http://orcid.org/0000-0003-2812-5377
ABSTRACT
Background: Intimate partner violence (IPV) and HIV are co-occurring global epidemics, with similar root causes of gender and economic inequalities. Economic interventions have become a central approach to preventing IPV and HIV.Objective/Methods: We undertook a comprehensive scoping review of published evaluations of economic interventions that sought to prevent IPV and/or HIV risk behaviours.Results: Forty-five separate analyses of interventions met our criteria. Broadly, unconditional cash transfer interventions showed either flat or positive outcomes; economic strengthening interventions had mixed outcomes, with some negative, flat and positive results reported; interventions combining economic strengthening and gender transformative interventions tended to have positive outcomes.Conclusions: The review highlighted a number of gaps. Specifically, there were limited studies evaluating the impact of economic interventions on female sex workers, young women, and men. In addition, there were missed opportunities, with many evaluations only reporting either IPV- or HIV-related outcomes, rather than both, despite overlaps.
Responsible Editor Isabel Goicolea, Umeå University, Sweden
Background
Intimate partner violence (IPV) and HIV acquisition are co-occurring global epidemics [Citation1]. Globally the World Health Organization (WHO) [Citation2] estimates that 30% of all women have experienced some form of sexual and/or physical violence from an intimate partner in their life. There is clear evidence that IPV is a major driver of HIV acquisition amongst heterosexual women [Citation1,Citation3] with studies suggesting up to 25% of all HIV acquisitions occurring amongst women are linked to their experiences of IPV [Citation3,Citation4]. In addition, HIV acquisition is also a cause of IPV [Citation1]. The recognition of these linkages has led to a concerted effort by global institutions and researchers to design interventions to prevent IPV and HIV simultaneously [Citation1,Citation5–Citation7], with programmes such as the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women’s (DREAMS) initiative, a President’s Emergency Plan for AIDS Relief (PEPFAR)-led programme in six countries across southern and eastern Africa, channelling significant money into tackling HIV acquisition through reducing women’s experiences of IPV, with a particular focus on adolescents.
Figure 1. Flow chart of search.
Studies highlight the overlapping drivers of IPV- and HIV-vulnerability, particularly poverty and gender inequalities [Citation6,Citation8–Citation10]. There is overwhelming evidence that gender inequalities shape men’s perpetration of IPV and women’s experience of IPV as well as their vulnerability to HIV in heterosexual relationships [Citation3,Citation11–Citation14]. The evidence linking poverty and HIV-vulnerability is less clear, with recent longitudinal studies suggesting poverty can either be a risk or protective factor for HIV depending on other social factors including community acceptability of violence against women [Citation15]. There is stronger evidence about the impact of poverty on women’s experiences of IPV. While it is certainly clear that IPV is a global phenomenon experienced by women in high-income as well as low-income countries [Citation2], studies consistently show that women’s recent experience of IPV is strongly associated with their experiences of poverty [Citation16–Citation18].
Less contentious is the argument that poverty, when intersecting with gender inequalities, places women in economically and socially dependent relationships with men, which increases their vulnerability to HIV and IPV. This exacerbates the challenges of negotiating condoms, leaving violent and controlling relationships and exposing them to controlling behaviours: all risk factors for HIV acquisition and experiencing IPV [Citation8–Citation10]. More recently for men, qualitative research has argued that men’s partial exclusion from the capitalist economy has led men to develop identities that draw on and deploy forms of emphasised heterosexuality (occassionaly labelled a ‘hyper-masculinity’), which include control and domination over women, including IPV as a way to control women, as well as seeking multiple sexual partners [Citation19–Citation21].
In recognising how poverty shapes IPV and HIV-vulnerability, there has been significant research around using economic interventions to prevent HIV and IPV [Citation6,Citation22–Citation24]. Broadly there are three conceptual approaches. The first is a social protection framework and the direct transfer of resources to households in the form of either cash or food/vouchers [Citation25]. Transfers can be unconditional, or conditional on recipients accessing services or similar, and target poverty as an ‘upstream’ driver of ill-health [Citation26]. A second approach is located within behavioural economics and uses direct cash transfers to incentivise certain behaviours or outcomes, be this HIV-testing or remaining Sexually Transmitted Infections (STI)-free [Citation26,Citation27]. These assume people make decisions based on trade-offs between alternatives and that the economic incentives are large enough to change behaviours in positive directions [Citation26]. A third approach focuses on supporting those targeted to develop their own economic assets through either extending savings and loans systems to poor populations (e.g. microfinance) or providing vocational training [Citation22]. A subset of these include gender transformative programming at the same time as economic strengthening [Citation6]. These combined interventions are often focused on challenging women’s social and economic dependency on men.
There has been recent interest in economic interventions to prevent HIV acquisition and IPV, particularly in the context of UNAIDS’ Investment Framework [Citation28,Citation29]. Currently there exist a number of reviews of this evidence base, but these have been limited in scope. Reviews have focused only on economic interventions [Citation22], or only on HIV outcomes or IPV outcomes, or have been of limited geographical scope [Citation6,Citation24,Citation25]. None have sought to review any economic interventions including combined economic and gender transformative interventions and include HIV and/or IPV as outcomes. In this paper we undertook a comprehensive review of economic interventions globally that seek to prevent HIV or IPV.
