Elsevier

The Lancet

Volume 361, Issue 9358, 22 February 2003, Pages 645-652
The Lancet

Articles
Syndromic management of sexually-transmitted infections and behaviour change interventions on transmission of HIV-1 in rural Uganda: a community randomised trial

https://doi.org/10.1016/S0140-6736(03)12598-6Get rights and content

Summary

Background

Treatment of sexually-transmitted infections (STIs) and behavioural interventions are the main methods to prevent HIV in developing countries. We aimed to assess the effect of these interventions on incidence of HIV-1 and other sexually-transmitted infections.

Methods

We randomly allocated all adults living in 18 communities in rural Uganda to receive behavioural interventions alone (group A), behavioural and STI interventions (group B), or routine government health services and community development activities (group C). The primary outcome was HIV-1 incidence. Secondary outcomes were incidence of herpes simplex virus type 2 (HSV2) and active syphilis and prevalence of gonorrhoea, chlamydia, reported genital ulcers, reported genital discharge, and markers of behavioural change. Analysis was per protocol.

Findings

Compared with group C, the incidence rate ratio of HIV-1 was 0·94 (0·60–1·45, p=0·72) in group A and 1·00 (0·63–1·58, p=0·98) in group B, and the prevalence ratio of use of condoms with last casual partner was 1·12 (95% CI 0·99–1·25) in group A and 1·27 (1·02–1·56) in group B. Incidence of HSV2 was lower in group A than in group C (incidence rate ratio 0·65, 0·53–0·80) and incidence of active syphilis for high rapid plasma reagent test titre and prevalence of gonorrhoea were both lower in group B than in group C (active syphilis incidence rate ratio, 0·52, 0·27–0·98; gonorrhoea prevalence ratio, 0·25, 0·10–0·64).

Interpretation

The interventions we used were insufficient to reduce HIV-1 incidence in rural Uganda, where secular changes are occurring. More effective STI and behavioural interventions need to be developed for HIV control in mature epidemics.

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.

Section snippets

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

References (27)

  • OakleyA et al.

    Behavioural interventions for HIV/AIDS prevention

    AIDS

    (1995)
  • KatzensteinD et al.
  • MoemaS et al.
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