Population-based interventions for reducing HIV infection

Ng BE, Butler LM, Horvath T, Rutherford GW

Published Online:

March 16, 2011

Community- or population-based sexually transmitted infection control does not appear to be an effective HIV prevention strategy in most settings. In the early 1990s, improved STI treatment services were shown to reduce HIV incidence in northern Tanzania, in an environment characterised by an emerging HIV epidemic, where STI treatment services were poor and where STIs were highly prevalent. Subsequent trials, however, failed to confirm these findings and also failed to show a substantial benefit for community-wide presumptive treatment for STIs. This is likely due to the endemic nature of HIV and relatively low incidence of STIs in these populations. There are, however, other good reasons as to why STI treatment services should be strengthened and the available evidence suggests that when an intervention is applied and accepted in a community, it can improve the quality of services provided. The trial in Masaka District, Uganda showed an increase in the use of condoms, a marker for less risky sexual behaviours, although a newer study by Gregson conducted in Zimbabwe suggested no effect. With the last three trials having shown disappointing results with respect to HIV prevention, it is unlikely that further community trials will be conducted, let alone yield different results. Future trials of biomedical interventions that involve individual randomisation, however, may represent an opportunity to reexamine presumptive treatment of STIs. Such trials should also aim to measure a range of factors that include health-seeking behaviour and quality of treatment, as well as HIV, STI and other biological endpoints.

Abstract (click to read)

Background:

The transmission of sexually transmitted infections (STIs) is closely related to the sexual transmission of human immunodeficiency virus (HIV). Similar risk behaviours, such as frequent unprotected intercourse with different partners, place people at high risk of HIV and STIs, and there is clear evidence that many STIs increase the likelihood of HIV transmission. STI control, especially at the population or community level, may have the potential to contribute substantially to HIV prevention.

This is an update of an existing Cochrane review. The review's search methods were updated and its inclusion and exclusion criteria modified so that the focus would be on one well-defined outcome. This review now focuses explicitly on population-based biomedical interventions for STI control, with change in HIV incidence being an outcome necessary for a study's inclusion.

Objectives:

To determine the impact of population-based biomedical STI interventions on the incidence of HIV infection.

Search strategy:

We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science/Social Science, PsycINFO, and Literatura Latino Americana e do Caribe em Ciências da Saúde (LILACS), for the period of 1 January1980 - 16 August 2010. We initially identified 6003 articles and abstracts. After removing 776 duplicates, one author (TH) removed an additional 3268 citations that were clearly irrelevant. Rigorously applying the inclusion criteria, three authors then independently screened the remaining 1959 citations and abstracts. Forty-six articles were chosen for full-text scrutiny by two authors. Ultimately, four studies were included in the review.

We also searched the Aegis database of conference abstracts, which includes the Conference on Retroviruses and Opportunistic Infections (CROI), the International AIDS Conference (IAC), and International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS) meetings from their inception dates (1993, 1985 and 2001, respectively) through 2007. We manually searched the web sites of those conferences for more recent abstracts (up to 2010, 2010 and 2009, respectively)

In addition to searching the clinical trials registry at the US National Institutes of Health, we also used the metaRegister of Controlled Trials.

We checked the reference lists of all studies identified by the above methods.

Selection criteria:

Randomised controlled trials involving one or more biomedical interventions in general populations (as opposed to occupationally or behaviourally defined groups, such as sex workers) in which the unit of randomisation was either a community or a treatment facility and in which the primary outcome was incident HIV infection. The term "community" was interpreted to include a group of villages, an arbitrary geographical division, or the catchment population of a group of health facilities.

Data collection and analysis:

Three authors (BN, LB, TH) independently applied the inclusion criteria to potential studies, with any disagreements resolved by discussion. Trials were examined for completeness of reporting. Data were abstracted independently using a standardised abstraction form.

Main results:

We included four trials. One trial evaluated mass treatment of all individuals in a particular community. The other three trials evaluated various combinations of improved syndromic STI management in clinics, STI counselling, and STI treatment.

In the mass treatment trial in rural southwestern Uganda, after three rounds of treatment of all community members for STIs, the adjusted rate ratio (aRR) of incident HIV infection was 0.97 (95% CI 0.81 - 1.2), indicating no effect of the intervention. The three STI management intervention studies were all conducted in rural parts of Africa. One study, in northern Tanzania, showed that the incidence of HIV infection in the intervention groups (strengthened syndromic management of STIs in primary care clinics) was 1.2% compared with 1.9% in the control groups (aRR = 0.58, 95% CI 0.42 - 0.79), corresponding to a 42% reduction (95% CI 21.0% - 58.0%) in HIV incidence in the intervention group. Another study, conducted in rural southwestern Uganda, showed that the aRR of behavioural intervention and STI management compared to control on HIV incidence was 1.00 (95% CI 0.63 - 1.58). In the third STI management trial, in eastern Zimbabwe, there was no effect of the intervention on HIV incidence (aRR = 1.3, 95% CI 0.92 - 1.8). These are consistent with data from the mass treatment trial showing no intervention effect. Overall, pooling the data of the four studies showed no significant effect of any intervention (rate ratio [RR] = 0.97, 95% CI 0.78 - 1.2).

Combining the mass treatment trial and one of the STI management trials, we find that there is a significant 12.0% reduction in the prevalence of syphilis for those receiving a biomedical STI intervention (RR 0.88, 95% CI 0.80 - 0.96). For gonorrhoea, we find a statistically significant 51.0% reduction in its prevalence in those receiving any of these interventions (RR 0.49, 95% CI 0.31 - 0.77). Finally, for chlamydia, we found no significant difference between any biomedical intervention and control (RR 1.03, 95% CI 0.77 - 1.4).

Authors' conclusions:

We failed to confirm the hypothesis that STI control is an effective HIV prevention strategy. Improved STI treatment services were shown in one study to reduce HIV incidence in an environment characterised by an emerging HIV epidemic (low and slowly rising prevalence), where STI treatment services were poor and where STIs were highly prevalent; Incidence was not reduced in two other settings. There is no evidence for substantial benefit from a presumptive treatment intervention for all community members. There are, however, other compelling reasons why STI treatment services should be strengthened, and the available evidence suggests that when an intervention is accepted it can substantially improve quality of services provided.

This record should be cited as:

Ng BE, Butler LM, Horvath T, Rutherford GW. Population-based biomedical sexually transmitted infection control interventions for reducing HIV infection. Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No.: CD001220. DOI: 10.1002/14651858.CD001220.pub3

Assessed as up to date:

February 15, 2011

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Primary Review Group:

HIV/AIDS Group

Health topics:

Gynaecology > Sexually transmitted disease > Preventing transmission

Infectious disease > HIV/AIDS > Prevention: behavioural/social/policy

Infectious disease > Sexually transmitted disease > Preventing transmission

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Population-based interventions for reducing HIV infection

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