s43058 020 00042 4

Iwelunmor et al.
Implementation Science Communications

https://doi.org/10.1186/s43058-020-00042-4
(2020) 1:53
Implementation Science
Communications
SYSTEMATIC REVIEW Open Access
Is it time to RE-AIM? A systematic review of

economic empowerment as HIV prevention
intervention for adolescent girls and young
women in sub-Saharan Africa using the RE-
AIM framework
Juliet Iwelunmor1*, Ucheoma Nwaozuru1, Chisom Obiezu-Umeh1, Florida Uzoaru1, John Ehiri2, Jami Curley1,
Oliver Ezechi3, Collins Airhihenbuwa4 and Fred Ssewamala5
Abstract
Background: Economic empowerment (EE) HIV prevention programs for adolescent girls and young women (AGYW) in sub-
Saharan Africa are gaining traction as effective strategies to reduce HIV risk and vulnerabilities among this population. While
intervention effectiveness is critical, there are numerous factors beyond effectiveness that shape an intervention’s impact. The
objective of this systematic review was to assess the reporting of implementation outcomes of EE HIV prevention programs for
AGYW in SSA, as conceptualized in the RE-AIM (reach, efficacy/effectiveness, adoption, implementation, and maintenance) framework.
Methods: We searched PubMed, Ovid/MEDLINE, Science Direct, Ebscohost, PsycINFO, Scopus, and Web of Science for EE HIV
interventions for AGYW in SSA. Study selection and data extraction were conducted according to the PRISMA (Preferred Reporting
Items for Systematic Reviews and Meta-analyses) guidelines. Two researchers coded each article using a validated RE-AIM data
extraction tool and independently extracted information from each article. The reporting of RE-AIM dimensions were summarized
and synthesized across included interventions.
Results: A total of 25 unique interventions (reported in 45 articles) met the predefined eligibility criteria. Efficacy/effectiveness
19(74.4%) was the highest reported RE-AIM dimension, followed by adoption 17(67.2%), reach 16(64.0%), implementation
9(38.0%), and maintenance 7(26.4%). Most interventions reported on RE-AIM components such as sample size 25(100.0%),
intervention location 24(96.0%), and measures and results for at least one follow-up 24(96.0%). Few reported on RE-AIM
components such as characteristics of non-participants 8(32.0%), implementation costs 3(12.0%), and intervention fidelity
0(0.0%).
(Continued on next page)
* Correspondence: Juliet.iwelunmor@slu.edu
1
College for Public Health and Social Justice, Saint Louis University, Salus
Center, 3545 Lafayette Avenue, Saint Louis, MO 63104, USA
Full list of author information is available at the end of the article
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which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
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Iwelunmor et al. Implementation Science Communications (2020) 1:53 Page 2 of 33
Contributions to the literature
This study addresses an important gap in knowledge given

the paucity of evidence regarding the extent to which
existing economic empowerment as HIV prevention
interventions for AGYW in SSA report on components of the
RE-AIM framework.
The RE-AIM framework is a useful evaluation framework for
assessing scale-up, dissemination, or implementation of eco-
nomic empowerment as HIV prevention interventions for
AGYW in SSA, to ultimately enhance population impact and
long-term sustainability.
Findings from this systematic review highlight gaps in
reporting of implementation outcome measures that could
inform decisions around the translation and scale-up of EE
HIV interventions targeting AGYW in SSA.
(Continued from previous page)

Conclusions: Results of the review emphasize the need for future economic empowerment HIV prevention interventions
for AGYW in SSA to report multiple implementation strategies and highlight considerations for translating such programs
into real-world settings. Researchers should pay close attention to reporting setting-level adoption, implementation cost, and
intervention maintenance. These measures are needed for policy decisions related to the full merit and worth of EE
HIV interventions and their long-term sustainability for AGYW.
Keywords: RE-AIM, Economic empowerment, Adolescent girls, Young women, Sub-Saharan Africa
Background double from 100 million in 1990 to 200 million by 2020

Across many countries in sub-Saharan Africa (SSA), [13]. This suggests a potential for new infections, and
adolescent girls live in a context of vulnerability and are consequently a need to address the growing education
exposed to a combination of intersecting systemic bar- and employment gap already faced by this population
riers based on their age, gender, education, ethnicity, so- [14]. While there may be some challenges posed by the
cioeconomic status, and place of residence [1–3]. Every growing youth population in SSA, there are opportun-
day, an estimated 1000 adolescent girls and young ities to optimize the demographic dividends from the
women aged 15–24 years are newly infected with human “youth bulge”, where more than half of the population is
immunodeficiency virus (HIV) [4]. Globally, there are younger than 20 years, to foster youth employment and
now 19.1 million adolescent girls and women living with economic empowerment [15]. The potential for elevated
HIV, of which 80% reside in sub-Saharan Africa [4]. infection rates among young females in SSA demon-
Data from the Joint United Nations Program on HIV strates an urgent need for sustainable programs that le-
and AIDS (UNAIDS) estimates that three out of four verage on the capabilities of young people to avert new
new HIV infections in SSA among 15–19 years olds are HIV infections in adolescent girls in high HIV risk set-
among young women, and 7 out of 10 young women do tings [16]. If not properly addressed, the mutually re-
not have comprehensive knowledge about HIV [5]. Add- inforcing crisis of poverty and disease may threaten
itionally, the interactive effects of youth poverty and dis- fragile development gains. The result of which is a dev-
ease are particularly severe in SSA [6]. Decades of astating downward spiral in human development over
economic crisis across SSA have left millions of youth the next generation for millions of adolescent girls and
that are currently out of school unemployed [7–9]. young women in the region.
These youth, particularly young girls, who miss out on Recognizing the urgency of the crisis, considerable re-
education are more likely to engage in risk-taking behav- search has been devoted over the past two decades to
ior such as unprotected sex, transactional sex, and age- developing effective strategies to prevent HIV among
disparate sex [10–12]. Simultaneously, the population of adolescents and young people globally [17–20]. A num-
adolescent girls and young women in SSA is expected to ber of theory-based prevention approaches targeting
individual-level, group, community, and structural bar- by Peters and colleagues, “implementation research
riers to HIV have been implemented, with some target- seeks to understand and work within real-world condi-
ing girls in schools [21–28] or within their tions, rather than trying to control for these conditions”
communities [29–31] and some showing evidence of ef- [55]. It also implies working with populations that will
ficacy or effectiveness. HIV prevention interventions be affected by an intervention (i.e., adolescent girls
also led to the development of effective approaches to themselves serving as an advisory board), rather than
combat a spectrum of other health and behavioral selecting beneficiaries who may not represent the target
problems, including depression, risky sexual behaviors, population of an intervention (such as studying only in-
pregnancy intentions, and intimate partner violence school girls or excluding girls who have comorbidities)
[17, 32–35]. Examples of economic empowerment in- [54, 56, 57]. One goal of implementation science is to
terventions include microfinance, vocational skills appropriately expand the use of interventions that have
training, business development training, micro- been found efficacious and as broadly as feasible in order
enterprise development, cash transfers, and savings-led to foster the greatest public health impact [51, 58]. The
asset-based programs that work to alleviate girls’ house- reach, effectiveness, adoption, implementation, and main-
hold economic hardships through the infusion of finan- tenance (RE-AIM) model is an implementation science
cial assets and resources [36–38]. Available evidence framework for expanding interventions that have been
suggests that when implemented in conjunction with fi- found to be effective in research settings [58, 59]. The
nancial literacy curricula, such economic empower- model focuses on the reach of the intervention to a repre-
ment programs increase school attendance and sentative proportion of the target population, the effective-
personal savings among girls [39, 40]. Additionally, ness of a program on specific outcomes, adoption of the
when these programs are combined with other social program in a specified setting, and details of program im-
empowerment programs such as safe spaces, peer- plementation and maintenance [58, 59]. To date, there are
support, and mentoring on female-specific issues re- no published studies using the RE-AIM framework to
lated to health and well-being, they can increase girls’ evaluate the public health impact of economic empower-
bargaining power, decrease their financial dependence ment HIV prevention programs for girls, and none of the
on others, and reduce engagement in sexual risk-taking published RE-AIM studies have looked at adolescent girls
behaviors [41]. Combination HIV prevention interven- and young women populations in SSA.
tions that include economic empowerment activities The present study seeks to bridge this gap between re-
are particularly beneficial in low-resource settings such search and practice in SSA. Our objectives are twofold: (1)
as SSA, where adolescent girls and young women are at to review the extent to which EE HIV prevention interven-
increased risk to engage in transactional and cross- tions for AGYW in SSA report on implementation out-
generational sex due to limited economic assets [42– comes, as conceptualized in the RE-AIM (reach, efficacy/
44]. Numerous studies continue to show that women who effectiveness, adoption, implementation, and maintenance)
lack economic independence are less able to negotiate safe framework; and (2) to make recommendations for using
sex with partners, less able to leave an abusive relation- the RE-AIM framework to advance the implementation of
ship, and are more likely to engage in transactional sex as these interventions for girls and young women in the re-
means of survival [45, 46]. These in turn increases their gion. Through highlighting the reach, effectiveness, adop-
risk for HIV. Such evidence shows a strong link between tion, implementation, and maintenance of economic
economic instability and risky sexual behaviors that in- empowerment HIV interventions for adolescent girls and
crease HIV risk among adolescent girls and young women young women in SSA, we aim to assist researchers, practi-
in the region [43, 47]. tioners, and policymakers in scaling up and evaluating new
Nevertheless, despite the increase in the number of and existing economic empowerment interventions aimed
these interventions targeting adolescent girls and young at reducing the rate of new HIV infections.
women in the region, it can take up to 17 years for these
interventions to make their way to other adolescent girls Methods
underrepresented in scientific trials or in settings where A multi-step process was used to identify, review, and analyze
its delivery could reasonably produce benefit [48, 49]. existing economic empowerment HIV prevention interven-
Additionally, a sizable gap remains between what is tions targeting adolescent girls and young women in SSA
known about what works and how to effectively translate using the RE-AIM framework. For the purposes of this review,
these interventions into practice [50, 51]. One potential economic empowerment intervention was defined as a set of
solution is the use of implementation science, and by economic-related actions (i.e., microfinance, cash transfers, fi-
this, we mean the scientific inquiry into what, why, and nancial literacy, savings, and asset-based programs) [60, 61]
how interventions work in “real world” settings and to with a coherent objective to bring about change or produce
test approaches to improve them [52–54]. As described identifiable HIV prevention outcomes in three broad sectors:
Fig. 1 Flow diagram of the search strategy. A total of 25 unique interventions reported in 45 articles were included in the review
health (i.e., girls’ overall sexual and reproductive health, HIV the PubMed database is provided in Additional file 2. In
and sexually transmitted infections (STIs), sexual risk-taking addition, published systematic reviews focused on eco-
behaviors, pregnancy, and gender-related violence), social (i.e., nomic strengthening for HIV prevention, as well as refer-
education-related outcomes such as school attendance, em- ence lists from the included studies, were searched to
ployment, mental health, future outlook, etc.), and economic augment the database literature search. The titles and ab-
(savings, asset accumulation, small business, etc.). stracts of potentially relevant articles were independently
screened by two reviewers (JI and UN) for eligibility. The
Search strategy full texts of articles that met the eligibility criteria were ob-
A systematic search of the literature was executed from tained and assessed by the two reviewers (JI and UN) in-
October 2018 to July 2019 to locate studies published in dependently for inclusion in the review. Discrepancies in
academic journals. Figure 1 outlines the search strategy, the screening process and study eligibility were discussed
which was reported according to Preferred Reporting and addressed based on consensus between the two re-
Items for Systematic Reviews and Meta-Analyses viewers (JI and UN).
(PRISMA) guidelines (see Additional file 1). Two re-
viewers (JI and UN) independently searched PubMed, Eligibility criteria
Ovid/MEDLINE, Science Direct, Ebscohost, PsycINFO, Inclusion and exclusion criteria were developed to iden-
Scopus, and Web of Science databases with the following tify original research that empirically evaluated or tested
approximate search terms: (girls or young women) AND economic empowerment strategies to prevent HIV
(HIV or AIDS) AND (prevention or intervention or pro- among adolescent girls and young women in SSA. Arti-
gram) AND (economic empowerment or microfinance or cles were eligible for inclusion if they were (a) conducted
cash transfers or savings-led programs or asset-based pro- in sub-Saharan Africa, (b) described an economic em-
grams) AND (sub-Saharan Africa or country-specific powerment intervention with outcomes related to HIV
terms for each SSA country). The search teams were prevention, (c) targeted adolescent girls and young
modified for each database. A detailed search strategy for women aged 10–24 or interventions that were not
specific to AGYW but reported separately on AGYW, each study included in the review. Secondly, the average
(d) written in English, and (e) published between 2000 proportion of components within each RE-AIM dimen-
and 2019. We included studies that used intervention sion across the 25 unique interventions included in the re-
designs ranging from randomized control trials to quasi- view was calculated. The percentage and number of
and non-experimental evaluations of the interventions. interventions reporting each RE-AIM dimension were re-
Non-empirical studies (e.g., reviews, commentaries, edi- ported to provide a comparable summary score across
torials, and dissertations) and studies that did not expli- interventions.
citly assess the effect of economic empowerment on
HIV prevention were excluded from the review. Risk of bias
To systematically compare the interventions, we evalu-
Data extraction ated the rigor of each intervention using the Cochrane
For studies meeting the inclusion criteria, we extracted the Collaboration risk-of-bias tool [66, 67]. The tool consists
following data: (1) title, author, country, study objective, of six domains: selection bias, performance bias, detec-
and design; (2) information on the intervention being evalu- tion bias, attrition bias, reporting bias, and other bias
ated, including type of economic empowerment HIV pre- [66, 67]. The risk of bias was independently rated as low,
vention intervention, and target AGYW populations; (3) high, or unclear by two authors using the guideline for
components of the intervention; and (4) RE-AIM frame- each domain. The raters discussed each domain of the
work implementation outcomes that included (a) reach (ab- assessment tool to apply consistent judgment. If ratings
solute number, proportion, and representativeness of differed, the rationale for the rating was discussed, and
AGYW in the economic empowerment HIV prevention in- the study was re-reviewed to reach consensus. The
terventions); (b) efficacy/effectiveness (impact of the inter- Cochrane Collaboration risk of bias assessment tool was
vention on AGYW HIV prevention behaviors, including only used to evaluate the internal validity of the inter-
overall sexual health factors, social factors, and economic ventions included in the review; no study was excluded
outcomes); (c) adoption (absolute number, proportion, and from the review based on the risk-of-bias score.
settings participating in the intervention, and the extent to
which the settings selected are representative of settings Results
that the target population use or visit); (d) implementation Study selection
(consistency of delivery as intended, time, and cost of im- The initial database search yielded 2205 potentially rele-
plementation); and (e) maintenance (extent to which a pro- vant citations based on publication titles and abstracts
gram has become part of routine practice at the (Fig. 1). A total of 542 papers were retrieved for full-text
organizational level or the long-term effects of a program review for eligibility, and 443 were excluded. The most
on outcomes at the individual level) [59]. common reasons for exclusions were the absence of an
economic empowerment HIV prevention intervention
Data analysis targeting adolescent girls and young women aged 10–
Data from the articles included in this review were ana- 24 (n=46), study location outside of sub-Saharan Af-
lyzed using narrative synthesis [62], with details on the rica (n=3), or not meeting study design criteria (n=15).
reporting of the RE-AIM components synthesized. The ar-
ticles included in this review are heterogeneous in terms Characteristics of included studies
of study design and measured outcomes; therefore, it was Forty-five articles were retained in the final group of arti-
not practical to conduct a meta-analysis. To evaluate the cles. Most of the articles were pulled from the electronic
included interventions within each dimension of the RE- data searches, except for 13 articles that were identified
AIM framework, two authors coded and scored each from the manual search of reference lists. The characteris-
article independently using an adapted RE-AIM data ex- tics of the final included articles are presented in Table 1.
traction form that included a series of yes or no questions We reported on 25 unique interventions that were
used to identify components within each of the RE-AIM highlighted across the forty-five articles included in the re-
dimension outcomes [63–65]. The adapted RE-AIM data view. All 25 interventions reported in the articles were
extraction form is presented in Additional file 3. The form published between 2006 and 2018, thirteen interventions
was used for calculating percentages of interventions were conducted in Southern Africa, nine in East Africa,
meeting the criteria for the five RE-AIM dimensions and one in Central Africa, West Africa, and North Africa
(reach, efficacy/effectiveness, adoption, implementation, respectively. The majority of AGYW targeted were be-
and maintenance). We summarized RE-AIM components tween the ages of 15 and 24 years. Seventeen (68%) inter-
using frequencies, proportions, and means. First, the fre- ventions were randomized controlled trials, three (12%)
quencies and proportion of reported 26 components for were cross-sectional interventions, three (12%) were quasi-
each RE-AIM dimension were calculated separately for experimental designs, one (4%) observational study, and
Table 1 General characteristics of 25 interventions reported in 45 articles included in the review
Study, location Design Description Outcome of interest RE-AIM dimension
Reach Adoption Implementation Efficacy/effectiveness Maintenance
Abdool Karim et al. Cluster RCT to evaluate To increase HIV testing, Study participants: Program delivered by Cash incentives of up After 2 years, CCTs Individual level:
(2015) [68]; Humphries the impact of a cash- reduce incidence of HIV 3217 adolescents; 53% trained field staff to US$175 over 2 reduced HSV-2 inci- Follow-up at 12 and
et al. (2017) [69], South incentivized prevention females (1705) years, conditional on dence by 30% (p = 24 months to assess
Africa intervention to reduce Age range, 13–24 for their participation in a 0.007). Among boys, individual behavior
HIV infection females (median: 16 life skills program, those in the incentive change participants)
Intervention: years). passing grades in 6 group had a 40% Program level:
Cash-incentivized Non-participants: months of academic lower incidence of Indicators of program
prevention intervention characteristics of non- exams, and HSV-2 than controls (p level maintenance
to reduce HIV infection participants were not acceptance of an HIV = 0.042), while girls were not reported
reported test had a 24% lower inci-
dence of HSV-2 com-
pared to controls (p =
0.035). The reduction
in HSV-2 infection was
greater the higher the
CCT amount. The
Iwelunmor et al. Implementation Science Communications
number of HIV infec-

