Gender-responsive and -transformative interventions in HIV, TB and malaria programmes: a review of evidence

Gender-responsive and -transformative interventions are essential for tackling harmful social norms and discriminatory laws, policies, and practices that drive gender inequalities and health inequities especially for women, girls, and gender-diverse communities. Despite a growing evidence base of interventions, no comprehensive review has synthesized gender-responsive and -transformative approaches related to Human Immunodeficiency Virus (HIV), tuberculosis (TB), and malaria. Strengthening this evidence is vital to inform strategies addressing structural drivers of gender-based vulnerability—especially amid rising backlash against gender equality and significant global health funding cuts. This rapid review addressed this gap by synthesizing evidence on changes in health- and gender-related outcomes from gender-responsive and -transformative interventions in HIV, TB, and malaria programmes. Systematic searches of PubMed and Scopus for English-language studies from low-and middle-income countries published between 2004 and 2024 were completed. Included studies clearly described gender-focused interventions and outcomes and incorporated evaluation designs or analysis frameworks. From 11,844 articles identified, 42 primary research articles were included—all focused-on HIV, with none on TB or malaria. These were categorized into five intervention types: resilient and sustainable health systems (n = 6); gender norms change (n = 9); social empowerment (n = 8); economic empowerment (n = 18); and law and policy reform (n = 1). Most interventions (n = 36) targeted HIV prevention and addressed both individual behaviours and structural factors. Multi-component, multi-level interventions using a socio-ecological framework showed more sustained improvements in health- and gender-related outcomes compared to single-component efforts. There was more evidence of couples-based approaches changing harmful gender norms than interventions engaging individuals, however these need to ensure safety and private spaces for women, especially when tests are taken and diagnosis and advice given. Given the importance of local context, identifying a universal set of priority interventions is difficult. However, this review highlights strategic approaches, promising practices, and lessons learned for designing and implementing more effective gender-focused interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-026-26622-y.

Key messages (3-4 key messages)

• While there are a large number of gender-focused interventions in specific health areas, there is a lack of consolidated evidence on gender-responsive and -transformative interventions that have been shown to have, or contribute to, a positive impact on gender- and health-related outcomes for HIV, tuberculosis, or malaria.

• There was strong evidence that gender-responsive and -transformative interventions target not just individual behaviours but also structural factors. These interventions clearly articulate the intention to tackle the structural gender inequalities underlying disease prevention and control.

• Although single-component and relatively short-duration interventions have achieved some success, there was more evidence that multi-component interventions implemented at multiple levels and employing a socio-ecological lens achieved the intended health and gender-responsive or -transformative outcomes. As gender inequalities are deeply entrenched, longer-term interventions tend to improve the sustainability of these effects.

• Most interventions focused on men and / or women, very few interventions focused on LGBTQI+ groups. While some successful interventions engage women- and men-only, in groups or as individuals, there was more evidence of couples-based interventions changing harmful gender norms. However, couple-based interventions need to ensure safety and private spaces for women, especially when tests are taken and diagnosis and advice given.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-026-26622-y.

Introduction

Human Immunodeficiency Virus (HIV), tuberculosis (TB), and malaria remain leading causes of infectious disease morbidity and mortality, disproportionately impacting the most marginalized and poorest populations around the world [1]. Over the last thirty years, significant strides have been made in tackling these infectious diseases particularly through multiple, large scale disease control programmes and international financing mechanisms, such as The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) [2]. However, recent and far-reaching cuts in international aid, wars and geo-political instability, widening inequalities and the wide-spread impacts of COVID-19 alongside climate change, are starting to reverse this progress [3]. In 2023 for instance, despite being preventable and curable, TB resumed its position as the world’s biggest infectious disease killer [4]. Similarly, projections estimate 4.43–10.75 million new HIV infections and 0.77–2.93 million HIV-related deaths between 2025 and 2030 due to the funding reductions [5]. However, the reversal of these gains is particularly stark along intersecting social fault lines, especially poverty, gender-based discrimination, exclusion, harmful social norms and stigma. In the current climate of intensified backlash against gender equality and human rights [5], it is critical that efforts to end HIV, TB and malaria remain firmly anchored in a gender equality and rights-based approach. This is particularly urgent as a sole focus on health outcomes means health programmes and policies risk exacerbating or entrenching existing gender inequalities and ultimately doing more harm than good.

It is recognized that ending the epidemics of HIV, TB and malaria will not be possible without prioritizing gender equality [6, 7]. Gender inequalities, namely harmful or discriminatory differences in power over access to resources, information, knowledge, decision-making, legal rights, and mental and physical safety, are a result of socially constructed norms and stereotypes associated with one’s gender identity [8]. These impact individual’s exposure to risk factors, access to healthcare and the quality of care they receive. For instance, gender norms surrounding intimate partner relations may increase women’s vulnerability to HIV infection [8]. They may not have the power to negotiate safe sex or may be reluctant to discuss the risk of HIV transmission with their partner, fearing they might disrupt a relationship of trust or provoke a violent reaction [8]. Similarly, stigma and discrimination experienced by sexual and gender minorities within the healthcare system may discourage them from seeking information and services for HIV prevention [8]. While women may encounter greater barriers to accessing TB care, men are more than twice as likely to be infected with the disease [8]. Harmful gender norms around masculinity - such as smoking, alcohol consumption, substance abuse, and working in high-risk occupations - may increase exposure to risk factors and reduce the likelihood of seeking care. Malaria epidemic, too, is gendered [8]. Women limited economic and decision-making power, along with their caregiving responsibilities may prevent them from attending antenatal care and receive malaria treatment or seek treatment for febrile children [8]. In many regions, adolescent boys and men are engaged in occupations, such as forestry, mining, with high presence of mosquitoes, resulting in a higher incidence of malaria among them. This in turn increases the risk of transmission to other household members [8].

