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Original Article

Effectiveness of interventions for preventing STIs in

women experiencing intimate partner violence:

systematic review

Iliana Patricia Vega-Campos

, Rosalva del Carmen Barbosa-Martínez

, Raquel Alicia

Benavides-Torres

& Yolanda Flores-Peña

Universidad Autónoma de Nayarit, Unidad Académica de Enfermería, Tepic, Nayarit,

México

Universidad Autónoma de Nuevo León, Facultad de Enfermería, Monterrey, Nuevo León,

México

*Corresponding author: Rosalva del Carmen Barbosa-Martínez. Universidad Autónoma de

Nuevo León, Facultad de Enfermería, Monterrey, Nuevo León, México.

rosalva.barbos[email protected]u.mx

Sent: 11/23/2023 Accepted: 03/21/2024 Published: 09/13/2024

Abstract. - Introduction: The aim of this systematic review was to synthesize the available

behavioral interventions that have proven effective in promoting safe sexual behavior and

the prevention of STIs, including HIV, in women who have experienced some form of

violence. It describes some of the characteristics of these interventions and their impact on

behavior modification. Method: Interventions published from January 1995 to January 2020,

indexed in JCR, were included. A systematic review was conducted of the scientific literature

included in the databases EBSCO Academic Search Complete, CINAHL, MEDLINE/PubMed,

Springer, Web of Science, Elsevier, Dialnet, SciELO, and Google Scholar. The PRISMA

statement recommendations and the steps proposed by Holly et al. were followed.

Interventions were selected according to the proposed inclusion criteria, and the analyses

were synthesized narratively, with the results tabulated. Results: Five intervention studies

met the established inclusion criteria, all of which were randomized controlled trials. These

interventions comprised between one and eight sessions in either individual or group

formats, with a duration ranging from ten to 250 minutes. The results showed effectiveness

in maintaining safer sexual behavior with condom use. Conclusions: Behavioral

interventions for STI prevention and the maintenance of safe sexual behavior in women

highlight the opportunity to guide research on intimate partner violence and STI prevention,

thereby reducing gender-related health disparities.

Keywords: Intimate Partner Violence, Systematic Review, Sexually Transmitted Diseases,

Sex Education, Sexual Behavior, Woman.

Horizon Interdisciplinary Journal (HIJ). ISSN: 2992-7706

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1. Introduction

Intimate partner violence (IPV) and

sexually transmitted infections (STIs) are

two public health issues that affect women

worldwide. IPV refers to any pattern of

behavior used by a partner to maintain

power and control over the other person

in an intimate relationship¹. Currently, IPV

occurs in one out of every three women

globally

1,2

. This violence can be physical,

psychological, economic, patrimonial,

and/or sexual

3-5

, leaving severe

consequences not only on physical and

mental health

5,6

but also increasing the risk

of contracting STIs and even being

associated with premature death.

According to the World Health

Organization (WHO)

, Borumandnia

, and

Goga

, violence against women is an

endemic phenomenon that saw a worrying

increase during the COVID-19 pandemic

due to confinement and the suspension of

certain support services. In Mexico, 70.1%

of women have experienced some form of

violence, which saw a substantial rise

during the pandemic confinement, from

7,723 cases in 2016 to 10,579 cases in 2021

Although IPV can be experienced by both

men and women, it has been documented

that women suffer from it in a higher

proportion¹²⁻¹⁴. The reported figures are

generally lower than the actual numbers,

as it has been shown that women do not

report every instance of violence and may

not even recognize it as such. Additionally,

they face difficulties in accessing health

services

15-18

Women exposed to IPV not only face an

increased risk of acquiring STIs but also of

unintended pregnancies and/or repeated

abortions

. The unequal power dynamics

in abusive relationships often make it

difficult for women to negotiate the use of

contraceptives and protective

mechanisms, such as condoms, making the

challenge of addressing STIs a global issue.

Women who suffer from IPV are in an

especially vulnerable group. In this

context, various interventions have been

developed to address this problem and

reduce the risk of STI transmission in this

population.

Although IPV is not gender-exclusive,

most efforts have concentrated on

violence against women

20-21

. According to

Basile²², interventions need to focus on

female empowerment to increase their

opportunities in economic, educational,

and employment aspects. In the same vein,

Campbell

23-26

refers to multiple

interventions aimed at mitigating the

adverse consequences and reducing the

harm suffered by women who have

experienced violence. Thus, various

approaches have been proposed to

address this issue, including awareness

campaigns and specific interventions,

encompassing diverse strategies to

prevent STIs and Human

Immunodeficiency Virus (HIV) in this

vulnerable group. These strategies range

from sexual health education, access to

health services, and psychological and

social support. Despite the potential

benefits of these interventions, significant

challenges remain, such as confidentiality,

safety, and adequate training of health

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professionals, which are critical aspects

that must be managed to ensure the

effectiveness of any prevention program in

this context.

