PROTOCOL: Peer-Based Interventions for reducing morbidity and mortality in HIV positive women: A systematic review protocol

The Problem

As of December 2002, 19.2 million women were living with HIV/ AIDS, nearly double the 1997 figure of 12.2 million infected women (UNAIDS 2002; UNAIDS 1998). The majority of infected women are of child-bearing age with the bulk of new infections occurring among adults under the age of 25 (UNAIDS 2001). It is increasingly recognized that gender inequality, in all its forms, it largely responsible for the rapid spread of HIV/AIDS throughout the world (UNIFEM 2001). The factors that increase women's vulnerability to HIV infection can be categorized into two main areas; physiological factors, and social, economic and political factors. In terms of sexual transmission of the virus, heterosexual women's increased physiological vulnerability to HIV is due to the sensitive nature of the mucosal lining of the vagina and cervix, its large surface area and the large concentrations of HIV virus present in infected male semen (as compared to female secretions). These factors combine to make unprotected heterosexual intercourse the leading source of HIV infection for women worldwide. Undiagnosed or asymptomatic sexually transmitted infections, which are common among women, also increase the chances of HIV infection. In addition to this physiological vulnerability, sociocultural factors interplay to create a reality that places women at increased risk. Gender inequity, economic vulnerability and cultural practices and norms that favor male sexuality and power create an environment where women have little choice and power to negotiate safer sexual practices. These factors intertwine in women's lives to not only increase their susceptibility to HIV infection but also to create barriers to effective care and support.

The aim of this systematic review is to assess the effectiveness of peer-based interventions to improve the health and well-being of women with HIV. A secondary objective is to assess whether peer-based interventions decrease health inequalities between advantaged and disadvantaged groups.

The Intervention

Interventions that involve contact with an individual or group of peers (paid or voluntary) offering support, education or counselling that is intended to influence one of the health related outcomes.

Types of Interventions:

One-on- one counselling and a peer group: is defined as a counselor/social worker giving one-on-one advice to the participant, and the participates involved in discussion groups with their following peers. Example, one-on-one counselling where psycho-educational content is the focus, one on one counselling might also address issues related to sexual abuse, ability to disclosure HIV status and drug use.

How the Intervention Might Work

Peer-based interventions have the potential to enhance health equity for women with HIV/AIDS by improving accessibility, acceptability and affordability of counselling and support (i.e. emotional, instrumental or informational) and may facilitate access to other treatment services. These interventions may help reduce feelings of isolation and stigma by providing social support (Sartore 2013). Moreover, in areas of the world where HIV is delaying progress towards gender equity, these types of interventions may be essential in imparting skills of self-efficacy and confidence among women and encouraging community advocacy and mobilization around issues of HIV/AIDS. See our logic model (Figure 1).

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Logic model for peer-based interventions for HIV-positive women

Why it is Important to do the Review

HIV positive women have distinct need for support, education and counselling. Peer to peer interactions are one way to deliver a support framework. Women are often the central caregivers in the family and cope with unique stressors and responsibilities. They have lower economic status and fewer resources. These factors create barriers to treatment, care and support. The rise in HIV infections in women necessitates urgent investigation into their psychological and social support needs and the interventions that are designed to address them.

The contribution of this review

To the best of our knowledge, this is the first systematic review to assess how peer-based interventions reduce the morbidity and mortality in HIV-positive women. Previous reviews exist that examine the efficacy of various interventions for ‘at-risk’ women but no systematic reviews were located that examine this question for women already infected with HIV. The results of this review will inform researchers and policy makers if peer-based interventions are effective in reducing the health outcomes mentioned in this review. This review will help policy makers make decisions with the best possible evidence.

Characteristics of studies relevant to the objectives of the review

Criteria for inclusion and exclusion of studies in the review

Interventions

Interventions that involve contact with an individual or group of peers (paid or voluntary) offering support, education or counselling that is intended to influence one of the outcomes listed below. Interventions led or facilitated by a professional (or non-peer) will be included providing the focus of the intervention is to provide peer-to-peer interaction and it can be determined that the professional maintains a secondary role. Information on the characteristics or roles of the intervention facilitators will be taken from the study publication if available or if necessary contact with the study authors will be made to clarify this information. For the purposes of this review a peer will be defined as: an individual who shares common characteristics with the ‘targeted’ group or individual allowing her to relate to, and empathize with, that individual on a level that a non-peer would not be able to do. Common characteristics required would vary in different contexts but should include: age, gender, sexual orientation, socioeconomic status, religion, ethnicity, place of residence, culture, education and value system. For the purposes of this review individuals do not have to be HIV positive in order to meet the definition of peer presented here. It is felt that in many cases women may share a multitude of risk factors and personal histories that will allow them to effectively relate to one another and be considered as ‘peers’ without having to share infection status. However, we will perform a sub-group analysis for those studies that used HIV-positive versus HIV-negative peer leaders.

