HIV‐sensitive social protection for vulnerable young women in ...

van derWal et al. Journal of the International AIDS Society 2021, 24:e25787http://onlinelibrary.wiley.com/doi/10.1002/jia2.25787/full | https://doi.org/10.1002/jia2.25787

REVIEW

HIV-sensitive social protection for vulnerable young womenin East and Southern Africa: a systematic reviewRan van der Wal1,§ , David Loutfi1, Quan Nha Hong2, Isabelle Vedel1, Anne Cockcroft1,3, Mira Johri4,5

and Neil Andersson1,6

§Corresponding author.Ran van der Wal, 5858 chemin de la Côte-des-Neiges, Montreal, H3S 1Z1, QC, Canada.E-mail: [email protected] Number: CRD42020161586

AbstractIntroduction: Social protection programmes are considered HIV-sensitive when addressing risk, vulnerability or impact of HIVinfection. Socio-economic interventions, like livelihood and employability programmes, address HIV vulnerabilities like povertyand gender inequality. We explored the HIV-sensitivity of socio-economic interventions for unemployed and out-of-schoolyoung women aged 15 to 30 years, in East and Southern Africa, a key population for HIV infection.Methods: We conducted a systematic review using a narrative synthesis method and the Mixed Methods Appraisal Toolfor quality appraisal. Interventions of interest were work skills training, microfinance, and employment support. Outcomesof interest were socio-economic outcomes (income, assets, savings, skills, (self-) employment) and HIV-related outcomes(behavioural and biological). We searched published and grey literature (January 2005 to November 2019; English/French)in MEDLINE, Scopus, Web of Science and websites of relevant international organizations.Results: We screened 3870 titles and abstracts and 188 full-text papers to retain 18 papers, representing 12 projects.Projects offered different combinations of HIV-sensitive social protection programmes, complemented with mentors, safespace and training (HIV, reproductive health and gender training). All 12 projects offered work skills training to improve lifeand business skills. Six offered formal (n = 2) or informal (n = 5) livelihood training. Eleven projects offered microfinance,including microgrants (n = 7), microcredit (n = 6) and savings (n = 4). One project offered employment support in the form ofapprenticeships. In general, microgrants, savings, business and life skills contributed improved socio-economic and HIV-relatedoutcomes. Most livelihood training contributed positive socio-economic outcomes, but only two projects showed improvedHIV-related outcomes. Microcredit contributed little to either outcome. Programmes were effective when (i) sensitive to ben-eficiaries’ age, needs, interests and economic vulnerability; (ii) adapted to local implementation contexts; and (iii) included lifeskills. Programme delivery through mentorship and safe space increased social capital and may be critical to improve the HIV-sensitivity of socio-economic programmes.Conclusions: A wide variety of livelihood and employability programmes were leveraged to achieve improved socio-economicand HIV-related outcomes among unemployed and out-of-school young women. To be HIV-sensitive, programmes should bedesigned around their interests, needs and vulnerability, adapted to local implementation contexts, and include life skills.Employment support received little attention in this literature.

Keywords: adolescent girls and young women; Africa region; HIV prevention; social support; structural drivers; structuralinterventions

Additional information may be found under the Supporting Information tab of this article.

Received 20 October 2020; Accepted 26 July 2021Copyright © 2021 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,provided the original work is properly cited.

Abbreviations: AGYW, adolescent girls and young women; ELA, Empow-erment and Livelihood for Adolescents; HIV, human immunodeficiency virus;HSV-2, herpes simplex virus-2; IGA, income-generating activity; IMAGE, Inter-vention with Microfinance for AIDS and Gender Equity; IPV, intimate part-

ner violence; SCIP, Strengthening Communities through Integrated Program-ming; SHAZ!, Shaping the Health of Adolescents in Zimbabwe; SS&CF, Step-ping Stones and Creating Futures; TRY, Tap and Reposition Youth; WINGS,Women’s Income Generating Support; ZOE, ZOE Orphan Empowerment

1

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1 INTRODUCT ION

In 2018, East and Southern Africa represented nearly one halfof global human immunodeficiency virus (HIV) incident cases[1]. Adolescent girls and young women (AGYW) aged 15 to25 years accounted for 26%, despite making up 10% of thepopulation [1]. With 6000 new infections per week, their HIVrisk is 60% higher than for same-aged males [1].

Vulnerable young women—defined as unemployed and out-of-school, aged 15 to 30 years—are at especially high risk ofHIV infection [2,3]. They may know about this risk [4] butstructural drivers of HIV vulnerability like poverty and gen-der inequality can reduce their ability to act on HIV preven-tion choices [5]. Absolute poverty is linked with unprotectedand transactional sex [6], and unemployment predicts youngwomen’s disproportionate HIV burden [2]. Economic vulnera-bility constrains their ability to negotiate safe sex and makesit harder to leave abusive relationships [7]. Gender inequalityat individual level can translate into women’s low relationshippower; at societal level, harmful hegemonic masculine normscan result in sexual risk taking and violence against women[8]. Out-of-school girls do not benefit from the protectionimplicit in educational attainment [9,10] or even the lower riskassociated with school attendance [11]. HIV infection amongfemale school dropouts is triple that of schoolgirls [3].

In 2005, UNAIDS advanced consensus on combining pro-grammes reducing HIV risk, vulnerability and impact, for-malized as ‘combination HIV prevention’ in 2009 [12,13].Socio-economic interventions addressing HIV vulnerabilitieslike poverty and gender inequality have since been fullyendorsed as part of combination HIV prevention [13,14].Socio-economic interventions could improve young women’spower to negotiate contraception and pregnancy, delay sexualdebut [15], reduce fertility [16], hence influence lifetime earn-ings and HIV risk. In the context of social protection, socio-economic interventions aim to enhance income and employ-ability through livelihood and skills development programmes[17]. Such programmes are considered HIV-sensitive whenthey also help reduce HIV risk and vulnerability, or mitigatesocial and economic impacts of the infection [18].

The United Nations Fast-Track Strategy recommends lever-aging HIV-sensitive social protection to end AIDS by 2030[19]. Commitment 6 prescribes that 75% of people at riskof, living with, or affected by, HIV benefit from HIV-sensitivesocial protection by 2020; Commitment 3 recognizes youngwomen in high-prevalence countries as key beneficiaries;Commitment 5 states 90% of youth should have the skills,knowledge and capacity to protect themselves from HIV inorder to reduce new infections among young women [20].Beyond income transfers that aim to prevent extreme poverty,like welfare or child grants, the 2018 UNAIDS Guidance Notealso encourages using socio-economic approaches to addressstructural drivers of HIV vulnerability [21].

Existing systematic reviews on HIV prevention have sum-marized combined structural interventions [22,23], incomegenerating [24], microenterprise [25], microcredit [23], andhousehold economic strengthening interventions [26]. Nopublished systematic review has examined HIV-sensitive socialprotection interventions for unemployed and out-of-schoolyoung women, and how they were leveraged for HIV

prevention. Most existing reviews included men and womenof all ages [22–24,26]. Some focused on female sex workers[25,26] or included quantitative studies only [22–24]. Addi-tionally, despite their premise that socio-economic empower-ment could reduce HIV risk, none assessed socio-economicoutcomes when reporting HIV outcomes.

In the context of HIV prevention, we reviewed publishedand grey literature on HIV-sensitive social protection inter-ventions that aim to enhance livelihood and employabilityamong vulnerable young women in East and Southern Africa.We aimed to collate their documented effects on socio-economic and HIV-related outcomes and how programmesachieved them.

2 METHODS

We conducted a systematic review using the narrative synthe-sis method by Popay et al. (2006), which supports synthesis ofcomplex interventions with considerable heterogeneity [27].The method relies on text to synthesize findings from stud-ies using different methods. It involves four steps: (i) develop-ing a theory of change or conceptual framework; (ii) a prelimi-nary synthesis; (iii) exploring of relationships within and acrossstudies; (iv) assessing the robustness of the synthesis [27].

2.1 Conceptual framework for HIV-sensitivesocial protection

Our theory of change is as follows: socio-economic and gen-der inequality increase HIV risk among vulnerable youngwomen, defined as unemployed and out-of-school, aged 15to 30 years, in East and Southern Africa. ‘Cash’ social pro-tection reduced sexual risk behaviours among adolescents inSouth Africa [28]. HIV-sensitive social protection interven-tions that improve livelihood and employability could enhanceincome and capabilities and similarly enable young women toact on HIV prevention choices. This could reduce sexual riskbehaviours and intimate partner violence (IPV) [29], which inturn may reduce incidence of HIV infection.

Interventions of interest are work skills training, microfi-nance, and employment support. Work skills training includelife skills and professional skills training, like business or liveli-hood training. Livelihood training can be formal (vocational)or informal (income-generating activity, IGA). Microfinanceincludes microcredit, savings and microgrants in the form oftransfers in cash, in-kind or productive assets. Employmentsupport can be offered in the form of income transfers forpublic works, work-integrated learning like apprenticeships, orjob matching services like job placement or career counsellingsupport. Box 1 provides detailed definitions.

We consider these interventions HIV-sensitive when theyaddress both socio-economic and HIV-related outcomes.Socio-economic outcomes include (self-) employment, income,assets, savings and skills (professional and life skills). HIV-related outcomes are behavioural (sexual risk behaviour andIPV) and biological: HIV infection, measured as HIV incidenceor prevalence, or sexually transmitted infections (Figure 1).

2




Box 1: Definitions of HIV-sensitive social protection components

HIV-sensitive social protection

components Definitions

Work skills training

Business training Entrepreneurial training with goal setting, budgeting, cash flow management, development of

business and marketing plans.

Financial literacy Ranges from basic numeracy to budgeting and accounting. Financial literacy is a combination

of awareness, knowledge, skill, attitude and behaviour necessary to make sound financial

decisions and ultimately achieve individual financial wellbeing.

Life skills Set of (non)cognitive skills and abilities that connect knowledge, attitudes and behaviour.

Skills that increase self- and social awareness; management of self- and relationships;

stress, coping, communication, negotiation, conflict resolution and self-efficacy. Higher order

life skills include problem solving, responsible decision-making and critical thinking.

Income-generating activity (IGA) training Informal professional skills training for low-skill self-employment.

