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Health Care for Women International

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HIV/STI interventions targeting women who experience forced sex: A systematic review of global literature Michelle E. Deming, Amir Bhochhibhoya, LaDrea Ingram, Crystal Stafford & Xiaoming Li To cite this article: Michelle E. Deming, Amir Bhochhibhoya, LaDrea Ingram, Crystal Stafford & Xiaoming Li (2018): HIV/STI interventions targeting women who experience forced sex: A systematic review of global literature, Health Care for Women International, DOI: 10.1080/07399332.2018.1464005 To link to this article: https://doi.org/10.1080/07399332.2018.1464005

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HEALTH CARE FOR WOMEN INTERNATIONAL https://doi.org/10.1080/07399332.2018.1464005

HIV/STI interventions targeting women who experience forced sex: A systematic review of global literature Michelle E. Deming, Amir Bhochhibhoya, LaDrea Ingram, Crystal Stafford, and Xiaoming Li Arnold School of Public Health, Health Promotion, Education, and Behavior, University of South Carolina, SC, USA

ABSTRACT

ARTICLE HISTORY

Women are disproportionately affected by HIV in many regions of the world and they represent the fastest growing demographic in the HIV epidemic. In addition, sexual violence against women is a global public health issue which increases women’s vulnerability of HIV/STI acquisition. However, the relationship between sexual violence and HIV/STI risk are complex and contribute to the growing epidemic of women infected with HIV/STIs. Our purpose for this review is to examine existing HIV/STI interventions that target women who experience forced sex. Interventions designed to address women’s unique needs in HIV/STI prevention are critical in reducing women’s vulnerability to HIV/STIs.

Received 6 March 2018 Accepted 8 April 2018

The intersection of women’s risk of HIV/STI infection and the economic, political, and social inequality they experience are critical in creating effective methods to reduce women’s risk of HIV within their heterosexual relationships (Wingood & DiClemente, 2000). Women are disproportionately affected by HIV in many regions of the world (Jewkes, Dunkle, Nduna, & Shai, 2010) and represent the fastest growing demographic in the HIV epidemic (Campbell, Lucea, Stockman, & Draughon, 2012; Panchanadeswaran et al., 2007; Pettifor, Measham, Reeves, & Padian, 2004). Currently, women constitute more than half of the people living with HIV. In 2016, 36.7 million people were living with HIV, and of these 17.8 million were adult women (UNAIDS, 2017). In addition, sexual violence against women is a global public health concern (Falb, Annan, & Gupta, 2015; GarciaMoreno & Watts, 2011; Heise & Kotsadam, 2015; Jewkes et al., 2010; World Health Organization [WHO], 2017) and one of the key drivers of the HIV epidemic (World Health Organization [WHO], 2004). Sexual violence creates barriers among women to negotiate safe sex practices, thereby increasing their risk for HIV/STI. Forced sex (e.g., sexual violence) is defined as:

CONTACT Michelle E. Deming [email protected] Education, and Behavior, University of South Carolina, SC, USA. © 2018 Taylor & Francis Group, LLC

Arnold School of Public Health, Health Promotion,

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Any sexual act, attempt to obtain a sexual act, or other act directed against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting. It includes rape [forced sex], defined as the physically forced or otherwise coerced penetration of the vulva or anus with a penis, other body part or object. (World Health Organization, 2017, p. 1)