While there is a growing evidence base on gender-focused interventions in health programmes and policies, to date there has not been a review and synthesis of existing published evidence related to gender-responsive and / or -transformative approaches in HIV, TB and malaria.

Focusing explicitly on gender-responsive and -transformative approaches is critical to move towards strengthening the evidence base on transforming inequitable social and cultural norms and discriminatory laws, policies and practices that contribute to gender inequalities and increase vulnerabilities to HIV, TB and malaria for women, girls and gender-diverse communities.

This rapid evidence review aimed to fill this gap by providing a synthesis of the evidence on changes to health- and gender-related outcomes resulting from gender-responsive and/or -transformative approaches and interventions in HIV, TB and malaria programmes. Furthermore, this review was generated with an intention to inform the Global Fund’s guidance and approaches to promote policies and actions to advance gender equality within its grants. The review is guided by the Global Fund’s understanding and definitions of gender-responsive and -transformative approaches to HIV, TB and malaria (see Table 1) [7].

Table 1.

Gender-responsive and-transformative definitions:

According to guidance from the Global Fund to Fight AIDS, Tuberculosis and Malaria, “Gender-responsive approaches to health recognize and respond to these differences and aim to ensure equitable health outcomes across the life course. They also collect and use sex and gender-disaggregated data, information and research to inform policy and programme decisions…”

“Gender-transformative programmes recognize how harmful gender norms and stereotypes, inequalities in power and control over resources, discriminatory laws, policies and practices impact women’s, girls’ and gender-diverse people’s vulnerability to the three diseases and take concrete actions to counter or change them. They have advancing gender equality and promoting positive gender norms, roles and relationships, as a key objective.” This review uses the umbrella term “gender-focused” to cover either gender-responsive or gender-transformative approaches, or both, as the case may be.

Methods

We employed a rapid review approach [9] to synthesize published peer-reviewed evidence on gender-responsive and/or -transformative interventions (together referred to as “gender-focused”) in HIV, TB and malaria programmes. The review analysed programmes that have been shown to have, or contribute to, a positive impact on shifting harmful gender norms and unequal power dynamics while also improving health outcomes, at least in intermediary terms (e.g., reducing risk of infection or transmission, reducing barriers to access, increasing uptake of services, increasing adherence to treatment). A rapid review approach was undertaken given short timelines to inform the revision of the Global Fund’s Modular Framework [10]. The approach we used was ‘rapid’ in that we searched two primary databases and the study selection and/or the data extraction process was based on one reviewer unless there were uncertainties, when articles were then screened by two reviewers.

Several consultations were held with Gender Advisers at the Global Fund to co-develop and refine the scope and research questions for the evidence review and summary. Relevant Global Fund documents, technical briefs and the current Modular Framework were also reviewed [2, 7]. This initial phase helped develop the search strategy and identify key databases, information sources and outcome criteria.

This rapid review was undertaken using methodology aligned to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [11].

Conceptual framework

Five broad types of gender-focused interventions were identified based on existing literature and reviews of Global Fund’s documentation, namely those that focus on: (1) resilient and sustainable health systems (2), gender norms change (3), social empowerment (4), economic empowerment, and (5) law and policy reform. These domains were adopted as an analytical framework for synthesizing the findings in this review (see Table 2).

Table 2.

Five types of gender-focused interventions

Resilient and sustainable health systems, which are the foundation of effective disease control, need to incorporate gender-focused approaches to achieve health programme and gender equality goals–or at least do no harm. Gender-focused interventions in this domain focus on various health system building blocks and include interventions such as reducing health service access barriers such as gender norms that constrain care-seeking, fragmentation of services, distance and costs; improving health service quality; improving health providers’ capacities and attitudes; utilizing community-based workers and peers; and promoting appropriate medical devices and technologies [12, 13].

Gender norms are socially constructed, often informal, rules that govern individual behaviour based on one’s gender identity and impact exposure to risk factors, diagnosis, access to services and adherence to treatment. Gender norms change interventions challenge these harmful and unequal social norms. For instance, interventions that challenge gender norms related to expectations of men that may encourage men to smoke, or take sexual risks, control decision making of their partners, or perpetuate violence. Gender norms change-related interventions are usually multi-component and multi-level and feature community-based, couples-based and behavioural components. They typically include gender-transformative participatory training and skills-building of couples or same-sex groups. Couples-based components engage men in their partners’ health and increase gender-equitable relationship dynamics and joint sexual and health decision-making. Community-based components include awareness, advocacy and engagement of local leaders, to challenge harmful gender norms [14–16].

Gender-focused social empowerment can be described as the process by which marginalized individuals or groups acquire knowledge, tools and skills to overcome structural gender-based discrimination and claim agency to reduce the health disparities they face. Social empowerment interventions often focus on marginalized and very vulnerable groups, such as sex workers, transwomen, women with HIV and very vulnerable adolescent girls and young women (AGYW). They are characterized by processes of organizing, collective action and self-empowerment; working through collectives, group-based networks and peer leaders or volunteers; and engaging multiple strategies and stakeholders. They are often longer-term in nature, evolving through stages of empowerment, such as engagement, involvement, ownership and sustaining. They embody gender-based principles such as gender power dynamics and gender affirmation and goals such as strengthened decision-making, negotiation and self-efficacy; and rights-based principles such as respect, reliance and recognition [14, 17].

Economic empowerment interventions aim to tackle key structural factors linked to gender inequality and poverty to reduce financial dependence, improve intra-household bargaining power and community standing, and reduce vulnerability due to healthcare expenditure. These interventions often include an economic component such as savings, microfinance, cash transfers, vocational skills, business training and income-generating activities alongside components related to gender norms change and social empowerment [14, 17]. Often, economic empowerment interventions target the most vulnerable groups in communities.

