JAIDS Journal of Acquired Immune Deficiency Syndromes:
What HIV Programs Work for Adolescent Girls?
Hardee, Karen PhD*; Gay, Jill MIA†,§; Croce-Galis, Melanie RN, MPH‡,§; Afari-Dwamena, Nana Ama MPH**
*Reproductive Health Program Population Council, Washington, DC;
†What Works Association, Takoma Park, MD;
‡What Works Association, New York, NY;
§Center for Policy and Advocacy, Health Policy Project, Futures Group, Washington, DC; and
**Consultant in Epidemiology and Occupational Health (CEOH), Bethesda, MD and former intern, Center for Policy and Advocacy, Health Policy Project, Futures Group, Washington, DC.
Correspondence to: Jill Gay, MIA, 7218 Spruce Avenue, Takoma Park, MD 20912 (e-mail: firstname.lastname@example.org).
Supported by USAID and PEPFAR.
The authors have no conflicts of interest to disclose.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jaids.com).
Background: Adolescent girls face unique challenges in reducing their risk of acquiring HIV because of gender inequalities, but much of HIV programming and evaluation lacks a specific focus on female adolescents.
Methods: This article, based on a review of 150 studies and evaluations from 2001 to June 2013, reviews evidence on programming for adolescents that is effective for girls or could be adapted to be effective for girls.
Results: The evidence suggests specific interventions for adolescent girls across 3 critical areas: (1) an enabling environment, including keeping girls in school, promoting gender equity, strengthening protective legal norms, and reducing gender-based violence; (2) information and service needs, including provision of age-appropriate comprehensive sex education, increasing knowledge about and access to information and services, and expanding harm reduction programs for adolescent girls who inject drugs; and (3) social support, including promoting caring relationships with adults and providing support for adolescent female orphans and vulnerable children.
Discussion: Numerous gaps remain in evidence-based programming for adolescent girls, including a lack of sex- and age-disaggregated data and the fact that many programs are not explicitly designed or evaluated with adolescents in mind. However, evidence reinforces bolstering critical areas such as education, services, and support for adolescent girls.
Conclusions: This article contributes to the growing body of literature on HIV and adolescent girls and reviews the vulnerabilities of girls, articulates the challenges of programming, develops a framework for addressing the needs of girls, and reviews the evidence for successful programming for adolescent girls.
“I have read about HIV… I think the young girls do not have this problem… If I meet somebody whom I don't know much, I may use a condom, but not with a young girl….” (Tanzanian man, age 36).1
The risks of HIV for adolescent girls have long been recognized.2–4 Approximately 2.1 million adolescents were living with HIV globally at the end of 2012. Approximately two thirds of new HIV infections in adolescents aged 15–19 years were among girls.5 Therefore, identifying key elements that address the different vulnerabilities of adolescent girls is crucial. Yet, programmatic efforts for adolescents have tended to lack specific focus on female adolescents and their needs. Furthermore, evaluations of such programs provide scant sex-disaggregated data, making it difficult to identify successful or promising programming specifically targeted to adolescent girls at risk for HIV. For example, a 2013 systematic review provided evidence of what works for adolescents but did not provide sex-disaggregated results.6 Much of the programming guidance related to adolescent girls has few specifics on what interventions might be applied to do so in ways that meet the needs of adolescent girls.3
Adolescent girls face unique challenges in reducing their risk of acquiring HIV. Appropriate interventions will vary depending on personal circumstances and context, including educational and marital status.
Age at First Sex and Numbers of Partners
The majority of girls, ages 10–14, in most countries are not yet sexually experienced; by age 19, many adolescent girls have had sex.7 Gender norms in many societies value sexual ignorance for girls while valuing multiple partnerships and sexual risk taking for boys.8–10
Education and Knowledge
Girls globally have a lower level of correct knowledge of HIV than boys and are less likely to attend and complete secondary school, where sex education is more likely to be taught than in primary schools.11,12 Girls are more likely to be illiterate than boys.
Gender Norms and Coercive Sex
In countries with the highest rates of HIV, males dominate sexual decision making.13–15 Disparities in gender dynamics mean that adolescent girls cannot enforce male or female condom use.16–18 Adolescent girls may have much older partners, and decisions about condom use have predominantly been made by the older “sugar daddy.”16,19–21 Adolescent girls with male partners living with HIV may not know their partners serostatus and cannot require that their partners access antiretroviral therapy and remain adherent. Therefore, adolescent girls are more likely to acquire HIV if their male partner is living with HIV.
For many girls, their first sexual experience is one of coerced sex; recent data, based on 141 studies in 81 countries, found that 29.4% of ever-partnered girls, ages 15–19, experienced intimate partner violence.22 Based on 17 studies, with data not disaggregated by age, those women reporting intimate partner violence in some regions were 1.52 times more likely to have acquired HIV.22
Adolescent Girls Who Inject Drugs
Adolescents who inject drugs are particularly vulnerable to acquiring HIV, with almost half of intravenous drug users injecting before age 18.23 But the special needs of women and adolescent girls who inject drugs are rarely considered.24
Orphans and Vulnerable Children
Girls who have been orphaned by HIV/AIDS face an intersection of vulnerabilities with unequal access to resources for schooling or health care.25,26 Female orphans are at increased risk of forced sex and at high risk of acquiring HIV.27,28
Indeed, it is “the strong combined impact of gender and income inequality, early sexual debut, age disparate sexual relationships, and heightened biological vulnerability of adolescent girls”3 that makes programming for adolescent girls both complex and essential. A range of challenges exist in providing evidence-based policy and programmatic guidance to reduce the vulnerability of adolescent girls to HIV acquisition, as well as HIV-related morbidity and mortality. The key challenges include a lack of evaluated interventions from developing countries that focus on adolescent girls; many programs do not adequately address gender dynamics; and a lack of evaluated interventions for adolescents overall, in part because obtaining parental consent (a legitimate ethical requirement and an issue beyond the scope of this article) makes these evaluations more complicated and expensive to conduct.
The article reviews evidence on programming for adolescents to identify interventions that have been shown to be effective with adolescent girls or for those conducted among adult women which could be adapted and made applicable to adolescent girls. This article reviews the vulnerabilities of girls, articulates the challenges of programming for girls, develops a framework for addressing the needs of girls, and reviews the evidence for programming for adolescent girls, providing examples of model programming and discussing opportunities for scaling up interventions for adolescent girls.
This article is based on a review of studies and evaluations published between 2001 and June 2013, with a focus on evaluated outcomes for interventions focused on women and girls in developing countries to reduce HIV acquisition and reduce the morbidity and mortality of girls and women living with HIV. The analysis for this article included a subset of articles and reports covering interventions for adolescents that were drawn from the wider review where the full methodology can be found.24 Overall, more than 150 articles or reports were included in the analysis for this article. Although most of the interventions identified relate to adolescents aged between 10 and 19 years, evidence of effective interventions conducted among adult populations older than 19 years, which could be applicable to adolescent populations aged 10–18 years, have also been included (see Table S1, Supplemental Digital Content, http://links.lww.com/QAI/A522).
Given the multiple influences on the lives of adolescents, from family to community to society,29 it is important to look beyond the health sector for interventions to reach adolescent girls. The evidence for programming for adolescent girls falls under a range of interventions in 3 areas: (1) to address the enabling environment30: increase educational attainment for girls, promote gender-equitable norms, include a focus on adolescents in programs to reduce gender-based violence, and strengthen legal norms to protect adolescent girls; (2) information and service needs of adolescent girls: provide age-appropriate comprehensive sex education, increase knowledge about and access to information and services including condoms and other contraceptives, and expand harm reduction programs to include adolescent girls who inject drugs; and (3) social support: promote caring relationships with adults and provide support for adolescent female orphans and vulnerable children (OVC). Discussion of the results below focuses on the main interventions and highlights 1 study example to demonstrate model programming. A full summary of all interventions and studies is included in Table S1 (see Supplemental Digital Content, http://links.lww.com/QAI/A522).
A number of evidence-based interventions to improve the enabling environment have been successful or promising for effectively addressing HIV risk for girls.