Methods
We conducted a comprehensive review of published and grey literature. We searched the formal academic websites PubMed, Web of Science and EbscoHost and searched grey literature using Google Scholar. The search terms covered (1) IPV, (2) HIV, (3) economic interventions (the full search string is given in the Appendix). We also used a snowballing technique to search reference lists and review articles to identify other studies.
Articles were included in the review if: (1) they had a quantitative evaluation of an intervention, whatever the study design (including cross-sectional, quasi-experimental and randomised control trial [RCT]); (2) they reported an outcome of either IPV or HIV risk behaviour – HIV risk behaviours had to be behavioural such as condom use at last sex, transactional sex and number of partners; (3) the intervention included an economic component; (4) they were published in English between 1 January 2000 and 1 January 2015.
Exclusion criteria were: (1) qualitative evaluations; (2) they only reported knowledge and/or intentions around HIV (rather than a behavioural outcome); (3) they fell outside of the date range for publication; (4) they were reviews synthesising other studies. There were no exclusion criteria based on quality of study design. The lack of inclusion of qualitative research means that there cannot be a focus on the processes of change in the review.
Initial searches were conducted on relevant databases with all references downloaded to EndNote 7 for review. Articles were initially screened based on title by the first author. A more comprehensive review of abstracts was then conducted. Full texts were read if clarity was further needed (see ). Data was extracted into a spreadsheet to ensure consistency of reporting.
Where a number of separate analyses sought to understand the impact of the same intervention (for instance multiple analyses of the Child Support Grant [CSG] in South Africa), these are reported separately. We provide a narrative review of the evidence.
Results
In total we identified 45 separate analyses of interventions meeting our criteria (see ). Given the heterogeneity in interventions we categorised interventions into three categories based on their economic intervention type: (1) evaluations of cash transfer interventions (n = 13; see ); (2); evaluations of economic strengthening interventions (n = 11; see ); and (3) and evaluations of economic strengthening and gender transformative interventions (n = 21; see ). Overall, only eight interventions were reported in the grey literature.
Cash transfer interventions
Table 1. Cash transfer interventions to prevent HIV or IPV (1 January 2000–1 January 2015).
Table 2. Economic strengthening interventions to prevent HIV or IPV (1 January 2000–1 January 2015).
Table 3. Economic strengthening and gender transformative interventions to prevent HIV or IPV (1 January 2000–1 January 2015).
Thirteen separate analyses of six different cash transfer interventions were identified. They were separated into whether they subscribed to a broad social protection approach, or used a behavioural economics approach as their theoretical underpinnings [Citation26].
(2) Social protection
Ten analyses of social protection interventions were identified on eight different interventions (); five focused only on child outcomes (all from Africa) and five focused only on adult women’s outcomes (all but one from Latin America).
(3) Child outcomes
Five analyses focused on two different interventions. In South Africa the CSG had three different analyses [Citation30–Citation32] and the Kenyan Cash Transfer for Orphans and Vulnerable Children (Kenya CT-OVC) had two different analyses from one study [Citation33,Citation34]. The Kenya CT-OVC [Citation33,Citation34]was an RCT, while one study of the South African CSG used a prospective cohort, with one analysis using propensity score matching to adjust for selection bias [Citation30,Citation31], while the other study of the South African CSG was a cross-sectional design [Citation32].
All five social protection cash transfer evaluations focused on child outcomes (under 18) reported on HIV risk behaviours; none reported on under-18s’ experiences of IPV. All analyses of the South African CSG reported positive outcomes for children. Cluver et al. [Citation30] reported a significant reduction in transactional sex and age-disparate sex for girls, but no impact for boys, amongst households receiving the CSG. Similarly cross-sectional analysis of the CSG by UNICEF reported a significant reduction in sexual activity, delayed sexual debut and reduced pregnancies for both girls and boys whose families received the CSG [Citation32]. Cluver and colleagues [Citation31] undertook a separate analysis of cash combined with care (defined as either a supportive teacher or positive parenting at home), and found significant reductions in HIV risk behaviour for girls and boys, where families received the CSG. In Kenya, Handa et al. [Citation33] reported a significant delay of sexual debut for children receiving cash; however, Rosenberg et al. [Citation34] reported no impact of the transfer on transactional sex or relative partner age. They do suggest that there were marginal reductions in transactional sex if the girl was younger or in school [Citation34].
(4) Adult outcomes
Five separate analyses of four different broad-based social protection interventions were identified; all reported adult women’s outcomes. All focused exclusively on women’s self-reported experiences of IPV, without consideration of HIV outcomes, with four from Latin America and one from Kenya. Two analyses focused on Mexico’s Oportunidades, which is a conditional cash transfer linked to accessing health and education services [Citation37,Citation38]; one focused on Bono de Desarrollo Humano (B.D.H), a state-run unconditional cash transfer in Ecuador [Citation35]; and one focused on a humanitarian relief intervention in Ecuador, which operated for six months [Citation75]. The final study was of an unconditional cash transfer called ‘GiveDirectly’ run by an NGO in rural Kenya, which provided either a lump sum or regular transfers of a smaller amount over nine months [Citation39]. Study quality was generally high with randomised designs in Kenya and Ecuador [Citation35,Citation36,Citation39]. Two studies, both from Mexico, were cross-sectional in design [Citation37,Citation38].
All analyses focused on women’s self-reported experience of IPV. Two studies reported reductions of physical and sexual IPV. In Kenya the GiveDirectly intervention showed a 30–50% reduction in various forms of physical violence and a 50% reduction in rape (p < 0.1) and 60% reduction in other forms of sexual violence (p < 0.05) [Citation39]. Similarly, in Ecuador, the short-term transfer intervention showed reductions in controlling behaviours and women’s experiences of IPV [Citation75].
