Adapting the Get Yourself Tested Campaign to Reach Black and Latino Sexual-Minority Youth.

BACKGROUND: Culturally appropriate efforts are needed to increase sexually transmitted disease (STD) testing and care among Black and Latino sexual-minority youth, who are at high risk for STDs. Get Yourself Tested, a national testing campaign, has demonstrated success among youth, but it has yet to be assessed for relevance or impact among this population. METHOD: This effort included (1) formative and materials-testing research through focus groups; (2) adaptation of existing Get Yourself Tested campaign materials to be more inclusive of Black and Latino sexual-minority youth; (3) a 3-month campaign in four venues of New York City, promoting STD testing at events and through mobile testing and online and social media platforms; (4) process evaluation of outreach activities; and (5) an outcome evaluation of testing at select campaign venues, using a preexperimental design. RESULTS: During the 3-month campaign period, the number of STD tests conducted at select campaign venues increased from a comparable 3-month baseline period. Although testing uptake through mobile vans remained low in absolute numbers, the van drew a high-prevalence sample, with positivity rates of 26.9% for chlamydia and 11.5% for gonorrhea. This article documents the process and lessons learned from adapting and implementing a local campaign for Black and Latino sexual-minority youth.

Male circumcision: a role in HIV prevention?

PIP: Speculation has existed for decades on the association between the lack of male circumcision and the sexual transmission of disease. It has been suggested that the surface epithelium of the glans develops a protective keratin layer following circumcision which functions like a natural condom against contracting disease. Circumcised males may therefore be less susceptible to contracting sexually transmitted diseases (STD), including HIV. The identification of simian immunodeficiency virus-infected mononuclear cells in the dermis and epidermis of the penile foreskin of macaques also suggests that male circumcision may reduce the infectivity of men with HIV. The authors review the evidence in support of the association between the lack of circumcision and STDs, and the possible biological explanations. They also discuss the implications for public health interventions and suggest areas and methods for further research. Twenty-three published study reports linking circumcision status to HIV infection are identified and include retrospective studies including partner studies, cross-sectional serosurveys, a longitudinal study, and ecological correlations. Five studies linked the lack of circumcision to STDs other than HIV infection. In interpreting the data, the authors consider susceptibility versus infectivity, assessment of behaviors and adjustment for confounding, selection bias, misclassification of exposure, measure of association, and publication bias. It is ultimately concluded that more studies are needed to quantify the relative risk associated with the lack of male circumcision. Observational designs could be employed to that end along with laboratory and primate research.^ieng

Cost of providing sexually transmitted disease services in Bangkok.

OBJECTIVE: The main purpose of this study was to assess the economic costs of sexually transmitted disease (STD) treatment and to identify opportunities for sustaining Bangkok's STD clinics. DESIGN: A cost analysis was used to assess the resources required to provide (i) STD services, (ii) additional services at STD clinics during the evening, and (iii) outreach activities with commercial sex workers. The cost analysis included a review of opportunities to increase sustainability through cost recovery and institutional restructuring. RESULTS: The study revealed that the cost of providing services does differ significantly across the five clinics analysed, with recurrent costs of day-clinic STD care varying from US$13-37 per patient reached. An analysis of expanded evening hours at STD clinics suggested that an investment of US$62 000 per year allowed an additional 2000 patients to receive STD treatment and that evening hours appear to offer greater convenience to patients. It was also found that outreach activities initiated by the STD clinics and carried out in brothels have been used inexpensively (US$0.20 per woman reached) to reach commercial sex workers with critical information on STDs, including HIV. An analysis of opportunities for cost recovery at public STD clinics indicated that although some resources can be recovered, government support will continue to be required. The cost recovery option believed to be most feasible for promoting sustainability was a proposed charge of US$2-4 for STD clinic attenders. This charge was projected to allow each clinic to recover between 11% and 22% of their recurrent costs. CONCLUSION: This study concluded that there are numerous opportunities for promoting the financial sustainability of STD services at public clinics. It was also concluded that the existing outreach program is extremely inexpensive and is reaching people who are in need of the services that are being offered. However, this study was not able to determine if it would be worthwhile to reopen public STD clinics during evening hours.

PIP: Findings are presented from an assessment of the economic costs of treating STDs and sustaining 5 STD clinics in the Bangkok metropolitan area. The cost analysis was done in June 1995 using a composite of costing guidelines. Costs were evaluated for 1994, and are therefore in 1994 dollars. The analysis determined that the cost of providing services differs significantly across the 5 clinics analyzed, with recurrent costs of day-clinic STD care at US$13-37 per patient reached. An analysis of expanded evening hours at the clinics suggests that an investment of US$62,000 per year would allow an additional 2000 patients to receive STD treatment and that evening hours seem to be more convenient for patients. Inexpensive outreach activities initiated by the clinics and conducted in brothels have reached prostitutes with important information on STDs, including HIV. An analysis of opportunities for cost recovery found that although some resources can be recovered, government support will continue to be required. The most feasible cost recovery option for promoting sustainability is a proposed charge of US$2-4 per STD clinic attender. This charge was projected to allow each clinic to recover 11-22% of their recurrent costs.

The interrelationship of sexually transmitted diseases and HIV infection: implications for the control of both epidemics in Africa.