Increase Educational Attainment of Girls
Among the structural interventions to reduce the risk of HIV for adolescent girls, the most powerful is to keep girls in school.31–38 Specific interventions that have demonstrated success in increasing educational attainment and are linked to better HIV outcomes include abolishing school fees to enable girls to attend (or stay in) school39–42 and providing educational support for orphans.43–45 Conditional cash transfers, for example, show promise for enabling girls to stay in school and may result in reduced incidence of HIV.46 In a randomized control trial, program beneficiaries receiving cash were 3–4 times more likely to be in school at the end of the school year than that in the control group. For program beneficiaries who were out of school at baseline, the probability of getting married and becoming pregnant also declined by more than 40% and 30%, respectively.46 Challenges to implement this type of intervention include the need for cross-sectoral collaboration and funding. However, some have argued that funds could come from multiple sectors and that this intervention is cost-effective.47
Promote Gender-Equitable Norms
Promoting gender-equitable attitudes, which should start in childhood48 and continue during the formative period of adolescence and into adulthood, can reduce the risk of acquiring HIV and reduce the acceptance of gender-based violence.49 Training, peer and partner discussions, and community-based education that questions harmful gender norms can improve HIV prevention, testing, treatment, and care. Many of the studies supporting this intervention were conducted with adolescent populations.50–55 Addressing gender norms requires working with boys and girls, both separately and together.9 For example, a study of boys and girls, ages 10–14, in Nepal with a curriculum to promote gender equity resulted in a doubling of gender-equitable attitudes concerning gender-based violence by boys and girls in the intervention group, with no changes in the control group.48 Reaching young men are critically important.56 The NGO, Promundo, started with Program H to promote more gender-equitable attitudes among young men, resulting in significant increases in male condom use in Brazil and India, significant reduction in use of violence against female partners in India, and significant changes in gender attitudes among young men in Brazil. Improvements in gender norm scale scores were associated with changes in at least 1 key HIV/sexually transmitted infection risk outcome.57 Building on the experiences of Program H, Promundo started Program M to promote the empowerment of young women, resulting in a significant increase in self-efficacy among young women.58 Although successful, NGO-led programs such as these are often limited in duration and scope, reaching at most a few thousand participants. Changing gender norms on a national scale would require augmenting these programs with structural interventions at the national level, engaging policymakers and community leaders,59 along with mass media, to promote equitable gender norms.
Include a Focus on Adolescents in Programs to Reduce Gender-Based Violence
Although gender-based violence is a key issue for many adolescents, little programming has been developed and evaluated for adolescents in developing countries. Gender-based violence, which is closely associated with inequitable gender norms, also increases the risk of HIV acquisition.60–63 Child sexual abuse is correlated with increased risk of HIV acquisition; therefore, any programs that reduce gender-based violence starting at an early age will help break this multigenerational cycle.13,64–66 UNAIDS has recently adopted incidence of gender-based violence as a key indicator of gender inequality.67 According to UNICEF, between 5% and 21% of adolescent girls, ages 15–19, reported that they have ever experienced sexual violence.68 Often, rape is considered justified or inevitable by girls and boys.69 “A major gap in sex education programs is the need for both girls and boys to understand what constitutes coercive sex.”70
Public health campaigns can influence communities so that violence against women becomes unacceptable.71–73 Among older adolescents, community-based participatory learning approaches involving men and women can create more gender-equitable relationships, thereby decreasing violence.51–54 Training teachers about gender-based violence is a promising strategy to change norms about acceptance of gender-based violence.74,75 Microfinance programs, such as the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) in South Africa, are promising interventions that can lead to a reduction in gender-based violence when integrated with participatory training on HIV, gender, and violence76,77 and could be adapted for use with older out of school adolescents. At the same time, microfinance programs that do not have a specific component to reduce gender-based violence and promote gender equity can have the unintended effect of increasing gender-based violence.78–82
Strengthen Legal Norms to Protect Adolescent Girls
Although evidence on the link between changing legal norms and reducing risk of acquiring HIV or in meeting the needs of women living with HIV has not been found for adolescent girls, it is clear that certain laws can be harmful for adolescent girls. Legislation that requires parental consent for adolescents to access HIV testing can deter adolescents from knowing their serostatus and if HIV-positive, accessing treatment in a timely fashion.83 Girls in child marriages are at increased risk of violence, acquiring HIV and reduced educational opportunities.68,84 Therefore, legislation and enforcement of legislation against child marriage are needed. Impunity regarding rape for girls and women should also be addressed in the laws, legislation, and enforcement, with monitoring for unintended consequences.85
Information and Services
Provide Comprehensive Sex Education
Substantial evidence exists demonstrating that sex and HIV education with certain characteristics57,86–88 before the onset of sexual activity may be effective in preventing transmission of HIV by increasing age at first sex and for those who are sexually active, increasing condom use, testing, and reducing the number of sexual partners.86,89–105 To meet the needs of adolescent girls, age-appropriate sex education should stress equitable gender norms, identify what constitutes coercive sex, and strengthen agency among girls.
It is important to note that school-based interventions alone have not shown impact in reducing HIV incidence, but they have shown beneficial effects on knowledge and reported behaviors,94 suggesting that sexuality education is necessary for effective HIV prevention but needs to be combined with other interventions including accessible and youth-friendly health services.106 The quality of sexuality education is as important as its provision; fidelity to successful components must be maintained. Training for teachers to conduct age-appropriate participatory sexuality education, which can improve students' knowledge and skills, is essential.74,86,107 Comprehensive sexuality education is under-programmed108; no developing country was found to have a functioning national-level comprehensive sex education program that meets the needed characteristics. “Even in the face of the HIV/AIDS pandemic, governments have been slow to implement comprehensive sexuality education and even slower to reach the most vulnerable young people.”109
Although keeping girls in school is a key intervention, those girls who are not in school also need to be reached with information and services, but no evaluated interventions were found to effectively provide comprehensive sex education outside school settings; however, the need for effective sexuality education for out of school youth has been noted as a gap by many.110–112
Provide Information and Access to Youth-Friendly Services
Young people's needs for services are frequently overlooked in HIV programming. Providing clinic services, which are acceptable and accessible to youth, conveniently located, affordable, confidential, and nonjudgmental, is a promising way to increase the use of clinical reproductive health services, including HIV testing and counseling (HTC).113–115 Beginning at sexual debut, promoting condoms through mass media in individual or group sessions, along with skills training, provision of condoms, and motivational education can increase condom use.115–122 Condom use remains a critical prevention method, reducing the chance of HIV acquisition by more than 95%,123–126 with comparable effectiveness between male and female condoms when used consistently and correctly.127–130 Increasing the accessibility and availability of male and female condoms can increase condom use,128,131–140 and promoting condoms for pregnancy prevention and protection from HIV can increase uptake among adolescents.109 Expanded access to condoms for young people can sometimes be fraught in communities, but condoms remain the best protection from HIV for sexually active individuals.
HTC services for adolescents are another important need; yet, HTC for women is often in the context of antenatal care, thus missing the needs of young unmarried women.141,142 Provision of HTC can help adolescent girls know their HIV status143 and increase their protective behaviors, particularly among those who test HIV-positive,50,144–151 yet many evaluated interventions are not adolescent-focused.152–158 Providing HTC together with other health services can increase the number of adolescent girls accessing HTC.159–162 For those adolescents living with HIV, provision of antiretroviral therapy can reduce (but does not eliminate) the risk of HIV transmission.163–166 Microbicides are a promising technology under development, and a clinical trial is underway to test the use of pre-exposure prophylaxis among adolescent girls in Kenya who have not been able to negotiate condom use.167,168 A survey of 445 young women with access to a no-cost youth-friendly clinic in Maputo City, Mozambique, demonstrated high levels of knowledge to avoid risk of HIV acquisition and low rates of HIV (4%) compared with HIV prevalence (17.3%) in the same city.114
Establishing comprehensive postrape care protocols, which include postexposure prophylaxis and emergency contraception, can improve services for all.169–173 However, rape of adolescent females, ages 10–19, is underreported, and services for this population are weak.173,174
Expand Harm Reduction Programs to Include Adolescent Girls
Comprehensive harm reduction programs, including needle exchange programs, condom distribution, opioid substitution therapy and outreach, HTC, and nonjudgmental risk reduction counseling, can reduce HIV risk behaviors.175–192 However, injecting drug use often starts in adolescence193 and no evaluated interventions were found for this population and the evidence here is based on adult women. In addition, although a conceptual framework exists for gender-sensitive harm reduction programs,194 only 1 evaluated intervention was found that meets the needs of adult women who inject drugs. A study in Kazakhstan found a comparison between 40 adult couples who had single gender group sessions with female and male partner injection drug users resulted in increased condom use and safe injection practices compared with 40 couples who did not have single gender group sessions. The intervention group had 2 sessions designed to help women anticipate and manage partner's negative reactions in response to requests to use condoms or not to share needles.195 This program could be assessed for applicability in an adolescent population.