Vocational training Formal professional skills training at nationally accredited institutions for wage employment.

Microfinance

Microfinance (MFI) Financial services for the poor who are unable to access formal banking services. It

encompasses a range of services including microgrants, microcredit and savings.

Microcredit Small business loans given to credit groups who use social pressure for loan repayment.

Group collateral often consists of mandatory savings. Upon repayment, groups can request

larger loans. These small business loans are characterized by short repayment periods and

high interest rates.

MFI in-kind Material contributions to provide investment capital like kits with products to sell, waiving of

training fees or subsidies of materials to support training and IGA.

MFI savings Services or support that encourage saving to absorb economic shocks or invest in future

expenditure: adolescent-friendly savings accounts; providing a safe place to save; informal

revolving group saving schemes.

Productive asset transfers Transfer of material as investment capital to generate sustainable income. Examples are tools,

sewing machines, or agricultural inputs like seed, fertilizer or livestock.

Employment support

Job matching Services that link individuals with public or private sector employment opportunities, career

counselling, job searching and placement support, including support for producing and

sharing of curriculum vitae.

Public works Infrastructure and development projects to transfer income to the poor through (temporary)

low-skill employment. Wages are kept low to target the poorest through self-selection.

Work-integrated learning Occupational opportunities to apply professional training in the real world through

observation (internships) or mentoring (apprenticeships).

Social support

Mentorship Provision of (health) information and (psychosocial) support, training and coaching by often

slightly older female mentors who model positive behaviour.

Safe space (social and physical) Social safe space: regular group meetings that serve as venues for training, information

dissemination, critical dialogue, but also for sharing of personal experiences and peer and

mentor support. Physical safe space: girls-only or girl-friendly clubs where girls benefit

from social safe space (meetings) or merely hangout with peers; often with social activities.

3




Figure 1. Conceptual framework HIV-sensitive social protection. The rounded rectangles are intervention components. The arrows rep-resent causal effect. The squares are intended outcomes with more distal outcomes darker.

2.2 Search strategy

A specialized librarian supported the search strategy based onpopulation, interventions and outcomes of interest describedin the theory of change. Studies reporting both socio-economic and HIV-related outcomes were included. We usedtext words and indexing terms to identify published studiesin three health and social science databases (MEDLINE, Sco-pus, and Web of Science Core Collection) and grey litera-ture from websites of the World Bank, International LabourOrganization, Centre for Social Protection (IDS), UNAIDS andsocialprotection.org. We conducted the search on 28 Octo-ber 2019 with start date January 2005, when socio-economicinterventions were acknowledged as part of combination HIVprevention [13]. The search was limited by language (Englishand French) and place (countries in East and Southern Africawith an adult HIV prevalence higher than 2.5%). Study designsincluded qualitative, quantitative and mixed methods. Wechecked references of included papers with backward and for-ward citation tracking. See Box 2 for inclusion and exclusioncriteria and Additional file 1 for the search string.

2.3 Study selection

We removed duplicates with EndNote and screened recordsin Rayyan QCRI. A two-stage process involved screeningof titles and abstracts, followed by full-text screening. Forreview efficiency, we double-screened a random sample ofrecords until reaching a good interrater agreement [30,31].Two reviewers (RW and DL) independently screened a ran-dom sample of 10% of titles and abstracts. They resolved

disagreements through discussion, which helped clarify selec-tion criteria. As the interrater agreement was good (k = 0.85),the first author (RW) screened remaining records [32]. Wefollowed the same process for full-text screening. During titleand abstract screening, we excluded six protocols pertainingto our review topic. In April 2020, we performed forwardcitation tracking of these protocols, identified associated pub-lished papers, and screened them against eligibility criteria.Two reviewers (RW and DL) reviewed all selected papers toconfirm the final sample of included studies.

2.4 Data extraction, appraisal and synthesis

Following a convergent data-based synthesis design, we pro-cessed included papers with the same synthesis method [33].One reviewer (RW) extracted data from included papers intwo stages. For step 2 of the narrative synthesis (the pre-liminary synthesis), data extraction followed the population,intervention, context, outcome, study design (PICOS) frame-work, reported by paper [34]. Several papers reported resultsfor the same project at different stages (pilot and trial) orfor different aspects (qualitative and quantitative results).Hence, the second data-extraction stage involved extractionof detailed implementation data per project (Additional file2) and programme delivery data (mentorship and safe space)(Additional file 3).

For synthesis step 3, the exploration within and acrossstudies [27,35], we shifted our focus from projects to inter-vention components for which we developed two additionaltables: (i) the Synthesis Table shows intervention compo-nents clustered under work skills training, microfinance and

4




Box 2: Inclusion and exclusion criteria

Inclusion criteria (PICOS) Exclusion criteria

∙ Population: young women aged 15 to 30 years,

unemployed and out-of-school (baseline dropouts)

∙ Intervention of interest: HIV-sensitive social protection

interventions, like work skills training, microfinance,

employment support

∙ Context: East and Southern African countries with HIV

prevalence >2.5% based on UNAIDS Africa - East and

Southern: Botswana, Eswatini, Kenya, Lesotho, Malawi,

Mozambique, Namibia, South Africa, Uganda, Tanzania,

Zambia and Zimbabwe

∙ Outcomes of interest: socio-economic outcomes include

wage and (self-)employment, income, earnings, assets,

savings, consumption, and capabilities like business,

financial or life skills. HIV-related outcomes include

behavioural outcomes like sexual behaviour and

intimate partner violence, and biological outcomes:

prevalence and incidence of HIV or sexually

transmitted illnesses

∙ Study design: quantitative, qualitative, and mixed

methods research papers

∙ Published in English or French

∙ Published from January 2005 to 28 October 2019

∙ Adolescents with mean age lower than 15 years

∙ Young women with mean age older than 29 years

∙ Female sex workers

∙ Studies reporting data not stratified by gender and age

∙ Studies that do not report on both socio-economic and HIV-related

outcomes

∙ Preventive or protective social protection like unconditional cash

transfers or emergency relief

∙ Interventions focused on return to regular education rather than

training in support of livelihood and employability

∙ Studies reporting the effect of HIV-sensitive social protection

interventions outside the context of HIV prevention, like testing,

linkage to care, adherence to treatment, viral suppression

∙ Editorials

∙ Commentaries

∙ Reviews

∙ Conference abstracts and proceedings

∙ Protocols

employment support. We report socio-economic and HIV-related outcomes and give brief comments on the implemen-tation; (ii) the Summary Table lists all intervention componentsper project, including supporting intervention components, toshow projects offered different intervention combinations.

To assess the robustness of included studies (synthesisstep 4), two reviewers (RW and DL) independently appraisedincluded papers with the Mixed Methods Appraisal Tool [36].We rated papers as high, moderate or low quality and con-tacted authors when missing information. No papers wereexcluded but ratings were taken into account during the inter-pretation of findings.

3 RESULTS

3.1 Study selection

The PRISMA flow diagram presents results of the searchand selection process (Figure 2) [34]. After removal of dupli-cate records, we reviewed 3870 titles and abstracts, exclud-ing 3682 in accordance with eligibility criteria (Box 2). Full-text screening of 188 papers identified 16 papers. Forward

citation tracking of relevant protocols identified two additionalpapers. The resulting 18 papers represented 12 projects.Additional file 4 presents excluded full-text papers with rea-sons for exclusion.

3.2 Study characteristics

Table 1 shows descriptive characteristics of the 18 includedpapers. Five papers used qualitative methods, two usedmixed methods, six were cluster-randomized controlled tri-als (CRCT), one was a randomized controlled trial (RCT) andfour were observational, of which one was analytical cross-sectional; one a clustered non-equivalent two-stage cohorttrial; one a longitudinal pre–post intervention with matchedcontrols, and one a shortened interrupted time series. The 18papers represented 12 different projects that included 22,288participants from eight countries in East and Southern Africa.All had been implemented by nongovernmental organizations.The average intervention duration was 2.8 years, ranging from18 months to five years. Four projects focused solely on ado-lescent girls (13 to 19 years) [37–44]; three on young women18 years and above [45–48]; and five on both AGYW [49–54].

5




Table

1.Descriptive

characteristicsofHIV-sen

sitive

social

protectionstudies

Author

Studydesign

Population

Interven

tion

Country/year

Outcomes

Score

Austrian

2015

Qua

litative

Interviewsan

d

focusgroups

Youngwomen

18–25years

n=

128

Asset

study

Comparisonofthreegroups

ofyoung

women

:

Binticompreh

ensive

youth

developm

ent

program

me:

sexual

andreproductive

health(SRH),HIV,finan

cial

education,

lead

ership

andcommunicationsskills;

cash

stipen

ds

Vocational

training

Incomegenerationactivities

(IGA)

withouttraining

Ken

ya

Feb–May

2010

Economic

needwas

keybarrier

to

tran

slatehealthkn

owledge

into

positive

beh

aviour.Most

positive

outcomes

were

inBintigroup(unw

antedsex,

pregnan

cy

anded

ucation).So

cial

assets

facilitated

findingem

ploymen

tan

dmitigating

pressure

lead

ingto

riskysex.

Human

assets

helpe

dto

avoid

healthrisksan

d

supp

orted

IGA.Economic

assets

increasednegotiationpo

wer.Assets

interacted

andreinforced

each

other

High

Austrian

2020

Cluster

randomized

controlledtrial

(CRCT)

Unmarried

,

out-of-school

adolescen

tgirlsan

d

youngwomen

(AGYW)

n=

4661

(3515:1146)

15–23years

AGEP

(1)Core

compo

nen

t:weeklygroup

meetings

(safespaces)withfemale

men

torto

receivetrainingonSR

H,

HIV,lifeskills,finan

cial

education

(2)Healthvouchersto

access

free

SRH

andgeneral

wellnessservices

(3)Adolescen

t-friendly

savings

accounts:

low

fees/ope

ningbalan

ce

Zam

bia

2013–2015

2years+

2

yearsafter

program

me

end

(4years)

Sustained

chan

geonSR

Hkn

owledge,

self-efficacyan

dsavings,butinterven

tion

did

notlead

toacombined

setofsocial,

healthan

deconomic

assets.It

did

reduce

tran

sactional

sex.