Part of the problem lies in the fact that as

long as people engage in risky sexual

behaviors, there is a likelihood of STI

transmission, including HIV, which not

only affects physical health but also

impacts life projects, financial situations,

and social relationships

27-29

. Today, society

considers sexual health a taboo topic,

especially when it comes to women. This

stigma has severe consequences, as it even

renders these issues invisible

, and

suppresses women from seeking help

when they experience STI symptoms

which can lead to chronic or even fatal

problems.

In other words, the shame women often

feel is usually a consequence of cultural

norms and inadequate sexual education,

leading many women to self-medicate or

ignore symptoms, resulting in delayed

diagnosis and treatment of STIs, which

increases the risk of severe complications

such as infertility, pelvic inflammatory

disease, and/or cancer in cases of

untreated STIs.

It is essential that women feel empowered

to take care of their sexual health,

including regular self-examinations and

seeking professional help. The National

Women’s Health Network³¹ points out that

a significant percentage of women have

never performed a self-examination, as

any act related to sexuality or

autoeroticism is considered masculine.

Some researchers recommend

incorporating the concept of

empowerment into the development of

interventions³²⁻³⁴. Campbell

mentions

that multiple interventions are directed at

reducing the harm women have suffered

due to IPV. On the other hand, evidence

has been documented evaluating

interventions for STI/HIV prevention,

which focus on reducing risky sexual

behaviors that may be associated with

drug use. However, there is little evidence

documenting the effectiveness of

interventions aimed at reducing risky

sexual behaviors (RSB) in specific

situations like IPV.

Scientific evidence has demonstrated the

coexistence of STIs/HIV and IPV.

Therefore, due to its incidence, more

efforts should be focused on prevention,

and it is considered crucial that public

health centers on improving women’s

health conditions, increasing

comprehensive sexual education,

including the prevention of STIs linked to

violence

35,36

Due to the vulnerability experienced by

women who suffer IPV and the

consequences on their sexual and

reproductive health compared to women

who do not, there is an incentive for

professionals and the health system to

adapt to these current needs where

violence has been on the rise. It is crucial

to identify interventions that promote

health and preserve the protective factors

observed in women who are victims of

violence. Therefore, the objective of this

systematic review was to analyze the

Horizon Interdisciplinary Journal (HIJ). ISSN: 2992-7706

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available interventions to prevent

STIs/HIV in young adult women who

experience IPV.

2. Method

This systematic review was developed

using the PRISMA method

, homogenizing

existing national and international

information to achieve an adequate

approach to the variables, and following

the steps proposed by Holly

, which are

described below:

2.1 Eligibility Criteria

The inclusion criteria for this systematic

review were as follows: 1) descriptors

included in the title and abstract, 2) full-

text studies, 3) studies with the objective

of preventing STIs/HIV and violence, 4)

randomized controlled trial (RCT) design,

5) studies with a comparison group, 6)

studies with follow-up results, 7) studies

specifically for the female gender, 8)

studies involving women aged 18 to 40

years, studies in English, Portuguese, or

Spanish, 9) publications from 1995 to

January 2020, 10) studies reporting

behavior modification in the results, 11)

studies describing the intervention.

2.2 Search Strategy and Study Selection

The search was conducted in the following

databases: EBSCO Academic Search

Complete, CINAHL, MEDLINE/PubMed,

Springer, Web of Science, Elsevier,

Dialnet, SciELO, and Google Scholar. The

descriptors integrated into the Medical

Subject Headings (MeSH) and Health

Sciences Descriptors (DeCS) were used,

along with Boolean operators, making

combinations with the following

descriptors: "Sexual education" OR

"Educational Program" OR "Brief

Intervention," OR "Behavioral

Intervention" AND "Partner Violence" OR

"Dating Abuse" OR "Dating Violence" OR

"Couple Violence" AND "Condom

Negotiation" OR "Safe Sex" OR "Safer Sex."

Additionally, gender and age filters were

applied.

A reference manager was used to organize

the located references and eliminate

duplicate studies. After concluding the

identification phase of the studies, a

screening of the data was performed by

title and abstract, selecting only the

articles that adhered to the inclusion

criteria. The identified articles were

evaluated following the recommendations

of the PRISMA guidelines, and the

evaluation of the methodological quality of

the studies was complemented by the

Joanna Briggs Institute's critical appraisal

checklist for studies and prevalence,

emphasizing the study's objective, applied

methodology, research design, and results

of the intervention's effectiveness.

