Date Published: March 27, 2007
Publisher: Public Library of Science
Author(s): Simon Gregson, Saina Adamson, Spiwe Papaya, Jephias Mundondo, Constance A Nyamukapa, Peter R Mason, Geoffrey P Garnett, Stephen K Chandiwana, Geoff Foster, Roy M Anderson, Joep M. A Lange
Abstract: BackgroundHIV-1 control in sub-Saharan Africa requires cost-effective and sustainable programmes that promote behaviour change and reduce cofactor sexually transmitted infections (STIs) at the population and individual levels.Methods and FindingsWe measured the feasibility of community-based peer education, free condom distribution, income-generating projects, and clinic-based STI treatment and counselling services and evaluated their impact on the incidence of HIV-1 measured over a 3-y period in a cluster-randomised controlled trial in eastern Zimbabwe. Analysis of primary outcomes was on an intention-to-treat basis. The income-generating projects proved impossible to implement in the prevailing economic climate. Despite greater programme activity and knowledge in the intervention communities, the incidence rate ratio of HIV-1 was 1.27 (95% confidence interval [CI] 0.92–1.75) compared to the control communities. No evidence was found for reduced incidence of self-reported STI symptoms or high-risk sexual behaviour in the intervention communities. Males who attended programme meetings had lower HIV-1 incidence (incidence rate ratio 0.48, 95% CI 0.24–0.98), and fewer men who attended programme meetings reported unprotected sex with casual partners (odds ratio 0.45, 95% CI 0.28–0.75). More male STI patients in the intervention communities reported cessation of symptoms (odds ratio 2.49, 95% CI 1.21–5.12).ConclusionsIntegrated peer education, condom distribution, and syndromic STI management did not reduce population-level HIV-1 incidence in a declining epidemic, despite reducing HIV-1 incidence in the immediate male target group. Our results highlight the need to assess the community-level impact of interventions that are effective amongst targeted population sub-groups.
Partial Text: HIV-1–prevalence declines may now be occurring in some sub-Saharan African countries . However, there remains little direct evidence that prevention measures—rather than natural HIV-1 epidemic dynamics  or behaviour change prompted by mortality —have contributed to the slowing of HIV-1 epidemics [4,5]. Syndromic management of sexually transmitted infections (STIs) proved effective early in an HIV-1 epidemic in north-west Tanzania . Peer education to promote safe behaviours showed promise in early process evaluations , but a randomised controlled trial (RCT) of factory workers in Harare, Zimbabwe, done in the mid-1990s, proved inconclusive . Subsequent RCTs of syndromic management  and mass treatment of STIs , together with an information, education, and communication (IEC) behaviour-change programme , showed no effect in more mature epidemics.