Kristien Michielsen PhD Thesis_website.pdf - International Centre ...

HIV PREVENTION FOR YOUNG PEOPLE IN 

SUB-SAHARAN AFRICA: EFFECTIVENESS OF 

INTERVENTIONS AND AREAS FOR IMPROVEMENT. 

EVIDENCE FROM RWANDA 

Kristien Michielsen 

Doctoral Thesis Submitted to the Faculty of Medicine and Health Sciences 

Ghent University 

PhD Supervisor: Prof. dr. Marleen Temmerman 

Department of Obstetrics and Gynaecology, Ghent University 

PhD Co-Supervisor: Prof. dr. Ronan Van Rossem 

Department of Sociology, Ghent University 

November 2012 

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Bedankt 

Dominiek 

voor het creëren van de omstandigheden 

Juliette 

voor de dagelijkse portie relativering (en kussengevechten) 

HIV Prevention for Young People in Sub-Saharan Africa: Effectiveness of Interventions 

and Areas for Improvement. Evidence from Rwanda. 

Kristien Michielsen 

Doctoral thesis submitted to the Faculty of Medicine and Health Sciences, Ghent 

University, Belgium. 

2012 

This title has been published in the series “ICRH Monographs.” 

ISBN 9789078128250 

International Centre for Reproductive Health (ICRH) 

Ghent University 

De Pintelaan 185P3 

B-9000 Ghent (Belgium) 

www.icrh.org 

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Supervisor: Prof. dr. Marleen Temmerman 

Department of Obstetrics and Gynaecology 

Faculty of Medicine and Health Sciences 

Ghent University, Belgium 

Co-supervisor: Prof. dr. Ronan Van Rossem 

Department of Sociology 

Faculty of Political and Social Sciences 


Members of the jury: Prof. dr. Steven Callens 

Department of Internal Medicine, 


dr. Olivier Degomme 

International Centre for Reproductive Health, 

Department of Obstetrics and Gynaecology, 


Prof. dr. Lea Maes 

Department of Public Health, 


Prof. dr. Dominique Meekers 

Department of Global Health Systems and Development, 

Tulane University 

New Orleans, USA 

dr. Christiana Nöstlinger 

Institute for Tropical Medicine, Antwerp 

Prof. dr. Geert Van Hove 

Department of Special Education, 


Prof. dr. Steven Weyers 

Department of Obstetrics and Gynaecology, 


Chairperson of the jury: Prof. dr. Johan Vande Walle 

Department of Pediatrics and Medical Genetics, 


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TABLE OF CONTENTS 

LIST OF FIGURES ................................................................................................................ vii 

LEXICON AND LIST OF ABBREVIATIONS .................................................................... viii 

1. INTRODUCTION ............................................................................................................. 1 

1.1. HIV/AIDS: History, Transmision and Stages ............................................................................ 2 

1.2. The HIV Epidemic ................................................................................................................................ 3 

1.2.1. Worldwide ................................................................................................................................. 3 

1.2.2. Sub-Saharan Africa ................................................................................................................ 4 

1.3. HIV in Young People in Sub-Saharan Africa ............................................................................. 7 

1.3.1. Focus on Young People ......................................................................................................... 7 

1.3.2. Being Young in Sub-Saharan Africa ................................................................................ 8 

1.3.3. HIV Prevention Interventions for Young People ....................................................... 9 

1.4. Conclusion ............................................................................................................................................. 11 

2. OBJECTIVES .................................................................................................................... 13 

2.1. General Objective ................................................................................................................................ 14 

14 

2.3. Presentation of Publications ........................................................................................................... 18 

3. STUDY SITES AND POPULATION .............................................................................. 21 

3.1. Study Setting: The District of Bugesera in the East Province of Rwanda .................... 22 

3.1.1. Young People ............................................................................................................................ 23 

3.1.2. School Life in Rwanda .......................................................................................................... 24 

3.2. The Intervention: The Peer Education Intervention of Rwandan Red Cross ............. 25 

3.2.1. Short History ............................................................................................................................ 25 

3.2.2. Objectives and Design .......................................................................................................... 25 

4. METHODOLOGY ............................................................................................................ 

4.1. Study Design .......................................................................................................................................... 

4.1.1. Sytematic Literature Reviews: Objective 1, 3.b and 3.c .......................................... 

(Paper 1: Meta-Analysis, Paper 5: Out-of-school Youth, and 

Paper 6: Theory Review) 

4.1.2. Qualitative Research: Objectives 2 and 3.a (Paper 2: Rwandan ......................... 

Intervention and Paper 4: Self -selection) 

4.1.3. Qualitative Study: Objective 3.b (Paper 4: Mailbox Technique) ......................... 

4.2. Research Ethics ..................................................................................................................................... 

4.2.1. Ethical Approval ...................................................................................................................... 

 

4.2.3. Exemption for Parental Consent ...................................................................................... 

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27 

27 

27 

29 

31 

33 

33 

33 

33

5. RESULTS ....................................................................................................................... 35 

5.1. Outline .............................................................................................................................................. 36 

5.2. To Assess the Overall Effectiveness of HIV Prevention Interventions .................. 36 

for Young People in Sub-Saharan Africa (Objective 1) 

5.3. To Assess the Effectiveness of a Peer-led School-based HIV Prevention ............ 50 

Intervention in Rwanda (Objective 2) 

5.4. To Identify and Study Possible Reasons for the Observed Limited ....................... 72 

Effectiveness of HIV Prevention Interventions for Young People in 

Sub-Saharan Africa (Objective 3) 

5.4.1. To Assess Young People’s Participation in HIV Prevention ........................ 72 

Interventions (Objective 3.a) 

5.4.2. To Study The Vulnerability of Young People for Poor Sexual and ............ 90 

Reproductive Health (Objective 3.b) 

5.4.3. To Assess the Theoretical Assumptions used to Change Sexual ............... 123 

Behaviour in HIV Prevention Interventions for Young People 

in Sub-Saharan Africa (Objective 3.c) 

6. DISCUSSION ................................................................................................................ 

6.1. Failure to Demonstrate the Effectiveness of HIV Prevention ..................................... 

Interventions 

6.2. Reasons for the Observed Limited Effectiveness of HIV Prevention ....................... 

Interventions 

6.3. Limitations ....................................................................................................................................... 

6.4. Conclusions, Recommendations and Directions for Further Resaerch ................. 

SUMMARY ......................................................................................................................... 169 

SAMENVATTING .............................................................................................................. 173 

REFERENCES .................................................................................................................... 178 

ANNEX ................................................................................................................................ 

Paper 7: Kenyan Intervention .............................................................................................................. 

Paper 8: Globalisation and Education .............................................................................................. 

vi 


143 

144 

146 

160 

162 

195 

195 

205

LIST OF FIGURES 

Figure 1.1: Evolution of HIV Infection [23] ......................................................................................... 

Figure 1.2: Reproduction of the HIV Virus [24] ................................................................................ 

Figure 1.3: Evolution of the number of people living with HIV (left) and of HIV ............... 

incidence (bleu, right) and AIDS-related deaths (grey, right) [25] 

Figure 1.4: Number of people living with HIV by region [27] .................................................... 

Figure 1.5: Evolution of HIV prevalence in sub-Saharan Africa among the adult .............. 

population (15-49 years), 1990-2009 [26] 

Figure 1.6: Aspects of the HIV epidemic addressed in this doctoral research .................... 

Figure 2.1: Overview of doctoral research objectives .................................................................... 

Figure 3.1: Map of Rwanda (left) and the district of Bugesera in the East ........................... 

Province of Rwanda (right) 

Figure 3.2: Rwandan national (red, middle), urban (blue, upper), and rural ...................... 

(green, lower) HIV prevalence curves [105] 

Figure 3.3: 

Figure 4.1: Quality assessment of articles included in paper 6 ................................................. 

Figure 6.1: Theoretical intervention sequence of HIV prevention interventions for ....... 

young people in sub-Saharan Africa 

Figure 6.2: Practical interpretation of intervention sequence ................................................... 

Figure 6.3: 

this doctoral research study 

vii 


3 

3 

4 

4 

5 

8 

17 

22 

23 

23 

29 

146 

147 

151

LEXICON AND LIST OF ABBREVIATIONS 

Adolescents People aged 10 to 19 years 

 

BSS Behavioural Surveillance Survey 

Children People aged under 18 years 

CSE Comprehensive Sexuality Education 

CNLS Comité Nationale de Lutte contre le Sida / National AIDS Commission 

DHS Demographic and Health Survey 

 

HSV-2 Herpes Simplex Virus type 2 

ICRH International Centre for Reproductive Health 

IPPF International Planned Parenthood Federation 

RRC Rwandan Red Cross 

SRH(R) Sexual and Reproductive Health (and Rights) 

(c)RCT (clustered) Randomized Controlled Trials 

STI Sexually Transmitted Infection 

UNAIDS Joint United Nations Programme on HIV/AIDS 

UNDP United Nations Development Programme 

UNFPA United Nations Population Fund 

UNGASS United Nations General Assembly Special Session on HIV and AIDS 

UNICEF United Nations Children’s Fund 

 

WHO World Health Organization 

Young people People aged 10 to 24 years 

Youth People aged 15 to 24 years 

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INTRODUCTION 

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1. Introduction 

1.1. HIV/AIDS: History, Transmission and Stages 

The HIV epidemic exploded in the early eighties. In the United States of America an 

increasing number of persons presented with an aggressive form of the rare skin cancer 

Kaposi Sarcoma [1]. Around the same period physicians noticed a stark increase in a 

severe lung infection Pneumocystis carinii pneumonia [2]. While these diseases where 

initially mainly observed in homosexual men, it rapidly became clear that also other 

population groups were affected. In 1982, while reports of similar diseases came from 

ciency 

Syndrome. Two years later, in 1984, French and American scientists succeeded in 

isolating a virus that was thought to be the cause of AIDS [3, 4], which would be named 

 

 

receiving a blood transfusion from an infected source, the chance of being infected is 

90% [5]. Second, HIV can be transmitted through needles: intravenous needles use has a 

0.7% [95% CI 0-10.2] chance of transmitting HIV [6-9], while needle sticks through the 

skin have a 0.3% chance [10]. Third, HIV can be transmitted from mother to child during 

pregnancy, childbirth and breastfeeding. Without treatment for the HIV-positive mother, 

the chance of transmitting the virus to her child is 25% to 40% [11, 12]. Finally, HIV can 

be transmitted through sexual intercourse. The risk of being infected with HIV through 

sexual intercourse depends on the type of sexual contact. It ranges from an estimated 

0.005% (man being fellated) [13] over 0.1% (receptive penile-vaginal intercourse) 

[14] to 1.7% [95% CI 0.3-8.9] (receptive anal intercourse) [6, 15]. Worldwide, the most 

common transmission route is heterosexual sexual intercourse [16-18]: it is estimated 

to account for about 70% of HIV infections [19, 20]. In some nations or regions, other 

transmission routes dominate, e.g. injecting drug use in Russia [21] or homosexual sexual 

intercourse among Belgians [22]. HIV infection can be prevented by screening donor 

blood for HIV, providing prophylaxis treatment to HIV positive pregnant women and 

their newborn babies, treating HIV positive persons 1 , making clean needles and syringes 

available, circumcising men, and having protected sexual intercourse. Currently, there is 

no vaccine or cure for HIV/AIDS. 

HIV infection has three main stages: acute infection, the latent phase, and AIDS (Figure 

1.1). Upon infection, when entering the blood stream, HIV rapidly multiplies. It attaches 

itself to CD4-cells, white blood cells playing a central role in the body’s immune response, 

and uses these cells to reproduce itself (Figure 1.2). This phase of acute infection is characterized 

by a rapid increase in HIV viral load and a stark decrease in CD4-cells. HIV viral 

load reaches its peak around six weeks after infection. 

1 ing 

HIV positive people is an effective prevention strategy. 

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Then the immune systems responds and reduces the number of viral particles in the 

blood. The infection enters into the latent phase, which can last between two and twenty 

years. Within this phase, we distinguish between asymptomatic and symptomatic HIV infection. 

The asymptomatic phase lasts on average ten years in which the infected person 

is free of major symptoms. In the symptomatic phase, symptoms start to appear because 

of the weakened immune system. Without treatment, gradually, the number of CD4-cells 

reduces. When it reaches the critical level of 200 cells per µL, the immune system is so 

weak that a number of opportunistic infections begin to show. To be diagnosed with 

AIDS, a person needs to be diagnosed with one or more severe opportunistic infections 

or cancers (as Pneumocystis carinii pneumonia, or Kaposi sarcoma). 

Figure 1.1: Evolution of HIV infection [23] Figure 1.2: Reproduction of the HIV virus [24] 

1.2 The HIV Epidemic 

1.2.1. Worldwide 

 

increased at a staggering rate. The peak of new infections occurred in the mid-nineties 

with 3.5 million [3.2 million – 3.8 million] new infections. Since then, the number of newly 

infected people has been decreasing slowly. Since the peak in HIV deaths in 2004 (2.2 

million [1.9 million – 2.6 million]), due to the widespread introduction of anti-retroviral 

treatment, also the number of AIDS-related deaths started to decrease (Figure 1.3). 

The continued large number of infections and a longer life expectancy of HIV-positive 

people, has resulted in an ever increasing number of HIV-positive persons worldwide. Recent 

UNAIDS data show that an estimated 34 million people [31.6 million–35.2 million] 

were living with HIV worldwide in 2010. This means that about 1% of the adult world 

population is infected with the virus. In 2010, an estimated 1.8 million [1.6 million – 1.9 

million] people died of an AIDS-related cause and 2.7 million [2.4 million – 2.9 million] 

new infections occurred [25]. 

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Figure 1.3: Evolution of the number of people living with HIV (left) and of HIV incidence 

(blue, right) and AIDS-related deaths (grey, right) [25] 

1.2.2. Sub-Saharan Africa 

Figure 1.4 and Figure 1.5 show that one region is particularly touched by the HIV epidemic. 

In 2010, 70% of the new HIV infections occurred in sub-Saharan Africa. This part 

of the world hosts two thirds of all HIV-positive people, while it is home to only 12% of 

 

e.g. Mauritania with an HIV prevalence of the adult population (15 to 49 years) of 0.7% 

[0.6%-0.9%], Cameroon with 5.3% [4.9%-5.8%] and Swaziland with 25.9% [24.9%- 

27.0%] [26]. While these data might be subject to reporting or measurement biases, the 

large differences between the countries indicate the existence of important differences 

within the sub-Saharan African region. Not neglecting this great variety, we cannot ignore 

that one part is highly affected: East and Southern Africa. Most countries in this subregion 

have an adult HIV prevalence of over 5%, some even exceed 20%. South Africa has 

more people with HIV than any other country in the world (5.6 million), while Botswana, 

Swaziland and Lesotho have the highest prevalence rates in the world. 

Figure 1.4: Number of people living with HIV by region [27] 

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There is no straightforward reason that explains why HIV prevalence is so high in this 

region. A combination of factors lies at the base. We touch on a non-exhaustive number of 

possible reasons, for the purpose of illustrating the complexity of the problem: interact- 

 

First, there are biological factors that account for part of this discrepancy. Communities 

with high prevalence of male circumcision are generally less affected by the HIV pandemic 

[31-34]. Also, the HIV subtype seems to play a role. Each HIV subtype has its preferred 

way of transmission. HIV-1 subtype C is most dominant in Southern Africa and fuels 

heterosexual epidemics, while subtype B, most prevalent in Europe and North America, is 

more easily transmitted through homosexual contact and intravenous drug use [35]. 

Figure 1.5: Evolution of HIV prevalence in sub-Saharan Africa among the adult population 

(15-49 years), 1990-2009 [26] 

Second, behavioural factors, such as condom use and the type of sexual partnerships, 

partly explain this difference. In East and Southern Africa there is a high prevalence of 

concurrent sexual partnerships [36-38]. Such overlapping relationships create a complex 

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and interlinked sexual network that, given the high chances of HIV transmission in the 

 

1.1), serves as a highway for HIV transmission [39-42]. Especially in Southern Africa 

 

between self-reported symptoms of sexually transmitted infections and having had a 

partner who engaged in concurrency. Helleringer and Kohler [44] mapped the sexual 

network of the general population of young adults on Likoma Island in Malawi: even 

though the number of sexual partners was not high (on average 2.6 for men and 2.2 for 

women in the last three years), about half of the respondents were connected to each 

cantly 

higher than in the smaller networks. In a survey among 3,500 young people in 

the Cape Town area in South-Africa, Mah [45] found that 13% reported a concurrent 

partnership during their last sexual relationship; men and so-called Black youth reported 

higher levels. Also in South Africa, in a household survey including 1,144 respondents 

between the ages of 15 and 24 years, 38% of sexually active men and 19% of sexually 

active women reported having had an overlapping second partner during their last 

relation [46]. In the same study, 40% of women said their partner had another partner. 

Several qualitative studies have shown that people categorize their relationships as 

‘main’/‘regular’/‘primary’ and ‘nonprimary’/‘other’ [47-50]. 

