Sexually transmitted infection control has not been shown to decrease HIV incidence.
When the ill fated World Health Organization Global Programme on AIDS segued into the Joint UN Programme on HIV/AIDS almost twenty years ago, sexually transmitted infection control public health doctors appeared to be in control of the global response to HIV. They were a well meaning lot who were often looked down upon by other disease control specialists. Their inability to control gonorrhea and syphilis, much less eradicate them, was not much of a problem. But when sexually transmitted HIV began to spread around the world, they gained money and power and the lack of effectiveness of their work began to be seen. It had little impact.
By the late 1980s, health scientists had found that sexually transmitted infections were associated with HIV infection. They also knew then that lack of circumcision, too, was associated with HIV infection. Inflammation from sexually transmitted infections increased HIV acquisition and transmission. It was biologically plausible that improved control of sexually transmitted infections would lead to improved HIV control. Hope was high.
The first trial to test this hypothesis was promising. First trials often are. But this trial was followed by several more trials that failed to show an impact. It has slowly dawned on HIV prevention professionals that sexually transmitted infection control would fail to decrease HIV incidence.
Two respected HIV prevention scientists have been brave enough to write what many others are thinking:
“Control of sexually transmitted infections provides important benefits for public health and individuals, and should unquestionably be provided and promoted for this reason. However, the hypothesis that control of sexually transmitted infections can prevent the spread of HIV in populations has been extensively tested and is not supported by evidence in seven of eight trials. It is, therefore, questionable whether control of such infections should be promoted specifically for HIV prevention in HIV-negative populations.”
Reassessing the hypothesis on STI control for HIV prevention
The Lancet, Volume 371, Issue 9630, Pages 2064 - 2065, 21 June 2008
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2808%2960896-X/fulltext
Many countries have spent millions of dollars in the last several years trying to control their sexually trasnmitted infection epidemics. Although HIV incidence is falling among some populations with high prevalence, new sexually transmitted infection rates are in general not falling. Chlamydia, syphilis, and gonorrhea are more transmissible than HIV.
Control of sexually transmitted infections has many public health benefits. Thirty years into the epidemic, control of HIV has not been shown to be one of them.
There is a great opportunity cost to spending money on sexually transmitted infection control as an ineffective measure against HIV. Let’s stop spending this money to try to prevent HIV infection.
Jamie
