Cui, R., Lee, R., Thirumurthy, H., Muessig, K., and Tucker, J. (2013). Microenterprise Development Interventions for Sexual Risk Reduction: A Systematic Review. AIDS Behaviour, 17, pp.2864–2877.Link to Source
Headline Findings: a summary statement
Microenterprise development has the potential to reduce risky sexual behaviour, particularly among female sex workers; however, further research is needed on how to effectively incorporate this into comprehensive HIV-prevention programmes.
The authors included seven studies covering a total of 2,290 participants from six countries (Haiti, India, Kenya, South Africa, the United States and Zimbabwe). These included four microlending programmes, two business-skills training programmes and one intervention that provided both. All studies were mixed interventions comprised of a microenterprise development component and an educational component, most commonly focusing on HIV prevention and safe sex. All of the studies targeted women. Three studies evaluated the effect of microenterprise development interventions on female sex workers.
Implications for policy and practice
Interventions for sex workers: Among the three studies that evaluated microenterprise development for female sex workers, two studies in India and the USA evaluated small-business and skills training, and one study in Kenya evaluated microloans to businesses. All three studies found a significant reduction in the number of sexual partners. Two studies in Kenya and the USA found evidence of an increase in condom use with sex-trade clients, while the only included randomised controlled trial in India found no change in condom use. The two studies that evaluate small-business training found that women’s overall income increased and that a lower proportion of their income originated from the sex trade.
Interventions for non-sex workers: Of the four studies that evaluated business-development programmes for non-sex workers, three studies in South Africa and Haiti evaluated microfinance interventions and one study in Zimbabwe evaluated combined microfinance and small-business training. Only one study in South Africa found a significant increase in condom use, and none found evidence for decreased numbers of sexual partners. However, all four studies reported increased relationship power and communication about sex were. One study from Zimbabwe reported increased income and savings, and one study from South Africa reported improved self-reported wellbeing.
Implications for further research
To better understand the potential for microenterprise development to reduce HIV/STI risk, the authors call for future research to focus on the following:
- Increase the number of randomised controlled trials evaluating microenterprise development interventions, as many of the included studies in the review were non-experimental and likely to suffer from selection bias.
- Measure additional biological outcomes such as HIV/STI incidence and employ validated measures of women’s empowerment, such as the Sexual Relationship Power Scale (SRPS), in future HIV/STI prevention studies to improve understanding of how microenterprises can improve gender equality.
- Evaluate these interventions in a greater variety of locations with the appropriate social, cultural and political contexts and conduct research that explores the underlying relationship between microenterprise development and HIV/STI prevention.
Poverty and gender inequality are two significant determinants of risk of contracting HIV and other sexually transmitted infections (STIs) in vulnerable populations. Interventions to control HIV transmission increasingly recognise the importance of addressing these social factors—for example, by incorporating microenterprise development interventions into comprehensive HIV-control strategies. Microenterprise development interventions can have a direct income effect. For example, income diversification can boost women’s economic independence and increase their negotiating power regarding conditions that may increase HIV risk. At the time of this review, no systematic review had assessed the effects of microenterprise development interventions on HIV/STIs.
To examine the effect of microenterprise development interventions on sexual risk behaviour and HIV/STI infection.
The authors included studies that assessed the impact of a microenterprise development programme on sexual risk behaviours (that is, condom use, number of sex partners, and so forth) or the prevalence or incidence of HIV or other STIs. The authors excluded review papers, non-peer-reviewed local or government reports, editorials, dissertations and descriptive studies, but they did not adopt any additional restrictions on inclusion by study design. The authors searched databases, including PubMed, SSRN, Cochrane and JSTOR, for studies published up to April 2013. There was no restriction on language of publication.
Due to the small number of studies identified and the diversity of the populations and interventions, the authors did not undertake a meta-analysis. Instead, they undertook a narrative synthesis. They assessed the quality of the studies using a validated quality-assessment tool adapted from that which the Agency for Healthcare Research and Quality (AHRQ) uses.
The authors make effort to reduce bias in the selection of studies through clear inclusion criteria, independent double screening and clear reporting of important characteristics and results of included studies. However, the systematic review has some major limitations. The search is limited and explicitly excludes important types of gray literature. Two reviewers did not independently extract data. Moreover, the quality-appraisal tool does not include a comprehensive assessment of risk of bias. Considering the broad range of study designs included this is a particular concern. The authors adopt a vote counting approach to the analysis, and are weighted equally in the analysis, despite the inclusion of a broad range of study types. Finally, there is at least one cluster RCT included, but no mention of unit of analysis issues.