 

 

nature. For example, poverty can been seen as an important factor [52-54]; it can lead 

to a lack of health care and treatment for HIV positive persons, but also to transactional 

sex – i.e. sex in exchange for money and/or goods – during which condom negotiation is 

demic, 

since they had access to paid sex and were mobile [55]. Another contextual factor 

is education. While one study show that HIV risk decreases with 7% for each additional 

year of educational attainment [56], another claims that this impact differs regionally, 

depending on the level of globalization [57]. Another example of social factors are laws 

discriminating against men who have sex with men, pushing them into the margins, and 

hence increasing their risk for unprotected sex. This shows that political leadership is essential 

in the response to HIV. While Uganda’s initial response to the epidemic, focussing 

on each individual’s responsibility to combat the epidemic, is put forward as a success 

story, South Africa’s leaders have received criticism for their HIV denialism. Socio-cultural 

issues, like gender inequality and taboos surrounding sexuality, are equally important. 

Only recently more positive news was reported. The latest UNAIDS report indicated that 

in 22 sub-Saharan African countries, HIV incidence declined by more than 25% between 

2001 and 2009, including in some of the world’s largest epidemics like Ethiopia, Nigeria, 

South Africa, Zambia and Zimbabwe. But, even though the epidemic seems to be leveling 

off, with an HIV incidence of 1.9 million [1.7 million–2.1 million], it remains at an unacceptably 

high level. [25] 

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1.3. HIV in Young People in Sub-Saharan Africa 

“Nothing should be more important than a major focus on young people” [58] 

1.3.1. Focus on Young People 

The changes in HIV incidence are most marked among young people. HIV incidence 

declined among young people aged 15 to 24 years in 16 of the 21 countries most affected 

by HIV. These declines have occurred amid signs of changes in sexual behaviour. The 

percentage of young men with multiple partners in the past 12 months decreased sig- 

 

of 14 countries. Among young men who had multiple partners in the last 12 months, the 

 

 

 

 

in 7 of 16 countries, respectively. [59, 60] 

Nevertheless, HIV incidence in young people aged 15 to 24 years remains worrying. Half 

of the new HIV infections occurs in this age group. Worldwide, on average, over 2,500 

young people get infected with HIV every day; almost 80% of these infections takes place 

in sub-Saharan Africa, resulting in a regional HIV prevalence of 1.4% [1.1%-1.8%] in 

young men and 3.3% [2.7%-4.2%] in young women [25]. Changing sexual behaviour in 

this group is crucial in tackling the pandemic [58, 61]. 

In many sub-Saharan African countries, young people aged 15 to 24 years make up over 

one third of the population. This means that in this region a large number of people are 

about to start their sexual lives or have just started it [62]. These young people are particularly 

vulnerable to HIV infection and poor sexual and reproductive health; due to the 

combination of universal risk-taking behaviours that emerge during adolescence, such 

as alcohol consumption, sexual initiation, and several individual, social and structural 

factors, including limited knowledge and skills with regard to sexual and reproductive 

health issues, poverty and gender imbalance [63]. The World Health Organization (WHO) 

estimated that nearly two thirds of premature deaths and one third of the total disease 

burden in adults are associated with conditions or behaviours that began in youth, such 

as drinking, unprotected sex or exposure to violence [64]. 

Girls and young women are most vulnerable in this respect. They are more prone to HIV 

infection, due to several factors, including biological susceptibility to HIV, economic dependence 

on men, sexual relationships with older men and less access to education. The 

 

number: globally, young women make up more than 60% of all young people living with 

HIV; in sub-Saharan Africa their share jumps to 72% [65]. 

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This study will focus on prevention of sexual transmission of HIV in young people in 

sub-Saharan Africa. Figure 1.6 indicates that focusing on prevention of sexual transmission 

of HIV among young people is only one of the many ways of managing the HIV/AIDS 

epidemic. 

Treatment of HIV 

positive persons 

Care and support 

for people infected 

with and affected 

by HIV 

Prevention of sexual transmission 

Biomedical ( male 

circumcision, 

microbicides, treatment 

as prevention, 

General population Young people 

Ways of managing the HIV epidemic 

Influence policy 

Ways of preventing HIV infection 

Prevention through blood (blood 

transfusion and needle sharing) 

Figure 1.6: Aspects of the HIV epidemic addressed in this doctoral research 

1.3.2. Being Young in Sub-Saharan Africa 

Young people in sub-Saharan Africa live in a complex world, characterized by rapid 

social change. Factors as increased school enrollment, globalization and increasing trade, 

democratization of political systems, and instantaneous global communication expose 

8 

Reduce the impact 

of HIV on society 

(education sector, 

health sector, 

 

Ways of preventing sexual transmission of HIV 

Behavioural (increase 

condom use, reduce 

number of sex partners, 

increase age of sexual 

debut, reduce 

concurrent 

partnerships, reducing 

the age gap between 

partners, HIV 

) 

Structural (education, 

 

Target groups of HIV prevention through sexual transmission 

Men who have sex 

with men 

Prevention of HIV 

Prevention of vertical transmission 

(mother-to-child transmission) 

Combination prevention 

Sex workers Mobile populations 

Kristein.indd 8 10/25/2012 8:36:13 PM

young people to information, challenges, and possibilities that threaten their customs 

and values [66]. Furthermore, with an increase in the age of marriage and schooling, a 

distinct period of adolescence was created in African societies; a period characterized by 

boy-girl friendships, likely to include sexual relationships [67-70]. 

For many young people in developing countries, this transitory life stage is further 

complicated by the clashes between the many forces of westernization, and the stricter 

traditional values of their societies [69]. The relatively new life phase of adolescence and 

 

 

concept of companionate heterosexual relations before and during marriage, as well as 

increased access to pornographic movies, is of great importance in shaping young people’s 

ideas and behaviours [68, 71-74]. As Maticka-Tyndale [75] puts it, young people are 

confronted with “a complex mix of traditional beliefs, norms and expectations, western 

values, ideas and modes of interaction, and a changing set of social expectations”. Luke 

[76] adds that “the cultural ideals for adolescent behaviour are being replaced by peers’ 

concerns for status and material goods and pressures to begin sexual relations”. Strong 

gender roles, norms and values concerning relationships coincide with differing religious 

and western views. 

The disintegration of traditional methods of sex education, such as rites of passage and 

elder’s narratives, and the lack of comprehensive sexuality education in school has created 

a void of knowledge on sexual and reproductive health matters for adolescents. On 

 

or incomplete [76-78] and peer pressure and norms can be counteractive [79, 80]. On 

the other hand, many governments, non-governmental organizations and international 

organizations are investing in HIV prevention interventions for young people. 

1.3.3. HIV Prevention Interventions for Young People 

In order to prevent sexual transmission of HIV, a number of strategies can be adopted: 

biomedical prevention (e.g. male circumcision, microbicides or treatment as prevention), 

individual behaviour change strategies and structural interventions. Our study 

focuses on the latter two. Behaviour change interventions promote actions as: abstinence 

 

the number of sexual partners. Additionally, they aim to increase knowledge, change 

attitudes, improve access to services and to reduce stigma or address other mediators 

 

attempt to motivate behavioural change within individuals and social units by use of a 

range of educational, motivational, peer-group, skills-building approaches, and community 

normative approaches”. Structural approaches to HIV prevention, on their turn, “seek 

to change social, economic, political, or environmental factors determining HIV risk and 

vulnerability” [51]. In practice, structural interventions might address factors as gender 

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inequality [83], the economic situation of young people [84] or stimulating young people 

to go to school [85]. 

Over a decade ago, Merson [86] concluded a review on the effectiveness of HIV prevention 

interventions by stating that there is a dearth of evaluated prevention interventions 

for young people. Since, the number of evaluations and literature reviews is increasing. 

tings, 

such as schools [87, 88], or with particular tools like mass media [89]. Others have 

 

[86, 91-95], and even others have focused on types of outcomes, e.g. including only evaluations 

that report on biological outcomes [96]. 

Gallant [87] studied the effectiveness of 11 school-based HIV prevention interventions 

in sub-Saharan Africa. Studies that assessed the effectiveness on HIV knowledge and attitudes 

reported positive results, respectively in 10 of 11 and 7 of 7 studies. Sexual debut 

was delayed in only 1 of 3 studies, and only for a subgroup of the population. Condom use 

increased in 1 of 2 studies. Some years later Paul-Ebhohimhen [88] published a review 

on the same topic: knowledge (12 of 13 measures) and attitudes (11/13) were changed 

in almost all studies measuring these items. Intention to use a condom, was only changed 

in 1 of 5 studies, and also condom use and abstinence increased in 1 of 5 studies. Bertrand 

[89] measured effectiveness of HIV prevention interventions for young people using 

media worldwide. Of the 9 studies reporting data on knowledge of HIV transmission 

and prevention, 4 measured an increase. As for sexual behaviour, abstinence increased in 

2 of 6 interventions, the number of partners reduced in 1 of 5 studies and 5 of 12 reported 

an increase in condom use. 

Speizer [91], Magnussen [93] and Kirby [92] reviewed the effectiveness of HIV prevention 

and reproductive health interventions for young people in developing countries 

worldwide. The studies demonstrated relatively little effectiveness on sexual behaviour 

outcomes: for most indicators only one fourth to one third showed positive changes. Ross 

[96] assessed the impact of behavioural interventions on HIV incidence using random- 

 

incidence. 

Three common messages dominate these reviews. Firstly, there is a paucity of evaluated 

 

of sub-Saharan Africa. Secondly, the quality of evaluation designs is relatively low, hence 

the level of evidence is questionable. Thirdly, the current evidence paints a mixed picture: 

while interventions generally succeed in increasing knowledge and, to a lesser extent, 

changing attitudes, the effectiveness on self-reported behaviour is more ambiguous and 

effectiveness to reduce HIV incidence has not been shown. Given the focus of these reviews 

(thematically, geographically or methodologically), none of these reviews focused 

 

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1.4. Conclusion 

In the past three decades HIV has had devastating effects on people’s lives. Especially 

young people in sub-Saharan Africa remain at the centre of the epidemic. Recently the 

ing 

visible in surveillance studies on national levels. However, in order to reverse the 

epidemic, a continuous focus on HIV prevention in young people is essential. Literature 

reviews on aspects of HIV prevention interventions for young people (e.g. media 

 

interventions and suggest limited effectiveness of these interventions in changing young 

people’s sexual behaviour and HIV incidence. 

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13 

OBJECTIVES 

Kristein.indd 13 10/25/2012 8:36:13 PM

2. Objectives 

2.1. General Objective 

Given that young people remain at the centre of the HIV epidemic, the general objective 

of this study was to improve the effectiveness of HIV prevention interventions for young 

people in sub-Saharan Africa. 

 

1. To assess the overall effectiveness of HIV prevention interventions for 

young people in sub-Saharan Africa 

Research question: what is the overall effectiveness of HIV prevention 

interventions in changing sexual behaviour of young people in sub-Saharan 

Africa? 

Literature reviews on aspects of HIV prevention interventions for young people 

(e.g. media interventions, school-based interventions) suggest a limited 

effectiveness of these interventions in changing sexual behaviour and 

reducing HIV incidence. However, a literature review and meta-analysis on the 

 

young people in sub-Saharan Africa, that allows drawing overall conclusions on 

their effectiveness, was missing. Studying evaluations of HIV prevention 

interventions for young people also gives insights in potential reasons for their 

success/failure. 

2. To assess the effectiveness of a peer-led school-based HIV prevention 

intervention in Rwanda 

Research question: What is the effectiveness of a peer-led HIV prevention 

intervention for young people in Rwanda? 

Peer education is a popular approach in HIV prevention for young people. It 

makes use of existing social processes, and actively involves young people in 

the intervention [97, 98]. In Rwanda, peer education has been adopted as a 

strategy to prevent HIV infection among in-school youth [99], but has not yet 

be thoroughly evaluated. 

To get a better understanding of how HIV prevention interventions for young 

people in sub-Saharan Africa are developed, implemented and evaluated, an 

evaluation of a peer-led intervention was set up. Besides contributing to the 

 

HIV prevention interventions and gain insights in the conditions for their 

success/failure. 

14 

Kristein.indd 14 10/25/2012 8:36:13 PM

Additionally, we participated in the evaluation of a peer-led sports-based HIV 

prevention intervention in Kenya, which can be found in annex. 

3. To identify and study possible reasons for the observed limited 

effectiveness of HIV prevention interventions for young people in 

sub-Saharan Africa 

Results from the previous objectives indicated a limited effectiveness of HIV 

prevention interventions on young people’s sexual behaviour and HIV 

 

reasons for this observed lack of effectiveness. Firstly, interventions might 

 

intervention. Secondly, it could be that HIV prevention interventions do not 

address the right topics to make young people change their sexual behaviour. 

Most HIV prevention interventions talk about ways of transmission and 

prevention of HIV, in order to make young people change their behaviour. 

But it is likely that sexual behaviour is based on more than knowledge on and 

attitudes towards HIV. Therefore, it is important to understand how young 

people think about sexuality and relationships and to study factors that 

determine their vulnerability to HIV. Thirdly, the observed limited 

 

reduction interventions, on how to change young people’s sexual behaviour. 

Finally, many HIV prevention interventions for young people have to deal with 

 

 

study. 

a. To assess young people’s participation in HIV prevention interventions 

Research question: To what extent do young people participate in a 

peer-led school-based HIV prevention intervention in Rwanda and what is 

 

Participation in most HIV prevention interventions is voluntary. Several 

studies have shown that young people with high exposure to the 

intervention are more likely to change their behaviour. However, these 

 

would provide more insight in the mechanisms of participation and would 

allow designing interventions that are attractive to all young people. Using 

data from the evaluation study of the peer-led school-based intervention in 

Rwanda, we analyzed participation in the intervention and developed 

 

15 

Kristein.indd 15 10/25/2012 8:36:13 PM

. To study determinants of young people’s vulnerability for HIV infection 

Research question: What factors contribute to the vulnerability of young 

people to HIV infection? 

Sexual intercourse is the main transmission route for HIV. However, this does 

 

behaviour. In order to develop effective interventions that succeed in changing 

sexual risk behaviour of young people, we should be aware of the important 

 

structural level, using a qualitative technique (the mailbox technique) and a 

systematic literature review. 

c. To assess the theoretical assumptions used to change behaviour in HIV 

prevention interventions for young people in sub-Saharan Africa 

Research question: On which theoretical assumptions are HIV prevention 

interventions for young people in sub-Saharan Africa based? 

In setting up and implementing interventions, programme planners - explicitly 

or implicitly - make assumptions on how sexual behaviour can be changed. 

Using a systematic literature review, we will study the assumptions used in HIV 

prevention interventions for young people in sub-Saharan Africa, identify their 

strengths and weaknesses and analyze if theory-based interventions are more 

effective than non-theory-based interventions. 

4. To formulate recommendations to improve the effectiveness of HIV 

prevention for young people 

16 

Kristein.indd 16 10/25/2012 8:36:13 PM

Figure 2.1: Overview of doctoral research objectives 

17 

1. Assess the overall 

effectiveness of HIV 

prevention interventions 

(paper 1) 

2. Assess the effectiveness of 

a peer-led school-based 

HIV prevention 

intervention in Rwanda 

(paper 2) 

Observed 

limited 

effectiveness 

3. Identify and study possible reasons for 

observed limited effectiveness 

a. participation in intervention (paper 3) 

b. intervention content: determinants of 

vulnerability (papers 4, 5) 

c. intervention theoretical assumptions 

(paper 6) 

Identify other reasons 

4. Formulate recommendations 

to improve the effectiveness 

of HIV prevention 

interventions for young 

people in sub-Saharan Africa 

Kristein.indd 17 10/25/2012 8:36:14 PM

2.3. Presentation of Publications 

This thesis is based on a number of papers that have been published or are under review 

in international peer-reviewed journals. The manuscripts are presented in full in the 

Results section (primary papers) or in annex (secondary papers): 

Primary papers: 

1. Michielsen K., Chersich MF., Luchters S., De Koker P., Van Rossem R., Temmerman M. 

(2010). Effectiveness of HIV prevention for youth in sub-Saharan Africa: systematic re 

view and meta-analysis of randomized and nonrandomized trials. AIDS 24(8):1193– 

202. Type: A1, IF: 6.348 (further referred to as “Paper 1: meta-analysis”) 

2. Michielsen K., Chersich M., Luchters S., Van Rossem R., Temmerman M. (2010). 

Concurrency and the limited effectiveness of behavioural interventions on sexual risk 

behaviour of youth in sub- Saharan Africa. AIDS 24(13):2140-2. Type: A1 

(correspondence), IF: 6.348 

3. Michielsen K., Beauclair R., Delva W., Van Rossem R., Temmerman M. (2012) The 

impact of a peer-led HIV prevention intervention in secondary schools in Rwanda: 

results from a cohort study with repeated measures and control group. BMC Public 

Health 12:729 Type: A1, IF: 2.0 (“Paper 2: Rwandan intervention”) 

4. Michielsen K., Celis H., Jingwa B., Degomme O., Van Rossem R., Temmerman M. Selfselection 

in a HIV prevention intervention: who is participating? Results from a peer 

education programme in secondary schools in Rwanda. Submitted to AIDS Education 

and Prevention (13/2/2012 – under review). Type: A1, IF: 1.59 (“Paper 3: selfselection”) 

5. Michielsen K., Remes P., Van Rossem R., Temmerman M. “I Think AIDS Is Raging 

among Teenagers Because of Their Passion for Possessions”. Rwandan Adolescents’ 

Perceptions on Sexual and Reproductive Health Vulnerability Using the ‘Mailbox 

technique’. Submitted to SAHARA (4/1/2012 – under review). Type: A1, IF: 0.741 

(“Paper 4: mailbox technique”) 

6. Stroeken K., Remes P., De Koker P., Michielsen K., Van Vossole A., Temmerman M. 

(2011). HIV among out-of-school youth in Eastern and Southern Africa: a review. AIDS 

Care 2012;24(2):186-94. Type: A1, IF: 1.603 (“Paper 5: out-of-school youth”) 

7. Michielsen K., Chersich M., Dooms T., Temmerman M., Van Rossem R.. Nothing as 

practical as a good theory? The theoretical basis of HIV prevention interventions for 

young people in sub-Saharan Africa. AIDS Research and Treatment. 2012:345327. 

