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. 2001 Oct 13;323(7317):867.
Reducing sexually transmitted infections among gay men
No doubt should be cast on efficacy of cognitive behavioural interventions
Editor—We applaud Imrie et al for conducting a rigorous, randomised clinical trial to reduce sexually transmitted infections in gay men.1 We have, however, concerns about the conclusions drawn from this comparatively small scale study to all cognitive behavioural interventions.
Firstly, to see changes in sexually transmitted infections as a result of an intervention, we need to see changes in safer sexual behaviours, such as increased use of condoms. The trials reported by Imrie et al did apparently not produce significant changes in safer sexual behaviour. Therefore, it was to be expected that no changes in the incidence of sexually transmitted infections were seen either.
Secondly, the fact that this trial was apparently not successful should not cast any doubt on the efficacy of cognitive behavioural interventions. Other, much larger, cognitive behavioural trials carried out with high risk populations in the United States and Thailand have been effective.2–4 Effectiveness has been shown not only by increases in use of condoms, but by decreases in sexually transmitted infections and incidence of HIV in some trials.2,4
Thirdly, it is not yet known what smallest “dose” of an intervention of this type will produce sustained effects. But the likelihood that an intervention of one session would be successful is quite small. Although brief interventions have been successful in other areas, they have not been successful in changing sexual behaviour.5 Furthermore, at least one study has shown a dose-response relation between number of sessions and change in behaviour, indicating that more sessions are required to change a complex behaviour such as using condoms.2
To see changes in sexually transmitted infections we need interventions to change sexual behaviours, such as use of condoms. To increase the use of condoms, we need longer, more intensive interventions such as those that have already shown effects.2–4
Finally, we suggest that a next question for the field not be “do cognitive behavioural interventions for HIV prevention work?” The answer to this is, yes. We believe the question should be “how, and under what circumstances, can we produce the greatest sustainable intervention effects through the use of cognitive behavioural interventions?”
2.The National Institute of Mental Health (NIMH) Multisite HIV Prevention Trial Group. The NIMH multisite HIV prevention trial: reducing HIV sexual risk behavior. Science. 1998;280:1889–1894. doi: 10.1126/science.280.5371.1889. [DOI] [PubMed] [Google Scholar]
3.The CDC AIDS Community Demonstration Projects Research Group. Community-level HIV intervention in 5 cities: final outcome data from the CDC AIDS community demonstration projects. Am J Public Health. 1999;89:336–345. doi: 10.2105/ajph.89.3.336. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Nelson KE, Celentano DD, Eiumtrakol S, Hoover DR, Beyrer C, Suprasert S, et al. Changes in sexual behavior and a decline in HIV infection among young men in Thailand. N Engl J Med. 1996;335:297–303. doi: 10.1056/NEJM199608013350501. [DOI] [PubMed] [Google Scholar]
5.Baker A, Heather N, Wodak A, Dixon J, Holt P. Evaluation of a cognitive-behavioural intervention for HIV prevention among injecting drug users. AIDS. 1993;7:247–256. doi: 10.1097/00002030-199302000-00014. [DOI] [PubMed] [Google Scholar]
BMJ. 2001 Oct 13;323(7317):867.
Social and behavioural interventions are effective in preventing HIV transmission
Editor—We were disappointed to see the paragraph in This week in the BMJ for the paper by Imrie et al conclude that behavioural interventions are ineffective in reducing the risk of HIV among gay men.1-1 Imrie et al reported a rigorously conducted evaluation of a one day groupwork intervention targeting gay men attending a genitourinary medicine clinic. Informed by cognitive behavioural theory, the intervention aimed to help these men assess their current risk taking and act to reduce this. The intervention was not effective with regard to either behavioural or biological outcomes.
Our disappointment is not the shock of health promoters suddenly discovering that our work is not achieving its aims. Our centre has pioneered the development of rigorous methods of evaluating social and behavioural interventions. We have sometimes been labelled arch-sceptics concerning the effectiveness of behavioural interventions.1-2 Our disappointment results from the manner in which a very general conclusion is drawn from a very specific study. The intervention by Imrie et al was not representative of all behavioural interventions to prevent transmission of HIV, which vary in terms of approach, location, and target group. We should not generalise its results to conclude, say, that outreach work with gay men in Amsterdam or Sydney is ineffective. We should not even automatically generalise its conclusions to other group work interventions for gay men that are based on cognitive behaviour, many of which are delivered over longer periods and are based on different theories.1-3
We wonder whether a similarly general conclusion would have been drawn on the basis of a clinical trial. Would, for example, a study reporting the ineffectiveness of antidepressants in treating post-traumatic stress disorder be accompanied by a paragraph in This week in the BMJ announcing that pharmacological interventions are ineffective in treating mental ill health? We presume not. We suggest that the BMJ adopts the same caution in reviewing trials as that of the Cochrane Collaboration.1-4 One trial is seldom sufficient to make conclusions about effectiveness, especially where the intervention in question is atypical of the interventions under consideration.
More thorough reviews of the effectiveness of behavioural interventions in HIV prevention reveal that while some have been ineffective, many others have been effective.1-4,1-5 In the absence of effective HIV vaccines, behavioural interventions remain one of our only options for preventing HIV transmission. Comment such as the paragraphs in This week in the BMJ contribute little to an informed debate, either in drawing conclusions from trials of behavioural interventions or in establishing how best to prevent new HIV infections.
