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Effectiveness of Interventions to Prevent Sexually Transmitted Infections and Human Immunodeficiency Virus in Heterosexual Men
A Systematic Review
A. Rani Elwy, PhD;
Graham J. Hart, PhD;
Sarah Hawkes, PhD, MBBS;
Mark Petticrew, PhD
Arch Intern Med. 2002;162:1818-1830.
ABSTRACT
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Our objective was to review systematically studies of interventions
to prevent transmission of sexually transmitted infections (STIs) and human
immunodeficiency virus (HIV) in heterosexual men. Of 1157 studies identified
through database and hand searching, 27 met our inclusion criteria. Most interventions
targeted specific groups of men (eg, those attending STI clinics) rather than
general populations. Few were conducted with men alone, and most focused on
behavioral and social psychological rather than morbidity outcomes. Of 8 interventions
designed to reduce STI incidence (including HIV), 5 were successful, 2 were
unsuccessful, and 1 had equivocal results. Of the 5 successful interventions,
1 was carried out in the workplace, 1 in the military, and 3 in STI clinics.They
included on-site individual counseling and HIV testing, mass communications
regarding risk reduction, and multiple-component motivation and skills education
in STI clinics. More high-quality research into the effectiveness of interventions
targeting heterosexual men is needed, especially methodologically sound trials
to evaluate effects on morbidity.
INTRODUCTION
Heterosexual transmission of human immunodeficiency virus (HIV) is increasing
globally.1 This is despite widespread efforts
to prevent the spread of the disease through behavioral and educational interventions
and delivery of services aimed at offering free HIV testing and counseling.
Additionally, treatment for sexually transmitted infections (STIs) known to
facilitate HIV transmission has also been used to control its spread among
men and women.2-3 Heterosexual
men may be key to controlling the spread of the STI and HIV epidemics. Sexually
transmitted infections, including HIV, are more easily transmitted from men
to women than women to men.4 Indeed, women
are twice as likely as men to become infected by a variety of sexually transmitted
pathogens,5 and the efficiency of male-to-female
transmission of HIV is approximately 4 times higher than female-to-male transmission.6 Aside from the increased biological risk of transmission,
women may be at high risk of STI and HIV owing to social and cultural norms
of behavior that dictate that women cannot decline sexual intercourse with
their partners or insist on the use of barrier methods for protection during
intercourse.7 Moreover, these same social and
cultural norms often allow men to seek sexual pleasure outside of the home,
thereby possibly increasing the risk of acquiring STIs, including HIV.8
No systematic reviews have been conducted to determine the most effective
social and behavioral means of preventing the spread of STIs and HIV among
heterosexual men. Reviews conducted on populations other than heterosexual
men have demonstrated that few studies are of sound methodological quality.
In a review of 68 behavioral interventions to prevent HIV and acquired immunodeficiency
syndrome (AIDS),9 the authors rated only 18
of these as being of high methodological quality. Five of the 18 interventions
were judged to be effective at preventing HIV and AIDS by the reviewers, while
7 were judged effective by the authors of the studies. Four of these 5 effective
interventions demonstrated a change in young people's sexual behavior, while
the remaining effective intervention targeted homosexual and bisexual men.
Systematic reviews of interventions that consist of providing information
on the HIV status of participants in an effort to prevent transmission have
also been undertaken. In a meta-analysis of 27 HIV testing and counseling
interventions,10 it was concluded that HIV
counseling and testing was not an effective primary prevention strategy for
uninfected participants, although it seemed to provide an effective means
of secondary prevention for HIV-positive individuals. However, heterosexual
men were not the main focus of these reviews. Men are not a homogeneous group.11 Heterosexual men of all ages may have different needs
than women, men who have sex with men, or adolescents as a group and, based
on prevailing attitudes and sociocultural and demographic characteristics,
they may also respond differently than these other populations to interventions.
Therefore results from existing systematic reviews cannot necessarily be generalized
to adult men who have sex with women.