Legal and policy reform are important avenues for institutionalizing gender equality in health through national structures and processes. These could include laws and policies on tuition-free primary education, paid maternity and paternal leave, incorporation of women’s and girls’ strategic gender needs into national strategic plans, training community paralegals to reduce legal and other barriers to access to services, and promoting behaviour change and risk reduction – all of which can improve both decision-making roles for women as well as their health. However, greater equality in leadership positions, gender responsive budgeting, and robust monitoring mechanisms in place are indispensable for effective implementation of these laws and policies [18].

Search strategy

A comprehensive search was conducted on PubMed and SCOPUS electronic databases. Search terms were created iteratively based on search terms related to gender-focused interventions, health outcomes (HIV, TB, malaria) and gender outcomes (Supplementary Tables S1 & S2). The search was limited to articles from low- and middle-income countries (LMICs) published between January 2004 and October 2024. Given this was a rapid review with limited time and resources available, only English-language primary research articles that clearly described the gender-focused intervention and outcomes and included an evaluation design or an articulated analysis framework for policy reviews were included.

In addition, reference lists of included studies were reviewed, and open web searches of the Global Fund, WHO, UNAIDS, LSHTM, Cochrane websites were conducted alongside contacting key experts working in HIV, TB and malaria to gather more information about particular interventions and obtain supporting literature. While peer-reviewed articles were considered the most credible, unpublished reports and other documentation also provided important data.

Screening and extraction

Covidence was used for the screening process [19]. Two stages were used to screen and select articles, namely title and abstract screening followed by a full-text review. In both stages the following inclusion criteria were used: (1) English text (2), interventions that took place in LMICs (3), primary research articles published between January 2004 – October 2024, and (4) articles with an evaluation design. Articles reporting on the same intervention were evaluated separately and included only if they reported both gender and health outcomes.

In the first stage (title and abstract screening) all articles were independently screened by two reviewers, while in the second stage (full text review), articles were divided up between two reviewers who only screened articles assigned to them. At each stage, ambiguities were discussed with a second reviewer to reach a consensus. In cases where a consensus could not be reached, disagreements were resolved by a third reviewer. In terms of assessing the level of gender-focused outcomes, we used an adapted version of the World Health Organization’s five-level Gender Responsive Assessment Scale where level 1 referred to gender unequal outcomes, level 2 to gender-blind, level 3 to gender-sensitive, level 4 to gender-responsive, and level 5 to gender-transformative [20].

A data extraction sheet was created by the review team and then piloted on a small set of articles, after which it was further refined (Supplementary Table S3). Data were extracted by a single reviewer with a second reviewer selecting a random sub-sample to check and verify extracted data.

Quality assessment

The 2018 version of the mixed methods appraisal tool (MMAT) was used to assess the methodological quality of the articles included in the review [21]. A single reviewer assessed the quality of each article. Since this was a rapid review of diverse study designs, the MMAT tool was selected as it allowed for quick appraisal of the methodological quality of the different categories of studies (e.g., randomized controlled trials, non-randomized trials, quantitative descriptive studies, qualitative studies, and mixed methods studies). We assessed the quality of studies against five criteria for each study design, as recommended by the tool (each category has five questions) (Supplementary Table S4).

Data analysis

Descriptive analyses were undertaken to provide a summary of the programmes reviewed. Then, for each disease group (HIV, TB, malaria) data were summarized and analysed according to the five types of gender-focused intervention categories developed in the review framework. Where interventions spanned more than one category, the review team selected the dominant category and grouped the article accordingly.

Results

Study selection

The initial search identified 11,844 articles, of which 24 duplicates were removed. After title and abstract screening of 11,820 articles, 11,288 were excluded as they were conducted in high-income countries, not focusing on HIV, TB, or malaria or lacked a gender focus. Thus, 522 articles were assessed in the full-text review out of which 42 primary research articles were included in the final review (Fig. 1). Notably, all of these articles focused on HIV, with none addressing TB or malaria. No articles were obtained from the grey literature or expert key informants.

Fig. 1.

Flowchart of study selection

Study settings, design and quality

Majority of the studies were from the sub-Saharan African region, including four multi-country studies from the region [22–25] and most single-country studies conducted in South Africa (n = 10) [26–35], followed by Tanzania (n = 5) [36–40], Uganda (n = 4) [41–44], Kenya (n = 3) [45–47], and Ethiopia (n = 2) [48, 49]. Lesotho [50], Mozambique [51], Nigeria [52], Zambia [53] and Zimbabwe [54] each had one study. In Asia, three studies were conducted in India [55–57] and one in the Philippines [58]. In Latin America, studies were conducted in Colombia (n = 1) [59] and the Dominican Republic (n = 1) [60], while the Middle East was represented by studies from Iran (n = 1) [61] and Lebanon (n = 1) [62] .

The studies employed a range of designs, including randomized control trials or cluster randomised control trials (n = 15) [22, 23, 28, 30–33, 37, 39, 41, 48, 50, 52, 53, 61], qualitative (n = 11) [25, 34, 36, 40, 42, 43, 45, 47, 55–57], quasi-experimental/quantitative non-randomized (n = 10) [27, 35, 44, 46, 49, 58–60, 63, 64], quantitative descriptive [24, 26, 54, 62], and mixed methods (n = 2) [38, 51].

Although the quality of studies varied by study design, overall study quality was high, with most studies meeting the majority of criteria. Approximately half of the studies (8 out of 15) using RCT/cluster RCT met four out of the five criteria recommended by the MMAT tool while six studies met three criteria, and one study fulfilled all five. Among studies using quasi-experimental/quantitative non-randomized designs, just over half of them (6 out of 10) met three out of five criteria, two met four of the criteria whereas the remaining two studies satisfied all five criteria. Almost all the qualitative studies (10 out of 11) met all five criteria. Two out of four studies with quantitative approach met all five criteria. Both mixed methods studies mixed fulfilled all criteria as well (Supplementary Table S4).