tions (75) was too
small to detect a dif-
ference between
intervention and
control.
(2020) 1:53
Adoho et al. (2014) [70], RCT comparing Promote safe sexual Study participants: Program delivered by Empowerment of Among participants, Individual level:
Liberia economic, behavior 2042 females; Age four NGOs selected Adolescent Girls and there was no follow-up at 6
empowerment, and range, 16–27 (mean, by the Liberian Young Women (EPAG) significant reduction months to assess in-
health outcomes 23 years) not enrolled Ministry of Gender provided 6 months of in the number of dividual behavior
between participants in school. and Development livelihoods and life sexual partners or change (sexual
and controls Non-participants: skills training (in either increase in condom behavior)
Intervention: Reasons for not a Job Skills or Business use as a result of the Program level:
Empowerment of participating in the Development Services intervention. There indicators of program
Adolescent Girls and program included (1) track) and 6 months of was also no difference level maintenance
Young Women (EPAG) they were back in follow-up support to in these outcomes were not reported
part of a larger school, (2) they had facilitate self or wage between the
Adolescent Girls moved to a distant employment. treatment and
Initiative (AGI) location, (3) they were intervention arms.
administered by the seriously ill, (4) they Attrition rate: 20% at
World Bank with had found full-time 6-months follow-up
support from the Nike work, (5) they were Cost: $1200 for the
Foundation and the not interested or able Business Skills Track;
Governments of to make such a big- $1650 for the Job
Australia, the UK, time commitment, or Skills Track
Norway, Denmark, and (6) they could not be
Sweden. The located despite nu-
intervention provided 6 merous efforts.
months of livelihoods
and life skills training (in
either a Job Skills or
Business Development
Page 6 of 33
Table 1 General characteristics of 25 interventions reported in 45 articles included in the review (Continued)
Services track) and 6
months of follow-up
support to facilitate self
or wage employment
for young girls (16–27
years) in Liberia
Austrian and Muthengi Cluster RCT to assess the Improve sexual and Study participants: Program There were 3 arms: No difference Individual level:
(2014) [71]; Muthengi impact of Adolescent reproductive health 4661 adolescent girls; implemented in arm 1: safe spaces between program and follow-up at 12
(2014) [72], Uganda Girls Empowerment outcomes (HIV age range, 10–19 partnership with key only; arm 2: safe control with social months and 24
Program on knowledge, HIV testing, Non-participants: stakeholders: safe spaces and health safety nets, gender months to assess in-
demographic, and knowledge of characteristics of non- spaces with YWCA voucher; and arm 3: norms at 24 months. dividual behavior
reproductive and health contraceptives) and participants were not Zambia; Health safe spaces, health AGEP also had no change among
outcomes increase in economic reported Vouchers with vouchers, and savings impact on HIV participants
Intervention: assets Ministry of account. prevalence or Program level:
Adolescent Girls Community incidence. AGEP indicators of program
Empowerment Program Development, Mother however improved level maintenance
that includes safe space, and Child and Savings sexual and were not reported
health vouchers and Program with reproductive health
savings account National Savings and knowledge, improved
Credit Bank and self-efficacy, improved
Making Cents saving behaviors, and
International. decreased transac-
(2020) 1:53
Program uptake tional sex (for girls

participants: 30% who were sexually ac-
attended 52+ tive at the start).
meetings Attrition rate, 18%
Baird et al. (2012) [73]; Cluster RCT comparing Decrease prevalence/ Study participants: A local NGO CCT (based on at least Overall, 2 years after Individual level:
Baird et al. (2013) [74], conditional cash incidence of HIV and 1706 never married implemented the CCT 80% school the program ended, follow-up at 6
Malawi transfers (CCT) recipients herpes simplex virus 2 young women; age program attendance) and UCT among school girls, months, 12 months,
versus unconditional (HSV-2) range, 13–22 participants neither CCTs nor UCTs 24 months to assess
cash transfer (UCT) (schoolgirls and received some money had any long-term ef- individual level
recipients and non- school dropouts) from 1–5/month and fect on HIV preva- change
recipients Non-participants: their parents lence, onset of sexual Program level:
Intervention: individuals who did received some money activity, risky sexual indicators of program
Conditional cash not want to get from 4–10/month for behaviors such as hav- level maintenance
transfers (CCT) tested for HIV 2 years ing older partners or were not reported
use of condoms, and
the following sexual
behaviors: sexual de-
but, age at first sex,
number of sexual
partners, condom use,
and age of sexual
partners. Among
school dropouts, CCTs
initially delayed the
onset of sexual activ-
ity, but 2 years after
Page 7 of 33
the end of the pro-
gram, 97% of this co-
hort is sexually active.
CCTs did not lead to
long-term changes in
condom use or age at
first sex among base-
line dropouts.
Attrition: 15.7%
among school
dropouts and 12.5%
among school girls.
Bandiera et al. (2012) Cluster RCT to evaluate To increase HIV- and Study participants: Program ELA combined the After 2 years, among Individual level:
[75]; Bandiera et al. the effects of the pregnancy-related 4800 adolescent girls. implemented by provision of life skills those sexually active, follow-up at 12 and
(2018) [76], Uganda Empowerment and knowledge and condom Age range, 14–20 NGO, BRAC Uganda to reduce risk routine condom use 24 months to assess
Livelihoods for use years. Mean age, 16 by trained mentors or behaviors and increased by 25% (p < individual level be-
Adolescents (ELA) years professional staff. vocational skills 0.05) and the number havior change
program Non-participants: not Program uptake by training to start small of girls reporting Program level:
Intervention: explicitly stated. participants, 21% income-generating having sex unwillingly authors alluded to
empowerment and However, authors activities dropped from 21% at the continuation of
Livelihoods for explain that distance baseline to under 4% the program beyond
Adolescents (ELA) to program location (p < 0.01). The study timeline. The
(2020) 1:53
program may have impacted intervention group program was