A second limitation of previous systematic reviews assessing the effectiveness
of interventions to prevent STIs and HIV is that they only sought to include
North American studies. It is known that men's attitudes toward contraception
affect efforts to prevent STIs in the United States.12
However, the association between men's sexual attitudes and their sexual behavior
in other parts of the world has not been reviewed systematically. The spread
of HIV is currently most rapid in other parts of the world, including the
countries of the former Soviet Union and Asia.1
Interventions targeting North American populations, while important, will
not substantially reduce the global threat of STI and HIV.
Finally, few reviews in this area have assessed the effectiveness of
interventions to prevent the spread of STIs, along with HIV, in heterosexual
men. Given that STIs can facilitate the acquisition and transmission of HIV13 and efforts to prevent the spread of HIV through
treatment of STIs in women and men have proven effective,14
it is imperative that systematic reviews to determine the effectiveness of
interventions to prevent HIV infection include interventions targeting STIs.
The present systematic review takes account of the above limitations of previous
reviews and seeks to determine the most effective social and behavioral means
of preventing the spread of HIV and other STIs in heterosexual men.
METHODS
AIM AND RESEARCH QUESTION
We undertook a systematic review to evaluate the evidence for the effectiveness
of social and behavioral interventions to promote men's sexual and reproductive
health, focusing on the prevention of STIs including HIV. To this end, we
sought to anwer the question, "Which interventions are successful in reducing
the transmission of STIs and HIV in heterosexual men?"
SEARCH STRATEGY
A list of the databases searched is given in Table 1. Key words used in the MEDLINE search are listed in Table 2. These were adapted for use in
the other database search strategies. Additional search strategies included
hand searching 4 key journals (AIDS, AIDS Care, International Journal of STD and AIDS, and Sexually Transmitted Diseases); hand
searching references of all studies meeting the reference criteria; and writing
to the first authors of all studies that met the inclusion criteria to request
information on unpublished work or research in progress.
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Table 1. Databases and Years Searched
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Table 2. MEDLINE Search Strategy: Key Terms Used
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Studies located by the search strategy were coded for inclusion using
a checklist. The reliability of this checklist was tested by 2 of the authors
on a subsample of 25 studies. The Cohen  for this reliability was 0.91,
considered a very high interrater agreement.15
One author coded the remaining studies for inclusion.
INCLUSION CRITERIA
Studies were selected for review if they met the following 5 criteria:
(1) intervention populations included heterosexual male subjects 15 years
or older; (2) data on heterosexual men's sexual behavior were presented and
analyzed separately from other groups included in the study or at least 80%
of the study participants were heterosexual men; (3) study designs were coded
in the following categories: (i) randomized or nonrandomized controlled, (ii)
prospective observational, or (iii) retrospective observational; (4) the outcomes
assessed in the study included at least 1 of the following: (i) morbidity
(new or reinfection with STI, including HIV), (ii) behavioral outcomes (eg,
condom use or reduction in the number of sex partners), and (iii) social psychological
outcomes (eg, attitudes toward condoms or HIV or intentions to use condoms);
and (5) study was coded as being of moderate to high methodological quality.
Unpublished studies and studies in all languages were considered for inclusion
in the review.
QUALITY ASSESSMENT
Two authors independently assessed the methodological quality of the
studies meeting the first 4 inclusion criteria by using 1 of 2 checklists.
For behavioral studies using a randomized controlled trial (RCT) or prospective-observational
design with more than 1 study group, an adapted version of a quality checklist
standardized by Jadad et al16 was used. We
adapted criterion 2 of the original checklist to read "Was this study single
blind?" instead of "double blind" and assigned a maximum score of 4 to each
study, with higher scores denoting higher methodological quality. For studies
using a prospective design with only 1 study group (before-and-after studies)
or a retrospective observational design, we used a methodological quality
checklist with a maximum quality score of 5.17
Both quality checklists included items consistent with the consensus statement
of meta-analysis reporting of observational studies in epidemiology.18 Differences in ratings between the authors were reconciled
through discussion, and consensus was reached. Studies that received a quality
score of 1 or lower based on these checklists were excluded from the review.
DATA COLLECTION
Data from studies meeting the inclusion criteria were extracted using
a checklist.17 Two authors pilot-tested this
checklist prior to its use in the study, and disagreements in data extraction
were resolved through discussion. Study information and data were recorded
in the Microsoft Access database.
