Economic strengthening for HIV prevention and risk reduction: a review of the evidence

Household economic strengthening (HES) is increasingly implemented alongside HIV programing to address economic drivers of the epidemic. The evidence base on HES for HIV outcomes is growing, and this evidence review aimed to comprehensively consolidate and synthesize the research linking 15 types of HES interventions with a range of HIV prevention and treatment outcomes. The review was conducted between November 2015 and October 2016 and consisted of an academic database search, citation tracking of relevant articles, examination of secondary references, expert consultation, and a gray literature search. Studies were included if they evaluated an HES intervention(s), reported on an HIV outcome(s), were available in English, and were relevant to low-income contexts or vulnerable populations. All evidence was assessed for quality. Over 108 citations were included and a matrix framework was used to map the evidence, linking each HES intervention with each HIV outcome, providing a precise visual depiction of the evidence base.Given the volume of evidence, the results are presented and discussed in three papers, each focused on a different HIV outcome area. This is the first paper in the series and focuses on the 64 studies that reported HIV prevention outcomes. Conditional and unconditional cash transfers, and educational support were each associated with reductions in self-reported risk behaviors, particularly among adolescents. Food assistance in combination with other support also shows a positive trend for adolescent risk reduction. Most studies relied on self-reported behavioral data, and clinical outcomes such as HIV or other sexually transmitted infection (STI) incidence or prevalence were mostly null or underpowered, calling into question the true effectiveness of these interventions in preventing HIV. Limited evidence also supports the effectiveness of financial incentives in increasing voluntary medical male circumcision. Well-designed vocational/entrepreneurial training and savings interventions could bolster HIV prevention efforts for female sex workers, while findings are less conclusive for adolescents.