Increased attention is being given to positive prevention, which emphasizes intervening with HIV-infected individuals to reduce their likelihood of infecting others, and enhancing quality of life [1,2]. Numerous published research studies have been conducted in wealthy countries on psychosocial support for individuals infected with HIV, some showing efficacy in reducing HIV risk behavior [3–5]. It is, however, unclear whether psychosocial support services will reduce HIV risk behaviors in less economically developed settings. To examine this issue we conducted a systematic review of quantitative studies in developing countries to establish an evidence base for psychosocial support services for HIV-infected clients as a behavioral risk reduction intervention.
We searched electronic databases including the US National Library of Medicine's Gateway system, PsycINFO, sociological abstracts, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature. Study staff also hand-searched the table of contents of the journals AIDS, AIDS and Behavior, AIDS Care, and AIDS Education and Prevention. Studies had to meet the following inclusion criteria: (i) present quantitative data from a developing country (the World Bank categories of low-income, lower-middle income, or upper-middle income economies) ; (ii) include participants who have received a diagnosis of HIV or who were presumed to be HIV infected based on clinical signs and symptoms; (iii) examine an intervention that provided social or psychological support to HIV-infected individuals; (iv) employ an evaluation design comparing post-intervention outcomes using either a pre/post or multi-arm study design (including post-only exposure analysis); (v) present behavioral, psychological, social, care, or biological outcome related to HIV prevention; and (vi) appear in a peer-reviewed journal from 1990 to 2004. Two separate staff independently assessed whether citations met our inclusion criteria, and the study principal investigator made an additional review of the results. Each citation was subjected to data extraction by three independent reviewers.
The initial search identified 69 articles with titles and abstracts indicative of potentially relevant citations (Fig. 1). Only one ultimately met the criteria for inclusion. No additional citations were identified through hand-searching of journals or secondary references. The one study meeting our inclusion criteria  was conducted in Tanzania between 1996 and 1997 with a sample size of 154 HIV-infected, sexually active participants who were newly diagnosed. Subjects were randomly assigned to receive either standard heathcare, or standard healthcare plus ongoing individual counseling by trained staff on prevention and problem solving, education of family members, provision of condoms, and referral to treatment. Participants were administered a baseline survey with 3 and 6-month follow-up interviews.
For the entire study group, regardless of treatment arm, the investigators found statistically significant improvements from baseline to follow-up for the following measures: sharing HIV test results with either parents or ‘anyone’, discussing HIV with partners, condom negotiation, use of condoms, extramarital sex (at 6 months), sexually transmitted disease, genital sores, and medical treatment seeking. There were, however, no statistically significant differences across intervention and comparison arms for any of the outcomes examined, indicating that enhanced psychosocial support was not associated with reductions in HIV risk behaviors.
Despite the frequency with which positive prevention is being promoted in developing countries, we have a limited evidence base on one of the main prevention components of this strategy. In this systematic review, we were able to identify only one study on psychosocial support for HIV-infected individuals. That single well-designed study showed no significant impact. We stress that lack of evidence should not be confused with lack of efficacy. As agencies expand positive prevention programmes in developing countries, they should concurrently evaluate their efficacy to ensure they are having the desired impact given the current lack of evidence.
The authors wish to thank Sarah Mauch, Devaki Nambiar, and Jennifer Gonyea for their coding work on this project.
Sponsorship: This research was supported by the US National Institute of Mental Health, grant no. 1R01 MH071204, the World Health Organization, Department of HIV/AIDS, and the Horizons Program. The Horizons Program is funded by the US Agency for International Development under the terms of HRN-A-00-97-00012-00.
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