1-2.Nutbeam D. Oakley's case for using randomised controlled trials is misleading. BMJ. 1999;318:944–945. doi: 10.1136/bmj.318.7188.944b. [DOI] [PMC free article] [PubMed] [Google Scholar]
1-3.Wanigaratne S, Billington A, Williams M. Initiating and maintaining safer sex: evaluation of group-work with gay men. In: Catalan J, Sherr L, Hedges J, editors. The impact of AIDS: psychological and social aspects of HIV infection. Singapore: Harwood Academic; 1997. pp. 27–41. [Google Scholar]
1-4.Wilkinson D, Rutherford G. Population-based interventions for reducing sexually transmitted infection, including HIV infection (Cochrane review). Cochrane Database Syst Rev 2001;2:CD001220. [DOI] [PubMed]
1-5.Centers for Disease Control and Prevention. CDC's HIV/AIDS prevention research synthesis project, compendium of HIV prevention interventions with evidence of effectiveness. Atlanta: CDC; 1999. [Google Scholar]
2Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, Mortimer Market Centre, off Capper Street, London WC1E 6AU
2Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, Mortimer Market Centre, off Capper Street, London WC1E 6AU
2Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, Mortimer Market Centre, off Capper Street, London WC1E 6AU
2Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, Mortimer Market Centre, off Capper Street, London WC1E 6AU
2Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, Mortimer Market Centre, off Capper Street, London WC1E 6AU
2Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, Mortimer Market Centre, off Capper Street, London WC1E 6AU
2Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, Mortimer Market Centre, off Capper Street, London WC1E 6AU
2Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, Mortimer Market Centre, off Capper Street, London WC1E 6AU
2Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, Mortimer Market Centre, off Capper Street, London WC1E 6AU
2Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, Mortimer Market Centre, off Capper Street, London WC1E 6AU
Roles
John Imrie: senior research fellow
Judith M Stephenson: senior lecturer in epidemiology
Frances M Cowan: senior lecturer in genitourinary medicine
Editor—Noar and Zimmerman are correct that behavioural change is a precondition to reducing the incidence of sexually transmitted infections. But which behaviours are most important is not always clear; the causal pathway between increased use of condoms and reduced infections proposed is not that simple. Use of condoms is not a single behaviour, nor is it certain to provide protection against infection.2-1 Our findings show a non-significant reduction in the highest risk sexual behaviours throughout the follow up, particularly at six months, but without a corresponding reduction in new infections.
Other studies have shown that the incidence of new infections may be influenced by a range of factors—for example, demographic characteristics, doubt on the efficacy of cognitive behavioural interventions, choice of partner, and consistent and correct use of condoms.2-2 This makes it difficult to predict the efficacy of an intervention in preventing a disease when the intervention is based on observed behaviour change or use of condoms alone.2-2 We know of only one study that has been able to show a causal pathway relation between adopting new behaviours and reduced incidence of sexually transmitted infections—condom use was only part of the explanation.2-3,2-4 As public health researchers, the effectiveness of our interventions is ultimately assessed by their impact on morbidity in the population. Two of the much larger trials that Noar and Zimmerman refer to were not randomised controlled trials, and the trial by Nelson et al did not entail a specifically described cognitive behavioural intervention.
We agree that our study should not cast doubt on the efficacy of cognitive behavioural interventions themselves. But it does raise important questions about the optimal dose and formulation of intervention that is able to produce sustained change of behaviour and can feasibly be delivered within routine care. Limited resources preclude providing long term one on one interventions for every patient at risk. So far there is limited indication that there is a uniform dose of intervention that can achieve sustained change in sexual behaviour.2-5
The question of how different therapeutic approaches and theoretically derived interventions can be optimally deployed in the different HIV prevention settings, including sexual health clinics is still largely unanswered. As Bonell and Strange point out, this was a trial of a highly specific intervention delivered within a particular context. We agreed with them that it may be hard to make major policy generalisations from it. Its greatest value is to remind us to think carefully about the potential impact of our interventions and consider, equally carefully, how best these effects can be measured.
References
2-1.Richens J, Imrie J, Copas A. Condoms and seatbelts: The parallels and the lessons. Lancet. 2000;355:400–403. doi: 10.1016/S0140-6736(99)09109-6. [DOI] [PubMed] [Google Scholar]
2-2.Peterman TA, Lin LS, Newman DR, Kamb ML, Bolan G, Zenilman J, et al. Does measured behavior reflect STD risk?: An analysis of data from a randomized controlled behavioral intervention study. Sex Trans Dis. 2000;27:446–451. doi: 10.1097/00007435-200009000-00004. [DOI] [PubMed] [Google Scholar]
2-3.Shain RN, Piper JM, Newton ER, Perdue ST, Ramos R, Champion JD, et al. A randomized, controlled trial of a behavioral intervention to prevent sexually transmitted disease among minority women. N Engl J Med. 1999;340:93–100. doi: 10.1056/NEJM199901143400203. [DOI] [PubMed] [Google Scholar]
2-4.Perdue S, Shain RN, Piper JM, Holden A, Newton ER, Dinmitt-Champion J, et al. Finding the elusive condom effect: incorporating the context of behavior. (Oral presentation—see abstracts from 14th Meeting of the International Society for Sexually Transmitted Diseases Research (ISSTDR) and International Congress of Sexually Transmitted Infections, Berlin, Germany. 24-7 June 2001: 59).
2-5.Kamb ML, Fishbein M, Douglas JM, Jr, Rhodes F, Rogers J, Bolan G, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases. A randomized controlled trial. JAMA. 1998;280:1161–1167. doi: 10.1001/jama.280.13.1161. [DOI] [PubMed] [Google Scholar]