In contrast, other studies reported mixed results. In Mexico, one analysis of Oportunidades showed mixed outcomes for women receiving a cash transfer: while it reduced physical IPV by 40% (p < 0.01), it increased women’s experiences of emotional violence by 3 to 5 percentage points, but this change was not statistically significant [Citation35]. In the BDH evaluation no impact was seen on reducing violence, while an increase in male controlling behaviours was reported (p < 0.05) [Citation35]. Another study showed no long-term impact on IPV; however, analyses suggested this was because women could leave abusive partners because of receipt of the transfer [Citation38].
(5) Cash transfers as incentive for behaviour change
Three cash transfer interventions were based in behavioural economics, aiming to shift health behaviours and thus HIV- or STI-status. Two studies were conducted in sub-Saharan Africa (SSA) [Citation40,Citation41] and one in the USA [Citation42]. In general study design was rigorous, using RCTs in two studies [Citation40,Citation41] and a quasi-experimental design in the other [Citation42]. In Tanzania remaining STI-free was incentivised with cash and assessed through testing every 4 months over a 12-month period [Citation40]. In Malawi a study focused on incentivising maintaining HIV status over 12 months for women and men (if HIV-negative at start, maintaining this; if HIV-positive, they automatically received the cash transfer at the end) [Citation41]. Finally, in the USA, a study provided cash transfers on progression through a series of health checks and training programmes [Citation42]. All three studies focused on women and men, 16 years old and older.
There was mixed evidence on the impact of incentivising HIV-status or STI-status. In Tanzania, adjusted analysis showed significant impacts of high-value incentives on remaining STI-free [Citation40]. In Malawi, however, there was no impact on maintaining HIV-status [Citation41]. But, when women and men were given the incentive, HIV risk behaviours reduced for women and increased for men [Citation41]. In the USA, the combination of incentives linked to accessing services and progression in training programmes reduced the likelihood that participants had sex [Citation42].
Economic strengthening interventions
Eleven studies sought to assess the impact of economic strengthening interventions on IPV and HIV-prevention (). Ten were from Bangladesh and one from South Africa. All studies focused on the impact of microfinance and used cross-sectional study designs. Given study designs – with many looking at population-level data – it is difficult to untangle whether similar interventions were assessed. In Bangladesh Bajracharya [Citation44] used propensity score matching on cross-sectional data to overcome bias. All studies included measures of IPV experienced by women; one study also included measures of HIV risk behaviours [Citation53].
Overall there was no clear evidence on the impact of microfinance on women’s experiences of IPV. Two studies – one from Bangladesh and one from South Africa – suggested women’s participation in microfinance had no impact on IPV [Citation44,Citation53], while two studies from Bangladesh suggested involvement in microfinance reduced IPV [Citation50,Citation52], with three others suggesting a potential initial increase in women’s experience of IPV, and a reduction in risk over a longer time period [Citation43,Citation45,Citation51]. In contrast, the other four studies suggested involvement in microfinance increased IPV, particularly under specific circumstances, including living in a conservative area [Citation48], being wealthier [Citation46,Citation47,Citation49] and residing in urban areas [Citation49], suggesting a significant role was played by contextual factors. The only study which looked at HIV risk behaviours cross-sectionally in South Africa found no impact on these [Citation53].
Economic strengthening and gender transformative
We identified 21 interventions, each with their own separate analysis, which combined economic strengthening interventions with gender transformative components, primarily group-based discussions, and couples interventions (). Three main types of economic interventions were identified: microfinance/Village Savings and Loans Association (VSLA), formal savings, and vocational training. We report under each of these types separately.
Microfinance/VSLA and gender transformative
Eleven interventions used microfinance or VSLA. Seven studies were undertaken in SSA, three in Asia and one in Latin America. Study design varied: six were RCTs [Citation54–Citation57,Citation60,Citation64], four were quasi-experimental [Citation59,Citation61–Citation63,Citation76] and one was cross-sectional [Citation58]. The additional gender transformative components varied widely. Two used couples discussion groups [Citation55,Citation57], while another study was embedded in a wider community mobilisation intervention for sex workers [Citation62]. The others all worked with women in group settings, such as VSLAs. Nine reported HIV outcomes and four IPV outcomes (only two reported both [Citation54,Citation60]).
In general, despite variations in reported outcomes, there was a trend towards positive outcomes. For HIV-related outcomes, six reported significant improvements in condoms use [Citation23,Citation58,Citation60,Citation62–Citation64], while two reported non-significant improvements [Citation59,Citation77] and one reported no change [Citation56]. Other changes in reported HIV risks included a reduction in STIs [Citation62] and a reduction in the number of sexual partners [Citation63,Citation64], all in sex worker populations.
Four studies reported IPV-related outcomes [Citation54,Citation55,Citation57,Citation60]. Three reported significant reductions on IPV [Citation23,Citation57,Citation60] and one a non-significant but positive outcome [Citation55]. One study also reported a reduction in economic abuse from their partner (p < 0.0001) in female participants [Citation55].
Savings and gender transformative
Only one discrete intervention was identified that reported a behavioural outcome in two studies [Citation65,Citation66]. This focused on young women and included a pilot from two countries (Kenya and Uganda) using a pre-test, post-test design [Citation66] and a subsequent larger study from Uganda, with three arms: full treatment, economic-only treatment and comparison group [Citation65]. The full intervention provided safe social spaces, reproductive health training, financial education and opened a savings account for children [Citation65,Citation66]. Only IPV outcomes data were reported.