Social Support for Adolescent Girls
Promoting Relationships With Supportive Adults
Encouraging communication between adults and young people about reproductive health information can increase protective behaviors among adolescents.196–198 A study of 186 girls, ages 12–18, and 183 of their mothers in Uganda found that 75.8% of mothers reported having discussed the issues of sexuality and HIV with their daughters and 67.9% of daughters reported having had their mothers discuss the topics with them. Parents were the major source of information concerning sexuality and HIV/AIDS for young girls. When asked, mothers requested seminars on communication skills to empower them to better communicate with their daughters on matters concerning HIV, AIDS, and sexuality.198
Programming to increase and improve communication between adults and children can be built into various interventions. For example, one component of the IMAGE study included encouragement of loan holders to engage with young people in their households about sexuality issues through (1) teaching the women participants about HIV, (2) allowing the women to recognize their responsibility in protecting young people from HIV, and (3) giving the women participants guidance in changing social taboos and norms. Although women were initially resistant, saying that they had talked to their children about AIDS, by the end of the program they saw value in learning how to more effectively engage with their children. They spoke to children about sexuality issues significantly more often, and rather than “vague admonitions,” they provided concrete guidance to young people; 97.6% of the women who communicated with children about sexuality discussed condoms whereas 58.2% discussed HIV testing. Young people who lived with the women participants generally wanted to discuss sexuality with their parents. The study lacked sex-disaggregated data of the young people, a missed opportunity, but did note that some women found it easier to talk to their daughters than their sons.196
Support for Adolescent Female OVC
Since orphans face particular HIV risk, programs that provide community-wide cash transfers, microenterprise opportunities, old-age pensions for the caregivers of OVC, or other targeted financial and livelihood assistance can be effective in supporting orphans.199–208 For example, a randomized clinic trial studied 268 adolescent orphans in their final year of primary school in Uganda found that at 10 months after intervention, adolescents who had participated in an economic empowerment intervention had significantly better self-esteem and self-rated health measures than the control group. Girls reported greater increases in self-esteem than boys and were less likely to intend to engage in risky sexual behaviors. Adolescents in the intervention group received 12 workshops on economic security and empowerment over the course of 10 months.199
Successful interventions for OVC include psychological counseling and mentoring, which may improve their psychological well-being.209–212 A school-based peer-group support intervention with adolescent OVC found that peer-group interventions when led by teachers and complemented by health care check-ups significantly decreased anxiety, depression, and anger among the intervention group.209 However, the evaluation of the intervention did not report findings by sex; therefore, it is not possible to say if the intervention was equally beneficial to girls and boys.
Given the epidemiological data showing the elevated HIV prevalence among girls that occurs during adolescence, as compared with boys, and the known distinct epidemiological and social vulnerabilities of girls, efforts to ensure that programming for adolescents takes the unique needs of adolescent girls into consideration and that some programs specifically for adolescent girls are warranted. Overall, the evidence does support programming specific interventions that address the enabling environment to keep girls in school, promote gender equity, and reduce gender-based violence, as well as the health information, service, and social support needs for adolescent girls.
This article has shown that there is evidence that could be used to guide programming to address the needs of adolescent girls and build their resilience and that serious gaps in programming continue to exist, including missed opportunities to understand the differential effects of programming for adolescents through sex-disaggregation of data in evaluations, or the effects of the legal environment where, despite the absence of a clear link to HIV risk among adolescent girls, it is evident that certain laws, such as those requiring parental consent for services or protecting child marriage, can be harmful for them. These and many other gaps in programming for adolescent girls must be addressed if we are to turn the tide of the increasingly feminine face of HIV.
1. Rasch V, Lyaruu MA. Unsafe abortion in Tanzania and the need for involving men in post-abortion contraceptive counseling. Stud Fam Plann. 2005;36:301–310.
2. Bruce J, Temin M, Hallman K. Evidence-based approaches to protecting adolescent girls at risk of HIV: AIDSTAR. New York, NY: Population Council, the Nike Foundation, and the NoVo Foundation; 2012.
3. Kasedde S, Luo C, McClure C, et al.. Reducing HIV and AIDS in adolescents: opportunities and challenges. Curr HIV/AIDS Rep. 2013;10:159–168.
4. Vuttanont U, Greenhalgh T, Griffin M, et al.. “Smart boys” and “sweet girls”—sex education needs in Thai teenagers: a mixed-method study. Lancet. 2006;368:2068–2080.
5. UNICEF. Towards an AIDS-free Generation: Children and AIDS Sixth Stocktaking Report. New York, NY: UNICEF; 2013.
6. Napierala Mavedzenge S, Luecke E, Ross D. Technical Brief: Effectiveness of HIV Prevention, Treatment and Care Among Adolescents: A Systematic Review of Systematic Reviews. New York, NY: UNICEF; 2013.
7. Kothari, Monica T., Shanxiao Wang, Sara K. Head, and Noureddine Abderrahim. Trends in Adolescent Reproductive and Sexual Behaviors. DHS Comparative Reports No. 29. Calverton, Maryland, USA: ICF International; 2012.
8. Pradhan MR, Ram U. Perceived gender role that shape youth sexual behaviour: evidence from rural Orissa, India. J Adolesc. 2010;33:543–551.
9. Greene M, Levack A. Synchronizing Gender Strategies: A Cooperative Model for Improving Reproductive Health and Transforming Gender Relations. Washington, DC: Population Reference Bureau, Interagency Gender Working Group; 2010.
10. Macia M, Maharaj P, Gresh A. Masculinity and male sexual behaviour in Mozambique. Cult Health Sex. 2011;13:1181–1192.
11. UNICEF. Progress for Children: A Report Card on Adolescents. New York, NY: UNICEF; 2012.
12. UNAIDS. Global Report: UNAIDS Report on the Global AIDS Epidemic 2013. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS (UNAIDS); 2013.
13. Decker MR, Miller E, Illangasekare S, et al.. Understanding gender-based violence perpetration to create a safer future for women and girls. Lancet Glob Health. 2013;1:e170–e171.
14. Ghanotakis E, Peacock D, Wilcher R. The importance of addressing gender inequality in efforts to end vertical transmission of HIV. J Int AIDS Soc. 2012;15(suppl 2):17385.
15. Geary C, Baumgartner J, Tucker H, et al.. Early sexual debut, sexual violence, and sexual risk-taking among pregnant adolescents and their peers in Jamaica and Uganda. Youth Research Working Paper No. 8. 2008.
16. Leclerc-Madlala S. Age-disparate and intergenerational sex in Southern Africa: the dynamics of hypervulnerability. AIDS. 2008;22(suppl 4):S17–S25.
17. Alexander KA, Coleman CL, Deatrick JA, et al.. Moving beyond safe sex to women-controlled safe sex: a concept analysis. J Adv Nurs. 2011;68:1858–1869.
18. Padian NS, Isbell MT, Russell ES, et al.. The future of HIV prevention. J Acquir Immune Defic Syndr. 2012;60(suppl 2):S22–S26.
