Improved knowledge of sexual health not translating into HIV decline

[Guest guest]

Improved knowledge of sexual health not translating into HIV decline

in adolescents in 8-year trial

Alcorn, Tuesday, December 09, 2008

A large randomised controlled trial of sexual and reproductive health

interventions in schools, health services and communities and

Tanzania has found that while the interventions increased adolescent

knowledge about sexual health, they had no significant impact on HIV

transmission or other sexually transmitted infections, nor on

pregnancy rates.

The findings were presented last week at the Fifteenth International

Conference on AIDS and Sexually Transmitted Infections in Africa,

held in Dakar, Senegal.

HIV prevention among young people is an urgent priority, since

according to UNAIDS 45% of HIV transmission worldwide takes place in

young people aged 15-24 years. However there is still a lack of

evidence about which approaches work best in preventing new

infections, the gold standard for any HIV prevention study.

In order to accumulate more evidence about what works, researchers at

the Tanzanian National Institute for Medical Research have been

conducting research in the Mwanza region of Tanzania for nearly ten

years, in a trial which randomised twenty communities either to

receive existing services or to receive a comprehensive package of

interventions aimed at adolescents. The study is called Mema kwa

Vijana (`Good things for young people`), and was developed in

partnership with the London School of Hygiene and Tropical Medicine,

Liverpool School of Tropical Medicine and the UK's Medical Research

Council.

The intervention package consisted of:

In-school sexual and reproductive health education targeting

adolescents aged 14 years and above

Youth-friendly reproductive health services

Community-based condom promotion (between 2000 and 2002 only)

Community interventions to create a supportive environment for the

interventions

The intervention package was implemented by the African Medical

Research Foundation (AMREF).

The first evaluation, of the initial cohort of 9,645 adolescents,

looked at outcomes after three years, and found substantial

improvements in knowledge about sexual health, but no significant

difference in biological outcomes such as HIV incidence, HSV-2

infection, sexually transmitted infections and pregnancy between the

intervention communities and the control group.

Study investigators questioned whether the intervention had carried

on for long enough, and a further evaluation was carried out in 2007-

8, covering 13,814 young people who had been exposed to the

intervention between 1999 and 2002 (together with the control

population).

The second evaluation found a sustained difference in knowledge of

sexual health, although not as pronounced as in 2002, and a trend

towards delayed sexual debut in the intervention group. Condom use

was significantly higher only among young women with a non-regular

partner in the intervention group. There was no difference in the

frequency with which concurrent sexual partnerships were reported,

nor in use of health services by those who experienced symptoms of a

sexually transmitted infection in the past 12 months.

There was no significant difference in sexually transmitted

infections, HIV prevalence or HSV-2 prevalence between intervention

and control communities, despite a much larger sample size and

greater statistical power to detect a difference in the second

evaluation, and despite the fact that two-thirds of the young people

surveyed had been exposed to the in-school intervention for at least

three years.

A second study, in Zimbabwe, using a similar package of

interventions, also showed an increase in knowledge in the

intervention group, but failed to show a significant impact on new

infections.

The researchers warn that further research is needed to better define

the package of interventions that can reduce new HIV infections and

other sexually transmitted infections among young people. They note

that while the 2001 UN Declaration of Commitment on HIV/AIDS called

for 95% of young people to have access to education about sexual

health by 2010, two well-designed randomised studies now show that

changes in knowledge and attitudes as a result of interventions do

not reliably predict changes in the most important outcomes, new HIV

infections.

In other words, improving knowledge and access to services among

young people is not enough to stem HIV infections in this age group.

Other factors are clearly preventing young people from acting on the

knowledge they have acquired.

The Mema kwa Vijana study could not measure population-wide attitudes

towards sexual behaviour that continue to pressurise young people –

especially young women – to engage in unprotected sex, and the

researchers say that more work is needed to determine how population

norms were changed in countries where HIV incidence has declined,

such as Uganda and Zimbabwe.

These norms include gender- and age-related power imbalances,

reluctance to use condoms, and transactional sex, especially between

young women and older males.

While education about sexual health will continue to be necessary in

order to equip young people with knowledge, additional interventions

will be necessary. Identifying effective interventions to change

population norms related to sexual risk behaviour should be a

priority, the researchers conclude, together with the investigation

of alternative interventions.

