Syndromic Sexually Transmitted Infections Research Articles

Risk factors for curable sexually transmitted infections among youth: findings from the STICH population survey in Zimbabwe

ObjectivesYouth are at high risk of sexually transmitted infections (STIs) in Africa. We aimed to determine the risk factors for curable STIs in youth in Zimbabwe.MethodsA population-based survey was conducted...

Acceptability, feasibility and cost of point of care testing for sexually transmitted infections among South African adolescents where syndromic management is standard of care

BackgroundYoung people (YP) in southern Africa are at substantial risk of HIV and sexually transmitted infections (STIs). Despite the epidemiological and biological link between STIs and HIV transmission and acquisition, infections such as Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) remain widely undiagnosed. Syndromic STI management is the standard of care in low- and middle-income countries (LMICs) despite a high prevalence of asymptomatic infections. We conducted an observational study to explore the acceptability, feasibility, and cost of a STI test-and-treat service for YP in Cape Town.MethodsYP attending a mobile clinic (MC) and a youth centre clinic (YC) were offered STI screening. Urine testing for CT and NG using a 90-min molecular point-of-care (POC) test on the GeneXpert platform was conducted and treatment provided. Data were collated on demographics, sexual behaviour, presence of symptoms, uptake of same-day treatment, prevalence of CT/NG, and service acceptability.ResultsThree hundred sixty six participants were enrolled (median age 20, 83% female).57% (209/366) of participants tested positive for either CT (126/366, 34%) or NG (57/366, 16%) or co-infection (26/366, 7%).Clinical symptoms were a poor predictor of GeneXpert diagnosed CT or NG, with a sensitivity of 46.8% and 54.0% for CT and NG respectively. Although half of participants initially chose to receive same day results and treatment, only a third waited for results on the day. The majority of participants (91%) rated the service highly via a post-visit acceptability questionnaire.ConclusionCurable STIs are highly prevalent in this population. STI screening using POC testing was feasible and acceptability was high. The study provides further impetus for moving policy beyond syndromic management of STIs in South Africa.

Integration of sexually transmitted infection and HIV pre-exposure prophylaxis services in sub-Saharan Africa: a scoping review.

Persons living in sub-Saharan Africa (SSA) face disproportionate risk from overlapping epidemics of HIV and bacterial sexually transmitted infections (STIs). Pre-exposure prophylaxis (PrEP) for prevention is gradually being scaled up globally including in several settings in SSA, which represents a key opportunity to integrate STI services with HIV pre-exposure prophylaxis (PrEP). However, there is limited literature on how to successfully integrate these services, particularly in the SSA context. Prior studies and reviews on STI and PrEP services have largely focused on high income countries. We conducted a scoping review of prior studies of integration of STI and PrEP services in SSA. We searched PubMed, EMBASE, Cochrane, and CINAHL, in addition to grey literature to identify studies that were published between January 2012 and December 2022, and which provided STI and PrEP services in SSA, with or without outcomes reported. Citations and abstracts were reviewed by two reviewers for inclusion. Full texts were then retrieved and reviewed in full by two reviewers. Our search strategy yielded 1951 records, of which 250 were retrieved in full. Our final review included 61 reports of 45 studies. Most studies were conducted in Southern (49.2%) and Eastern (24.6%) Africa. Service settings included public health clinics (26.2%), study clinics (23.0%), sexual and reproductive care settings (23.0%), maternal and child health settings (8.2%), community based services (11.5%), and mobile clinics (3.3%). A minority (11.4%) of the studies described only syndromic STI management while most (88.6%) included some form of etiological laboratory STI diagnosis. STI testing frequency ranged from baseline testing only to monthly screening. Types of STI tested for was also variable. Few studies reported outcomes related to implementation of STI services. There were high rates of curable STIs detected by laboratory testing (baseline genitourinary STI rates ranged from 5.6-30.8% for CT, 0.0-11.2% for GC, and 0.4-8.0% for TV). Existing studies have implemented a varied range of STI services along with PrEP. This range reflects the lack of specific guidance regarding STI services within PrEP programs. However, there was limited evidence regarding implementation strategies for integration of STI and PrEP services in real world settings.

