TO: HIV Prevention Technical Working Group of Botswana
FROM: Ministry of Health
DATE: November 2, 2011
SUBJECT: Population-level STD Control To Lower Incidence of HIV-1 Infection
HIV penetrates all levels of society in Botswana with a prevalence of around 25%, the second highest prevalence in sub-Saharan Africa, affecting 320,000.1 Although enough evidence show that STD control reduces risk of acquiring or transmitting HIV at an individual level, few studies have proven this intervention effective at the population-level. Several studies utilizing different intervention methods have produced mixed conclusions regarding population-level STD control and incidence of HIV. Careful analyses of these studies are summarized below for Botswana’s future recommended action to uptake STD intervention programs.
Relevant Evidence from Mwanza study2
- Grosskurth et al. claim that syndromic STD treatment significantly reduced HIV incidence by 40% (p=0.04). The extensive STD intervention program involved five key components that go beyond just STD treatment: 1) establishment of a local STD reference clinic and laboratory, 2) training of existing staff from health centers and dispensaries, 3) regular supply of drugs to treat STDs effectively, 4) regular supervisory visits by a program officer, 5) periodic visits by a team of health educators to the villages served.
- This intervention targets symptomatic patients and relies on individuals to seek treatment. This method maximize drug use such that only those truly affected with STDs are treated; however, many who are affected but are asymptomatic and those who do not seek treatment will be left untreated.
Relevant evidence from Rakai study3
- Wawer et al. claims that there is no effect of STD intervention on the incidence of HIV infection and that STD is not a dependent cofactor of HIV acquisition. The intervention involved a randomized, single-masked, home-based mass antibiotic treatment while the control received mass vitamins/anthelmintic treatment.
- Both treatment and control drugs were given and taken in presence of the project worker, which ensures compliance. However, being a single-masked intervention, project workers can consciously or subconsciously give cues to subjects as to which treatment they are receiving. This can affect participant’s behaviors skewing the study’s results.
- Control group did not receive a biologically inert treatment usually expected of a placebo. The mass anthelmintic, vitamin, and iron-folate treatment does have beneficial outcomes for subject’s overall health that could account for the non-significant difference between treatment groups.
Listed are some recommendations which have taken the strengths of these interventions with modification based on its limitations:
- Administer mass STD treatment at baseline. By starting with the Rakai approach, treatment will reach the whole population and ensure complete compliance. Assuming 90% success of treatment, this will equalize the population’s STD status at baseline. Successfully doing so will create a more manageable situation in which patients are still able to seek treatment similar to the Mwanza study after the initial mass treatment that will also cover those who are asymptomatic or those who would normally not seek treatment.
- Form all necessary local establishments needed for a sustainable program. Extensive establishment of the program seen in the Mwanza study creates local support and involvement. Equipping Botswana with such establishments will empower them to sustain the intervention independently and push for improved infrastructure where it is needed which will benefit not only the program, but the communities as well.
- Continue sexual education. STD management will reduce STD prevalence in hope of reducing HIV incidence; however, STD treatment does not tackle its root cause. Sexual behavior change is required for a more permanent change not involving medication and sexual education should be continued and not forgotten in lieu of the available STD treatment.
With stacking evidence of STD management being an effective tool in preventing the spread of HIV at the individual level suggests that there is no reason it would not work at the population level.4 The key is developing an effective intervention program that can successfully target whole communities. Utilizing the strengths and learning from the limitations of these studies, I believe that my recommendations can be operative in Botswana. Careful consideration of my recommendations can lead to better population health that in turn will have beneficial economic impact by increasing the number of able workers, reducing orphaned children, and better distribution of energy investment at the individual level. Having been the first African country to aim to provide antiretroviral drugs made Botswana an example for other African nations to follow, let the implementation of STD management be another action for others to imitate. If you have any questions, please feel free to contact me as I will be glad to discuss my recommendations in greater detail.
1 UNAIDS, “AIDSinfo Country Fact Sheets”, 2009, accessed Nov. 1 2011
2 Grosskurth, H., Mosha, F., Todd, J., Mwijarubi, E., Klokke, A., Senkoro, K., Mayaud, P., Changalucha, J., Nicoll, A., ka-Gina, G., Newell, J., Mugeye, K., Mabey, D., Hayes, R. (1995). Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomized controlled trial. The Lancet, 346, 530-536.
3 Wawer, M.J., Sewankambo, N.K., Serwadda, D., Quinn, T.C., Paxton, L.A., Kiwanuka, N., Wabwire-Mangen, F., Li, C., Lutalo, T., Nalugoda, F., Gaydos, C.A., Moulton, L.H., Meehan, M.O., Ahmed, S., Rakai Project Study Group, Gray, R.H. (1999). Control of sexually transmitted diseases for AIDS prevention in Uganda: a randomized community trial. The Lancet, 353, 525-536.
4 CDC, “Sexually Transmitted Diseases (STDs)”, Sept. 2010, accessed Nov. 2 2011 <http://www.cdc.gov/std/hiv/STDFact-STD-HIV.htm>