Subsequently, the authors reviewed the

titles and abstracts of each reference to

verify that each abstract met the inclusion

criteria, and articles that did not describe

the intervention for preventing STIs/HIV

in women were eliminated. Furthermore,

the methods/methodology and results

sections were read to verify adherence to

the eligibility criteria. A full reading was

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conducted for each of the interventions

that met each inclusion criterion.

Independent coding and extraction of the

studies included in the systematic review

were carried out, followed by a

comparison by each author to achieve

greater accuracy and avoid discrepancies

in criteria. Characteristics such as the

origin of the study, application location,

study design, follow-up, intervention

modality, sample size, number of sessions,

intervention duration, primary and

secondary outcomes related to the risk of

STI/HIV transmission, acceptability,

feasibility, and fidelity of the studies were

analyzed.

The methodological quality of the articles

was evaluated using the MINCIR

checklist

, which includes the assessment

of three domains: Domain 1: study design;

Domain 2: population studied with

justification factor; Domain 3:

methodology used (objective, design,

selection criteria, and sample size). The

protocol for this review was registered in

PROSPERO (547838).

3. Results

From the included studies, identification

information such as the authors' names,

year and country where the study was

conducted, study design, sample size, and

characteristics of post-intervention

measurements were extracted. Finally, an

analysis, integration, and interpretation of

the intervention studies aimed at

preventing STIs/HIV and managing safe

sexual behavior in women exposed to

violence was carried out. Figure 1 shows

the search results, the exclusion criteria

for intervention studies using the PRISMA

methodology.

During the initial search, 2,753 potentially

relevant citations were identified, with

1,432 duplicate citations being removed

due to systematic search criteria. This

resulted in 1,321 abstracts that were

independently selected.

A total of 1,253 citations were excluded for

not meeting the inclusion criteria, leaving

68 full-text articles that underwent a more

detailed review. Finally, 14 studies met the

inclusion criteria. These 14 were further

reduced to five articles because not all the

characteristics of the intervention

implementation were found in the analysis

of the descriptions (Figure 1).

Horizon Interdisciplinary Journal (HIJ). ISSN: 2992-7706

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Figure 1. Flow chart for STI prevention interventions for women with intimate partner

violence.

Regarding the methodological quality of

the intervention studies, 100% (n=5)

obtained an acceptable quality score

according to the MINCIR scale (Table 1),

with a score above 18 points being

considered acceptable.

Table 1 presents the five selected studies,

of which four were conducted in the

United States

39-42

and one in Latin

America⁴³; all studies were randomized

controlled trials.

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Table 1. Description of intervention programs.

Author

Delivery

Sessions

Main component

Months

Follow-

Primary results

MINCIR

Score

Mittal

I - G

Safe sex/condom use

negotiation.

Direct STI/HIV risk, Episodes of

unprotected SR, STI knowledge, Safer sex

intention, Condom use self-efficacy

negotiation skills.

26*

Meléndez

4 or 8

Communication and

empowerment.

1, 6, 12

Direct STI/HIV risk, Episodes of

unprotected SR, Intention of safe sex,

Comfort in communication, Self-efficacy of

condom use.

31*

Wingood

I - G

Risk, vulnerability.

6 y 12

Consistent use of condoms, HIV and STI

reduction, STI/HIV knowledge.

35*

Villegas

Self-efficacy.

STI/HIV knowledge, Attitude towards

condom use, Self-efficacy for STI/HIV

prevention, Vulnerability, Internet use,

Internet use, Internet use, Internet use,

Internet use, Condom use.

Vulnerability, Internet use.

23*

Jemmott

Self-efficacy, SR negotiation

and condom use, Assertive

Sexual Communication, Sexual

Empowerment

3, 6, 12

STI/HIV risk reduction, Drug use reduction,

Self-efficacy, Consistent condom use

episodes, Condom use negotiation skills.

35*

Note: I = Individual, G= Group. SR= Sexual Relationship, STI= Sexually Transmitted Infection, HIV = Human Immunodeficiency

Virus.

* Adequate methodological quality according to MINCIR scale (adequate = 18 points).

Below is a description of the identified interventions, with an analysis of each one based on

the aforementioned inclusion criteria.

