Evaluation of behavioural interventions in HIV/STI prevention

Correlates of prevalent sexually transmitted infections among participants screened for an HIV incidence cohort study in Kisumu, Kenya

We determined the prevalence of four sexually transmitted infections and the demographic and behavioural correlates associated with having one or more sexually transmitted infections among participants in an HIV incidence cohort study in Kisumu, western Kenya. Participants were enrolled from a convenience sample and underwent aetiologic sexually transmitted infection investigation. Demographic and behavioural information were collected and basic clinical evaluation performed. Multiple regression analysis was done to determine variables associated with having one or more sexually transmitted infections. We screened 846, 18- to 34-year-olds. One-third had at least one sexually transmitted infection with specific prevalence being: syphilis, 1.6%; gonorrhoea, 2.4%; herpes simplex virus type-2, 29.1%; chlamydia, 2.8%; and HIV, 14.8%. Odds of having any sexually transmitted infection were higher among participants who were women, were aged 20-24 or 30-34 years compared to 18-19 years, had secondary or lower education compared to tertiary education, were divorced, widowed or separated compared to singles, reported having unprotected sex compared to those who did not, reported previous sexually transmitted infection treatment, and tested HIV-positive. Multiple strategies are needed to address the overall high prevalence of sexually transmitted infections as well as the gender disparity found in this Kenyan population. Structural interventions may be beneficial in addressing educational and socio-economic barriers, and increasing the uptake of health-promoting practices.

A rapid assessment of community-wide HIV/STI intervention in China

BACKGROUND/OBJECTIVES

The key to HIV/STI control is community-wide intervention (CWI) which depends heavily on continuous monitoring and evaluation. Unfortunately, comprehensive CWI assessment methodology and reports are generally lacking. This study developed, applied, and evaluated a rapid tool for assessing CWI in China.

METHODS

A total of 120 county level respondents in charge of county-wide responses to HIV/STI throughout China were selected randomly and surveyed using a structured inventory consisting of three tiers of indicators developed via consensus group techniques. The respondents were asked to rate each of the indicators against a five grade (1-5) scale. 30 pairs of the same staff from within Anhui Province were surveyed to gauge inter-rater reliability.

RESULTS

Response rate for the nationwide survey was 85% and for inter-rater reliability survey, 90%. Correlation coefficients between the inter-rater ratings ranged from 0.68 to 0.95. The overall average rating of CWI in China was 2.85. Average ratings for the six first tier indicators, organisation and policy development, goals and objectives setting, project and action planning, resource exploitation, project and task implementation, and CWI evaluation were 2.87, 2.83, 2.67, 2.77, 3.26, and 2.71 respectively. Ratings derived for the 24 second tier indicators ranged from 2.1 to 3.86; while for the 96 third tier indicators, 1.90 to 4.40

CONCLUSIONS

The instrument developed proved to be reliable, useful, and easily applicable in common communities. Application of it in China revealed that a large gap exists between desired and actual CWI, and areas meriting particular attention include policy and incentives development, intervention planning and evaluation, and fund raising and utilisation.

Exploring the community response to a randomized controlled HIV/AIDS intervention trial in rural Uganda

Investigators need, both for ethical and methodological reasons, to consider the acceptability of their intervention to the study population. We explored the response to a community-based randomized controlled trial (RCT) of an HIV/AIDS behavioral change intervention in rural Uganda. The views of field-workers, trial community, nongovernment organization representatives, and religious leaders were explored via focus groups (13) and interviews (45). The results suggest that the components of the intervention valued by the community are not necessarily those prioritised by trial implementers. Specifically, prevention activities appear to be valued less than material assistance. Furthermore, universal acceptance of the trial is probably unattainable. For these reasons, sensitive mobilization, respect for community members and their appointed leaders, and ongoing communication is essential. We suggest that evaluations of process be regarded as essential to the conduct of community-based RCTs and highlight the need for appropriate evaluation indicators to facilitate this.