Further information

The study has a website that provides comprehensive information about

the interventions carried out during the study.

http://www.memakwavijana.org

Briefing papers providing more detailed information on the trial

results and their policy implications are available by following this

link.

http://www.aidsmap.com/en/news/07DE1C91-62B6-4F99-8610-

5FAFF2326F8B.asp

[Guest guest]

Improved knowledge of sexual health not translating into HIV decline

in adolescents in 8-year trial

Alcorn, Tuesday, December 09, 2008

A large randomised controlled trial of sexual and reproductive health

interventions in schools, health services and communities and

Tanzania has found that while the interventions increased adolescent

knowledge about sexual health, they had no significant impact on HIV

transmission or other sexually transmitted infections, nor on

pregnancy rates.

The findings were presented last week at the Fifteenth International

Conference on AIDS and Sexually Transmitted Infections in Africa,

held in Dakar, Senegal.

HIV prevention among young people is an urgent priority, since

according to UNAIDS 45% of HIV transmission worldwide takes place in

young people aged 15-24 years. However there is still a lack of

evidence about which approaches work best in preventing new

infections, the gold standard for any HIV prevention study.

In order to accumulate more evidence about what works, researchers at

the Tanzanian National Institute for Medical Research have been

conducting research in the Mwanza region of Tanzania for nearly ten

years, in a trial which randomised twenty communities either to

receive existing services or to receive a comprehensive package of

interventions aimed at adolescents. The study is called Mema kwa

Vijana (`Good things for young people`), and was developed in

partnership with the London School of Hygiene and Tropical Medicine,

Liverpool School of Tropical Medicine and the UK's Medical Research

Council.

The intervention package consisted of:

In-school sexual and reproductive health education targeting

adolescents aged 14 years and above

Youth-friendly reproductive health services

Community-based condom promotion (between 2000 and 2002 only)

Community interventions to create a supportive environment for the

interventions

The intervention package was implemented by the African Medical

Research Foundation (AMREF).

The first evaluation, of the initial cohort of 9,645 adolescents,

looked at outcomes after three years, and found substantial

improvements in knowledge about sexual health, but no significant

difference in biological outcomes such as HIV incidence, HSV-2

infection, sexually transmitted infections and pregnancy between the

intervention communities and the control group.

Study investigators questioned whether the intervention had carried

on for long enough, and a further evaluation was carried out in 2007-

8, covering 13,814 young people who had been exposed to the

intervention between 1999 and 2002 (together with the control

population).

The second evaluation found a sustained difference in knowledge of

sexual health, although not as pronounced as in 2002, and a trend

towards delayed sexual debut in the intervention group. Condom use

was significantly higher only among young women with a non-regular

partner in the intervention group. There was no difference in the

frequency with which concurrent sexual partnerships were reported,

nor in use of health services by those who experienced symptoms of a

sexually transmitted infection in the past 12 months.

There was no significant difference in sexually transmitted

infections, HIV prevalence or HSV-2 prevalence between intervention

and control communities, despite a much larger sample size and

greater statistical power to detect a difference in the second

evaluation, and despite the fact that two-thirds of the young people

surveyed had been exposed to the in-school intervention for at least

three years.

A second study, in Zimbabwe, using a similar package of

interventions, also showed an increase in knowledge in the

intervention group, but failed to show a significant impact on new

infections.

The researchers warn that further research is needed to better define

the package of interventions that can reduce new HIV infections and

other sexually transmitted infections among young people. They note

that while the 2001 UN Declaration of Commitment on HIV/AIDS called

for 95% of young people to have access to education about sexual

health by 2010, two well-designed randomised studies now show that

changes in knowledge and attitudes as a result of interventions do

not reliably predict changes in the most important outcomes, new HIV

infections.

In other words, improving knowledge and access to services among

young people is not enough to stem HIV infections in this age group.

Other factors are clearly preventing young people from acting on the

knowledge they have acquired.

The Mema kwa Vijana study could not measure population-wide attitudes

towards sexual behaviour that continue to pressurise young people –

especially young women – to engage in unprotected sex, and the

researchers say that more work is needed to determine how population

norms were changed in countries where HIV incidence has declined,

such as Uganda and Zimbabwe.

These norms include gender- and age-related power imbalances,

reluctance to use condoms, and transactional sex, especially between

young women and older males.

While education about sexual health will continue to be necessary in

order to equip young people with knowledge, additional interventions

will be necessary. Identifying effective interventions to change

population norms related to sexual risk behaviour should be a

priority, the researchers conclude, together with the investigation

of alternative interventions.

Further information

The study has a website that provides comprehensive information about

the interventions carried out during the study.

http://www.memakwavijana.org

Briefing papers providing more detailed information on the trial

results and their policy implications are available by following this

link.

http://www.aidsmap.com/en/news/07DE1C91-62B6-4F99-8610-

5FAFF2326F8B.asp