RESULTS
INTERVENTION CHARACTERISTICS
Of the 1157 articles located through hand searching and electronic databases,
27 studies met the inclusion criteria (Figure
1). No additional studies were located through contact with experts
in the field. Twelve (44%) of the studies were conducted on male-only populations.
Heterosexual men in the 27 studies tended to fall into 5 well-defined populations:
drug users receiving treatment (3/27, 11%); injecting drug users out of treatment
(2/27, 7%); patients of sexually transmitted disease clinics (9/27, 33%);
men in the workplace (3/27, 11%); and students (6/27, 22%). Other populations
of men included (in 1 study each) were African American men via outreach (ie,
not attending clinic); prisoners; homeless men with psychiatric problems;
and military men.
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Selection of interventions for systematic review.
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Women were included in 15 (56%) of the studies. In 8 of these, the interventions
addressed men and women in different groups, or men and women were given individual
intervention sessions; in the other 7 studies, women and men were addressed
together in groups.
Most studies were North American, with 17 (63%) conducted in the United
States. Eight (30%) of the 27 studies specifically targeted racial and ethnic
minorities in US populations. Two studies were undertaken in Brazil, and 1
study each was conducted in Britain, Australia, India, Kenya, Mozambique,
Namibia, Senegal, and Thailand.
Twenty studies included in the review were RCTs, and the other 7 were
of a prospective experimental design. Six of these studies did not have a
control or a comparison group.19-24
No retrospective observational interventions were included in the review.
Eight studies (30%) evaluated morbidity outcomes (new HIV infection
or new or reinfection of STI); 21 (78%) assessed behavioral outcomes (condom
use, reduction in number of sex partners, and unprotected sex); and 15 (56%)
assessed social psychological outcomes (attitudes toward condoms or HIV, intentions
to use condoms or change risky behavior, knowledge of HIV and AIDS, self-efficacy
of condom use, communication skills, and quality of sexual relationships).
The interventions identified by the present review are either group-based
or individual interventions with heterosexual men (and sometimes women). Group-based
interventions tended to be weekly 1- to 2-hour sessions over 2 to 4 weeks.
These sessions involved exclusively male groups or men and women together,
and they were conducted by trained facilitators, either professionals or peer
educators. Usually, the goal of these sessions was to change sexual risk behavior
through education, communication skills training, and role-playing. Condoms
were often distributed free of charge during these sessions, and condom use
skills were taught.
Individually based intervention sessions tended to consist of individual
counseling with a trained professional or peer educator. These sessions were
aimed at either men alone or at men and women, but men and women did not meet
with the counselor together. The counselor offered pre–HIV test counseling,
confidential HIV testing, posttest counseling, a personalized evaluation of
risk for STI and HIV, and/or a personalized risk reduction plan. Further education
could be offered to the client, and condoms were often distributed free of
charge.
INTERVENTIONS BY GROUP OF MEN
Drug Users Receiving Treatment
All included sources,19-45
categorized according to groups of men, are listed in Table 3. Three studies of moderate quality were carried out with
heterosexual men receiving treatment for drug use. Two of these studies were
RCTs,25-26 and 1 used a prospective
uncontrolled design.22 Two interventions aimed
to increase condom use,22, 25 and
1 aimed to decrease the number of sex partners of these men.26
These interventions were highly successful at changing the sexual behavior
of this group of men. Both interventions that aimed to increase condom use
in men reported a significant intervention effect in the experimental group.22, 25 A decrease in the number of sex partners
was reported for the study that aimed to change this behavior.26
Interventions that reported a significant effect on behavioral outcomes varied
in their design. Two interventions featured educational and motivational aspects
and focused on risk prevention, increasing levels of personal concern regarding
HIV/AIDS, and personalizing the threat of HIV.25-26
These interventions also addressed the skills needed for negotiating condom
use and preventing a relapse in drug use and risky sexual behavior, with men
participating in separate intervention sessions from women25
or in a group exclusively of men.26 One intervention
that was successful in increasing condom use involved a condom giveaway program
in a drug abuse outpatient treatment clinic.22
There were no educational or cognitive-behavioral elements in this intervention.