Balancing rigour and acceptability: the use of HIV incidence to evaluate a community-based randomised trial in rural Uganda

Recent debate about the evaluation of community based, HIV/AIDS behavioural interventions has focused on the appropriateness of the randomised controlled trial (RCT) design, and the difficulty of obtaining reliable outcome measures. A community based HIV AIDS behavioural change RCT, recently conducted in rural Uganda, used HIV incidence as the principal outcome measure. This paper examines the acceptability of the trial from the community perspective. It asks whether, in a rural African setting, it is possible to implement a scientifically rigorous evaluation without compromising acceptability of the trial to the community. Opinions of the trial held by community members working as trial field workers were collected by semi-structured interview (n = 37), and focus group discussions (4) Community opinions of the trial were ascertained through 10 focus groups. For both field workers and the community, the sero-survey was more salient than the intervention, and the source of many rumours and disputes. Despite intensive mobilisation and close monitoring of field workers, it was impossible to ensure the veracity of explanations about the survey at ground level, and to protect each individual from coercion. The community expected a reward in return on their blood. Although the introduction of incentives at the final survey round increased the acceptability of the trial, they not only created jealousies and tensions, but also led to expectations of greater rewards in future. We conclude that RCTs in poor, rural communities are feasible, but the challenges involved should not be underestimated. Obtaining community support for the trial, respecting established hierarchies, and close supervision of field workers are all essential, but even then, controversies should be anticipated. There is an urgent need for relevant guidelines to help researchers navigate the complex ethical issues involved.

Strategies for improving sexual health in ethnic minorities

In many developed countries, ethnic minority communities bear the brunt of poor sexual health outcomes, with high rates of HIV/AIDS, sexually transmitted infections and their sequelae. Economic disadvantage, social exclusion and racism experienced by these communities all contribute to the observed inequalities. However, culturally prescribed attitudes and behaviours also play an important role. A review of the literature suggests that multifaceted and sustained approaches are needed to improve the sexual health of ethnic minority communities. Chief among these approaches are improving sexually transmitted infection surveillance and research tools; creating collaborative partnerships with communities; targeting high-risk groups and networks; and improving access to, and the utilization of, proven effective interventions.

Biologic approaches to the prevention of sexual transmission of human immunodeficiency virus

HIV prevention science has made progress, especially in Thailand and some sub-Saharan African countries. New cases of HIV in the United States, however, have not diminished and explosive epidemics in India and the People's Republic of China seem inevitable. Therefore, HIV prevention activities must move forward in parallel. Funding for biologic and behavioral research efforts must be balanced. Behavioral research must inform biologic strategies. In addition, HIV prevention efforts have been distorted by forces that require further consideration. First, the stigmatization associated with a diagnosis of HIV infection led to prevention efforts that virtually ignore the index case. Focusing entirely on the susceptible population puts intense and unrealistic pressure on behavior change and vaccine development. Although development of an HIV vaccine is desirable, there is no evidence that this goal can be achieved in the near future. Blind faith in vaccine technology detracts from pursuit of alternative aspects of prevention science. Vaccine development is but one of several key components to a broad-based prevention strategy. The history of control of infectious diseases has shown the need for targeting index cases. This certainly will prove important in HIV over the next few years. In developed countries, antiretroviral therapy for established HIV infection has become the standard of care. Increased knowledge of the biology of transmission of HIV suggests use of ART to prevent transmission. Such intervention must be accompanied by safer sex behavior in the index cases, and ultimately could lead to some form of monitoring and directly observed therapy. At this time, the latter approach seems unrealistic in developing countries, where the expense of drugs renders them unavailable. But there is every reason to believe that cheaper, more appropriate drugs will be developed before an effective vaccine. Furthermore, targeted use of ART might have disproportionate benefits in some countries. Women are the fastest growing HIV risk group. Several issues, both biologic and social, make this trend a concern. Increases in the number of HIV-infected women will lead to greater vertical transmission. Women possibly have different risk factors for acquisition and transmission than men. Information about the effects of vaginal ecology, specifically, the role of bacterial vaginosis, in the acquisition of HIV is essential because bacterial vaginosis can be reversed, at least transiently. To allow women to take an active role in HIV prevention methods, development of a topical microbicide is vital and may prove easier than a vaccine. Finally, HIV prevention efforts require knowledgeable, central leadership. All prevention efforts should be developed and implemented in parallel, to gain a synergistic result. Few vaccine experts are enthusiastic about microbicides, and HIV caregivers only rarely focus on the public health considerations of their patients. Stopping the spread of HIV requires a coordinated, concerted efforts using "all the tools in the toolbox."