Short-term

chan

gesdid

notlead

tolong-term

impactsoned

ucationorfertility

High

Ban

diera

2015

CRCT

In/out-of-school

adolescen

tgirls

14–20years

Mean(M

n)age16

n=

4800

ELA

-Uganda

(1)Vocational

training:

2-yeartraining

period:general

businessskills,finan

cial

literacy,trainingforIG

A

(2)Life

skillsforSR

H/H

IVkn

owledge

(men

struation,pregnan

cy,ST

I,HIV,

family

plan

ning)

andgender

issues

(brideprice,

child

marriage,

gender-based

violence—GBV)

(3)Physicalsafe

spaceforgirls

Uganda

2008–2010

2years

Girls

ininterven

tionareasweretw

iceas

likelyen

gagedin

IGA(self-em

ploymen

t).

Theirearnings

andmonthly

consumption

expe

nditure

increased.They

repo

rted

higher

levels

ofen

trep

reneu

rial

skills.

Fewer

girlsworriedab

outfuture

jobs.

Interven

tionreducedteen

agepregnan

cy,

marriage,

sexagainst

theirwill

and

increasedcondom

use

Moderate

Ban

diera

2018

CRCT

In/out-of-school

adolescen

tgirls

14–20years

Mnage16

n=

5966(3964:2002)

ELA

-Uganda

Seeunder

Ban

diera

2015

Only

physical

safe

spacecontinued

duringthe2yearsoffollow-up.

Girls

continued

usingclubsas

safe

space

withoutreceivingfurther

training

Uganda

2008–2012

4years

Sustained

increasesforself-rep

orted

entrep

reneu

rial

skillsan

dIG

A;notfor

monthly

expe

nditure.Controlover

body:

sign

ifican

tincrease

inSR

Han

dHIV

knowledge.Tren

dscontinued

fordelayed

pregnan

cy/m

arriagean

dreduced

unw

antedsex.

Increasedcondom

use

was

notsustained

Moderate

(Contin

ued)

6




Table

1.Continued

Author

Studydesign

Population

Interven

tion

Country/year

Outcomes

Score

Bueh

ren

2017

CRCT

In/out-of-school

adolescen

tgirls

13–19years

n=

5454

(3197follow-up)

ELA

-Tanzania

(1)Vocational

training:

IGAin

local

context

(2)Life

skillsforSR

H/H

IVkn

owledge

(fam

ilyplan

ning,

men

struation,

pregnan

cy,ST

I,HIV)

(3)Physicalsafe

spaceforgirls

(4)Communityen

gagemen

t(sen

sitization

ofparents

andvillage

eldersonissues

regardingad

olescen

tgirls)

(5)Microfinan

ce(M

FI):offered

toolder

adolescen

tsto

engage

inIG

A;finan

cial

literacyan

dindividual

businesssupp

ort

(planningan

dman

agem

ent)

Tanzania

2009–2011

2years

Rep

licationtrialofELA

-UgandawithMFI

added

toclubactivities.Despite

low

MFIuptake,

MFIincreasedclub

participation,havingsavings

and

participationin

inform

alsavinggroups.

Therewerenoother

sign

ifican

teffects

onoutcomes

ofinterest,likelydueto

lack

ofim

plem

entationfidelity.

Unpu

blished

qualitativeprocess

evaluationrevealed

resources

constraints,inad

equatemen

tortraining

anddonated

safe

spaces

werenot

alwaysaccessible

orsafe.Tanzaniangirls

had

differentpriorities

(preferred

educational

supp

ort

rather

than

IGA)

Low

Burke

2019A

Quasi-expe

rimen

tal

(clustered

non-equivalen

t

two-stage

cohort

trial)

Adolescen

tgirls

13–19years

Mnage15.5

n=

885

Interviews:

n=

266

SCIP

(1)Businessed

ucationan

dbusinesskits

ofincreasingvalue.

Girls

had

tosell

andrepaykits.Graduationafterthird

kit;then

eligible

toreceiveabicycle.

Somehad

access

togroupsaving

optionsan

dlinkedbusinesscapital

(2)Facilitator-leded

ucationsessionson

gender

norm

s,pregnan

cy,HIV,

unw

antedsexual

advances,plan

ning

goals,assessingvalues,money,gifts

andskillsto

communicatewith

adults/partners.To

reduce

HIV

risk

and

encourage

return

toschool

Mozambique

Evaluation2015

6months

(interven

tion

lasted

5years)

The6-m

onth

inciden

ceofintergen

erational

(1%)an

dtran

sactional

sex(7%)at

baselinewas

solow

that

measureswere

dropp

ed

Noeviden

cethat

interven

tionhad

impact

ongirls’GBVkn

owledge

orschool

attendan

ce.Noaccurate

measurescould

beobtained

forother

outcomes

Moderate

(Contin

ued)

7




Table

1.Continued

Author

Studydesign

Population

Interven

tion

Country/year

Outcomes

Score

Burke

2019B

Qua

litative

Interviewsan

d

focusgroups

Tworoundsofdata

collection

(follow-up)

49AGYW

13–25years,

24headofhouseholds,

36influen

tial

males,

12community

lead

ers

SCIP

SeeBurke2019A

Mozambique

2015–2016

12months

Round1:Most

girlsrepo

rted

earning

money

withbusinesskits.This

helpe

dto

stay

in/return

toschool,buynecessities,

reduce

tran

sactional

sex

Round2:Aquarterofgirlscontinued

earningmoney.Perceptions:

Interven

tion

was

tooshort,businesskits

not

sustainab

le.Most

incomewas

usedto

repaykits.Girls

feltsham

ewhen

having

toreturn

totran

sactional

sex.

Girls’GBV

knowledge

was

supe

rficial.Others

perceivedinterven

tioncontributedto

reducedearlymarriagean

dpregnan

cies

andim

proved

social

interactionwith

girlswhose

beh

aviourthey

perceivedas

more

respectful.Respo

nden

tsfrom

all

groups

repo

rted

increasedcommunity

awaren

esshad

decreased

perpetration

ofGBV

High

Dunbar

2010

Mixed

methods

Out-of-school

adolescen

torphan

girls

16–19years

n=

50

SHAZ!-I

(1)Allreceived

lifeskills(communication

andrelationship

skills)

andhealth

educationonHIV,an

dgender.

Interven

tiongroupalso

received

:

(2)Livelihoodsupp

ort:businesstraining,

skill

buildingworkshops

andmen

tors

iden

tified

bycommunity

(3)MFI(grouplendingmodel)

Zim

bab

we

2004

6months

Incomean

dsavings

sign

ifican

tlyincreased

(likely

dueto

loan

s),as

did

girls’

relationship

power

innonsexual

roman

tic

relationships.Therewas

nochan

gein

sexual

activity,condom

use

orfuture

aspirations.Therewas

poorloan

repaym

ent,businesssuccess,men

toring.

Unintended

consequen

ces:

cross-border

trad

eincreasedtheirvu

lnerab

ility.MFIis

notsuitab

leforad

olescen

tgirls

Moderate

(Contin

ued)

8




Table

1.Continued

Author

Studydesign

Population

Interven

tion

Country/year

Outcomes

Score

Dunbar

2014

RCT

Out-of-school

HIV-negativeorphan

girls

16–19years

Mnage18

n=

315(158:157)

SHAZ!-II

(1)Allreceived

lifeskills(communication

andrelationship

skills)

andhealth

educationonHIV,an

dgender

(2)Allreceived

access

tohealthservices:

SRH,HIV

screen

ing/treatm

entat

every

studyvisit,free

condoms,contracep

tion

upo

nrequest,HIV

referral,paym

ent

CD4tests

Interven

tiongroupalso

received

:

(2)Cogn

itive,

materialan

dsocial

supp

ort

forlivelihood:finan

cial

literacy,

vocational

trainingofchoice(nationally

accred

ited

),businessplan

developm

ent,

microgran

tan

dself-selectedmen

tors

Zim

bab

we

2006–2008

Sign

ifican

tresultsforreducedfood

insecurity,havingownincome,

less

tran

sactional

sex,

condom

use.There

werefewer

unintended

pregnan

cies

(40%).Nostatistically

sign

ifican

tchan

ges

forcontracep

tive

use,HIV

andherpe

s

simplex

virus-2(H

SV-2)inciden

ce.So

cial

supp

ort,relationship

power

andsexual

activity

werethesameacross

study

arms

Moderate

Dunbar

2017

Qua

litative

Casestudy

interviews,focus

groups,process

data

SeeDunbar

2014

SHAZ!-II

SeeDunbar

2014

Zim

bab

we

2006–2008

Authors

exploredqualitative(community

maps)

andprocess

dataofDunbar

2014

study.Effects

werelikelydiluteddueto

thelack

ofatruestan

dardofcare

and

controlgirlsusingtran

sport

money

for

IGA.Fe

wgirlsreceived

gran

t:they

moved

out/returned

toschool.Barriers

tovocational

trainingwerelangu

age(not

inSh

ona),length(6

months)

andgirls’

care

responsibilities

Low

Erulkar

2005

Longitudinal

pre–

post

with

matched

controls

Out-of-schoolAGYW

16–22years

n=

100pilot

n=

326baseline

TRY

-Modifiedgroup-based

microcred

it

model

inthreeph

ases:

(1)Pilot(1998–2000):minim

alistmodel;

locked

upgroupcollateral;social

supp

ort

(2)2001:loan

srequired

adult

guaran

tors.2002:ad

ultmen

tors

and

educational

seminarsad

ded

(healthan

d

gender)

(3)2004assets

replacead

ultgu

aran

tors.

