HIV Prevention Knowledge Base
Biomedical Interventions: Diagnosis and Treatment of Sexually Transmitted Infections
Quality Assurance and Quality Improvement Using Supportive Supervision in a Large-Scale STI Intervention with Sex Workers, Men Who Have Sex with Men/Transgenders and Injecting-Drug Users in India
This evaluation monitored the performance of Avahan, the India AIDS Initiative, using a supportive supervision tool to analyze outcomes from three perspectives: clinical, community, and management. The tool assessed the accessibility, acceptability, and contact coverage of sexually transmitted infection clinical services. It looked at barriers to access and monitored the quality of individual service components, including correct treatment, infection control, confidentiality, and counseling. Monitoring demonstrated that Avahan improved and sustained quality in terms of coverage, quality, technical support, community involvement, and networks of referrals. The monitoring tool provides timely and useful feedback but can be time-consuming and resource-intensive to implement.
Changes in Risk Behaviours and Prevalence of Sexually Transmitted Infections Following HIV Preventive Interventions Among Female Sex Workers in Five Districts in Karnataka State, South India
This study used biological and behavioral surveys to assess the impact of HIV prevention programs targeted at female sex workers, such as peer outreach and behavior change communication and provision of sexual health clinic services including syndromic and presumptive management of sexually transmitted infections (STIs). By follow-up, almost all participants had been visited by a peer educator, at least three-quarters had visited a drop-in center or sexual health clinic, and two-thirds had received presumptive treatment for chlamydia and gonorrhea. Rates of condom use with clients improved but were static with regular partners. The prevalence of HIV reduced significantly across the board, but for curable STIs, only street-based female sex workers had a reduced prevalence at follow-up. Rates of curable STIs did not decrease for brothel- and home-based female sex workers.
Prioritising Prevention Strategies for Patients in Antiretroviral Treatment Programmes in Resource-Limited Settings
Twenty-seven antiretroviral therapy programs in Africa, Asia, and South America were surveyed to determine the extent of preventive services they offered. The survey showed that prevention efforts in most programs focused on health education to change behavior, supply of male condoms, and prevention of mother-to-child transmission. Other interventions (e.g., protocols for partner notification and interventions for high-risk groups such as serodiscordant couples and adolescents) were less common. Few sites offered regular sexually transmitted infection screening. Survey respondents cited stigma, lack of financial resources, and high patient load as the main obstacles to implementing preventive services within antiretroviral therapy programs.
Control of Sexually Transmitted Infections and Prevention of HIV Transmission: Mending a Fractured Paradigm
This paper argues that the “fractured paradigm” of HIV prevention separate from programs to tackle sexually transmitted infections (STIs) is counterproductive for both, given that weak control of STIs may undermine HIV prevention efforts. The paper reviews the components, benefits, and feasibility of STI control and offers an alternative, unified paradigm to tackle HIV together with other STIs. A useful table lays out the epidemiological parameters for integrating HIV prevention and STI control, detailing which target groups and diseases should get priority in which settings and when STI interventions are most effective in preventing HIV transmission.
Linking Sexual and Reproductive Health and HIV/AIDS, Gateways to Integration: A Case Study From Haiti
In Haiti, voluntary HIV counseling and testing became a gateway to providing comprehensive sexual and reproductive health services including condom use promotion, family planning, maternal child health services, and services specifically for young people and survivors of sexual violence. Integration made sense because most HIV infections in Haiti are transmitted sexually, mother-to-child transmission is common, and people living with HIV face stigma and discrimination in accessing health services. Services evolved as needs were identified. Although such integration requires great efforts to overcome the stigma associated with HIV, providing access to a range of health services greatly improves uptake of HIV counseling and testing.
Monthly Antibiotic Chemoprophylaxis and Incidence of Sexually Transmitted Infections and HIV-1 infection in Kenyan Sex Workers
The randomized double-blinded and placebo-controlled trial enrolled Kenyan female sex workers to test whether the use of antibiotic prophylaxis to treat common sexually transmitted infections (STIs) would also reduce the rate of HIV acquisition. Four hundred and sixty-six seronegative sex workers were enrolled in the study. All women were provided with risk-reduction counseling, condoms, treatment of symptomatic STIs, and biannual screening and treatment for asymptomatic STIs. Oral azithromycin was given to half of the participants and the other half was given a placebo. There was no statistically significant difference between the treatment and placebo groups on HIV-1 incidence. Out of 35 seroconversion cases, 19 were in the treatment group and 16 were in the placebo group. There was a strong association between prior STI and incident HIV-1 infection, and a significant positive effect of azithromycin on the reduction of incidence and prevalence of bacterial STIs. A reduction in risky sexual behaviors in both groups was found. Condom use with all clients increased from less to 20 percent to more than 50 percent within one month. The number of clients per week decreased from more than 16 to less than 6 within six months. There was a correlation between HIV-1 infection and risky sexual behaviors within the year of seroconversion. The authors provide plausible reasons for the lack of effectiveness in reducing HIV-1 acquisition with azithromycin treatment in this population.
Changing Patterns in Sexually Transmitted Disease Syndromes in Kenya After the Introduction of a Syndromic Management Program
This study of Kenya’s syndromic management program for sexually transmitted infections (STIs) used HIV sentinel surveillance data in patients with STIs to identify changes in the proportion of patients with three syndromes associated with increased HIV acquisition: genital ulcer disease, urethral discharge, and vaginal discharge. Incidence declined after the introduction of the program in 1995 and then increased again when free STI medication was no longer offered in 2001. As this was an ecological study, it was vulnerable to possible selection bias, and the authors recommend further studies such as randomized clinical trials to better understand the impact of complex interventions like STI syndromic management programs.
How Effective is Syndromic Management of STDs? A Review of Current Studies
This review of programs implementing syndromic management of sexually transmitted infections (STIs) found that the processes for diagnosis and treatment of urethral discharge and genital ulcer disease in men were highly sensitive or had good cure rates, but those for women were less sensitive, particularly for those without symptoms. Algorithms for vaginal discharge do not effectively detect gonorrhea or chlamydia in women. Once the qualitative aspects of STI syndromic management are taken into account, the algorithms are likely to be even less sensitive than the literature suggests, and the authors urgently call for the development of affordable and effective rapid STI testing for use in resource-poor settings.