One intervention with drug users receiving treatment also focused on social
psychological outcomes: Malow et al26 reported
increases in knowledge of HIV, condom use skills, sexual communication skills,
and response efficacy for using condoms in the intervention and control groups.
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Table 3. Characteristics, Results, and Assessed Quality of Included
Sources*
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Out-of-Treatment Injecting Drug Users
Two moderate- to high-quality studies aimed to increase use of condoms
among a groups of heterosexual men,27-28
and 1 study also aimed to decrease numbers of sexual partners.27
Both studies used RCT designs. Cottler et al27
conducted drug awareness, stress management, AIDS education, and personal
risk awareness sessions through a peer-education outreach program, using a
storefront satellite to recruit men. The authors report that no change in
condom use or number of sexual partners was reported as a result of the intervention.
Condom use did increase in the study by Robles et al.28
This intervention consisted of 8 sessions designed to improve individuals'
perceptions of risk and provide motivation to change risk behavior. Risk behavior
was monitored over 6 months of follow-up. A control group received 2 sessions
of standard care including HIV pretest and posttest counseling. The reported
increase in condom use was seen in the intervention and control groups.
Men in the Workplace
Three moderate-quality studies of a prospective uncontrolled design
were carried out with heterosexual men in the workplace.19, 23-24
One study, which consisted of an intervention with trucking workers in Kenya,
reported a significant intervention effect on lowering the STI incidence and
decreasing the number of sex partners of these men.23
An increase in condom use was not reported for this cohort. The intervention
comprised on-site counseling and HIV testing. Skills in condom negotiation,
condom use demonstration and promotion, and STI and HIV risk reduction were
provided in individual sessions with the men.
The intervention evaluated by Hearst et al19
aimed to change the sexual behavior and attitudes toward condoms of Brazilian
port workers and to increase their knowledge of AIDS using face-to-face contact
by peer outreach workers to discuss HIV and AIDS, either individually or in
groups, and free distribution of condoms. The authors reported a significant
increase in reported condom use and a decrease in the number of sex partners
of the men over a 2-year follow-up period. However, no change was reported
in the men's attitudes toward condoms or their knowledge of HIV and AIDS.
In a peer-education intervention with trucking workers in Senegal, significant
effects were reported over 2 years of study in increasing men's condom use
and HIV knowledge and in eliminating perceived barriers to changing sexual
behavior.24 The peer educators, initially part
of the intervention group and subsequently selected and trained as peer educators
by the authors, gave the workers information about HIV and STDs, including
mode of transmission, signs and symptoms, and methods of prevention. Skills
related to condom use, condom negotiation, and communication were all taught.
Reports from female sex workers frequented by the men corroborated the reports
of men's use of condoms. However, reports of men having fewer sex partners
after intervention were not corroborated by the women. The intervention effect
on the men's reports of decreases in the number of sex partners was determined
unreliable by the authors.
Men Attending STI Clinics
Nine moderate- to high-quality studies focused on preventing the spread
of STIs and HIV in men attending public STI clinics.21, 29-36
Interventions with this group of men were characterized by their use of an
RCT study design and their focus on US men. Only 1 intervention used a prospective
uncontrolled design with a long follow-up period, and this was conducted in
a non-US population.21 Most interventions with
this group of men sought to reduce morbidity: 5 studies in this group aimed
to decrease the incidence of STI.29-33
Two studies reported a significant decrease in STI incidence as a result of
the intervention; these interventions involved a multiple-component motivation
and skills approach to reducing the risk of HIV.29-30
Two studies reported no decrease in STI incidence; these interventions also
consisted of a multiple-component motivation and skills approach to reducing
the risk of HIV.31-32 One study
reported a decrease in STI in the intervention and control groups.33 This intervention involved an individually based
AIDS education session, while the comparison and control groups consisted
of either a video-based education session or the clinic's standard care and
education.
Five interventions in STI clinics aimed to change men's sexual behavior.21, 30-32,34
One study reported significant intervention effects in the experimental group
on unprotected sexual acts, condom use, and consistent condom use.30 In a study involving an individual counseling session
providing education and condom use skills, condom use increased in this group
of men.21 However, the number of sex partners
did not decrease over the 2-year follow-up. Three studies reported an increase
in condom use in men in the experimental and control groups.31-32,34
These interventions all consisted of motivational and skills-building components.