The outcomes of this saving and gender transformative intervention were mixed. In the pilot there were limited effects seen in Kenya, but in Uganda there was a significant decrease in being indecently touched by anyone (whether a partner or non-partner) in the past six months [Citation66]. In the subsequent controlled study, the full intervention showed no impact on sexual violence; however, in the economic-only arm, there was a significant increase in indecent touching by anyone in the past six months (p < 0.01) [Citation65].
Vocational training and gender transformative
Eight interventions provided vocational training combined with gender transformative training [Citation59,Citation68–Citation74]. Four were in SSA, two in Asia and two in the USA. One study was an RCT, although randomisation occurred at the individual, rather than group, level [Citation67]. All others were quasi-experimental, although some did include elements of randomisation. All eight reported on a variety of HIV-related outcomes, however only three reported on IPV as well [Citation67,Citation68,Citation73].
Vocational training varied. For instance, in the JEWEL intervention, Sherman et al. [Citation70] provided jewellery-making training; SHAZ! provided options including hairdressing, garment making and receptionist training, alongside broader business skills [Citation67]; while in the MEN Count intervention [Citation73] employment counselling was provided. In contrast, in Stepping Stones and Creating Futures [Citation68] there was no specific skills training, but rather the intervention focused on promoting critical thinking and reflection around livelihoods and job opportunities. There was a greater focus on younger people in these programmes, with four interventions (out of eight) targeting youth participants [Citation10–Citation24] and typically both women and men were included [Citation67–Citation69,Citation74].
There were significant variations in HIV-related outcomes. Seven studies reported positive outcomes in terms of HIV-related ones, although the specific impact varied. In three studies condom use improved significantly [Citation67,Citation72,Citation73]. In five studies, there were significant changes in other types of sexual behaviour or partner types, suggesting a reduction in HIV risk behaviour [Citation59,Citation68,Citation70,Citation71,Citation74]. Only one study reported entirely no impact on behavioural measures related to HIV risk [Citation69].
In the three studies reporting IPV, all reported reductions in IPV. Dunbar et al. [Citation67] reported a non-significant reduction in IPV (IOR = 0.10 vs COR = 0.63; p = 0.06) for SHAZ!, while Jewkes et al. [Citation68] reported a significant reduction in any sexual IPV experienced by women (37%; p = 0.033), but did not see a reduction in men’s perpetration of IPV for Stepping Stones and Creating Futures. The MEN Count intervention had too small a sample at baseline to report IPV trends, but suggested there was a non-significant reduction [Citation73].
Discussion
This is the first study to undertake a comprehensive review of any types of economic intervention which report either an HIV-related and/or IPV behavioural outcome. We identified 45 separate analyses of interventions that sought to use economic interventions (either on their own or in combination with other interventions) to prevent HIV risk behaviours and/or IPV. Interventions varied substantially in how they conceptualised the role of economics in preventing HIV or IPV, in study design, and in measurement. As such there was too much heterogeneity to undertake a meta-analysis of outcomes. However, the broad scope of the review enables some assessments of the field of interventions to be made.
The provision of cash through broad-based social protection programmes appears to have broadly positive outcomes for children targeted through these interventions. In the five separate analyses that looked at the impact of providing cash transfers to families with children, the results were positive in four of the studies in reducing HIV risk behaviours of children [Citation30–Citation33] and showed no impact in the fifth [Citation34]. This is highly suggestive that, following a range of other reviews, the provision of broad-based social protection mechanisms as an approach to improving child health has multiple and overlapping positive outcomes [Citation26,Citation78]. However, no study looked at the potential impact of social protection on reducing children’s vulnerability to IPV as they moved into adolescence.
For adults, however, interventions that solely strengthened economic well-being, through either cash transfers, or involvement of adults in economic strengthening activities such as microfinance or VSLA approaches, showed mixed outcomes, with studies reporting increases, decreases and no impact on HIV risk behaviours and IPV. The ‘mixed’ findings of these interventions can be explained in a number of ways. First, some studies have emphasised that as women gain economic autonomy and power in relationships more generally, they may face a ‘male-backlash’ [Citation79], as men start to feel their ‘authority’ is challenged. In India, a prospective cohort study of married women found that those who secured work in the study period were more likely to experience IPV than those who remained unemployed [Citation80]. Second, studies reviewed highlighted that the impact of economic strengthening interventions on IPV may be contextually specific, with contextual factors including urban or rural residence [Citation49] and whether the community was more liberal or conservative [Citation48] shaping outcomes. Similarly, Heise and Kotsadam [Citation81] in their cross-country analysis highlight that women’s work is protective for IPV in contexts where many women work, but increases IPV-vulnerability if few women work.
In contrast, the interventions which combined economic and gender transformative interventions showed positive or flat results, and no negative findings. This highlights the fact that women’s experiences of HIV- and IPV-vulnerability are often shaped at the intersection of gender inequalities and economic marginalisation [Citation79] and that successfully working to reduce these risks needs to combine economic and gender transformative interventions [Citation82].