PIP: There is a high burden of sexually transmitted diseases (STDs) in many parts of Africa. As for HIV, the highest rates of STDs are found in urban men and women aged 15-35 years. STDs may be responsible for up to 17% of productive life years lost to disease in sub-Saharan urban populations. Despite this heavy burden of STDs, however, their diagnosis and treatment remain neglected by public health in most of the developing world. Many factors drive the epidemiology of STDs in Africa. The disproportionate number of men relative to women in many cities prompts many men in urban areas to have sex with a core group of prostitutes who facilitate the spread of STDs. In other cities, the frequent change of sex partners, economic factors, access to health services, lack of health education, health seeking behavior, and lack of political will play roles in the spread of STDs. Genital ulcer disease is also more frequent in Africa than in developed countries. The authors discuss the interactions between HIV and other STDs, the impact of HIV infection upon other STDs, the impact of the HIV/STD interactions upon the HIV and STD epidemics, and implications for STD and HIV control programs.^ieng

Improved treatment services significantly reduce the prevalence of sexually transmitted diseases in rural Tanzania: results of a randomized controlled trial.

OBJECTIVE: To evaluate the impact of improved case management for sexually transmitted diseases (STD) at the primary health care level on the incidence and prevalence of STD. DESIGN: Community-randomized controlled trial. SETTING: Mwanza region, Tanzania. SUBJECTS: A random cohort of about 1000 adults aged 15-54 years from each of 12 communities, in six matched pairs. One member of each pair was assigned at random to receive the intervention, and the others served as a comparison community. This cohort was surveyed at baseline and at follow-up 2 years later. About 100 antenatal clinic attenders were also studied in each community on two occasions: the first shortly after the implementation of the intervention, and the second approximately 1 year later. INTERVENTION: Improved services were established for the management of STD, using the syndromic approach, in rural health units. RESULTS: A total of 12,534 individuals were enrolled in the cohort study, of whom 8844 (71%) were seen again 2 years later. The prevalence of serological syphilis (rapid plasma reagin titre > or = 1:8, Treponema pallidum haemagglutinin assay positive) was 6.2% in both intervention and comparison communities at baseline. At follow-up it was 5.0% in the intervention community and 7.0% in the comparison community [adjusted relative risk (RR), 0.71; 95% confidence interval (CI), 0.54-0.93; P < 0.02]. The prevalence of urethritis in males did not differ significantly between intervention and comparison groups at follow-up, but the prevalence of symptomatic urethritis was reduced by about 50% (adjusted RR, 0.51; 95% CI, 0.24-1.10; P = 0.08). There was no significant difference between the groups in the incidence of self-reported STD symptoms over the last year of the follow-up period, or in the prevalence of any STD in antenatal clinic attenders. CONCLUSION: The reduction in HIV incidence previously reported in this intervention study can be attributed to a reduction in the duration, and hence the prevalence of symptomatic STD.

PIP: A community-randomized controlled trial was conducted in Mwanza region, Tanzania, to assess the impact of improved case management for sexually transmitted diseases (STDs) at the primary health care level on the incidence and prevalence of STD. A random cohort of about 1000 adults aged 15-54 years from each of 12 communities, in 6 matched pairs, participated, with 1 member of each pair receiving the intervention and the others serving as controls. The intervention consisted of improved services to manage STDs, using the syndromic approach, in rural health units. 12,534 people were enrolled in the study, of whom 8844 were seen again 2 years later at follow-up. The prevalence of serological syphilis was 6.2% in the intervention and comparison communities at baseline. However, at follow-up, the prevalence was 5.0% in the intervention community and 7.0% in the comparison community. The prevalence of urethritis in males did not differ significantly between intervention and comparison groups at follow-up, but the prevalence of symptomatic urethritis was nonetheless reduced by about 50%. No significant difference was observed between the incidence and control groups in the incidence of self-reported STD symptoms during the last year of the follow-up period or in the prevalence of any STD in antenatal clinic attenders.

Social marketing sexually transmitted disease and HIV prevention: a consumer-centered approach to achieving behaviour change.

This paper proposes that international sexually transmitted disease (STD)/HIV prevention efforts might be enhanced by the application of social marketing principles. It first outlines the conceptual basis of social marketing approaches to health behaviour change generally and then explores key issues and opportunities for using these principles to improve current STD/HIV prevention efforts.

PIP: Social marketing is a research-driven, consumer-centered process used in the field of public health to change individuals' behavior. Social marketing differs from other health education strategies only in its approach, which is based upon commercial marketing techniques. In social marketing campaigns, social products such as condom use are viewed as commercial products and promoted using the same principles applied in the commercial sector. With consistent and long-term government commitment, social marketing programs have been highly effective. When used properly, social marketing-based public health interventions can help to prevent and control STDs and HIV. Health consumer behavior and focus, targeting and audience segmentation, social market research, the social marketing mix, and implications for social marketing STD/HIV prevention are discussed. Decreasing sexual partner change and making sex safe, improving access to effective STD treatment, and condom social marketing are then discussed as elements of social marketing to reduce sexual risk, followed by an examination of important policy considerations.

The effectiveness of barrier methods of contraception in preventing the spread of HIV.