In one study, men and women were divided into single-sex intervention groups31; in another, men and women participated in mixed-sex
sessions32; and in another study (exclusively
with men), participants were placed into groups.34
Four studies focusing on men in STI clinics sought to change social
psychological outcomes.21, 34-36
Intentions to use condoms increased in the 2 studies of video-based education
interventions that aimed to change this behavior.35-36
In 1 study of a motivational and skills-based intervention, intentions to
use condoms did not increase in the experimental group.34
Mixed results were found in the 2 studies addressing attitudes toward condoms,34-35 with one reporting a positive change
in attitudes35 and the other reporting no change.34 Mixed results were also reported for knowledge of
AIDS. One study of a counseling and skills-based intervention showed a positive
intervention effect on knowledge,21 while another
of a motivational and skills-based intervention reported no effect.34 Communication skills with sex partners about the
risk of AIDS34 and condom use34-35
showed a significant intervention effect in the 2 studies addressing these
outcomes.
Heterosexual Male Students
Six moderate- to high-quality RCTs targeted heterosexual male students.37-42
These studies aimed to change behavioral and social psychological outcomes;
morbidity was not addressed. Four studies focused on younger school-aged men,37-39,41 one
on university men,41 and 1 study targeted men
attending night school.40 Two studies were
conducted with non-US populations.39-40
The behavioral outcomes addressed were unprotected sex,37
condom use,37-41
and number of sex partners.38 In a behavioral
skills-training intervention, St Lawrence et al37
reported a decrease in the frequency of unprotected sex among men in the intervention
and control groups.37 Significant intervention
effects on condom use were reported in 2 studies,38-39
while 3 studies reported no effect.37, 40-41
All 5 interventions aimed at increasing condom use included cognitive-behavioral
and skills training components.
All 6 studies aimed to change social psychological outcomes. In the
study to address intentions to use condoms, these intentions did not change,39 while in the study that sought to change intentions
to engage in risky behavior, significant intervention effects were reported.38 Attitudes toward condoms did not change in one study,37 but attitudes toward risky behavior did in another.38 Increases in knowledge about sexual health41 and AIDS38 were successfully
brought about by interventions that addressed these outcomes. However, knowledge
of AIDS did not change in another intervention.37
Mixed results were also reported for changes in communicating about sex and
AIDS with partners: intervention effect was reported in one study,39 but no change was reported in another.40
Self-efficacy for using condoms was found to increase in one study42 and not another.37
Each of these interventions was similar in that each involved behavioral skills
training in condom use, decision making, and communication skills. Active
learning, role-playing, and practicing of skills were all part of the interventions.
Other Men
Four studies involved different male populations.20, 43-45
A mass national communication campaign was conducted in Thailand, and its
effectiveness was assessed through a prospective cohort study with men entering
the Thai military over 2 periods.43 The authors
reported a significant reduction in the incidence of new STIs over the course
of the study. Two moderate-quality RCTs addressed behavioral outcomes.44-45 One RCT with homeless men with psychiatric
diagnoses reported a positive intervention effect on the frequency of unprotected
sex, condom use, and the number of sex partners of these men.44
Another RCT with African American men contacted through an outreach program
reported no intervention effect on condom use.45
Both interventions consisted of multiple skills training sessions focusing
on decision making, condom use, and behavioral self-management.
Two studies aimed to change social psychological outcomes. In a cognitive-behavioral
RCT, changes were reported in intentions to engage in risky behavior and AIDS-related
knowledge in the intervention and control groups.45
A significant increase in knowledge of AIDS was reported in a prospective
uncontrolled study with male prisoners in Mozambique consisting of education
sessions led by prisoner activists.20
COMMENT
This is the first systematic review to assess the effectiveness of interventions
to prevent STIs and HIV in heterosexual men—a heterogeneous population
currently the focus of a concerted global effort to reduce the risk of STI
for themselves and their partners, including the risk of HIV.1
We found 27 studies that met our inclusion criteria for a systematic review.