participation. also had a 26% lower expanded to include
rate of fertility over 2 a microfinance
years (p < 0.05). component that
Attrition rate: 18% at provides financial
24 months’ follow-up support for
Program costs: year 1: microenterprise
US$365,690; year 2:
US$232,240
Individual participant
cost: $17.9
Bazika (2007) [77], Cross-sectional survey Increase condom use Study participants: 372 Implemented by local IGAs consisting mostly Approximately 25% of Individuals level:
Congo and FGDs to understand young people; age authorities of “trade and craft the youth were follow-up at 4 years
how involvement in range, 15–24 Program uptake by apprenticeships” involved in IGAs; 5% after intervention im-
IGAs is associated with Non-participants: participants: not of all participants plementation to as-
HIV risk characteristics of non- stated reported sexual sess individual level
Intervention: income- participants were not intercourse with a change.
generating activities re- reported new partner without a Program level: the
lated to trade and craft condom, which was program was
apprenticeships significantly lower discontinued 3
among those months after
currently involved in implementation
IGAs (p < 0.01);
however, higher levels
of unprotected sex
were reported by
Page 8 of 33
youth involved in
agriculture.
Cho et al. (2018) [78], Cluster RCT to test Reduction in HIV and Study participants: 835 Program The intervention arm After 3 years, school Individual level:
Kenya whether keeping orphan herpes simplex virus 2 orphaned adolescents; implemented by received payment of support reduced the follow-up at 12, 24,
adolescents in school (HSV-2) incidence age range, 11–20; trained research staff. school fees, school med-likelihood of en- and 36 months to as-
reduces HIV risk mean age, 15 years; uniforms, and nurse’s gaging in transac- sess individual level
Intervention: involved 48% were adolescent visits to monitor tional sex. High (AOR change
providing school fees, girls (401) absenteeism = 0.49, p = 0.03) and Program level:
school uniforms, and Non-participants: one increased VMMC indicators of program
nurse’s visits to monitor individual was not among males (AOR = level maintenance
absenteeism interested in the 1.66, p = 0.04), but no were not mentioned
study. However, more differences were seen
details on in sexual debut, age
characteristic of non- at first sex, number of
participants were not sexual partners, or
provided condom use between
intervention and con-

trol participants. The
study was underpow-
ered to detect a differ-
ence on HIV or HSV-2
incidence between
(2020) 1:53
arms.
Attrition rate: 10%
Cluver et al. (2016) [79], Prospective Reduction in HIV Study participants: Program “Cash” defined as Child-focused grants, Individual level:
South Africa observational study with incidence 2668 adolescent boys implemented by household receipt of a free schooling, school follow-up at 12
random sampling to and girls; age range, trained research staff child support grant or feeding, teacher months to assess in-
assess the relationship 12–18; mean age, 14 foster care grant, support, and parental dividual level change
between receipt of years; 56% were school feeding, and/or monitoring were Program level:
social services (“cash,” adolescent girls (1494) food gardens; “cash independently indicators of program
“cash plus care,” or “no Non-participants: plus care” adds receipt associated with level maintenance
support”) and HIV risk characteristics of non- of teacher social reduced HIV-risk be- were not reported
behaviors participants were not support and/or havior incidence (OR
Intervention: reported positive parenting. 0.10–0.69). For ex-
Intervention provided ample, girls predicted
“cash” defined as past-year incidence of
household receipt of a economically driven
child support grant or sex dropped from
foster care grant, school 11% with no interven-
feeding, and/or food tions to 2% amongst
gardens; “cash plus care” those with a child
adds receipt of teacher grant, free school, and
social support and/or good parental moni-
positive parenting toring. Similarly, girls’
incidence of unpro-
tected/casual sex or
multiple partners
dropped from 15%
Page 9 of 33
with no interventions
to 10% with either
parental monitoring
or school feeding and
to 7% with both
interventions.
Attrition rate: 3%
de Walque et al. (2012) RESPECT RCT to assess Reduction in risky sexual Study participants: Program CCTs of US$10 (low- At 12 months, the Individual level:
[80]; de Walque et al. the effectiveness behaviors, reduce 2399 males and implemented by value) or US$20 (high- high-value CCT arm follow-up at 12 and
(2014) [81], Tanzania of Conditional Cash incidence of HIV, herpes females; age range, trained research staff. value) per testing had a lower risk of 24 months to assess
Transfers (CCTs) on simplex virus 2, and 18–30; mean age round conditioned on combined prevalence individual level
prevention of STIs syphilis range, 27 years; testing negative for 4 of any of the four STIs change
Intervention: RESPECT- females, 50% (1199) curable STIs every 4 compared to controls Program level:
provided conditional Non-participants: the months (3 testing (aRR = 0.73, p < 0.05) conditional cash
cash transfers authors noted that rounds in 12 months) and compared to the transfer and other
some participants low-value arm (aRR = components of the
explicitly refused to 0.69, p < 0.05). At end intervention were

participant in the line, the combination discontinued after 1
study and some of syphilis prevalence year of
declined. However, and new cases of HIV implementation
detailed reasons and and HSV2 were not
characteristic of these different between
(2020) 1:53
non-participants were study arms.

not stated. One year after the
end of the
intervention, both the
high and low value
CCTs lowered the risk
of testing positive for
any one of the 7 STIs
(0.799 and 0.818,
respectively, p < 0.05).
Only the low-value
arm significantly low-
ered the prevalence
when looking only at
the 4 STIs on which
the CCT was condi-
tioned (RR = 0.766, p
< 0.05), and only the
high-value arm signifi-
cantly reduced the
prevalence when
looking at HIV/HSV/
syphilis. Results were
sustained 12 months
post-intervention for
males, but not
Page 10 of 33
females. There were
no significant differ-
ences in self-reported
sexual risk behavior at
24 months.
Attrition rate: 6.4%
attrition at 12 months
and 9.3% attrition at
24 months
Dunbar et al. (2010) [82]; Individual RCT to Increase correct HIV Study participants: 315 Program SHAZ! Intervention After 2 years, within Individual level:
Dunbar et al. (2014) [83], compare the effects of knowledge, increase HIV- female, out of implemented by consisted of (1) the intervention arm, follow-up at 6, 12, 18
Zimbabwe the Shaping the Health condom use school orphans; age trained research staff reproductive health there Med- were and 24 months to as-
of Adolescents in range, 16–19; mean services; (2) life skills, statistically significant sess individual level
Zimbabwe (SHAZ!) age, 18 years gender, and HIV reductions in high change
intervention on Non-participants: education; (3) financial transactional sex (IOR Program level:
structural factors and individuals who did literacy education and = 0.64, p < 0.05), and indicators of program
sexual risk behaviors not return for a choice of 6-month increases in condom level maintenance
Intervention: enrollment. However, vocational training use with current were not reported
Shaping the Health of the authors did course; and (4) inte- partners (IOR = 1.79, p
Adolescents in provide additional grated social support < 0.05) compared to
Zimbabwe (SHAZ!) details on the and adult mentoring. baseline, but these
intervention on characteristic of these The control arm re- were not significantly
(2020) 1:53
structural factors and individuals. ceived components 1 different from the

sexual risk behaviors Participants who and 2 only. results in the control
returned to school, group. Sexual debut
relocated or where also did not differ
influenced by partners between arms.
to not participate in Unintended
the study. pregnancy was
marginally significantly
lower in intervention
arm (AHR = 0.61, p =
0.06). Intervention
participants also had a
greater reduction in
the experience of
violence over time
(AHR = 0.10, p = 0.06).
The study was not
powered to detect
differences in HIV and
HSV-2 incidence.
Attrition: 19% at 24
months
Erulkar and Chong Longitudinal (pre-post Increase condom use Study participants: 444 Program delivered by The TRY intervention At program exit (after Individual level:
(2005) [84]; Hall et al. intervention) study of and sexual and out-of-school adoles- project officers and combined training on < 1 year to 3 years), follow-up at 12, 24
(2006) [85], Kenya Tap and Reposition reproductive health/HIV cent females; age mentors business management 80.3% High of TRY and 36 months to as-
Youth (TRY) participants knowledge, increase range, 16–22 and reproductive participants were able sess individual level
Page 11 of 33
and matched controls to ability to negotiate Non-participants: health, group savings, to refuse sex with change
assess changes in issues related to sexual characteristics of non- and formal their partner, Program level:
vulnerabilities and risk behavior, increase participants were not microcredit to compared to 71.6% of indicators of program
behaviors economic assets reported individual group controls (p < 0.05), level maintenance
Intervention: (earning, savings, members contingent though TRY girls were were not reported
Tap and Reposition household assets) on other members’ significantly more
Youth (TRY) - combined timely repayment likely to insist on
training on business condom use
management and compared to controls
reproductive health, (61.7% vs. 49.3%, p <
group savings, and 0.01). There was no
formal microcredit to significant difference
individual group in the likelihood of
members’ contingent on having used a
other members’ timely condom at last sex
repayment between the two
groups, though both