Because barrier methods provide protection against bacterial sexually transmitted diseases, these methods are valuable public health adjuncts irrespective of their effect on HIV. Male latex condoms offer substantial protection against HIV infection. Women at risk of sexual acquisition of HIV infection need one or more prophylactic methods that they can control. While the available spermicide products may serve this purpose, current data do not allow firm casual inferences. Large and well designed epidemiologic studies are required to examine the association between female use of barrier methods and HIV infection. These are difficult and costly to perform, however, and to date have yielded conflicting results. Finally, prospective studies in high-incidence cohorts are necessary, and the relationships between spermicide use, local irritation, the vaginal flora and HIV incidence rates must be clarified.

PIP: The effectiveness of barrier methods of contraception in preventing sexually transmitted diseases (STDs) such as human immunodeficiency virus (HIV) has been assessed in vitro studies and epidemiologic research. Both types of studies have indicated that consistent use of high-quality latex condoms confers substantial protection against HIV transmission. Less certain is the capability of nonoxynol-9 to inactivate HIV. Of concern are several studies indicating that 1-8% of female nonoxynol-9 users experience signs and symptoms of tissue irritation, which can facilitate HIV transmission. These findings may reflect overenrollment of women with a high incidence of STDs and above-average (more than one per day) spermicide doses. Meetings sponsored by the World Health Organization and the US Public Health Service during 1993-94 reached consensus on five ethical and methodological principles to govern studies investigating whether currently available nonoxynol-9 spermicides reduce the incidence of HIV infections: 1) a randomly allocated controlled trial in which all participants are given male condoms; 2) allocation of half the women to an active spermicidal product and the other half to a placebo product; 3) counseling participants to use both a condom and the vaginal product at every coital act; 4) sufficient study size to measure HIV rate ratios within frequency strata; and 5) inclusion of colposcopic examinations and regular appraisal of participant safety by a data and safety monitoring board. Studies of less irritating yet effective spermicidal compounds, the determinants of consistent use of barrier methods, and the impact of social marketing are also recommended.

Decreased incidence of sexually transmitted diseases among trucking company workers in Kenya: results of a behavioural risk-reduction programme.

OBJECTIVE: To establish a cohort of high-risk individuals suitable for HIV-prevention trials, and to measure changes in sexual behaviour and sexually transmitted disease (STD) incidence after a behavioural intervention. DESIGN: Prospective cohort study in trucking company depots in Mombasa, Kenya. PARTICIPANTS: A total of 556 male HIV-seronegative employees of trucking companies. INTERVENTIONS: HIV serological testing, individual counselling, condom promotion, STD diagnosis and management. MAIN OUTCOME MEASURES: Sexual risk behaviour and symptomatic STD incidence. RESULTS: Using time-trend modelling, significant declines in self-reported high-risk sexual behaviour were demonstrated during a 1-year follow-up. The percentage of men reporting any extramarital sex during the 3-month period prior to a follow-up visit decreased from 49% durig the first quarter of follow-up to 36% during the last quarter (P < 0.001). The decline in reported female sex worker contact was from 12% to 6% (P = 0.001). Approximately 30% of men reported consistent condom use during extramarital sex and this percentage remained unchanged during the study period. The incidence of STD declined from 34 per 100 person years (PY) during the first quarter to 10 per 100 PY during the last quarter (P = 0.001). Significant reductions in gonorrhoea (15 to five cases per 100 PY, P = 0.04), non-gonococcal urethritis (10 to two cases per 100 PY, P = 0.05), and genital ulcer disease (nine to two cases per 100 PY, P = 0.02) were observed. CONCLUSIONS: Among truck company workers who participated in a cohort study in Mombasa, Kenya, there was a significant decrease in sex with high-risk partners, but no change in condom use. The change in heterosexual risk behaviour was accompanied by a significant decrease in incidence of gonorrhoea, non-gonococcal urethritis, and genital ulcer disease.

PIP: 556 male HIV-seronegative male employees of trucking companies in Mombasa, Kenya, were exposed to HIV serological testing, individual counseling, condom promotion, and sexually transmitted disease (STD) diagnosis and management, and returned for at least one follow-up visit in a prospective study to measure changes in sexual behavior and STD incidence after the intervention. There was a significant decrease in sex with high-risk partners over the 1-year period of follow-up, but no change in condom use among study participants; 30% of men reported consistent condom use during extramarital sex throughout the study period. The change in heterosexual risk behavior was accompanied by a significant decrease in the incidence of gonorrhea, nongonococcal urethritis, and genital ulcer disease. The percentage of men reporting extramarital sex decreased from 49% to 36%, while contact with female prostitutes declined from 12% to 6%.

Risk factors for HIV-1 transmission from HIV-seropositive male blood donors to their regular female partners in northern Thailand.