Developing and validating a risk algorithm to diagnose Neisseria gonorrhoeae and Chlamydia trachomatis in symptomatic Rwandan women

BackgroundAlgorithms that bridge the gap between syndromic sexually transmitted infection (STI) management and treatment based in realistic diagnostic options and local epidemiology are urgently needed across Africa. Our objective was to develop and validate a risk algorithm for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) diagnosis among symptomatic Rwandan women and to compare risk algorithm performance to the current Rwandan National Criteria for NG/CT diagnosis.MethodsThe risk algorithm was derived in a cohort (n = 468) comprised of symptomatic women in Kigali who sought free screening and treatment for sexually transmitted infections and vaginal dysbioses at our research site. We used logistic regression to derive a risk algorithm for prediction of NG/CT infection. Ten-fold cross-validation internally validated the risk algorithm. We applied the risk algorithm to an external validation cohort also comprised of symptomatic Rwandan women (n = 305). Measures of calibration, discrimination, and screening performance of our risk algorithm compared to the current Rwandan National Criteria are presented.ResultsThe prevalence of NG/CT in the derivation cohort was 34.6%. The risk algorithm included: age < =25, having no/primary education, not having full-time employment, using condoms only sometimes, not reporting genital itching, testing negative for vaginal candida, and testing positive for bacterial vaginosis. The model was well calibrated (Hosmer-Lemeshow p = 0.831). Higher risk scores were significantly associated with increased prevalence of NG/CT infection (p < 0.001). Using a cut-point score of > = 5, the risk algorithm had a sensitivity of 81%, specificity of 54%, positive predictive value (PPV) of 48%, and negative predictive value (NPV) of 85%. Internal and external validation showed similar predictive ability of the risk algorithm, which outperformed the Rwandan National Criteria. Applying the Rwandan National Criteria cutoff of > = 2 (the current cutoff) to our derivation cohort had a sensitivity of 26%, specificity of 89%, PPV of 55%, and NPV of 69%.ConclusionsThese data support use of a locally relevant, evidence-based risk algorithm to significantly reduce the number of untreated NG/CT cases in symptomatic Rwandan women. The risk algorithm could be a cost-effective way to target treatment to those at highest NG/CT risk. The algorithm could also aid in sexually transmitted infection risk and prevention communication between providers and clients.

Sexually Transmitted Infections in Pregnancy: A Narrative Review of the Global Research Gaps, Challenges, and Opportunities.

Sexually transmitted infections (STI), such as chlamydial, gonorrheal, and trichomonal infections, are prevalent in pregnant women in many countries and are widely reported to be associated with increased risk of poor maternal and neonatal outcomes. Syndromic STI management is frequently used in pregnant women in low- and middle-income countries, yet its low specificity and sensitivity lead to both overtreatment and undertreatment. Etiologic screening for chlamydial, gonorrheal, and/or trichomonal infection in all pregnant women combined with targeted treatment might be an effective intervention. However, the evidence base is insufficient to support the development of global recommendations. We aimed to describe key considerations and knowledge gaps regarding chlamydial, gonorrheal, and trichomonal screening during pregnancy to inform future research needed for developing guidelines for low- and middle-income countries. We conducted a narrative review based on PubMed and clinical trials registry searches through January 20, 2020, guidelines review, and expert opinion. We summarized our findings using the frameworks adopted by the World Health Organization for guideline development. Adverse maternal-child health outcomes of potential interest are wide-ranging and variably defined. No completed randomized controlled trials on etiologic screening and targeted treatment were identified. Evidence from observational studies was limited, and trials of presumptive STI treatment have shown mixed results. Subgroups that might benefit from specific recommendations were identified. Evidence on harms was limited. Cost-effectiveness was influenced by STI prevalence and availability of testing infrastructure and high-accuracy/low-cost tests. Preliminary data suggested high patient acceptability. Preliminary data on harms, acceptability, and feasibility and the availability of emerging test technologies suggest that etiologic STI screening deserves further evaluation as a potential tool to improve maternal and neonatal health outcomes worldwide.

Prevalence and correlates of sexually transmitted infections in pregnancy in HIV-infected and- uninfected women in Cape Town, South Africa.

