The SHAZ! Project: Results from a Pilot Randomized Trial of a Structural Intervention to Prevent HIV among Adolescent Women in Zimbabwe

Abstract

Adolescent females in Zimbabwe are at high risk for HIV acquisition. Shaping the Health of Adolescents in Zimbabwe (SHAZ!) was a randomized controlled trial of a combined intervention package including life-skills and health education, vocational training, micro-grants and social supports compared to life-skills and health education alone. SHAZ! was originally envisioned as a larger effectiveness trial, however, the intervention was scaled back due to contextual and economic conditions in the country at the time. SHAZ! enrolled 315 participants randomly assigned to study arm within blocks of 50 participants (158 intervention and 157 control). The intervention arm participants showed statistically significant differences from the control arm participants for several outcomes during the two years of follow up including; reduced food insecurity [IOR = 0.83 vs. COR = 0.68, p-0.02], and having their own income [IOR = 2.05 vs. COR = 1.67, p = 0.02]. Additionally, within the Intervention arm there was a lower risk of transactional sex [IOR = 0.64, 95% CI (0.50, 0.83)], and a higher likelihood of using a condom with their current partner [IOR = 1.79, 95% CI (1.23, 2.62)] over time compared to baseline. There was also evidence of fewer unintended pregnancies among intervention participants [HR = 0.61, 95% CI (0.37, 1.01)], although this relationship achieved only marginal statistical significance. Several important challenges in this study included the coordination with vocational training programs, the political and economic instability of the area at the time of the study, and the difficulty in creating a true standard of care control arm. Overall the results of the SHAZ! study suggest important potential for HIV prevention intervention packages that include vocational training and micro-grants, and lessons for further economic livelihoods interventions with adolescent females. Further work is needed to refine the intervention model, and test the impact of the intervention at scale on biological outcomes.Trial RegistrationClinicalTrials.gov NCT02034214

A global comprehensive review of economic interventions to prevent intimate partner violence and HIV risk behaviours

“…age: 41.09227 women; 2-year follow-up; pre-test, post-test; no randomisation* Reduction in number of sexual partners in past week ( p  < 0.001)* Reduction in number of casual partners ( p  = 0.098)* Reduction in number of regular partners ( p  < 0.001)* No impact on condom use with casual partners ( p  = 0.727)* Increase in condom use with regular partners ( p  = 0.031) Witte et al [64]34-session HIV sexual risk reduction intervention; microfinance; vocational trainingMongoliaFemale sex workers; av. age 36107 women randomised into intervention or control; clusters 3- and 6-month follow-up* Reduction in number of paying sexual partners ( p  < 0.001)* 3.72 times more likely to report no unprotected vaginal sex acts at 6 months ( p  < 0.05)  Savings and gender transformative Austrian and Muthengi [65]Safe spaces; reproductive health training; financial education; savings accountsUgandaGirls 10–23; majority under 191159 of which 451 received full intervention; 300 savings only; 311 control; 12-month follow-up; delivery error led to natural randomisation * No impact on indecent touching in full intervention, but in economic-only arm significant increase ( p  < 0.01)Austrian and Muthengi [66]Safe spaces; reproductive health training; financial education; savings accountsKenya; UgandaGirls 10–191473 in Kenya; 1564 in Uganda; 18-month follow-up; comparison groups * In Kenya no impact on indecently touched in past 6 months* Significant decrease in being indecently touched in past 6 months in Uganda Vocational strengthening and gender transformative interventions  Dunbar et al [67]SHAZ! reproductive health services; life skills-based HIV education; vocational training and microgrants; integrated social supportZimbabweAdolescent female orphans (having lostat least one parent) aged 16 to 19315 randomly assigned to intervention or control; 24-month follow-up* No difference in sexual debut*Reduction in transactional sex (Intervention Odds Ratio [I.O.R] = 0.64; 95% C.I 0.50–0.83)* Increased likelihood of using condom (I.O.R = 1.79; 95% C.I 1.23–2.62)* Reduction in violence (I.O.R = 0.10 vs Control Odds Ratio [C.O.R] = 0.63; p  = 0.06)Jewkes et al [68]Stepping St...…”

“…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 [67]. All others were quasi-experimental, although some did include elements of randomisation.…”

“…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 [67,68,73]. …”

“…For instance, in the JEWEL intervention, Sherman et al [70] provided jewellery-making training; SHAZ! provided options including hairdressing, garment making and receptionist training, alongside broader business skills [67]; while in the MEN Count intervention [73] employment counselling was provided. In contrast, in Stepping Stones and Creating Futures [68] there was no specific skills training, but rather the intervention focused on promoting critical thinking and reflection around livelihoods and job opportunities.…”

“…In contrast, in Stepping Stones and Creating Futures [68] 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 [10–24] and typically both women and men were included [67–69,74]. …”