The review highlighted a lack of evidence around effective interventions for a number of specific populations: in particular female adolescents, female sex workers and men. In general, interventions tended to focus on adult women, with only 14 out of the 45 analyses including women under the age of 18 (of which 5 were child outcomes for broad-based social transfer programmes). The lack of inclusion of women and girls under the age of 18 has been noted in wider reviews of women’s economic empowerment interventions [Citation83]. The lack of inclusion of younger women emerges from a confluence of factors including lack of recognition of their vulnerability to HIV and IPV, ethical challenges of working with younger people, and resistance to seeing adolescent girls as autonomous actors.
Only three interventions specifically focused on female sex workers, despite global evidence on the overwhelming burden of HIV and violence in this population [Citation84,Citation85]. Overall, sex worker interventions showed positive results, and were often embedded in wider sex worker mobilisation interventions, rather than being ‘stand-alone’ interventions. The potential of wider structural and social change through community mobilisation, as with sex worker mobilisation, is an important avenue for further consideration. In addition, there remains an ongoing debate about definitions of sex work and transactional sex, especially for women under 18, where women who do not identify as sex workers may be excluded from sex worker mobilisation and interventions.
The lack of research around interventions for these two populations (women under 18 and female sex workers) is critical not only because of the high burden of HIV and IPV they face, but also because it is likely they face specific programming challenges. Indeed, the first generation of interventions with adolescent girls and young women showed many of the challenges, with flat or underwhelming outcomes [Citation59,Citation61]. Yet as lessons have been learnt and interventions have been modified, programmes with adolescent girls are increasingly showing positive outcomes [Citation67,Citation68]. Similarly, a review by the Global Network of Sex Work Projects of economic interventions for female sex workers in Africa highlighted the importance of involving sex workers in the design and implementation of projects [Citation86], suggesting that there needs to be significant investment in developing and evaluating economic interventions for sex workers and that there is no simple transferability of interventions from one setting to another.
There was also a lack of focus on the potential and pitfalls of including men in economic and gender transformative interventions. Only 11 interventions out of 41 directly targeted men as recipients of the intervention and/or evaluated the impact on them. That there is little focus on including men in evaluations is a challenge for three reasons. First, men are already included in large-scale public works programmes across the world that seek to build their economic livelihoods and little is known about the impact of involving these men on HIV risk behaviours and IPV perpetration. Second, studies working with men for gender equality continually raise the challenge of poverty and the barriers this causes for transformation of masculinities [Citation87] and as such, there may be significant benefit in including men in combination gender transformative and economic strengthening interventions. Third, given the potential for a ‘male-backlash’ around women’s involvement in economic strengthening interventions, understanding men’s responses remains critical. Further research and theorising need to be done to understand how working with men on strengthening livelihoods can be done in a way that promotes gender equality and does not lead to the exclusion of women [Citation88].
The review also highlights missed opportunities in understanding the impacts of interventions at the intersections of HIV and IPV; only 6 out of 45 studies measured both HIV risk behaviours and IPV outcomes. Given the clear evidence of how IPV and HIV have common risk factors, the failure to include both sets of measures is a major evidence gap. Moreover, studies also point to the need to include a wider range of measures. For instance some studies pointed to the potential of economic-based interventions to either increase or decrease male controlling behaviours [Citation35,Citation36,Citation68], an important factor for HIV acquisition and IPV [Citation89], but this measure was not common across many studies. In addition, economic violence was only measured in a limited number of studies [Citation55], yet given the underlying aim of some economic interventions is to increase women’s economic autonomy in relation to male partners, this is similarly a missed opportunity.
This review has a number of limitations. There is a widely known publication bias whereby positive results are much more likely to be published [Citation90], which while somewhat mitigated by the inclusion of grey material, is unlikely to have been totally overcome. Additionally, as any quantitative evaluation was included, irrespective of the quality of the study design, comparing different studies to each other may misrepresent interventions’ true effectiveness. Finally, as the review was not a full systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, there are likely to be differences between this review and a PRISMA-guided one.
This comprehensive review of economic interventions highlights the large evidence base that exists around reducing HIV risk and IPV globally through tackling poverty through a variety of interventions. It is highly suggestive that broad-based cash transfer interventions have widespread positive benefits for women who receive them, as well as their children targeted. In addition, it emphasises the positive outcomes of combining economic strengthening and gender transformative interventions. However, it also highlights the need for further research on this topic, including research on specific populations, female adolescents, female sex workers and men, if a full understanding of the benefits of these interventions is to be achieved.
Ethics and consent
Not required.
Paper context
Intimate partner violence and HIV are co-occuring global epidemics. Reviews have not explored the impact of economic interventions on both of these. We undertook a comprehensive review of these interventions. The review highlights that economic interventions combined with gender transformative components have stronger outcomes than economic interventions alone; there is a lack of meaningful inclusion of sex workers, young women and men in evaluations; and there are missed opportunities for measuring HIV risk and intimate partner violence.
Acknowledgments
Thanks are due to Charlotte Watts (LSHTM, DfID) for input on the original research and report on which this paper is based.
Disclosure statement
No potential conflict of interest was reported by the authors.
Additional information
Funding
Notes on contributors
Andrew Gibbs
AG, AKW and JJ conceptualised the study. AG conducted the study and wrote the first draft. AKW and JJ contributed sections, revised sections for intellectual content and edited the paper. All authors approved the paper for publication.
References
- WHO and UNAIDS. 16 ideas for addressing violence against women in the context of HIV epidemic: a programming tool. Geneva: WHO and UNAIDS; 2013.
- WHO. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: WHO; 2013.