Epub 2012 Aug 1. Type: A2 (“Paper 6: theory review”) 

 

Secondary papers (in annex): 

1. Delva W., Michielsen K., Meulders B., Groeninck S., Wasonga E., Ajwang P., 

Temmerman M., Vanreusel B. (2010), HIV prevention through sport: the case of the 

Mathare Youth Sport Association in Kenya, AIDS Care 22(8):1012-20. Type: A1, IF: 

1.684 (“Paper 7: Kenyan intervention”) 

18 

Kristein.indd 18 10/25/2012 8:36:14 PM

2. Stroeken K., Michielsen K., Remes P., Meeuwis M. The region-sensitive effect of 

globalization on HIV in Eastern and Southern Africa: The dual role of education. 

Submitted to AIDS & Behavior (08/2012 – under review). Type: A1, IF: 3.494 (“Paper 

8: globalization and education”) 

19 

Kristein.indd 19 10/25/2012 8:36:14 PM

20 

Kristein.indd 20 10/25/2012 8:36:14 PM

STUDY SITES AND 

POPULATION 

21 

Kristein.indd 21 10/25/2012 8:36:14 PM

3. Study Sites and Population 

As an introduction to the results, we present some background into the setting in which 

our studies took place, i.e. the Republic of Rwanda. 

3.1. Study setting: the district of Bugesera in the East Province of 

Rwanda 

Rwanda is a small landlocked country situated at the centre of the African continent. It 

has a surface of 26,338 square kilometres, slightly smaller than Belgium, and a population 

of almost 11.7 million [100], making it the most densely populated country in Africa. 

Rwanda has a very young population, the median age being 18.7 years, with a strong 

population growth (fertility rate: 5.4 children per woman) [101]. Rwanda has known 

a recent history of extreme violence. Since the Hutu ethnic group overthrew the Tutsi 

ruling king in 1959, there have been regular killings of Tutsis and moderate Hutus. This 

violence culminated in the 1994 genocide, where in the course of a month an estimated 

one million Tutsis and moderate Hutus were killed. Rwanda occupies rank 166 on the 

Human Development Index list [102], slightly below the sub-Saharan African average 

Figure 3.1: Map of Rwanda (left) and the district of Bugesera in the East Province of Rwanda 

(right) 

 

only a few years later a national HIV prevalence of 17.8% in urban areas and 1.3% in 

rural areas was registered. After the extreme violence and high number of sexual assaults 

during the genocide, the prevalence peaked in 1996 with an estimated 27% HIV-infected 

persons in urban areas and 6.9% in rural populations. While these data were mainly 

collected among pregnant women in antenatal care centres and patients from sexually 

transmitted infections (STI) clinics, more precise sentinel data were collected in 2002, 

22 

Kristein.indd 22 10/25/2012 8:36:14 PM

that found that prevalence varied between 2.6% and 3.6% in rural areas and between 

7.0% and 8.5% in urban areas. More recent surveys (2005 and 2010) established the 

adult HIV prevalence at 3% (4% in women and 2% in men). Urban areas remain most 

affected with a prevalence of 7.1%, compared to 2.3% in rural areas [103, 104]. 

The Rwandan government puts HIV high 

on the agenda. Over 110 million dollar 

was spent on HIV related activities 

in 2008 (mostly coming from external 

donors). A considerable part of this 

budget (26% or 29 million in 2008) is 

allocated to prevention. The Rwandan 

Government published an ambitious 

3-year National Strategic Plan on HIV/ 

AIDS (2009-2012) in which it aims 

to reduce the incidence of HIV in the 

general population by half. Concerning 

behavioural prevention, the Rwandan 

Government uses the EABC approach: 

education, abstinence, being faithful and 

condom use. [99] 

Our study takes place in the East Province 

of Rwanda, in the neighbouring districts 

of Bugesera (intervention district) 

and Rwamagana (control district). This 

province is characterized by low levels 

of knowledge on HIV, early sexual debut, 

high levels of risky sexual behaviour, and 

low uptake of HIV prevention related 

services [99]. It is a rural province, with few urban centres. 

3.1.1. Young People 

43.5% of the Rwandan population is under the age of 15 years, 53% are under the age 

of 20 years [107]. In Rwanda, HIV prevalence among young people aged 15-24 years is 

1.9% for women and 1.3% for men. Especially young women aged 20-24 years are affected: 

the HIV prevalence rises from 0.8% among those aged 15-19 years to 2.4% among 

those aged 20-24 years [103]. 6.6% of young people had sex before the age of 15 years 

[108]. Modern contraceptive use 2 among young women is 30.6% for women aged 15-19 

years and 42.1% for those aged 20-24 years. 11% of young people aged 15-24 years had 

comprehensive knowledge of HIV/AIDS [110]. 

2 “Modern methods of contraception include the pill, female and male sterilization, IUD [intrauterine device], injectables, implants, male and female 

condom, diaphragm, and emergency contraception. Traditional methods include periodic abstinence, withdrawal and folk methods” [109. Family 

Planning [http://www.measuredhs.com/topics/Family-Planning.cfm] 

23 

Kristein.indd 23 10/25/2012 8:36:14 PM

In the National Strategic Plan on HIV [99] young people get a prominent place; halving 

the HIV prevalence among young people is one of the key indicators. This should be 

reached by delaying the onset of sexual activity, expanding youth-friendly HIV prevention 

and reproductive health services, and integrating sexual and reproductive health and HIV 

prevention in the school curricula (p. 53). School-based sexual health and anti-AIDS clubs 

will be used to reach young people (p. 54); a total of 2.5 million dollar (2% of the total 

budget) is dedicated for HIV related activities among secondary school students. Young 

 

The overall coordination of the National Strategic Plan on HIV is done by the National 

AIDS Control Commission (CNLS). The implementation is divided into 12 sectors (according 

to the sector in which it takes place), under the responsibility of the corresponding 

ministry. Other partners in implementation are civil society organizations, the private 

sector, regional and international programmes, and national reference institutions [99]. 

3.1.2. School life in Rwanda 

The secondary education system in Rwanda is divided into two parts. In lower secondary, 

 

dents 

in secondary education ranges from 12 up to 30 years and even older. 

The gross enrolment rate (number of pupils enrolled in a given level of education related 

 

education is 143, which drastically reduces for lower secondary education (43) and higher 

secondary education (32 3 ) [111]. The gross graduation ratio is 53 for primary school, 

19 for lower secondary education [111] and 10 for higher secondary education [112]. 

The majority of secondary school students reside in boarding schools and only return 

home for holidays two or three times a year. In most schools, boarding school students 

 

‘clubs’ operate in the schools, giving the students the opportunity to engage in free time 

activities, such as football clubs, music clubs, or religious clubs. In each school, the Rwandan 

Government installed a mandatory ‘anti-AIDS club’. This club is tasked with motivating 

students to take preventive efforts against HIV infection. 

3 This means that, for each 100 young people that are, given their age, expected to be in higher secondary education, 32 are actually enrolled. 

24 

Kristein.indd 24 10/25/2012 8:36:14 PM

3.2. The intervention: the Peer Education intervention of the 

Rwandan Red Cross 

3.2.1. Short History 

 

beginning of the nineties. After the genocide, however, the programme stopped for sev- 

 

 

living with HIV/AIDS and prevention activities for youth, in the former provinces of 

Gikongoro and Gisenyi and later in Kibungo and Kibuye. In 2003, the Red Cross Belgium 

Flanders injected additional funds enabling the Rwandan Red Cross to set up an HIV prevention 

programme in secondary schools in the former province of Gitarama. 

The Gitarama programme was evaluated in the framework of a policy study for the Bel- 

es 

and points for improvement, a process was put in place to strengthen it and implement 

an improved new intervention in the district of Bugesera. A joint effort by the RRC, 

the Belgian Red Cross Flanders, Sensoa (the expert centre for sexual health in Flanders) 

and the International Centre for Reproductive Health (ICRH) was set up. Workshops were 

organized in Spring and Autumn 2008, to develop clear goals and objectives for the intervention, 

and to elaborate a monitoring and follow-up plan. Red Cross staff was trained in 

HIV/AIDS and sexual and reproductive health issues and in educational tools by Sensoa, 

who also developed a training for the peer educators. The intervention was funded by the 

Belgian Red Cross Flanders. 

3.2.2. Objectives and Design 

The main objective of the Peer Education intervention was to reduce sexual risk behaviour 

and to promote sexual and reproductive health in the secondary school community. 

 

- to increase knowledge of the students regarding HIV/AIDS and sexual and reproductive 

health; 

- to reduce discrimination and stigmatization of HIV positive people in the secondary 

schools and in the community; 

- to promote responsible sexuality; 

- to reduce sexual risk behaviours for STI/HIV and unplanned pregnancies; 

- to promote voluntary HIV/STI counseling and testing. 

 

were selected and given a 6-day training. The training consisted of information on the 

Red Cross and its main principles, HIV/AIDS, sexually transmitted diseases, family planning 

and pregnancies, the role of the peer educator (what is expected of a peer educator 

25 

Kristein.indd 25 10/25/2012 8:36:14 PM

and what is the deontology of a peer educator?) and teaching methods (how to best approach 

students and how to transmit messages and counsel?). The peer educators were 

selected by the disciplinary teacher, who lives in the school and knows the students well, 

 

teacher per school (‘encadreur’) equally received a training in order to be able to support 

the peer educators in their activities. School principals attended a half day information 

session on the intervention. Two-yearly follow-up trainings (‘recyclage’) and trimestral 

 

activities took place. Each trimester the peer educators handed in an activity report. The 

District Red Cross Coordinator paid regular visits to the schools and was available for 

questions at any time. 

The activities of the peer educators primarily focused on sensitizing their fellow students 

for adopting positive and responsible behaviours towards HIV/AIDS. This was done 

through group and individual counseling, theatres, songs and other interactive methods. 

The intervention started in August 2009 and ended in October 2010. It was implemented 

in all (15) secondary schools in the district of Bugesera. 

26 

Kristein.indd 26 10/25/2012 8:36:14 PM

METHODOLOGY 

27 

Kristein.indd 27 10/25/2012 8:36:15 PM

4. Methodology 

To reach the aforementioned objectives, several study designs were chosen: systematic 

literature reviews and a meta-analysis (objectives 1, 3.b and 3.c), quantitative (objectives 

2 and 3.a) and qualitative designs (objective 3.b). The advantage of combining several research 

methods is that they can counteract each other’s weaknesses while taking advantage 

of the particular strengths of each method; combining research methods most likely 

results in a more complete picture of the topic under study. The study designs will be 

discussed in detail in the papers presented in Chapter 5; hereafter a general description 

of the most important methodologies used throughout the doctoral study is presented. 

The chapter concludes by discussing the research ethics. 

4.1. Study Designs 

4.1.1. Systematic literature reviews: objectives 1, 3.b and 3.c (paper 1: 

meta- analysis, paper 5: out-of-school youth, and paper 6: theory 

review) 

Systematic literature reviews are used to identify and interpret all available relevant 

 

of the knowledge on a given topic, but equally allow to identify research gaps. 

Based on the PRISMA-and QUOROM-statement [114, 115], we performed two systematic 

literature reviews, one including a meta-analysis. These reviews resulted in three 

 

in sub-Saharan Africa (paper 1: meta-analysis), on the HIV and sexual and reproductive 

health status of out-of-school youth compared to in-school youth (paper 5: out-of-school 

youth) and on the theoretical basis of HIV prevention interventions for young people in 

sub-Saharan Africa (paper 6: theory review). 

Before the studies were effectuated, a study protocol was developed, which included procedures 

for the literature search strategy, the inclusion criteria, the data to be extracted, 

the extraction procedure and the data analysis methods. Both literature searches included 

academic and grey literature. Paper 5 included an assessment of the overall quality 

of the articles, based on Taylor [116] (Figure 4.1). The quality of the articles included in 

papers 1 and 6 was guaranteed by the use of inclusion criteria on methodological soundness. 

Inclusion criteria were developed. Inclusion was decided by two independent researchers 

(paper 5: out-of-school youth) and by one researcher performing the literature 

study twice with a six month time lapse in between (paper 1: meta-analysis and paper 6: 

theory review). For both reviews, an electronic data extraction sheet was piloted by the 

- 

 

discussion between the pair of reviewers. 

28 

Kristein.indd 28 10/25/2012 8:36:15 PM

Study Type 

Qualitative Quantitative 

Description of the sampling 

(inadequate=0; adequate=1) 

How was data collected? 

(inadequate=0; adequate=1) 

Independent inspection of data (1 

rater=0; >1 rater=1) 

Was there a clear description of data 

analysis? (no=0; yes=1) 

Use of supportive quantitative 

methods? (no=0; yes=1) 

Figure 4.1: Quality assessment of articles included in paper 6 

4.1.2. Quantitative research: objectives 2 and 3.a (paper 2: Rwandan 

intervention and paper 4: self-selection) 

In order to study the effectiveness of a peer-led HIV prevention intervention for young 

people in secondary schools in Rwanda (paper 2: Rwandan intervention), and to assess 

 

undertook a longitudinal non-randomized controlled trial. Such methodology allows to 

quantify the effectiveness of and participation in the intervention, to compare between 

intervention and control groups and between participants and non-participants. If collected 

properly, quantitative data also allow generalizations to a broader population. 

Study design: Longitudinal Nonrandomized Controlled Trial: Studies 2 and 4 

We undertook a longitudinal non-randomized controlled trial including 8 intervention 

and 6 control schools. The study assessed students’ knowledge, attitudes and behaviours 

3 times over a period of 18 months: March 2009 (Baseline), March 2010 (T1) and Sep- 

 

baseline and T1 surveys were used, assessing if respondents’ characteristics at baseline 

could predict participation in the intervention at T1. 

Since the study was already planned to take place in all 15 secondary schools in the 

district of Bugesera over a certain period of time, it was not possible to randomly allocate 

schools, let alone, students, to the intervention or control condition. In the district 

of Bugesera 8 out of 15 schools were selected on a purposive basis. We aimed to include 

the greatest variety of schools in the study and applied several selection criteria: location 

(urban/rural), funding (public/private), number of students (small/large), religious 

background, and education offered (lower/higher secondary education). Control schools 

29 

Population size ( 1000=3) 

Design: clear question/hypothesis 

(no=0; yes=1) 

Design: Type of study (other=1; 

cross-sectional=2; casecontrol=3;cohort=4; 

RCT=5; review 

& meta-analysis=6) 

Data analysis 

Clear analysis plan (no=0; 

yes=1) 

Reporting on all participants 

(no=0; yes=1) 

Clear results (no=0; yes=1) 

Kristein.indd 29 10/25/2012 8:36:15 PM

in the neighbouring district of Rwamagana were selected using the same criteria. The 

 

chance of still being in school at the end of the survey. Drop-out rates are highest after 

 

year. Since no roads directly connect intervention and control sites, cross-site contamination 

was unlikely. 

enced 

sexual behaviour (condom use and recent history of sexual intercourse), sample 

size calculations were based on Wald tests for the odds ratio associated with the interaction 

term in regression models with two binary variables (intervention/control and T0/ 

T1 or T0/T2) and their interaction. For logistic regression models, a minimum of 1,241 

observations are required to detect an adjusted odds ratio of 2 or more with 80% power 

lence 

of the outcome variable and no changes over time in the control group [117]. For 

linear regression models, a minimum of 348 observations are required to detect a small 

 

[118, 119]. Further, we assumed a design effect of 2, due to possibly strong correlation 

of repeated measurements from the same participant (T0/T1/T2), resulting in a minimum 

of 2,482 observations required from 1,241 participants. Anticipating a 25% loss to 

follow-up, we increased the target sample size to 1,655 participants. 

Data Collection 

The data were collected using paper-based self-administered questionnaires with closed 

ended questions. The questionnaire was developed in French, translated in Kinyarwanda 

and back translated in French. The questionnaires were developed using existing, 

validated questions and scales both for Rwanda [120-123] and Kenya [124-129] and 

were pretested among a small group of young people. In Rwanda, the questionnaires 

were administered in classrooms or refectories. The data-entry was done electronically 

 

was done by or under supervision of the main researcher and consistency checks with 

the paper versions were done by the main researcher. 

Statistical Analysis 

Three statistical packages were used to analyse our data: Stata version 11 (Stata Corporation, 

College Station, TX) (papers 2 and 4), R version 2.9.0 (Ihaka & Gentleman, 1996; 

R Development Core Team, 2005) (paper 3), and SAS version 9.2 (SAS Institute Inc., Cary, 

North Carolina). The latter was used to test if answers from students within one school 

were correlated. Since this was not the case, it was decided not to include schools as a 

dures 

that were used to analyse our data. 

Propensity score matching (paper 2: Rwandan intervention) 

The allocation of schools to the intervention and control group in the Rwandan study was 

30 

Kristein.indd 30 10/25/2012 8:36:15 PM

not randomized. Therefore we had to consider the possibility of selection bias. We evalu- 

 

in the intervention and control groups, which appeared to be the case. To control for this 

imbalance we calculated propensity scores. A propensity score is the probability of a unit 

being assigned to a particular condition in a study given a set of known covariates [130]. 

