Treatment of sexually transmitted infections (STIs) and behavioural interventions are the main methods to prevent HIV in developing countries. Anatoli Kamali from the Medical Research Council Programme on AIDS in Uganda and colleagues assessed the effect of behaviour change and STI management on the incidence of HIV-1 and other STIs in Uganda.
All adults living in 18 communities in rural Uganda were randomly allocated into three groups: the first group received behavioural interventions alone (promotion of safer sex behaviour); the second group received both behavioural and STI interventions; the third was a control group where individuals received routine government health services and community development activities.
Follow-up took place after three and a half to four years. Only condom use with last casual partner increased significantly more in the two intervention groups compared with the control group. Despite significant reductions in acute syphilis, gonorrhoea, and unprotected casual sex in the combined intervention group, there was no effect on HIV incidence attributable to either intervention. The investigators comment that more effective STI and behavioural interventions need to be developed for HIV control in mature epidemics in countries like Uganda.
Judith Stephenson and Frances Cowan from the Royal Free and University College Medical School, London, UK, observe in an accompanying Commentary (p 633) that the timing of the study could partly explain the surprising results; the fact that the overall HIV incidence is falling in Uganda suggests that the study could have been underpowered to detect substantial differences in HIV incidence between the intervention and control groups. They conclude: "What does this tria
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