ObjectivesSexually transmitted infections (STIs) are associated with adverse outcomes in pregnancy, including mother-to-child HIV transmission. Yet there are limited data on the prevalence and correlates of STI in pregnant women by HIV status in low- and middle-income countries, where syndromic STI management is routine.MethodsBetween November 2017 and July 2018, we conducted a cross-sectional study of consecutive pregnant women making their first visit to a public sector antenatal clinic (ANC) in Cape Town. We interviewed women ≥18 years and tested them for Chlamydia trachomatis (CT), Neisseria gonorrhoea (NG) and Trichomonas vaginalis (TV) using Xpert assays (Cepheid, USA); results of syphilis serology came from routine testing records. We used multivariable logistic regression to identify correlates of STI in pregnancy.ResultsIn 242 women (median age 29 years [IQR = 24–34], median gestation 19 weeks [IQR = 14–24]) 44% were HIV-infected. Almost all reported vaginal sex during pregnancy (93%). Prevalence of any STI was 32%: 39% in HIV-infected women vs. 28% in HIV-uninfected women (p = 0.036). The most common infection was CT (20%) followed by TV (15%), then NG (5.8%). Of the 78 women diagnosed with a STI, 7 (9%) were identified and treated syndromically in ANC. Adjusting for age and gestational age, HIV-infection (aOR = 1.89; 95% CI = 1.02–3.67), being unmarried or not cohabiting with the fetus’ father (aOR = 2.19; 95% CI = 1.16–4.12), and having STI symptoms in the past three days (aOR = 6.60; 95% CI = 2.08–20.95) were associated with STI diagnosis.ConclusionWe found a high prevalence of treatable STIs in pregnancy among pregnant women, especially in HIV-infected women. Few women were identified and treated in pregnancy.

The Association between Sexually Transmitted Infections, Length of Service and Other Demographic Factors in the U.S. Military.

BackgroundNumerous studies have found higher rates of sexually transmitted infections (STIs) among military personnel than the general population, but the cumulative risk of acquiring STIs throughout an individual’s military career has not been described.MethodsUsing ICD-9 diagnosis codes, we analyzed the medical records of 100,005 individuals from all service branches, divided in equal cohorts (n = 6,667) between 1997 and 2011. As women receive frequent STI screening compared to men, these groups were analyzed separately. Incidence rates were calculated for pathogen-specific STIs along with syndromic diagnoses. Descriptive statistics were used to characterize the individuals within each accession year cohort; repeat infections were censored.ResultsThe total sample included 29,010 females and 70,995 males. The STI incidence rates (per 100 person-years) for women and men, respectively, were as follows: chlamydia (3.5 and 0.7), gonorrhea (1.1 and 0.4), HIV (0.04 and 0.07) and syphilis (0.14 and 0.15). During the study period, 22% of women and 3.3% of men received a pathogen-specific STI diagnosis; inclusion of syndromic diagnoses increased STI prevalence to 41% and 5.5%, respectively. In multivariate analyses, factors associated with etiologic and syndromic STIs among women included African American race, younger age and fewer years of education. In the overall sample, increasing number of years of service was associated with an increased likelihood of an STI diagnosis (p<0.001 for trend).ConclusionIn this survey of military personnel, we found very high rates of STI acquisition throughout military service, especially among women, demonstrating that STI-related risk is significant and ongoing throughout military service. Lower STI incidence rates among men may represent under-diagnosis and demonstrate a need for enhancing male-directed screening and diagnostic interventions.

Inflammatory cytokine biomarkers to identify women with asymptomatic sexually transmitted infections and bacterial vaginosis who are at high risk of HIV infection

BackgroundUntreated sexually transmitted infections (STIs) and bacterial vaginosis (BV) cause genital inflammation and increase the risk of HIV infection. WHO-recommended syndromic STI and BV management is severely limited as many...

P06.13 Inflammatory cytokine biomarkers identify women with asymptomatic genital infections that increase the risk of hiv infection

