The impact of social services interventions in developing countries: A review of the evidence of impact on clinical outcomes in people living with HIV

Bateganya, MH; Dong, M; Oguntomilade, J; Suraratdecha, C PubMed, 2015; www.ncbi.nlm.nih.gov/pubmed/25768875

The vast evidence of the impact of HIV/AIDS on livelihoods has prompted efforts to invest in social services to protect the vulnerable and/or to improve the life and living conditions of HIV-infected and HIV-affected individuals. Countries most affected by the HIV epidemic, especially in resource-limited settings (RLS), generally lack proper social protection and welfare systems to support needy populations.

Social protection interventions have the potential to reduce vulnerability to HIV infection and strengthen the livelihood of affected individuals and household economies.

This review of current evidence has summarised available information on economic strengthening activities for people living with HIV (PLHIV) in RLS. It searched electronic databases from January 1995 to May 2014 and reviewed relevant literature from RLS on the impact of social service interventions on:

  • mortality
  • morbidity
  • retention in HIV care
  • quality of life
  • ongoing HIV transmission
  • cost-effectiveness

To assess the evidence gaps on the impact of social service interventions on HIV outcomes, this review examined evidence to answer two key questions:

  1. Do social service interventions - specifically income-generation activities, livelihood and legal services – have an impact on mortality, morbidity, retention in HIV care, quality of life, and prevention of ongoing HIV transmission?
  2. And are these interventions cost-effective?

The review describes what inclusion criteria was used, how the reviewers evaluated abstracts and identified relevant studies for their systematic review and their approach to data abstraction and analysis.

Findings

The quality of the evidence was rated as poor or fair overall because the studies used study methods of low rigor, and most of the studies had other limitations. Nonetheless, all studies showed associations between economic strengthening interventions and HIV care outcomes. The expected impact of these interventions was rated as high for Quality of Life (QOL).

The evidence on the impact of the interventions on mortality, morbidity, retention in care, and HIV transmission was inconclusive, and the expected impact on these outcomes was therefore rated as uncertain.

Limitations

  • Some studies targeted only men and others only women; results may therefore not be generalisable to the broader population.
  • Lack of comparative baseline data for the control group in 2005 and the increased use of ART in the interim.
  • A significant number of programme participants were excluded from the analysis.
  • Two studies, in Ethiopia and Peru, reported on mortality outcomes and were rated poor. The expected impact of the economic strengthening interventions on mortality was rated as uncertain because of the lack of comparative baseline data for the control group in 2005
  • Studies reporting on morbidity in Ethiopia, Peru and Kenya were rated poor because the findings could not be generalised. Similarly, the expected impact of economic strengthening interventions on morbidity was rated as uncertain
  • Seven studies reported on QOL and reported improved social well-being, reduced stigmatisation, and increasing members’ sense of dignity and self-worth. The overall quality of evidence from these seven studies was rated as fair and therefore the expected impact was rated as high
  • One study reported findings that have implications for HIV transmission. The quality of evidence was rated as poor because the evidence available is not adequate to estimate the impact of the study in different settings. The study reported only intermediate outcomes such as behaviour change without any objective measure of transmission and therefore the expected impact was rated as uncertain

Research gaps

The review highlights knowledge gaps and helps establish a foundation for future work. None of the studies addressed:

  • costs associated with the interventions or cost-effectiveness of the interventions on key HIV outcomes
  • the feasibility and sustainability of interventions in the scale-up of economic strengthening interventions
  • target population groups with the greatest need and those that may benefit most from the interventions

More rigorous research is needed on the impact of more targeted intervention components on health outcomes.

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