The intersection between women’s risk of HIV/STI transmission and violence against women are complex (Jewkes et al., 2010). Studies show long-term direct and indirect pathways between violence against women and HIV/STI risk (Agrawal, Bloom, Suchindran, Curtis, & Angeles, 2014; Dunkle & Decker, 2012; Heise, Ellsberg, & Gottmoeller, 2002; Jewkes et al., 2010; Maman, Campbell, Sweat, & Gielen, 2000; WHO, 2004). There is a direct link between violence against women and HIV/STI risk when it interferes with women’s ability to negotiate safe sex (e.g., sexual assault, forced sex, sex trafficking, etc.) (Andersson, 2006; Andersson et al., 2013; Dunkle & Decker, 2012; Heise et al., 2002; Stockman, Campbell, & Celentano, 2010; Wagman et al., 2015; Watts & Zimmerman, 2002; WHO, 2017). Alternatively, there is an indirect link of HIV/STI vulnerability associated with social, cultural, and economic factors (Heise et al., 2002; Higgins, Hoffman, & Dworkin, 2010; Jewkes et al., 2010; Panchanadeswaran et al., 2007; Wingood & DiClemente, 2000) that contribute to the global gender imbalance (Higgins et al., 2010). The result is women’s unequal access to resources including: food and/or housing insecurity (Abdool Karim, Sibeko, & Baxter, 2010b; Krishan et al., 2008; WHO, 2005), intergenerational sex and child marriage (UNICEF, 2014; WHO, 2005), lack of educational resources and employment (Krishan et al., 2008; UNICEF, 2014; WHO, 2005), access to reproductive health services (UNICEF, 2014), transactional sex (Carlson et al., 2012; Decker et al., 2017; Reza-Paul et al., 2012), and sex that becomes a commodity for survival (Abdool Karim et al., 2010a; Panchanadeswaran et al., 2007; Watts & Zimmerman, 2002). Hence, sexual violence against women is a global public health concern not only increasing their risk for HIV/STI but also for other aspects of their physical and mental health (Garcia-Moreno & Watts, 2011; Heise & Kotsadam, 2015; Jewkes et al., 2010; WHO, 2017). While women are economically, politically, and socially disadvantaged, the direct pathway between women’s vulnerability and their HIV/STI transmission is through sexual intercourse with their male partners. Interventions designed to address sexual violence can enhance the effectiveness of HIV/STI interventions (Falb et al., 2015; Heise & Kotsadam, 2015; Watts & Zimmerman, 2002; WHO, 2005). However, HIV/STI interventions that assume sexual equality between men and women undermine women’s agency and ability to negotiate safer sex practices with their male partners (e.g., male condom usage) (Krishan et al., 2008; Pulerwitz, Amaro, De Jong, Gortmaker, & Rudd, 2002). This notion of addressing sexual violence is not a new concept and is well documented at the policy level (Garcia-Moreno & Amin, 2016; Higgins et al., 2010; Maman et al., 2000). In public health settings, the term agency refers to women’s ability to take care of their health needs (Campbell & Mannell, 2016). Women’s agency refers to their freedom of choice without social, economic, and/or political consequences (Campbell & Mannell, 2016). It is critical to understand that agency

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is defined from the perspective of individual women and enhancing women’s agency in their heterosexual relationships relies on offering women choices to protect their health (Campbell & Mannell, 2016). However, there is a lack of comprehensive reviews that evaluate the application of gender empowerment (i.e., agency) and the effectiveness of reducing sexual violence and consequently preventing HIV/STI prevalence among women. Thus, our purpose for this systematic review is to conduct a comprehensive review of the interventions targeting women who experience sexual violence (e.g., forced sex). Specifically, the current systematic review is focused on the following research questions: (a)What are the key design features of existing HIV/STI interventions that target women who experience non-consensual forced sex? (b)How do existing interventions address sexual violence in HIV/STI prevention strategies?

Method Study search and selection strategy

We conducted a systematic review of the literature following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines (Moher, Liberati, Tetzlaff, & Altman, 2009). Using A Boolean search strategy, the keywords used in the search included: (rape OR sexual assault OR domestic violence OR battered women OR intimate partner violence OR spousal abuse OR non-consensual sex OR forced sex OR coerced sex) AND (sexually transmitted infections/diseases OR human immunodeficiency virus OR HIV infection). The search was conducted in three databases: PsycINFO (n D 949), CINAHL Complete (n D 874), and MEDLINE (EBSCO) with full text (n D 1,219) from 2007–2017 producing 3042 articles to review. After screening journal titles, and abstracts, 1870 articles were removed due to not meeting the inclusion criteria. The final 45 full text articles were reviewed by two independent researchers using the inclusion criteria focused on HIV/STI interventions for women who explicitly experienced sexual violence. In our search, we produced 17 articles included in the systematic review (Figure 1). As indicated in Table 1, inclusion criteria for screening articles included: (a) population: women who experience forced sex (forced sex is often implicit in domestic violent relationships, therefore the articles included in the full text review had to explicitly state “rape/forced sex/coerced sex” or use the Conflict Tactics Scale (CTS) which identifies forced sex among the sample of women in the interventions); (b) interventions: any type of HIV/STI intervention targeting women who experienced forced sex; (c) empirically based studies (including quantitative and qualitative studies); (d) intervention outcomes; and (e) full-text peer-reviewed articles published in English. Two researchers independently examined the full text articles identified through the systematic search and placed them into an electronic spreadsheet for subsequent review. Any disagreements among researchers regarding inclusion/exclusion criteria were resolved by discussion.