Introduction Untreated sexually transmitted infections (STIs) and bacterial vaginosis (BV) cause genital inflammation and increased risk of HIV infection. WHO-recommended syndromic STI and BV management is limited as large numbers of women with asymptomatic infections go untreated. The purpose of this study was to evaluate genital cytokine profiles as a biomarker to identify women with asymptomatic, treatable infections. Methods Luminex was used to measure the concentrations of 42 cytokines in cervicovaginal lavages (CVL) from 227 HIV-uninfected women from Durban, South Africa, and nine cytokines in endocervical swabs from 264 women from Bondo, Kenya and Pretoria, South Africa. Women were screened for BV and treatable STIs ( Chlamydia trachomatis , Neisseria gonorrhoeae , Trichomonas vaginalis , Mycoplasma genitalium ) using microscopy and molecular assays. Nonparametric receiver operating characteristic curves and logistic regression were used to identify cytokine profiles associated with STIs/BV. Results In women from Durban, concomitant increased IL-1α and IL-1β and decreased IP-10 concentrations in CVLs predicted the presence of a treatable genital condition, correctly classifying 76% of women (sensitivity 72%, specificity 81%, PPV 86% and NPV 64%). In a separate validation cohort of women from Bondo and Pretoria, IL-1α, IL-1β and IP-10 concentrations in endocervical swabs correctly classified 72% of the participants according to STI/BV status. This approach performed substantially better than clinical signs in both cohorts from Durban (sensitivity 19%, specificity 92%, PPV 79% and NPV 40%) and Pretoria and Bondo (sensitivity 29%, specificity 78%, PPV 68%, NPV 39%). Conclusion Across two cohorts of women residing in different regions in sub-Saharan Africa, genital IL-1α, IL-1β and IP-10 together was the best immunological predictor of the presence of an STI or BV. Supplementing syndromic management with point-of-care assessment of biomarkers of genital inflammation may improve STI/BV management for women, enabling more effective treatment of asymptomatic infections and potentially reducing their risk of HIV infection. Disclosure of interest statement This work was supported by a Strategic Health Innovation Partnerships (SHIP) grant from the South African Medical Research Council and grants from the Poliomyelitis Research Foundation (PRF) of South Africa and European and Developing Countries Clinical Trials Partnership (EDCTP). The cohorts were supported by grants from the Comprehensive International Program of Research on AIDS (CIPRA) of the Division of AIDS (DAIDS); National Institute of Allergy and infectious Disease (NIAID); National Institutes of Health (NIH) and US Department of Health and Human Services (DHHS) [grant number U19 AI51794]. FEM-PrEP was conducted under two grants funded by the United States Agency for International Development (USAID): the Contraceptive and Reproductive Health Technologies and Research Utilisation Program (GPO-A-00–05–00022–00), and the Preventive Technologies Agreement (GHO-A-00–09–00016–00). Early support was also provided by the Bill and Melinda Gates Foundation. Gilead Sciences, Inc. donated Truvada® and placebo. LM was supported by the PRF; South African Medical Research Council (MRC); the Carnegie Corporation; the National Research Foundation (NRF) of South Africa and the UCT Clinical Infectious Diseases Research Initiative/Wellcome Trust. No pharmaceutical grants were received in the development of this study.

P09.22 The aetiology of genital discharge syndromes in zimbabwe

Background In many countries, sexually transmitted infections (STI) are treated syndromically. Thus, male and female patients with genital discharge syndromes (GDS) receive antimicrobials covering Chlamydia trachomatis (CT), Neisseria Gonorrhoeae (NG) and Trichomonas vaginalis (TV) infections and bacterial vaginosis (BV) among women. However, periodic surveys into the aetiology of GDS are necessary to inform treatment guidelines. Methods For this study, we enrolled 400 patients with GDS at 6 regionally diverse clinics in Zimbabwe. To date, test procedures have been completed for patients enrolled at the Harare study sites (N = 137). Sites were visited sequentially by a mobile unit of 3 trained nurses to enrol patients with STI syndromes, including GDS. STI history and risk data were collected by questionnaire and uploaded to a web-based database. Urine and vaginal specimens were taken for testing with a validated multiplex polymerase chain reaction assay (M-PCR, National Institute of Communicable Diseases, Johannesburg) for CT, NG, TV and Mycoplasma genitalium (MG). Smears for Gram stain and subsequent assessment using Nugent criteria for the diagnosis of BV were obtained from all women with vaginal discharge. Results M-PCR testing is complete for all GDS patients enrolled in Harare; 68 men and 69 women. Positivity rates were as follows. Men: NG = 60.3%, CT = 13.2%, TV = 4.4%, MG = 2.9%. Women: NG = 18.8%, CT = 8.7%, TV = 14.5%, MG = 7.3%. Among women, 31.9% met Nugent criteria for BV and 20.0% had yeast infection identified on Gram stain. Conclusions In this preliminary analysis, gonorrhoea was the most common cause of GDS among both men and women, but much more common among men. Chlamydia infections were substantially less common among both men and women and trichomoniasis was more common than chlamydia infections among women. Regardless of investigated microbiologic causes, many women met criteria for BV. M. genitalium infections were uncommon overall. These findings will inform development of future syndromic STI management guidelines.