19. Maswanya ES, Moji K, Aoyagi K, et al.. Sexual behavior and condom use in female students in Dar-es-Salaam, Tanzania: differences by steady and casual partners. East Afr J Public Health. 2011;8:69–76.
20. Watt MH, Aunon FM, Skinner D, et al.. “Because he has bought for her, he wants to sleep with her”: alcohol as a currency for sexual exchange in South African drinking venues. Soc Sci Med. 2012;74:1005–1012.
21. Wood EB, Hutchinson MK, Kahwa E, et al.. Jamaican adolescent girls with older male sexual partners. J Nurs Scholarsh. 2011;43:396–404.
22. WHO, London School of Hygiene and Tropical Medicine, South African Medical Research Council. Global and Regional Estimates of Violence against Women: Prevalence and Health Effects of Intimate Partner Violence and Non-Partner Sexual Violence. Geneva, Switzerland: World Health Organization; 2013.
23. Strathdee SA, Shoptaw S, Dyer TP, et al.. Towards combination HIV prevention for injection drug users: addressing addictophobia, apathy and inattention. Curr Opin HIV AIDS. 2012;7:320–325.
24. Gay J, Croce-Galis M, Hardee K. What Works for Women and Girls: Evidence for HIV/AIDS Interventions. Washington, DC: Futures Group, Health Policy Project; 2012. Available at: http://www.whatworksforwomen.org
. Accessed June 1, 2014.
25. Heymann J, Sherr L, Kidman R. Meeting the essential needs of all children. In: Heymann J, Sherr L, Kidman R, eds. Protecting Childhood in the AIDS Pandemic: Finding Solutions that Work. New York, NY: Oxford University Press; 2012:1–18.
26. Robertson L, Gregson S, Garnett GP. Sexual risk among orphaned adolescents: is country-level HIV prevalence an important factor? AIDS Care. 2010;22:927–938.
27. Birdthistle IJ, Floyd S, Machingura A, et al.. From affected to infected? Orphanhood and HIV risk among female adolescents in Urban Zimbabwe. AIDS. 2008;22:759–766.
28. Gregson S, Nyamukapa CA, Garnett GP, et al.. HIV infection and reproductive health in teenage women orphaned and made vulnerable by AIDS in Zimbabwe. AIDS Care. 2005;17:785–794.
29. UNFPA. Motherhood in Childhood. Facing the Challenge of Adolescent Pregnancy. New York, NY: UNFPA; 2013.
30. Hardee K, Gay J, Croce-Galis M, Peltz A. Strengthening the enabling environment for women and girls: what is the evidence in social/structural approaches in the HIV. Journal of the International AIDS Society. 2014;17:18619.
31. Hargreaves JR, Slaymaker E, Fearon E, et al.. Changes over time in sexual behaviour among young people with different levels of educational attainment in Tanzania. J Int AIDS Soc. 2012;15(suppl 1):1–7.
32. Hargreaves JR, Bonell CP, Boler T, et al.. Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in Sub-Saharan Africa. AIDS. 2008;22:403–414.
33. Hargreaves JR, Morison LA, Kim JC, et al.. The association between school attendance, HIV infection and sexual behaviour among young people in rural South Africa. J Epidemiol Community Health. 2008;62:113–119.
34. Barnighausen T, Hosegood V, Timaeus IM, et al.. The socioeconomic determinants of HIV incidence: evidence from a longitudinal, population-based study in rural South Africa. AIDS. 2007;21(suppl 7):S29–S38.
35. Pettifor AE, Levandowski BA, MacPhail C, et al.. Keep them in school: the importance of education as a protective factor against HIV infection among young South African women. Int J Epidemiol. 2008;37:1266–1273.
36. Bradley H, Bedada A, Brahmbhatt H, et al.. Among Ethiopian voluntary counseling and testing clients. AIDS Behav. 2007;11:736–742.
37. Clark S, Poulin M, Kohler HP. Marital aspirations, sexual behaviors, and HIV/AIDS in rural Malawi. J Marriage Fam. 2009;71:396–416.
38. Greener R, Sarkar S. Risk and vulnerability: do socioeconomic factors influence the risk of acquiring HIV in Asia? AIDS. 2010;24(suppl 3):S3–S11.
39. World Bank, UNICEF. Abolishing School Fees in Africa: Lessons from Ethiopia, Ghana, Kenya, Malawi, and Mozambique. Washington, DC: World Bank; 2009.
40. Burns B, Mingat A, Rakotomalala R. Achieving Universal Primary Education by 2015: A Chance for Every Child. Washington, DC: World Bank; 2003.
41. UNICEF. Progress for Children: A Report Card on Gender Parity and Primary Education. New York, NY: UNICEF; 2005. No. 2.
42. Deininger K. Does cost of schooling affect enrollment by the poor? Universal primary education in Uganda. Econ Educ Rev. 2003;22:291–305.
43. Hallfors D, Cho H, Rusakaniko S, et al.. Supporting adolescent orphan girls to stay in school as HIV risk prevention: evidence from a randomized controlled trial in Zimbabwe. Am J Public Health. 2011;101:1082–1088.
44. Cho H, Hallfors DD, Mbai II, et al.. Keeping adolescent orphans in school to prevent human immunodeficiency virus infection: evidence from a randomized controlled trial in Kenya. J Adolesc Health. 2011;48:523–526.
45. Chatterji M, Hutchinson P, Buek K, et al.. Evaluating the impact of community-based interventions on schooling outcomes among orphans and vulnerable children in Lusaka, Zambia. Vulnerable Child Youth Stud. 2010;5:130–141.
46. Baird SJ, Garfein RS, McIntosh CT, et al.. Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial. Lancet. 2012;379:1320–1329.
47. Remme M, Vassall A, Lutz B, et al.. Paying girls to stay in school: a good return on HIV investment? Lancet. 2012;379:2150.
48. Lundgren R, Beckman M, Chaurasiya SP, et al.. Whose turn to do the dishes? Transforming gender attitudes and behaviours among very young adolescents in Nepal. Gend Dev. 2013;21:127–145.
49. Shannon K, Leiter K, Phaladze N, Hlanze Z, Tsai AC, et al.. Gender inequity norms are associated with increased male-perpetrated rape and sexual risks for HIV infection in Botswana and Swaziland. PLoS One. 2012;7(1):e28739.
50. Swartz S, Deutsch C, Makoae M, et al.. Measuring change in vulnerable adolescents: findings from a peer education evaluation in South Africa. SAHARA J. 2012;9:242–254.
51. Jewkes R, Nduna M, Levin J, et al.. A cluster randomized-controlled trial to determine the effectiveness of stepping stones in preventing HIV infections and promoting safer sexual behaviour amongst youth in the rural Eastern Cape, South Africa: trial design, methods and baseline findings. Trop Med Int Health. 2006;11:3–16.
52. Pulerwitz J, Martin S, Mehta M, et al.. Promoting Gender Equity for HIV and Violence Prevention: Results from the PEPFAR Male Norms Initiative Evaluation in Ethiopia. Washington, DC: PATH; 2010.
53. Colvin C. Report on the Impact of Sonke Gender Justice Network's “One Man Can” Campaign in the Limpopo, Eastern Cape and KwaZulu Natal Provinces, South Africa. Johannesburg, South Africa: Sonke Gender Justice Network; 2009.
54. Jewkes R, Wood K, Duvvury N. “I woke up after I joined stepping stones”: meanings of an HIV behavioural intervention in rural South African young people's lives. Health Educ Res. 2010;25:1074–1084.
55. Maganja R, Maman S, Groves A, et al.. Skinning the goat and pulling the load: transactional sex among youth in Dar es Salaam, Tanzania. AIDS Care. 2007;19:974–981.
56. Verma R, Pulerwitz J, Mahendra V, et al.. Promoting Gender Equality as a Strategy to Reduce HIV Risk and Gender-bases Violence Among Young Men in India. Horizons Final Report. Washington, DC: Population Council; 2008.
57. Pulerwitz J, Barker G, Segundo M, et al.. Promoting More Gender-equitable Norms and Behaviors Among Young Men as an HIV/AIDS Prevention Strategy. Washington, DC: Horizons Program, Population Council; 2006.