arms experienced a
decrease from
baseline levels.
Attrition rate: 32% at
end line (36 months
follow-up)
(2020) 1:53
Goodman et al. (2014) Stratified-random, cross- Increase condom use, Study participants: 707 Program Three-year Among females, those Individual level:
[86], Kenya sectional survey to as- increase financial OVC-headed house- implemented by intervention grouping in higher cohorts had follow-up at 12, 24,
sess differences among literacy, increase holds (aged 13 to 25); community 20–40 families fewer sex partners (p and 36 months to as-
three program cohorts economic assets mean age 19 years; stakeholders and together for = 0.03) and greater sess individual level
(those involved for 4 (earnings, savings) 66% females (467) trained social workers vocational training, condom use at last change
months, over 1 year, and Non-participants: group income- sexual encounter (p = Program level:
over 2 years) in a range characteristics of non- generating activities 0.015). Among males authors alluded to
of outcomes, including participants were not (IGAs), and provision there was no the continuation of
sexual practices. Some reported of business start-up significant difference the program and
families received cash kits. They also re- in number of sexual implementation in
transfers. Some families ceived weekly group partners or condom four other sub-
received cash transfers trainings on business, use. Saharan African
Intervention: health, hygiene, and Attrition rate: figure countries
The intervention agriculture. Some fam- not reported
provided vocational ilies received cash
training, group income- transfers.
generating activities
(IGAs), and provision of
business start-up kits
Hallfors et al. (2011) [22]; Cluster RCT to assess the Reduce school drop- Study participants: 328 Not clearly stated, but Payment of school At 5 years, no Follow up at 12, 24,
Hallfors et al. (2015) [23]; effects of the school outs, reduce unintended orphan girls (aged 14– can be inferred to be fees, uniforms, differences for either 36 and 60 months.
Luseno et al. (2015) [87], subsidies (school fees, pregnancy, decrease age 21 years); mean age, members of the supplies, and a HIV or HSV-2 were Program level: the
Zimbabwe uniforms, schools’ of sexual debut, and 12 years. research team school-based female found by study condi- intervention lasted
supplies, and school promote gender equity Non-participants: teacher to serve as a tion. Prevalence was for 5 years. The
helpers) on HIV risk characteristics of non- helper to assist with similar, by condition, duration of the
Page 12 of 33
behaviors participants were not attendance monitor- among the never mar- research trial.
Intervention: reported ing and assist with at- ried, with a trend to- Program level
The intervention tendance problems ward higher HIV and continuation in the
provided payment of HSV-2 infection setting was not
school fees, uniforms, among the married reported
supplies, and a school- comprehensive inter-
based female teacher to vention group com-
serve as a helper to as- pared with the
sist with attendance delayed partial inter-
monitoring and assist vention group. Also,
with attendance fewer girls among the
problems comprehensive inter-
vention group re-
ported sexual debut,
marriage, or preg-
nancy compared with
the delayed partial

intervention group.
12 months follow-up;
12% at 24 months
follow-up
(2020) 1:53
Handa et al. (2014) [88]; Cross-sectional data Reduce age of sexual Study participants: Program delivered by Government of The rate of sexual Individual level: first
Rosenberg et al. (2014) from cluster RCT debut, increase condom 1433 females (out of a the Children’s Kenya’s unconditional debut was 38% in the follow-up at 2 years
[89], Kenya participants, comparing use, decrease number of total sample of 2210 Department of the Cash Transfer (CT) CT group vs. 44% in and 4 years to assess
adolescent sexual debut sexual partners and Orphans and Ministry of Gender, Program for OVC (KES the control (p = individual level
in households receiving decrease engaging in Vulnerable Children Children and Social 1500 or US$20 per 0.001); the reduction change
the transfer and those in transactional sex (OVC)); age range, 15– Development of the month per household) in odds of sexual Program level:
control households 25 years Government of Kenya paid to OVC debut for CT indicators of program
Intervention: Non-participants: caregivers. recipients was 31%. level maintenance
Unconditional Cash characteristics of non- Eligible households The effect size was were not reported
Transfer (CT) Program participants were not received monthly CTs. larger for females
for orphans and reported There was no (AOR = 0.58) than
vulnerable children condition placed on males (AOR = 0.74),
through the Kenyan receiving the CTs; but not significantly
government however, beneficiaries so. Other sexual risk
were told that they behaviors (engaging
were expected to use in transactional sex)
the money for the were not statistically
care and development significantly different
of the OVC resident in between the study
the household arms.
Frequency: cash was Attrition rate: 17%
paid bimonthly to (between baseline
participants’ caregivers assessment and first
Duration: 4 years follow-up in 2009 (24
(2007–2011) months follow-up)),
5% (between 2008–
Page 13 of 33
2011 (48 months
follow-up))
Cost: the program
budget for FY 2011/22
is KES 3.5 billion, of
which 31% were from
general tax revenues,
37% from
development loans,
and 31% from foreign
aid donations.
Jewkes et al. (2014) [90], Shortened interrupted Increase household Study participants: 122 Program delivered by Training on livelihood After 58 weeks, for Individual level: 28
South Africa time-series study to as- assets and promote safe out-of-school young trained facilitators strengthening women there was a weeks post-baseline
sess the effects of the sex negotiation women (from a total from an NGO called through finding work significant reduction and second follow-
intervention on HIV risk, of 232 out-of-school Project Empower or establishing a in the experience of up 58 weeks post-
IPV, economic, and so- young people mostly business, combined sexual IPV from 9.8% baseline to assess in-
cial outcomes under 30 years) with HIV, gender, and at baseline to 3.6% (p dividual level change
Intervention: Age range, 17–34 violence prevention = 0.033), though for Program level:
Stepping Stones—the years training men there was no indicators of program
intervention provided Non-participants: Intervention group: change in level maintenance
training on livelihood characteristics of non- frequency—10 perpetration of sexual were not reported
strengthening through participants were not sessions of Stepping IPV. For women, there
(2020) 1:53
finding work or reported Stones and 11 were positive but not

establishing a business, sessions of Creating statistically significant
combined with HIV, Futures changes in condom
gender, and violence Duration: 3 h bi- use at last sex and
prevention training weekly for 12 weeks engagement in
transactional sex,
while there was no
change in these
metrics for men
Attrition rate:
acknowledged but
figure was not
reported
Khoza et al. (2018) [91], Qualitative data To promote visits to Study participants: 49 This was not specified The 3 CT strategies: (1) In interviews 6 months Individual level:
South Africa collection with a sub- clinics for sexual adolescents unconditional after the receipt of follow-up 6 and 12
sample of participants in reproductive health Age range, 16–18 monthly payments of CTs and up to 12 months to assess in-
a pilot RCT (N = 120 ad- education, services years 280 ZAR (US$20) for 6 months after the end dividual level change
olescents) of 3 CT strat- related to family Non-participants: months; (2) monthly of the intervention, Program level:
egies to explore the planning and characteristics of non- payments of 280 ZAR some girls mentioned indicators of program
consequences of CTs on contraception, HIV participants were not for 6 months, that CTs were level maintenance
adolescents counseling and testing, reported conditional on 80% protective against were not reported
Intervention: HIV risk assessment, and school attendance; transactional sexual
CHANGE Study— HIV risk reduction and (3) and a single relationships.
monthly cash transfers counseling payment of 280 ZAR Attrition rate: not
provided to participants conditional on a reported. May not be
to promote uptake of once-off clinic visit applicable for the
Page 14 of 33
sexual risk reduction involving sexual repro- qualitative study
services in clinics ductive health educa-
tion, services related
to family planning
and contraception,
HIV counseling and
testing, HIV risk assess-
ment, and HIV risk re-
duction counseling.
Kim et al. (2009) [92]; Cross-sectional study of Condom use, household Study participants: The microfinance MF-component: At 24 months, Individual level:
Pronyk et al. (2006) [93]; randomly selected communication about 1409 female component was groups of 5 women participants in MF- follow-up at 24
Kim et al. (2007) [94] ; matched clusters to sex, communication participants; 1835 implemented by an served as guarantors only group showed months and 36
Pronyk et al. (2008) [95], compare associations with intimate partner people age 14–35 NGO called Small for each loan, and all an improvement in all months to assess in-
South Africa between IPV, sexual risk about sexual matters living with those Enterprise Foundation 5 must repay their nine indicators of eco- dividual level change
behaviors, economic women; and 3881 loans before they nomic well-being, in- Program level: the
well-being, and em- people age 14–35 qualify for more cluding household intervention was
powerment between living in intervention credits. The loan asset value, ability to completed at the 3-
three clusters: villages and control villages centers met repay debts, and abil- year study period.
exposed to IMAGE Age: 18 years and over fortnightly to repay ity to meet basic However, sustain-
(group-based microfi- Non-participants: loans, apply for household needs ment of intervention
nance with 12-month authors stated that additional loan credit, compared to the con- beyond study period
gender and HIV training some individuals and discuss business trol group. was not reported.
(2020) 1:53
curriculum), villages ex- refused to participate plan. Likewise, compared to

posed to microfinance in the study. However, Frequency: loan the control group,
(MF) only, and control the characteristic of center meetings every participants in the
villages these individuals was 2 weeks IMAGE group showed
Intervention: IMAGE— not reported Duration: individual improved all
intervention with borrowing and indicators of
microfinance fir AIDS repayment of loans economic well-being,
and gender equity. over 10 or 20-week as well as in em-
Combined intervention cycle powerment (e.g.,
of group-based microfi- IMAGE incorporated a greater self-
nance with gender and participatory gender- confidence, autonomy
HIV training curriculum, focused learning pro- in decision-making),
Sisters for Life gram called Sisters- IPV (including reduc-
for-Life into the MF- tion in past-year ex-
component. perience of IPV) and
Frequency of the HIV risk behavior (in-
Sisters-for-Life compo- cluding increased con-
nent: phase 1 condom use).
sisted of ten 1-h There was no
trainings and the difference between
phase 2 was where MF-only and IMAGE in
participants engaged improving economic
youths and men in well-being among
the community participants. However,
through community IMAGE showed great
mobilization. effects on improving
Page 15 of 33
Duration: 12–15 empowerment, IPV
months and HIV risk behaviors
among participants.
After 2 years,
participants in the
intervention group
experienced
significantly less IPV in
the previous 12
months compared to
controls (RR = 0.45, p
< 0.05). The
intervention had no
effect on the rate of
unprotected sexual
intercourse at last
occurrence with a
non-spousal partner
for young people in
the households of
participants, or for
young people living
in participant villages.
(2020) 1:53
There was also no dif-

ference in HIV inci-
dence among young
people in intervention
and comparison
villages
2 years follow-up; 40%
at 3 years follow-up
Kohler and Thornton RCT to assess the effects Reduce HIV incidence, Study participants: The Incentives were The Malawi Incentives There was no effect of Individual level:
(2012) [96], Malawi of two levels of CCTs on promote safe sex 1307 participants (55% delivered by the Project builds upon the offered incentives follow-up at 2 years
sexual risk behaviors (condom use), HIV females) organizers of the the Malawi Diffusion on participants’ HIV to assess individual
CCTs of K500 or K2000 testing Age range, 14–49 Malawi Incentives and Ideational Change status or self-reported level change
(USD 4 or 16) for years Project. This was not Project (MDICP), reported sexual be- Program level:
individuals or K2000 or Mean age, 36 years explicitly stated where participants haviors. Compared to indicators of program
K4000 (USD 16 or 32) for Non-participants: were offered free male participants, fe- level maintenance
couples were given characteristics of non- door-to-door HIV test- male participants who were not reported
conditional on participants were not ing and randomly received CCTs were
maintaining HIV status reported assigned to cash in- 6.7% points less likely
(positive or negative) centives groups. to engage in risky sex.
throughout the Frequency: Among the male par-
intervention period participants received ticipants, receipt of
Intervention: The Malawi cash incentives at the CCTs showed an in-
Incentives Project—the end of the year if they creased likelihood of
intervention builds upon maintained negative risky sex.
Page 16 of 33
the Malawi Diffusion HIV status Attrition rates: 17%
and Ideational Change among the entire
Project (MDICP) where sample; 16% among
participants were HIV negative
offered free door-to- participants
door HIV testing and
randomly assigned to
cash incentives group.
The Malawi Incentive
projects provided condi-
tional cash transfers in
addition to the compo-
nents of MDICP
Nyqvist et al. (2015) [97]; Parallel 3—group RCT to Reduction in HIV and Study participants: Program was 3 groups: (1) control Over 2 years, in the Individual level:
Nyqvist et al.(2018) [98], examine the impact of a other STI incidence 3029 females and delivered by an NGO arm, (2) intervention pooled intervention follow-up at 16, 20,
Lesotho financial incentive males arms: Lottery incentive Med- group, HIV and 24 months to as-
lottery program on HIV Number of females program separated incidence was 21.4% sess individual level
incidence not specified into low-value lottery lower high compared change
Intervention: Age range, 18–32 (individuals were eli- to the control (p < Program level:
A financial incentive Non-participants: gible to win lottery .05). In the high-prize indicators of program
lottery program to characteristics of non- prizes worth 500 mal- arm only, HIV inci- level maintenance
reduce HIV incidence participants were not otis equivalent to dence was 28% lower were not reported
(2020) 1:53
reported US$50 every 4 compared to the con-

