ArticlesSyndromic management of sexually-transmitted infections and behaviour change interventions on transmission of HIV-1 in rural Uganda: a community randomised trial
Introduction
The main methods of prevention against the pandemic of HIV-1 infection in sub-Saharan Africa are promotion of safer sexual behaviour and treatment of sexually transmitted infections (STIs).1, 2 Two community-based randomised trials assessing the effect of treatment for STIs have been reported. In Mwanza, Tanzania, syndromic management of STIs at government health units was associated with a 40% reduction in incidence of HIV-1,3 whereas in Rakai, Uganda, mass treatment of whole communities with antibiotics to cure STIs at 10-month intervals was not associated with any reduction in HIV-1 incidence.4 Various hypotheses have been put forward to explain these discrepant findings,5, 6 including differences between the two studies in the maturity of the epidemic, the patterns of STIs, and the effectiveness of the regimens assessed.
No community-based randomised controlled trials of sexual behaviour interventions using HIV incidence as an outcome measure have been reported from Africa,7, 8 although one inconclusive study9 has been done in factory workers in Zimbabwe and a study10 of gold miners is in progress in South Africa.
We postulated that unsafe sexual behaviour and acquisition of an STI were independent risk factors for HIV-1 infection.11 We aimed to ascertain whether behavioural interventions alone, or in combination with improved management of STIs, were effective in reducing incidence of HIV-1 and occurrence of other STIs in rural Uganda.
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Study population
Between 1994 and 2000, we investigated 18 rural communities each of which had a government health facility, in Masaka district, southwestern Uganda (figure 1), providing a total population of about 96 000 adults (aged 13 years or older).12 Communities were randomly allocated to receive information, education, and communication activities alone (group A), these activities with improved management of STIs (group B), or routine government health facilities with general community development
Results
20 516 adults were censused as resident at baseline survey, 21 587 at round 2, and 14 488 at round 3, with similar numbers in each group (figure 2). Of those censused, 14 554 (71%) provided blood samples at baseline, 15 614 (72%) at round 2, and 13 220 (91%) at round 3. In all groups combined, 54% received long questionnaires at baseline, 52% at round 2, and 48% at round 3. For all rounds, about 2% of those who provided blood samples refused to be interviewed. Of the eligible population at
Discussion
In this community-randomised trial in rural south-western Uganda, behavioural and STI interventions were associated with an increase in condom use with the last casual partner—a proxy measure for consistent condom use in high-risk encounters, and substantial reductions in incidence of active syphilis and prevalence of gonorrhoea. There was also evidence in group A of reduced incidence of HSV2—a proxy measure of unprotected sexual contact, and increased recognition of symptoms of STIs in group
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2020, International Journal of Infectious DiseasesCitation Excerpt :Potential biologic mechanisms that facilitate and activate HIV replication include alterations in the genital tract microbiome, localized inflammation, recruitment of CD4+ T-cells, monocytes, Langerhans’ cells, and increased levels of interleukin-10 (Abdool Karim et al., 2019; Cohen et al., 2019; Mwatelah et al., 2019). Whilst these findings provide strong biological plausibility for STI control as an effective HIV prevention strategy, clinical trial evidence has produced conflicting results (Grosskurth et al., 1995; Wawer et al., 1999; Kamali et al., 2003; Hayes et al., 2010; Torrone et al., 2018). The differences in trial design, robustness of the interventions, population characteristics, stage of the HIV epidemic at the time of the study and baseline prevalence of STIs may have contributed to these mixed results (Stillwaggon and Sawers, 2015), but nonetheless, treatment of STIs remains a public health priority (Hayes et al., 2010; Cohen, 2012; Stillwaggon and Sawers, 2015).
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