58. Ricardo C, Nascimento M, Fonseca V, et al.. Engaging Young Men and Empowering Young Women to Promote Gender Equality and Health. Washington, DC: PAHO and Promundo; 2010.
59. Gurman T, Underwood C. Using Media to Address Adolescent Health: Lessons Learned Abroad. In: Brown J, ed. Managing the Media Monsters: National Campaign to Prevent Teen and Unplanned Pregnancy. Washington, DC: The National Campaign; 2008.
60. World Health Organization (WHO), UNAIDS. Addressing Violence Against Women and HIV/AIDS: What Works? Geneva, Switzerland: WHO and UNAIDS; 2010.
61. Campbell J, Baty M, Ghandour R, et al.. The intersection of violence against women and HIV/AIDS. Background paper for IOM. 2008. Violence Prevention in Low-and Middle-Income Countries: Finding a Place on the Global Agenda
. Washington, DC: National Academies Press; 2008.
62. Coker AL. Does physical intimate partner violence affect sexual health? A systematic review. Trauma Violence Abuse. 2007;8:149–177.
63. Townsend L, Jewkes R, Mathews C, et al.. HIV risk behaviours and their relationship to intimate partner violence (IPV) among men who have multiple female sexual partners in Cape Town, South Africa. AIDS Behav. 2011;15:132–141.
64. Kayibanda JF, Bitera R, Alary M. Violence toward women, men's sexual risk factors, and HIV infection among women: findings from a national household survey in Rwanda. J Acquir Immune Defic Syndr. 2012;59:300–307.
65. Tenkorang EY, Obeng Gyimah S. Physical abuse in early childhood and transition to first sexual intercourse among youth in Cape Town, South Africa. J Sex Res. 2012;49:508–517.
66. Lewis IR. At risk: the relationship between experiences of child sexual abuse and women's HIV status in Papua New Guinea. J Child Sex Abuse. 2012;21:273–294.
67. UNAIDS, UNICEF, WHO. Global AIDS Response Progress Reporting 2013. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS (UNAIDS); 2013.
68. UNICEF. Child Protection from Violence, Exploitation and Abuse: A Statistical Snapshot. New York, NY: UNICEF; 2011.
69. Jejeebhoy S, Bott S. Non-consensual Sexual Experience of Young People: A Review of the Evidence from Developing Countries. South and East Asia Regional Working Paper No. 16. New Delhi, India: Population Council; 2003.
70. Pulerwitz J, Michaelis A, Verma R, et al.. Addressing gender dynamics and engaging men in HIV programs: lessons learned from horizons research. Public Health Rep. 2010;125:282–292.
71. Jewkes R, Nduna M, Levin J, et al.. A Cluster Randomized-Controlled Trial to Determine the Effectiveness of Stepping Stones in Preventing HIV Infections and Promoting Safer Sexual Behaviour amongst Youth in the Rural Eastern Cape, South Africa: Trial Design, Methods and Baseline Findings. Tropical Medicine and International Health. 2006;11 (1): 3–16.
72. Pulerwitz J, Martin S, Mehta M, et al.. Promoting Gender Equity for HIV and Violence Prevention: Results from the PEPFAR Male Norms Initiative Evaluation in Ethiopia. Washington, DC: PATH; 2010.
73. Colvin C. Report on the Impact of Sonke Gender Justice Network's ‘One Man Can’ Campaign in the Limpopo, Eastern Cape and KwaZulu Natal Provinces, South Africa. Johannesburg, South Africa: Sonke Gender Justice Network; 2009.
74. James-Traore T, Finger W, Ruland C, et al.. Teacher Training: Essential for School-based Reproductive Health and HIV/AIDS Education: Focus on Sub-Saharan Africa. Arlington, Virginia: Family Health International; 2004.
75. USAID. Safe Schools Program Final Report. Arlington, VA: DevTech; 2008.
76. Kim J, Ferrari G, Abramsky T, et al.. Assessing the Incremental Effects of Combining Economic and Health Interventions: The IMAGE Study in South Africa. Bulletin of the World Health Organization. 2009;87(11): 824–832.
77. Kim J, Watts C, Hargreaves J, et al.. Understanding the Impact of a Microfinance-Based Intervention on Women's Empowerment and the Reduction of Intimate Partner Violence in South Africa. American Journal of Public Health. 2007;97(10):1794–802.
78. Lucea MB, Hindin MJ, Kub J, et al.. HIV risk, partner violence, and relationship power among Filipino young women: testing a structural model. Health Care Women Int. 2012;33:302–320.
79. Schuler SR, Hashemi SM, Badal SH. Men's violence against women in rural Bangladesh: undermined or exacerbated by microcredit programmes? Dev Pract. 1998;8:148–157.
80. Gupta GR, Parkhurst JO, Ogden JA, et al.. Structural approaches to HIV prevention. Lancet. 2008;372:764–775.
81. Dunbar MS, Maternowska MC, Kang MS, et al.. Findings from SHAZ! A feasibility study of a microcredit and life-skills HIV prevention intervention to reduce risk among adolescent female orphans in Zimbabwe. J Prev Interv Community. 2010;38:147–161.
82. Gibbs A, Willan S, Misselhorn A, et al.. Combined structural interventions for gender equality and livelihood security: a critical review of the evidence from Southern and Eastern Africa and the implications for young people. J Int AIDS Soc. 2012;15(suppl 1):1–10.
83. Binagwaho A, Fuller E, Kerry V, et al.. Adolescents and the right to health: eliminating age-related barriers to HIV/AIDS services in Rwanda. AIDS Care. 2012;24:936–942.
84. Raj A, Saggurti N, Lawrence D, et al.. Association between adolescent marriage and marital violence among young adult women in India. Int J Gynaecol Obstet. 2010;110:35–39.
85. Parikh SA. “They arrested me for loving a schoolgirl”: ethnography, HIV, and a feminist assessment of the age of consent law as a gender-based structural intervention in Uganda. Soc Sci Med. 2012;74:1774–1782.
86. UNESCO. International Technical Guidance on Sexuality Education: An Evidence-informed Approach for Schools, Teachers and Health Educators. Paris, France: UNESCO; 2009.
87. Barker G, Ricardo C, Nascimento M, et al.. Questioning gender norms with men to improve health outcomes: evidence of impact. Glob Public Health. 2010;5:539–553.
88. Peacock D, Stemple L, Sawires S, et al.. Men, HIV/AIDS, and human rights. J Acquir Immune Defic Syndr. 2009;51(suppl 3):S119–S125.
89. Kirby DB, Laris BA, Rolleri LA. Sex and HIV education programs: their impact on sexual behaviors of young people throughout the World. J Adolesc Health. 2007;40:206–217.
90. Kirby D, Laris B, Rolleri L. Sex and HIV Education Programs for Youth: Their Impact and Important Characteristics. Research Triangle Park, NC: Family Health International; 2007.
91. Kirby D, Obasi A, Laris BA. The effectiveness of sex education and HIV education interventions in schools in developing countries. World Health Organ Tech Rep Ser. 2006;938:103–150; discussion 317–141.
92. Kirby D. Email to Jill Gay, Nov. 4 with sex disaggregated data from the studies included. 2009.
93. Michielsen K, Chersich MF, Luchters S, et al.. Effectiveness of HIV prevention for youth in Sub-Saharan Africa: systematic review and meta-analysis of randomized and non-randomized trials. AIDS. 2010;24:1193–1202.
94. Napierala Mavedzenge S, Doyle AM, Ross DA. HIV prevention in young people in Sub-Saharan Africa: a systematic review. J Adolesc Health. 2010;49:568–586.
95. Burnett SM, Weaver MR, Mody-Pan PN, et al.. Evaluation of an intervention to increase human immunodeficiency virus testing among youth in Manzini, Swaziland: a randomized control trial. J Adolesc Health. 2011;48:507–513.
96. Ross DA, Changalucha J, Obasi AI, et al.. Biological and behavioural impact of an adolescent sexual health intervention in Tanzania: a community-randomized trial. AIDS. 2007;21:1943–1955.
