathematical modeling of population-level impacts.

Public Health Relevance

The US Government is the leading funder of HIV prevention and care in low- and middle-income countries. The epidemic continues to inflict enormous impacts globally, and there are ever increasing numbers of people globally becoming dependent on foreign-funded care for HIV/AIDS. Concurrent with these trends are declining budgets for prevention and care leading to a dire need to allocate resources with evidence-based strategies proven to work in the most efficient manner possible. This requires up to date systematic reviews and meta-analyses, which is the state of the art method for determining intervention efficacy. There are a host of promising and newly emerging prevention strategies that would benefit from systematic review and meta-analyses. These include couples HIV testing, strategies to reduce partner concurrency, social protection schemes, incentive / sanction- based approaches, new strategies to increase HIV testing, and those linked to mobile and internet delivery. Moreover, successes in both prevention and care realized through biomedical strategies have rapidly changed the strategies utilized in the field, and as a result the behaviora aspects of successful biomedical strategies is now a critical dimension of the field's ability to mitigate the epidemic with these breakthroughs in using treatment, surgical strategies (circumcision), and drug- based prophylaxis as prevention. Systematic reviews and meta-analyses are direly needed in this emerging field. Finally, there has been recognition that combining intervention modalities can have profound synergistic effects, yet there have been only minimal attempts to systematically review the evidence. The Evidence Project has been highly productive over the past 5-years in providing evidence-based guidance to the field with the production of 16 peer reviewed manuscripts, 12 policy guidance reports targeting program managers and policy makers, and contributing important guidance to multiple USAID, WHO, and UNAIDS consensus meetings and policy setting processes. We have also added new review strategies that focus on better understanding the reasons a minority of interventions sometimes succeed, when the majority fail. To better understand the role of culture and context on these heterogeneous outcomes we also will now enlist the assistance of low- and middle-income collaborators to provide interpretation. With the renewal of support for our project we seek to provide needed policy and program advice on what is working in HIV prevention based on the strength of evidence from the scientific literature, addressing the most salient needs emerging in the field.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Research Project (R01)
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Study Section
Behavioral and Social Science Approaches to Preventing HIV/AIDS Study Section (BSPH)
Program Officer
Brouwers, Pim
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Medical University of South Carolina
Schools of Medicine
United States
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O'Reilly, Kevin R; d'Aquila, Erica; Fonner, Virginia et al. (2017) Can Policy Interventions Affect HIV-Related Behaviors? A Systematic Review of the Evidence from Low- and Middle-Income Countries. AIDS Behav 21:626-642
Kennedy, Caitlin E; Fonner, Virginia A; Armstrong, Kevin A et al. (2015) Increasing HIV serostatus disclosure in low and middle-income countries: a systematic review of intervention evaluations. AIDS 29 Suppl 1:S7-S23
Zajac, Kristyn; Kennedy, Caitlin E; Fonner, Virginia A et al. (2015) A Systematic Review of the Effects of Behavioral Counseling on Sexual Risk Behaviors and HIV/STI Prevalence in Low- and Middle-Income Countries. AIDS Behav 19:1178-202
Fonner, Virginia A; Kennedy, Caitlin E; O'Reilly, Kevin R et al. (2014) Systematic assessment of condom use measurement in evaluation of HIV prevention interventions: need for standardization of measures. AIDS Behav 18:2374-86
Kennedy, Caitlin E; Fonner, Virginia A; O'Reilly, Kevin R et al. (2014) A systematic review of income generation interventions, including microfinance and vocational skills training, for HIV prevention. AIDS Care 26:659-73
Fonner, Virginia A; Armstrong, Kevin S; Kennedy, Caitlin E et al. (2014) School based sex education and HIV prevention in low- and middle-income countries: a systematic review and meta-analysis. PLoS One 9:e89692
O'Reilly, K R; Fonner, V A; Kennedy, C E et al. (2014) Free condom distribution: what we don't know may hurt us. AIDS Behav 18:2169-71
Kennedy, Caitlin E; Fonner, Virginia A; Sweat, Michael D et al. (2013) Provider-initiated HIV testing and counseling in low- and middle-income countries: a systematic review. AIDS Behav 17:1571-90
O'Reilly, Kevin R; Kennedy, Caitlin E; Fonner, Virginia A et al. (2013) Family planning counseling for women living with HIV: a systematic review of the evidence of effectiveness on contraceptive uptake and pregnancy incidence, 1990 to 2011. BMC Public Health 13:935
Sweat, Michael D; Denison, Julie; Kennedy, Caitlin et al. (2012) Effects of condom social marketing on condom use in developing countries: a systematic review and meta-analysis, 1990-2010. Bull World Health Organ 90:613-622A

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