Summarised from the article Hybrid STI Interventions: Putting new prevention and treatment approaches to the test by Johannes Van Dam, M:D:, in Horizons Report Spring 2000, the bi-annual newsletter produced by the Horizons Project.
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One of the most important prevention discoveries made about HIV is that the presence of other sexually transmitted infections (STIs) greatly increases vulnerability to, and transmission of, the virus. This has been a key factor in HIVs virulent spread through such regions as sub-Saharan Africa where untreated STIs are also endemic. Strengthening STI prevention and management and, wherever possible, incorporating those into HIV prevention programmes have become a key global strategy for curbing HIV.
But this is never a simple matter especially in developing countries. The stigmatization of those with STIs inhibits people from seeking treatment. Designing effective behaviour change campaigns that address sexual behaviour is often difficult, especially if literacy is low. There are also budget constraints and limited access to care. Even in countries with more resources, STI prevention and control programmes are often insufficiently funded and a low priority for health ministries.
A key lesson learned in recent years has been that - like the HIV and STI epidemics themselves- real solutions are complex and multifaceted. For STI control, the logical next step is the implementation of hybrid STI intervention studies, which combine different approaches to STI prevention and treatment. The most interesting new hybrid combines periodic presumptive treatment of groups with high rates of partner change with strengthened service delivery, behaviour change communication and condom promotion that focuses both on those groups and on the general population.
When the Horizons Project began in 1997, it identified the study of hybrid approaches as a top priority in its strategic agenda for operations research (OR). OR is especially useful for studying the implementation of different approaches to STI prevention and case management under real-life field conditions. The three innovative Horizons OR studies described below all build on the lessons learned about STIs in the past two decades to help determine best practices for the future.
100 % condom use policy in the Dominican Republic
In 1991, Thailand introduced a 100% condom use policy in all brothels in the country, accompanied by a massive public health education and awareness campaign. This policy resulted in a significant reduction in rates of HIV infection among recruits in the Thai army, as well as a countrywide reduction in rates of STIs. A question that has often been posed is: can the Thai experience be replicated?
A Horizons OR project in the Dominican Republic - implemented in collaboration with COIN and CEPROSH (two local NGOs), the national AIDS programme and researchers from Johns Hopkins University - seeks to answer that question. Two different approaches to ensuring 100% condom use in commercial sex establishments in Santo Domingo and Puerto Plata are being compared.
In Santo Domingo the intervention consists of educational and community mobilization activities among sex workers and sex establishment owners and staff. Condoms and posters are made available to all participating establishments and the programme relies on voluntary commitment to achieve its objective.
In Puerto Plata, an identical intervention is reinforced with a system of graded sanctions; sex establishments that violate the policy are subject to regulatory measures, ranging from warnings and additional education to closure. In both cases, compliance with the intervention programme is measured through a number of behaviour change indicators, the availability of condoms and the presence of STIs in sex workers.
The study is scheduled for completion by December 2001.
STI Management in Africa
Many believe that interventions focusing on individuals with high numbers of partners, who when infected are likely to be responsible for the continued spread of STIs, are more cost-effective in controlling a disease than targeting the population at large. But it has been difficult to determine the effectiveness and sustainability of interventions that target such groups and what combination of STI prevention and case management interventions is best.
To find out, Horizons has implemented a multi-site, three-country study in collaboration with the University of Zimbabwe, the University of Zambia and the provincial health authorities in Mpumalanga, South Africa. The study compares three different levels of an intervention programme focusing on sex workers operating in the vicinity of industrial or agricultural estates. At the first level, the intervention consists of an enhanced intervention for the general public of health education, condom promotion and syndromic management of STIs, a common programmatic combination. At the second level, the intensity of the intervention is increased by adding targeted peer education and condom promotion, focusing on sex workers and clients. At the third level, a programme of periodic presumptive STI treatment for sex workers is added. Outcome indicators include the impact of the different interventions on STI rates among sex workers and on STI and HIV rates in the male workforce, levels of condom use and preventive behaviour among sex workers.The cost-effectiveness, feasibility and acceptability of these interventions will also be assessed.
Mining communities in South Africa
In the gold mining area of Carletonville, South Africa, Horizons supports an STI/HIV intervention project that studies an intervention similar to the previous study but looks at different aspects of such an intervention. This project seeks to assess the operational aspects, efficacy and cost-effectiveness of an intervention package that includes peer education for sex workers and miners, condom promotion and delivery, and strengthened STI management for sex workers, miners and the general population. In a second phase which started early in 2000, and is being implemented with support from FHI/IMPACT, the project seeks to study the operational aspects, efficacy, cost-effectiveness and ideal frequency of a periodic presumptive STI treatment programme for sex workers.
Particular attention is paid to the effects of the intervention on social and community mobilization around HIV and STI issues. Results of this study are expected by the middle of 2001. It is anticipated that the findings of this and other studies of STI intervention strategies will contribute to the formulation of more effective STI control programmes in southern Africa and other parts of the world.