Duration and care pathway stages targeted by the interventions

Just over half of the studies evaluated interventions that lasted for more than two years (n = 22) [22, 23, 32–36, 41–44, 46, 49–51, 55–58, 62–64]; a third examined interventions that were in place for one to two years (n = 12) [24, 28, 30, 31, 37, 38, 40, 45, 47, 48, 59, 60] and six related to interventions lasting for one year or less [26, 27, 38, 52, 53, 61]. Two studies did not mention any specific duration [25, 54].

The majority of interventions focused on the prevention stage of the HIV care pathway (n = 35) [22, 24, 27, 28, 30–35, 37–41, 43, 44, 46–58, 60–64]. Seven interventions focused on treatment [23, 26, 43, 45, 53, 57, 59] ; four on reducing barriers to services (n = 4) [36, 37, 55, 57] ; screening, testing or diagnosis (n = 3) [36, 53, 57]; and health-seeking behaviour (n = 1) [42]. Note, some interventions tackled more than one stage of the care pathway. Figure 2 provides an overview of the gender-related barrier and gender-related interventions across the HIV care pathway.

Fig. 2.

Summary of gender-related barriers and interventions across the HIV care pathway

Resilient and sustainable health systems (RSSH)

The review identified six articles that evaluated interventions on health system building blocks and improved both health- and gender-related outcomes [23, 26, 36, 37, 45, 53]. Interventions reported in these articles broadly fall into the following categories: health service-related interventions linked to service integration, modified service delivery models, and quality improvement, interventions tackling financial barriers, interventions focusing on the health workforce.

Health service-related interventions integrated services to meet multiple health needs, that is, approaches where HIV services and other types of health services were delivered together—e.g., by integrating HIV counselling and testing (HTC) into routine ante-natal care (ANC) services; or integrating comprehensive services for gender-based violence (GBV), a risk factor for HIV, into an HIV programme platform. Studies related to health service integration reported positive effects on health- and gender-related outcomes [36, 37]. For instance, integrating HTC into ANC services improved peer-based knowledge sharing and HTC uptake, increased confidentiality and reduced stigma among women, men and couples and increased testing among men [37]. Similarly, integrating comprehensive GBV services into an HIV programme platform increased use of GBV and HIV services. The study observed nearly three times as many clients visits for GBV in intervention sites (N = 1427) as compared to control (N = 489). The intervention also shifted harmful community gender norms, reduced acceptance of GBV and increased knowledge and action among individuals, couples and communities, reducing GBV prevalence [36].

Other health service-related interventions modified service delivery models to bring services closer to communities–e.g., through home-based voluntary counselling and testing (VCT) delivered by lay counsellors or community- or peer-based delivery of antiretroviral therapy (ART) [23, 53]. Compared to facility-based VCT, home-based VCT by lay counsellors was found to increase uptake of joint testing by couples. It was found that 62% of those counselled at home reported having been counselled together with their partner; of those who were tested at home,70% reported having received the test together with their partner [53]. With regards to gender-related effects, community- or peer-based ART were reported to improve viral suppression rates, especially among men (73%, RR 1.34, 95% CI 1.16–1.55, p<0.0001 Vs 54%) [23] and increased male partner involvement (MPI) in family planning and HIV prevention [23, 53].

Gender-focused health workforce interventions included training to strengthen health care providers’ knowledge, awareness, skills and attitudes to provide stigma-free and appropriate services to specific client groups [45]. One study found that appropriately training health care providers reduced personal opinion-based judgments of specific patient groups, such as men who have sex with men (MSM) and enabled them to integrate new knowledge and skills about HIV/sexually transmitted infections (STIs) into their practice [45] .

Gender norms change

The review identified nine articles that evaluated interventions targeting gender norms change [22, 27, 28, 41, 42, 48, 51, 52, 54]. Gender norms change-related interventions usually included multiple components (community-based, couples-based and behavioural) operating at multiple levels. Examples of components were gender-transformative participatory training and skills-building of couples or same-sex groups; couples-based components that aimed to engage men in their partners’ health and increase gender-equitable relationship dynamics and joint sexual and health decision-making; and community-based components that strengthen awareness, advocacy and engagement of local leaders and communities and challenge harmful gender norms. HIV-related outcomes included HIV risk reduction and increasing the uptake of testing, referral, vertical transmission prevention and other services. These interventions have also been found to have reduced STIs and the risk of acquiring HIV; tackled intimate partner violence (IPV) and the risk of acquiring HIV in an integrated manner; reduced the risk of acquiring an HIV infection during pregnancy; and promoted MPI in the context of maternal health.

The review identified community-level interventions that employed multiple strategies to improve health- and gender-related outcomes [22, 40, 50]. For instance, such interventions recruited and trained community activists; mobilized communities and built awareness; engaged with media and undertook advocacy; promoted violence against women (VAW) prevention and response; and strengthened the capacity of community-based organizations. They thereby reduced behaviours related to the risk of acquiring HIV and resulted in fewer sexual partners, lower rates of men purchasing sex, improved knowledge of HIV status, increased condom use and increased testing and referral to HIV services. These interventions also led to more gender-equitable attitudes among men and women, couples and communities [22, 40, 50].

Similarly, couple-based interventions combining components such as gender-transformative cognitive-behavioural skills-building training, HIV and alcohol risk reduction education and distribution of condoms were found to increase HIV testing and safer sexual behaviours, such as condom use at last intercourse and partner disclosure of HIV serostatus. They also increased male attendance in ANC. At the same time, these interventions improved communication, the use of negotiation and shared decision-making in heterosexual relationships and more equitable sharing of unpaid household work. MPI interventions improved gender relations between couples [28, 48].