- Jewkes R, Dunkle K, Nduna M, et al. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. Lancet. 2010;376:84–99.
- Kouyoumdjian FG, Calzavara LM, Bondy SJ, et al. Intimate partner violence is associated with incident HIV infection in women in Uganda. AIDS. 2013;27:1331–1338.
- Gibbs A, Mushinga M, Crone ET, et al. How do national strategic plans for HIV and AIDS in Southern and Eastern Africa address gender-based violence? A women’s rights perspective. Health Hum Rights. 2012;14:1–11.
- 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;15:17362.
- Jewkes R. HIV/AIDS. Gender inequities must be addressed in HIV prevention. Science. 2010;329:145–147.
- Campbell C, Gibbs A. Poverty, AIDS and gender. In: Chant S, editor. International handbook on poverty and gender. Cheltenam: Edward Elgar; 2010.
- Kim JC, Watts CH. Gaining a foothold: tackling poverty, gender inequality, and HIV in Africa. BMJ. 2005;331:769–772.
- Krishnan S, Dunbar MS, Minnis AM, et al. Poverty, gender inequities, and women’s risk of human immunodeficiency virus/AIDS. Ann N Y Acad Sci. 2008;1136:101–110.
- Connell R. Masculinities. 2nd ed. Cambridge (UK): Polity; 2005.
- Jewkes R, Sikweyiya Y, Morrell R, et al. Gender inequitable masculinity and sexual entitlement in rape perpetration South Africa: findings of a cross-sectional study. Plos One. 2011;6:e29590.
- Fleming PJ, McCleary-Sills J, Morton M, et al. Risk factors for men’s lifetime perpetration of physical violence against intimate partners: results from the international men and gender equality survey (IMAGES) in eight countries. Plos One. 2015;10:e0118639.
- Fulu E, Jewkes R, Roselli T, et al. UN multi-country cross sectional study on men and violence. Prevalence of and factors associated with male perpetration of intimate partner violence: findings from the UN multi-country cross-sectional study on men and violence in Asia and the Pacific. Lancet Global Health. 2013;1:e187–e207.
- Hargreaves JR, Davey C, Fearon E, et al. Trends in socioeconomic inequalities in HIV prevalence among young people in seven countries in Eastern and Southern Africa. Plos One. 2015;10:e0121775.
- Stockl H, March LM, Pallitto C, et al. Intimate partner violence among adolescents and young women: prevalence and associated factors in nine countries: a cross sectional study. BMC Public Health. 2014;14:751.
- Decker MR, Peitzmeier S, Olumide A, et al. Prevalence and health impact of intimate partner violence and non-partner sexual violence among female adolescents aged 15–19 years in vulnerable urban environments: a multi-country study. J Adolesc Health. 2014;55:S58–S67.
- Heise L, Kotsadam A. Cross-national and multilevel correlates of partner violence: an analysis of data from population-based surveys. Lancet Global Health. 2015;3:e332–e340.
- Jewkes R, Morrell R. Gender and sexuality: emerging perspectives from the heterosexual epidemic in South Africa and implications for HIV risk and prevention. J Int AIDS Soc. 2010;13:6.
- Gibbs A, Sikweyiya Y, Jewkes R. “Men value their dignity”: securing respect and identity construction in urban informal settlements in South Africa. Global Health Action. 2014;7:1–10.
- Silberschmidt M. Disempowerment of men in rural and urban East Africa: implications for male identity and sexual behavior. World Dev. 2001;29:657–671.
- Vyas S, Watts C. How does economic empowerment affect women’s risk of intimate partner violence in low- and middle-income countries? A systematic review of published evidence. J Int Dev. 2009;21:577–602.
- Pronyk PM, Hargreaves JR, Kim JC, et al. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial. Lancet. 2006;368:1973–1983.
- Dworkin SL, Blankenship K. Microfinance and HIV/AIDS prevention: assessing its promise and limitations. AIDS Behav. 2009;13:462–469.
- UNDP. Discussion paper: cash transfers and HIV prevention. New York (NY): UNDP; 2015.
- Heise L, Lutz B, Ranganathan M, et al. Cash transfers for HIV prevention: considering their potential. J Int AIDS Soc. 2013;16:18615.
- Pettifor AE, MacPhail C, Nguyen N, et al. Can money prevent the spread of HIV? A review of cash payments for HIV prevention. AIDS Behav. 2012;16:1729–1738.
- Schwartländer B, Stover J, Hallett TB, et al. Towards an improved investment approach for an effective response to HIV/AIDS. Lancet. 2010;377:2031–2041.
- UNAIDS and UNDP. Understanding and acting on critical enablers and development synergies for strategic investments. Geneva: UNDP; 2011.
- Cluver L, Boyes M, Orkin M, et al. Child-focused state cash transfers and adolescent risk of HIV infection in South Africa: a propensity-score-matched case-control study. Lancet Global Health. 2013;1:e362–e370.
- Cluver LD, Orkin FM, Boyes ME, et al. Cash plus care: social protection cumulatively mitigates HIV-risk behaviour among adolescents in South Africa. AIDS. 2014;28:S389–S397.
- Development SADoS and UNICEF. The South African child support grant impact assessment: evidence from a survey of children, adolescents and their households. Pretoria, South Africa: Department of Social Development; 2012.
- Handa S, Halpern CT, Pettifor A, et al. The Government of Kenya’s cash transfer program reduces the risk of sexual debut among young people age 15-25. Plos One. 2014;9:e85473.
