title: Effectiveness of a peer-led HIV prevention intervention in secondary schools in Rwanda: results from a non-randomized controlled trial.
abstract: BACKGROUND
  While the HIV epidemic is levelling off in sub-Saharan Africa, it remains at an unacceptably high level. Young people aged 15-24 years remain particularly vulnerable, resulting in a regional HIV prevalence of 1.4% in young men and 3.3% in young women. This study assesses the effectiveness of a peer-led HIV prevention intervention in secondary schools in Rwanda on young people's sexual behavior, HIV knowledge and attitudes.
  
  
  METHODS
  In a non-randomized longitudinal controlled trial, fourteen schools were selected in two neighboring districts in Rwanda Bugesera (intervention) and Rwamagana (control). Students (n = 1950) in eight intervention and six control schools participated in three surveys (baseline, six and twelve months in the intervention). Analysis was done using linear and logistic regression using generalized estimation equations adjusted for propensity score.
  
  
  RESULTS
  The overall retention rate was 72%. Time trends in sexual risk behavior (being sexually active, sex in last six months, condom use at last sex) were not significantly different in students from intervention and control schools, nor was the intervention associated with increased knowledge, perceived severity or perceived susceptibility. It did significantly reduce reported stigma.
  
  
  CONCLUSIONS
  Analyzing this and other interventions, we identified several reasons for the observed limited effectiveness of peer education: 1) intervention activities (spreading information) are not tuned to objectives (changing behavior); 2) young people prefer receiving HIV information from other sources than peers; 3) outcome indicators are not adequate and the context of the relationship in which sex occurs and the context in which sex occurs is ignored. Effectiveness of peer education may increase through integration in holistic interventions and redefining peer educators' role as focal points for sensitization and referral to experts and services. Finally, we argue that a narrow focus on sexual risks will never significantly turn the tide.
authors.affiliation: International Centre for Reproductive Health, Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan, 185 6K4, 9000, Gent, Belgium. Kristien.Michielsen@ugent.be
authors.forename: Kristien
authors.initials: K
authors.lastname: Michielsen
authors.forename: Roxanne
authors.initials: R
authors.lastname: Beauclair
authors.forename: Wim
authors.initials: W
authors.lastname: Delva
authors.forename: Kristien
authors.initials: K
authors.lastname: Roelens
authors.forename: Ronan
authors.initials: R
authors.lastname: Van Rossem
authors.forename: Marleen
authors.initials: M
authors.lastname: Temmerman
mesh_terms: D000293:Adolescent; D018849:Controlled Clinical Trials as Topic; D003376:Counseling; D004059:Diffusion of Innovation; D005260:Female; D015658:HIV Infections / Q000517:prevention & control*; D007722:Health Knowledge, Attitudes, Practice; D006293:Health Promotion / Q000379:methods; D006801:Humans; D008297:Male; D010379:Peer Group; D015397:Program Evaluation; D060728:Reproductive Health / Q000193:education; D012432:Rwanda; D012572:School Health Services / Q000706:statistics & numerical data; D012736:Sex Education / Q000379:methods*; D012725:Sexual Behavior; D058992:Social Participation; D011795:Surveys and Questionnaires; D014505:Urban Population