The effectiveness of community interventions to promote condom use in the prevention of HIV and sexually transmitted infections

Bakground

Since the advent of the HIV/AIDS epidemic in the 1980s, condom promotion has become one of the most widely used interventions to prevent transmission of HIV and sexually transmitted infections (STIs). However, despite widespread promotion of condom use globally, new cases of HIV and other STIs either remain high or continue to rise in some particular regions and settings across the world. It is believed that by modifying the environment in which people live, it is possible to improve access and use of condoms on a large scale so that the transmission of HIV and other STIs decreases. This review aimed to assess if this theory was correct.

Methods

We screened all relevant literature from January 1980 to April 2014. Two independent authors selected and assessed the trials.

Results

We obtained nine studies, involving 75,891 participants and with a duration raging from one to nine years. Seven of these studies were conducted in Sub-Saharan Africa, one in Peru, and one in a multi-country location. Condom promotion was implemented in all the studies. Our results did not provide clear evidence that condom promotion in these specific contexts led to a decrease in the transmission of HIV and other STIs. However, knowledge about HIV and other STIs increased, as did reported condom use. A likely reason for the negative results in this review is that sexual behaviors are difficult to change. For example, we found no difference in the number of sexual partners after the intervention was implemented. Also, if there is not consistent condom use the risk of transmission remains for HIV and other STIs. The quality of the evidence was deemed to be moderate.

Conclusions

Our findings should be interpreted with caution since most of the studies in the present review were carried out in Sub-Saharan Africa, region that is very diverse, and whose social and cultural characteristics are different from those in other developing nations. Thus, our results present a limited generalizability.

Authors' conclusions: 

There is no clear evidence that structural interventions at the community level to increase condom use prevent the transmission of HIV and other STIs. However, this conclusion should be interpreted with caution since our results have wide confidence intervals and the results for prevalence may be affected by attrition bias. In addition, it was not possible to find RCTs in which extended changes to policies were conducted and the results only apply to general populations in developing nations, particularly to Sub-Saharan Africa, a region which in turn is widely diverse.

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Background: 

Community interventions to promote condom use are considered to be a valuable tool to reduce the transmission of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). In particular, special emphasis has been placed on implementing such interventions through structural changes, a concept that implies public health actions that aim to improve society's health through modifications in the context wherein health-related risk behavior takes place. This strategy attempts to increase condom use and in turn lower the transmission of HIV and other STIs.

Objectives: 

To assess the effects of structural and community-level interventions for increasing condom use in both general and high-risk populations to reduce the incidence of HIV and STI transmission by comparing alternative strategies, or by assessing the effects of a strategy compared with a control.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, from 2007, Issue 1), as well as MEDLINE, EMBASE, AEGIS and ClinicalTrials.gov, from January 1980 to April 2014. We also handsearched proceedings of international acquired immunodeficiency syndrome (AIDS) conferences, as well as major behavioral studies conferences focusing on HIV/AIDS and STIs.

Selection criteria: 

Randomized control trials (RCTs) featuring all of the following.

1. Community interventions ('community' defined as a geographical entity, such as cities, counties, villages).

2. One or more structural interventions whose objective was to promote condom use. These type of interventions can be defined as those actions improving accessibility, availability and acceptability of any given health program/technology.

3. Trials that confirmed biological outcomes using laboratory testing.

Data collection and analysis: 

Two authors independently screened and selected relevant studies, and conducted further risk of bias assessment. We assessed the effect of treatment by pooling trials with comparable characteristics and quantified its effect size using risk ratio. The effect of clustering at the community level was addressed through intra-cluster correlation coefficients (ICCs), and sensitivity analysis was carried out with different design effect values.

Main results: 

We included nine trials (plus one study that was a subanalysis) for quantitative assessment. The studies were conducted in Tanzania, Zimbabwe, South Africa, Uganda, Kenya, Peru, China, India and Russia, comprising 75,891 participants, mostly including the general population (not the high-risk population). The main intervention was condom promotion, or distribution, or both. In general, control groups did not receive any active intervention. The main risk of bias was incomplete outcome data.

In the meta-analysis, there was no clear evidence that the intervention had an effect on either HIV seroprevalence or HIV seroincidence when compared to controls: HIV incidence (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.69 to 1.19) and HIV prevalence (RR 1.02, 95% CI 0.79 to 1.32). The estimated effect of the intervention on other outcomes was similarly uncertain: Herpes simplex virus 2 (HSV-2) incidence (RR 0.76, 95% CI 0.55 to 1.04); HSV-2 prevalence (RR 1.01, 95% CI 0.85 to 1.20); syphilis prevalence (RR 0.91, 95% CI 0.71 to 1.17); gonorrhoea prevalence (RR 1.16, 95% CI 0.67 to 2.02); chlamydia prevalence (RR 0.94, 95% CI 0.75 to 1.18); and trichomonas prevalence (RR 1.00, 95% CI 0.77 to 1.30). Reported condom use increased in the experimental arm (RR 1.20, 95% CI 1.03 to 1.40). In the intervention groups, the number of people reporting two or more sexual partners in the past year did not show a clear decrease when compared with control groups (RR 0.90, 95% CI 0.78 to 1.04), but knowledge about HIV and other STIs improved (RR 1.15, 95% CI 1.04 to 1.28, and RR 1.23, 95% CI 1.07 to 1.41, respectively). The quality of the evidence was deemed to be moderate for nearly all key outcomes.

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