Two articles focused on men only. One assessed a 5-session training for men designed to reduce IPV and risk of acquiring HIV. The study found greater intention among participants to reduce the risk of acquiring HIV behaviours as well as lower likelihood of perpetrating verbal and physical violence towards their sexual partners (3.5+/-0.5 versus 3.4+/-0.7, p<0.05) [28]. The other article explored men’s responses to a 5-phase mass media and interpersonal media campaign designed to increase male partners’ involvement in the health of pregnant women. The study reported increased male attendance in ANC, improved relationship with their spouse, and men’s acknowledgment that their support during pregnancy is a loving behaviour that can improve maternal and child health outcomes [48].

Other studies also examined gender-focused interventions with men and women, individually or in groups. These interventions included components such as gender-transformative participatory training, HIV and alcohol risk reduction education, distribution of condoms and skills-building activities. Studies observed a reduction in the number of sexual partners, changed gender attitudes towards better equity, reduction in men’s perpetration of sexual violence, increased condom use rates and better risk preventive behaviours such as reduction in unprotected sex and negative condom attitudes [28, 48, 52, 54]. Related to GBV, an HIV risk factor, interventions were found to have lowered the social acceptance of IPV and the likelihood of its perpetration (AOR: 0.73; 95% CI: 0.56–0.94, p = 0.014) [28, 48].

Social empowerment

Social empowerment interventions typically feature multiple components, including educational, environmental, structural, policy advocacy and institutional. They often focus on very vulnerable groups, such as sex workers, transwomen, women with HIV and very vulnerable adolescent girls and young women (AGYW). They embodied gender-based principles such as gender power dynamics and gender affirmation; gender-focused goals such as strengthened decision-making, negotiation and self-efficacy; and rights-based principles such as respect, reliance and recognition. These interventions were characterized by processes of organizing, collective action and self-empowerment through peer-led mobilization, legal empowerment and community advocacy to challenge structural discrimination and violence and facilitate service access and gender affirmation.

The review identified eight articles that evaluated social empowerment interventions and improved health- and gender-related outcomes [49, 55–58, 60–62]. Five articles focused on interventions among sex workers [55–58, 60] while the remaining three targeted transwomen [62], women living with HIV [61] and AGYW [49] respectively.

Among sex workers, social empowerment interventions featured sex workers organizing, collectivizing and empowering themselves and influencing government policies. Such interventions were found to have increased HIV prevention and treatment service uptake and reduced STI prevalence and new HIV infections [55–57, 60]. They increased sex establishments’ ability to achieve the goal of no STIs in routine monthly screenings of sex workers (OR = 1.17; 95% CI = 1.12, 1.22) [60]. Further, they helped sex workers understand the need for collective action, strengthened their negotiation and self-advocacy skills, including for safer sex, and improved their access to legal and informational resources for advocacy [56, 60]. The interventions reduced sex workers’ stigma in health facilities and the structural violence they encounter [55–57, 60] and increased their awareness of their human rights and the notion that sex work is valid work [60]. One successful example was a multi-component educational and structural intervention among women bar workers and their clients in the Philippines, developed through community-based and participatory approaches with peer educators and managers being trained and engaged in implementation. It achieved highly significant improvements (F = 428.31, df = 2, P = 0.001) in consistent condom use behaviour among participants assigned to the combination of peer education and manager training [58] .

A social empowerment intervention among transwomen, based on gender affirmation and social support, comprised a trans-facilitated six-session group-level intervention promoting HIV testing among transwomen in Lebanon. It reported improvements in gender affirmation satisfaction, community connectedness and social cohesion scores (at 6-month post-test, 7 of 13 participants had improved gender affirmation satisfaction scores compared with baseline; 9 had improved community connectedness scores compared with baseline; and 9 participants had improved social cohesion scores) [62]. Among women living with HIV, interventions such as tele-counselling-based motivational interviewing, social activities, and routine healthcare were able to increase safer sexual behaviour (condom negotiation skills, p < 0.001) [61]. Among AGYW, interventions that included components such as training and awareness-building (with topics including self-esteem, communication, gender and power dynamics, rape and coercion, menstruation, STIs, HIV and AIDS, VCT, ART, and financial literacy) and literacy support were reported to increase knowledge on HIV, including where to obtain voluntary counselling and testing (VCT) and the intention to be tested (OR = 2). They also increased social support among very vulnerable adolescent girls (OR = 2) [49].

Economic empowerment

Economic empowerment interventions are typically multi-component and multi-level in nature and often, if not usually, include components related to gender norms change and social empowerment, but in addition, feature an economic component, such as savings, microfinance, cash transfers, vocational skills and business training and income-generating activities to improve financial independence and reduce HIV risk. Their focus population groups range from AGYW and women only to young men, young people and adults. Our search yielded the largest number of primary articles in this category.

Among AGYW, economic empowerment interventions were found to increase HIV testing and counselling as well as uptake of contraception and STI treatment and decrease transactional sex and the experience of STIs [24, 30–32, 34, 35, 38–40, 49, 50, 63, 64]. They also improved gender equitable attitudes [24, 30–32, 34, 35, 38–40, 49, 50, 63, 64], which have shown a protective effect against and herpes simplex virus type 2 [32]. These initiatives improved AGYW’s financial well-being and independence; access to savings; self-efficacy; negotiating power in relationships; communication about sex at home; the ability to resist unwanted and transactional sex; and reduced partner and non-partner physical and sexual violence [24, 30–32, 34, 35, 40, 49, 50, 63, 64]. Economic well-being was found to have improved the most among the poorest AGYW [32] .

Interventions with young people more broadly increased their access to and decision-making about sexual and reproductive health (SRH) services; availability of post-exposure prophylaxis; uptake of STI testing and treatment; HIV and AIDS testing, counselling and treatment; health education services such as condom use demonstrations; and HIV and AIDS knowledge and awareness [70% of girls in the intervention (compared to 26% of those who did not participate) and 51% of boys (versus 23%)] [63]. They also improved young peoples’ attitudes towards GBV [44]. Such interventions were also observed to reduce inequitable gender norms among young men [44, 63].