OBJECTIVE: To describe risks for HIV transmission from male blood donors to their regular female sex partners in Chiang Mai, Thailand. DESIGN: Cross-sectional study. METHODS: From March 1992 through September 1995, 405 HIV-seropositive male blood donors (index cases) and their regular female partners were enrolled in the study. Women with risk factors for HIV infection other than sexual contact with the index male were excluded. Couples were interviewed and examined; specimens were collected for laboratory analysis. RESULTS: Overall, 46% of the 405 women enrolled were HIV-positive. Ninety-eight per cent of male index cases had a history of sex with a female prostitute; 1.5% reported always using condoms with their regular partner. History of sexually transmitted disease (STD) and swollen inguinal lymph nodes in the female partner were associated with an increased risk of HIV infection in the female. History in the female of genital herpes [odds ratio (OR), 3.46; 95% confidence interval (CI), 1.50-8.78], gonorrhea or chlamydia infection (OR, 2.71; 95% CI, 1.39-5.53), and stable relationship of longer than 24 months (OR, 2.28; 95% CI, 1.02-5.09) were associated with an increased risk of HIV infection in the female. Consistent condom use in the past 2 years (OR, 0.10; 95% CI, 0.01-0.79) was associated with a decreased risk of HIV infection in the female. CONCLUSIONS: Married women in northern Thailand who appear otherwise to be at low risk for HIV infection may be exposed to this virus by their husbands. High rates of sex with commercial sex workers among men and low use of condoms within stable relationships may be important factors promoting the transmission of HIV in married couples. Programs to increase the regular use of condoms among married couples could be an important public health intervention to prevent transmission of HIV and other types of STD in northern Thailand.

PIP: The risk factors for HIV transmission from infected male blood donors to their regular female sex partners were investigated in a cross-sectional study conducted in Chiang Mai, Thailand, in 1992-95. During the 3.5-year study period, 405 couples were recruited. 98% of male blood donors reported a history of sex with female prostitutes. Only 28 men (7%) were aware of their seropositivity prior to notification by the blood bank, and just 1.5% always used condoms with their regular sex partner. 187 (46%) of the 405 female sex partners--none of whom had HIV risk factors other than sexual contact with their husbands--were HIV-positive at baseline. In the multivariate analysis, three variables were associated with a significantly increased risk of HIV in female partners: history of genital herpes (odds ratio (OR), 3.46; 95% confidence interval (CI), 1.50-8.78), history of gonorrhea or chlamydia (OR, 2.71; 95% CI, 1.39-5.53), and a stable relationship of at least 2 years' duration (OR, 2.28; 95% CI, 1.02-5.09); consistent condom use in the past 2 years was significantly associated with a decreased risk of HIV (OR, 0.10; 95% CI, 0.01-0.79). Medroxyprogesterone acetate injection and oral contraceptive use were not associated with HIV risk. These findings confirm a high risk of HIV transmission through monogamous sexual relationships in Thailand. Recommended are campaigns to increase regular condom use among married couples.

Traditional Balinese youth groups as a venue for prevention of AIDS and other sexually transmitted diseases.

OBJECTIVES: Our aims were to assess the feasibility of conducting peer-led educational interventions against AIDS and other sexually transmitted diseases (STDs) through traditional Balinese youth groups and to gather information on sexual risk-taking and its correlates among Balinese youth. DESIGN: A cross-sectional survey was conducted, with follow-up questionnaires for pilot intervention participants. SUBJECTS AND METHODS: A self-administered questionnaire was given to 375 subjects (aged 16-25 years) from 12 youth groups representing four main resort areas in Bali. Post-intervention data were collected from 97 of these subjects who had taken part in pilot educational programs. Focus groups supplemented survey data in evaluating the intervention and understanding risk behaviors. RESULTS: In a cross-sectional survey, one-quarter of males and few females reported sexual activity; subsequent focus groups suggested under-reporting by females. While knowledge and worries about HIV/AIDS were high, only 10% of sexually active males and no females reported consistent condom use. The mean age of first sexual intercourse was highly correlated with first alcohol consumption (P = 0.0003). Peer educators from selected youth groups planned and implemented interventions for their own groups. Post-intervention data indicated significant increases in communication about sexual issues with friends and parents. Condom attitudes became less negative and efficacy increased. Participants reported this as a first experience with peer-led health education, preferred interactive activities to adult-led lectures and recommended follow-up educational sessions. CONCLUSIONS: Peer educators from traditional youth groups can plan and conduct prevention programs for HIV/STDs that are well-received by their group memberships. Using such venues may be an efficient way to reach a wide range of pre-sexual Balinese youth, as well as those already at risk for HIV/STD due to unprotected sex, alcohol consumption and multiple sexual partners.

PIP: In a 1995 survey of Balinese youth, 75% expressed a desire to discuss sexual issues and AIDS/sexually transmitted diseases (STDs) with their peers. A cross-sectional survey of 375 young people 16-25 years of age assessed the feasibility of using traditional Balinese youth groups as a vehicle for peer-led AIDS education. In Bali virtually all youth, regardless of educational level or socioeconomic status, join the youth group in their neighborhood at puberty and remain members until they marry. The average age at first intercourse reported in the baseline survey was 18.8 years for males and 20.0 years for females. For 46% of sexually active males, intercourse was accompanied by alcohol consumption. Although youth had adequate knowledge of AIDS before the intervention, only 10% of sexually active males reported consistent condom use. Follow-up interviews with 97 young people from 3 resort areas of Bali who were exposed to the peer-led intervention revealed significant increases in communication about sexual matters with friends and family, more positive attitudes toward condoms, and increased condom use. Exposed youth who participated in focus group discussions expressed a preference for peer-led interactive activities over lectures and indicated they felt more comfortable asking their peers questions about sex. Use of peer educators from Balinese youth groups appears to represent an efficient way to reach young people before the initiation of sexual activity as well as those at high risk of AIDS and other STDs as a result of unprotected sex, alcohol consumption, and multiple sexual partners.