months) and high- trol (p < 0.05); the
value lottery (individ- low-prize arm was not
uals were eligible to significantly lower
win lottery prizes than the control. Ef-
worth 1000 malotis fects of the interven-
equivalent to US$100 tion on HIV incidence
every 4 months). Par- were greater for
ticipants’ eligibility for women. The number
the lotteries organized of high-risk sexual acts
every fourth month was significantly re-
was conditioned on duced in the pooled
participants testing intervention group
negative for syphilis compared to the
and trichomoniasis control.
vaginalis (2 curable Attrition rate: 5.4% at
STIs) a week prior to 16 months follow-up;
lottery draw 4.6% at 24 months
Frequency: the lottery follow-up
draws were
conducted every 4
months for 2 years
O’Neill Berry et al. (2013) Cross-sectional survey of Increase knowledge on Study participants: 40 Program delivered by Girls Empowerment Findings show Individual level:
[99], Lesotho participants in the Girls income-generating ac- girls aged 17–22 trained staff Program (GEP) camp considerable follow-up at 6
Empowerment program tivities, reduce transac- Non-participants: focused on providing improvement in the months and 12
Intervention: Girls tional sex, and promote characteristics of non- entrepreneurial girls’ knowledge months to report on
Page 17 of 33
Empowerment HIV testing participants were not training to develop about income- participants’
program—provided reported concrete, feasible, and generating activities. businesses
entrepreneurial training bankable ideas to start In addition, almost Program level:
to develop concrete, their own small half of the camp at- indicators of program
feasible, and bankable businesses as well as tendees participated level maintenance
ideas to start their own HIV/AIDS risk in further entrepre- were not reported
small businesses as well reduction and neurial training and
as HIV/AIDS risk prevention, life skills. about half of these
reduction and girls went on to de-
prevention, life skills velop small
businesses.
Pettifor et al. (2016) [18]; Individually randomized Reduce HIV and herpes Study participants: Not specified Young women and Conditional cash Individual level:
Pettifor et al. (2016b) controlled trial to simplex virus 2 (HSV-2) 2448 HIV negative their parent/guardian transfer on school follow-up at 12, 24,
[100], South Africa evaluate the efficacy of incidence females in high school received a monthly attendance did not and 36 months until
a CCT conditional on Median age, 15 years cash transfer of ZAR reduce HIV incidence study completion to
school attendance on Age range, 13–20 100 (US$10) and ZAR among study assess individual level
HIV incidence compared years 200 (US$20), participants. There change

to a control group Non-participants: respectively, was no statistically Program level: not
Intervention: characteristics of non- conditional on 80% significant difference reported
Conditional cash participants were not school attendance in HIV incidence
transfers to promote reported Intervention group between participants
school attendance received CCTs once a who received cash
(2020) 1:53
month. transfer (1.94% per

Duration: participants person-years) and
were eligible for CCTs those who did not
up to a maximum of (1.70% per person-
3 years years; hazard ratio
1.17, 95% CI 0.80–1.72,
p = 0.42). School at-
tendance however
was found to reduce
HIV acquisition, irre-
spective of study
groups.
Attrition rate: 9% at 36
months follow-up
Rotheram-Borus et al. Pilot pre- and post- Increase in condom use, Study participants: 100 The project was Frequency and At 4-month follow-up, Individual level:
(2012) [101], Uganda intervention assessment reduction in number of youth delivered by an duration: 10 session of there were no signifi- follow-up at 4 and
of HIV risk behaviors sexual partners, Females not specified NGO—The Ugandan the adapted HIV cant differences be- 24 months to assess
among those receiving economic assets Age range, 13–23 Youth Development education session tween the arms in individual level
HIV education plus voca- (employment type and years league. The vocational (Street Smart) over 10 average number of change
tional training compared length) Non-participants: training component weeks; 4–8 h, 5 days a sexual partners, or in Program level:
to those with HIV educa- characteristics of non- was delivered by local week of vocational abstinence or 100% indicators of program
tion only; cohort study participants were not artisans within the training. condom use. After 24 level maintenance
of effects of combined reported NGO months, the com- were not reported
intervention over time. bined intervention
Study participants were groups showed de-
randomized to an creases from baseline
Page 18 of 33
immediate vocational in the average num-
training or delayed ber of sex partners
vocational training (4 (2.12 to 1.12, p =
months delay). The 0.013) and increases in
vocational training abstinence or 100%
included hairdressing, condom use (45% to
catering, tailoring, 71%, p = 0.003).
mechanics, electronics, Attrition rate:15% at 4
carpentry, cell phone months and 26% at
repair, and welding. All 24 months
participants in the two
groups received an
adapted Street-Smart
HIV prevention program
at the same time
Intervention:
The intervention
provided HIV education
(adapted Street-Smart
HIV prevention program)
plus vocational training.
The vocational training
included hairdressing,
(2020) 1:53
catering, tailoring, me-