We believe that this reflects the relatively new focus of interest in heterosexual
men's sexual health. Until recently, the main focus on heterosexual men's
reproductive and sexual health has been on attitudes toward contraception
and family planning and men's roles in increasing the risk and vulnerability
of their female sex partners, with relatively little effort concentrated on
men's own sexual health concerns.11 Given that
in many settings it is the behavior of the male partner that places women
at increased risk of STI, including HIV, it is imperative to identify strategies
and interventions that may work to decrease the burden of risk and disease
among heterosexual men and their female partners.
Most of the studies identified through the present review were designed
to evaluate behavioral and/or social psychological, rather than morbidity,
outcomes. Most were undertaken in the United States, and thus do not reflect
the global epidemiology of STIs and HIV in terms of incident and prevalent
infections. Nonetheless, we believe that the review has highlighted the following
points that will influence the design of future interventions and further
research.
WHICH INTERVENTIONS WERE EFFECTIVE IN REDUCING THE BURDEN OF NEW DISEASE?
Only a minority of studies were designed to evaluate the effectiveness
of reducing the incidence of new STIs or HIV infection. Most interventions
aimed to change social psychological or behavioral outcomes. Of the 8 interventions
designed to reduce the incidence of new STIs (including HIV), 5 were deemed
to be successful, 2 were not successful, and 1 gave equivocal results (reduction
in incidence in the intervention and control groups). The 5 successful (but
not necessarily high methodological quality) interventions were carried out
among men in the workplace (1 study), men in the military (1 study), and men
in STI clinics (3 studies). A variety of methods were used in these interventions,
including on-site counseling and HIV testing at a trucking company with individual
sessions for participating men; a mass communications (and multiple-sector)
approach to risk reduction in Thailand; and multiple-component motivation
and skills approaches in STI clinics. In the latter case, 2 further studies
using similar intervention methods reported no decrease in STI incidence.
What do these results tell us about the effectiveness of interventions?
First, it is important to examine the need for studies that use laboratory-diagnosed
STI as the outcome of interest. If reduced incidence of HIV or other STI is
to become the gold standard goal of intervention research,46
studies of social psychological programs will have to demonstrate empirically
the relationship between cognitions and infection. Many psychological theories
of behavior emphasize the role of attitudes, intentions, and self-efficacy
in determining behavior.47-49
However, systematic reviews and meta-analyses of these theories have shown
that the evidence supporting the role of social psychological variables in
predicting behavior is often conflicting.50-51
It is possible that attitudes and intentions predict behavior, and that these
may be important variables to include in interventions to prevent the spread
of STIs and HIV. In this review, only 1 study among heterosexual men was identified
that made the connection between change in social psychological measures,
behavior, and morbidity, but this study did not use an RCT design to assess
efficacy.21
Second, there is no single intervention that can be identified as being
more effective than others in reducing the incidence of STI and HIV in heterosexual
men. This finding is presumably a reflection of the heterogeneity of the groups
of men under study and the wide variety of different contexts in which interventions
were being evaluated. Successful interventions ranged from localized to national
responses, but all were resource intensive either in their execution or their
measurement (eg, the 2 successful interventions in STI clinics were both RCTs).
This carries important implications for those charged with program and intervention
design—a single "cookie-cutter" approach is unlikely to be successful
in any given setting. Moreover, achieving and recording the success of an
intervention is a resource-intensive undertaking, especially if gold standard
laboratory outcomes are to be measured.
WHICH INTERVENTIONS WERE EFFECTIVE IN CHANGING MEN'S ATTITUDES AND
BEHAVIORS?
Most studies were designed to measure the effect of interventions to
change social psychological and behavioral outcomes. As with the studies that
aimed to decrease incident STI, there was no single method that could be identified
as being effective in all situations aiming to change behaviors, increase
knowledge, or measure an intention to change.
All 3 studies targeting heterosexual drug users in treatment reported
success in increasing condom use, decreasing the number of reported sexual
partners, and improvement in social psychological outcomes. These results
are especially notable in a population often described as "difficult." In
addition, 2 studies were carried out among drug users out of treatment programs,
and one showed an increase in condom use (but in both the intervention and
control groups). Again, no single intervention strategy could be identified
as being consistently successful, partly because a variety of methods were
used in all the interventions reviewed.
