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Rapid Responses: Rapid Responses published:
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Systematic review of STI/HIV interventions in Africa
- Edwin R. van Teijlingen, Amudha S. Poobalan & Virginia A. Paul-Ebhohimhen (11 August 2008)
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“Stepping Stones” and stumbling blocks
- Chris P Hudson (18 August 2008)
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Preventing HIV in young people in Africa: time to cut the Gordian knot?
- John J. Potterat (19 August 2008)
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incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: results of study to be interpreted with caution
- Hadi Meeran Hussain (4 September 2008)
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Edwin R. van Teijlingen, Reader in Public Health University of Aberdeen, Aberdeen, AB25 2ZD, Scotland, Amudha S. Poobalan & Virginia A. Paul-Ebhohimhen
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The editorial by Hayes identified some of key difficulties in evaluating community-based Public Health interventions. These include differences within the population one tries randomise and individuals in the target population being aware whether or not they are allocated to the control or intervention group [1]. Moreover as the Stepping Stones intervention reported by Jewkes et al. in rural South Africa [2] involved ‘presumably’ well motivated volunteers Hayes is right to warn that their results should be interpreted with caution. We like to congratulate Jewkes and her colleagues on their attempts to evaluate such a hard-to- measure Public Health intervention, and we are encouraged by the reported improvements in behaviour amongst the male participants. Earlier this year we published a systematic review of school-based sexual health interventions to prevent STI/HIV in Sub-Saharan Africa [3]. We found plenty of published papers in this field, but as in all systematic reviews in the public health field most papers did not meet key inclusion criteria of having a comparison group and reporting before-and- after measurements. Our review suggested that knowledge and attitudes are easier to change than behavioural intentions and the actual behaviour. Our conclusion was that there is a great need in sub-Saharan Africa for well-evaluated and effective school-based sexual health interventions, as highlighted by Jewkes and colleagues . A similar recommendation can, of course, be made for other community-based sexual health interventions in Africa. References 1. Hayes, C. Prevention of HIV in young people in Africa (editorial) BMJ 2008;337:a743 2. Jewkes, R., Nduna, M,Levin, J., Jama, N, Dunkle, K, Puren, A. Impact of Stepping Stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial BMJ 2008;337:a506 doi:10.1136/bmj.a506 3. Paul-Ebhohimhen, V.A., Poobalan, A., van Teijlingen, E.R. (2008) Systematic review of effectiveness of school-based sexual health interventions in Sub-Saharan Africa, BMC Public Health, 8: 4. Web address: www.biomedcentral.com/1471-2458/8/4 Competing interests: None declared |
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Chris P Hudson, Epidemiologist None
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Rachel Jewkes and colleagues are to be praised for subjecting the “Stepping Stones” sexually transmitted infections (STI)/HIV prevention workshop programme to a rigorous evaluation (1). They found no evidence of benefit in HIV incidence. Does this call into question the global Stepping Stones venture? What have Jewkes and her colleagues taught us about the process of doing research? The first question is best addressed by asking whether the programme is justified for men and separately whether it is desirable for women. Given the lack of impact on HIV incidence a cost benefit analysis is essential to determine whether the modest but widespread beneficial effects in the lives of the young men justify the expense. Given the lack of overall impact in women it is unlikely that a cost-benefit analysis would support promotion of the programme for them. Furthermore, as noted by the authors, there is evidence of behavioral disinhibition (risk compensation) in young women, rendering the programme potentially harmful. Participation in the programme may have benifitted some women - as reflected in the decline in herpes simplex type 2 (HSV-2) - but caused others to take increased risks, as measured in the rates of transactional sex. It has been argued previously that sexual behaviour of young women is the key issue in HIV prevention in rural Africa (2). It is clear we need to come up with something more compelling than Stepping Stones, including achieving a higher rention rate through the educational sessions. Jewkes and colleagues have overturned the previous favourable evaluation of Stepping Stones. This was a methodologically limited 4 community study in The Gambia (3). It is now questionable whether anything less than a cluster-randomised trial (CRT) - as conducted by Jewkes and colleagues - is acceptable for evaluating interventions being considered for widespread implimentation. The findings from Jewkes and colleagues also call into question the use of HSV-2 incidence as a surrogate for HIV incidence. This is in keeping with the finding 5 years ago in another CRT that beneficial effects on HSV-2 were not matched by benefit in HIV incidence (4). Earlier work from the same research team showed the convers - that high HSV-2 incidence can occur without any HIV infections. 