Participants with propensity scores outside of the area of common support ([0.17, 0.98]) 

were excluded from subsequent analyses [131]. The propensity scores were also included 

as a covariate in the multivariate effectiveness analysis. 

Generalized estimation equations (paper 2: Rwandan intervention) 

Given the longitudinal nature of the Rwanda study (each respondent participated three 

times in the study), we needed to take into account the possibility of correlation between 

 

averaged linear regression models to correlated data [132]. Parameter estimates from 

 

In the Rwandan effectiveness study, marginal linear and logistic regression analyses, using 

GEE, were conducted to determine the likelihood of experiencing different outcomes 

based on which group the participant belonged to, while accommodating for repeated, 

 

binomial or Gaussian distribution depending on which dependent variable was analysed. 

Ordinal, multinomial and linear regression techniques (paper 3: self-selection) 

To study determinants of binary and categorical dependent variables, we used binary, 

ordinal and multinomial logistic regression. When studying determinants of a linear variable 

we used linear regression models with backward variable selection technique. The 

 

effects in a step-wise manner. At each step, the independent predictor with the least contribution 

to the total variability was deleted. Akaike Information Criterion (AIC) was used 

 

where -2Log Likelihood is twice the difference in the log Likelihood of the full model and 

the alternative model [135] and k is twice the number of estimated parameters in the 

model (number of variables and the intercept). For linear regression, competing models 

 

related to the independent predictors (link function). Fitting models with different possible 

distributions and link functions is an integral part of model selection by goodness of 

 

4.1.3 Qualitative study: objective 3.b (paper 4: mailbox technique) 

One of the hypotheses of the observed limited effectiveness of HIV prevention interventions 

for young people in sub-Saharan Africa, and in Rwanda in particular, is that HIV 

prevention interventions do not address the right topics to make young people change 

their sexual behaviour. Hence, a study into the factors that determine this sexual behav- 

31 

Kristein.indd 31 10/25/2012 8:36:15 PM

iour is advisable, but complex and sensitive. The main objective of this study was to gain 

a thorough understanding of young Rwandans perceptions on sex and relationships. 

 

sexual and reproductive health and 2) to formulate recommendations for interventions 

that more directly address young people’s needs. Given the exploratory nature of such a 

study, we opted for a qualitative approach. This allows to uncover hidden and underlying 

ing 

of the perspectives of the study population. 

Study Design 

There were several concerns for collecting data among in-school Rwandan youth on the 

sensitive topic of sexuality and relationships using traditional qualitative methodologies. 

Interviews and focus group discussions would likely not generate useful information, 

because of the taboo on the topic and social desirability bias. Since the majority of the 

students live in boarding schools, without privacy, using a diary method was not appropriate 

because of the lack of safe storage spaces. An essay method, asking young people 

to write an essay on a particular subject would have the downside that students would 

only be able to express their ideas on one particular (imposed) moment. We sought a 

way in which young people could freely and voluntarily express their ideas on paper 

without having to store their written documents in an unsafe place. The idea of a mailbox 

emerged, which offered the advantages of anonymity and spontaneity. 

Data Collection 

Six secondary schools, selected on a purposive basis, were given a mailbox in March 

2009 and asked to install it in a place with a large passage of students, away from signs 

 

by the principal investigator. Instructions were attached to the mailbox and the students 

received detailed information on the objectives of the study in a school assembly. While 

ated 

in September 2009. 

Almost half of the relevant letters came from one (rural, lower secondary) school, even 

though all schools were given similar levels of information about the project. School 

administration and teachers of this school were asked if they had undertaken actions to 

motivate their students to write the letters, which was not the case. The reason for this 

difference between schools is not clear. 

Data Analysis 

In total, 186 letters were collected. Analysis was done in QSR NVivo 9 (QSR International 

 

reproductive health or relationship issues were excluded from the analysis. Second, a 

closed coding system was applied, using the theoretical framework of Delor and Hu- 

32 

Kristein.indd 32 10/25/2012 8:36:15 PM

ert [137] as a guideline. The coding was done twice by the same researcher with four 

months between each coding. 

4.2. Research Ethics 

4.2.1 Ethical Approval 

The study was approved by the Ethics Commission of the Ghent University Hospital 

(2008/485), on the condition that approval was obtained from a local Ethics Commission. 

The Rwanda National Ethical Committee (42/RNEC/2009), the Rwandan Institute 

for Statistics (130/2009/INSR) and the Rwandan National AIDS Commission (0135/ 

CNLS/2009/S.E) also approved the study. 

 

Participants in the survey were explained the objectives of the study and the principles 

 

informed consent form prior to participation. Since it was a longitudinal study, we used 

a coding system guaranteeing anonymity to link answers of the same respondent over 

time. 

Participation in the mailbox study was voluntary. Students were gathered and explained 

the objectives of the study. Then, once the mailboxes were installed, students could 

themselves take the initiative to participate. Providing their name, sex, age or any other 

personal information was not required. When provided, this information was treated 

 

All school authorities were explained the objectives of the study and asked to sign a form 

consenting to use their school as a study setting. Collaborators in the study were asked to 

read and consent to the ethics code of the American Sociological Association [138]. 

4.2.3. Exemption for Parental Consent 

Even though the legal age of majority is 21 years in Rwanda, and our study included 

 

submission of our research project to the Rwandan National Ethical Committee was not 

approved for that reason. Argumentation in the second submission convinced the Committee 

members that parental consent was not necessary. Two main arguments were 

given. First, practical considerations: most students live in boarding schools and return 

home only two or three times a year. Parents rarely come to the school. The school does 

not possess all addresses or phone numbers of the parents, making it impossible to visit 

them or contact them by letter or phone. Low literacy rates and a low number of phone 

ownership was an additional problem. Second, we argued for a more developmental 

approach to adolescence and adulthood and stressed the importance of collecting data 

directly from adolescents. Based on guidelines from the World Health Organization [139], 

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the Society for Adolescent Medicine [140], the American Sociological Association [141] 

standing 

studies and have the cognitive capacity to take decision concerning participation 

and that the generally accepted age limit for this capacity is 14 years. 

34 

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35 

RESULTS 

Kristein.indd 35 10/25/2012 8:36:15 PM

5. Results 

5.1. Outline 

The results section is divided into three parts, following the objectives of the study. 

Firstly, we will elaborate on the overall effectiveness of HIV prevention interventions for 

young people in sub-Saharan Africa, by presenting the results of a literature review and 

meta-analysis (objective 1, paper 1: meta-analysis). 

Secondly, we will present the results of the evaluations of a peer-led school-based HIV 

prevention interventions for young people in Rwanda (objective 2, paper 2: Rwandan intervention). 

Both the meta-analysis and the Rwanda study demonstrate that HIV prevention 

interventions for young people do not result in large changes in sexual behaviour. 

Thirdly, we will analyse the possible reasons for this observed limited effectiveness 

(objective 3): participation in the intervention (paper 3: self-selection), determinants 

of young people’s vulnerability (paper 4: mailbox technique and paper 5: out-of-school 

youth) and the theoretical assumptions used in these interventions (paper 6: theory 

review). 

 

5.2. To assess the overall effectiveness of HIV prevention 

interventions for young people in sub-Saharan Africa 

(objective 1) 

Introduction 

Literature reviews on the effectiveness of particular types of HIV prevention interventions 

for young people and other populations in sub-Saharan Africa and other regions, 

suggest a limited effectiveness of such interventions in changing sexual behaviour and 

reducing HIV incidence. However, a literature study and meta-analysis on the effective- 

 

Saharan Africa, that allows drawing overall conclusions on their effectiveness, was missing. 

Studying evaluations of HIV prevention interventions for young people also provides 

insights in possible reasons for their success/failure. 

Papers 

Michielsen K., Chersich MF., Luchters S., De Koker P., Van Rossem R., Temmerman M. 

(2010). Effectiveness of HIV prevention for youth in sub-Saharan Africa: systematic review 

and meta-analysis of randomized and nonrandomized trials. AIDS 24(8):1193–202. 

Michielsen K., Chersich M., Luchters S., Van Rossem R., Temmerman M. (2010). Concurrency 

and the limited effectiveness of behavioural interventions on sexual risk behaviour 

of youth in sub- Saharan Africa. AIDS 24(13):2140-2 (correspondence). 

36 

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37 

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38 

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39 

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40 

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41 

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42 

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43 

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44 

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45 

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46 

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47 

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48 

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49 

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5.3. To assess the effectiveness of a peer-led school-based HIV 

prevention intervention in Rwanda (objective 2) 

Introduction 

The literature review and meta-analysis indicated a rather limited effectiveness of HIV 

prevention interventions in sub-Saharan Africa in changing young people’s sexual behaviour 

or HIV incidence. To get a better understanding of how HIV prevention interventions 

for young people in sub-Saharan Africa are developed, implemented and evaluated, we 

set up an evaluation study of a peer-led school-based intervention in Rwanda. Given the 

limited number of evaluated HIV prevention interventions for young people in sub-Saha- 

more, 

studying the intervention in detail provides more insights into the possible reasons 

for success or failure of interventions in general. 

Furthermore, we collaborated in the evaluation of a peer-led sports-based HIV prevention 

intervention for young people in Kenya. The paper presenting the results of this 

effectiveness evaluation can be found in annex to this thesis (Delva W., Michielsen K., 

Meulders B., Groeninck S., Wasonga E., Ajwang P., Temmerman M., Vanreusel B (2010), 

HIV prevention through sport: the case of the Mathare Youth Sport Association in Kenya, 

AIDS Care, Aug;22(8):1012-20). 

Papers 

Michielsen K., Beauclair R., Delva W., Van Rossem R., Temmerman M. (2012) The impact 

of a peer-led HIV prevention intervention in secondary schools in Rwanda: results from a 

cohort study with repeated measures and control group. BMC Public Health, 12:729. 

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51 

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52 

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53 

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54 

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55 

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56 

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57 

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58 

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59 

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60 

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61 

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62 

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63 

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65 

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67 

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5.4. To identify and study possible reasons for the observed limited 

effectiveness of HIV prevention interventions for young people 

in sub-Saharan Africa (objective 3) 

Both the literature review and evaluations of peer-led HIV prevention interventions 

showed that such interventions do not seem to live up to their goal of reducing sexual 

 

reasons that might explain this observed lack of effectiveness: interventions do not succeed 

in reaching their target population, interventions do not address the crucial factors 

to reduce young people’s vulnerability to HIV, and interventions start from the wrong 

assumptions to change sexual behaviour of young people. 

5.4.1. To assess young people’s participation in HIV prevention interventions 

(objective 3.a) 

Introduction 

One of the conclusions of the literature review and meta-analysis was that there was a 

differential effectiveness of HIV prevention interventions; studies that compared young 

people highly exposed to interventions with those who had less exposure report more 

 

active participants was rarely further elaborated upon. 

Paper 2 (Rwandan intervention) showed that participation in the intervention was very 

low, with a large proportion of the target population not participating in the intervention. 

This was equally the case for the Kenyan intervention presented in annex. In the Rwandan 

intervention, over 40% of the respondents had not participated in any of the intervention 

activities. In the Kenyan intervention, about one in six never participated. 

Using the data from the Rwandan study we analysed if pre-intervention characteristics 

 

 

in the intervention, participation in group discussions and participation in individual 

advice. 

Paper 

Michielsen K., Celis H., Jingwa B., Degomme O., Van Rossem R., Temmerman M. Selfselection 

in an HIV prevention intervention: who is participating? Results from a peer 

education programme in secondary schools in Rwanda. Submitted to AIDS Education and 

Prevention. 

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73 

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74 

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75 

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76 

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77 

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78 

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79 

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80 

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81 

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82 

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83 

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84 

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85 

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86 

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87 

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88 

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89 

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5.4.2. To study the vulnerability of young people for poor sexual and 

reproductive health (objective 3.b) 

Introduction 

A possible explanation of the limited effectiveness of HIV prevention interventions could 

be that the interventions do not address the right topics to make young people change 

their behaviour. Since sexuality and sexual relationships are inherently embedded in a 

social context, a thorough contextualized understanding of young people’s perceptions 

on sex and relationships is essential for formulating effective SRH promotion interventions. 

However, few studies on sexuality of youth in Africa go beyond describing HIV risk 

related behaviours. We undertook two studies on determinants of young people’s sexual 

health, focussing on different levels. 

Firstly, we aimed to gain a thorough understanding of young Rwandans’ perceptions 

on sexuality and relationships, by analysing the stories they spontaneously write about 

sexuality and relationships. This allowed to identify factors that young people themselves 

indicate to be important in their sexual decision making and allows to analyse their particular 

vulnerability for HIV infection and poor sexual and reproductive health. 

Secondly, focussing on the environmental level, we assessed the link between being 

out-of-school on the one hand and HIV status and risky sexual behaviour on the other 

hand, thereby uncovering the protective/hazardous effect of schooling for young people. 

This study aims to demonstrate the important role of structural level factors on young 

people’s HIV status, sexual and reproductive health and sexual behaviour. To this end, we 

undertook a literature review of descriptive studies in East and Southern Africa. 

Furthermore, we lifted the education factor to the highest level and studied its impact as 

a structural factor on HIV prevalence. The starting hypothesis was that the link between 

 

of globalization. Analysing data from the Demographic Health Survey and other datasets, 

we tried to uncover, qualify and contextualize this link. This study is presented in annex 

to this thesis (Stroeken K., Michielsen K., Meeuwis M., Remes P. The region-sensitive 

effect of globalization on HIV in Eastern and Southern Africa: The dual role of education. 

Submitted to AIDS & Behavior). 

Papers 

Michielsen K., Remes P., Van Rossem R., Temmerman M. “I Think AIDS Is Raging among 

Teenagers Because of Their Passion for Possessions”. Rwandan Adolescents’ Perceptions 

on Sexual and Reproductive Health Vulnerability Using the ‘Mailbox technique’. Submitted 

to SAHARA. 

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Stroeken K., Remes P., De Koker P., Michielsen K., Van Vossole A., Temmerman M., (2011). 

HIV among out-of-school youth in Eastern and Southern Africa: a review. AIDS Care 

2012;24(2):186-94. 

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92 

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93 

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94 

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95 

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96 

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97 

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98 

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99 

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106 

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108 

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109 

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111 

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116 

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117 

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118 

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5.4.3. To assess the theoretical assumptions used to change sexual behaviour in 

HIV prevention interventions for young people in sub-Saharan Africa 

(objective 3.c) 

Introduction 

One of the conclusions of our literature review and meta-analysis was that the observed 

 

reduction interventions. We undertook a study assessing the theoretical underpinnings 

of HIV prevention interventions for young people in sub-Saharan Africa. This section 

assesses the extent to which these interventions are grounded in theory, how these 

theories are used and if theory-based interventions are more effective in changing sexual 

behaviour than interventions not based on theory. We discuss the gaps in the theoretical 

basis of HIV prevention interventions for young people in sub-Saharan Africa. 

Papers 

Michielsen K., Chersich M., Dooms T., Temmerman M., Van Rossem R.. Nothing as practical 

as a good theory? The theoretical basis of HIV prevention interventions for young 

people in sub-Saharan Africa. AIDS Research and Treatment. 2012: 345327. Epub 2012 

Aug 1, 

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124 

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126 

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127 

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128 

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129 

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130 

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131 

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133 

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134 

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135 

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136 

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138 

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139 

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140 

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141 

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142 

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143 

DISCUSSION 

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6. Discussion 

Given the high burden of HIV on young people in sub-Saharan Africa, the main objective 

of this study was to improve the effectiveness of HIV prevention interventions for young 

people in this region. To that end, we assessed the overall effectiveness of such interven- 

 

improvement. 

This discussion is divided in four parts. Firstly, we discuss the effectiveness of HIV prevention 

interventions for reducing sexual risk behaviour of and HIV incidence in young 

 

most important reasons for this observed limited effectiveness is presented, suggesting 

 

study. Finally, recommendations, conclusions, and suggestions for further research are 

formulated. 

6.1. Failure to demonstrate the effectiveness of HIV prevention 

interventions 

The literature review and meta-analysis (paper 1) showed limited effectiveness of HIV 

prevention interventions for young people in sub-Saharan Africa. Young people did 

 

condom use only increased notably among males, but remained at a low level. Further- 

 

 

changes in knowledge and attitudes, but only small changes in sexual behaviour [88-91, 

93, 163]. None of the interventions included in the meta-analysis had an overall positive 

 

meta-analysis. Mavedzenge [164] systematically reviewed evidence on the effectiveness 

of youth HIV/AIDS prevention interventions in sub-Saharan Africa and made evidence- 

 

 

 

evaluations that were not overall positive (e.g. [165-167]). For all other types of interventions 

the evidence was too weak to advice scale-up. A review of Ross [96], including 

randomized controlled trials (RCTs) of HIV prevention interventions with biological end- 

 

of which none measured a reduction in HIV incidence. 

 

remains a mismatch between the number of evaluated HIV prevention interventions for 

young people in sub-Saharan Africa and the burden of the HIV epidemic for youth in this 

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egion. In 2010, young people aged 15 to 24 years accounted for 42% of new HIV infections 

[25]. These numbers justify an important focus on young people in HIV prevention 

efforts and contrast sharply with the fact that we could only identify 34 relatively wellevaluated 

interventions in sub-Saharan Africa that aim to reduce young people’s sexual 

risk behaviour, over a period of over two decades (paper 1: meta-analysis and paper 6: 

theory review). 

