Treatment of sexually transmitted infections (STIs) and behavioural interventions are the main methods to prevent HIV in developing countries. Anatoli Kamali from the Medical Research Council Programme on AIDS in Uganda and colleagues assessed the effect of behaviour change and STI management on the incidence of HIV-1 and other STIs in Uganda.
All adults living in 18 communities in rural Uganda were randomly allocated into three groups: the first group received behavioural interventions alone (promotion of safer sex behaviour); the second group received both behavioural and STI interventions; the third was a control group where individuals received routine government health services and community development activities.
Follow-up took place after three and a half to four years. Only condom use with last casual partner increased significantly more in the two intervention groups compared with the control group. Despite significant reductions in acute syphilis, gonorrhoea, and unprotected casual sex in the combined intervention group, there was no effect on HIV incidence attributable to either intervention. The investigators comment that more effective STI and behavioural interventions need to be developed for HIV control in mature epidemics in countries like Uganda.
Judith Stephenson and Frances Cowan from the Royal Free and University College Medical School, London, UK, observe in an accompanying Commentary (p 633) that the timing of the study could partly explain the surprising results; the fact that the overall HIV incidence is falling in Uganda suggests that the study could have been underpowered to detect substantial differences in HIV incidence between the intervention and control groups. They conclude: "What does this trial tell us for the future? Rigorous evaluation of promising interventions should be encouraged early on when HIV incidence is rising and high-risk groups are readily identifiable. It is vital to know which approaches actually work and which do not. The evaluation of complex behavioural interventions is challenging, but expertise in this area is accumulating. The development, piloting, and full-scale evaluation of promising interventions is essential to the success of HIV prevention and should receive greater priority."
Contact: Dr Anatoli Kamali, Medical Research Council Programme on AIDS in Uganda, Uganda Virus Research Institute, PO Box 49, Entebbe, Uganda; T)+256 41 320042; F)+256 41 321137; E) mrc@starcom.co.ug
Dr Judith Stephenson, Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, London WC1E 6AK, UK; T) F) E) jstephen@gum.ucl.ac.uk or Dr Frances Cowan; T) +263 9125 7949.
Journal
The Lancet