Recorded presentation

Lisa E. Manhart, PhD and King K Holmes, MD. Departments of Epidemiology and Medicine, University of Washington, 325 9th Avenue, Seattle, WA 98104-2499, (206) 731-3646, lmanhart@u.washington.edu

Background: Advancing multi-level epidemiologic and prevention research for STD/HIV must be founded in critical review of existing interventions. Many reviews of interventions have included trials with quasi-experimental study designs, convenience samples, non-biomedical endpoints, and/or passive ascertainment of biomedical outcomes, all of which can lead to bias. We review randomized controlled trials of interventions to prevent sexual transmission of any STI, employing a multi-level perspective. Methods: We searched MEDLINE, the Cochrane CENTRAL Registry, and recent unpublished presentations through 2003 to identify randomized controlled trials of STI prevention interventions having systematic, objective measurement of STI outcomes. We classified trials according to intervention target and level of randomization (individual, group, or community); impact target (acquisition, transmission, or complications of STI); and primary intervention modality. Results: Of 82 trials identified, 40 met inclusion criteria, including 27 individual-level, 9 group-level, and 4 community-level interventions. Among individual- and group-level interventions, 31 targeted acquisition, 4 transmission, and 1 complications of STI. The four intervention modalities most often used included behavior change interventions (11 studies), vaccination (7), topical microbicide (10) and prophylactic, curative, or suppressive therapy (10). Community-level interventions had multiple impact targets and two employed multiple modalities. Only one intervention showed efficacy against sexual transmission of HIV, but 22 (53.7%) reported effectiveness against other STIs. Conclusions: Despite many interventions found effective against STI, few have been replicated, widely implemented, or carefully evaluated for effectiveness in other settings. We will discuss implications of the reviewed trials on future intervention development and offer guidelines for prioritizing limited resources.

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