chanics, electronics, car-
pentry, cell phone repair,
and welding
Ssewamala et al., (2009) Longitudinal RCT (pre- Attitudes toward Study participants: 161 The workshops were Suubi Project provides Between wave 1 and Individual level:
[39]; Ssewamala et al. Suubi intervention engaging in sexual risk- adolescent girls (out delivered by students orphaned children wave 2, girls in the follow-up at 10
(2010) [102]; Ssewamala (wave 1) and 10–12 taking behavior, increase of 286 orphaned from Makerere with 3 component intervention group months to assess in-
et al. (2010b) [26]; months post-Suubi inter- economic assets (sav- adolescents from 15 University in Uganda. programs: (1) reported a 33% dividual level change
Ismayilova et al. (2012) vention (wave 2)) to ings), enhance educa- primary schools). University students workshops focused on increase in positive Program level:
[103], Uganda examine the influence tional plans and Mean age, 13.5 years were trained by the financial education, educational plans indicators of program
of Suubi Project on edu- aspirations, reduce sex- Non-participants: research team asset building, and while 27% of girls in level maintenance
cational outcomes ual risk-taking behaviors adolescents whose career building; (2) the control group were not reported
Intervention: and attitudes parents were skeptical mentorship from reported increase in
Suubi Project—the of some aspects of peers to reinforce positive education
intervention provided the program, learning; (3) a joint plans. In wave 2, girls
orphaned children with specifically the Conditional in the intervention
3 component programs component of a Development group reported
matched savings Accounts (CDAs) in statistically significant
account, which they both the child’s and more positive
said was too good to caregiver’s name educations plans than
be true. those in the control
group (t (154) = 2.94,
p < 0.01).
Between wave 1 and
wave 2, there was a
Page 19 of 33
31% increase in the
number of girls in the
intervention group
reporting more
optimistic and higher
level of confidence in
achieving their
educational plans,
while in the control
group, there was only
10% increase in these
outcomes. In wave 2,
girls in the
intervention group
reported statistically
significant more
confidence in
achieving their
educational plans
than those in the
control group (t (122)
= 4.70, p < 0.00).
Attrition rate: 9.1% at
(2020) 1:53
10 months
Stark et al. (2018) [41]; RCT to assess the Increase school Study participants: 919 The program was The core component The intervention did Individual level:
Falb et al. (2016) [104], effectiveness of Child attendance, earnings, girls implemented by the of the COMPASS no impact economic follow-up at 10
Ethiopia Development Accounts and reduce transactional Age range, 13–19 International Rescue program was to and education months to assess in-
(CDAs) versus control sex exploitation years Committee (IRC) and provide opportunities outcomes measured dividual level change
condition on sexual risk- Non-participants: program sessions for girls to build assets in the study. Program level:
taking intentions characteristics of non- were delivered by to protect against and Participants in the indicators of program
Intervention: participants were not young female respond to violence intervention group level maintenance
COMPASS program— reported mentors (from their and establish a did not differ from were not reported
the intervention late teens to 30 years) foundation for a those in the control
provided (1) twelve 1-to- healthy transition to group in school
2-h workshops on assets adulthood. COMPASS attendance or
building and financial program frequency/ engaging in
planning for 10 months; duration: (1) twelve 1 transactional sexual
(2) monthly mentorship to 2 h workshops on exploitation.
program for adolescents assets building and
with peer mentors on financial planning for
future planning; and (3) 10 months; (2)
Child Development Ac- monthly mentorship
counts (CDAs) to reduce program for
sexual risk-taking adolescents with peer
intentions mentors on future
planning.
The CDAs were
matched savings
Page 20 of 33
account with a match
rate of 2:1 as an
incentive for
participants to save,
but with a limit (“cap”)
on the maximum
savings that could be
matched (the match
cap, in this case, was
equivalent to US$10 a
month). Each control
condition adolescent
received the usual
care for orphaned
children, which
consisted of
counseling and
educational-related
supplies (including
textbooks).
Visser et al. (2015) [105]; Mixed methods quasi- Reduce HIV risk, reduce Study participants: 604 The program was The core of the 12.9% of ex- Individual level:
Visser et al. (2018) [106], experimental design in- number of sexual (55% female) OVC developed by the ISIBINDI model is participants of ISIBINDI follow-up duration
(2020) 1:53
South Africa vestigating differences partners, and to Age range, 18–25 National Association home visits to reported HIV risk be- not reported (there
in HIV risk behavior and promote consistent Non-participants: of Child Care Workers, promote OVC havior compared to was post-intervention
other outcomes be- condom use characteristics of non- then was wellbeing and 19.7% of controls (p = assessment)
tween former ISIBINDI participants were not implemented by includes optional 0.012). Program level:
participants and a con- reported community-based components of career The percentage of indicators of program
trol group organizations guidance, job participants that level maintenance
Intervention: empowerment, food received food aid was were not reported
ISIBINDI—the program gardens, and IGAs. not reported.
involves home visits to The ISIBINDI model Attrition rate: not
promote orphans and develops the capacity reported
vulnerable children’s of child and youth
wellbeing. This includes (CYCWs) care workers
optional components of to respond directly to
career guidance, job the needs of
empowerment, food vulnerable children,
gardens, and income- youth, and families,
generating activities particularly those
affected by HIV/AIDS
and poverty. CYCWs
training modules
comprise of 14
sessions of 6–30 h
over a 2–3-year
period.
Page 21 of 33
Table 2 Reporting on quality of included interventions (25 interventions reported in 45 papers included in the review)
Selection Selection Performance Detection Attrition Reporting Other % risk Comments
bias bias bias bias bias bias sources of
(random (allocation (incomplete (selective of bias bias
sequence concealment) outcome reporting)
generation) data)
Abdool Karim et al. Low risk Low risk Low risk Low risk Unclear Low risk Low risk 14.3% Study design:
(2015) [68]; quantitative (comparison
Humphries et al., of treatment and control
(2017) [69], South groups)
Africa
Adoho et al. (2014) Low risk Unclear Low risk Low risk Low risk Low risk Unclear 28.6% Study design:
[70], Liberia quantitative (comparison
of two treatment groups
to a control group)
Austrian and High risk Unclear Low risk Low risk Low risk Low risk Unclear 42.9% Study design: mixed
Muthengi (2014) [71]; methods (comparison of
Muthengi (2014) [72], two treatment groups to
Uganda a control group)
Baird et al. (2012) Low risk Low risk Low risk Low risk Unclear Low risk Low risk 14.3% Study design: mixed
[73]; Baird et al. methods (pre- and post-
(2013) [74], Malawi test comparison for inter-
vention and control
groups)
Bandiera et al. (2012) Low risk Unclear Low risk Low risk Low risk Low risk Low risk 14.3% Study design:
[75]; Bandiera et al. quantitative (pre- and
(2018) [76], Uganda post-test comparison for
intervention and control
groups)
Bazika (2007) [77], Unclear Unclear Low risk Low risk Unclear Unclear Unclear 71.4% Study design:
Congo quantitative (pre- and
post-test assessment of
intervention participants)
Cho et al. (2018) [78], Low risk Unclear Low risk Low risk Low risk Low risk Low risk 14.3% Study design:
Kenya quantitative (comparison
between intervention
and control groups)
Longitudinal study with
annual repeated
measures over 4 years
Cluver et al. (2016) Low risk Unclear Low risk Low risk Low risk Low risk Low risk 14.3% Study design:
[79], South Africa quantitative (comparison
between cash alone and
integrated cash plus care
intervention for HIV-risk
reduction)
Prospective longitudinal
study
de Walque et al. Low risk High risk Low risk Low risk Low risk Low risk Low risk 14.3% Study design:
(2012) [80]; de quantitative (pre- and
Walque et al. (2014) post-test comparison for
[81], Tanzania intervention and control
groups)
Dunbar et al. (2010) Low risk High risk Low risk Low risk Low risk Low risk Low risk 14.3% Study design:
[82]; Dunbar et al. quantitative (pre- and
(2014) [83], post-test comparison for
Zimbabwe intervention and control
groups)
Erulkar and Chong High risk High risk Low risk Low risk Low risk Low risk Unclear 42.9% Study design:
(2005) [84]; Hall et al. quantitative (pre- and
(2006) [85], Kenya post-assessment of inter-
vention participants)
Longitudinal study
Goodman et al. Low risk Unclear Low risk Low risk Unclear Low risk Low risk 28.6% Study design:
Table 2 Reporting on quality of included interventions (25 interventions reported in 45 papers included in the review) (Continued)
generation) data)
(2014) [86], Kenya quantitative (cross-
sectional comparison
among 3 cohorts)
Hallfors et al. (2011) Low risk Unclear Low risk Low risk Low risk Low risk Low risk 14.3% Study design:
[22]; Hallfors et al. quantitative (comparison
(2015) [23]; Luseno between intervention
et al. (2015) [87], and control groups)
Zimbabwe Longitudinal study with
annual repeated
measures over 3 years
Handa et al. (2014) Low risk Unclear Low risk Low risk Low risk Low risk Low risk 14.3% Study design:
[88]; Rosenberg et al. quantitative (comparison
(2014) [89], Kenya between intervention
and control groups)
Longitudinal study with
repeated measures
Jewkes et al. (2014) High risk High risk Low risk Low risk Unclear Low risk Unclear 57.1% Study design: mixed
[90],South Africa methods (interviews and
quantitative time series
design for pre- and post-
intervention assessment)
Khoza et al. (2018) Low risk Unclear Unclear Unclear Unclear Low risk Unclear 71.4% Study design: qualitative
[91], South Africa (using interviews)
Kim et al. (2009) [92]; Low risk Low risk Low risk Low risk Low risk Low risk Low risk 0.0% Study design: mixed
Pronyk et al. (2006) methods pre- and post-
[93]; Kim et al. (2007) test comparison of inter-
[94]; Pronyk et al. vention and control
(2008) [95], South group)
Africa
Kohler and Thornton Low risk Unclear Low risk Low risk Low risk Low risk Low risk 14.3% Study design:
(2012) [96], Malawi quantitative (pre- and
post-comparison be-
tween intervention and
control groups) (longitu-
dinal study)
Nyqvist et al. (2015) Low risk Unclear Low risk Low risk Low risk Low risk Low risk 14.3% Study design:
[97]; Nyqvist quantitative (pre- and
et al.(2018) [98], post-comparison of inter-
Lesotho vention and control
groups)
O’Neill Berry et al., Unclear High risk High risk Low risk High risk Low risk High 71.4% Study design: mixed
(2013) [99], Lesotho risk method (pre- and post-
test comparison of inter-
vention and control
group, as well as follow-
up observations of inter-
vention group)
Pettifor et al. (2016) Low risk Low risk Low risk Low risk Low risk Low risk Low risk 0.0% Study design:
[18]; Pettifor et al. quantitative (pre- and
(2016b) [100], South post-comparison of inter-
Africa vention and control
groups)
Rotheram- Borus Unclear High risk Low risk Low risk Low risk Low risk Unclear 42.9% Study design:
et al. (2012) [101], quantitative
Uganda Had a delayed
intervention group. Pre-
and post-test comparison
between immediate
intervention and delayed
Table 2 Reporting on quality of included interventions (25 interventions reported in 45 papers included in the review) (Continued)
generation) data)
intervention group
Ssewamala et al., Low risk Unclear Low risk Low risk Low risk Low risk Low risk 14.3% Study design:
(2009) [39]; quantitative (pre- and
Ssewamala et al. post-comparison of inter-
(2010) [102]; vention and control
Ssewamala et al. groups)
(2010b) [26];
Ismayilova et al.
(2012), Uganda
Stark et al. (2018) Low risk Unclear Low risk Unclear High risk Low risk Unclear 57.1% Study design:
[41]; Falb et al. (2016) quantitative (pre- and
[104], Ethiopia posttest comparison for
intervention and control
groups).
Reported null findings
that the intervention did
not seem to keep the
participants in school, nor
influence out-of-school
girls to return to school
Visser et al. (2015) High risk Unclear Low risk High risk High risk Low risk Unclear 71.4% Study design: mixed
[105]; Visser et al. method (quasi-
(2018) [106], South experimental post-
Africa intervention assessment
between intervention
and control group and
focus group discussions).
Utilized focus group dis-
cussions to generate in-
formation on strategies
to sustain ISIBINDI
intervention
one (4%) time-series design study. Six types of economic Among the interventions using quantitative methods,
empowerment (EE) interventions were in the included in one of the interventions [18] was found to have a 0.0%
the review: cash transfers (conditional or unconditional) (low) risk of bias. The risk of bias for quantitative
[18, 41, 68, 73, 80, 86, 88, 91, 96, 97, 107], job skills or busi- methods ranged from 0.0% (low) [18] to 71.4% (high)
ness development [70, 84, 86, 99, 108], matched savings ac- [77]. Among interventions using mixed methods, one of
count [71, 102], vocational skills training [75, 77, 82, 101, the interventions [92] was also found to have a 0.0%
105], payment of school fees and school supplies [23, 78], (low) risk of bias. The risk of bias for mixed methods in-
and loan credit [92]. Several HIV prevention outcomes terventions also ranged from 0.0% (low) [92] to 71.4%
were targeted, including reduction in HIV incidence [18, (high) [99]. The only qualitative study in the review had
22, 68, 80, 82, 97], increase in condom use [70, 73, 75, 77, a high risk of bias (71.4%) [91].
78, 83, 84, 86, 90, 92, 96, 101, 107], reduction in the num- The most common strengths of the interventions that
ber of sexual partners [70, 73, 78, 86, 101, 107], reduction utilized quantitative methods were: the ability to conduct
in transactional sex [41, 71, 78, 82, 88, 90, 91], increase in a longitudinal follow-up of study participants over time,
sexual and reproductive health knowledge [71], self- the random selection and assignment of participants, and
efficacy [71, 84], and delay in sexual debut [22, 73, 78, 88, the reporting of descriptive intervention details. However,
101]. one of the common weaknesses was the limited use of
intent-to-treat analysis, although attrition was acknowl-
Quality of evidence edged by the majority of the interventions [18, 22, 41, 70,
The quality assessment of the selected articles is re- 71, 75, 78–80, 83, 84, 88, 92, 96, 97, 101, 102]. For the in-
ported in Table 2. The level of bias varied widely, with a terventions that utilized mixed-methods [71, 73, 90, 92,
range of 0.0% to 71.4% risk among the interventions. 99, 105], common strengths were the ability to triangulate
Table 3 Proportion of interventions reporting RE-AIM dimensions and components