YoungSavers

Club(savings

only):with

passbook

Ken

ya

1998–2000

(pilot)

2001–2004

(scale-up)

TRYgirlsworked

more

forpay(from

44%

to57%)an

dsign

ifican

tlyim

proved

their

income,

assets,savings

andsafe

savings

(savingat

aban

k).Older

TRY

participan

ts(aged20an

dolder)had

sign

ifican

tlymore

assets,earnings

from

paid

work,safe

savings

TRYgirlsdid

nothavemore

SRH

knowledge

butsign

ifican

tlyincreased

theirab

ility

torefuse

sex(O

R1.7)an

d

insist

oncondom

use

(OR2.86).Overall,

thepe

rcen

tage

repo

rtingab

ility

to

refuse

sexdecreased

,however

Moderate

(Contin

ued)

9




Table

1.Continued

Author

Studydesign

Population

Interven

tion

Country/year

Outcomes

Score

Erulkar

2006

Qua

litative

Casestudy

SeeErulkar

2005

TRY

SeeErulkar

2005

Therewas

amismatch

betweenproject

designan

dAGYW.Barriers:

inflexible

grouplendingsystem

,longwaitingtimes

forcred

it(1–30months;

average

6months),inab

ility

toaccess

savings

locked

upas

collateral,divisivenature

groupcollateral,lack

ofcred

itofficers

NeedsAGYW:acquiringsocial

capital,a

safe

spaceto

meet,aplaceto

save

money.Thereis

aneedforastaged

program

memodel

witholder,bolder

AGYW

movingonto

vocational

and

businesstraining,

work-integrated

learning,

MFI

Low

Gibbs

2020

CRCT

Unem

ployed

and

out-of-schoolyouth

18–30years

Mnage23.8

(both

sexes)

n=

1351

(677women

;674men

)

SS&CF

(1)Step

pingStones:Agender

tran

sform

ativeparticipatory

trainingon

HIV

andviolence

preven

tion

program

meaimed

atmore

gender-equitab

lerelationships,

communicationskills

(2)CreatingFutures:

Participatory

learningto

critically

reflecton

livelihood/skilldevelopm

entusing

existingresources

intheiren

vironmen

t

todevelopIG

A.Trainingincluded

businesstraining,

psychosocial

skillsto

get/keep

jobs,savings,man

agedeb

t,

cope

withshocks

South

Africa

2015–2018

At2-yearen

dlinewithITT:

Nodifference

inanyoftheintimatepartner

violence

(IPV)outcomes,butmen

’sself-rep

orted

physical/severeIPVpe

rpetration

sign

ifican

tlyreduced

Forwomen

,sign

ifican

tincrease

of

past-m

onth

earnings

(47%

increase)an

d

savings

(25%)

Future

studiesshould

tryrecruiting

couples

tovalidatemen

’sself-rep

orted

reductionsin

IPVpe

rpetration

High

(Contin

ued)

10




Table

1.Continued

Author

Studydesign

Population

Interven

tion

Country/year

Outcomes

Score

Goodman

2015

Ana

lytical

cross-sectional

Orphan

andvu

lnerab

le

childrenwith1,2,3

yearsin

empo

wermen

t

program

me

Med

ianage18(Y1an

d

2)an

d19(Y3)for

girls

n=

1060

ZOE

(ZOEOrphan

Empo

wermen

t)

(1)Economic

empo

wermen

t:Groups

received

microgran

tan

ddecided

how

toinvest

it(w

hichen

trep

reneu

rial

endeavours/training,

finan

cial

products,

orcash);communitymen

tor

(2)Sexual

beh

aviourchan

getrainingan

d

voluntary

counsellingan

dtesting

Ken

ya

2012–2014

Although

overallprogram

meparticipation

seem

edprotectiveagainst

sexual

initiation/unprotected

sex,

material

tran

sfersan

dincreasedmonthly

income

werelargelyunassociated

withriskysex

beh

aviour.Se

lf-efficacywas

protective

forsexual

initiation(past6months);

unprotected

sexan

dmultiple

sex

partners(pastyear).Im

proved

food

consumptionincreasedoddsofall

outcomes.Differential

gender

impact:

Girls

had

less

butboysmore

sexually

activity

High

Green

2015

CRCT

Youngwomen

Mnage27.3

n=

896

Secondexpe

rimen

t:n

=904youngwomen

+partners.

Totaln=

1800

(86%

female)

WINGS-Tw

ointerven

tionsto

start

non-farm

businesses:

(1)Economic

interven

tionwithbusiness

training

+seed

gran

t+

follow-up(FU)

supp

ort

formonitoringan

dad

vice

(2)Economic

interven

tionbecam

e

control.

New

interven

tion(W

omen

Plus—

W+):

Women

andmalehousehold

mem

ber

(mostly

intimatepartner)receive

additional

1-day

gender

training/communicationskills

Uganda

2009–2011

3years

WIN

GS:

Noeffect

onIPV.Women

increasedhousehold

chores.Doublingof

businessownership

andincome

(p<

0.01)16monthsafterinitialgran

ts,

moderated

byinitialqualityof

relationships.Those

sufferingIPV

increasedassets

andconsumptionbut

notincome

W+:still

noeffect

onIPV/gen

der

norm

s,

butW+

improved

relationship

quality

andmalesupp

ort

forbusinessan

d

household

chores.Therewas

little

impact

oneconomic

outcomes

High

(Contin

ued)

11




Table

1.Continued

Author

Studydesign

Population

Interven

tion

Country/year

Outcomes

Score

Jewkes

2014

Shorten

ed

interrupted

time-series

design

Out-of-schoolyouth

18–34years

n=

232

(n=

122youngwomen

andn=

110young

men

)

SS&CF

Pilotoftrialdescribed

above(G

ibbs

2020)

South

Africa

2012–2013

58weeks

Sign

ifican

tincreasesin

last

month

earnings

(278%),finan

cially

supp

ortingchildren,

receivingchild

gran

t,ab

ility

tomobilize

emergency

money

andfeelings

about

work

situation

Sign

ifican

tlyim

proved

gender

attitudes,

decreased

sexual

IPV,combined

physical/sexual

IPVin

thepast

3months.

Problem

alcoholdrinkingincreasedfrom

26.6%

to35.5%

butquarrellingab

out

alcoholdrinkingreducedby

ahalf

High

Pettifor

2019

Qua

litative

Exploratory

Narrative

timeline

interviews

Out-of-schoolAGYW

15–23years

n=

40

WORTH+

AGYW

attendingat

least10hours

of

beh

aviourchan

gecommunicationwere

eligible

toreceivecash

tran

sfers(CT

$31/3

months)

for18months.They

wereoffered

aplacein

asm

allMFI

group(savings

andloan

s)an

dreceived

finan

cial

literacytrainingan

d

men

torship

Tanzania

2017–2018

18months

AGYW

internalized

stated

aim

todevelop

business,earn

money

andbecomeless

dep

enden

tonmen

.Cashhelpe

dto

reduce

tran

sactional

sexam

ongthe

poorest

bymeetingbasic

needs.

Businessskillsen

han

cedfuture

aspirationsan

dself-esteem

gave

AGYW

agen

cyto

refuse

unw

antedsex.

Social

supp

ort

(fam

ilyan

dmen

tors)en

han

ced

entrep

reneu

rial

success

High

Pronyk

2008

Mixed

method

CRCT+

qua

litative

interviews,focus

groups,

observation,

diaries

Poorest

AGYW

Nearlyallout-of-school

14–35years

Mnage29

n=

262(108:112)

IMAGE

(Interven

tionwithMicrofinan

ceforAID

S

andGen

der

Equity)

(1)MFI:Sm

allbusinessloan

s

(2)Sistersforlife:

Participatory

learning

sessionsab

outgender

roles,IPV,HIV,

culturalbeliefs,relationships,

communicationevery2weeks

for

aboutayear

South

Africa

2002–2004

2years

Sign

ifican

tresultsforincreased

communicationsab

outsex,

havinggo

ne

fortesting,

reducedunprotected

sex

withnon-spo

usalpartner

HIV

inciden

cewas

toolow

(n=

8)to

exam

ineim

pact.Qualitativefindings

revealed

increasedcommunicationab

out

sex/HIV,espe

cially

withchildren

High

12




Figure 2. PRISMA flowchart.

3.3 Quality assessment

We rated nine papers as high, six as moderate and three aslow quality. Additional file 5 shows the full appraisal of eachpaper.

3.4 HIV-sensitive social protection interventionsand socio-economic and HIV-related outcomes

All projects included work skills training, nine offered micro-finance, one offered employment support in the form ofapprenticeships. None leveraged employment support in theform of public works or job matching. The Synthesis Table ofHIV-sensitive social protection interventions (Table 2) showsintervention components with associated socio-economicand HIV-related outcomes and additional implementationinformation.

3.4.1 Work skills training

All projects offered work skills training. Life and businessskills contributed improved socio-economic and HIV-relatedoutcomes, which were often sustained after interven-

tions ended. Livelihood training produced mixed results:IGA training improved self-employment and income, butfailed to reduce HIV-risk behaviours with one excep-tion [37]; standalone vocational training was less suitablefor vulnerable young women than more comprehensiveinterventions.Life skills training. All projects offered life skills training, butfew described content and only five reported outcomes ofinterest [37,38,45–49]. Life skills ranged from skills in com-munication, negotiation, leadership and conflict-resolution tohigher order skills like problem-solving and critical thinking.Life skills training increased self-esteem, self-confidence, self-efficacy and aspirations, which helped negotiate condom use,resist transactional sex [47,49], mediate economic empower-ment and unwanted sex [37,38]. Psychosocial and sexual riskbehaviour outcomes were sustained two years after projectsended [37,38,49]. ZOE Orphan Empowerment (ZOE) in Kenyashowed mixed results. Self-efficacy was significantly associ-ated with reduced odds of unprotected sex, sexual initiationand concurrency. Increased resilience, however, was associ-ated with small increases of sexual initiation and concurrency[48].

