Household economic strengthening and the global fight against HIV

ABSTRACT A range of economic interventions focused on vulnerable households and individuals – here collectively referred to as household economic strengthening (HES) – aim to address economic wellbeing and influence the economic determinants of HIV. Increasingly implemented as part of multi-sectoral programs, HES interventions have the potential to mitigate HIV-related risk behaviors and improve care and treatment outcomes. In order to engage donors, practitioners and researchers in a thoughtful discussion about where the field stands, the Accelerating Strategies for Practical Innovation and Research in Economic Strengthening (ASPIRES) project conducted an evidence review that comprehensively documents the literature linking a wide range of HES activities to HIV prevention and risk reduction as well as outcomes across the HIV care and treatment cascade. ASPIRES then held an expert consultation to reflect on the evidence review findings and define priorities for the field going forward. This article introduces this special issue of AIDS Care on HES for HIV Outcomes as an effort to expand and continue this discussion with a wider group of stakeholders. We present where the field stands, highlighting high level findings from the evidence review. Next, we present an overview of the expert consultation and resulting recommendations, highlighting concrete ways to strengthen the evidence base. Finally, we introduce the contents of this special issue and present insights on where the field is going.

Spearheaded by the Joint United Nations Programme on HIV/AIDS (UNAIDS), donors, activists, practitioners, researchers, and clinicians are now working together toward the Fast-Track strategy to end the HIV epidemic by 2030. Bold goals include major reductions in HIV transmission along with ambitious increases in the proportion of people living with HIV who get tested and know their status, receive antiretroviral therapy (ART), and are virally suppressed (UNAIDS, 2015). Global efforts towards these goals have led to a 16% reduction in annual new infections from 2010 to 2016. Similarly, the estimated proportion of people living with HIV who know their status increased to 70% in 2016, and for the first time over half of all people living with HIV globally are receiving life-saving treatment, with most achieving viral suppression (UNAIDS, 2017). Despite these impressive gains, additional strategies are needed to support ongoing prevention, testing, and treatment efforts to keep pace with the Fast-Track targets.
Structural factors, including economic status, are known drivers of the HIV epidemic (Gupta, Parkhurst, Ogden, Aggleton, & Mahal, 2008). Economic vulnerability has the potential to reduce agency in sexual decision-making and increase HIV-related risk behavior (Pascoe et al., 2015;Tsai et al., 2013). Poverty also negatively influences care seeking and clinical outcomes for people living with HIV (Boyer et al., 2009;Weiser et al., 2003). Increasingly, evidence shows that economic barriers must be addressed in order to reduce HIV incidence and improve care and treatment outcomes for those living with HIV (Cluver, Orkin, Meinck, Boyes, & Sherr, 2016;Hardee, Gay, Croce-Galis, & Peltz, 2014;Seeley et al., 2012). A range of economic interventions focused on vulnerable households and individuals here collectively referred to as household economic strengthening (HES)aim to address economic wellbeing and influence the economic determinants of HIV. Increasingly implemented as part of multi-sectoral programs, HES interventions have the potential to mitigate HIV-related risk behaviors and improve care and treatment outcomes.
The Accelerating Strategies for Practical Innovation and Research in Economic Strengthening (ASPIRES) project, funded by United States Agency for International Development (USAID) and the President's Emergency Plan for AIDS Relief (PEPFAR) and led by FHI 360, explores whether a range of HES approaches improve economic well-being and influence HIV-related outcomes. In order to engage donors, practitioners, and researchers in a thoughtful discussion about where the field stands, ASPIRES conducted an evidence review that comprehensively documents the literature linking a wide range of HES activities to HIV prevention and risk reduction as well as outcomes across the HIV care and treatment cascade. To start the conversation, ASPIRES then held an expert consultation to reflect on the evidence review findings and define priorities for the field going forward. This special issue on HES for HIV Outcomes is an effort to expand and continue this discussion with a wider group of stakeholders. Below, we present where the field stands, highlighting high level findings from the evidence review. Next, we present an overview of the expert consultation and resulting recommendations, highlighting concrete ways to strengthen the evidence base. Finally, we introduce the contents of this special issue and present insights on where the field is going.