97. Chen X, Stanton B, Gomez P. Effects on condom use of an HIV prevention programme 36 months postintervention: a cluster randomized controlled trial among Bahamian youth. Int J STD AIDS. 2010;21:622–630.
98. Reddy P, James S. Programming for HIV Prevention in South African Schools. Horizons Research Summary. Washington, DC: Population Council; 2003.
99. Aggleton P, Chase E, Rivers K, et al.. Innovative Approaches to HIV Prevention: Selected Case Studies. Geneva, Switzerland: UNAIDS; 2000.
100. Maticka-Tyndale E. Sustainability of gains made in a primary school HIV prevention programme in Kenya into the secondary school years. J Adolesc. 2010;23:563–573.
101. Agbemenu K, Schlenk E. An integrative review of comprehensive sex education for adolescent girls in Kenya. J Nurs Scholarsh. 2011;43:54–63.
102. Ishikawa N, Pridmore P, Carr-Hill R, et al.. The attitudes of primary school children in Northern Thailand towards their peers who are affected by HIV and AIDS. AIDS Care. 2011;23:237–244.
103. Andrade H, de Mello M, Sousa M, et al.. Changes in sexual behavior following a sex education program in Brazilian public schools. Cad Saude Publica. 2009;25:1168–1176.
104. Pick S, Givaudan M, Sirkin J, et al.. Communication as a protective factor: evaluation of a life skills HIV/AIDS prevention program for Mexican elementary-school students. AIDS Educ Prev. 2007;19:408–421.
105. Al-Iryani B, Basaleem H, Al-Sakkaf K, et al.. Evaluation of a school-based HIV prevention intervention among Yemini adolescents. BMC Public Health. 2011;11:279.
106. UNESCO. Comprehensive Sexuality Education: The Challenges and Opportunities of Scaling up. Paris, France: UNESCO; 2012.
107. Arcand JL, Wouabe ED. Teacher training and HIV/AIDS prevention in West Africa: regression discontinuity design evidence from the Cameroon. Health Econ. 2010;19(suppl):36–54.
108. Smith KA, Harrison A. Teachers' attitudes towards adolescent sexuality and life skills education in rural South Africa. Sex Educ. 2013;13:68–81.
109. Haberland N, Rogow D. Comprehensive Sexuality Education. Background Paper for Expert Group Meeting on Adolescent Sexual and Reproductive Health. Manhasset, New York: UNFPA; 2013.
110. Tsala Dimbuene Z, Kuate Defo B. Fostering accurate HIV/AIDS knowledge among unmarried youths in Cameroon: do family environment and peers matter? BMC Public Health. 2011;11:348.
111. Ishida K, Stupp P, McDonald O. Prevalence and correlates of sexual risk behaviors among Jamaican adolescents. Int Perspect Sex Reprod Health. 2011;37:6–15.
112. Carnevale J, Gropper AB, Agnew-Blais J, et al.. Knowledge base and caretaker-child communication about HIV in peri-urban schoolchildren of Lusaka, Zambia. AIDS Care. 2011;23:646–653.
113. Ross DA, Dick B, Ferguson J. Preventing HIV/AIDS in young people. A systematic review of the evidence from developing countries. Introduction and rationale. World Health Organ Tech Rep Ser. 2006;938:1–13; discussion 317–341.
114. Melo J, Folgosa E, Manjate D, et al.. Low prevalence of HIV and other sexually transmitted infections in young women attending a youth counselling service in Maputo, Mozambique. Trop Med Int Health. 2008;13:17–20.
115. Neukom J, Ashford L. Changing Youth Behavior Through Social Marketing: Program Experiences and Research Findings from Cameroon, Madagascar, and Rwanda. Washington, DC: Population Reference Bureau; 2003.
116. Scott-Sheldon LA, Huedo-Medina TB, Warren MR, et al.. Efficacy of behavioral interventions to increase condom use and reduce sexually transmitted infections: a meta-analysis, 1991 to 2010. J Acquir Immune Defic Syndr. 2011;58:489–498.
117. Underwood C, Hachonda H, Serlemitsos E, et al.. Impact of the HEART Campaign, Findings from Youth Surveys. Baltimore, MD: Johns Hopkins Population Communication Services Project; 2011.
118. Nobelius AM, Kalina B, Pool R, et al.. “The young ones are the condom generation”: condom use amongst out-of-school adolescents in rural Southwest Uganda. J Sex Res. 2012;49:88–102.
119. Maticka-Tyndale E. Condoms in Sub-Saharan Africa. Sex Health. 2012;9:59–72.
120. Exavery A, Lutambi A, Mubyazi G, et al.. Multiple sexual partners and condom use among 10-19 year-olds in four districts in Tanzania: what do we learn? BMC Public Health. 2011;11:490.
121. Napierala S, Kang M, Chipato T, et al.. Female condom uptake and acceptability in Zimbabwe. AIDS Educ Prev. 2008;20:121–134.
122. Wechsberg W, Luseno W, Kline T, et al.. Preliminary findings of an adapted evidence-based woman-focused HIV intervention on condom use and negotiation among at-risk women in Pretoria, South Africa. J Prev Interv Community. 2010;38:132–146.
123. Institute of Medicine (IOM), National Academy of Sciences (NAS). No Time to Lose: Getting More from HIV Prevention. Washington, DC: National Academy Press; 2001.
124. Cochrane Collaborative Review Group on HIV Infection and AIDS. Evidence Assessment: Strategies for HIV/AIDS Prevention, Treatment and Care. San Francisco, CA: University of California; 2004.
125. Davis KR, Weller SC. The effectiveness of condoms in reducing heterosexual transmission of HIV. Fam Plann Perspect. 1999;31:272–279.
126. Hughes JP, Baeten JM, Lingappa JR, et al.. Determinants of per-coital-act HIV-1 infectivity among African HIV-1-serodiscordant couples. J Infect Dis. 2012;205:358–365.
127. PATH, United Nations Population Fund (UNFPA). Female Condom: A Powerful Tool for Protection. New York, NY: United Nations Population Fund; 2006.
128. Hoke TH, Feldblum PJ, Van Damme K, et al.. Temporal trends in sexually transmitted infection prevalence and condom use following introduction of the female condom to Madagascar sex workers. Int J STD AIDS. 2007;18:461–466.
129. Feldblum PJ, Kuyoh MA, Bwayo JJ, et al.. Female condom introduction and sexually transmitted infection prevalence: results of a community intervention trial in Kenya. AIDS. 2001;15:1037–1044.
130. Telles Dias PR, Souto K, Page-Shafer K. Long-term female condom use among vulnerable populations in Brazil. AIDS Behav. 2006;10(4 suppl):S67–S75.
131. Charania MR, Crepaz N, Guenther-Gray C, et al.. Efficacy of structural-level condom distribution interventions: a meta-analysis of U.S. and international studies, 1998-2007. AIDS Behav. 2011;15:1283–1297.
132. Papo JK, Bauni EK, Sanders EJ, et al.. Exploring the condom gap: is supply or demand the limiting factor—condom access and use in an urban and a rural setting in Kilifi District, Kenya. AIDS. 2011;25:247–255.
133. Barbosa RM, Kalckmann S, Berquo E, et al.. Notes on the female condom: experiences in Brazil. Int J STD AIDS. 2007;18:261–266.
134. Thomsen SC, Ombidi W, Toroitich-Ruto C, et al.. A prospective study assessing the effects of introducing the female condom in a sex worker population in Mombasa, Kenya. Sex Transm Infect. 2006;82:397–402.
135. Dowdy DW, Sweat MD, Holtgrave DR. Country-wide distribution of the nitrile female condom (FC2) in Brazil and South Africa: a cost-effectiveness analysis. AIDS. 2006;20:2091–2098.
136. Liao S, Weeks MR, Wang Y, et al.. Inclusion of the female condom in a male condom-only intervention in the sex industry in China: a cross-sectional analysis of pre- and post-intervention surveys in three study sites. Public Health. 2011;125:283–292.