13




Table

2.SynthesisTable:Outcomes

per

HIV-sen

sitive

social

protectioncomponen

tandim

plemen

tationcommen

ts

Project

Socio-economic

outcomes

HIV-related

outcomes

Work

skillstraining

SEHIV

Commen

tsonim

plemen

tation

Life

skills

Allprojects

Lack

ofdescriptionofcontent,length,quality

AGEP

Life

skillstrainingincreasedself-efficacy

atprogram

meen

dan

d2yearslater

Decreased

tran

sactional

sex,

sustained

2yearsafterprogram

me

end.Noeffect

onlongerterm

outcomes

(educationan

dfertility)

++/−

Self-efficacywas

alifeskillsoutcome,

butlifeskills

trainingwas

notdescribed

Asset

Teachings

inBintiincreasedself-esteem

Self-esteem

helpe

dtran

slate

knowledge

tobeh

aviourchan

ge.It

helpe

dwithstan

dpe

erpressure

into

tran

sactiona

lsexan

d

negotiatecondoms

++

Life

skillstrainingincluded

communicationan

d

lead

ership

skillsbutalso

reproductivehealthan

d

HIV

inform

ation

ELA

-Uganda

Life

skillsmed

iatedsocio-economic

outcomes

Life

skillsmed

iatedHIV-related

outcomes

++

Life

skillspe

rtained

toman

agem

entskills:

negotiation,conflictresolution,lead

ership

IMAGE

Improved

communicationskills,

increasedself-confiden

ce,im

proved

bargainingpo

wer

tonegotiatesafe

sex(life

skills)

Testingan

dcommunicationsab

out

sexim

proved

andunprotected

sex

reduced

++

IMAGEoffered

bi-weeklygender

andHIV

training

forayear.Authors

suggestedtherewas

potential

forprotectiveeffectsofincreasedtestingan

d

communicationsonsexual

beh

aviourchan

ge

SS&CF

Criticaldialogu

ean

dreflectiononhow

touse

existingresources

inthe

environmen

tto

developIG

A

contributedto

impressive

increasesin

last

month

earnings

Gen

der

trainingeffect

oncombined

sexual

andph

ysical

IPVin

pilot;

notin

trial.Noeffect

on

expe

rien

ceofIPVin

women

.No

effectsonsexual

beh

aviourchan

ge

++/−

Harsh

environmen

tofinform

alsettlemen

tsmay

be

conducive

toresortingto

violence,whichmight

bedifficultto

chan

ge

ZOEKenya

Increasedself-efficacyan

dresilience

Increasedself-efficacywas

protective

forsexual

initiation,unprotected

sex,

multiple

sexpartners.

Increasedresilience

was

associated

withsm

allincreasesofsexual

initiationan

dmultiple

sexpartners

++/−

Thepape

rrefers

to‘other

lifeskillstraining’

ontop

ofen

trep

reneu

rial

trainingwithoutspecifying

content

Businesstraining

Nearlyall

Lack

ofdescriptionofcontent,length,quality.

AGEP

Modestincrease

offinan

cial

literacyat

program

meen

d;notsustained

2

yearslater.Savings

increasedan

d

weresustained

Totalinterven

tiondecreased

tran

sactional

sexsustainab

ly,

withoutim

pactinglongerterm

educationorfertility

outcomes

++/−

Interven

tioncompo

nen

tis

finan

cial

education

Asset

Only

Bintigirlssaved,plan

ned

and

spen

tresponsibly.They

foundmore

waysto

increase

income

Thelittlemoney

they

savedhelpe

d

youngwomen

tonoten

gage

in

tran

sactiona

lsex

++

Interven

tioncompo

nen

treferred

tofinan

cial

education,whichwas

form

ally

integrated

inBinti

curriculum

andhelpe

dinstilsavingbeh

aviour

(Contin

ued)

14




Table

2.Continued

Project

Socio-economic

outcomes

HIV-related

outcomes

Work

skillstraining

SEHIV

Commen

tsonim

plemen

tation

ELA

-Uganda

Self-rep

orted

entrep

reneu

rial

skillsup

by8%

(ITT);50%

(TOT).This

increasedself-employmen

t

Thetotalmix

ofinterven

tions

sign

ifican

tlyreduced

marriage/cohab

itation,teen

age

pregnan

cyan

dsexagainst

their

will

++

Businessskillsreferto

general

businessskillsan

d

finan

cial

literacy(budgeting,

finan

cial

services,

accounting)

tosupp

ort

IGAactivities.Voluntary

participationin

developm

entclubs:

21%

participationbutintense

participation(2

or

3/w

eekfor2years)

Vocational

training

Asset

Youngwomen

only

receivingvocational

trainingrepo

rted

savingtheleastan

d

havingthelowesteconomic

assets

They

werealso

perceivedas

more

vulnerab

leto

peer

pressure

and

tran

sactiona

lsexthan

youn

g

women

engagedin

IGAor

grad

uates

from

acompreh

ensive

program

me(Binti)

−−

Overw

helmingunem

ploymen

tan

dhighpo

verty

context.Vocational

traininggirlslacked

seed

capitalan

dprofessional

networksto

startIG

A.

They

lacked

thepo

sitive

peer

groups

andsocial

supp

ort

Bintigirlsen

joyed

SHAZ!-II

Incombinationwithother

compo

nen

ts

reducedfoodinsecurity,havingown

income

Pilotwithsm

allsamplesize

(n=

315);underpo

wered

todetect

effect

onHIV

orHSV

-2.Red

uced

tran

sactional

sex,

unintended

pregnan

cies;increasedcondom

use

+?

+/−

?SH

AZ!offered

6monthsvocational

trainingat

a

nationally

accred

ited

institution.Only

63%

completed

training;

60%

received

gran

t.Barriers:

Vocational

trainingwas

inEnglishan

dat

inconven

ienttimes;compe

tingcare

andhousehold

dem

ands

IGAtraining

SS&CF

One-year

pilotstage,

last

month

income

increasedby

278%;duringthe2-year

CRCT,

incomeincreasedby

47%

Decreased

combined

sexual/physical

IPVin

pilot.Trial:IPVexpe

rien

ce

amongwomen

did

notdecrease,

butmen

repo

rted

reduced

perpetrationofIPV.Neither

the

pilotnorthetrialshowed

sign

ifican

tresultsforsexual

beh

aviourchan

ge

+−

Participatory

learningsessionswithwideranging

topics

included

sometrainingonIG

A.SS

&CF

likelyinvested

thelittleonIG

Atraining.

Itis

unclearwhat

IGAwerepu

rsued

andhow.

Economic

resultswerelikelydueto

critical

approach

SHAZ!-I

More

incomebutthis

could

becaused

byloan

Nosign

ifican

tchan

gein

condom

use,

sexual

activity

+?

−IG

Atraininginvolved

4-day

workshops

oncandle

or

soap

making,

tiedye.Girls

engagedin

risky

livelihoodstrategies,likecross-border

trad

e.Lack

ofad

equatesocial

supp

ort;negativeunintended

consequen

ces,IG

AincreasedHIV

risk

ZOE

Monthly

incomeforgirlswhowere

1year

intheprogram

mewas

twice

that

ofgirlsjust

startingthe

program

me;

nodifference

inincome

betweengirlswhohad

been1or

2yearsin

theprogram

me

Monthly

salary

was

notassociated

withsexual

initiationor

unprotected

sex.

Multiple

partners

even

increasedwithprogram

me

participation

+?

−IG

Atrainingincluded

barbering,

tailoring,

car

mechan

ics.Paper

does

notdescribeIG

Aen

ough

tokn

ow

how

much

money

andtimeparticipan

ts

spen

tonIG

A

(Contin

ued)

15




Table

2.Continued

Project

Socio-economic

outcomes

HIV-related

outcomes

Work

skillstraining

SEHIV

Commen

tsonim

plemen

tation

ELA

-Uganda

Increased(andsustained

)en

gagemen

t

withIG

Adueto

self-employmen

t

(72%

-ITT).Interven

tiongirlswere

twiceas

likelyen

gagedin

self-employmen

tthan

controlgirls

(6×more

likelywithTO

Tan

alysis).

Increasedincomeat

program

meen

d

was

notsustained

2yearslater

Teen

pregnan

cyfellby

26%;delayed

marriage(58%);sexagainst

their

will

(44%);allsustained

2years

afterproject

++

ELA

offered

manytype

sofIG

Atraining:

Small-scale

agriculture

andlivestock

rearing,

hairdressing,

tailoringan

dsm

alltrad

e.Lo

calen

trep

reneu

rs

wereinvolved

indevelopm

entan

ddeliveryof

trainingcurriculum

ELA

-Tanzania

IGAtrainingdid

notresultin

any

employmen

t,norin

more

earnings

Noeffect

onsexual

risk

beh

aviours

−−

Resourceconstraints

affected

thedeliveryof

interven

tions.Donated

clubspaces

werenot

alwaysaccessible

andsafe;themen

torcompo

nen

t

suffered

from

inad

equatetraining,

longdelaysin

replacem

ent,an

dlack

ofsupe

rvision

Microfinance

Microgrants

(cash)

Asset

Stipen

dsgave

Bintigirlsfinan

cial

assets

andinstilled

savingbeh

aviour

Bintigirlspe

rceivedim

proved

negotiationpo

wer

towithstan

d

unw

antedsexan

dpregnan

cy

++

Bintigirlsreceived

stipen

dsan

dpe

rceivedthat

economic

groundingwas

keyto

tran

slatehealth

knowledge

into

safe

sexual

beh

aviours

SHAZ!-II

Incombinationwithother

compo

nen

ts,

foodinsecurity

reduced

Pilotwas

underpo

wered

todetect

effect

onHIV/H

SV-2.Red

uctions

intran

sactional

sex,

unintended

pregnan

cies;increasedcondom

use

++

After

finishingvocational

training,

girlsreceived

microgran

t(U

S$100)to

invest

insupp

lies,capital

equipmen

torfurther

training.

Only

60%

ofgirls

received

microgran

tsbecau

seofchallenges

completingvocational

trainingan

dbusinessplan

s

WINGS

Neardoublingofmonthly

earnings

and

IGA(cropsales,an

imal

rearing,

petty

trad

e,retail).Women

sufferingIPVat

baselineonly

increasedassets

and

foodconsumption

Noeffect

onIPV;slightbut

sign

ifican

tincrease

inmarital

control

+−

Increase

of5.8

more

household

chores.WIN

GS+

included

malepartnersin

asecondph

ase.

It

increasedhousehold

andbusinesssupp

ort,but

did

notreduce

IPV,marital

control

WORTH+

Increasedagen

cy,self-esteem,

aspirationsan

dfuture

orien

tation.

Thebetteroffwereab

leto

develop/expandbusinesses,attend

training.