- Rosenberg M, Pettifor A, Thirumurthy H, et al. The impact of a national poverty reduction program on the characteristics of sex partners among Kenyan adolescents. AIDS Behav. 2014;18:311–316.
- Hidrobo M, Fernald L. Cash transfers and domestic violence. J Health Econ. 2013;32:304–319.
- Hidrobo M, Hoddinott J, Peterman A, et al. Cash, food, or vouchers? Evidence from a randomized experiment in northern Ecuador. J Dev Econ. 2014;107:144–156.
- Bobonis GJ, González-Brenes M, Castro R. Public transfers and domestic violence: the roles of private information and spousal control. Am Econ J Econ Policy. 2013;5:179–205.
- Bobonis G, Castro R. The role of conditional cash transfers in reducing spousal abuse in Mexico: short-term vs. long-term effects. Toronto: University of Toronto, Toronto Processed; 2010.
- Haushofer J, Shapiro J. The short-term impact of unconditional cash transfers to the poor: experimental evidence from Kenya. Q J Econ. 131(4):1973–2042.
- de Walque D, Dow WH, Nathan R, et al. Incentivising safe sex: a randomised trial of conditional cash transfers for HIV and sexually transmitted infection prevention in rural Tanzania. BMJ Open. 2012;2:e000747.
- Kohler H-P, Thornton RL. Conditional cash transfers and HIV/AIDS prevention: unconditionally promising? World Bank Econ Rev. 2012;26:165–190.
- Minnis AM, van Dommelen-Gonzalez E, Luecke E, et al. Yo Puedo-a conditional cash transfer and life skills intervention to promote adolescent sexual health: results of a randomized feasibility study in San Francisco. J Adolesc Health. 2014;55:85–92.
- Ahmed SM. Intimate partner violence against women: experiences from a woman-focused development programme in Matlab, Bangladesh. J Health Popul Nutr. 2005;23:95–101.
- Bajracharya A, Amin S. Microcredit and domestic violence in Bangladesh: an exploration of selection bias influences. Demography. 2013;50:1819–1843.
- Chin Y-M. Credit program participation and decline in violence: does self-selection matter? World Dev. 2012;40:1690–1699.
- Dalal K, Dahlstrom O, Timpka T. Interactions between microfinance programmes and non-economic empowerment of women associated with intimate partner violence in Bangladesh: a cross-sectional study. BMJ Open. 2013;3:e002941.
- Murshid NS, Akincigil A, Zippay A. Microfinance participation and domestic violence in Bangladesh: results from a nationally representative survey. J Interpers Violence. 2016;31(9):1579–1596.
- Koenig MA, Ahmed S, Hossain MB, et al. Women’s status and domestic violence in rural Bangladesh: individual- and community-level effects. Demography. 2003;40:269–288.
- Naved RT, Persson LA. Factors associated with spousal physical violence against women in Bangladesh. Stud Fam Plann. 2005;36:289–300.
- Schuler S, Hashemi A, Riley K, et al. Credit programs, patriarchy and men’s violence against women in rural Bangladesh. Soc Sci Med. 1996;43:1729–1742.
- Hadi A. Prevalence and correlates of the risk of marital sexual violence in Bangladesh. J Interpers Violence. 2000;15:787–805.
- Bates LM, Schuler SR, Islam F, et al. Socioeconomic factors and processes associated with domestic violence in rural Bangladesh. Int Fam Plan Perspect. 2004;30:190–199.
- Kim J, Ferrari G, Abramsky T, et al. Assessing the incremental effects of combining economic and health interventions: the IMAGE study in South Africa. Bull World Health Organ. 2009;87:824–832.
- Pronyk PM, Hargreaves JR, Kim JC, et al. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial. Lancet. 2006;368:1973–1983.
- Gupta J, Falb KL, Lehmann H, et al. Gender norms and economic empowerment intervention to reduce intimate partner violence against women in rural Cote d’Ivoire: a randomized controlled pilot study. BMC Int Health Hum Rights. 2013;13:1–10.
- Spielberg F, Crookston BT, Chanani S, et al. Leveraging microfinance to impact HIV and financial behaviors among adolescents and their mothers in West Bengal: a cluster randomized trial. Int J Adolesc Med Health. 2013;25:157–166.
- IRC. Getting down to business: women’s economic and social empowerment in Burundi. New York (NY): International Rescue Committee; .
- Rosenberg MS, Seavey BK, Jules R, et al. The role of a microfinance program on HIV risk behavior among Haitian women. AIDS Behav. 2011;15:911–918.
- Dunbar MS, Maternowska MC, Kang M-SJ, 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.
- Bandiera O, Buehren N, Burgess R, et al. Empowering adolescent girls: evidence from a randomized control trial in Uganda. Washington, D.C.: World Bank; 2012.
- Erulkar A, Chong E. Evaluation of a savings & micro-credit program for vulnerable young women in Nairobi. New York (NY): Population Council; 2005.
- Souverein D, Euser SM, Ramaiah R, et al. Reduction in STIs in an empowerment intervention programme for female sex workers in Bangalore, India: the Pragati programme. Global Health Action. 2013;6:22943.
- Odek WO, Busza J, Morris CN, et al. Effects of micro-enterprise services on HIV risk behaviour among female sex workers in Kenya’s urban slums. AIDS Behav. 2009;13:449–461.