137. Liao S, Weeks MR, Wang Y, et al.. Female condom use in the rural sex industry in China: analysis of users and non-users at post-intervention surveys. AIDS Care. 2011;23(suppl 1):66–74.
138. Cleland J, Ali M, Shah I. Trends in protective behavior among single vs. married young women in Sub-Saharan Africa: the big picture. Reprod Health Matters. 2006;14:17–22.
139. Maharaj P, Cleland J. Condoms become the norm in the sexual culture of college students in Durban, South Africa. Reprod Health Matters. 2006;4:104–112.
140. Callegari L, Harper C, van der Straten A, et al.. Consistent condom use in married Zimbabwean women after a condom intervention. Sex Transm Dis. 2008;35:624–630.
141. Agha S. Factors associated with HIV testing and condom use in Mozambique: implications for programs. Reprod Health. 2012;9:20.
142. Mbonye AK, Wamono F. Access to contraception and HIV testing among young women in a peri-urban district of Uganda. Int J Adolesc Med Health. 2012;24:301–306.
143. Terry P, Mhloyi M, Masvaure T, et al.. An examination of knowledge, attitudes and practices related to HIV/AIDS prevention in Zimbabwean university students: comparing intervention program participants and non-participants. Int J Infect Dis. 2006;10:38–46.
144. Kennedy CE, Medley AM, Sweat MD, et al.. Behavioural interventions for HIV positive prevention in developing countries: a systematic review and meta-analysis. Bull World Health Organ. 2010;88:615–623.
145. Voluntary HIV-1 Counseling and Testing Efficacy Study Group. Efficacy of voluntary HIV-1 counselling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomised trial. Lancet. 2000;356:103–112.
146. Denison JA, O'Reilly KR, Schmid GP, et al.. HIV voluntary counseling and testing and behavioral risk reduction in developing countries: a meta-analysis, 1990–2005. AIDS Behav. 2008;12:363–373.
147. Bunnell R, Opio A, Musinguzi J, et al.. HIV transmission risk behavior among HIV-infected adults in Uganda: results of a nationally representative survey. AIDS. 2008;22:617–624.
148. Cremin I, Nyamukapa C, Sherr L, et al.. Patterns of self-reported behaviour change associated with receiving voluntary counselling and testing in a longitudinal study from Manicaland, Zimbabwe. AIDS Behav. 2010;14:708–715.
149. Leon N, Naidoo P, Mathews C, et al.. The impact of provider-initiated (opt-out) HIV testing and counseling of patients with sexually transmitted infection in Cape Town, South Africa: a controlled trial. Implementation Sci. 2010;5:8.
150. Pettifor A, MacPhail C, Suchindran S, et al.. Factors associated with HIV testing among public sector clinic attendees in Johannesburg, South Africa. AIDS Behav. 2010;14:913–921.
151. Huchko MJ, Montandon M, Nguti R, et al.. The association of HIV counseling and testing with HIV risk behaviors in a random population-based survey in Kisumu, Kenya. AIDS Behav. 2011;15:718–724.
152. Mola, O., M. Mercer, R. Asghar, K. Gimbel-Sherr, S. Gimbel-Sherr, M. Micek and S. Gloyd. Condom Use after Voluntary Counselling and Testing in Central Mozambique. Tropical Medicine and International Health 2006;11(2):176–181.
153. Maman S, Mbwambo J, Hogan N, et al.. Women's barriers to HIV-1 testing and disclosure: challenges for HIV-1 voluntary counseling and testing. AIDS Care. 2001;13:595–603.
154. Maman S, Mbwambo J, Hogan N, et al.. HIV and Partner Violence: Implications for HIV Voluntary Counseling and Testing Programs in Dar Es Salaam, Tanzania. Washington, DC: Population Council; 2001.
155. Kamenga C, Sangiwa G, Kaliba S, et al.. Voluntary HIV counseling and testing in Tanzania. In: Makinwa B, Grady MO, eds. FHI/UNAIDS Best Practices in HIV/AIDS Prevention. Arlington, VA: Family Health International; Geneva, Switzerland: UNAIDS; 2001.
156. Solomon SS, Solomon S, Masse B. Risk reduction counseling is associated with decreased HIV transmission-associated behaviors in high-risk Indian heterosexuals. J Acquir Immune Defic Syndr. 2006;42:478–483.
157. Kalichman K, Simbayi L, Vermaak R, et al.. Randomized trial of a community-based alcohol-related HIV risk-reduction intervention for men and women in Cape Town South Africa. Ann Behav Med. 2008;36:270–279.
158. Mackenzie C, Kiragu K, Odingo G, et al.. Is it Feasible to Integrate Alcohol-related Risk Reduction Counseling into VCT Services? Findings from Kenya. Horizons Final Report. Washington, DC: Population Council; 2008.
159. Bradley H, Bedada A, Tsui A, et al.. HIV and family planning service integration and voluntary HIV counselling and testing client composition in Ethiopia. AIDS Care. 2008;20:61–71.
160. Peck R, Fitzgerald DW, Liautaud B, et al.. The feasibility, demand, and effect of integrating primary care services with HIV voluntary counseling and testing: evaluation of a 15-year experience in Haiti, 1985-2000. J Acquir Immune Defic Syndr. 2003;33:470–475.
161. Liambila W, Askew I, Mwangi J, et al.. Feasibility and effectiveness of integrating provider-initiated testing and counselling within family planning services in Kenya. AIDS. 2009;23(suppl 1):S115–S121.
162. Kharsany AB, Karim QA, Karim SS. Uptake of provider-initiated HIV testing and counseling among women attending an urban sexually transmitted disease clinic in South Africa—missed opportunities for early diagnosis of HIV infection. AIDS Care. 2010;22:533–537.
163. Cohen M, Chen Y, McCauley M, et al.. Prevention of HIV-1 Infection with Early Antiretroviral Therapy. New England Journal of Medicine. 2011;365:493–505.
164. Donnell D, Kiarie J, Thomas K, et al.. ART and risk of heterosexual transmission in HIV-1 serodicordant African couples: a multinational prospective study. Paper presented at: Seventeenth Conference on Retroviruses and Opportunistic Infections; 2010; San Francisco, CA.
165. Attia S, Egger M, Muller M, et al.. Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis. AIDS. 2009;23:1397–1404.
166. Sarna A, Chersich M, Okal J. Changes in sexual risk taking with anitretroviral treatment: influence of context and gender norms in Mombasa, Kenya. Cult Health Sex. 2009;11:783–797.
167. Abdool Karim Q, Abdool Karim SS, Frohlich JA, et al.. Prevention of HIV-1 Infection with Early Antiretroviral Therapy. New England Journal of Medicine. 2011; 365: 493–505.
168. Personal communication from Cleopatra K. Mugyenyi, Research Manager, Liverpool VCT Care & Treatment (LVCT), Nairobi, KENYA.
169. Kim J, Mokwena L, Ntelmo E, et al.. Developing an Integrated Model for Post-rape Care and HIV Post-exposure Prophylaxis in Rural South Africa. Washington, DC: Population Council, Rural AIDS & Development Action Research Programme, School of Public Health, University of Witwatersrand, South Africa and Tshwaranang legal Advocacy Centre, South Africa; 2007.
170. Kim JC, Askew I, Muvhango L, et al.. Comprehensive care and HIV prophylaxis after sexual assault in rural South Africa: the refentse intervention study. BMJ. 2009;338:b515.
171. Kilonzo N, Theobald SJ, Nyamato E, et al.. Delivering post-rape care services: Kenya's experience in developing integrated services. Bull World Health Organ. 2009;87:555–559.
172. Siika AM, Nyandiko WM, Mwangi A, et al.. The structure and outcomes of a HIV postexposure prophylaxis program in a high HIV prevalence setup in Western Kenya. J Acquir Immune Defic Syndr. 2009;51:47–53.
173. Keesbury J, Askew I. Comprehensive Response to Gender Based Violence in Low-resource Settings: Lessons from Implementation. Lusaka, Zambia: Population Council; 2010.
174. Ramiro LS, Madrid BJ, Brown DW. Adverse childhood experiences (ACE) and health-risk behaviors among adults in a developing country setting. Child Abuse Negl. 2010;34:842–855.