 

Africa is dominated by behavioural interventions using educational and sensitising 

tools to achieve behaviour change. This is generally called the “Information, Education, 

Communication” (IEC) approach. Even though our literature study allowed to include 

 

sexual behaviour applying a structural approach: using cash transfers, the intervention 

aimed to stimulate girls to stay in school and to reduce their economic dependence on 

 

than the control group, though the absence of HIV baseline data warrants caution. Also 

recently, the Population Council published the results of the Siyakha Nentsha Programme 

 

to school-aged boys and girls. The evaluation showed that young men had reduced onset 

of sexual activity and fewer partners [168]. 

 

evaluations and reviews on related topics have found: interventions aiming to reduce 

sexual risk behaviour of and HIV incidence in young people using IEC approaches generally 

do not live up to their goal. The peer-led school-based intervention in Rwanda (paper 

2) did succeed in increasing young people’s perception that AIDS is a serious disease and 

 

differences between the intervention and control group when it came to self-reported 

sexual behaviour including condom use. Participants in the peer-led sports-based intervention 

in Kenya (paper 7, annex) reported more condom use, but this remained at a low 

level and the effect disappeared in the multivariate analysis. In addition, the intervention 

group reported higher behavioural control. There were no differences between the intervention 

and control groups concerning attitudes, sexual activity, concurrent partnerships 

and number of partners. 

Three decades of developing, implementing and evaluating HIV prevention programmes 

for young people in sub-Saharan Africa has not resulted in a ‘gold standard’ intervention. 

Both on the macro-level (meta-analysis) and the micro-level (peer-led interventions) no 

convincing evidence was found of the effectiveness of these interventions in reducing 

sexual risk behaviour of and HIV incidence in the target population. 

On the other hand, UNAIDS reports that HIV incidence declined among young people in 

21 countries with generalized epidemics between 2001 and 2009 and that these reduc- 

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tions occurred amid signs of changes in sexual behaviour (later sexual debut, reduction 

of multiple partnerships and increase of condom use at last sex) [59, 60]. This means that 

young people are changing their behaviour, but that these changes are hardly observed as 

the results of HIV prevention interventions. In the next section, we will elaborate on the 

possible reasons for the observed limited effectiveness of HIV prevention interventions 

on sexual risk behaviour of young people in sub-Saharan Africa. 

6.2. Reasons for the observed limited effectiveness of HIV 

prevention interventions 

The observed limited effectiveness of HIV prevention interventions in sub-Saharan Africa 

in changing young people’s sexual behaviour and reducing HIV incidence cannot be at- 

 

of possible mechanisms: 

- factors related to the intervention (6.2.1.): intervention design (content and objec - 

tives) and intervention implementation (participation and approach); 

- factors related to the evaluation (6.2.2.): evaluation design and evaluation outcomes. 

6.2.1. Intervention related factors 

In assessing evaluations of HIV prevention interventions, much attention goes to the 

quality of the evaluation design, to avoid Type I (false positives) and Type II (false negatives) 

errors [135], but less consideration is given to what Green [169] calls Type III errors: 

the adequacy of the intervention itself. In this section, we will discuss the intervention 

design (content and objectives) and implementation (participation and approach). 

6.2.1.1. Intervention design 

The ultimate objective of most HIV prevention interventions, including those studied in 

this thesis, is to reduce HIV incidence in young people. By trying to do so, interventions 

aim to reduce sexual risk behaviour resulting in the following logical sequence (Figure 

6.1): 

HIV prevention 

intervention 

Figure 6.1: Theoretical intervention sequence of HIV prevention interventions for young 

people in sub-Saharan Africa 

Sexual risk behaviour 

Despite the simplicity of this sequence, the practical interpretation seems less straightforward; 

interventions focus on cognitions to increase condom use and reduce unsafe 

sexual activity, which on its turn should result in a reduced HIV incidence (Figure 6.2). 

 

146 

HIV incidence 

Kristein.indd 146 10/25/2012 8:37:56 PM

the intervention content - which is traditionally focused on increasing HIV related knowledge, 

adopting HIV related positive attitudes and learning HIV related skills - and the 

interventions’ objectives, i.e. changing sexual behaviour. The second problem concerns 

the choice of the interventions’ behavioural outcomes and strength of association with 

HIV incidence. 

 

Traditional interventions: 

ABC, IEC, skills building, 

stigma reduction, risk 

perception 

Intervention outcome 

objectives: increase 

condom use, reduce 

sexual activity 

Figure 6.2: Practical interpretation of intervention sequence 

Intervention content 

The objectives of HIV prevention interventions for young people in sub-Saharan Africa 

are broad. The Rwandan intervention aimed to reduce sexual risk behaviour and to promote 

sexual and reproductive health and the Kenyan intervention had as a main objective 

to promote sexual behavioural change among the youth of the Mathare Valley community. 

To achieve this, the interventions educated participants on HIV transmission routes 

and protection modes through traditional and interactive learning methods. These are no 

exceptions; many other (peer education) interventions have similar objectives and use 

comparable methods (e.g. [124, 170-173]). 

Looking at their theoretical basis, we found that HIV prevention interventions are based 

on cognitive behavioural models, that explain sexual behaviour through a number of 

cognitions as intentions, attitudes, beliefs and expectations (paper 6). By focussing on 

cognitive constructs of behaviour, the interventions start from the assumption that cogni- 

 

The discrepancy between knowledge and behaviour may also be related to adolescent 

brain development: since the prefrontal cortex, which is associated with risk-taking and 

decision-making, is among the last regions of the brain to gain maturity [175, 176], it is 

 

are prone to impulsive behavior [177]. 

 

critical determinants of sexual behaviour, forming a complex multi-layered and interde- 

 

 

four levels: 

- personal factors: characteristics of the individual; 

- interpersonal factors: direct relationships between the young person and another 

person; 

- environmental factors: organizational or institutional factors that shape the direct, 

proximate environment; 

- social and cultural factors: factors that shape the society and context on a higher, distal 

level. 

147 

Ultimate objective: 

reduce HIV 

incidence 

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Personal level 

Adolescents go through a period of physical and emotional maturation on their way to 

adulthood, constructing their adult identity by exploring and experimenting, including 

sexually. They might not yet have stable internalized values and norms concerning 

 

relationship. Their limited experience makes them vulnerable to peer pressure and unhealthy 

decisions (paper 4: mailbox technique). 

Although the level of HIV knowledge of young people in Rwanda was high - after the 

Rwandan intervention the median score for knowledge of HIV transmission routes was 

10/11 (paper 2) - the questions posted in the mailboxes (paper 4) demonstrated a low 

understanding of the biological mechanisms of HIV and human reproduction. It seemed 

that young people in our study can replicate the prevention messages they hear (abstain, 

be faithful, use a condom), but might lack understanding of the reasons for proposing 

these behaviours. 

Interpersonal level 

Young people engage in different types of sexual relationships, putting them differently 

at risk for HIV infection. Age-disparate relationships are more risky because they expose 

the younger person (mostly a girl) to a partner who is more likely to be sexually 

experienced and hence more likely to be HIV positive [36, 180-182]. Overlapping sexual 

partnerships or concurrent relationships create a highly connected sexual network that 

serves as a highway for HIV transmission [40-42]. 

Among young people in Rwanda, both types of relationships exist, driven by an underlying 

phenomenon: transactional sex, in which money or gifts are given in exchange for 

sexual intercourse (paper 4: mailbox technique). The “desire to lead a modern life”, as it 

is called by Remes [183], is a driving factor in engaging in transactional sex, on its turn 

encouraging multiple partners and relationships with older partners to increase material 

gain. The letters written by Rwandan students indicated that peer pressure is a driving 

factor in these types of relationships. Also, it is clear from their letters that young people 

are curious and experiment with sex, or wish to do so. These experimental sexual interactions 

are driven by factors as curiosity and sexual desire, and occur among same-age 

youth. Given their ad hoc nature, these interactions often taken place unprepared and 

unprotected. 

Different types of sexual relationships are motivated by different factors, and put young 

people differently at risk. While experimental sex puts young people at risk because of 

the ad hoc nature and unavailability of condoms, the lack of condom use in transactional 

sex is often the result of a negotiation process. In steady, long-term relationships, young 

people can be at risk because proposing condoms might be seen as a lack of trust. Hence, 

these different types of partnership should be recognized and dealt with differently in 

HIV prevention interventions. In the evaluation studies included in our literature review 

and meta-analysis (paper 1), most researchers dichotomize sexual relationships either 

with a ‘steady’ or ‘casual’ partner, the latter being portrayed as considerably more risky 

 

prevention efforts; it risks conveying that long-term steady partnerships are safe, while 

in reality they might well be most hazardous [40-42]. 

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The interpersonal level not only concerns peers and partners, but also other important 

 

teachers fail to inform them on sexual health topics (paper 4: mailbox technique). 

Environmental level 

The situation in which the Rwandan study participants live – boarding schools with 

relatively limited supervision - allows for much contact between boys and girls, but 

few opportunities for planned sexual intercourse. Paper 5 (out-of-school youth) found 

that in-school youth have a lower HIV prevalence and less risky sexual behaviour than 

out-of-school youth. Although it cannot be ignored that this is partly because of other 

background difference between these two groups, the study suggests that schools may 

be relatively isolated communities where risky sexual behaviour might be less problematic 

than in the open network. On the other hand, schools can also be a risky place: 

several letters written by Rwandan students (paper 4: mailbox technique) mentioned the 

phenomenon of (male) teachers having sex with (female) students in exchange for school 

 

is commonly mentioned. 

Social and cultural factors 

Norms. Sex between young people is taboo and considered morally and legally (under 18 

itive 

aspects of relations, sex and sexuality. In the letters written by Rwandan students 

(paper 4: mailbox technique), a positive discourse on adolescent sexuality and relationships 

is almost completely absent. While young Rwandans do have sex for pleasure, the 

values attributed to adolescent sexuality are negative and sinful. 

Gender. Girls are usually seen as the provokers of sexual desire in boys; in experimental 

sex because of their provocative clothing and in transactional sex because of their desire 

for gifts. Boys are seen as only to act upon their physical needs. Nevertheless, girls are 

supposed to say ‘no’ to every attempt for intimacy, thereby devaluating the meaning of a 

‘real no’ (paper 4: mailbox technique). Paper 3 (self-selection) found that being a boy or 

girl was a dominant predictor of participation in the peer-led intervention. Those who 

are more outgoing and at ease with their sexuality are more likely to participate in group 

activities. In general, in Rwandan culture, while it can be considered a sign of masculinity 

to have sex, openly talking about sex is taboo for girls [161]. 

 

technique). Young people in Rwanda, especially girls, have sex in exchange for money and 

ence 

sexual decisions, in the sense that youth need money to buy less essential goods as 

telephones and body lotion that others may have. The less urgent need for these products 

in comparison to survival sex surely might put young people in a stronger negotiation 

position. However, they seem to use this power to negotiate more goods, instead of safer 

sex. 

Future perspective. In resource-limited societies with limited tangible opportunities and 

 

might win over the fear of possibly getting infected with a disease that will affect one 

- 

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Kristein.indd 149 10/25/2012 8:37:56 PM

pation in the peer-led intervention in Rwanda depended, among others, on the future 

perspective of the students: students who never had sex were more likely to participate 

when they have a more positive future perspective. 

Education and globalization. Paper 8 (globalization and education, in annex) found that 

 

literacy and a secluded or safer sex network, outweigh the risks of education, such as 

increase of mobility and of the reach and/or density of social (hence sexual) networks. 

This tipping point regionally differs because it relates to the level of globalization, itself 

determining the extent to which secondary education is common in a region and thus 

no longer a comparatively strong booster of the sexual network. Education therefore 

reduces prevalence and saves lives mostly in regions that have reached a certain level of 

globalization and thus passed the tipping point. In the less globalized regions, education 

should be prevented from creating a cultural vacuum, alienating pupils, or creating social 

division, as in the formation of elites with the means of engaging in much partner concurrency. 

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Kristein.indd 150 10/25/2012 8:37:56 PM

Policy 

Gender norms 

Family 

Teachers 

Parents 

Globalization 

Peers 

HIV related cognitions: 

knowledge, attitudes 

151 

Education 

Sexual and 

reproductive health 

services 


Partner characteristics 

Socio-demographic 

characteristics 

sexual 

behaviour 

HIV 

incidence 

Future 

perspective 

Access to 

condoms 

Type of relationship 

Individual factors 

Life stage: adolescence 

Economic factors 

School 

Interpersonal factors 

Environmental factors 

Norms 

Social and 

cultural factors

Gaps in intervention content 

 

indication of the complexity of young people’s sexual behaviour. The combination of 

studies suggests that sexual behaviour is determined by more than cognitive predictors 

as HIV related knowledge, attitudes and skills. Sexual decisions depend on interlinked 

personal factors, partner characteristics, type of relationship, the proximate context (e.g. 

school, family) and the more distal social and cultural context (e.g. norms, gender, poverty) 

(Figure 6.3). Seen from an ecological viewpoint, it is clear that interventions mainly 

focusing on personal HIV knowledge, attitudes and skills can only have limited effects 

on sexual behaviour. Recognizing the complexity and heterogeneity of sexual behaviour, 

theory could provide guidance in simplifying this complex behaviour and in identifying 

key determinants. However, the implicit assumptions made by many HIV prevention 

interventions might simplify sexual behaviour too much. They generally do not account 

for inter-personal, environmental, social and cultural factors related to the complexity 

of sex, the experience of youth and disparities in social, cultural and economic realities 

of young people in sub-Saharan Africa. As Mason-Jones [184] explained after evaluating 

the lack of effectiveness of a peer education programme: “It may be that social factors are 

 

changes”. It is possible that interventions are doomed from the outset, simply because it 

munity 

norms and structural factors. Ross [96] and Hayes [185] even stated that such 

interventions may be “inherently ineffective”. 

The vulnerability model [137] and the socio-ecological approach [178] may be good alternative 

frameworks to guide interventions. While the vulnerability model puts a strong 

emphasis on the interaction (sexual relationship), the socio-ecological model stresses the 

importance of both proximate and distal determinants of behaviour. Nevertheless, since 

young people are not a homogenous population and contexts differ, the most important 

part of developing an effective intervention is understanding the behaviour that one is 

trying to change, and using a thorough situation analysis and needs assessment to identify 

the determinants of this behaviour and causal pathways through which these deter- 

 

Interventions’ outcome objectives 

Interventions aim to reduce HIV incidence and, to that end, focus on reducing sexual risk 

behaviours. However, several studies have failed to demonstrate a consistent link between 

certain sexual behaviours and HIV incidence/prevalence. Buvé [186] looked at the 

difference in HIV prevalence between four cities in four different countries. The observed 

differences could not be explained by differences in sexual behaviour (even though 

ence 

HIV transmission, i.e. male circumcision and HSV-2 infection. Also Chapman [187] 

compared HIV prevalence and sexual behaviours in four countries and concluded that socalled 

sexual risk behaviours were higher in low prevalence populations. Pettifor [188] 

compared two nationally representative surveys of young people, one in South Africa and 

one in the USA. While HIV prevalence in South African young people is ten times higher 

 

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partners, and practiced safer sex. There are several possible explanations: South African 

young girls are more likely to have older sexual partners, male circumcision levels are 

lower, STI prevalence is higher, and the South African society is more characterized by 

gender power imbalances, poverty, coerced sex and rape, lack of youth friendly services, 

 

studied the role of education and demonstrated that HIV prevalence can be linked to 

structural factors as education and globalization and that this relationship differs regionally, 

nationally and sub-nationally. 

Reducing sexual risk behaviour among young people is essential in reducing HIV inci- 

 

in HIV incidence also depends upon relational and contextual factors. Otherwise put, the 

same behaviour does not result in the same risk for HIV infection in every relationship 

or context. In order to have a high impact, interventions should focus on the most risky 

behaviour(s) of their target population, and its dominant predictors, and should consider 

the position of the target population within the dynamic sexual network through which 

HIV is spread [189]. 

The Rwandan and Kenyan interventions described in this review were not based on a 

thorough assessment of dominant sexual behaviours and relationships, or on a contextual 

study. Therefore, it is possible that the interventions were targeting the wrong behav- 

 

Rwanda (paper 4) demonstrated that young people do have sex and that transactional 

sex, often with older partners, is one of the dominant forms of sexual relationships. 

 

young people on how to deal with this. Neither did it provide a positive approach to 

young people’s sexual relationships, which would allow discussion on how to integrate 

protective measures in such transactional relationships. 

comes. 

The behavioural objectives mostly aimed at are increased condom use (at last 

 

number of sexual partners, recent sexual activity). While protective sexual intercourse 

through condom use is unambiguously a positive measure against HIV infection, sexual 

activity is an outcome of a different sort. Many interventions attribute a positive connotation 

to postponing sexual debut and to reducing sexual activity and sexual partners, 

hence dividing sexual behaviours into ‘good’ and ‘bad’ behaviours. While manuals for 

setting up HIV prevention interventions for young people prioritize a non-judgemental 

 

(unconsciously) implies a moralistic judgement on young people’s sexual behaviour. We 

argue that HIV prevention interventions should question the utility of these behavioural 

outcomes and should more consciously choose how to reach their ultimate objective 

(reducing HIV incidence). A promising, alternative outcome was developed by Wellings 

[193]: sexual competence, which stimulates young people to be sexually responsible, 

making sure sexual intercourse is characterised by absence of coercion and regret, autonomy 

of decision, and use of a reliable method of contraception. While currently used 

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desired outcomes impose judgment on young people’s sexual behavioural choices, the 

latter approaches young people as responsible persons who can make conscious decisions, 

while at the same time acknowledging the importance of safe sexual behaviour. 