Female-controlled methods to prevent sexual transmission of HIV.

UNLABELLED: THE NEED FOR PREVENTION: Women throughout the world face a growing risk of infection with HIV. Consistent condom use, one cornerstone of primary prevention strategy, is not always feasible for many women. Consequently, women urgently need infection prevention technology that is within their personal control. METHODS: This session will review current efforts to develop and test female-controlled methods for preventing sexual transmission of HIV and other sexually transmitted pathogens. Both physical and chemical methods will be summarized, including recent findings concerning the efficacy and acceptability of the vaginal pouch (female condom), as well as an overview of research on vaginal microbicides. Data from studies of existing over-the-counter spermicides will be reviewed. The wide range of novel microbicidal products currently being evaluated in the laboratory and early clinical trials demonstrate the breadth of possibilities presented by chemical barrier methods. However, formidible challenges face public and private sector research and development efforts. This session will conclude by highlighting several issues related to the clinical evaluation and introduction of female-controlled prevention technology.

PIP: This article presents a literature review of contraception research on female-controlled methods that prevent transmission of HIV infections and other sexually transmitted diseases (STDs). The review includes efforts to develop and test new methods in laboratory and clinical trials. The main research challenges are a better understanding of reproductive biology pertaining to STD and HIV transmission, better animal models for determining safety and efficacy of candida microbicides, improved methods for conducting HIV and STD incidence cohort analyses in communities at risk, and improved understanding of the determinants of vaginal product use. Product development challenges include testing a range of new products that evolved or will evolve from a better understanding of the role of mucosal immunity, normal flora, and other aspects of vaginal ecology. Funding for research and development of female-controlled methods is low. Private pharmaceutical companies have a low investment in these methods due to liability, regulatory uncertainty, and the perception of marginal profitability. Clinical trials are costly. Alliances must be formed across disciplines within the scientific community, between scientists and the communities at risk, and with industrial partners. Women living with HIV infection should be involved. HIV infection is a greater risk to women in developing countries, particularly poor countries. Data reveal that HIV infections among women are transmitted through vaginal intercourse, and the presence of STDs often facilitates transmission. Female-controlled methods are not a substitute for male condoms but a form of protection for women who are unable to negotiate for safer sex and an option for increasing choice. This review includes new barrier methods (diaphragms, cervical caps, and female condoms), vaginal microbicides, existing spermicides, and novel vaginal microbicides.

A randomized, community trial of intensive sexually transmitted disease control for AIDS prevention, Rakai, Uganda.

OBJECTIVE: To describe the design and first-round survey results of a trial of intensive sexually transmitted disease (STD) control to reduce HIV-1 incidence. STUDY DESIGN: Randomized, controlled, community-based trial in Rakai District, Uganda. METHODS: In this ongoing study, 56 communities were grouped into 10 clusters designed to encompass social/sexual networks; clusters within blocks were randomly assigned to the intervention or control arm. Every 10 months, all consenting resident adults aged 15-59 years are visited in the home for interview and sample collection (serological sample, urine, and, in the case of women, self-administered vaginal swabs). Sera are tested for HIV-1, syphilis, gonorrhea, chlamydia, trichomonas and bacterial vaginosis. Following interview, all consenting adults are offered directly observed, single oral dose treatment (STD treatment in the intervention arm, anthelminthic and iron-folate in the control arm). Treatment is administered irrespective of symptoms or laboratory testing (mass treatment strategy). Both arms receive identical health education, condom and serological counseling services. RESULTS: In the first home visit round, the study enrolled 5834 intervention and 5784 control arm subjects. Compliance with interview, sample collection and treatment was high in both arms (over 90%). Study arm populations were comparable with respect to sociodemographic and behavioral characteristics, and baseline HIV and STD rates. The latter were high: 16.9% of all subjects were HIV-positive, 10.0% had syphilis, and 23.8% of women had trichomonas and 50.9% had bacterial vaginosis. CONCLUSIONS: Testing the effects of STD control on AIDS prevention is feasible in this Ugandan setting.

PIP: An ongoing (1994-98) randomized, community-based trial in Uganda's Rakai District is assessing the assumption that intensive sexually transmitted disease (STD) control efforts result in marked declines in HIV/AIDS prevalence. Described, in this article, are the project design and findings of the first-round baseline survey. 56 communities were grouped into 10 clusters designed to encompass social/sexual networks and clusters within blocks were randomly assigned to the intervention or control arm. All consenting permanent residents of the district are visited in their homes at 10-month intervals where they are administered extensive questionnaires, provide urine and vaginal swab samples, and are offered mass treatment regardless of symptoms or laboratory testing (single oral dose STD treatment in the intervention arm and anthelmintics and iron folate in the control arm). Both groups receive identical health education, condom promotion, and serologic counseling services. In the first round of home visits, 5834 intervention and 5784 control arm subjects were enrolled, representing about 90% of eligible adults. The groups were comparable in terms of sociodemographic and behavioral characteristics and baseline rates of HIV and STDs. 16.9% of subjects were HIV-positive, 10.0% had syphilis, 23.8% of women had trichomonas, and 50.9% had bacterial vaginosis. Detailed STD assessment is expected not only to document the relationship between STD control and HIV, but also to identify which STDs confer the greatest population attributable risk for HIV transmission, facilitating targeted control efforts in the future.