Economic empowerment interventions implemented among low-income men and women living with HIV and receiving ART were found to increase condom use and improve diet quality and virologic and immunologic outcomes. They also improved joint sexual decision-making and reduced or eliminated extra-marital relationships and increased women’s ability to negotiate condom use [47]. For women living in poverty with HIV and on ART, such interventions were found to improve knowledge of HIV and ART (from a median pre-intervention score of 9 to 25 post-intervention, p < 0.0001), health status and adherence to ART and reduce anxiety and stigma (from 16.5 to 52.5, p < 0.001) [59]. Among women living with HIV enrolled in prevention of vertical transmission programmes, such interventions enhanced women’s “usefulness” in the eyes of their families [43].

Legal and policy reform

The review identified only a single primary research article that examined legal or policy reform. In their assessment of the National Strategic Plans (NSPs) for HIV and AIDS of 20 countries in eastern and southern Africa, Gibbs et al. [25] found generally poor inclusion of women and girls in NSPs. The authors reported that the HIV field’s emphasis on integrating HIV interventions into sexual and reproductive health and rights related services was largely absent from the NSPs reviewed. Regarding HIV care and treatment, the main areas where NSPs were found to perform well were with regard to increasing access to post-exposure prophylaxis in the case of sexual violence (13 countries) and to vertical transmission services (15 countries), reflecting a conceptualization of women in their reproductive roles rather than in broader ways. Only four included measures to increase women’s and girls’ access to HIV treatment outside perinatal settings.

12 NSPs recognized the structural gender inequalities underlying HIV transmission and 13 included at least one intervention to address these. However, only four had interventions to tackle gender-based violence. Only half include two or fewer interventions related to women’s and girls’ burden of unpaid HIV care work. Few include measures for women with specific needs, such as those living with HIV (7 NSPs) or young women (8 NSPs). Drawing on Moser’s framework, the authors emphasize that, even where women and girls are considered, policies or programmes tend to target their practical rather than strategic gender needs—in other words, they aim to make women’s and girl’s lives easier given existing structural gender-based inequalities rather than being concerned with transforming these inequalities. Beyond recognizing the importance of disaggregated data for monitoring, the NSPs were found to perform poorly on accountability and budgeting [25].

Discussion

Overall, the evidence consolidated as part of this review focused solely on HIV programmes and policies. Given the deeply rooted social nature of harmful gender norms, stereotypes, beliefs and practices, and similarities across the care pathways there are a number of transferable lessons that can be drawn for TB and malaria programmes. However, the significant gap of evidence in these two health areas warrants concerted efforts in designing, implementing and assessing contextually relevant gender-focused TB and malaria interventions.

This review found strong evidence that gender-focused interventions target not just individuals and their behaviours but also structural factors. These interventions clearly articulated the intention to tackle the structural gender inequalities underlying disease prevention and control. Although single-component and relatively short-duration interventions were found to have achieved some success, there was more evidence that multi-component interventions implemented at multiple levels and employing a socio-ecological lens achieved the intended health and gender outcomes. Further, given that gender inequalities are deeply entrenched, longer-term interventions tended to improve the sustainability of effects. While some successful interventions engaged women and men only, in groups or as individuals, there was more evidence that couples-based interventions tended to change harmful gender norms. However, couple-based interventions need to ensure adequate safety and private spaces for women. Interventions that engage men only need to avoid common limitations, such as focus on individual agency or behaviour rather than structural issues, that can result in backlash. User preferences and participation were found to be key to good design and implementation of gender-focused interventions.

As we examine gender-focused interventions and their contributions to health- and gender-related outcomes, it is important also to consider issues related to their implementation. The review yielded some insights in this regard. For instance, civil society organizations were key implementation partners for successful gender-focused interventions and peers and champions often played critical roles. At the same time, government stakeholders’ engagement and capacity were important in designing and implementing gender-focused strategies. Government engagement is especially important to strengthen the resilience and sustainability of health systems and ensure sustainable funding.

With regard to gender-focused interventions that strengthen the resilience and sustainability of health systems, the review found that positive changes can result even from a single intervention relatively short intervention periods or modest coverage levels [26]. With regard to financial incentives, larger amounts, including full subsidies, may be needed to achieve intended change [26]. Users’ preferences were found to be key to successful design and implementation–e.g., HIV+ pregnant women preferred health education and counselling, home visits and improved clinic services over financial incentives to support their post-partum retention in ART [26]. With regard to health care provider-focused interventions, addressing provider stigma was key to improving service utilization. Interventions that improved health care provider (HCP) skills and attitudes typically featured collaborative approaches that relied on teamwork, peer learning, mutual support and “reinforcement by higher authorities” [45]. Short and single-component interventions significantly improved HCPs’ HIV- and AIDS-related knowledge, even at 9 months follow-up, but multi-component interventions that combined information sharing, skill-building and increased contact with PHLWA reduced discriminatory attitudes [45]. For behavioural interventions to reduce IPV and HIV, one consideration is the need to integrate more nurse-led components, especially for women IPV survivors as HIV–nurses and other HCPs were almost entirely missing from such interventions. For couple-based behavioural interventions, such as those for HCT, a review of 17 papers related to behavioural intervention programs to address HIV and IPV in sub-Saharan African countries, found that there was a need for these to be restructured to improve HCPs’ awareness of women’s increased safety risks from their HIV status and HCPs’ skills to implement effective precautions [65]. It is important to consider that health system-focused approaches alone may have limited potential to challenge the harmful gender inequalities that are pervasive in communities and affect disease prevention and control. Such approaches need to be complemented by strategies that aim to shift unequal gender norms, achieve social and economic empowerment of vulnerable groups, address legal barriers and reduce risks through policy change.