6.2.1.2. Intervention implementation 

A second reason why HIV prevention interventions for young people in sub-Saharan 

Africa fail to demonstrate success is that they are confronted with implementation problems. 

Studying the implementation of interventions is an essential condition for improving 

interventions’ effectiveness. It allows us to not only answer the question ‘Does the 

intervention work?’, but also questions as ‘How does it work?’ and ‘What components are 

essential to its success?’ [169, 194]. An extensive literature review by Durlak [195] provided 

strong evidence that effective implementation is associated with better outcomes 

in promotion and prevention interventions. 

Studies included in our literature review and meta-analysis partially ascribed the limited 

impact of interventions to poor implementation of the intervention [129, 149, 150, 196- 

198]. A process analysis of the Rwandan intervention was done by master student Hanne 

Celis in two intervention schools [199]. She found that practical problems hampered the 

implementation of the intervention. Firstly, because of internal organisational issues the 

intervention was cut off funding for a certain period. Fortunately, this happened during 

the second part of the intervention, when the peer educators were already trained and 

could continue their activities. However, they missed out on the follow-up trainings. Secondly, 

peer educators complained that not enough time and space was allocated to their 

activities. Thirdly, several aspects of the planned intervention, e.g. the development of a 

booklet for the peer educators, were not implemented [199]. 

The observed limited effectiveness of HIV prevention interventions for young people in 

sub-Saharan Africa is not responded to by extensive (published) process evaluations. 

Little is known about the implementation quality of interventions; in evaluation studies, 

ing 

uniquely on the implementation of interventions are even rarer; it seems that only 

large trials and study groups can afford to invest extensively in evaluating the process 

of developing and implementing HIV prevention interventions [83, 200-205]. Further- 

 

 

science for health interventions, a large number of journals are interested in outcome 

evaluations of health interventions. The limited word count that applies to most journals 

hinders that both evaluation types are presented together. 

 

prevention interventions, but represent a more general problem with intervention planning, 

budgeting and monitoring that exists in many other sectors. Therefore, we will not 

elaborate on this, and focus on less recognized implementation issues: participation and 

approach. 

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Participation 

HIV prevention interventions for young people often do not succeed in reaching the 

complete target population. In Rwanda, about 40% of potential participants did not participate 

in any intervention activity (paper 2: Rwandan intervention). In Kenya, one in six 

respondents said to have never participated (paper 7: Kenyan intervention, in annex). 

In Rwanda, we found that group activities are attended by three types of students. Firstly, 

we see that those who are at ease with their sexuality are more likely to participate. 

Secondly, practical considerations play their part in participation in group activities: 

students living in boarding schools tend to participate more. Thirdly, we identify a group 

of students that very consciously participates in the group activities: those who were 

recently sexually active, those who feel susceptible to HIV infection, those who were ever 

tested for HIV and those who are consciously abstaining from sexual intercourse. For in- 

 

lack of dominant predictors could equally mean that participation in individual advice is 

not greatly determined by pre-intervention characteristics, but by other factors occurring 

during the period of the intervention. 

This study showed that the type of activity chosen by the intervention planners has an 

impact on the type of participants. Therefore, in a homogenous group it is essential to be 

aware of the preferred activity type of the target population. In a heterogeneous group it 

is critical to offer a variety of activities in order to appeal to all young people involved. 

Another point of interest is the gender difference in participation. It seems that boys 

were more likely to participate in group activities, thereby suggesting the need for girlsonly 

spaces or activities on HIV prevention, encouraging young girls to openly discuss 

these topics. Since a positive sexual self-concept contributed to participation in the intervention, 

we recommend to include the general well-being of young people into interven- 

 

feelings, and to engage in healthy and respectful relationships. Finally, structural factors 

play an important role in intervention effectiveness: if the context where young people 

live in does not provide much perspective or support, implementing healthy behaviours 

is hampered. 

Approach: peer education 

The interventions we evaluated in Rwanda and Kenya used peer educators to transfer 

HIV prevention messages. Peer education is a popular approach: 17 of the 28 interventions 

in our literature review and meta-analysis used this approach (paper 1). Since 

many Rwandan school-going youth stay in a boarding school and only return to their 

families two or three times a year, they have no other option than to rely on peers or 

teachers for HIV/SRH information. Therefore, intuitively, peer education seems like a 

good strategy. However, the fact that young people need to rely on peers for information 

on HIV/SRH does not mean they want to rely on them. In our study, students were asked 

to indicate the two main channels through which they would prefer to receive information 

on HIV. Friends ranked sixth as a preferred source of information, preceded by radio, 

 

countries [206-209]. 

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Not disregarding the capacities young people have, it is a very tall order to expect a young 

person – possibly discovering his/her sexuality him/herself - to act as an expert and 

guide, counsel, teach and advise peers on a personal, sensitive and complex issue as sexu- 

 

to young people, the notion of ‘peer’ oftentimes refers to someone of the same age. This 

is a very simplistic notion: even though they might be of approximately the same age, this 

does not mean they have a similar background, similar experiences, similar values and 

norms [180]. Besides personal characteristics, a peer educator’s credibility is determined 

by their own behaviour and by how they transmit messages [210]. 

Peer education is an attractive tool for HIV prevention and SRH promotion, because it 

makes use of existing social processes and actively involves young people in the intervention. 

However, given its limited effectiveness, it might be necessary to re-evaluate the use 

and role of the peer educators. Firstly, in the Rwanda study we received reports of peer 

educators feeling superior to their peers. It seemed that peer education created some 

sort of hierarchy among the students. In personal communication with programme managers 

of other peer education interventions, the same issue was mentioned. The choice 

of peer educators, the support they receive and the monitoring of their work is essential 

to counteract this, and for the overall success of such interventions. Secondly, programme 

planners and evaluators must set realistic expectations for peer education. Peer education 

based on information sharing will never on its own change sexual behavior to a 

large extent. Yet, it can however be valuable in creating an open, positive climate around 

sexuality and in breaking taboos and have a long-term effect on sexual behaviour. Thirdly, 

while peer educators are now the centre of the intervention, informing, counseling and 

 

as focal points: beside spreading information on HIV/SRH through theatre, songs and 

discussions, they could be the ones who are aware of key specialists and services to 

which they can refer. Peer education should not be a stand-alone intervention and should 

be embedded in a larger strategy. Finally, peer education interventions seemingly actively 

involve young people in prevention efforts. However, only involving them in the implementation 

phase of an already developed intervention is not very participatory. True 

involvement goes further; young people can be involved in the needs assessment, in the 

set-up of the intervention, in the monitoring and in the evaluation. Their input in these 

phases might proof to be more valuable than in the actual implementation. 

6.2.2. Evaluation related factors 

 

explain the observed limited effectiveness of HIV prevention interventions for young 

people in sub-Saharan Africa, UNAIDS data report that “young people are leading the HIV 

prevention revolution” and that reductions in HIV prevalence coincide with changes in 

sexual behaviour among young people. Therefore, we cannot exclude that interventions 

do have an effect on young people’s sexual behaviour, but that evaluations do not succeed 

in demonstrating this effect. 

An overview of evaluations of HIV prevention interventions for young people in sub-Sa- 

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haran Africa (paper 1: meta-analysis) demonstrates few commonalities in study design, 

perhaps suggesting that there is little consensus on the optimal approach and that few 

studies have built upon previous knowledge in a linear way. No two studies use the same 

methods of analysing or reporting data, and outcome indicators are markedly diverse. 

 

analysis was far from universal. Other problems that surfaced concerned implementation 

of the intervention (as a result of which the evaluation does not measure the effectiveness 

of the intervention), comparativity of the control population, indicators used 

 

in participant retention). As Mavedzenge [164] compared a recent review on papers 

published between 2005 and 2008 with a review of papers published before 2005, she 

argues that the quality of recent studies was generally higher, “however, high quality was 

not universal, and this review was still hindered by poor study design and lack of analytical 

rigor in some evaluations.” The same observation has been made by other reviews on 

comparable topics [87, 91, 93, 94]. 

This chapter deals with issues in evaluation design quality and outcome measures used 

to evaluate interventions. 

6.2.2.1. Evaluation design 

Evaluators mostly try to use or approximate to (clustered) randomized controlled trials 

(cRCT), which are considered the gold standard for demonstrating cause-and-effect relation 

between an intervention and an outcome. In total, worldwide, nine behavioural or 

structural HIV prevention interventions for all populations have been evaluated using a 

well-developed randomized controlled trial [84, 96, 202, 211-218]. Their use to evaluate 

complex, multicomponent, multilevel interventions has been questioned for several years 

[51, 194, 219-222]. 

When applied to evaluate complex prevention approaches as behavioural prevention 

of HIV, several essential conditions of (c)RCTs are regularly compromised [221]. Firstly, 

study participants themselves should remain ignorant of the study arm they are attributed 

to. In most evaluations of HIV prevention interventions study participants are aware 

 

and generate reporting bias. Randomisation might also be compromised by the fact that, 

in the end, participants often decide themselves to what extent they participate in the 

intervention (paper 3: self-selection). Secondly, the large number of interventions and 

campaigns being implemented in many sub-Saharan African countries and of which it 

cannot always be controlled if they reach both intervention and control arm equally, even 

further complicates this. The condition of having a ‘naïve’ control group can rarely be ful- 

 

results from (c)RCTs may not be easily transferable, hence their utility is questionable 

[51, 194]. Furthermore, many evaluations seem to measure effectiveness on a relatively 

short term. Only one intervention was evaluated on a longer term (8 years) [223], while 

other evaluations did not exceed 3 years and often even did not measure effectiveness 

after 1 year. This observation is especially relevant given the long pathway targeted in 

public health interventions (increasing knowledge, changing attitudes, improving skills, 

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generating behavioural intention and then changing sexual behaviour and HIV incidence). 

Changes in sexual behaviour after interventions might pass through social and 

institutional changes or follow long causal pathways before they succeed in changing 

 

sexual behaviour and HIV incidence might not be observed on the short term, they may 

still occur in a later stage. 

An additional challenge of evaluation studies, not only (c)RCTs, is making sure the evalu- 

 

 

 

and 30% loss to follow-up (based on an incidence rate of 1.6%) [211]. It is possible that 

the intervention did reduce HIV incidence, but by less than 50%, making it not possible 

 

reduction of 25% in HIV incidence would already be of great value to public health, this 

would require an even larger sample size. For example, a decrease in HIV incidence 

from 0.5% to 0.4% would require 72,307 persons in each study arm [225]. Especially in 

dence 

requires an enormous sample size, and many trials are underpowered because of 

estimation or recruitment problems [96, 185]. Behavioural outcomes are more prevalent 

and require smaller, but still considerable, sample sizes: in our evaluation of the Rwanda 

intervention (paper 2) we calculated that for logistic regression models, a minimum of 

1,241 observations are required to detect an adjusted odds ratio of 2 or more with 80% 

 

prevalence of the outcome variable and no changes over time in the control group. 

Problems with the correct use of evaluation designs might lead to false conclusions, 

 

effects. Even though (c)RCTs are still considered by many to be “the cornerstone of the 

evidence needed to support implementation of HIV prevention programmes” [185] and 

“will remain the most rigorous and convincing intervention study design” [96], we follow 

Laga [194] when she “advocates for realism and pragmatism when it comes to generating 

more convincing evidence to guide prevention programming” and proposes “plausibility 

designs” as an alternative, an approach followed by the latest meeting of the UNAIDS 

Programme Coordinating Board (June 2012). Such designs rely on a number of information 

sources from mixed methods - including monitoring, process evaluation, qualitative 

methods, modeling, population based surveys, quasi-experimental designs – to build a 

plausible case for intervention effectiveness. 

6.2.2.2. Outcome measures 

To measure the effectiveness of HIV prevention interventions, studies rely on two main 

types of outcome indicators: biological and behavioural endpoints. Since the ultimate 

objective of HIV prevention interventions is to reduce incidence of HIV, this seems to be 

the best outcome to use. 

The use of such a biological endpoint is rare. In our meta-analysis (paper 1), two studies 

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were included that measured HIV status [211, 212]. Since then three additional studies 

were published: one evaluated a multicomponent HIV prevention intervention for young 

people in Zimbabwe [226], one updated the evaluation of Ross [96] with a long-term 

impact study [223] and one presented results of a cash transfer intervention for school 

girls [84]. We are aware of one other trial in South Africa and Tanzania that assesses the 

impact of a multicomponent behaviour change intervention for young people, but of 

which the results of the biological endpoint are not yet published [227, 228]. 

Of the ones studied, no IEC intervention, even though well designed and implemented, 

succeeded in causally linking a reduction of HIV incidence to the intervention (paper 1: 

- 

 

 

incidence. Doyle [223] hypothesized that the impact of the intervention on biological 

endpoints would increase over time, but an evaluation eight years post-intervention did 

 

As the previous section demonstrated, using such biological outcomes requires very 

large sample sizes, making it complex and expensive. Sometimes, other STIs are used as 

substitutes for HIV incidence. However, a good biological substitute would have to share 

characteristics as prevalence level, stage of the epidemic, risk groups and behaviour and 

probability of transmission with HIV which is rarely the case [229, 230]. 

As an alternative, many evaluations rely on self-reports of sexual behaviour. Using this 

strategy many studies have been confronted with discrepancies between reported sexual 

 

Shiri trial is that none of the four girls who were pregnant reported that they had sex 

in the questionnaire [202]. In a study in the UK, more than 10% of young adults with a 

 

in the 12 months before STI testing [231]. Sison [232] found that women with genitourinary 

symptoms may over-recall frequency of sexual behaviour compared to women 

without these symptoms. In a study among Zimbabwean women, 12% of the participants 

that tested positive for recent semen exposure reported no sex in the previous two days 

[233]. These discrepancies are caused by recall bias and social desirability bias, depending 

on the timeframe studied (e.g. lifetime recall versus last month recall), the interview 

mode (e.g. face-to-face, self-administered, computer-assisted) and the study population 

[234, 235]. These problems have been extensively studied and documented [236-240], 

and will not be discussed here. 

A more overlooked problem to evaluation research, is the choice and interpretation of 

outcome measures. In our and many other evaluation studies, internationally recognized 

indicators are used and interpreted as follows: ‘condom use at last sex’ (if this increases, 

the intervention is considered successful), ‘recent sexual activity’ (if this decreases, 

the intervention is considered successful), or ‘number of sexual partners in the last 6 

months’ (if this reduces, the intervention is considered successful). In using these indica- 

 

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use, abstinence, other STIs) and D is the duration of infectiousness (stage of HIV infection, 

treatment). This formula clearly shows that it is the combination of these aspects 

that determines the risk of infection, and not each aspect in itself. Measuring the use of 

condoms or the number of sexual partners separately does not give a good indication of 

the risk for HIV infection. This could explain why studies trying to predict HIV/STI infection 

by using individual indicators, e.g. condom use, show weak correlations [211, 212, 

242-246]. Furthermore, the indicators mostly used, measure proportions of behaviour, 

ignoring differences in absolute numbers. Someone who reports to use condoms ‘most 

of the time’ and has had 10 sexual encounters is at less risk than someone who uses condoms 

‘most of the time’ during 100 sexual encounters. Neither do these indicators take 

into account the position of the individual in the sexual network [229]. 

For example, the indicator ‘condom use at last sex’ might hide an increase in young 

people having equal, respectful relationships who decided not to use a condom after a 

negative HIV test. Or why would having a large number of sexual partners be negative 

for one’s sexual health if the sexual intercourse were consensual and protected? It is 

likely that people make risk assessments and adapt their behaviour accordingly. This 

may result in high condom use with perceived high risk partners and in low condom use 

with perceived low risk partners. Hence, using a condom use indicator or a sexual activ- 

 

 

alcohol use and sexual self-concept, but not for relational and contextual characteristics. 

 

exclude the possibility that interventions do have an effect, but that this effect is not accurately 

measured in the evaluation. Understanding the HIV risk of young people necessitates 

that their risk behaviours are conceptualized as mutually dependent, and are measured 

as such [225]. While this was a topic for discussion in the beginning of this century 

[229, 237, 247], it faded to the background of methodological debate in recent years. The 

recent focus on sexual networks and types of sexual relationships (particularly concur- 

 

248]. We suggest two alternatives for the currently used indicators. Firstly, giving preference 

to scales instead of dichotomous variables, allowing for more nuanced reporting on 

risks. Secondly, developing composite risk scores, including exposure, transmission and 

infectiousness for measuring real risk for HIV infection among young people [247]. 

6.3. Limitations 

 

Here we will discuss limitations related to the overall study set-up. 

 

school (often boarding school) students. School attendance in Rwanda is low. The gross 

enrolment rate (number of pupils enrolled in a given level of education related to the age 

- 

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tion is 143, which drastically reduces for lower secondary education (43) and higher 

secondary education (32 4 ) [111, 112]. In a study among 285 students of the last year 

of secondary education in a selection of four schools in the same Rwandan district (not 

presented in this thesis), we found that, compared to the general population, more respondents 

have running water at home or in the community (55.4% vs. 35.6% in general 

 

indicates that overall this group is better off than the average Rwandan youth [249]. 