Hes for HIV outcomes evidence review
The overall picture that emerged from the HES for HIV Outcomes evidence review is a complex one. The review identified 108 relevant citations, so the overall evidence base is not thin, but it is extremely varied. Existing studies differ widely in terms of quality and context. Nonetheless, the papers in this issue highlight several promising HES interventions that demonstrate effectiveness for HIV risk reduction as well as testing, care, and treatment outcomes.
Several important trends and limitations within the overall evidence base were also identified. Many of the studies in this review lacked sufficient details about the programs or interventions on which the research was based, providing only a limited understanding of what service was assessed. Similarly, a wide range of outcome measuresincluding self-reported measures, clinical record data on services received, and clinical outcomes or test resultswere used to assess the same constructs, limiting the comparability of study outcomes.
Recent research has shown that some kinds of HES support are more effective in combination with other social support (Cluver, Orkin, Boyes, & Sherr, 2014), therefore studies of integrated interventions provide important information about what combinations of support are effective for HIV outcomes. Nearly half of the studies in the full review look at integrated interventions with multiple components, but less than a quarter of these were designed to assess the individual contribution of each intervention component to the outcome(s), limiting our understanding of what is working. For example, a combined HIV risk reduction and savings intervention may have had greater, lesser, or the same effectiveness in reducing HIV risk without the savings component.
Most of the studies in the review focused on HES interventions that directly provided cash or resources. The relative strength of the evidence for these interventions is intuitive because they affect behavior by providing immediate infusions of material aid. By contrast, interventions that require beneficiaries to apply their own time, energy, and resources may take longer to achieve the desired economic, health, or other social benefits, and the pathways of effect are less direct. The comparatively limited data on interventions that build skills rather than provide material aid restricts our understanding of their value in the context of HIV prevention, care, and treatment. Relatedly, few studies followed participants for two years or more, and even fewer looked at effect sustainability after the intervention. Shorter study periods may not allow sufficient time for HES interventions to affect HIV-related behaviors and, therefore, may be missing some longer-term trends.
In addition, the qualitative evidence in this area is minimal. HES interventions can affect HIV outcomes through multiple, potentially complex pathways. For example, some HES interventions such as savings and income generating activities can be delivered in a group context, and it is unclear whether the observed outcomes are a result of group dynamics, economic benefits of the intervention, or both. Although some qualitative data explained how interventions enabled or motivated behavior change, most studies were too broad in scope to provide a clear causal pathway, minimizing their value to this evidence base.

HES for HIV outcomes expert consultation
After documenting the evidence base, ASPIRES shared findings with a group of stakeholders to begin the process of translating this research into policy and practice. In February 2017, 32 participants from the research, donor, and practitioner communities with demonstrated interest and expertise in HES and HIV outcomes participated in a one-day workshop with the intention of outlining a research agenda for the field. Participants reflected on the evidence review findings and contributed insights to a rich discussion of priorities for the field. Given the breadth and variation in the existing evidence and a wide range of perspectives from participants, the workshop did not result in a concrete research agenda, but rather generated a framework of key recommendations to strengthen the evidence base. These recommendations focus on increasing our understanding of which HES interventions work for which populations, as well as when and how they work.

What: defining interventions under investigation and disaggregating intervention components
To strengthen the evidence base, we need to understand what activities or interventions are being implemented and how much intervention exposure, or dosage, participants are receiving. Better documentation by implementers and researchers of intervention components and proceduresincluding how support was provided, frequency, duration, length, and specific features of the support or service(s) providedwill improve our understanding of what is provided and enhance our ability to assess what is working. Similarly, greater standardization of outcome measures will support the identification of more definitive trends across studies and help to determine which HES interventions are most effective for outcomes in various contexts. Improving the rigor with which self-reported behavioral outcomes are measured is also essential to understanding what works.
Since few stand-alone HES interventions are likely to have large and lasting impacts on HIV outcomes, research in this field should focus on how HES works within an integrated package of interventions while seeking to understand the contributions of specific HES components through factorial study designs. In addition, prioritizing research on interventions that focus on building participants' skills and competencies, rather than providing material goods, will improve our understanding of the effectiveness of program approaches that may support longer-lasting benefits for a range of outcomes.

Who: describing and disaggregating study participants
Where study resources permit, thoughtful disaggregation of data by different study populations (e.g., by gender and relevant age groups) will support a deeper understanding of who experiences different intervention effects. When funding or sampling capacity is too limited to allow for statistically powered sub-group analyses, research may have to proceed in parallel, with different studies looking at different groups but using similar outcome measures so that meta-analyses can later be performed.
When: assessing intervention timing and outcomes over time Evidence should inform the timing of HES interventions based on when they are likely to have the greatest effect. For example, adherence support may be most effective at key transition points such as when individuals start ART, when they are reengaged in care after dropping out, or during pregnancy. Timing of effects of different interventions is also a critical area for research, since desired effects may manifest at different time points. While onetime financial incentives are typically bound to a single, discrete action such as testing or voluntary medical male circumcision uptake, ongoing HES interventions may require different implementation time periods in order to have the desired effect on HIV outcomes; studies of these interventions should be timed accordingly. Longitudinal data as well as longer study follow-up periods will improve our understanding of when the effects of different HES interventions occur or change over time, as well as the sustainability of those effects.