1. Jewkes, R., Nduna, M,Levin, J., Jama, N, Dunkle, K, Puren, A. Impact of Stepping Stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial BMJ 2008;337:a506 doi:10.1136/bmj.a506 2. Hudson CP. AIDS in rural Africa: A paradigm for HIV prevention. Int J STD AIDS 1996;7:236-243. 3. Paine K, Hart G, Jawo M, et al. “Before we were sleeping, now we are awake”: Preliminary evaluation of the Stepping Stones sexual health programme in The Gambia. 4. Kamali A, Quigley M, Nakiyingi J, Kinsman J, Kengeya-Kayondo J, Gopal R, et al. Syndromic management of sexually-transmitted infections and behavior change interventions on transmission of HIV-1 in rural Uganda: a community randomized trial. Lancet 2003;361:645-52. 5. Wagner HU, Van Dyck E, Roggen E, et al. Seroprevalence and incidence of sexually transmitted diseases in a rural Ugandan population. Int J STD AIDS 1994;5:332-7. Competing interests: None declared |
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John J. Potterat, Independent consultant Colorado Springs, Colorado 80909
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In his editorial commenting on the Stepping Stones HIV prevention program for young people in South Africa (1), Hayes confesses that “At first sight the greatest puzzle is how the intervention moderately reduced HSV-2 but had little impact on HIV…” (2). In fact, this puzzling finding remains on second sight, for neither the South African researchers nor Hayes consider a crucial difference between HSV-2, a sexually transmitted, and HIV, a sexually transmissible, infection (viz., one not uncommonly transmitted in non-sexual ways). HSV-2 is entirely spread by behaviors covered by their intervention, but this is not necessarily the case for HIV transmission. Since blood exposures were not assessed in the Stepping Stones study, both researchers and readers are condemned to speculation about this puzzling anomaly. To resolve this issue, why not cut the Gordian knot and control for a broad array of potential blood exposures, particularly in studies conducted in countries where exposures to contaminated sharps may be common (3)? 1. Jewkes R, Nduna M, Levin J, Jama N, Dunkle K, Puren A, et al. Impact of Stepping Stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomized controlled trial. BMJ 2008; 337: a506. 2. Hayes R. Prevention of HIV in young people in Africa (Editorial). BMJ 2008; 337: a743 3. Hutin YJF, Hauri AM, Armstrong GL. Use of injections in healthcare settings worldwide, 2000: literature review and regional estimates. BMJ 2003; 327: 1075. Competing interests: None declared |
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Hadi Meeran Hussain, Department Of Internal medicine Combined Military Hospital,Saddar,Lahore cantt,Pakistan
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This study by Jewkes et al,(1) brings home the saddening reality that short interventions that decrease reported sexual risk behaviour may not necessarily impact HIV-1 incidence in the long term. It also reiterates that, although strong links exist between certain sexual risk behaviours and sexually transmitted infections and HIV, preventing the former does not necessarily impact the latter. Although not the main focus of the paper, there were two other disheartening findings in this study: (1)The risk behaviour in this large sample of youths was extremely high -- with transactional sex at around 30% and physical or sexual violence and rape at around 20% of participants, and (2) retention on an individual level was very poor, speaking to the challenges faced when researching this mobile age group. This was a village cluster-randomized trial evaluate the effect of a sexual health intervention, 'Stepping Stones', on sexual behaviour and HIV and HSV-2 incidence of 16- to 24-year-olds. Although the intervention decreased HSV-2 seroincidence in the intervention arm, there was no difference in HIV-1 incidence. There were differences in change in sexual behaviour between the intervention and control arms. Although the results were somewhat disappointing, the results should be interpreted with caution. Firstly, a large proportion of the participants did not attend all the sessions and, therefore, the full impact of the intervention was probably underestimated. The study was designed to measure a 50% reduction in HIV incidence, which is rather optimistic, and there may have been a smaller difference seen with larger sample size (as the difference in HSV- 2 acquisition was certainly promising). It is unlikely that an intervention that lasts six to eight weeks will have sexual risk behaviour and STI prevention effects that last 12 to 24 months, and perhaps repeating the intervention at regular time points may have made more of an impact. Also, the control arm had a shorter but similar intervention and the differences may have been further minimized. Therefore, we should not give up hope that a behavioural intervention may impact HIV incidence. Reference: 1.Rachel Jewkes, M Nduna, J Levin, N Jama, K Dunkle, A Puren, and N Duvvury. Impact of Stepping Stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial.BMJ 2008; 337: a506 Competing interests: None declared |
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