Utility and delivery of behavioural interventions to prevent sexually transmitted infections

Over the past three decades, research focus on the development and evaluation of behavioural interventions aimed at reducing the spread of sexually transmitted infections (STIs) including HIV has expanded considerably. Individual, couple and group level interventions aimed at improving condom use, HIV testing, linkage to care and retention, medication adherence, partner counselling and referral services, and decreasing number of partners have been developed and evaluated for many subpopulations.1–5 The interventions have been evaluated among African–Americans, Asian and Pacific Islanders, drug users, heterosexual adults, high-risk youth, Hispanic populations, men who have sex with men, people living with HIV, STI clinic patients, and transgender populations. However, despite their availability, behavioural interventions are inadequately utilised, and evidence of their population level impact is lacking. In this paper we discuss issues related to the utility of behavioural interventions, including questions around feasibility of implementation, scale-up and maintenance, and suggest new directions for planning, implementation, evaluation and continuous improvement of social and behavioural interventions in the context of STI and HIV prevention programmes. Most evidence on the efficacy of behavioural interventions is based on self-reported behaviour, and change in self-reported behaviour, as outcome. Assessment and reporting of sexual behaviour is subject to ascertainment and reporting bias.6 Such bias is particularly important in the context of behavioural intervention trials, because the intervention directly manipulates the desirability of certain reported behaviours, and subjects cannot be effectively blinded to the intervention. For behavioural intervention trials, STI and HIV incidence are the outcome measures of greatest interest. Unfortunately, trials that use STI and HIV incidence as outcome measure have not shown high levels of efficacy. Of the seven randomised controlled trials of behavioural interventions that measured HIV incidence as outcome, none were found to be efficacious.7 Of …