Evaluation of syndromic management of sexually transmitted infections within the Kisumu Incidence Cohort Study

While laboratory aetiological diagnosis is considered the gold standard for diagnosis and management of sexually transmitted infections (STIs), syndromic management has been presented as a simplified and affordable approach for STI management in limited resource settings. STI signs and symptoms were collected using staff-administered computer-assisted personal interview and audio computer-assisted self-interview. Participants underwent a medical examination and laboratory testing for common STIs. The performance of syndromic management was assessed on the agreement between interviewing methods as well as accurate diagnosis. We screened 846 participants, of whom 88 (10.4%) received syndromic STI diagnosis while 272 (32.2%) received an aetiological diagnosis. Agreement between syndromic and aetiological diagnoses was very poor (overall kappa = 0.09). The most prevalent STI was herpes simplex virus type 2 and the percentage of persons with any STI was higher among women (48.6%) than men (15.6%, p < 0.0001). Agreement between audio computer-assisted self-interview and computer-assisted personal interview interviewing methods for syndromic diagnosis of STIs ranged from poor to good. Our findings suggest that syndromic management of STIs is not a sufficient tool for STI diagnosis in this setting; development and improvement of STI diagnostic capabilities through laboratory confirmation is needed in resource-limited settings.

Priority interventions to reduce HIV transmission in sex work settings in sub‐Saharan Africa and delivery of these services

IntroductionVirtually no African country provides HIV prevention services in sex work settings with an adequate scale and intensity. Uncertainty remains about the optimal set of interventions and mode of delivery.MethodsWe systematically reviewed studies reporting interventions for reducing HIV transmission among female sex workers in sub-Saharan Africa between January 2000 and July 2011. Medline (PubMed) and non-indexed journals were searched for studies with quantitative study outcomes.ResultsWe located 26 studies, including seven randomized trials. Evidence supports implementation of the following interventions to reduce unprotected sex among female sex workers: peer-mediated condom promotion, risk-reduction counselling and skills-building for safer sex. One study found that interventions to counter hazardous alcohol-use lowered unprotected sex. Data also show effectiveness of screening for sexually transmitted infections (STIs) and syndromic STI treatment, but experience with periodic presumptive treatment is limited. HIV testing and counselling is essential for facilitating sex workers’ access to care and antiretroviral treatment (ART), but testing models for sex workers and indeed for ART access are little studied, as are structural interventions, which create conditions conducive for risk reduction. With the exception of Senegal, persistent criminalization of sex work across Africa reduces sex workers’ control over working conditions and impedes their access to health services. It also obstructs health-service provision and legal protection.ConclusionsThere is sufficient evidence of effectiveness of targeted interventions with female sex workers in Africa to inform delivery of services for this population. With improved planning and political will, services – including peer interventions, condom promotion and STI screening – would act at multiple levels to reduce HIV exposure and transmission efficiency among sex workers. Initiatives are required to enhance access to HIV testing and ART for sex workers, using current CD4 thresholds, or possibly earlier for prevention. Services implemented at sufficient scale and intensity also serve as a platform for subsequent community mobilization and sex worker empowerment, and alleviate a major source of incident infection sustaining even generalized HIV epidemics. Ultimately, structural and legal changes that align public health and human rights are needed to ensure that sex workers on the continent are adequately protected from HIV.

P1-S2.54 Repeat Gonococcal and chalymadial infections in a cohort of men who have sex with men in India

BackgroundMen who have sex with men (MSM) are found to be at increased risk for many sexually transmitted infections (STI). Among the STIs, most common are bacterial STIs such as...

P5-S6.19 Prevalence and incidence of sexually transmitted infections among female sex workers in two cities in India: implications for STI control strategies

BackgroundIndia is a large country with marked heterogeneity in prevalence of sexually transmitted infections (STIs) which has implications for STI control strategies. The study objective was to measure the prevalence...

Population-based biomedical sexually transmitted infection control interventions for reducing HIV infection

Population-based biomedical sexually transmitted infection control interventions for reducing HIV infection

Low effectiveness of syndromic treatment services for curable sexually transmitted infections in rural South Africa

Objectives:Syndromic sexually transmitted infection (STI) treatment remains a cost-saving HIV prevention intervention in many countries in Africa. We estimate the effectiveness of syndromic treatment for curable STIs in rural KwaZulu-Natal,...