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Studies identified through database search using PICO guidelines (n=3,042)

Articles produced for abstract/title review (n=1,915)

Articles accepted for full text review (n =45)

Duplicates studies removed (n=1,127)

Articles removed (did not meet criteria) (n=1,870)

Articles removed after full text review (n=28) (did not meet inclusion criteria)

Articles included in systematic review (n=17)

Figure 1. Selection process for intervention studies included in systematic review.

Data extraction

The key variables that were extracted from the studies included: study details (author, intervention timeframe, location of the study, etc.), purpose of the study, sample details (target population and sample size), intervention design, theoretical framework used in the studies, and study focus.

Results The majority of interventions were conducted in the United States (n D 6); while interventions were also conducted in South Africa (n D 3), India (n D 3), Uganda (n D 2), Mongolia (n D 2), and Haiti (n D 1). The interventions included women aged 18C years who experienced non-consensual forced sex. Many of the Table 1. Criteria for inclusion/exclusion of studies in the review.

Population Intervention Comparison Outcome Type of study

Inclusion criteria

Exclusion criteria

Adults; women who experience non-consensual/ forced sex (if not explicit/were identified by the Conflict Tactics Scale [CTS]) HIV/STI interventions only (the focus cannot be on IPV) N/A (control group not necessary) Specific HIV/STI outcomes (behavioral change); qualitative and aquantitative Outcomes Randomized controlled trials (RCT); quasiexperimental designs, qualitative (group counseling sessions)

Interventions that only target men; pregnant women; children and pediatrics; childhood sexual abuse; same-sex sexual partners Sexual violence interventions; economic-based interventions N/A Outcomes not reported Articles without original data; theses/ dissertations; non peer reviewed articles

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interventions were quantitative using randomized controlled trials (n D 7) and quasi-experimental (n D 3) methods. One study used only qualitative methods (interviews and focus groups), and six studies employed mixed-method designs to include both qualitative and quantitative components. We present Table 2 to display summary results of each article including: the target sample, dates of the intervention, intervention design, and theoretical constructs. To create a comprehensive picture of existing interventions that target women who experience forced sex, we introduce each targeted sample of women to illustrate the unique needs of women and HIV/STI prevention strategies. Sexually assaulted women

In a randomized controlled trial (n D 279), Abrahams and colleagues sought to explore women’s adherence to a 28-day post-exposure prophylaxis (PEP) drug regimen after experiencing sexual assault to prevent HIV transmission (Abrahams et al., 2010). The intervention group received telephone support on minimizing the side effects of PEP as well as a daily diary and an informational brochure. The control group only received “standard care” consisting of a medical exam, HIV/ STI testing and treatment, rape counseling, and emergency contraception. Overall adherence to PEP was greater in the intervention group (38.2%) versus 31.9% in the control and increased among women who also read the pamphlet and used the daily diary. Female sex workers

Female sex workers (FSWs) frequently experience violence (e.g., forced sex, choking, stabbing, etc.) from clients, pimps, club owners, and law enforcement (Watts & Zimmerman, 2002), therefore increasing their risk of HIV/STIs. Four of the 17 interventions specifically targeted FSWs (Carlson et al., 2012; Decker et al., 2017; Reza-Paul et al., 2012; Tsai et al., 2016). Reza-Paul et al. (2012) intervention targeted a group of FSW (n D 20) in India that did not have a shared sense of community and thus created an intervention that would assist in creating structured support by creating physical “drop in centers” to assist in the development of solidarity among these women. The objective of this intervention was to allow the FSW to decide how to structure the center and the formal rules and guidelines (e.g., safety and HIV/STI prevention) for the use of the space. This intervention was qualitatively assessed as effective and contributed to the long-term sustainability of the drop-in center (Reza-Paul et al., 2012). One intervention used a pre/posttest design among a single group of FSW (n D 60) with a 10- to 12-week follow-up (Decker et al., 2017). Using the Integrating Safety Promotion with HIV Risk Reduction (INSPIRE) model, the intervention program focused on violence-related support, safety, and condom negotiation. Women’s negotiation strategies significantly increased in male condom negotiation with clients from baseline to followup (p < 0.0001) (Decker et al., 2017).