Skillsen

han

cedfuture

aspirationslikego

ingforjobtraining,

buyingassets

(livestock,land,sewing

machine)

tosecure

incomebeyond

cash

tran

sfer

timepe

riod

Grantreducedtran

sactional

sexfor

basic

needs.Nothavingto

ask

parentorboyfriendsformoney

may

also

havereducedtension

withfamily

andboyfriendsan

d

potential

violence

++

Women

internalized

theaim

todevelopIG

Ato

becomeless

dep

enden

tonmen

.Grantsize

(US

$31every3months)

was

likelytoosm

allto

reduce

tran

sactional

sexforother

motivations

than

basic

needs.Increasedagen

cy,self-esteem,

aspirationsan

dfuture

orien

tationlikelyaffected

HIV

risk

reductionmore

(Contin

ued)

16




Table

2.Continued

Project

Socio-economic

outcomes

HIV-related

outcomes

Work

skillstraining

SEHIV

Commen

tsonim

plemen

tation

ZOE

Cohort

2girlsearned

twicetheincome

comparedwithCohort

1girls.No

further

increase

forCohort

3girls

Materialinpu

tsan

dmonthly

income

wereunassociated

withriskysex.

Increasedfoodconsumptionwas

associated

withincrease

insexual

risk

beh

aviours

+−

Valueofgran

tis

notrepo

rted

.Notallparticipan

ts

received

thesameam

ountofmoney.Increase

in

riskysexcould

bereversecausationorpe

rhaps

girlswerepe

rceivedas

more

desirab

lenow

they

weremore

foodsecure.Needforlongitudinal

data

Microgrants

(in

kind)

SCIP

Qualitativefindings

repo

rtthat

three-fourthsofthegirlsearned

money

inthefirstround,halfby

the

secondroundan

donly

one-fourthat

timeofinterview

Unab

leto

determineeffect

dueto

designan

dmeasuremen

tissues

andlow-inciden

ceriskysex

beh

aviours.Manyrepo

rted

reducingtran

sactional

sexin

round

1butsomere-engagedin

round2

dueto

finan

cial

need

+?

+/−

Girls

discontinued

sellingbusinesskits

dueto

the

lack

ofdiversity

ofproducts,low

profits,travel,

highcostsin

acontext

ofdrough

tan

dhunger.

Project

could

bemad

emore

sustainab

leby

addinglifean

dprofessional

skills,supp

lier

networks;

alongerduration

Productiveassets

ELA

-Uganda

Sustained

increasedself-employmen

tSu

stained

reducedsexual

risk

beh

aviours

++

ELA

-Ugandaoffered

US$30worthofproductive

assets

(seeds,tools,chicks

-repo

rted

inBueh

ren

2017)

ZOE

Cohort

2girlsearned

twicetheincome

comparedwithCohort

1girls.No

further

increase

forCohort

3girls

Noneofthematerialinpu

tswere

associated

withreducedoddsof

sexual

initiationan

dunprotected

sex

+−

Start-upkits

included

sewingmachines

fortailors,

haircuttingaccessories

forhair-dressersan

dtools

formechan

ics.Notallparticipan

tsreceived

start-upkits

Microcred

itELA

-Tanzania

Creditincreasedsavings;spillover

effect

from

social

networks:

savings

mainly

occurred

ininform

alrotating

cred

it/savingschem

es

Noeffect

onsexual

risk

beh

aviours

+?

−Microcred

itonly

offered

toad

olescen

tsto

engage

in

IGA;supp

orted

withfinan

cial

andbusiness

training.

TheMFIcompo

nen

tincreasedinterest

in

overallprogram

me,

increasingparticipationwith

6%,buttherewas

avery

low

uptakeofMFI(4%)

IMAGE

Nomicrocred

itresultsrepo

rted

Testingan

dcommunicationsab

out

sexim

proved

andunprotected

sex

reduced

+IM

AGEoffered

trad

itional

microcred

it:Yo

ung

women

received

smallbusinessloan

s

(Contin

ued)

17




Table

2.Continued

Project

Socio-economic

outcomes

HIV-related

outcomes

Work

skillstraining

SEHIV

Commen

tsonim

plemen

tation

SCIP

Nooutcomes

repo

rted

forsm

all

businessloan

s

Somecommunitiesusedcred

itassociationsto

providegroupsavingan


(loan

s),butthemaincompo

nen

tinvolved

kits

SHAZ!-I

More

income,

could

becausedby

loan

Nosign

ifican

tchan

gein

condom

use,

sexual

activity

?−

This

was

conven

tional

microcred

itincludinggroup

lending,

weeklyrepaym

entmeetings

andnew

loan

supo

nfullrepaym

ent.Lo

answereUS

$51–87;repaym

ent3–9months.Interest

30%

(vs.50%–60%

commercial

lending).At6months,

only

20%

had

repaid

loan

;fullloan

repaym

ent

was

6%.Theproject

adaptedto

nomore

collateral/weeklyinstalmen

tsupo

ntimely

repaym

ent,butthen

lacked

social

pressure

to

encourage

repaym

ent.Trad

itional

MFIloan

smay

notbeappropriate

forvu

lnerab

lead

olescen

tgirls

TRY

TRYgirlsworked

more,had

more

income,

savings

andsavedat

safer

places;more

pronouncedforthose

20yearsan

dolder

They

sign

ifican

tlyincreasedab

ility

to

refuse

sexan

dinsist

oncondom

use

andhad

more

liberal

gender

attitudes

+?

+TRYoffered

trad

itional

microcred

itwithgroup

savings

ascollateral.Groups

consisted

offive

girls.Thetw

owiththebestplan

sreceivecred

it;

when

fully

repaid,thenexttw

o,etc.

Therewas

littleinterest

inmicrocred

it(54%

youngwomen

borrowed

;56%

had

problemswithrepaym

ent)

andfacedmanybarriers

WORTH+

Nooutcomes

repo

rted

forloan

program

me

WORTH+

offered

microfinan

cewithindividual

savings,loan

san

dfinan

cial

literacy

Savings

AGEP

Girls

increasedsavings

Tran

sactional

sexreduced.Sh

ort-term

chan

gesdid

notlead

tolong-term

impactsonfertility

++/−

Low

participation:25%

did

notparticipateat

all;

30%

participated

inhalformore

sessions.

Interven

tionmay

nothavebeenmeaningful

enough

.Household

povertymay

needto

be

addressed

toim

pact

fertility

(Contin

ued)

18




Table

2.Continued

Project

Socio-economic

outcomes

HIV-related

outcomes

Work

skillstraining

SEHIV

Commen

tsonim

plemen

tation

Asset

Youngwomen

inBintian

dsomewith

IGAactivities

man

aged

tosave

Savings

helpe

dto

nothavingto

resort

totran

sactional

sex

++

Mainchallenge

tosavingwas

notearningen

ough

money,whichwas

espe

cially

trueforthose

who

tookcare

ofothers(childrenorsiblings)

SCIP

Nooutcomes

repo

rted

forthis

savings

option

Somecommunitiesusedcred

itassociationsto

providegroupsavingan


(loan

s)

TRY

Savings

increasedfrom

43%

to95%;

savingat

saferplaces

(ataban

k;42%

vs.24%

control);

savings

remained

stab

lein

2002/2003buttookoffin

2004when

voluntary

savingschem

e

was

introduced

They

sign

ifican

tlyincreasedab

ility

to

refuse

sexan

dinsist

oncondom

use

andhad

more

liberal

gender

attitudes

++

Inph

ase3(2004),stan

dalonevoluntary

savings

weread

ded

forthose

enjoyingthesocial

aspe

cts

oftheclub/needingasafe

placeto

save.TRYgirls

wereinterested

in(in

form

al)savings

options.

Stan

dalonesavings

andlow-riskincome

generationactivities

werevalued

by(younger)

girls

WORTH

Savings

improvefuture

orien

tation:

AGYW

savedto

buyland,assets,

livestock

Asthey

canasksavings

groupfor

money,they

areless

tempted

to

engage

intran

sactiona

lsex

++

Savings

groups

werenotdescribed

Employm

entsupport

Public

works

None

Thelack

ofresearch

onpu

blic

worksmay

bedueto

socio-culturalnorm

sthat

view

public

worksas

appropriate

formen

.Public

worksprojectsmay

needto

paymore

attentionto

gender

and

consider

additional

supp

ort

tomakethem

sensitive

toyoungwomen

Work-integrated

learning

SHAZ!-I

Distrust

betweenmen

tors

andstuden

ts;

60%

ofthegirlsweresatisfiedwith

theirmen

tor.More

income-likely

dueto

loan

Nosign

ifican

tchan

gein

condom

use,

sexual

activity

+?

−Work-integrated

learningmay

requiremore

attentionto

trainingofmen

tors,compe

nsationof

studen

ts,access

toan

dinvolvem

entwith

professional

networksan

dhiringopp

ortunitiesfor

employmen

taftertheappren

tice

period

Jobmatching

None

Thelack

ofresearch

onem

ploymen

tsupp

ort

may

bedueto

incompatibility

oflow-skilledvu

lnerab

le

youngwomen

andlim

ited

(higher

skills)

wagejobs

available

incontextswithgeneralized

poverty

Note:

+:po

sitive

chan

ge;+?:po

sitive

chan

geis

doubtful;−:nochan

ge;+/−

both

positive

andnochan

ge;em

ptycell:

noresultsrepo

rted

.

19




Stepping Stones and Creating Futures (SS&CF) in SouthAfrica took a critical participatory approach to life skills train-ing. Vulnerable young women reflected on skills and resourcesthey could leverage for livelihood and income. Both pilot andfull trial reported statistically significant increases in earningsby 278% and 47%, respectively. In the pilot, IPV reduced[46] but the trial showed no effect on women’s experience ofIPV, although self-reported male IPV-perpetration significantlydecreased [45]. Neither pilot nor the trial found changes insexual risk behaviour. The pilot saw young women’s drinkingproblem significantly increased by 33% but quarrelling aboutalcohol reduced by half. Authors suggested improved commu-nication skills may have de-escalated conflicts. A similar trendin the trial mid-way was not sustained at two years [45].Business and financial literacy training. Nearly all projectsoffered some business or financial training without describ-ing content, duration or level of training. The threeprojects reporting outcomes offered financial educationor general business skills like budgeting and accounting[37,38,47,49]. Financial literacy, self-efficacy and self-reportedentrepreneurial skills increased. Business skills signifi-cantly increased self-employment [37] and helped youngwomen save, plan and spend responsibly [47,49]. Projectsreported reduced sexual risk behaviour [37,47,49]. Improvedentrepreneurial skills were sustained two years later [37].Livelihood training (vocational and IGA-training). Six projectsoffered livelihoods training, of which four offered IGA training[37–39,45,46,48]. Shaping the Health of Adolescents in Zim-babwe (SHAZ!-I and II) offered both IGA and vocational train-ing [42,43] and the Asset project in Kenya compared the twotypes of training [47].