Participants

Studies targeting HIV positive women in any setting (i.e. clinic, home, community, church) are eligible for inclusion. Studies targeting women ‘at-risk’ of HIV infection, but who are not currently infected, will be excluded. In order to address the second objective of this review we will aim to identify studies that include women from various demographic groups.

Outcomes

Studies reporting at least one of the following outcomes were included:

Physical health outcomes: vertical HIV transmission (from mother to child), t-cell count, opportunistic infections, mortality, morbidity, progression to AIDS, pain.

To assess effects of peer-based interventions on health inequalities, the effects of peer-based interventions across PROGRESS will be examined, if these are reported by the study authors. PROGRESS is an acronym used to identify characteristics which may contribute to disadvantage, including: Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, and Social capital/resources (Evans 2003, O'Neill 2014).

Research methods/designs

We will include randomised controlled trials (RCTs), controlled before-after CBA (studies), and interrupted time series (ITS) studies. Those studies that do not include a control or comparison group will be excluded. Studies that include a control group that are qualitative in nature will also be included (see data analysis section for more detail).

Search strategy for finding eligible studies

The following search strategy will be used to search the following databases: MEDLINE, CINAHL, PSYCINFO, EMBASE, CENTRAL, AMED, Sociological Abstracts. Minor terminology changes will be made to suit the various databases.

Search Strategy:

exp hiv infections/

Data extraction and study coding procedures

Data will be extracted independently in duplicate. The data abstraction forms will be based on the EPOC data collection forms, and modified to fit this review. Data will be extracted on: study design, description of the intervention, context of intervention (i.e. health facility, church-based, community, non-governmental organization, etc.), details about group leader (i.e. demographics, training, serostatus, professional etc.), details about participants (including number in each group, baseline health information), length of intervention and follow-up, definition of peer used, health outcomes, PROGRESS characteristics and data analysis. Consensus will be reached by discussion, when necessary. We will carefully describe the interventions given to both ‘experimental’ and ‘control‘ groups.

Risk of bias

The EPOC quality checklists for randomized controlled trials (RCTs), interrupted time series(ITS), controlled clinical trials (CCT), and controlled before-after studies (CBAs) will be used (EPOC 2002). These checklists account for study design, randomization method, appropriate selection of outcomes and statistical methods, confounding factors, method of data collection, and characteristics of control groups.

Synthesis procedures and statistical analysis

Treatment effects will be calculated for randomized controlled trials (RCTs) and controlled before-after studies (CBAs) separately. For continuous outcomes, where baseline data is available from randomized controlled trials (RCTs) and controlled before-after studies (CBAs), pre-intervention and post-intervention means or proportions will be reported for both study and control groups and the absolute change from baseline will be calculated (mean difference (MD) change in study group values minus change in control group values), along with 95 per cent confidence intervals. When baseline data is not available, results will be expressed as the relative percentage change (a difference between post-intervention values in the study and control groups expressed as a percentage of post-intervention values in the control group). For dichotomous outcomes, the relative risk (RR) of the outcome compared to the control group will be calculated.

When possible, studies with cluster allocation (e.g., cluster-randomized trials, cluster-allocated controlled before and after studies, and interrupted time series) that have errors in the unit of analysis will be adjusted using the variance inflation factor, as described in the Cochrane Handbook, if the required data can be obtained from the study authors. If not available, we will obtain ICC from other similar studies with similar outcomes if the ICC is not published.

Subgroup analysis and investigation of heterogeneity

We plan to assess effects of peer-based interventions on health inequities by conducting subgroup analyses across PROGRESS categories. PROGRESS identifies eight categories across which differences in health might be considered health inequities: Place of residence (e.g. low- and middle-income country/high-income country), Religion, Occupation, Gender, Race/ethnicity/culture, Education, Socioeconomic status and Social capital/resources (Evans 2003, O'Neill 2014).

Heterogeneity will be assessed by statistical tests for heterogeneity (I² and chi-squared) as well as visual inspection of the forest plots.

Sensitivity analysis

If possible, we will investigate whether characteristics of the intervention or population mediate the effect using process evaluation and sensitivity analysis.