Socio‐cultural, psychosexual and biomedical factors associated with genital symptoms experienced by men in rural India

Biomedical, anthropological and psychiatric frameworks have been used to research different elements of men's sexual health - sexually transmitted infections, psychosexual concerns and psychological distress - but rarely within the same study. We combined these in a study in rural north India. In Tehri Garhwal and Agra districts, we explored male perceptions of genital and sexual symptoms through focus group discussions and then conducted a clinic-based survey of 366 symptomatic men who presented at rural private provider clinics. Men's urine specimens were tested for gonorrhoea and chlamydia infection using polymerase chain reaction techniques. Researchers screened them for probable psychological distress by administering the General Health Questionnaire (12- items). Results revealed that local and traditional notions of health influenced men's symptom perceptions, with semen loss their predominant concern. Dhat, commonly perceived as an involuntary semen loss, corresponded most closely with the symptom of urethral discharge, but was attributed mainly to non-infectious causes. It could also manifest as a syndrome with physical weakness and mental lethargy. FGD participants lacked correct and complete information on reproductive health. Around 75% of the symptomatic men presented with dhat, but only 5.5% tested positive for gonorrhoea or chlamydia. Application of syndromic sexually transmitted infection (STI) guidelines in these settings could result in over diagnosis and over treatment with antibiotics. In contrast, there was a significant association between dhat and probable psychological distress as detected by the GHQ (Adjusted OR, GHQ case positive: 2.66, 95% CI: 1.51-4.68). Our study confirms the existence of a dhat syndrome in rural India, which is culturally influenced and reflects heightened psychosexual concerns as well as mental distress states. Comprehensive health services for men should include assessments of their psychosexual needs and be supported by reproductive/sexual health education. STI treatment guidelines for urethral symptoms should be revised and be based on epidemiological data.

Treating Curable Sexually Transmitted Infections to Prevent HIV in Africa

Evidence regarding the effectiveness of sexually transmitted infection (STI) treatment for HIV prevention in Africa is equivocal, leading some policy makers to question whether it should continue to be promoted for HIV control. We explore whether treating curable STIs remains a cost-effective HIV control strategy in Africa. The model STDSIM was fitted to the characteristics of 4 populations in East and West Africa. Over the simulated HIV epidemics, the population-attributable fractions (PAFs) of incident HIV attributable to STIs, the impact of syndromic STI management on HIV incidence, and the cost per HIV infection averted were evaluated and compared with an estimate of lifetime HIV treatment costs (US $3500). Throughout the HIV epidemics in all cities, the total PAF for. all STIs remained high, with > or = 50% of HIV transmission attributed to STIs. The PAF for herpes simplex virus type 2 increased during the epidemics, whereas the PAF for curable STIs and the relative impact of syndromic management decreased. The models showed that the absolute impact of syndromic management remains high in generalized epidemics, and it remained cost-saving in 3 of the 4 populations in which the cost per HIV infection averted ranged between US $321 and $1665. Curable STI interventions may remain cost-saving in populations with generalized HIV epidemics, particularly in populations with high-risk behaviors or low male circumcision rates.

Impact and Process Evaluation of Integrated Community and Clinic-Based HIV-1 Control: A Cluster-Randomised Trial in Eastern Zimbabwe

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.

Risk Factors Influencing HIV Infection Incidence in a Rural African Population: A Nested Case‐Control Study

Risk factors influencing the incidence of human immunodeficiency virus (HIV) infection were investigated in a case-control study nested within a community-randomized trial of treatment of syndromic sexually transmitted infections (STIs) in rural Tanzania. Case patients were persons who became HIV positive, and control subjects were randomly selected from among persons who remained HIV negative. For each sex, we obtained adjusted odds ratios (ORs) and population-attributable fractions (PAFs) for biomedical and behavioral factors. We analyzed 92 case patients and 903 control subjects. In both sexes, the incidence of HIV infection was significantly higher in subjects with an HIV-positive spouse than in those with HIV-negative spouse (men: OR, 25.1; women: OR, 34.0). The incidence of HIV infection was significantly higher in those who became positive for herpes simplex virus type 2 (HSV-2) (men: OR, 5.60; women: OR, 4.76) and those who were HSV-2-positive at baseline (men: OR, 3.66; women: OR, 2.88) than in subjects who were HSV-2 negative. In women, living elsewhere (OR, 3.22) and never having given birth (OR, 4.27) were significant risk factors. After adjustment, the incidence of HIV infection was not significantly associated with a history of injections or STIs in either sex. HSV-2 infection was the most important risk factor for HIV infection, which highlights the need for HSV-2 interventions in HIV infection control, and there were particularly strong associations with recent HSV-2 seroconversion. The PAF associated with having an HIV-positive spouse was low, but this is likely to increase during the epidemic.