Mittal

presents the results of an

intervention focused on reducing HIV

risks for women with a history of intimate

partner violence. This intervention proved

promising in addressing the vulnerability

of women to violence and STIs, providing

a comprehensive approach to women's

sexual and emotional health. The

intervention was conducted both

individually and in groups across 8

sessions. Three individual sessions (1, 3,

and 4) focused on psychoeducation

regarding relationships, resilience, and

empowerment; the remaining five

sessions addressed activities centered on

STIs/HIV, gender violence, self-

protection, and healthy living. The

intervention showed efficacy at three

months in maintaining safe sexual

behavior, communication skills, and

condom use skills, as well as reducing

anxiety and depression.

Meléndez⁴¹ highlights the importance of

negotiating safe sexual practices in the

context of intimate partner violence. This

intervention was applied in two dosage

levels: one group received 4 sessions and

the other 8 sessions, covering STI

knowledge, motivation, attitudes, beliefs,

Horizon Interdisciplinary Journal (HIJ). ISSN: 2992-7706

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and condom use skills. The intervention

demonstrated efficacy in maintaining safe

sexual behavior with condom use and

increasing self-efficacy in communication

up to 12 months post-intervention.

Wingood⁴² conducted the AMIGAS

intervention, an adaptation of the SiSTA

intervention, designed to reduce

behaviors that increase the risk of HIV and

STI transmission among women living

with HIV. The intervention was conducted

over a total of 8 sessions, with three

individual sessions and five group

sessions, incorporating mindfulness

meditation exercises and addressing

topics such as HIV/STI knowledge,

communication skills, condom use, and

healthy relationships. The results showed

a decrease in STI incidence, improved

condom use skills, and maintenance of

protected sex up to 12 months post-

intervention.

Villegas⁴⁴ emphasizes the importance of

considering psychosocial and gender

factors in the design of interventions for

STI prevention in women experiencing

intimate partner violence. This

comprehensive approach acknowledges

the intersectionality of these women's

experiences and the need for strategies

sensitive to their particular contexts. The

intervention was conducted in small

groups of 8-10 women, covering topics

such as STIs, HIV prevention, negotiation

knowledge, couple communication,

violence prevention and control, in

participatory sessions that included

videos, role-playing, and discussions to

develop self-efficacy and communication

skills. A follow-up was conducted at 3

months, reporting an increase in

knowledge levels, positive attitudes

towards reducing stigmatization,

improvement in negotiation and

communication skills, and a reduction in

risky sexual behaviors.

Jemmott⁴³ has emphasized the relevance

of behavior theory-based interventions

that seek to modify risky behaviors

through education, motivation, and the

strengthening of negotiation skills in the

context of intimate relationships. This

perspective focuses on empowering

women to make informed decisions about

their sexual and reproductive health.

The Sister to Sister intervention

demonstrated efficacy in young women

for maintaining safe sexual behavior and

reducing STI incidence. It is a brief

intervention involving group discussions,

videos, games, and exercises for STI/HIV

reduction, development of correct

condom use skills, and sexual relationship

negotiation skills. The intervention is

conducted in a group setting in a single

session. It showed efficacy in reducing

risky behaviors, decreasing STI

prevalence, and reducing alcohol and drug

use during sex, with results persisting at 3,

6, and 12 months follow-up.

4. Discussion

In this systematic review, five STI/HIV

prevention interventions specifically

tested in young women experiencing

intimate partner violence were identified.

Four of these were implemented in the

United States

40-43

and one in Latin

America

Globally, the existing literature recognizes

the magnitude of the problem

. However,

while there are studies addressing the

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problem and prevention of HIV, there are

few interventions that have been carried

out in women who have experienced

violence. Therefore, the effects of

interventions on women who live or have

lived through intimate partner violence

are unclear, as there are undoubtedly

variables that influence this population

group and affect their behavior regarding

STI/HIV prevention. Women who suffer

intimate partner violence face unique

challenges in negotiating safe sexual

practices and preventing STIs.

Adolescence is considered a vulnerable

and at-risk population group, which is why

most studies are conducted in this group.

However, there are very few studies

directed at adult women. In this sense, it is

important to recognize that women

experiencing intimate partner violence are

also a vulnerable group in terms of

STI/HIV transmission due to the

characteristics that influence their

decision-making.

Systematic reviews have been conducted

focusing on HIV prevention, especially in

adolescent populations

21,44,45

; however,

there are few interventions that aim to

prevent STIs in women and in early

adulthood

47-50

, resulting in limited

evidence on STI prevention in this

population.

Most of the reviewed articles used

different theoretical frameworks to

support the design and implementation of

the intervention, with the most commonly

used being the following: Bandura's Social

Cognitive Theory

, Ajzen's Theory of

Planned Behavior

, and Fisher's

Information-Motivation-Behavioral Skills

(IMB) model

53,54

The focal points identified in the articles

were: empowerment, self-esteem,

barriers to condom use, self-efficacy,

negotiation skills, and communication

skills. In addition, the study by Villegas⁴⁴

included gender roles, machismo, and

feminism, while Mittal

reinforced the

psychoeducational aspect of family and

couple relationships. Most interventions

combined two or more of these focal

points.