Improving sexually transmitted disease management in the private sector: the Jamaica experience.

OBJECTIVES: To improve the quality of sexually transmitted disease (STD) case management in Jamaica by providing comprehensive continuing medical education to private practitioners who manage 60% of all STDs on the island. METHODS: Six half-day STD seminars were presented at 3-4-month intervals and repeated in three separate geographic locations. All Jamaican practitioners received invitations. The subjects were as follows: urethritis, genital ulcer disease, HIV infection, vaginal discharge syndrome, STDs in children and adolescents, and a review seminar. The program effectiveness was evaluated with a written, self-reported pre-test and a telephone post-test that measured changes in clinical management. RESULTS: Six hundred and twenty eight practitioners attended at least one seminar. Comparing pre- versus post-test scores, there were practitioner improvement trends in all four of the general STD management categories: counseling/education (69.8-73.3%; P > 0.05); diagnostics/screening (57.2-71.0%; P= 0.042); treatment (68.3-74.5%; P> 0.05); and knowledge (66.4-83.2%; P= 0.002). Obtaining syphilis serologies during pregnancy rose from 38.3 to 83.8% (P= 0.001), and providing effective treatment for gonorrhea rose from 57.8 to 81.1 % (P= 0.002), but correct responses on treatment for mucopurulent cervicitis at the post-test was a low 32.4%. CONCLUSION: The introduction of continuing medical education for improved STD care targeting private physicians in Jamaica was successful based on high attendance rates and self-reported STD management practices. However, efforts should continue to address the weaknesses found in STD management and counseling and to reach the providers who did not participate. In the global effort to reduce HIV transmission by improving STD care services, continuing education programs that target the private sector can be successful and should be included as a standard activity to improve care and provide a public/private link to STD/HIV control.

PIP: The Jamaican Ministry of Health has estimated that over 60% of all sexually transmitted diseases (STDs) are managed within the private sector, where 800 (66%) of the country's 1200 registered physicians practice. To improve the quality of STD case management provided by these practitioners, the Medical Association of Jamaica organized a series of 6 half-day seminars repeated at 3-4 month intervals in three geographic locations between December 1993 and July 1995. Topics addressed included urethritis, genital ulcer disease, HIV/AIDS, vaginal discharge, pelvic inflammatory disease, and STDs in children and adolescents. A total of 628 private practitioners attended at least one seminar and almost half the physicians attended two or more. Comparisons of scores on a written pretest completed before the seminar and those from a post-test conducted by telephone after the seminar revealed significant improvements in all four general STD management categories: counseling/education, diagnostics/screening, treatment, and knowledge. The proportion of practitioners who obtained syphilis serologies during pregnancy rose from 38.3% to 83.8% and those providing effective treatment for gonorrhea increased from 57.8% to 81.1%. Overall, 96% of practitioners were providing some level of risk-reduction counseling at the time of the post-test and 74% were prescribing correct treatment regimens. Ongoing education and motivation by the national STD control program or the Medical Association are recommended to improve STD case management even further.

Knowledge of AIDS among secondary school pupils in Bagamoyo and Dar-Es-Salaam, Tanzania.

We assessed knowledge of AIDS among pupils in selected schools in Tanzania in August 1989. Four hundred and eight-one pupils from four randomly selected secondary schools, two from Dar-Es-Salaam (a city) and two from Bagamoyo (a semi-rural town), were interviewed using a structured questionnaire. Of these, 476 (99.0%) had heard of AIDS, and 447 (92.9%) were able to mention spontaneously at least one sexually transmitted disease (STD), of whom 374 (83.7%) mentioned AIDS. Knowledge was found to increase with age and tended to be higher among women in Dar-Es-Salaam than in Bagamoyo. These data suggest that communication channels directed at women in rural areas should be strengthened. While knowledge of sexual transmission of HIV was generally high, and prevalence of reported misconceptions about modes of transmission was very low, knowledge of non-sexual means of transmission (transfusions, injections, vertical) was lacking. Although 80% of pupils mentioned reduction of number of sexual partners as a means of AIDS prevention, only 22% mentioned condom use, and less than 5% reported that they had ever used a condom. Future research should concentrate on means of promoting sexual behavior change, the ultimate aim of any AIDS prevention strategy.

Changes in male sexual behaviour in response to the AIDS epidemic: evidence from a cohort study in urban Tanzania.