175. Strathdee S, Newell M, Bastos F, Patterson T. HIV Prevention Programmes: An Overview. In: E. Beck, N. Mays, A. Whiteside, J. Zuniga, L. Holland, ed. The HIV Pandemic: Local and Global Implications. 1 ed. Oxford, UK: Oxford University Press; 2006.
176. Bruce RD. Methadone as HIV prevention: high volume methadone sites to decrease HIV incidence rates in resource limited settings. Int J Drug Policy. 2010;21:122–124.
177. Roberts A, Mathers B, Degenhardt L; Reference Group to the UN on HIV and Injecting Drug Use. Women Who Inject Drugs: A Review of Their Risks, Experiences and Needs. Sydney, Australia: National Drug and Alcohol Research Centre (NDARC), University of New South Wales; 2010.
178. Kimber J, Palmateer N, Hutchinson S, et al.. Harm Reduction Among Injection Drug Users—Evidence of Effectiveness. Lisbon, Portugal: European Monitoring Centre for Drugs and Drug Addiction; 2010:115–163.
179. Institute of Medicine, National Academy of Sciences. Preventing HIV Infection Among Injecting Drug Users in High Risk Countries: An Assessment of the Evidence. Washington, DC: National Academy Press; 2007.
180. Smyrnov P, Broadhead RS, Datsenko O, et al.. Rejuvenating harm reduction projects for injection drug users: Ukraine's nationwide introduction of peer-driven interventions. Int J Drug Policy. 2012;23:141–147.
181. Dutta A, Wirtz AL, Baral S, et al.. Key harm reduction interventions and their impact on the reduction of risky behavior and HIV incidence among people who inject drugs in low-income and middle-income countries. Curr Opin HIV AIDS. 2012;7:362–368.
182. Mattick R, Kimber J, Breen C, et al.. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2008:CD002207.
183. Mattick R, Breen C, Kimber J, et al.. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev. 2009:CD002209.
184. Gowing L, Farrell M, Bornemann R, et al.. Oral substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database Syst Rev. 2011:CD001445.
185. McCarthy J, Leamon M, Parr M, et al.. High-dose methadone maintenance in pregnancy: maternal and neonatal outcomes. Am J Obstet Gynecol. 2005;193:606–610.
186. Topp L, Day C, Iverson J, et al.. On behalf of the collaboration of Australian NSPs. Fifteen years of HIV surveillance among people who inject drugs: the Australian needle and syringe program survey 1995-2009. AIDS. 2011;25:835–842.
187. Palmateer N, Kimber J, Hickman M, et al.. Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus transmission among injecting drug users: a review of reviews. Addiction. 2010;105:844–859.
188. Medley A, Kennedy C, O'Reilly K, et al.. Effectiveness of peer education interventions for HIV prevention in developing countries: a systematic review and meta-analysis. AIDS Educ Prev. 2009;21:181–206.
189. Hammett T, Kling R, Van N, et al.. HIV prevention interventions for female sexual partners of injection drug users in Hanoi, Vietnam: 24-month evaluation results. AIDS Behav. 2012;16:1164–1172.
190. Meader N, Li R, Des Jarlais D, et al.. Psychosocial interventions for reducing injection and sexual risk behavior for preventing HIV in drug users. Cochrane Database Syst Rev. 2010:CD007192.
191. Booth R, Lehman W, Dvoryak S, et al.. Interventions with injection drug users in Ukraine. Addiction. 2009;104:1864–1873.
192. Wodak A, Cooney A. Do needle syringe programs reduce HIV infection among injecting drug users: a comprehensive review of the international evidence. Subst Use Misuse. 2006;41:777–813.
193. Wu Z, Luo W, Sulliban S, et al.. Evaluation of a needle social marketing strategy to control HIV among injecting drug users in China. AIDS. 2007;21(suppl 8):S115–S122.
194. Open Society Foundations (OSF). By Women for Women, New Approaches to Harm Reduction in Russia. New York, NY: OSF; 2012.
195. Gilbert L, El-Bassel N, Terlikbayeva A, et al.. Couple-based HIV prevention for injecting drug users in Kazakhstan: a pilot intervention study. J Prev Interv Community. 2010;38:162–176.
196. Phetla G, Busza J, Hargreaves JR, et al.. “They have opened our mouths”: increasing women's skills and motivation for sexual communication with young people in rural South Africa. AIDS Educ Prev. 2008;20:504–518.
197. Wolf RC, Pulerwitz J. The influence of peer versus adult communication on AIDS-protective behaviors among Ghanaian youth. J Health Commun. 2003;8:463–474.
198. Damalie N; Organization for Social Research in Eastern and Southern Africa. Communication Between Mothers and Their Adolescent Daughters on the Subject of Sexuality and HIV/AIDS in Uganda. Gender Issues Research Report Series. 2001:1–23.
199. Ssewamala FM, Han CK, Neilands TB. Asset ownership and health and mental health functioning among AIDS-orphaned adolescents: findings from a randomized clinical trial in rural Uganda. Soc Sci Med. 2009;69:191–198.
200. Ssewamala FM, Han CK, Neilands TB, et al.. Effect of economic assets on sexual risk-taking intentions among orphaned adolescents in Uganda. Am J Public Health. 2010;100:483–488.
201. Skovdal M, Mwasiaji W, Webale A, et al.. Building orphan competent communities: experiences from a community-based capital cash transfer initiative in Kenya. Health Policy Plann. 2010;26:233–241.
202. Adato M, Bassett L. What Is the Potential of Cash Transfers to Strengthen Families Affected by HIV and AIDS? A Review of Evidence on Impacts and Key Policy Debates. Boston, MA: Joint Learning Initiative on Children and HIV/AIDS (JLICA); 2008.
203. Kidman R, Petrow S, Heymann S. Africa's orphan crisis: two community-based models of care. AIDS Care. 2007;19:326–329.
204. Miller C, Sawyer M, Rowe W. My Skills, My Money, My Brighter Future in Zimbabwe: An Assessment of Economic Strengthening for Adolescent Girls. Baltimore, MD: Catholic Relief Services; 2011.
205. Thurman T, Jarabi B, Rice J. Caring for the caregiver: evaluation of support groups for guardians of orphans and vulnerable children in Kenya. AIDS Care. 2012;24:811–819.
206. Wallis A, Dukay V, Mellins C. Power and empowerment: fostering effective collaboration in meeting the needs of orphans and vulnerable children. Glob Public Health. 2010;5:509–522.
207. Freeman M, Nkomo N. Assistance needed for the integration of orphaned and vulnerable children—views of South African family and community members. SAHARA J. 2006;3:502–509.
208. Nyangara F, Thurman T, Hutchinson P, et al.. Effects of Programs Supporting Orphans and Vulnerable Children: Key Findings, Emerging Issues, and Future Directions from Evaluations of Four Projects in Kenya and Tanzania. Chapel Hill, NC: MEASURE Evaluation; 2009.
209. Kumakech E, Cantor-Graae E, Maling S, et al.. Peer-group support intervention improves the psychosocial well-being of AIDS orphans: cluster randomized trial. Soc Sci Med. 2009;68:1038–1043.
210. Brown L, Thurman TR, Rice J, et al.. Impact of a mentoring program on psychosocial wellbeing of youth in Rwanda: results of a quasi-experimental study. Vulnerable Child Youth Stud. 2009;4:288–299.
211. Nyangara F, Obiero W, Kalungwa Z, et al.. Community-based Psychosocial Intervention for HIV-affected Children and Their Caregivers: Evaluation of the Salvation Army's Mama Mkubwa Program in Tanzania. Chapel Hill, NC: MEASURE Evaluation; 2009.
212. Zhao G, Zhao Q, Li X, et al.. Family-based care and psychological problems of AIDS orphans: does it matter who was the care-giver? Psychol Health Med. 2010;15:326–335.
HIV; adolescents; women; girls; programming
Supplemental Digital Content
© 2014 by Lippincott Williams & Wilkins
Highlight selected keywords in the article text.