How and why: breaking down causal pathways and incorporating qualitative research
Articulating a theory of change at the outset of an intervention or research study, and measuring proximal and intermediate variables associated with the outcomes of interest, would allow us to test specific causal pathways by which HES interventions are influencing outcomes of interest. Robust qualitative and mixed-methods research will also deepen our understanding of how and why interventions are affecting outcomes of interest. This, in turn, will support the development of welldefined theories of change, leading to more effective targeting of resources and laying the ground work for future inquiry.

Other recommendations
Costing data are critical to making the case for the sustainability and continuity of successful HES interventions. Determining what to invest in should depend not only on identifying which HES interventions are the most cost-efficient in achieving the desired HIV outcomes, but also on the costs of interventions as compared to the costs of inaction.
As the evidence base on HES grows, cross-sectoral collaboration and large, multi-outcome studies are needed to understand the complex set of factors that link HES with HIV-related outcomes. In addition, increased data sharing would allow researchers to continue learning from existing datasets and encourage analysis from different disciplinary perspectives to answer new research questions. Ultimately, researchers and institutions will need to bridge sectoral divides to pool data and resources to expand study of HIV-related outcomes. Recognizing the mutually reinforcing effects of poverty and HIV, we encourage donors, researchers, and practitioners working in separate spheres of economics and public health to reach beyond traditional institutional boundaries, bridge research agendas, and combine the financial and human resources needed for large-scale, multidisciplinary research.

This special issue and where the field is headed
Putting the recommendations outlined above into action requires collaboration between researchers, practitioners, and donors, who each have a particular role to play in strengthening both evidence and practice in HES for HIV outcomes. ASPIRES compiled this special issue focused on the HES/HIV intersection to invite more voices into the conversation. The issue is anchored with the above-mentioned evidence review that comprehensively documents the literature linking various HES activities to a range of HIV outcomes. The review is broken into three papers, each focused on a distinct HIV outcome area: prevention, testing and linkage to care, and retention in and adherence to care. For each of these outcome areas, Swann details the evidence base for the range of HES interventions and summarizes trends and gaps in what we know about their effectiveness.
Complementing these reviews are original HES/HIV research articles that contribute new evidence to the field and reflect the types of studies that will help us respond to the recommendations above. Namey and colleagues provide detailed mixed-methods data on the financial lives of female sex workers in Côte d'Ivoire to provide insight into the types of HES activities that could best mitigate the financially-driven sexual risk behaviors that put female sex workers at risk of HIV. Addressing the testing portion of the cascade, Sande and colleagues offer new data on the costs of accessing "free" HIV testing services within rural Malawian communities, quantifying direct and indirect costs to testing, including lost income. Finally, Kadota and colleagues assess differences in effects of short-term conditional cash and food transfers on HIV-infected patients' possession of antiretroviral therapy and retention in care, furthering our understanding of how best to target HES activities in support of HIV treatment outcomes. Together, these articles provide a summary of the state of the evidence around the intersection of HES and HIV and point to several opportunities for program refinement and for future research.
The global community is at a critical juncture in the effort to control the HIV epidemic. This effort requires a range of innovative approaches to complement traditional interventions to reach greater numbers of people and support continued engagement in HIV prevention and treatment efforts. The evidence to date suggests that HES has an important role to play in this effort, but we need to act quickly to better understand how to achieve optimal effectiveness for different HIV outcomes. We hope this issue will inform researchers and practitioners about the evidence linking HES with HIV outcomes and encourage the use of evidence to inform practice and strengthen future research efforts. We invite you to explore the details of the following papers to add to this ongoing discussion.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
This editorial was produced under United States Agency for International Development (USAID) Cooperative Agreement No. AID-OAA-LA-13-00001 and was made possible by the generous support of the American people through USAID and the United States President's Emergency Plan for AIDS Relief. The contents are the responsibility of FHI 360 and do not necessarily reflect the views of USAID or the United States Government.