Article type
Year
Abstract
Background: The STD and HIV epidemics are interdependent. Similar behaviors, such as frequent unprotected intercourse with different partners, increase risk for both, and there is clear evidence that certain bacterial and viral STDs increase the likelihood of HIV transmission. To determine the impact of STD prevention on the incidence of HIV infection, we conducted a systematic review of randomised controlled trials of population-level STD interventions. Potential interventions included campaigns to promote safer sexual behavior and better STD treatment-seeking behavior, improved STD treatment services, integration of STD case finding in family planning and antenatal care services, STD screening programs and mass treatment of whole communities for STDs.
Methods: We searched MEDLINE, CDSR, DARE and EMBase for relevant randomised controlled trials in which the unit of randomisation was either a community or a treatment facility. We also searched abstracts of relevant conferences and scanned reference lists of review articles and primary studies. Authors of included trials and other experts in the field were also contacted. Outcome variables included frequency of HIV infection, frequency of STDs, quality of STD treatment, treatment-seeking behavior, utilization of STD services and safer sexual behavior. Trials identified as randomized controlled clinical trials were examined for completeness of reporting. We assessed the methodological quality of each trial and recorded details of allocation method, blinding, use of intention-to-treat analysis and patients lost to follow-up.
Results: We identified four studies that met our inclusion criteria, two that measured HIV and STD incidence and two that measured improvements in STD treatment-seeking and quality of care. The two that directly measured HIV incidence were conducted in communities in Africa and involved improved provision of STD diagnostic and treatment services (Mwanza, Tanzania) and mass STD treatment (Rakai, Uganda). Their results differed substantially; the Mwanza intervention showed substantial benefit (RR 0.62, 95% CI 0.44-0.88), but the Rakai intervention had no effect (RR 1.03, 95% CI 0.77-1.37). When pooled the interventions did not decrease incidence of HIV (RR 0.84, 95% CI 0.67-1.04), gonorrhea or chlamydia but were associated with decreases in syphilis (RR 0.77, 95% CI, 0.69-0.77). In the Rakai study, where they were measured, decreases were also seen in trichomoniasis and bacterial vaginosis. The other two interventions were directed at pharmacists (Lima, Peru) and primary health care clinic staff (Hlabisa, South Africa). In these studies there were also divergent results with only 2/172 patients in Lima (NS) but 42/48 in Hlabisa (RR 0.18, 95% CI 0.08-0.42) being correctly treated. In the Hlabisa study there were improvements in the numbers of patients given partner-notification cards and condoms and in both studies improvements in numbers of patients counseled (RR 0.52, 95% CI 0.35-0.77).
Conclusions: Population-based STD interventions may be associated with a slightly decrease incidence of HIV. However, given the very different interventions employed and the divergent results in the Mwanza and Rakai studies, a combined quantitative estimate of efficacy may not be possible. The studies do suggest, however, that population-level STD interventions can improve quality of some STD services and are associated with decreases in some STDs.
Methods: We searched MEDLINE, CDSR, DARE and EMBase for relevant randomised controlled trials in which the unit of randomisation was either a community or a treatment facility. We also searched abstracts of relevant conferences and scanned reference lists of review articles and primary studies. Authors of included trials and other experts in the field were also contacted. Outcome variables included frequency of HIV infection, frequency of STDs, quality of STD treatment, treatment-seeking behavior, utilization of STD services and safer sexual behavior. Trials identified as randomized controlled clinical trials were examined for completeness of reporting. We assessed the methodological quality of each trial and recorded details of allocation method, blinding, use of intention-to-treat analysis and patients lost to follow-up.
Results: We identified four studies that met our inclusion criteria, two that measured HIV and STD incidence and two that measured improvements in STD treatment-seeking and quality of care. The two that directly measured HIV incidence were conducted in communities in Africa and involved improved provision of STD diagnostic and treatment services (Mwanza, Tanzania) and mass STD treatment (Rakai, Uganda). Their results differed substantially; the Mwanza intervention showed substantial benefit (RR 0.62, 95% CI 0.44-0.88), but the Rakai intervention had no effect (RR 1.03, 95% CI 0.77-1.37). When pooled the interventions did not decrease incidence of HIV (RR 0.84, 95% CI 0.67-1.04), gonorrhea or chlamydia but were associated with decreases in syphilis (RR 0.77, 95% CI, 0.69-0.77). In the Rakai study, where they were measured, decreases were also seen in trichomoniasis and bacterial vaginosis. The other two interventions were directed at pharmacists (Lima, Peru) and primary health care clinic staff (Hlabisa, South Africa). In these studies there were also divergent results with only 2/172 patients in Lima (NS) but 42/48 in Hlabisa (RR 0.18, 95% CI 0.08-0.42) being correctly treated. In the Hlabisa study there were improvements in the numbers of patients given partner-notification cards and condoms and in both studies improvements in numbers of patients counseled (RR 0.52, 95% CI 0.35-0.77).
Conclusions: Population-based STD interventions may be associated with a slightly decrease incidence of HIV. However, given the very different interventions employed and the divergent results in the Mwanza and Rakai studies, a combined quantitative estimate of efficacy may not be possible. The studies do suggest, however, that population-level STD interventions can improve quality of some STD services and are associated with decreases in some STDs.