Our review yielded some key implementation insights related to gender norms change interventions. Overall, we found that multi-component strategies, combining capacity building and community engagement were important for changing community gender norms [51]. Another systematic review of interventions involving men living with HIV positive pregnant women found that multi-component strategies that included health education and health workers development were also more likely to promote male partner involvement than single intervention strategies [66]. Other published evidence also reported that the sustainability of gender norms change interventions depended on long-term engagement and community ownership [54, 67]. A review by Nikolova et al. found that longer duration male-focused interventions also generally showed better effects on outcomes such as multiple partnerships, sex with concurrent partners, condom use and sex with casual partners [67].

Other systematic reviews also reported that couples-based interventions were more successful (e.g., at promoting condom use and HIV testing) than those targeting individuals. Two reviews found that when delivered around the time of pregnancy, couple-based interventions tended to promote positive behaviours linked to uptake of interventions focused on the prevention vertical transmission [68, 69]. However, adequate guidance and adaptation of couples-based interventions to local cultural contexts are needed to inform implementation, especially in LMICs [68] .

Similar to evidence from other reviews, we found that engaging men as allies in gender-transformative programmes was critical, as male resistance or backlash can undermine programme effectiveness [22, 70]. However, it is critical that interventions focused on men should not be funded by diverting resources from women-led and women-engaged efforts, which are already severely underfunded. Instead, they should be supported through additional funding that does not compromise core support for women-led initiatives. Regarding male involvement, it is important both to select interventions that work and to ensure care in implementing them. If not thoughtfully implemented, male-only interventions have been known to unintentionally reinforce harmful gender norms, such as perpetuating male partner control over women’s mobility or their access to financial resources [71]. In addition, gender norms-related interventions need to follow differentiated approaches for men and for women, as women face specific gender-based constraints in sexual behaviour change [72]. Gender norms change interventions also need to invest in improving the skills and practices of nurses and other health care providers, especially for women IPV survivors acquiring HIV [65].

This review found that community- or peer-led structural social empowerment interventions based on principles such as respect, reliance and recognition can contribute to both HIV prevention and gender equality goals [55]. Interventions that combine community solidarity and government policy showed positive effects on HIV and STI reduction among sex workers [56, 57]. Collectivization was key to improving sex workers’ improved relationships with local health services for HIV prevention [56]. Implementing successful social empowerment interventions required community-driven approaches and sustained engagement with policymakers. Additionally, programmes that integrated legal support with community mobilization efforts tended to achieve more sustainable impacts [56]. We also found that organisational and individual interventions, in the absence of structural social empowerment interventions, are insufficient to sustain change and influence male partner practices [58]. Lastly, having a strategic, evidence-based targeting and recruitment strategy, featuring elements such as house-to-house recruitment, negotiation, and follow-up, was found to be particularly important for reaching very vulnerable populations, such as adolescent girl domestic workers and migrants [49]. Not to mention, sensitivity to local cultural contexts and non-judgmental facilitation being critical as well [55].

In designing economic empowerment interventions [31], and Stepping Stones studies [72], other published reviews have corroborated the need for HIV interventions that promote individual-level changes, to also include gender-focused components that address structural changes in the unequal gender norms that underpin risk of acquiring HIV [31, 72]. A review by Small et al. reported that these components should address the individual- and structural-level social context; modify this context through structural interventions; root programmes in gender-transformative theoretical approaches; engage communities through qualified and trained community facilitators; and rigorously evaluate research results [73]. Similarly, other reviews reported that multi-component programmes that integrate financial support with gender-transformative components like life skills training and peer and community meetings were more successful than micro-finance only interventions in improving intermediary outcomes such as women’s economic empowerment, gender equitable attitudes and reduced IPV, as well as in reducing HIV-related risk behaviours [25, 74, 75]. Longer-term exposure to microfinance interventions was also associated with more negotiating power with partners and lower infidelity among partners [71].

Other reviews report that community-based organizations and participation by the most vulnerable groups are key to successful implementation [71] of economic empowerment interventions. Implementation through collaboration with the right technical and government stakeholders (communities, education, health, non-governmental organisations, community health workers, trained local mentors) and sustainable funding, especially for non-governmental organisations, which usually serve as implementing partners, are vital components of successful interventions [75]. Critically, economic interventions should be designed to avoid inadvertently reinforcing harmful gender norms, triggering male backlash or increasing interpersonal (couple) conflict and IPV. Challenging entrenched gender power dynamics needs to go with complementary gender-transformative programming and careful implementation and monitoring for potential harms [73, 75].

A critical piece of economic empowerment interventions for AGYW was supportive policies and implementation that took into account the local- and age-specific nature of their risks [24, 76]. Evidence suggests that policy-makers should consider better targeting of the most vulnerable AGYW in economic empowerment programmes to reduce HIV, for more efficient use of limited resources [32]. Other reviews reported that for AGYW, early intervention (before age 13) enabled utilizing a sensitive formative window, while delaying beyond this age entailed lower chances of ‘catching up’ [75, 76]. Other lessons learned for AGYW from other reviews include: (ii) providing girls only safe spaces and older role models and mentors; (iii) strengthening vulnerable girls through community engagement and promotion of continued education in the context of child marriage; and (iv) providing livelihoods and financial skills [76]. For young men, this review found that peer health leadership interventions improved HIV testing rates [38, 39]. However, overall more evidence is needed on vulnerable groups including sex workers, AGYW and on the benefits and risks (male backlash, increase in controlling behaviours) of including men in interventions combining economic and gender-transformative components [25].