OBJECTIVE: To examine changes in sexual behaviour among men in urban Tanzania. DESIGN: An observational cohort study among factory workers during 1991-1994. METHODS: Data from five follow-up visits with structured questionnaire-guided interviews and biomedical data were analysed to examine trends in sexual behaviour and sexually transmitted disease/HIV among 752 men. In-depth interviews were conducted to evaluate the magnitude of reporting bias. RESULTS: During the 2 years of observation, the proportion of men with more than one sexual partner during the month preceding the interview declined from 22.3 to 12.2%. The proportion of men reporting casual sex partners during the last month was almost halved: from 9.8 to 5.2%. The decline in the reporting of extramarital partners was gradual and pronounced. There were only minor changes in reported condom use, notably an increase in use with casual partners, and no changes in coital frequency. Data from in-depth interviews confirmed that reduction in sexual partners was the predominant change. CONCLUSIONS: This study documents that, in response to the AIDS epidemic, changes in male sexual behaviour are taking place in urban areas in Africa. The predominant change among these men, who are predominantly married and aged over 25 years, is a reduction of the number of sexual partners, although condom use remains low.

PIP: During October 1991 to April 1994, health workers in Tanzania interviewed and conducted a physical examination of 752 men who had made at least 4 follow-up visits to the clinic at a large urban textile factory in Mwanza to examine trends in sexual behavior and sexually transmitted disease (STD)/HIV of factory workers and their spouses. Each man was followed for about 2 years. Researchers aimed to determine whether the intervention to reduce HIV transmission at the clinic had an impact on sex behavior. The intervention included free and effective treatment of STDs, a syphilis test at each visit, voluntary HIV counseling services, and health education activities (workshops, peer educators). The proportion of married men increased from 83.4% to 88.4% during the study period. Men were less likely to have more than 1 sexual partner in the previous month after 5 visits than before the first visit (12.2% vs. 22.3%; p 0.01 for trend). They were also less likely to have had casual partners during the previous month (5.2% vs. 9.8%; p 0.001 for trend). Married men were less likely to have extramarital relations (6.5% vs. 20.1% for regular non-cohabiting partner; p 0.01 and 2.7% vs. 8; p 0.001). Condom use in the previous month did not change significantly (2.5% vs. 3.1%; p = 0.377). It did increase significantly with a casual partner, however (7.6% vs. 27.3%; p = 0.002 for trend). Frequency of intercourse did not change. The HIV-incidence rate decreased considerably (1.77 vs. 0.66/100 person-years of observation for a rate ratio of 0.37). Multiple sex partners in the previous month was more common among men 20-29 years old or who consumed moderate or excessive amounts of alcohol than among those over age 40 or who consumed no alcohol. These findings suggest that even though sexual activity did not decline, it became more commonly with 1 partner and within marriage, especially among men 40 and older who did not drink alcohol. Condom use remained low, except with casual partners. ¿

Involving traditional healers in AIDS education and counselling in sub-Saharan Africa: a review.

PIP: Traditional healers are the preferred and most accessible care providers in Africa. The AIDS epidemic in sub-Saharan Africa has stimulated interest on the part of modern biomedical health practitioners in collaboration with these traditional healers. The literature includes numerous studies of healers' perceptions of HIV/AIDS and other sexually transmitted diseases. On the basis of study findings, healers have been trained as educators and counselors to disseminate HIV/AIDS information and prevention practices among their peers and communities. This article reviews the initial outcomes and challenges of such new initiatives in Zambia, Uganda, Botswana, Malawi, Mozambique, South Africa, and Central African Republic. None of the projects has completed a comprehensive evaluation of the different approaches used and their real impact on the population served. Overall, however, the case studies indicate that traditional healers are capable of performing at least as well as their biomedical counterparts as AIDS educators and counselors. Of concern is the failure of many projects to provide systematic follow-up to healers after their initial training. Such follow-up is essential to support healers in dealing with unfamiliar issues such as condom use and death and dying.^ieng

Targeted intervention research studies on sexually transmitted diseases (STD): methodology, selected findings and implications for STD service delivery and communications.

OBJECTIVE: To report the findings of qualitative studies designed for use in improving sexually transmitted disease (STD) programs. The studies explore illness conceptions and treatment behaviors for STD in five African countries. These targeted intervention research (TIR) studies were performed on clinic-based and community-based samples in representative communities and utilized a variety of qualitative research methods (e.g. in-depth and key informant interviews, focus group discussions). FINDINGS: Study findings revealed that community members' explanations of symptoms, classification of illnesses, and perceptions of whether symptoms are pathological or serious influence individual health-care-seeking behaviors. Data also showed that local terms for STD are often disparaging and do not fit into biomedical designations. STD patient care-seeking frequently reflects an ordered, albeit loosely constructed, process of elimination in pursuit of symptom relief, wherein alternative treatments are tried and proven effective or abandoned. CONCLUSIONS: The TIR studies highlight the importance of community-specific strategies aimed at increasing prompt care seeking at qualified biomedical facilities. Information from study data should lead programs to sensitize health professionals to community understanding about STD and to design services and communication programs that are meaningful and appropriate to local contexts.