Formal vocational training took place at nationally accred-ited institutions. Asset found vulnerable young women withvocational training at increased socio-economic and HIV riskcompared with peers engaged in IGA or in a comprehensiveprogramme [47]. SHAZ-II combined vocational training withmicrogrants, mentors and health services. It found statisticallysignificant results for increased income, food security, con-dom use, reduced transactional sex and unintended pregnan-cies [42]. While incidence of HIV (2.3/100 years) and herpessimplex virus-2 (HSV-2) infection (4.7/100 years) were high,SHAZ!-II was not powered to detect statistically significantchanges. Only 60% of intervention girls completed vocationaltraining, as they struggled with instruction in English and com-peting family responsibilities [42,44].

Informal IGA training ranged from candle or soap making,tailoring, hair dressing to small-scale agriculture or animalrearing. Whereas, income increased in all projects but one,IGA training failed to show impact on sexual risk behaviours.The exception was Empowerment and Livelihood for Ado-lescents (ELA) in Uganda, which reported increased self-employment, sustained after two years, and significant reduc-tions of teenage pregnancy, unwanted sex and delayed mar-riage/cohabitation [37,38]. The ELA replication trial in Tan-zania failed to demonstrate any statistically significant out-come. Resource constraints negatively affected implementa-tion fidelity. The process evaluation identified girls would havepreferred supplementary tutoring. Authors suggest this couldbe linked with school enrolment being higher in Tanzania thanin Uganda [39].

Some studies reported unintended outcomes. In Zim-babwe’s collapsing economy, some orphan girls started cross-border trading and faced physical and sexual harm thatincreased their HIV risk [43]. Increased food consumptionin ZOE, Kenya, was associated with increased transactionalsex. The authors suggested reverse causality, whereby trans-actional sex might have increased access to food [48].

3.4.2 Microfinance

All projects offered some form of microfinance, exceptfor SS&CF that encouraged leveraging available resourcesthrough capabilities development [45,46]. Microgrants con-tributed positive socio-economic outcomes like increasedearnings and savings, but did not always reduce IPV [52]or sexual risk behaviour [48], and impacted the poorest andmost vulnerable differently [40,41,53]. The single microcreditproject showing positive effects judged it suitable for ‘olderand bolder’ young women only [50]. Projects offering savingsreported improved socio-economic and HIV-related outcomes.Microgrants: Cash, in-kind and productive assets. Sevenprojects offered microgrants, of which five offered cashgrants [42,47,48,52,53]; two offered productive assets[37,48]. Strengthening Communities through Integrated Pro-gramming (SCIP) in Mozambique offered in-kind grants in theform of business kits [40,41]. All projects reported improvedsocio-economic outcomes like increased earnings [41,48,52],food security [42,52], savings [47] and self-employment [37].

Results were mixed for HIV-related outcomes. Five projectsreported reduced sexual risk behaviours [37,41,42,47,53].When earnings from business kits halted, some SCIP girlsmarried or re-engaged in transactional sex out of financialneed. SCIP also explored perceptions of heads of households,influential males and community leaders. Many credited theintervention for perceived reductions in early marriage andpregnancy, and more ‘respectful’ behaviour in girls, whichcould reflect prevailing gender norms. Respondents believedgender training had increased community awareness, reducingintergenerational sex and gender-based violence (GBV) [41].Productive assets in ZOE were not associated with sexualbehaviour change [48]. In Northern Uganda, microgrants inWomen’s Income Generating Support (WINGS) had no effecton IPV except for a small but significant increase in mari-tal control. A one-day gender training session for women andtheir partners, added in a second phase, had no effect onIPV and economic outcomes, but found significant results forimproved communications, quality of relationships and maleimplication in household chores [52]. Out-of-school AGYW inWORTH+ received three-monthly grants for 18 months. Theyperceived increased self-esteem, agency and aspirations. Theyinternalized the goal to develop IGA to reduce transactionalsex. Linked to basic needs, only the poorest girls reportedreducing transactional sex, whereas the better off developedor expanded businesses. The young women also reportedcash grants reduced tensions with family and boyfriends andpotential IPV [53].Microcredit. Six projects offered microcredit[37–41,43,50,51,53,54]. Only Tap and Reposition Youth(TRY) in Kenya reported both positive socio-economic andHIV-related outcomes, but only 53% of young women took up

20




the offer of microcredit and half had difficulties to repay. Theinflexible lending system led to high dropout rates, but youngwomen appreciated the club’s safe space and mentors andleveraged their newfound social networks to start informalrotating saving schemes. Those 20 years and older had signif-icantly more assets, income and savings than adolescent girls,and authors concluded that microcredit was appropriate for‘older and bolder’ young women only [50,51]. In ELA-Tanzania,savings similarly increased. Despite low uptake (4%), the offerof microcredit triggered interest in club participation, offeringopportunities for informal saving schemes [39].

The Intervention with Microfinance for AIDS and Gen-der Equity (IMAGE) in our review [54] concerns the sub-group of young women (n = 262) from the CRCT in SouthAfrica, which had been ineligible due to women’s meanage (41 years) [29]. It combined microcredit with gendertraining and reported significant results for reduced sex-ual risk behaviour, improved communications about sex andhaving gone for testing. Qualitative findings suggested thatdiscussing sex and testing increased young women’s self-confidence and facilitated negotiating safe sex. With eight newHIV infections, the event rate was too low to measure impacton HIV incidence [54].Savings. Of five projects that mentioned savings [40,41,47,49–51,53], SCIP did not report savings outcomes [40,41].Four projects reported improved socio-economic outcomeswith increased savings [47,49–51], saving at safer places [50,51], and increased future orientation, as young women savedto buy land or productive assets [53]. Savings enabled youngwomen to refuse sex, insist on condom use [50,51] and resisttransactional sex [47,49,53]. In the Adolescent Girls Empow-erment Program (AGEP), outcomes did not impact fertilitytwo years after the intervention ended and the most vulnera-ble girls were more likely married, pregnant or had given birth[49].

3.4.3 Employment support

Only one project, SHAZ!-I, offered employment support inthe form of work-integrated learning. SHAZ!-I identified men-tors for apprenticeships through community outreach. Ham-pered by trust issues due to perceived exploitation when men-tors lacked time for on-the-job training, and perceived lazinessof mentees not showing up for work when lacking transportmoney, SHAZ!-I changed to mentees choosing their own men-tors in SHAZ!-II. Increased income likely resulted from loansand sexual risk behaviours did not change [42–44].

3.4.4 Supporting intervention components

All projects offered supporting intervention components thatlikely contributed to outcomes too (Table 3). Except forWINGS [52], all projects stressed the link with HIV throughHIV and sexual and reproductive health education. Someprojects facilitated access to healthcare by offering healthservices [42,44], health vouchers [49], or encouraged volun-tary counselling and testing [48]. Nine projects offered gendertraining [37–46,50–54].

3.4.5 Mentorship and safe spaces

All projects instrumentalized mentorship and/or safe spaceto deliver interventions. Ten projects used mentors whowere slightly older young women from the same commu-nity [37–39,45–47,49] or adults [42–44,50,51]. They werepositive role models [38,47] delivering health, gender orlife skills training [37,48–51], or offering business support[42–44,49–52]. Most mentors received remuneration andmentor training. Mentors helped create social cohesion, boostattendance [50] and were generally appreciated by girls andyoung women. The lack of a structured framework in SHAZ!-Iled to mistrust between mentors and mentees [43] and inad-equate mentor training in ELA Tanzania contributed to nullresults [39].

Safe space was social space, in the form of regular groupmeetings, or physical space, as girls-only clubs. Except forWINGS [52], all projects offered regular group meetings,although only three referred to it as safe space [37–39,49].Meetings were venues for peer or mentor support, criticaldialogue and sharing of experiences. Many offered socializa-tion free from pressures from (older) men and several offeredrecreational activities. In TRY, these meetings were the onlysource of social contact and support for girls [50]. BintiPamoja Centre in Kenya and ELA clubs in Uganda and Tan-zania were physical safe spaces [37–39,47]. Girls and youngwomen formed new social networks in social and physical safespaces and leveraged them to start informal rotating savingschemes [39,50,51]. They relied on these social networks intimes of need, reducing their reliance on transactional sex[47,53]. In ELA-Uganda, sustained reductions in sexual riskbehaviours at four-year follow-up were attributed to mentorsand physical safe spaces, as girls continued attending clubsafter training activities halted at two years [37]. In contrast,donated club spaces ELA-Tanzania used were not safe, con-tributing nonsignificant outcomes [39].

4 D ISCUSS ION

Our systematic review identified 12 HIV-sensitive social pro-tection projects that aimed to improve socio-economic andHIV-related outcomes among unemployed and out-of-schoolyoung women in East and Southern Africa. All projects offeredwork skills training, with a majority also offering some typeof microfinance. Most projects leveraged mentorship and safespace for programme delivery. Impact on socio-economic out-comes was mostly positive, albeit modest, but impact on HIV-related outcomes was less consistent. Employment supportwas under-researched.