Concerning legal and policy reform interventions, this review found limited evidence in this space. Of the one primary article included, it showed that NSPs for HIV and AIDS generally reflect a conceptualization of women in their reproductive roles and even where women and girls are considered, policies or programmes typically aim to make women’s and girl’s lives easier given existing structural gender-based inequalities (for example, building knowledge and skills for HIV prevention, implementing biomedical interventions such as post exposure prophylaxis to prevent HIV, and linking HIV care services to antenatal care etc.) rather than being concerned with transforming these inequalities (for example, fostering gender equal decision-making spaces and negotiation skills, increasing girls’ retention in schools, reducing gender-based violence, and reducing girls’ and women’s unpaid care burdens). NSPs also performed poorly on accountability and budgeting. Overall, they miss important opportunities to guide national HIV responses in ways that transform the harmful gender norms and relations driving HIV [25]. A review of policy interventions affecting HIV-related behaviours found that interventions to create cadres of paralegals (for example, to tackle barriers to HIV prevention and treatment, and often GBV, by documenting rights violations, securing sex workers’ release from detention, averting child marriages and increasing links with health services, post-exposure prophylaxis and referrals to SRH services) incorporated gender unevenly. Therefore, investment in paralegal programmes could be increased. There was also some evidence that successful policies to change behaviours related to risk of acquiring HIV were implemented alongside behavioural and community mobilization components [77]. However, if ill-conceived, such policies may have the “cobra effect” or unintended negative consequences (e.g., such as blanket bans on sex work in Bangladesh) [78]. Policies that advance small, incremental changes or that “nudge” people towards desired behavioural outcomes generally hold better promise [77]. Strong accountability mechanisms–including ensuring costing and funding for interventions targeting women and girls, research on women and girls and effective monitoring and evaluation–are needed to ensure gender considerations are implemented [25]. It is critical to safeguard against human rights violations and tailor policies to local contexts during policy implementation [77]. Additionally, more systematic inclusion of gender and more rigorous evaluations of legal or policy reform interventions in future are needed [79].

Across the various categories, evaluating the effects of multi-component, multi-level structural interventions pose obvious challenges. It is important for future interventions to clearly articulate gendered theories of change, measure intermediate health and gender outcomes and use designs that enable assessment of intended structural changes.

Ultimately, changing deeply entrenched gender norms and power structures is complex work. This review suggests that this complexity needs to be acknowledged and embraced. Gender inequalities need to be tackled at multiple levels, through multiple stakeholders and multiple approaches. And ultimately, the politics of change need to be confronted, especially in the current increasingly hostile environment towards gender equality and rights, by appropriately framing the issues to the given context and pushing the combined gender and health agendas.

Limitations of the evidence review

This evidence review had some obvious limitations. First, given the significant time constraints imposed by the Global Fund’s funding programme cycle, the review was conducted as a rapid exercise and not as a full systematic review, which in turn dictated some important decisions. For example, the search strategy was limited to two electronic databases, namely, PubMed and SCOPUS. The review team did search the Global Fund, WHO, UNAIDS, LSHTM and Cochrane websites and experts working in HIV, TB and malaria were contacted to request more information about programmes and obtain supporting literature. However, these strategies did not yield much additional information that met the inclusion criteria.

In addition, the team confined itself to the literature published in the English language. It is therefore possible that key information about effective gender-focused interventions in languages other than English may have been missed.

Finally, given that this was a review of available evidence, the team did not themselves evaluate the interventions reported on; rather, reliance was placed on the existing studies identified that have evaluated these interventions. However, to ensure the quality of studies included in this review, the team conducted a rapid quality assessment of these studies to ascertain whether the included studies had incorporated an adequate degree of methodological rigor.

Looking forward, future reviews focusing on a similar topic should consider expanding the scope to include other databases and also review published literature in non-English languages. In addition, given the rise in conflict affected health systems, future analyses can also focus on health system resilience, particularly in emergency settings.

Conclusions

This review demonstrates stark gaps in evidence related to gender-focused interventions for TB and malaria programming but a rich body of gender-focused interventions in HIV programming, with the potential to improve both health and gender-related outcomes. Much of this evidence comes from sub-Saharan Africa and focuses on prevention and risk reduction stages of the HIV and AIDS care pathway, while evidence on later stages in the HIV care pathway, such as treatment uptake and adherence remains scarce.

Gender-focused interventions in this review have attempted to address the structural factors to improve gender and health-related outcomes related to HIV by strengthening the health system, promoting economic and social empowerment, changing gender norms, and implementing law and policy. Given the current polycrises and rising anti-gender movements, this evidence review reinforces two important points. First, an urgent need to build an evidence base assessing gender-focused interventions in TB and malaria programming. Second, the need to draw on the existing evidence base to strengthen gender-focused interventions to end HIV and where relevant draw transferable lessons for TB and malaria programming. Both aspects are critical since solely relying on biomedical approaches risk exacerbating existing gender inequalities and ultimately doing more harm than good.

Abbreviations

AGWY

Adolescent girls and young women

ANC

Ante-natal care

ART

Antiretroviral therapy

GBV

Gender-based violence

HCP

Health care provider

HIV

Human Immunodeficiency Virus

HTC

HIV testing and counselling

IPV

Intimate partner violence

LMICs

Low-and middle-income countries

MPI

Male partner involvement

STI

Sexually transmitted infection

TB

Tuberculosis

VCT

Voluntary counselling and testing

Authors’ contributions

Conception or design of the work – Johanna, Anjana. Data collection – Anjana, Sapna, Zaida, Johanna. Data analysis and interpretation - Anjana, Sapna, Zaida, Johanna. Drafting the article - Anjana, Sapna, Zaida, Johanna. Critical revision of the article – Johanna. All authors approved the final version of the paper prior to submission.

Funding

The research was supported by the New Venture Fund, US.

Data availability

Data and materials are attached as supplementary files.

Declarations

Ethics approval and consent to participate

This section belongs to participants consent if any identifiable information is included in the manuscript. The manuscript does not hold any such information. Therefore, consent to participate is not applicable.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.