2007–2009

2015

2003–2006

2007–2012

N/A

2010

2008–2010

2008–2009

2012–2013

Carlson et al., 2012

Decker et al., 2017

Kacanek et al., 2013

Kyegombe et al., 2014

Laughon et al., 2011

Logie & Daniel, 2016

McCabe et al., 2016

Mitrani et al., 2013

Mittal et al., 2016

2008–2010

2007–2008

Abrahams et al., 2010

Peragallo et al., 2012

Intervention timeframe

Author

United States

United States

United States

United States

Haiti

United States

Uganda

South Africa

United States

Mongolia

South Africa

Location

Table 2. Interventions included in the systematic review.

Mixed methods

RCT

Mixed methods

Mixed methods

Qualitative

Mixed-methods quasiexperimental Mixed-methods quasiexperimental

RCT

Mixed-methods quasiexperimental

RCT

RCT

Intervention design

Theoretical construct/model

Outcomes

PEP adherence pamphlet and diary use n D 229 sex workers Social cognitive theory (SCT) Intimate partner violence safety behaviors Male condom usage n D 60 sex workers Structural intervention Women’s safety behavior Knowledge and use of sexual violence support Intimate partner violence support Male condom negotiation Depression symptomology n D 4505 women in general N/A Diaphragm, male condom usage, and gel adherence n D 1583/2532 (baseline/ Community mobilization Refusal of sex Increase follow-up) women in intervention and social communication skills Male general diffusion condom usage n D 88 women in general N/A Severity and frequency of violence Safety behaviors/safer sex strategies Male and female condom usage n D 47 women in general Community based intervention Gaining knowledge, confidence, and greater awareness of HIV Male condom negotiation n D 548 U.S. Hispanic women Community based intervention Alcohol intoxication Partner and social cognitive theory communication Male condom (SCT) usage and negotiation n D 548 U.S. Hispanic women Community based intervention Study attrition rates Male condom and social cognitive theory usage and negotiation (SCT) Social cognitive theory (SCT) and Frequency of unprotected sex n D 55 women in general theory of gender and power Safer sex communications (TGP) Male condom negotiation n D 548 U.S. Hispanic women Community based intervention Male condom usage Intimate and social cognitive theory partner violence Partner (SCT) communication

n D 279 sexual assault victims Psycho-social support

Target population

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2006

2010–2011

2003–2004

2011–2013

2005–2009

Reza-Paul et al., 2012

Saggurti et al., 2014

Sikkema et al., 2010

Tsai et al., 2016

Wagman et al., 2015

RCT D randomized controlled trial.

2010–2011

Raj et al., 2013

Uganda

Mongolia

South Africa

India

India

India

n D 220 Indian women

Social cognitive theory (SCT) and Rates of unprotected sex Male condom negotiation theory of gender and power (TGP) Mixed-methods n D 22 sex workers Community led structural Male condom usage intervention (engagement, involvement, ownership, and sustainability) RCT n D 220 Indian women Social cognitive theory (SCT) and Male condom usage and theory of gender and power negotiation Marital intimate (TGP) partner violence Marital sexual coercion Quasi-experimental N D 97 women in general Community based intervention Attrition rates Psychosocial and trauma indicators Male condom usage RCT n D 107 sex workers Social cognitive theory (SCT) Intimate partner violence from paying partners Male condom usage Mixed-method n D 11,448 women in general The transtheoretical model HIV risk behaviors Male condom design (including men) usage

RCT

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In two community intervention models, Carlson et al. (2012) and Tsai et al. (2016) used the social cognitive theory (SCT) to conduct the same 3-arm randomized controlled trial with sex workers in Mongolia (n D 229) and (n D 107), respectively. The intervention groups received four sessions of a relationship based HIV/STI risk reduction intervention and the other group received the same HIV/ STI risk reduction intervention plus two additional motivational interviewing sessions. The control group received a four-session control condition focused on wellness promotion. These results were not statistically significant at the 2-week, 3- and 6-month follow up (Carlson et al., 2012). Tsai et al.’s (2016) intervention targeted the same sample and included a microfinance component with the HIV/ STI intervention; however, the results of the microfinance component were not statistically significant either. Internally displaced women