RE-AIM dimensions and components Reporting frequency (n = 25) Reporting proportion (%)
Reach
Method to identify target population 24 96.0
Inclusion criteria 16 64.0
Exclusion criteria 3 12.0
Sample size 25 100.0
Participation rate 9 36.0
Characteristics of participants 25 100.0
Characteristics of non-participants 8 32.0
Representativeness 18 72.0
a
Average of overall reach dimensions 16.00 64.00
Efficacy/effectiveness
Measures/results for at least one follow-up 24 96.0
Intent to treat utilized 5 20.0
Quality-of-life measure 23 92.0
Baseline activity measured 25 100.0
Percent attrition 16 64.0
a
Average of overall efficacy/effectiveness dimensions 18.60 74.4
Adoption
Description of intervention location 24 96.0
Description of staff who delivered intervention 22 88.0
Method to identify target delivery agent 16 64.0
Level of expertise of delivery agent 19 76.0
Adoption rate 3 12.0
a
Average of overall adoption dimensions 16.80 67.2
Implementation
Intervention duration and frequency 25 100.0
Extent protocol delivered as intended 0 0.0
Measures of cost of implementation 3 12.0
a
Average implementation dimensions 9.33 37.3
Maintenance
Individual-level maintenance
Was individual behavior assessed ≥ 6 months post-intervention 23 92.0
Was individual behavior assessed ≥ 24 months post-intervention a
3 12.0
Was individual behavior assessed ≥ 48 months post-interventiona 4 16.0
Program-level maintenance
Indicators of program continuation 2 8.0
Some measure/discussion of alignment with organization/setting 1 4.0
a
Average of overall maintenance dimensions 6.60 26.4%
a
Average percent for overall 26 components within each RE-AIM dimension. The proportions are based on the 25 unique interventions included in the Review.
Components were included to ensure relevance with HIV prevention health behavior change
data obtained from qualitative and quantitative methods Reporting of RE-AIM dimensions
and providing additional explanation for the quantitative The reporting of RE-AIM dimensions was assessed using
data using qualitative data. The strength of the qualitative a previously developed and validated data extraction tool
studies were the use of detailed quotes and narratives to that included implementation outcome components
explain study findings. based on the RE-AIM framework [59, 63]. Across all the
interventions, average reporting rates (defined here as criteria. Participant inclusion criteria were typically re-
the overall percent of components) were highest for effi- lated to participants’ age, place of residence, membership
cacy/effectiveness ≈19(74.4%) and adoption ≈17(67.2%), (e.g., being part of the school), parental status (being an
followed by reach 16(64.0%), and lowest for implementa- orphan), and gender. Individuals were mainly excluded if
tion ≈9(37.3%) and maintenance ≈7(26.4%). Table 3 pro- they did not meet the inclusion criteria for the interven-
vides details on each of the components assessed across tions. Participation rate was reported in nine(36.0%) [18,
the RE-AIM framework and a summary of the overall 68, 70, 75, 79, 83, 90, 92, 96] of the included interven-
percentage of interventions reporting on each of the RE- tions. The participation rate ranged from 21% to 97.50%.
AIM dimensions. The reporting status for the 26 compo- Eighteen(72.0%) of the interventions [18, 41, 68, 70, 73,
nents for the RE-AIM dimensions per study is provided 75, 78, 80, 83, 84, 86, 88, 90–92, 97, 102, 107] reported
in Additional file 2. on the representativeness of recruited study participants’
relative to the target population. This was determined
Reach based on comparing demographic characteristics (e.g.,
The average proportion reporting on the reach compo- age, education level) of study participants to those of the
nents was 16(64.0%). The sample size and participants’ target population. Reporting on this component allowed
characteristics were the most frequently reported item the researchers to assess the extent to which the inter-
25 (100%). All interventions reported on sample size, de- vention could be generalizable across the target popula-
fined as the number of participants who consented to tion and setting. The rigor of the study design was
participate in the study/intervention. Of the interven- reported as an indicator of representativeness. Interven-
tions that recruited only AGYW (n=12) [18, 22, 41, 70, tions that utilized randomized controlled trials reported
72, 73, 75, 84, 87, 92, 99], sample size ranged from n=40 representativeness as one of the strengths of their stud-
in the O’Neill Berry and colleagues study [99] to n=4800 ies. According to the RE-AIM framework, studies should
in the study by Bandiera and colleagues [75]. In inter- describe the characteristics of participants of the target
ventions that recruited other populations in addition to population in comparison with non-participants.
AGYW, the sample size ranged from n=46 to n=6576 Eight(32%%) of the interventions provide some form of
(with the AGYW sample size being between 122 and information on the characteristics of individuals who did
1705). Five (20%) interventions [77, 91, 96, 97, 101] did not participate in their study. Some of the reasons for
not explicitly report the sample size for AGYW, al- non-participation included unavailability of individuals
though it was mentioned that AGYW were included in (e.g., going back to school and having full-time jobs), in-
the study. Participant characteristics included; reports ability to complete study procedures (e.g., not wanting
on age, gender (for interventions that included other to test for HIV, not returning for study procedure, and
population), employment status, education attainment, not obtaining consents from parents), limited access to
and socioeconomic status (measured as household in- the study location (e.g., distance from the individuals’
come in some interventions). The next commonly re- residence to study site was a barrier to participating and
ported reach component was the method for identifying geographic relocations) and lack of interest in the study.
the target population for the study and this was assessed
in 24(96.0%) of the studies reviewed [18, 22, 39, 41, 68, Efficacy/effectiveness
70, 71, 73, 75, 77, 78, 80, 82, 84, 86, 88, 90–92, 96, 97, Efficacy/effectiveness was the most consistently re-
99, 101, 105]. Most of the interventions were conducted ported RE-AIM dimension across all interventions
in Southern Africa, specifically in South Africa where 7 (74.4%). Twenty four(96.0%) interventions reported on
[18, 68, 79, 90–92, 105] out of the 25(28%) interventions at least one post-intervention effect; 5(20.0%) inter-
were located. The description of methods utilized to ventions used intent-to-treat analyses and the remain-
identify the target population varied across interventions der analyzing only data from participants who
from single-sentence descriptors to detailed reporting of completed the intervention. All interventions included
the protocol used. Strategies utilized to identify the tar- in the review included HIV prevention measures as
get population included using schools, youth centers, primary outcomes. HIV prevention measures included;
and community stakeholders. Regarding factors that fos- reduction in HIV incidence [22, 68, 79, 80], reduction
ter or hinder the ability to reach the target audience, in number of sexual partners [70, 73, 79, 86], condom
stakeholders’ engagement and school recruitment were use [70, 73, 75, 77, 78, 83, 84, 86, 90, 92, 101], de-
emphasized as beneficial strategies to enhance reach. crease in transactional sex [41, 71, 78, 83, 89–91],
Sixty-four percent(16) of the interventions [18, 26, 41, and sexual debut [23, 73, 78, 83, 87, 88, 97]. Of the
70, 73, 75, 80, 83, 84, 86, 88, 90–92, 96, 97] reported 25 interventions that measured HIV prevention out-
study participants’ inclusion criteria. Only 3(12.0%) stud- comes, 20(80%) reported that the economic empower-
ies [18, 73, 80] explicitly stated participants’ exclusion ment HIV prevention intervention resulted in
statistically significant positive changes in HIV pre- 24(96.0%) studies [18, 22, 39, 41, 68, 70, 71, 73, 75, 78,
vention outcomes. 80, 82, 84, 86, 88, 90–92, 96, 97, 99, 101, 105]. Interven-
Sixteen(64.0%) interventions reported their percent at- tion locations included schools, community centers, and
trition [22, 70, 71, 75, 78–80, 83, 84, 88, 92, 96, 97, 100– refugee camps. These locations were identified as typical
102], which ranged from 5% to 40%. Attrition rates were settings that the target population visit or use. Also,
examined in relation to participants’ loss to follow-up and most of the interventions were restricted to a specific
non-use of the intervention [75]. Reasons for attrition in- geographical area. Most of the interventions were imple-
cluded; participants’ relocation, death, change of phone mented in one site. The least reported adoption compo-
number, and logistics challenges. In terms of logistics nent was the adoption rate. Only 3 (12.0%) interventions
challenges, Erulkar and Chong [84] reported some delays reported on intervention adoption rate among partici-
in participants receiving their loans and accessing their pants [86, 99, 101]. There were no reports on setting
savings account as a result of limited human resources level adoption rates.
which accounted for some of the attritions they faced.
Some participants were concerned that they may not have Implementation
access to their savings account or loans; therefore, they The average proportion reporting on implementation
dropped out of the study. In addition, Bandiera and col- components was about 9(37.3%). All 25(100.0%) interven-
leagues [75] examined how participants’ characteristics in- tions reported on the format of the intervention; specif-
fluence attrition between the intervention and control ically, they provided information on intervention
groups and found that married AGYW in the intervention duration and frequency [18, 22, 39, 41, 68, 70, 71, 73, 75,
were less likely to be tracked at follow-up. A high propor- 77, 78, 80, 82, 84, 86, 88, 90–92, 96, 97, 99, 101, 105].
tion of the interventions 23(92.0%) reported on partici- Intervention ranged in duration from a single session to
pants’ quality of life [18, 22, 39, 41, 70, 71, 73, 75, 77, 78, two or more (up to 14) sessions. None of the interven-
80, 82, 84, 88, 90–92, 96, 97, 99, 101, 105] and found that tions explicitly reported on fidelity or the extent to
economic empowerment HIV prevention interventions which the intervention protocol was delivered as
generally improved quality of participants lives and did intended.
not have any significant negative outcomes. The cost of delivering the intervention was mentioned
in only three (12.0%) interventions [70, 73, 75]. Implemen-
Adoption tation cost items included skills training cost [70, 75], ad-
The average proportion reporting on adoption components ministrative cost [73, 75], and cost of monetary incentive
was 17(67.2%). Twenty-two of the interventions [22, 39, 41, [73, 75]. Two interventions [70, 75] further conducted
68, 70, 71, 73, 75, 78, 80, 82, 84, 86, 88, 90, 92, 96, 97, 99, cost-benefit analyses to determine if the benefits/returns
101, 105] provided some description of the staff who deliv- from the interventions for the participants outweighed the
ered the intervention. Interventions were delivered by a cost of implementing the interventions. These two inter-
range of staff with different levels of expertise and included ventions assessed intervention benefit based on the num-
research assistants, community leaders, and organization ber of participants who participated in the income-
staff. Staff responsibilities included delivering parts of the generating component of the intervention. The authors
interventions that consisted of moderating the discussion highlighted that equipping AGYW with skills to generate
and intervention meeting groups, distributing conditional sustainable income, which would in return reduce their
cash incentives, training participants’ income-generating chance of engaging in risky sexual behaviors [70, 75]. Spe-
skills, and educating participants on intervention curricu- cifically, Adoho and colleagues [70] found that the value
lum (e.g., sexual and reproductive health training, financial provided by the program was equivalent to a 3 year in-
training, and income-generating skills and crafts). Seventy- crease in income among EE program participants. The
six percent (19) of the interventions explicitly stated imple- study by Bandiera and colleagues [75] reported gains/ben-
menting staff level of expertise [22, 39, 41, 68, 70, 71, 73, efits to the economic empowerment intervention in the
75, 80, 82, 84, 86, 88, 90, 92, 99, 101, 105], but for those that form of delaying early marriage and childbirth and im-
were not stated, it could be inferred from their job titles or proving HIV and pregnancy-related knowledge.
their organization’s focus. Sixteen(64.0%) interventions re-
ported on the methods used to identify staff who delivered Maintenance
the intervention [22, 70, 71, 73, 75, 78, 80, 82, 86, 88, 90, The average proportion reporting on maintenance com-
92, 97, 99, 101, 105]. Intervention staff were mainly identi- ponents was about 7(26.4%). Among the maintenance
fied through their participation in the research project or components, individual-level indicators were reported
collaborating organization. more frequently than program-level indicators. Twenty-
The most commonly reported adoption component three (92.0%) interventions reported at least one follow-
was the description of intervention location, reported by up measure, particularly the primary outcomes at 6
months [18, 22, 39, 41, 68, 70, 71, 73, 75, 77, 78, 80, 82, level components such as implementation costs,
84, 86, 88, 91, 92, 96, 97, 99, 101]. The longest follow-up program-level sustainability, and intervention fidelity.
period reported was 24 months after baseline assessment Although concerning, the underreporting of broad or
[71]. The majority of the post-intervention assessments system-level elements is consistent with reports from
were conducted within 12 to 24 months after completion other systematic reviews using the RE-AIM framework
of the intervention. There were a few interventions that [110–115] that also found limited reporting of these di-
had follow-up assessments beyond 24 months after inter- mensions. This further confirms the previous report on
vention completion; 6 for 36 months [18, 22, 78, 84, 86] the predominant focus on intervention effectiveness,
follow-up, 2 for 48 months [88, 89] follow-up, and 1 for with limited attention to external factors that may im-
60 months follow-up [23]. pact the translation of effective interventions to real-
In terms of program-level maintenance, six interven- world settings. Researchers need to also focus on report-
tions reported [22, 75, 77, 80, 86, 92] on indicators of ing broad or system-level measures as well as
program level maintenance or sustainability. Only intervention-specific measures. Broad or system-
two(8%) interventions explicitly stated that the interven- level factors are critical with understanding how findings
tions were sustained beyond the study period [75, 86] from interventions apply to local settings, population,
For one study, the intervention was adapted to fit the and available resources [116]. It informs the overall rele-
context by including an additional component [75]. vance and appropriateness of these interventions in real-
Two(8%) interventions were discontinued before the world settings, and the potential for health gains by re-
study period end date [77, 80], and another two(8%) ducing HIV incidence among AGYW in SSA.
ended at the completion of the study period [22, 92]. For Reporting on intervention reach is important to in-
the two interventions that were completed at the end of form future dissemination of interventions that have
the study period, it was not clear if they were sustained been found to be effective or efficacious towards behav-
beyond the study period. ior change. To scale-up economic empowerment HIV
prevention intervention, there is the need to under-
Discussion stand how to reach target populations. In this review,
The primary aim of this review was to systematically as- participants’ characteristics and sample sizes were con-
sess the implementation of economic empowerment sistently reported across interventions. This is congru-
HIV prevention programs for AGYW in SSA. This re- ent with previous reviews on HIV prevention
view goes beyond an assessment of intervention effect- interventions [32, 117] that reported frequent reporting
iveness to report implementation outcomes as of participants characteristics such as their demograph-
conceptualized by the RE-AIM framework. The RE-AIM ics. Some of the interventions in the review specified
framework was used as a guideline to determine the im- the degree to which the target samples were represen-
pact of EE HIV prevention interventions for AGYW. We tative of the larger population. Information on the ex-
evaluated five key components important for the transla- ternal population from which a study sample is drawn
tion of research findings to practice: reach, effectiveness, from helps to inform the generalizability of the findings
adoption, implementation, and maintenance [59, 109]. to a larger population [111]. However, the characteris-
These components are important in understanding tics of non-participants and participants, as well as the
the factors that influence, not only adoption, but the reasons for non-participation, were rarely reported in
cost and sustainability of economic empowerment inter- the interventions. This limits the understanding of con-
ventions as a strategy for HIV prevention among AGYW textual factors that may influence AGYW participation
in SSA. in such interventions. With scant information on char-
A total of 25 (reported in 45 papers) economic em- acteristics of non-participants, researchers may be miss-
powerment interventions among AGYW were identified, ing individuals who are most in need of
described, and evaluated based on the five RE-AIM di- these interventions, such as AGYW residing in remote
mensions. On average, the included interventions re- areas, rural areas, and those with low literacy. To en-
ported on 14(53.86%) of the 26 components that hance the translation of intervention to a wider popula-
constitute the RE-AIM dimensions. Major knowledge tion, researchers should improve on the reporting of
gaps exist relating to reporting of implementation and the characteristics of non-participants as this may ex-
maintenance (least reported RE-AIM dimensions) of tend program reach and inclusivity.
economic empowerment HIV interventions for AGYW Consistent with past reviews, intervention effectiveness
in SSA. Specifically, the interventions in the review was the most commonly reported RE-AIM element
mainly focused on reporting intervention-specific com- across all interventions, with baseline activity measures
ponents (e.g., sample size, intervention location, and ef- reported for all included interventions [110, 111]. The
fectiveness), with minimal reporting of broad or system- outcome measures included; HIV incidence, number of
sexual partners, condom use, transactional sex, and sex- of economic empowerment HIV prevention for AGYW
ual debut. Findings from this systematic review high- [119–121]. Likewise, documenting cost-effectiveness is cru-
light the impact on economic empowerment cial for sustainability and large-scale dissemination of HIV
intervention on HIV reduction among AGYW, with prevention interventions in SSA [120]. Cost information
about 19(74.7%) of the interventions reporting statisti- also helps to allocate resources efficiently particularly in set-
cally significant improvements on HIV risk reduction tings were resources are scare. This in turn may help
measures among intervention participants compared maximize the impact of positive health outcomes among
with controls. For effectiveness analyses, only 5(20%) in- AGYW [119].
terventions reported using intent-to-treat analyses; this In terms of implementation, intervention duration and
in turn may have impacted the positive effect of the frequency were consistently measured across the inter-
intervention across the interventions. The positive effect ventions. However, none of the interventions reported
found in these interventions were only limited to partici- on the fidelity of the study, although it is a critical meas-
pants who were present for follow-up assessments and ure of the internal validity of the interventions. There-
did not account for attrition. There were variations in fore, it is unclear if the reported intervention impact
the reporting of attrition rates across the interventions, were attributed to the fidelity of the intervention or to
and few studies provided information on reasons for at- the actual intervention components [110]. Considering
trition. Information on the reasons for attrition may help the critical role of these components in enhancing the
to highlight barriers or challenges that influence impact and scale-up of such intervention, the scarcity of
AGYW participation in the interventions. For instance, evidence in this area is a concern. Future interventions
one of the interventions encountered some logistics should clearly specify implementation components such
challenges in the form of delays in providing loans to as fidelity to enhance the translation of these interven-
participants [84]. Such logistical challenges are critical tions to other settings and populations.
information that may influence AGYW attrition and Regarding maintenance, about 7(26%) reported on this
participation in HIV prevention interventions. Thus, ef- RE-AIM dimension. This is a favorable result, compared
forts to account for factors influencing attrition are ne- to other reviews that have reported between 0.0% and
cessary for identifying barriers and challenges to 11.0% maintenance [110, 122]. This RE-AIM dimension
AGYW continued participation in interventions. helps to understand the long-term maintenance of be-
For adoption, the description of the intervention loca- havior change among intervention participants and the
tion, staff delivering the intervention, and level of staff sustainability of the interventions at implementing loca-
expertise were well documented in the reviewed inter- tions. Most of the interventions measured maintenance
ventions. However, there was minimal reporting on the of individual behavior at least 6 months following the
methods used to enhance staff and intervention set- completion of the intervention, with only 4 of the inter-
tings adoption. This is consistent with other reviews ventions measuring behavior at 48 months after inter-
using the RE-AIM framework, where there is consistent vention completion. While individual-level maintenance
under-reporting on methods used to enhance adoption components were frequently reported, little attention
by intervention delivery agents [111, 118]. This makes it was paid to the assessment of setting- and program-level
challenging to determine what types of delivery agents maintenance components. Intervention maintenance also
may be appropriate for the optimal implementation of known as sustainability is influenced by an interplay of
the intervention [111]. Furthermore, only 3(12%) inter- individual-, program-level factors and broader socio-
ventions reported on the intervention adoption rate. cultural- and community-level factors, which collect-
Reporting of adoption rate and characteristics of partici- ively determine long-term intervention impact. There-
pating intervention locations versus non-participating lo- fore, future research should address critical gaps in the
cations may help highlight components of intervention assessment of intervention maintenance, and apply a
design that either hinder or foster adoption across vari- more comprehensive approach in the evaluation of this
ous settings [111]. implementation outcome dimension.
The cost of intervention implementation is an import-
ant factor in determining the translation of research Limitations
findings to real-world settings. Three (12%) of the 25 in- Our review has some limitations. First, our conclusions
terventions in the review reported on the cost of inter- are based on the degree to which the included interven-
vention delivery. The findings of the review reveal a tions reported on specific RE-AIM dimensions. It is pos-
paucity of data on the cost and cost-effectiveness of sible that some of the RE-AIM dimensions were
implementing economic empowerment HIV prevention measured, but not reported in the interventions due to
interventions among AGYW. Report on delivery cost al- editorial restrictions. To address this limitation, we in-
lows for effective planning to optimize the yield and reach cluded all available articles on a specific intervention.
Second, we did not conduct a meta-analysis. While this interventions for addressing HIV prevention among at-
was not the focus of this systematic review, the hetero- risk AGYW in SSA.
geneity of the included interventions and variations in
HIV prevention outcomes would not have supported a Supplementary information
meta-analysis. Third, our search strategy was limited to Supplementary information accompanies this paper at https://doi.org/10.
published articles and those available in English; this is 1186/s43058-020-00042-4.
potentially subject to selection bias. Fourth, it is worth