Our review found insufficient tailoring to participants andlocal implementation contexts in several interventions. Thisoffers three transferable lessons. First, sensitivity to needs,age, interests, and socio-economic vulnerability of target pop-ulations is essential. Of all interventions, microcredit seemedleast responsive to vulnerable young women’s needs. Lowuptake, as little as 4%, indicates little interest in microcre-dit among adolescent girls [39,43,50,51]. With few assetsand high mobility they are considered credit risks [55].Loan repayment among microcredit users was low indeed

21




Table

3.Su

mmaryTable

ofallinterven

tioncomponen

ts

HIV-sen

sitive

social

protectioninterven

tioncomponen

tsOther

interven

tioncomponen

ts

Workforcetraining

Microfinance

Employm

ent

support

SRH/H

IV/GBV

training

Social

support

Health

Project

nam

e

Country

Life

skills

Business

and

financial

training

Livelih

ood

training:

IGA&

vocational

Grants:

cash

&

in-kind

assets

Credit

Savings

Apprentice

ship

Gen

der

training

SRH/H

IV

training

(Fem

ale)

Men

tor

Social

safe

space

Physical

safe

space

Health

services

1AGEPZam

bia

xx

xx

xx

x

2Asset

Ken

yax

xx

xx

xx

x

3ELA

-Uganda

xx

xx

xx

xx

x

4ELA

-Tan

zania

xx

xx

xx

xx

x

5IM

AGESo

uth

Africa

xx

xx

x

6SC

IPMozambique

xx

xx

xx

xx

7SH

AZ!Zim

bab

we

xx

x/x

x/x/

xx

xx

/x

8SS

&CFSo

uth

Africa

xx

xx

xx

x

9TRYKen

ya/x

xx/

/x/x

/x/x

x

10

WIN

GSUganda

/xx

x/x

x

11

WORTH+

Tanzania

xx

xx

xx

xx

x

12

ZOEKen

yax

xx

xx

xx

Note:

‘x/’meansthat

compo

nen

twas

offered

inan

earlierph

aseoftheinterven

tion;an

d‘/x’in

thelaterph

ase.

Abbreviations:

IGA,income-generatingactivity;SR

H,sexual

andreproduc-

tive

health.

22




[43,50,51]. A recent study found that constraints in sav-ings rather than credit contributed to the inability to sustainincreased income after receiving microgrants [56]. Our reviewshows that young women were eager to save, even startinginformal saving schemes in their newfound social networks[39,50,51]. These informal saving schemes can help smoothconsumption and guard against negative income shocks, butsavings will not overcome poverty if all members are poor[57]. Participants’ socio-economic vulnerability also requiresattention in programme design. Although microgrants con-tributed positive socio-economic and HIV-related outcomes,grants only reduced transactional sex among the poorest whoused it for basic needs, whereas the financially better off man-aged to develop or expand IGA [53]. The poor are often reluc-tant to go into debt and lack time and resources to investin credit groups [58]. In TRY, authors recommended micro-credit, but also work-integrated learning and vocational train-ing for ‘older and bolder’ young women only [50]. Livelihoodtraining should be adapted to young women’s social realities.For example, offered at flexible hours with free childcare toaccount for competing care responsibilities [59]. Vulnerableyoung women may also need psychosocial support to bene-fit from interventions. Mentorship and safe space were key toprogramme delivery but their spillover effect on social capi-tal may indicate another change mechanism. Frequent social-ization and sharing of personal experiences created socialnetworks of trust and reciprocity on which young womenrelied for psychosocial and economic support, enabling someto reduce transactional sex. IMAGE found social networksincreased self-confidence and self-esteem [60], which facili-tated acting on HIV-prevention choices. Another study foundyoung women belonging to voluntary savings clubs more likelyto drink alcohol and engage in casual sex, however [61]. Safespace may therefore require supportive mentors who modelpositive behaviour.

Second, interventions need to be comprehensive, adaptedto local contexts and rely on enabling environments. Althoughstructural, interventions in our review mostly relied on indi-vidual behaviour change mechanisms to reduce HIV risk,whereas social and economic environments need to changeto address drivers of HIV vulnerability. The Asset studydescribed a context of overwhelming unemployment, sex-ual harassment while job seeking, and young women lackingprofessional networks [47]. Zimbabwe’s collapsing economydrove girls to risky livelihoods [43], and business kits in SCIPwere insufficiently adapted to local context [41]. IGA requiresrelatively inelastic demand. Vulnerable people prefer steadyincome flows as they value income most for its capacity toabsorb shocks [62]. This requires evaluation of, and inter-action with, local markets. In our review, only ELA-Ugandadescribed demand-driven IGA with local entrepreneurs deliv-ering training adapted to local markets. It led to high self-employment and big reductions in sexual risk behaviour, sus-tained two years after programme end [38].

Vulnerable young women need linking interventions to facil-itate their transition into productive livelihoods. The lack ofliterature on employment support, notably work-integratedlearning and job matching, suggests a lack of ‘linking socialcapital’, the deliberate connecting of young women with othernetworks [63]. Interventions could forge private sector links

through apprenticeships and coaching like projects did in LatinAmerica [64,65], Liberia [59] or Uganda [66].

More generally, interventions may require more time andwork with other population groups to change gender norms.WINGS added a gender component for men, but the one-dayworkshop was insufficient to change gender norms [52]. Inter-ventions could look at how community mobilization efforts inBotswana, South Africa and Uganda changed gender normsthrough engagement with other population groups [67–71].Projects in our review were delivered by NGOs and lastedon average 2.8 years, which might be too short to detectsignificant improvements in socio-economic and HIV-relatedoutcomes, let alone change gender norms. Livelihood andemployability interventions may require government involve-ment and ownership to support a more prolonged, intersec-toral approach to HIV-sensitive social protection and achievemore than the mostly modest outcomes we reported.

Third, the review highlights the pivotal role of life skills.Rarely described in detail although offered by all, few projectsaimed to measure life skills outcomes. Life skills trainingimproved self-efficacy, self-esteem, sexual negotiation [48,54],HIV testing [54] and reduced sexual risk behaviours [48,49].Self-confidence and future aspirations facilitated investing inIGA and productive assets [37,38,53]. Communication skillsmay have de-escalated IPV [45,46,52]. SS&CF demonstratedthat higher order life skills like critical thinking and dialoguecan lead to economic empowerment without any material orfinancial support [45,46]. Even when increased income wasnot associated with reduced sexual risk behaviours, increasedself-efficacy was [48]. Enhanced capabilities can sustain out-comes beyond interventions. Improved self-efficacy and self-esteem continued to reduce sexual risk behaviours two yearsafter programmes ended [37,38,49], despite not sustainingincreased earnings [37,38].

4.1 Updated conceptual framework forHIV-sensitive social protection

We updated the conceptual framework with findings of thisreview (Figure 3). For livelihood and employability inter-ventions, we included workforce training, microfinance andemployment support. The lack of research on the latter indi-cates a research gap. As nearly all projects offered addi-tional health and gender training, these have been added assupporting intervention components. We added mentorshipand safe space as delivery components along causal path-ways to intended outcomes. In addition to income and capa-bilities, we have added social capital as socio-economic out-come. Improved income, capabilities and social capital maycontribute to reduced IPV and sexual risk behaviour and,ultimately, reduced HIV infection among vulnerable youngwomen.

To our knowledge, this is the first systematic reviewon HIV-sensitive social protection interventions for unem-ployed and out-of-school young women reporting both socio-economic and HIV-related outcomes. Our use of multipledatabases, specialized librarian, two reviewers for qualityassessment, detailed data extraction and conceptual ground-ing contribute to the strengths of this review.

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Figure 3. Updated conceptual framework HIV-sensitive social protection. The rounded rectangles are intervention components. Thearrows represent causal effect. The squares are intended outcomes with more distal outcomes darker.

As with any comprehensive intervention with multiple out-comes, it was challenging to attribute specific results todifferent components. Lack of biomarkers in included stud-ies was another limitation. Including quantitative, qualitativeand mixed methods studies provided complementary informa-tion that improved understanding of phenomena under study.The narrative synthesis method helped draw out transferablelessons for both impact and change mechanisms.

We recognize a potential selection bias due to indepen-dent screening of a proportion of abstracts, titles and full-text papers by the second reviewer. Other reviews took asimilar approach [72,73] and our selection criteria were clear,reflected by a satisfactory kappa statistic [32].

5 CONCLUS IONS

Given intersecting structural drivers of HIV vulnerability, HIV-sensitive social protection interventions need to be compre-hensive and designed around young women’s needs, interestsand socio-economic vulnerability. They need to be sensitive tolocal implementation contexts, to leverage local demand andresources. Microgrants, savings and skills development seemto contribute positive socio-economic and HIV-related out-comes, of which life skills are most likely sustained. Microcre-dit may not be appropriate for unemployed and out-of-schoolgirls and young women. The potential of leveraging employ-ment support for HIV-sensitive socio-economic programmingrequires further research. Young women may need psychoso-

cial and professional support to achieve and sustain socio-economic outcomes from livelihood interventions. This couldbe instrumentalized in design and delivery through mentor-ship, safe space and the establishing of linking social capi-tal. To also achieve HIV-related outcomes, interventions maybenefit from government involvement, longer implementationdurations and simultaneously work towards an enabling envi-ronment in support of more gender-equal norms.

AUTHORS ’ AFF I L IAT IONS

1Department of Family Medicine, McGill University, Montreal, Quebec, Canada;2EPPI-Centre, UCL Social Research Institute, University College London, Lon-don, UK; 3CIET Trust, Gaborone, Botswana; 4Centre de recherche du CentreHospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada;5Département de gestion, d’évaluation, et de politique de santé, École de santépublique de l’Université de Montréal, Montreal, Quebec, Canada; 6Centro deInvestigación de Enfermedades Tropicales, Universidad Autónoma de Guerrero,Acapulco, Mexico

COMPET ING INTERESTS

The authors declare that they have no competing interests.

AUTHOR CONTR IBUT IONS

R.W. conceptualized the study; collected, analysed and interpreted the data;appraised quality of included papers; wrote first and subsequent drafts of the paperand revised it after submission. D.L. collected data; reviewed analysis and inter-pretation; appraised quality of included papers; critically reviewed paper. I.V. andQ.N.H. providedmethodological supervision and critically reviewed the paper. A.C.,M.J. andN.A. critically reviewed the paper. All authors approved the final version ofthe manuscript.

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ACKNOWLEDGEMENTS

We thank peer reviewers for their constructive feedback and Genevieve Gore,family medicine librarian at McGill University for her help with the search strategy.

FUNDING

R.W. is supported by CIHR Vanier Canada Graduate Scholarship; Q.N.H. was sup-ported by a FRQS postdoctoral fellowship. The authors thank the Quebec Popu-lation Health Research Network (QPHRN) for its contribution to the financing ofthis publication.

DISCLA IMER

Funding agencies had no role in the study design, data collection and analysis.

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