Women who experience natural disasters are at increased risk for HIV/STI transmission and sexual violence due to the structural barriers that impede access to services and increase women’s economic vulnerability (Logie & Daniel, 2016). Therefore, researchers targeted women in Haiti who were internally displaced due to the earthquake in 2010 (Logie & Daniel, 2016). The community-based intervention included a six-week program focused on HIV/STI prevention, interpersonal relationships, communication, and decision-making skills with sex partners, mental health, resilience and coping, and creating community change. The intervention consisted of four focus groups (n D 40) and in-depth interviews with peer health workers (n D 7). Findings indicated that these women gained confidence, knowledge, and awareness of safer sex practices related to HIV/STI transmission after the intervention. Women in this study qualitatively reported a positive change in their self-efficacy and negotiation strategies with their sexual partners (Logie & Daniel, 2016). Hispanic women

The Salud [health], Educaciόn [education], Promociόn [promotion], y [and] Autocuidado [self-care] (SEPA) is a community-based intervention that specifically targeted Hispanic women using the SCT. Researchers in three studies reported results from the same sample of Hispanic women (n D 548) (McCabe, Gonzalez-Guarda, Peragallo, & Mitrani, 2016; Mitrani, McCabe, Gonzalez-Guarda, Florom-Smith, & Peragallo, 2013; Peragallo, Gonzalez-Guarda, McCabe, & Cianelli, 2012). The SEPA program was an HIV risk reduction intervention using group sessions to address: HIV/STI prevention, male condom negotiation and use, partner communication, and intimate partner violence (IPV). The SEPA intervention used an intention-to-treat (ITT) model that retained every participant randomized to either intervention condition, regardless of any events that happen after randomization (McCabe et al., 2016). The program for

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SEPA included five 2-hour group sessions to develop communication skill building to assist in mediating the effects of intimate partner violence. Overall, women in the SEPA intervention had increased HIV knowledge, improved safety health behaviors, and improved partner communication (McCabe et al., 2016; Mitrani et al., 2013; Peragallo et al., 2012). Indian women

In two articles, authors reported on the efficacy of the Raising HIV Awareness in Non-HIV Infected Indian Wives (RHANI Wives) intervention. Using the same sample of Indian women (n D 220), the researchers examined Indian women’s risk of HIV transmission from their husbands who patronized sex workers (Raj et al., 2013; Saggurti et al., 2014). This intervention was guided by the SCT and the Theory of Gender and Power modeled after an intervention that targeted Hispanic women in the U.S. (SEPA model) who are at risk of HIV from their partner (Raj et al., 2013). The program consisted of a multisession group-based intervention focused on HIV risk, communication skills, economic stressors, and substance abuse. Findings indicated that the rates of unprotected sex in the intervention group were lower than the control group. Women in general who experienced forced sex

Finally, in seven studies there were reports about women in general who experienced forced sex within their heterosexual relationships. The first intervention consisted of a 10-minute counseling session focused on intimate partner violence and basic HIV information, safer sex practices, and safety planning for women (Laughon, Sutherland, & Parker, 2011). The women in the study were given the Severity of Violence Against Women Scale to determine their experiences with sexual violence at baseline and 3-month follow up. The severity and frequency of violence did decrease over time; however, these results were not statistically significant. The Start, Awareness, Support, Action (SASA!) program was a community mobilization intervention focused on HIV/STI knowledge and increasing agency among women (and men) (Kyegombe et al., 2014). The randomized controlled trial (n D 1,583) used social diffusion to focus on shifting gendered norms at the community level. Overall, the results indicated that the SASA! intervention had a small impact on HIV risk behaviors among women. Women in the intervention also reported a significant difference in refusing sex with their partner and were less likely to experience forced sex in the past year at follow up; however, the results were not statistically significant (Kyegombe et al., 2014). Qualitative interviews in this study revealed improvements in women’s relationships (e.g., greater trust and cooperation) and an increase in the connection between HIV/STIs and intimate partner violence. The Methods for Improving Reproductive Health (MIRA) intervention was a randomized controlled trial that assessed the use of diaphragms, lubricant gels, and male condoms (intervention arm) compared to the use of condoms only