PIP: Targeted intervention research (TIR) studies were performed in five African countries (Senegal, Ethiopia, Benin, Morocco, and Swaziland) to improve the utilization of a community perspective in sexually transmitted disease (STD) programs. TIR, conducted by program managers with the aid of a multidisciplinary technical advisory group, examines factors at five levels of analysis (individual, social network, organization, community, and policy) through a variety of qualitative methods. The TIR studies indicated that patients' conceptions of normal versus abnormal health are fundamental to the process of interpreting symptoms and subsequently seeking care. The interpretation of STD symptoms varied across settings (e.g., vaginal lesions and discharge were considered signs of healing in Morocco and Benin), but increasing pain and discomfort were key triggers to seeking treatment. The concept of sexual transmission was blended with other causes such as violation of religious or moral codes, consumption of certain foods, and supernatural forces. Care-seeking tended to reflect an ordered yet loosely constructed process of elimination in pursuit of symptom relief, beginning with alternative regimens. Barriers to biomedical STD care included the need for husband's permission, costs, confidentiality concerns, long waits in public clinics, and fear of judgmental health provider attitudes. Overall, the findings highlight the importance of location-specific strategies aimed at increasing prompt care-seeking at qualified biomedical facilities.

HIV and other sexually transmitted diseases among female prostitutes in Kinshasa.

In 1988, 1233 prostitutes from different geographic areas of Kinshasa participated in a cross-sectional survey on HIV infection and other sexually transmitted diseases (STDs). Despite relatively good knowledge about AIDS and STDs, the reported preventive behaviour was poor. Only 12% of the women reported regular use of condoms, while greater than 50% of the women reported regular use of antibiotics and 38% reported doing nothing specific to prevent STDs. Thirty-five per cent of the women were HIV-positive compared with 27% in a similar survey in Kinshasa in 1986. The prevalence of other STDs was very high, ranging from 5% for genital ulcer disease (GUD) to 23% for gonococcal infection. HIV-positive women were older than HIV-negative women (26.9 versus 25.4 years; P less than 0.001), had a significantly lower level of reported condom use (9 versus 14%, P = 0.009), and reported more frequent use of antibiotics to prevent STDs (55 versus 42%, P = less than 0.001). The prevalence of syphilis, gonorrhoea, chlamydial infection and trichomoniasis was not higher in HIV-positive women compared with HIV-negative women. However, HIV-positive women had a higher prevalence of GUD (9 versus 3%, P less than 0.001), antibodies against Haemophilus ducreyi (82 versus 57%, P less than 0.001), antibodies against herpes simplex virus type 2 (96 versus 76%, P less than 0.001), condylomata accuminata (5 versus 1%, P = 0.003) and cytologic evidence of human papilloma virus on Papaniclaou cervical smear (11 versus 5%, P = 0.006). This study confirms the high incidence of HIV and other STDs among prostitutes in Africa.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of spermicide containing nonoxynol-9 in the prevention of HIV infection.

PIP: In 1980, the US Food and Drug Administration found nonoxynol 9 to be safe and effective as a vaginal contraceptive and, with regard to local toxicity, its decision on results of only 1 animal study and the shortage of reported significant adverse effects in humans, and not on clinical trials. Even though little research has looked specifically at vaginal spermicide toxicity to genital and rectal epithelia, other research reported genital irritation rates ranging from minimal to 10%. Nevertheless most literature reviews on nonoxynol 9 concluded that any reports of local toxicity were only minimally significant. Many studies have indicated that nonoxynol 9 protects against sexually transmitted diseases, but most of these did not control for consistency and frequency of use, different sexual practices, and the use of barrier methods. In fact, 1 study revealed a positive association between nonoxynol 9 and candida infections. In vitro research has consistently demonstrated nonoxynol 9's ability to inactivate HIV, but little research in humans exists on its safety and effectiveness in preventing HIV infection. The earliest report of local toxicity involved research in Nairobi, Kenya. It revealed who used vaginal sponges with nonoxynol 9 than those who used vaginal suppositories without it. These genital ulcerations may have indeed facilitated HIV entry thereby contributing to the higher incidence of new HIV infections among those using nonoxynol 9. Another study revealed that among 71 sex workers using condoms lubricated with nonoxynol 9 in Vancouver, British Columbia 53.5% reported adverse reactions. In the recent past, published information about AIDS in the US and UK promoted use of condoms lubricated with nonoxynol 9, but did not tell users about the possible adverse effects. Since research has not verified the safety of nonoxynol 9 with regard to local toxicity, its potential benefits in HIV prevention cannot yet be determined.^ieng

Controlling HIV in Africa: effectiveness and cost of an intervention in a high-frequency STD transmitter core group.

Since 1985, a population of over 1,000 predominantly HIV-positive female prostitutes residing in a low-income area of Nairobi, has been enrolled in a sexually transmitted disease (STD)/HIV control programme. The major elements of the programme include the diagnosis and treatment of conventional STD, and the promotion of condom use to prevent the transmission of HIV and other sexually transmitted infections. Using estimates of numbers of HIV-seropositive prostitutes, numbers of sexual contacts, susceptibility of clients to HIV, HIV transmission efficiency, rates of condom use and the basic reproductive rate of HIV infection in Kenya, we estimate that the programme is responsible for preventing between 6,000 and 10,000 new cases of HIV infection per year among clients and contacts of clients. The total annual operating cost of the programme is approximately US$77,000 or between US$8.00 and US$12.00 for each case of HIV infection prevented. Programmes to reduce the transmission of HIV and other sexually transmitted infections which are targeted at high-frequency STD transmitters, such as prostitutes, can be effective and relatively inexpensive to undertake. More such programmes should be developed and evaluated in different settings.