 

in sub-Saharan Africa. Nevertheless, we found some striking similarities in intervention 

 

validity of our studies. 

Second, while a process evaluation was undertaken by a master student in two Rwandan 

 

 

process analyses as a weakness of HIV prevention interventions, and as a possible explanation 

of why interventions do not seem to learn from each other [250]. 

Third, one of the main points of critique on HIV prevention interventions for young people 

in sub-Saharan Africa is that the content is too much focussed on HIV, while sexual behaviour 

is determined by many other factors. These factors and their causal pathways to 

 

mailbox study (paper 4) did unveil several critical factors, additional qualitative research 

would have been able to identify more factors and to qualify their causal pathways. 

Furthermore, qualitative research could also have been used for other aspects of the 

doctoral study, such as the process of implementation of the intervention, narratives of 

students’ conversations or thematic analysis of drama plays and songs of peer educators. 

Hence, we acknowledge that the evidence-base of the conclusions and recommendations 

of this doctoral thesis mainly consists of quantitative effectiveness studies, while a 

broader evidence-base would have been preferable. 

Fourth, while this could also be considered a strength, we want to discuss the multicultural 

aspect of our research in the limitations section. Working mainly in Rwanda with 

Rwandan researchers and students has proven enriching, but at the same time, challeng- 

 

development: we used a standardized questionnaire that was developed in French, 

translated into Kinyarwanda, back translated and tested among a group of students. Nev- 

 

Rwandan young people. Second, we collected data using multiple choice, often with 5- or 

7-point Likert scales. We found that the great majority of students always entered the extreme 

values (completely disagree or completely agree). Possibly, more nuanced answers 

are considered unclear or vague, and a clear opinion is preferred. Third, while a Rwandan 

4 For each 100 young people that are, given their age, expected to be in higher secondary education, 32 are actually enrolled. 

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esearcher did verify our analysis and interpretation of the results, we cannot exclude 

that we analysed and interpreted the results from a western point of view, overlooking 

 

6.4. Conclusions, recommendations and directions for further 

research 

HIV prevention interventions for young people in sub-Saharan Africa show disappointing 

results in reducing sexual risk behaviour and HIV incidence. Even though recent UNAIDS 

data indicate a decreasing HIV incidence among young people in a number of highly 

affected countries, it remains high and effective interventions are an urgent priority. 

Research should continue to focus on how to develop, implement and evaluate effective 

 

observed limited effectiveness: interventions might be inherently ineffective (intervention 

design), they might be poorly implemented (participation, approach) or the evaluation 

may not be capable of measuring the actual effectiveness (design, power, outcome 

measures). 

enced 

by countless interacting factors on different levels - interventionists and evaluators 

are, as Delor [137] puts it, prone to two pitfalls: “retreating into vagueness under the 

pretext of complexity and, on the contrary, making a conquest at the expense of causal 

reduction” (i.e. aiming to contribute a phenomenon to one cause while, in fact, is has several 

causes). In the interventions included in our literature review and the interventions 

we evaluated, we found evidence of such causal reductionism both in the intervention 

design (interventions focused on HIV knowledge, attitudes and skills and largely ignored 

inter-personal, environmental and social and cultural factors) and in intervention out- 

 

 

of young people, is a complex issue, and requires complex interventions and complex 

evaluations. 

timately, 

we cannot indicate which factor is most likely to be responsible for the observed 

limited intervention effect on sexual behaviour and HIV incidence: comparing different 

intervention designs is only useful when the interventions are well implemented and a 

good evaluation strategy is applied, while an effectiveness evaluation is only meaningful 

if the intervention is well designed and implemented. We recommend further research 

on three levels. 

 

 

the intervention. Given the (often complex) causal pathway that interventions aim to 

 

 

measure and attribute to an intervention. It could, for example, be possible that the 

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ecently observed reduction in HIV incidence in young people is a result of two decades 

of implementing HIV prevention interventions in the severely affected countries, but cur- 

searchers 

should invest in developing alternative, innovative, evaluation approaches that 

 

tion 

should not be limited to outcome effectiveness, but should parallel the intervention 

process, including the essential phases of intervention development and implementation. 

 

interventions’ effectiveness requires a creative combination of alternative approaches 

(“combination evaluation”), studying plausibility of effectiveness, rather than probability: 

process analysis and monitoring should be triangulated with (quasi-)experimental 

designs and other information sources as e.g. population-based surveys and statistical 

modeling [194]. The latter can also assist programme developers and evaluators in understanding 

the expected effect of the intervention on HIV incidence. 

Since the use of biological endpoints is costly and not always appropriate, many evaluations 

will continue to rely on self-reported sexual behaviour to measure intervention 

effectiveness. Too often, these sexual behaviours are extracted from their context and 

measured in single variables. Complementing these indicators with newly developed 

contextualized, composite sexual behaviour measures is essential to measure the real 

risks young people are taking, and hence, the true effectiveness of interventions. Composite 

indicators should include three aspects: exposure (relationship and partner 

characteristics), transmission (type of sex and protective measures) and infectiousness 

(HIV infection and stage of infection of the partners). Such indicators can be developed 

in relatively small-scale studies, informed by qualitative research, measuring both sexual 

behaviour and HIV/STI status. The use of existing datasets including all three aspects of 

risk for HIV infection can be used to test if combined indicators better predict HIV/STI 

status. 

Research into structural evolutions might shed light into the long-term effectiveness of 

HIV prevention interventions. These evolutions include changes in HIV treatment and 

societal changes as gender empowerment, poverty alleviation, globalization and technological 

evolutions [251]. Societal changes and changes in the natural evolution of the HIV 

epidemic might interact with the intervention effect. A study by Bajos [252] about the 

evolution of sexual behaviour in France indicated how much this evolution is determined 

by changes in nuptiality and broader social and structural factors, more than by public 

health interventions. For example, changes observed in HIV incidence and sexual behaviour 

of young people in sub-Saharan Africa can be a long-term result of HIV prevention 

intervention and awareness campaigns, but might also be linked to the natural evolution 

of the epidemic or to societal changes, such as women’s emancipation. Given that the 

HIV epidemic has been present for three decades and that there are a large number of 

interesting data sources available (e.g. DHS, DSS, globalization indicators,…), it might be 

feasible to link societal changes to changes in HIV prevalence and estimate the relative 

effect of public health interventions. 

Secondly, the intervention: young people’s vulnerability is determined by different fac- 

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tions. 

Existing data should be used, and new information needs to be collected, on what 

determines sexual behaviour of young people and how. Correcting what Bertozzi [250] 

 

ability 

in a single behavioural intervention, research into the importance of the factors 

 

 

people’s sexual behaviour and HIV prevalence. This is essential both for intervention 

development (what are the determining factors of risky sexual behaviour and how can 

mediate 

determinants of sexual behaviour). As Laga [194] puts is: “the goal of a better 

articulation of [the programme’s] impact pathways is to assist planners and evaluators 

in simplifying the complex reality without becoming simplistic”. By studying these causal 

pathways, it is possible that shifts in paradigms might occur, for example from an individual-focused 

approach to a more community-centered approach. 

Making these pathways explicit also relates to the use of theory in HIV prevention interventions. 

While many interventions report the use of behavioural theories to guide the 

intervention or evaluation, few reports are made on why a particular theory was chosen, 

how it was used and what the added value of this theory was. More research should be 

done into the practical use of behavioural theories for HIV prevention interventions for 

young people, taking into account the complexity of sexual behaviour (including determinants 

on different levels). Only this way, knowledge can be cumulated and intervention 

effectiveness can increase. 

 

tervention 

deserves a central place in HIV prevention – e.g. start with a situation analysis 

 

intervention including key stakeholders [253], and taking into account past, ongoing and 

planned interventions. The interventions included in our literature review and metaanalysis 

did not seem to take extensive time to optimize their intervention before it was 

implemented and tested. The interventions presented in this study are dominated by the 

IEC approach, spreading information and sensitizing young people, sometimes complemented 

with service provision, to come to behaviour change, and hence HIV incidence 

reduction. Project-based IEC approaches are just one of many possible interventions, and 

researchers and intervention managers should experiment with alternative approaches. 

Piot [254] expresses as follows: “Any explanation based on a single risk factor for this 

very high HIV endemicity ignores the realities of complex societies and human behaviour. 

A complex and diffuse epidemic should be addressed by an equally nuanced and 

multipronged response”. It is possible that such complex interventions are already taking 

 

 

The intermediate and ultimate objectives of interventions should be clear and neutral. 

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Ultimately, interventions want to reduce HIV incidence. If they plan to do this through 

the intermediary objective of sexual behaviour change, they must be sure to focus on the 

most relevant behaviours. If awareness raising is the intermediary objective, the pathway 

to HIV incidence reduction is longer, and no immediate effects on sexual behaviour 

 

abstinence, or the reduction of the number of partners, intervention planners might be 

(unconsciously) sending messages to young people with a moralizing tone. Therefore we 

would argue to study the use of an alternative, less judgmental, and more empowering, 

intervention outcome in HIV prevention interventions for young people in sub-Saharan 

Africa: making young people sexually competent, stimulating them to be sexually responsible, 

making sure sexual intercourse is characterised by absence of coercion and 

regret, autonomy of decision, and use of a reliable protection method [193]. A factor that 

deserves particular attention is gender equality, since gender norms and roles strongly 

cial 

in all phases of the intervention. Essential in this process is uncovering and questioning 

the prevailing gender norms of the study population, and the importance of striving 

for mutually respectful (sexual) relationships. 

Young people in the same type of relationship with the same type of partner might take 

different decisions concerning protective measures. A possible confounding factor in 

the association between individual behaviour (e.g. condom use) and type of relationship 

is personality. Risk taking is deeply rooted in an individual’s personality – varying 

from consistent risk seeking to consistent risk avoiding - with sensation-seeking as a key 

 

helps explain how decisions are made concerning young people’s sexual health. 

Thirdly, the implementation: interventions should be regularly monitored and adjusted if 

necessary, as an integral part of the implementation and evaluation process. A large number 

of interventions report implementation problems. When such implementation errors 

occur, the evaluation does not longer measure if the designed intervention is effective 

and is no longer valuable. Reports on implementation, and how to overcome implemen- 

 

Interventions do not seem to reach the complete target population, because of their 

choice for a certain implementation approach (e.g. peer education) and certain activities 

(e.g. group activities). In the preparatory phase of the intervention, intervention planners 

should study the preferred information sources and activities of the target population 

and adapt the intervention accordingly. The choice of an intervention strategy should be 

done in concordance with other activities taking place in the region. 

In order to increase collaboration between and among intervention planners, researchers 

and evaluators [51, 194, 250], we propose the development of a central online 

repository that gathers information on interventions (e.g. content, set-up), monitoring 

and process evaluations (e.g. implementation issues and solutions) and effectiveness 

evaluations (e.g. evaluation designs, outcome measures) [258]. This would increase comparability 

of interventions and would allow people to build upon previous experiences. 

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Hence, such repository would have a dual functionality: collect evidence on effective HIV 

prevention interventions and guide intervention planners and evaluators in their work 

towards more quality, uniformity and comparability. Several organizations tried to address 

some of these aspects, such as UNAIDS’s minimum quality standards for or their 

trol’s 

compendium of USA-based HIV prevention interventions with evidence of effective- 

 

[262], and USAID’s handbook of indicators for HIV programmes [263] or their database 

on US international aid [264]. However, to our knowledge a comprehensive repository, 

encompassing evidence on and guidelines for the full intervention process (from design 

to evaluation) does not yet exist for young people’s HIV or sexual health related interventions 

in sub-Saharan Africa. To be comprehensive, such repository should also not be 

 

evidence collected by non-governmental organizations, which form a large part of existing 

evidence in developing countries. Initiatives as Programme Science, that try to close 

aged 

[265-268]. 

While such repository might help in making implementation information more easily 

available, researchers should be encouraged to effectively set-up, implement and report 

more process evaluations. Therefore, funding needs to be made available and donors 

have to be convinced that this is an integral part of intervention research. Furthermore, 

aging 

qualitative publications of this particular type of research. Alternatively, by in- 

 

intervention, the implementation and the effectiveness in one manuscript, which would 

be a large step forward. 

- 

 

of a vaccine or a cure, the focus remains on preventing HIV transmission. By analysing 

existing data on the determinants of the complex sexual behaviour of young people and 

their causal pathways, and by gathering additional information, researchers should make 

unprecedented efforts to develop alternative and more effective interventions. Accepting 

the complexity of sexual behaviour of young people, also means dealing with a consider- 

 

evaluation are to be considered inseparable: results of effectiveness evaluations should 

be considered of little use if no information is provided on the intervention or its implementation 

and vice versa. Since the evaluation should be an integral part of the intervention, 

intervention managers and evaluators need to work in close collaboration, without 

suspicion. Donors have to accept that a complex intervention cannot be designed beforehand, 

but requires a process approach that maps risky behaviours, dominant predictors, 

causal pathways and key stakeholders. This pre-intervention research should be considered 

a fundamental part of the intervention and donors should be aware that effectiveness 

depends on this phase, hence funding should be made available. In this process, 

reality, and not morality, should be at the forefront: young people should be approached 

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as responsible individuals who are able to make their own decisions and need to be 

made competent to ensure their choice to (not) have sexual intercourse is made autonomous, 

without coercion or regret and with the necessary in-depth knowledge of risks. 

This requires a change in attitudes of all stakeholders involved. A complex intervention 

approach also means that the intervention is monitored and can be changed during its 

 

 

responsibility to make innovative approaches public, even though they might not be 

 

reports on intervention development and implementation. We are convinced this can be 

done if all parties remain conscious of the ultimate objective; eradicating HIV among the 

important and vulnerable population of young people. 

 

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Key recommendations for establishing more effective HIV prevention 

interventions: 

- accept the complexity of HIV and sexual and reproductive health of 

young people: investment in a thorough baseline and needs assessment 

for the development of population- and context specific interventions is 

crucial; 

- map the causal pathways through which the intervention aims to reach 

its outcomes; 

- beware of a (implicit, unconscious) moralizing tone in prevention 

messages when focusing on specific risk behaviours; 

- align the intervention with past, existing and future 

activities/campaigns/interventions in the same field; 

- allow for flexibility in intervention design, implementation and 

evaluation based on regular monitoring of the intervention; 

- consider the intervention development, implementation and evaluation 

as an inseparable whole; 

- combine different evaluation methods to study the probability and 

plausibility of effectiveness, as well as the process of development and 

implementation of the intervention. 

Additionally, in order to contribute to more effective interventions, researchers 

should study: 

- the development of more appropriate, contextualized indicators to 

adequately assess sexual risk taking; 

- factors determining vulnerability to HIV infection among young people 

and their inclusion in applicable theoretical frameworks; 

- societal evolutions influencing sexuality on a large scale. 

These recommendations can only be implemented, or even considered, if the 

context in which interventions are planned, implemented, evaluated and studied 

changes as well. This means that the funding climate should be sensitized about 

the importance of pre-intervention research, close monitoring and evaluation, 

and the necessity of flexible planning and evaluation. Researchers should get 

more opportunities to publish implementation research, preferable in 

combination with research on intervention development and effectiveness. 

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Summary 

Introduction 

Worldwide, on average, 2,500 young people (15-24 years) get infected with HIV every 

 

in a regional HIV prevalence of 1.4% in young men and 3.3% in young women. Since 

no cure or vaccine is available, reducing sexual risk behaviour in this group is crucial in 

tackling the epidemic. 

Objectives and methods 

The general objective of this doctoral study was to improve the effectiveness of HIV 

- 

 

the population of young people in sub-Saharan Africa, given that there were indications 

that they were not very effective. This was done through a systematic literature review 

and meta-analysis. A study protocol described procedures for the literature search strategy, 

the inclusion criteria, the data to be extracted, the extraction procedure and the data 

analysis methods. 

Secondly, we aimed to evaluate a peer-led school-based HIV prevention intervention in 

Rwanda, to get more hands-on insight into how such interventions are developed, implemented 

and evaluated. We used a nonrandomized controlled trial. In fourteen schools 

(eight intervention and six control schools) 1,950 students completed a standardized 

questionnaire at baseline. We undertook two additional measurements, six and twelve 

months in the intervention. Statistical analyses were done in Stata, SPSS and SAS, using 

propensity score matching, generalized estimation equations and multivariate regression 

analysis. 

 

objective aimed to identify and study more in-depth the possible reasons for this limited 

effectiveness of HIV prevention interventions for young people in sub-Saharan Africa. 

This objective mainly relied on studies taking place in Rwanda. First, participation in the 

intervention was assessed by identifying baseline characteristics of respondents that 

could possibly predict participation in the intervention. To that end, we applied multinomial 

and linear regression models with backward variable selection in Stata to the longitudinal 

data collected for the effectiveness evaluation. Second, we studied determinants 

of young people’s sexual behaviour. To that end, we used a qualitative ‘mailbox study’ 

that assessed determinants of young people’s sexual risk behaviour. This study assessed 

the spontaneous thoughts of Rwandan adolescents on sexuality, allowing us to identify 

 

schools in Rwanda and students were invited to write about their ideas, secrets, wishes, 

desires and fears on sexuality and relationships. Analysis was done in NVivo9. Further- 

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literature review that compared HIV status and sexual behaviour of out-of-school and 

in-school youth. Third, using a systematic literature, we assessed the theoretical underpinnings 

of existing HIV prevention interventions for young people in sub-Saharan Africa. 