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(control arm) among 4,505 women (Kacanek et al., 2013). Women’s condom adherence (i.e., negotiation of male condom use with consistent partner) was assessed in both the intervention and control arms at baseline, 12 and 24 months. The baseline condom adherence rates for women were similar; however, as the intervention progressed, non-adherence decreased in both the control (69.7% to 40.8% at 12 months and 43.6% at 24 months [p < 0.0001]) and intervention arms (72.1% to 62.7% at 12 months and 60.2% at 24 months [p < 0.0001]). In addition, diaphragm non-adherence was not statistically significant in the intervention group. The Supporting Positive and Healthy Relationships (SUPPORT) intervention used the SCT and the Theory of Gender and Power. The SUPPORT intervention consisted of counseling sessions (three individual and five group sessions) and included a pre- and post-test along with a three month follow up addressing male condom use, communication skills regarding safer sex practices, and relationship power among women (n D 55) (Mittal et al., 2016). Women in the intervention had a significant decrease in the frequency of unprotected sex (p < 0.05) and reported four times the number of safe sex conversations with their partners at the three month follow up. The Safe Homes and Respect for Everyone (SHARE) intervention was a four-year community-led program that sampled men and women (n D 11,448) from household clusters (Wagman et al., 2015). The SHARE program used the Transtheoretical Model to address HIV/STIs and intimate partner violence from the individual to societal level (Wagman et al., 2015). One of the components of the intervention focused on HIV disclosure among women and men. Women in the intervention group reported higher rates of disclosure compared to the control group although these results were not statistically significant. Finally, the People Opposing Women Abuse (POWA) was a community based intervention that consisted of a six workshop program (intervention) or a single workshop (control) with women who were seeking intimate partner violence services (n D 97) (Sikkema et al., 2010). The focus of the intervention was designed to address issues with: understanding abuse and HIV risk, general knowledge about HIV/AIDS, male condom use, communication and skill building, empowerment models that address economic insecurity, and gender roles (Sikkema et al., 2010). Although the sexual behavior indicators were not statistically significant, the women in the group felt a sense of community and continued to meet after the study ended (Sikkema et al., 2010). In summary, in seven studies researchers used randomized controlled trials and three used quasi-experimental methods with mixed results. Of these, the most effective interventions targeted sexual assault survivors and PEP adherence (Abrahams et al., 2010), FSW’s condom negotiation (Decker et al., 2017), Hispanic women’s communication skills with their partners and condom use (McCabe et al., 2016; Peragallo et al., 2012), Indian women’s frequency of unprotected sex and experiences

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with forced sex from their husbands (Raj et al., 2013; Saggurti et al., 2014), and women’s HIV risk behaviors and safer sex communication skills in community settings (Kyegombe et al., 2014; Mittal et al., 2016; Wagman et al., 2015).

Discussion Our purpose for this review was to evaluate the HIV/STI intervention designs that target women who experienced forced sex. With the exception of one article that focused on PEP adherence among sexually assaulted women, the remaining 16 articles did address the intersection of forced sex and HIV/STI interventions driven by theories that address gender inequality. However, we concluded that each of the articles included in this systematic review did not account for women’s unique needs when it comes to comprehensive programming and HIV/STI prevention. Each of the 16 articles incorporated the use of male condoms and/or communication skill building to increase male condom use during heterosexual intercourse. However, employing methods to prevent HIV/STI transmission that require active participation from men undermines women’s agency in their sexual relationships (Laughon et al., 2011). Interventions need to incorporate female-controlled methods to reduce their HIV/STI risk (Wingood & DiClemente, 2000). Other methods in the prevention of HIV/STI infection have shown to be effective, including the use of: microbicide gel (Abdool Karim et al., 2010b; Abdool Karim et al., 2010a), diaphragm use (Kacanek et al., 2013), female condoms (Green, 2011; Masvawure et al., 2014; Weeks et al., 2015), and long-acting ARV-based vaginal rings (MacQueen et al., 2014). The efficacy and cost-effectiveness of these female-controlled methods are dependent upon a number of factors associated with women’s adherence: Are they accessible, acceptable, and practical methods to reduce women’s risk of HIV/STI infection? (French et al., 2003; Mack et al., 2014; MacQueen et al., 2014). While male condoms are extremely effective at preventing HIV infection, male condom use is often inconsistent (Jones et al., 2014). In a study assessing male-condoms versus female-condoms efficacy in heterosexual relationships, researchers found that the female condom was just as effective at preventing sexually transmitted infections (French et al., 2003). The following limitations in the current systematic review must be considered. First, it was difficult to assess the efficacy of the interventions because less than half of the studies (n D 7) used randomized controlled trials and many outcomes were either qualitatively assessed or did not have specific directives that produced comparable outcomes among the studies in this systematic review. Second, several studies recruited participants from ongoing studies. Carlson et al.’s (2012) sample of FSW came from women already enrolled in a National AIDS Foundation (NAF) program. Any reported results of this intervention were potentially biased due to FSW in the study were already receiving HIV prevention programming. In