The approaches of the interventions were

group-based in all five reviewed articles

40-

, with two also including individual

sessions

40,42

. It can be deduced that group

sessions are more effective, primarily due

to the feedback provided among the

participants.

The duration of the sessions in the

identified interventions varied

significantly, ranging from 10 to 250

minutes. It is considered that, in the case

of women with multiple responsibilities

such as household chores, childcare, work

outside the home, among other activities,

it is preferable to have shorter sessions to

maintain their attention and prevent

participant dropout.

The environmental context of the

interventions was similar across all five

articles; all were conducted in community

clinics, and based on the mentioned

descriptions, there was geographic

diversity. Four studies were developed in

the United States

40-43

, and only one in

South America, specifically in Chile⁴⁴. The

majority of the participants were African

American and Latina women.

The identified interventions were mainly

based on individual behavior change

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mechanisms to reduce the prevalence of

STIs/HIV, seeking to address the factors

that drive vulnerability to STIs/HIV. The

studies by Mittal

and Jemmott⁴³

emphasize the importance of promoting

behavior modification from a risk

reduction perspective.

All the selected interventions reported

positive outcomes for the participants. For

instance, Jemmott⁴³, Wingood⁴², and

Mittal

developed skills for correct

condom use and communication skills

with partners, achieving successful

condom negotiation and a reduction in STI

prevalence. Additionally, Meléndez⁴¹

confirmed that the two-level program is

considered effective based on participant

feedback.

Jemmott's study⁴² highlights the

fundamental role of negotiation self-

efficacy in maintaining protected sexual

relations. The life skills training improved

self-efficacy, self-esteem, and sexual

negotiation

41,42

, STI/HIV testing

40,42

, and

reduced risky sexual behaviors

40-43

Improved communication skills may have

mitigated intimate partner violence

40,42

which could lead to sexual empowerment.

The enhancement of skills may sustain

post-intervention outcomes. The

improvement in self-esteem, sexual

negotiation self-efficacy, and condom use

continued to maintain safe and protected

sexual behaviors even two years after the

completion of the programs⁴¹.

5. Conclusions

This systematic review on STI and intimate

partner violence prevention has shed light

on the need to implement comprehensive

interventions that address not only the

prevention of STIs/HIV but also intimate

partner violence and the structural

barriers that contribute to their

persistence.

It is crucial to recognize that STI

prevention goes beyond the promotion of

condom use. While this method is

effective, interventions need to be broader

and consider factors such as sexual

education, access to healthcare services,

gender equity, and the empowerment of

individuals to make informed decisions

about their sexual health.

Intimate partner violence is a public health

issue closely related to STIs. Individuals

experiencing intimate partner violence are

at greater risk of contracting STIs due to a

lack of control over their sexual and

reproductive health, as well as the

difficulty in negotiating safe sexual

practices. Therefore, interventions that

address intimate partner violence not only

improve the emotional and physical health

of individuals but also contribute to STI

prevention.

It is essential to consider the structural

barriers that hinder access to sexual and

reproductive health services. The

literature indicates that these barriers

must be addressed for a better

understanding of the phenomenon under

study. In this case, factors such as

stigmatization, discrimination, lack of

economic resources, and lack of education

can limit individuals' ability to seek

medical care or adopt safe sexual

practices. These barriers should be

addressed by communities, institutions,

and governments to ensure that everyone

has access to quality healthcare services.

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The results of this review correlate with

the study's limitations. It was previously

noted that only one study was located in

the Latin American context, which is

concerning as violence and STIs/HIV are

global factors.

6. Declarations

6.1 Author Contributions

IPVC: Conceptualization, methodology,

formal analysis, research, original draft

writing, formal analysis, data curation.

RCBM: Conceptualization, methodology

validation, formal analysis, writing: review

and editing, supervision, visualization,

formal analysis, data curation, project

management.

RABT: Writing: review and editing,

visualization, formal analysis, data

curation.

YFP: Visualization, supervision, review.

6.2 Conflict of Interest

The authors declare that they have no

conflicts of interest.

6.3 Acknowledgments

The authors express their gratitude for the

support received from the Graduate

Studies Department of the Faculty of

Nursing at the Autonomous University of

Nuevo León, for the facilities provided for

the completion of this systematic review.

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Alicia Benavides Torres and Yolanda Flores Peña

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