Results 

The literature review and meta-analysis showed limited effectiveness of HIV prevention 

 

reduce sexual activity, and condom use only increased notably among males, but remained 

at a low level. Furthermore, this study demonstrated a paucity in evaluated HIV 

prevention interventions for young people in sub-Saharan Africa. The evaluation study in 

vention 

did succeed in increasing young people’s perception that AIDS is a serious disease 

and reduced self-reported enacted stigma. However, multivariate analyses showed 

no changes in sexual behaviour of the intervention group in neither country. Dose-effect 

analyses found that active participants did not change their behaviour more than passive 

participants. 

 

large number of potential participants never participated in intervention activities: in the 

Rwandan intervention, over 40% did not participate in any of the intervention activi- 

 

at ease with their sexuality, those consciously seeking information, and those who seek 

to pass time, were more likely to participate in the intervention. For participation in an 

 

occurring during the intervention and not pre-intervention characteristics are crucial. 

Secondly, the intervention might not deal with the right issues. Letters written by Rwandan 

young people in the qualitative mailbox technique, revealed a large number of determinants 

of sexual behaviour, ranging from personal factors (e.g. puberty, knowledge) 

over inter-personal factors (e.g. type of sexual relationships) and environmental factors 

(e.g. school) to social and cultural factors (e.g. norms, economic factors, gender), demonstrating 

the complexity of sexual behaviour of young people. The letters found a dominance 

of two types of sexual relationships: experimental sex taking place unprepared 

among same-age youth and driven by sexual desire, and transactional sex, where young 

people have sex with an (often older) partner in exchange for money or goods and driven 

by peer pressure to possess the right material goods. While these types of relationships 

and contextual factors put young people at risk for HIV infection, they were not dealt 

with in the intervention. The important role of structural factors is further shown in the 

study on the role of education. We found that in-school youth have less HIV and demonstrated 

less risky sexual behaviour than out-of-school youth. However, school attendance, 

especially in less globalized regions, can also alienate pupils, or create social division, as 

in the formation of elites with the means of engaging in much partner concurrency. 

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Thirdly, three behavioural theories were found to be at the basis of most interventions: 

social cognitive theory, theory of reasoned action/planned behaviour and health belief 

model. While such theories could provide guidance in simplifying this complex behaviour 

and in identifying key determinants, their focus remains on individual cognitions, such as 

HIV related knowledge and attitudes, simplifying sexual behaviour too much. To face the 

complexity of young people’s sexual behaviour, interventions often resort to causal reductionism 

and simple, often (unconsciously) moralising messages. Thereby they ignore 

 

behaviour. 

Discussion and conclusion 

Our studies observed little effectiveness of HIV prevention interventions for young 

people in sub-Saharan Africa. We discuss two groups of factors that may be accountable 

 

too much on cognitions on the individual level, ignoring other determinants of sexual 

behaviour, making it possible that they are doomed from the outset, simply because it is 

munity 

norms and social and cultural factors. Furthermore, interventions often (unconsciously) 

send moralizing messages, sometimes ignoring the reality of young people’s 

sexual behaviour and hence, ignoring to focus on their most risky sexual behaviours. 

Interventions are also confronted with implementation issues, resulting in problems to 

reach the target population and in maladapted intervention approaches. 

The second group of factors is situated on the level of the evaluation. Randomized controlled 

trials are considered the gold standard for determining cause-and-effect relationships. 

However, their use in measuring the effectiveness of HIV prevention interventions 

on sexual behaviour is often compromised by the complexity of the real life situation 

in which these interventions take place. The long causal pathway in changing sexual 

 

changes to the intervention. While the ultimate objective of the interventions is to reduce 

 

necessary to measure changes in HIV incidence. Therefore, evaluators often rely on selfreported 

sexual behaviour. We argue that the indicators currently used to measure this 

 

the context of the relationship and network in which they take place. It is possible that 

interventions do change sexual behaviour, but that these changes are not observed due to 

 

We recommend further research on three levels. Firstly, the evaluation: alternative 

evaluation designs should be formulated, combining different evaluation approaches 

mirroring the intervention process (“combination evaluation”), and studying plausibility 

of effectiveness, rather than probability. In order to adequately measure sexual risk, 

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composite contextualized indicators have to be developed combining aspects of transmission 

(including relational characteristics), exposure and infectiousness. Secondly, the 

intervention: by analysing existing data on the determinants of this complex behaviour 

and their pathways, and by gathering additional information, researchers should make 

unprecedented efforts to develop more effective interventions. Interventions should be 

vention 

planning: the situation analysis and needs assessment. Thirdly, the implementation: 

monitoring interventions is essential in understanding their effectiveness. Evalu- 

 

importance of making the processes of intervention development and implementation 

publicly accessible, in order for others to learn from successes and failures. 

In conclusion, we can state that complex problems require complex interventions and 

complex evaluations. Accepting this complexity means dealing with a considerable de- 

 

and implementation is feasible if all parties involved (researchers, intervention manag- 

 

and remain conscious of the ultimate objective; eradicating HIV among the important 

and vulnerable population of young people in sub-Saharan Africa. 

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Samenvatting 

Inleiding 

Wereldwijd worden dagelijks 2500 jongeren (15-24 jaar) besmet met hiv; bijna 80% van 

deze infecties vindt plaats in sub-Sahara Afrika. Dit weerspiegelt zich in een regionale 

hiv-prevalentie van 1,4% bij jonge mannen en 3,3% bij jonge vrouwen. Omdat er op korte 

termijn geen effectief vaccin of geneesmiddel verwacht wordt, blijft het voorkomen van 

besmetting essentieel. Verminderen van seksueel risicogedrag bij jongeren staat hierbij 

centraal. 

Doelstellingen en onderzoeksmethoden 

De algemene doelstelling van dit doctoraatsonderzoek was het verhogen van de effectiviteit 

van hiv-preventie-interventies voor jongeren in sub-Sahara Afrika. Daartoe formu- 

 

van deze interventies voor jongeren in sub-Sahara Afrika bestuderen; dit omdat er 

aanwijzingen waren dat ze slechts beperkt effectief zijn. We ontwikkelden een studieprotocol 

voor een systematische literatuurstudie en meta-analyse waarin zoekstrategie, 

inclusiecriteria, te extraheren gegevens, extractieprocedure en de methode voor dataanalyse 

beschreven werden. 

Ten tweede evalueerden we een hiv-preventie-interventie in secundaire scholen in 

Rwanda, om een concreter inzicht te krijgen in hoe zulke interventies worden ontwikkeld, 

geïmplementeerd en geëvalueerd. Beide interventies maakten gebruik van ‘peer 

educatie’. De effectiviteit werd gemeten via een niet-gerandomiseerde longitudinale gecontroleerde 

studie: Voor de start van de interventie vulden 1950 leerlingen in veertien 

secondaire scholen (acht interventie- en zes controlescholen) een vragenlijst in. Tijdens 

de interventie, op zes en twaalf maanden, werden nogmaals vragenlijsten afgenomen. 

Analyse werd gedaan in Stata, SPSS en SAS. 

Terwijl de vorige doelstellingen de beperkte effectiviteit van de interventies aantoon- 

 

redenen hiervoor. Het bereik van de Rwandese interventie werd bestudeerd door te 

onderzoeken of bepaalde factoren een deelname konden voorspellen. Hiervoor werden 

in Stata multinomiale en lineaire regressiemodellen toegepast op de longitudinale data 

verzameld voor het evaluatieonderzoek. Vervolgens keken we naar de determinanten 

van seksueel gedrag van jongeren. Een kwalitatieve ‘brievenbusstudie’, waarbij Rwandese 

jongeren in vijf secondaire scholen werden gevraagd om spontaan verhalen te 

schrijven, vragen te stellen en gedachten te delen over seksualiteit en relaties, maakte 

 

 

structurele factor: onderwijs. Een literatuuronderzoek vergeleek de hiv-status en het seksueel 

gedrag van schoolgaande en niet-schoolgaande jeugd in Oost- en Zuidelijk Afrika. 

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Tenslotte onderzochten we de theoretische onderbouw van hiv-preventieprogramma’s 

voor jongeren in sub-Sahara Afrika, gebruik makend van de bestaande literatuur. 

Resultaten 

De literatuurstudie en meta-analyse toonden aan dat hiv-preventie-interventies het 

seksueel gedrag (leeftijd bij eerste seksueel contact, aantal partners en recente sek- 

 

hiv-incidentie niet daalt. Enkel condoomgebruik bij mannen lijkt toe te nemen, hoewel 

het onvoldoende blijft. Verder toonden de studies aan dat er een duidelijk gebrek is aan 

kwaliteitsvolle evaluaties van hiv-preventie-interventies. 

Ook de evaluatiestudie in Rwanda bevestigde dat het verminderen van seksueel risicogedrag 

bij jongeren uiterst moeilijk is. Hoewel de Rwandese interventie ervoor zorgde 

dat meer jongeren aids als een ernstige ziekte gingen beschouwen en dat gerapporteerd 

stigma daalde, bleek uit de multivariate analyse dat het seksueel gedrag niet veranderd 

was. Bijkomende analyses die actieve deelnemers vergeleken met passievere deelnemers 

veranderden de conclusies niet. 

Mogelijke redenen voor deze waargenomen beperkte effectiviteit werden onderzocht. 

Ten eerste, stelden we vast dat een groot aantal potentiële deelnemers nooit deelnam aan 

de interventieactiviteiten: in Rwanda nam meer dan 40% van de potentiële deelnemers 

 

 

jongeren die comfortabel kunnen communiceren over (hun) seksualiteit, jongeren die 

bewust zoeken naar informatie, en jongeren die proberen de tijd te doden. Zij die beant- 

 

 

opgesteld worden, wat aangeeft dat factoren die zich tijdens de interventie voordoen en 

dus niet pre-interventie kenmerken van belang zijn. 

In de tweede plaats onderzochten we de inhoud van de interventies. Brieven geschreven 

door Rwandese jongeren in de kwalitatieve ‘brievenbusstudie’, legden een groot aantal 

determinanten van seksueel gedrag bloot, gaande van persoonlijke factoren (b.v. puberteit, 

kennis) over interpersoonlijke factoren (b.v. type van seksuele relaties) en omgevingsfactoren 

(b.v. school) tot sociale en culturele factoren (b.v. normen, economische 

factoren, gender). Dit toont aan hoe complex het seksueel gedrag van jongeren is. Verder 

maakten de brieven duidelijk dat jongeren voornamelijk twee soorten seksuele relaties 

aangaan: experimentele seks, die vaak onvoorbereid plaatsvindt tussen jongeren van 

dezelfde leeftijd en gedreven wordt door seksueel verlangen en nieuwsgierigheid, en 

transactionele seks, waarbij jongeren seks hebben met een (vaak oudere) partner in ruil 

voor geld of materiële zaken, gedreven door groepsdruk om de juiste zaken te bezitten. 

Hoewel deze types relaties en contextuele factoren jongeren kwetsbaar maken voor hiv- 

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infectie, werden ze niet betrokken in de interventie. De belangrijke rol van structurele 

factoren werd verder aangetoond in een studie over de rol van onderwijs. We vonden dat 

onder schoolgaande jeugd t.o.v. niet-schoolgaande jeugd minder hiv voorkomt en dat er 

minder risicovol seksueel gedrag wordt vertoond. Echter, onderwijs kan ook een ander 

effect hebben, zoals het vergroten van de sociale kloof door de vorming van elites die de 

middelen hebben om meerdere seksuele partners te onderhouden, wat meer risico’s met 

zich meebrengt. 

Tenslotte, de gedragstheorieën die aan de basis liggen van de meeste interventies – social 

cognitive theory, theory of reasoned action/planned behaviour en health belief model 

– worden in interventies zodanig ingevuld dat de focus grotendeels ligt op cognities 

op het individueel niveau, zoals hiv-gerelateerde kennis en houdingen. Om te kunnen 

omgaan met de complexiteit van seksueel gedrag, nemen hiv-preventie-interventies voor 

jongeren vaak hun toevlucht tot reductionisme en eenvoudige, vaak (onbewust) moraliserende 

boodschappen. Daarbij negeren ze de realiteit en de grote hoeveelheid andere 

factoren die vanop verschillende niveaus een impact hebben op seksueel gedrag. 

Discussie en conclusie 

Evaluaties van hiv-preventie-interventies tonen een beperkte effectiviteit in het verminderen 

van seksueel risicogedrag van en hiv-incidentie bij jongeren in sub-Sahara 

 

mogelijk verantwoordelijk zijn. Een eerste groep betreft de interventie zelf. Onze studies 

wezen uit dat interventies zich voornamelijk richten op hiv-gerelateerde cognities op het 

individuele niveau terwijl we eveneens aantoonden dat heel wat andere factoren een rol 

spelen in het nemen van seksuele beslissingen. Daarom is het mogelijk dat de interventies 

van bij aanvang gedoemd zijn om te mislukken, gegeven de moeilijkheid om individueel 

seksueel gedrag te veranderen in de aanwezigheid van statische sociale normen en 

culturele factoren. Bovendien doen interventies vaak (onbewust) beroep op moraliserende 

boodschappen over seksueel gedrag, waarbij ze niet steeds uitgaan van de realiteit 

en veronachtzamen zich te concentreren op het meest risicovol seksueel gedrag. Verder 

worden interventies ook geconfronteerd met implementatieproblemen. 

De tweede groep factoren ligt op het niveau van de evaluatie. Gerandomiseerde gecontroleerde 

studies worden beschouwd als de gouden standaard voor het bepalen van 

oorzaak-gevolgrelaties. Het correct toepassen van de regels van zulke designs botst 

echter vaak met de complexiteit van hiv-preventie-interventies voor jongeren. De lange 

weg die gevolgd moet worden om seksueel gedrag en hiv-incidentie te wijzigen, in combinatie 

met de hoeveelheid contextuele factoren die dit kan beïnvloeden, maakt het extra 

moeilijk om waargenomen veranderingen toe te wijzen aan de interventies. Bovendien 

 

 

moeten dus beroep doen op zelf-gerapporteerd seksueel gedrag. Echter, we stelden 

vast dat de indicatoren die momenteel gebruikt worden voor het bepalen van seksueel 

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isicogedrag geen juiste afspiegeling zijn van de risico’s die jongeren daadwerkelijk nemen: 

ze worden immers gemeten buiten de context van de relatie en het netwerk waarin 

ze plaatsvinden. Het is dus mogelijk dat interventies er in slagen om seksueel gedrag te 

veranderen, maar dat de evaluaties niet in staat zijn om deze veranderingen te meten. 

Om de effectiviteit van hiv-preventie-interventies voor jongeren in sub-Sahara Afrika 

te verhogen, formuleren wij aanbevelingen op drie vlakken. Ten eerste, de evaluatie: 

het gebruik van alternatieve evaluatiedesigns, waarbij verschillende methodes worden 

gecombineerd doorheen het volledige interventieproces (“combinatie-evaluatie”), en 

waarbij onderzoek naar de plausibiliteit van effectiviteit, eerder dan de probabiliteit, 

centraal staat. Om adequaat seksueel risicogedrag te meten, raden wij de ontwikkeling 

van samengestelde, contextuele indicatoren aan. Zulke indicatoren combineren aspecten 

van transmissie (inbegrepen relationele kenmerken), blootstelling en besmettelijkheid. 

Ten tweede, de interventie: door het bestuderen van de determinanten van seksueel gedrag 

en hoe ze dit gedrag beïnvloeden, en het verzamelen van nieuwe gegevens, moeten 

onderzoekers het mogelijk maken om effectievere interventies te ontwikkelen. Zulke 

 

voor de eerste fase van de interventieplanning vraagt: de situatie- en behoefteanalyse. 

Ten derde, de uitvoering: het monitoren van interventies is essentieel in het begrijpen 

176 

Kristein.indd 176 10/25/2012 8:37:58 PM

van hun effectiviteit. Evaluatoren, interventiemanagers en uitgevers van wetenschappelijke 

tijdschriften moeten zich bewust worden van het belang van het publiceren van 

ontwikkelings- en implementatieprocessen van interventies, zodat anderen kunnen leren 

van successen/mislukkingen. 

Samenvattend kunnen we stellen dat, om complexe problemen op te lossen, er complexe 

interventies en complexe evaluaties nodig zijn. Het accepteren van deze complexiteit 

eit 

toelaten in de interventie, implementatie en evaluatie is haalbaar als alle betrokken 

 

wetenschappelijke tijdschriften) bereid zijn op een open manier samen te werken en zich 

bewust blijven van het uiteindelijke doel; hiv elimineren bij de belangrijke en kwetsbare 

bevolkingsgroep van jongeren in sub-Sahara Afrika. 

177 

Kristein.indd 177 10/25/2012 8:37:58 PM

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Annex 

Paper 7 

Delva, W., Michielsen, K., Meulders, B., Groeninck, S., Wasonga, E., Ajwang, P., Temmerman, 

M., Vanreusel, B. (2010), HIV prevention through sport: the case of the Mathare 

Youth Sport Association in Kenya, AIDS Care, Aug;22(8):1012-20. 

 

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Paper 8 

Stroeken, K., Michielsen, K., Remes, P.,Meeuwis, M. The region-sensitive effect of globalization 

on HIV in Eastern and Southern Africa: The dual role of education. Submitted to 

AIDS & Behavior (08/2012) 

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Kristien Michielsen PhD Thesis_website.pdf - International Centre ...

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