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Wagman et al., (2015) study, women in the SHARE intervention were recruited from clusters of women already enrolled in the SASA! intervention. Again, the results of the study were potentially biased because the women had exposure to both HIV/STI interventions. Third, although each article selected for this systematic review met the inclusion criteria, several studies failed to measure outcomes directly related to HIV/STI prevention. For example, the POWA study only measured attrition rates of women from the intervention (Sikkema et al., 2010). And lastly, two studies that focused on FSW had very small sample sizes (Decker et al., 2017; Reza-Paul, 2012).

Future directions Given the changing landscape of the HIV epidemic, the face of HIV is now a woman from the global south (Higgins et al., 2010). Effective strategies should include engaging men in separate HIV strategies for prevention (Higgins et al., 2010) and strategies that consider the gender imbalance that exists in women’s relationships with men and the cultural atmospheres in which women construct their lives (Higgins et al., 2010; Wingood & DiClemente, 2000). Most interventions targeting women are predicated on the assumption that women have agency in their sexual relationships (Andersson et al., 2013; Laughon et al., 2011) and can negotiate male condom use with their heterosexual partners (Higgins et al., 2010; Jewkes et al., 2010; Krishan et al., 2008). While some studies show effective results by increasing male condom use among FSW (Decker et al., 2017), women who do not engage in transactional sex, but initiate condom use with male partners are at an increased risk of violence (Lary, Maman, Katebalila, McCaulty, & Mbwambo, 2004). The very act of suggesting the use of male condoms with a consistent partner has the potential to instigate a violent event (Heise et al., 2002; Lary et al., 2004) and women’s negotiation of condom use is often difficult due to their unequal power in their sexual relationships (Higgins et al., 2010; Pettifor et al., 2004). Future HIV/STI interventions should incorporate methods that reduce HIV/ STI transmission that do not require active participation from men in order to be effective (Wingood & DiClemente, 2000). In addition, women in clinical trials have the choice to enroll in studies assessing the efficacy of HIV/STI prevention strategies. However, women rarely have the choice of the intervention method. The only choice women have is whether or not to participate in trials where the prevention method has already been chosen for them (MacQueen et al., 2014). Participant-centered approaches are recommended by assessing the most effective strategies and implementing female-controlled HIV/STI preventative methods (MacQueen et al., 2014) that includes choices and/or combinations of preventative methods (Jones et al., 2014).

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In addition, structural interventions that address gender inequality and women’s unequal access to social, economic, and political power as well as female-controlled methods are important in addressing women’s continued risk of HIV/STIs (Krishan et al., 2008). Long-term sustainable tailored interventions for specific demographic/cultural groups may reduce or eliminate health disparities among women and increase their power in their sexual relationships (Higgins et al., 2010). The World Health Organization (2004) recommends scaling up interventions to address the intersection of women’s HIV/STI risk and sexual violence against women. Effective strategies should address the complex components of the violence women experience (e.g., psychological, emotional, sexual, etc.) (Krishan et al., 2008). The most effective strategies include multi-pronged interventions that address the complexities of gender inequality (Kaufman, Cornish, Zimmerman, & Johnson, 2014; Lary et al., 2004) and sexual agency, access to financial independence, and equality in shared decision making tasks. Research strategies and interventions that challenge gendered norms are essential (Lary et al., 2004). Heterosexual men are routinely regarded as transmitters of HIV/STIs, but are not considered active agents in HIV/STI prevention programming (Higgins et al., 2010). It is essential to include men in prevention strategies that address power dynamics and safe sex practices separate from initiatives that promote women’s agency and safe sex practices in their sexual relationships (Jewkes et al., 2010; WHO, 2005). To date, few interventions address the intersection of HIV/STI risk and the sexual violence that many women experience. The gaps in this literature review call for the implementation of female-controlled methods to prevent HIV/STI infection among women in a global effort to reduce their risk of HIV/STIs.

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