- Witte SS, Batsukh A, Chang M. Sexual risk behaviors, alcohol abuse, and intimate partner violence among sex workers in Mongolia: implications for HIV prevention intervention development. J Prev Interv Community. 2010;38:89–103.
- Austrian K, Muthengi E. Can economic assets increase girls’ risk of sexual harassment? Evaluation results from a social, health and economic asset-building intervention for vulnerable adolescent girls in Uganda. Child Youth Serv Rev. 2014;47:168–175.
- Austrian A, Muthengi M. Safe and smart savings products for vulnerable adolescent girls in Kenya and Uganda. New York (NY): Population Council; 2013.
- Dunbar MS, Dufour M-SK, Lambdin B, et al. The SHAZ! project: results from a pilot randomized trial of a structural intervention to prevent HIV among adolescent women in Zimbabwe. Plos One. 2014;9:e113621.
- Jewkes R, Gibbs A, Jama-Shai N, et al. Stepping stones and creating futures intervention: shortened interrupted time series evaluation of a behavioural and structural health promotion and violence prevention intervention for young people in informal settlements in Durban, South Africa. BMC Public Health. 2014;14:1325.
- Rotheram-Borus MJ, Lightfoot M, Kasirye R, et al. Vocational training with HIV prevention for Ugandan youth. AIDS Behav. 2012;16:1133–1137.
- Sherman SG, German D, Cheng Y, et al. The evaluation of the JEWEL project: an innovative economic enhancement and HIV prevention intervention study targeting drug using women involved in prostitution. AIDS Care. 2006;18:1–11.
- Sherman SG, Srikrishnan AK, Rivett KA, et al. Acceptability of a microenterprise intervention among female sex workers in Chennai, India. AIDS Behav. 2010;14:649–657.
- Lee H, Pollock G, Lubek I, et al. Creating new career pathways to reduce poverty, illiteracy and health risks, while transforming and empowering Cambodian women’s lives. J Health Psychol. 2010;15:982–992.
- Raj A, Dasgupta A, Goldson I, et al. Pilot evaluation of the Making Employment Needs [MEN] Count intervention: addressing behavioral and structural HIV risks in heterosexual Black men. AIDS Care. 2014;26:152–159.
- Hallman K, Roca E. Siyakha Nentsha: building economic, health, and social capabilities among highly vulnerable adolescents in KwaZulu-Natal, South Africa. New York, USA: Population Council. 2011.
- Hidrobo M, Peterman A, Heise L. The effect of cash, vouchers and food transfers on intimate partner violence: evidence from a randomized experiment in Northern Ecuador. Washington (DC): International Food Policy Research Institute; 2013.
- Shahnaz R, Karim R. Providing microfinance and social space to empower adolescent girls: an evaluation of BRAC’s ELA centers. Bangladesh: BRAC; 2008.
- Erulkar A, Bruce J, Dondo A, et al. Tap and Reposition Youth (TRY) providing social support savings and microcredit opportunities for young women in areas with high HIV prevalence. New York, USA: Population Council. 2006.
- Cluver L, Toska E, Orkin F, et al. Achieving equity in HIV-treatment outcomes: can social protection improve adolescent ART-adherence in South Africa? AIDS Care. 2016;28:73–82.
- Krishnan S, Rocca CH, Hubbard AE, et al. Do changes in spousal employment status lead to domestic violence? Insights from a prospective study in Bangalore, India. Soc Sci Med. 2010;70:136–143.
- Dworkin SL, Colvin C, Hatcher A, et al. Men’s perceptions of women’s rights and changing gender relations in South Africa lessons for working with men and boys in HIV and antiviolence programs. Gend Soc. 2012;26:97–120.
- Heise LL, Kotsadam A. Cross-national and multilevel correlates of partner violence: an analysis of data from population-based surveys. Lancet Global Health. 2015;3:e332–e340.
- Ellsberg M, Arango DJ, Morton M, et al. Prevention of violence against women and girls: what does the evidence say? Lancet. 2014;385(9977):1555–1566.
- Taylor G, Pereznieto P. Review of evaluation approaches and methods used by interventions on women and girls’ economic empowerment. London, UK: ODI; 2014.
- Baral S, Beyrer C, Muessig K, et al. Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Infect Dis. 2012;12:538–549.
- Beattie TS, Bhattacharjee P, Ramesh B, et al. Violence against female sex workers in Karnataka state, south India: impact on health, and reductions in violence following an intervention program. BMC Public Health. 2010;10:476.
- Global Network of Sex Work Projects. Economic empowerment: does rehabilitation have a role? Lessons learnt in Africa. Edinburgh, UK: Global Network of Sex Work Projects; 2015.
- Gibbs A, Jewkes R, Sikweyiya Y, et al. Reconstructing masculinity? A qualitative evaluation of the Stepping Stones and Creating Futures intervention in urban informal settlements in South Africa. Culture Health Sex. 2015;17: 208–222.
- Jewkes R, Flood M, Lang J. From work with men and boys to changes of social norms and reduction of inequities in gender relations: a conceptual shift in prevention of violence against women and girls. Lancet. 2015;385:1580–1589.
- Durevall D, Lindskog A. Intimate partner violence and HIV in ten sub-Saharan African countries: what do the demographic and health surveys tell us? Lancet Global Health. 2015;3:e34–e43.
- Dwan K, Altman DG, Arnaiz JA, et al. Systematic review of the empirical evidence of study publication bias and outcome reporting bias. Plos One. 2008;3:e3081.
Appendix A
The search string used for the review was as follows.
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