Additional file 1. PRISMA checklist.
noting that the Cochrane Collaboration risk of bias as-
Additional file 2. Search strategy.
sessment tool used in assessing study quality is biased
Additional file 3. RE-AIM components extraction.
towards purely quantitative study designs and quite lim-
ited in appraising mixed and qualitative study designs.
Given the limitation of this tool, it was only used to Abbreviations
AGYW: Adolescent girls and young women; CCTs: Conditional cash transfer;
evaluate the internal validity of the interventions in- CA: Collins Airhihenbuwa; CO: Chisom Obiezu-Umeh; FE: Fred Ssewamala;
cluded in the review and not to select articles included FU: Florida Uzoaru; HIV: Human immunodeficiency virus; JC: Jamie Curley;
in the review. JI: Juliet Iwelunmor; JE: John Ehiri; OE: Oliver Ezechi; PRISMA: Preferred
Reporting Items for Systematic Reviews and Meta-Analyses;
Nonetheless, this study has a number of strengths. RCTs: Randomized control trials; RE-AIM: Reach, effectiveness, adoption,
First, this review was conducted with a well-constructed implementation, and maintenance; SSA: Sub-Saharan Africa; STIs: Sexually
search strategy, created with the help of the college li- transmitted infections
brarian, and was supplemented by a manual search of

Acknowledgements
the reference list of included articles. Second, to the best We would like to acknowledge Donghua Tao, MLIS MS PhD (Assistant
of our knowledge, this is the first study to collate and Director for Information Services, College for Public Health and Social
examine the measurement of implementation outcomes Justice), the college librarian for her assistance with developing a literature
search strategy for this systematic review
among economic empowerment interventions HIV pre-
vention for adolescent girls and young women in sub- Authors’ contributions
Saharan Africa using the RE-AIM framework as a guide. JI conceived the idea for the systematic review. JI and UN abstracted data
from paper. JI and UN wrote the first draft of the paper. CO, FU, JE, JC, OE,
CA, and FS critically reviewed the manuscript. All authors read and approved
Conclusion the final manuscript
Emerging evidence suggests that economic strengthen-
ing interventions can be effective in reducing adolescent Funding
No funding was received to carry out this work.
girls’ and young women’s risks for HIV. RE-AIM assess-
ment showed that economic empowerment intervention Availability of data and materials
provides AGYW with skills to reduce their risk of HIV. Articles included in this systematic review are cited in the reference list.
Our findings further show that although researchers fre-
quently reported on intervention-specific implementa- Ethics approval and consent to participate
Not applicable
tion science outcome components, broad or system-level
implementation outcome indicators of these interven- Consent for publication
tions are scarce. Considering the critical role of these Not applicable
implementation factors in enhancing the ultimate impact
of combination economic strenghtening intervention on Competing interests
The authors declare that they have no competing interests
HIV prevention among AGYW in SSA, the scarcity of
evidence is a concern. We recommend the use of RE- Author details
1
AIM components in future EE HIV interventions target- College for Public Health and Social Justice, Saint Louis University, Salus
Center, 3545 Lafayette Avenue, Saint Louis, MO 63104, USA. 2Mel and Enid
ing AGYW, with special consideration given to factors Zuckerman College of Public Health, University of Arizona, 1295 N Martin
relevant to the adoption, implementation (such as imple- Avenue, Tucson, AZ 85724, USA. 3Nigerian Institute of Medical Research, 6
mentation cost, adoption rate, and intervention fidelity) Edmund Crescent, Yaba, Lagos State, Nigeria. 4School of Public Health,
Global Research Against Noncommunicable Diseases, Georgia State
and long-term sustainability of these interventions in University, 140 Decatur Street SE, Atlanta, GA 30303, USA. 5Brown School,
SSA. We further suggest the measurement of other im- Washington University in Saint Louis, 1 Brookings Drive, Saint Louis, MO
plementation science outcomes beyond RE-AIM indica- 63130, USA.
tors to provide a holistic indicator of factors and Received: 25 November 2019 Accepted: 24 May 2020
measures to promote intervention scale-up, dissemin-
ation and sustainability. Overall, the findings of this sys-
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Iwelunmor et al.

Implementation Science Communications

SYSTEMATIC REVIEW Open Access

Is it time to RE-AIM? A systematic review of

Contributions to the literature

 This study addresses an important gap in knowledge given

(Continued from previous page)

Background double from 100 million in 1990 to 200 million by 2020

number of HIV infec-

Program uptake tional sex (for girls

program may have impacted intervention group program was

intervention and con-

explicitly refused to 0.69, p < 0.05). At end intervention were

non-participants were study arms.

structural factors and individuals. ceived components 1 different from the

groups, though both

the delayed partial

finding work or reported Stones and 11 were positive but not

curriculum), villages ex- refused to participate plan. Likewise, compared to

There was also no dif-

reported US$50 every 4 compared to the con-

HIV incidence compared years 200 (US$20), participants. There change

month. transfer (1.94% per

catering, tailoring, me-

Table 3 Proportion of interventions reporting RE-AIM dimensions and components

potentially subject to selection bias. Fourth, it is worth

brarian, and was supplemented by a manual search of

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This study addresses an important gap in knowledge given