Among men in other clinic-based settings (STI clinics), a small number
of interventions were found to improve behavioral outcomes. A variety of methods
were used, but positive effects were noted as frequently in the control groups
as in the intervention groups in most studies. Two studies using video-based
education programs showed an increase in intention to use condoms, and a counseling
and skills-based intervention showed a significant improvement in communication
skills with partners. However, the results for all other social psychological
outcomes were difficult to interpret, with studies showing no improvement
in other indicators of attitudinal change.
Studies of interventions with men in the workplace all reported significant
intervention effects on the men's sexual behavior and knowledge of HIV and
STI. These interventions show that other study designs apart from RCTs can
demonstrate changes in sexual behavior of high-risk men (eg, truckers who
have frequent contact with commercial sex workers). The use of peer educators
in interventions of longer duration seem to have been effective. Accuracy
of self-reports can also be validated by secondary sources, as in the study
by Leonard and colleagues.24
Similar results were found in studies among men in other settings—students,
homeless men, and prisoners. Even when similar intervention methods were used,
results were not consistent between one group of men and another. Interventions
that showed a positive outcome in one setting produced equivocal results elsewhere.
A wide variety of approaches were used throughout these interventions, including
individual counseling, group counseling, mixed-sex counseling, single-sex
counseling, and repeat and one-off sessions, with no evidence of effect size
being related to the form that interventions took.
POTENTIAL BIASES OF THE REVIEW PROCESS
Although we attempt herein to answer the question, "Which interventions
are successful in reducing the transmission of STIs in heterosexual men?"
most of the studies we evaluate do not include only heterosexual men. Interventions
that included women along with heterosexual men were included if data on men
were presented and analyzed separately from those on women or if men constituted
80% or more of the study population. While it is possible that the presence
of women in mixed-sex intervention sessions may have influenced men's participation
in these sessions,52 without further empirical
investigation it is difficult to determine this influence. We decided to include
these studies to increase the number for review when it became apparent that
few interventions exclusively addressed heterosexual men.
Many of the studies were small and reported statistically significant
results, which suggests that there is a risk of publication bias (ie, that
small studies with negative findings are under-represented in the present
review). This may be because such studies have been rejected for publication
or because researchers have not submitted them for publication. A formal test
for publication bias has not been carried out given the heterogeneity of the
study designs and the ongoing debate about the applicability of current statistical
approaches to observational studies.53 However,
the number of small studies with positive results is suggestive of publication
bias, and the possibility remains that this review may, if anything, overestimate
the effectiveness of interventions in this area.
POTENTIAL BIASES OF THE STUDIES THEMSELVES
Most of the studies were conducted in the United States, with just under
half of these US-based studies conducted on racial and ethnic minority populations.
While recognizing the importance of these results for STI and HIV control
in the United States (and especially given racial disparities in STI risk
in the country), the findings cannot easily be transferred to the rest of
the world, and especially to those countries currently experiencing the burden
of incident and prevalent STIs and HIV infection. Several areas of the world
are notable by their complete absence from the evidence base that we have
reviewed: Eastern Europe and Central Asia (currently experiencing epidemics
of HIV and other STIs) and Eastern Asia (home to a significant proportion
of the world's population and under increasing threat of an HIV epidemic).
In addition, other regions with a high burden of STIs and HIV disease or a
potential burden of disease are represented by only 1 or 2 study results (eg,
Africa and South Asia).
Most of the studies were undertaken among groups of men who were easily
identifiable as being at risk of STIs and HIV (men attending STI clinics or
injecting drug users). Other studies targeted very specific groups of men
in the population: homeless men, students, and prisoners.
CONCLUSIONS
These potential biases suggest that caution should be used when interpreting
the results. On the basis of the present review, it is not possible to prescribe
the optimum approach to reduce the risk of transmission of STIs, including
HIV, in heterosexual men. We identified relatively few methodologically rigorous
studies (and even fewer with a gold standard biological indicator of behavior
as the outcome) and no single consistently effective approach to reduce incident
infections, change behavior, or change social psychological outcomes.
On a more optimistic note, however, it is worth remembering that although
there were only 4 interventions that addressed most men in the population
(who are not in clinic populations, not in education, or do not have an identifiable
risk behavior), they all showed a positive behavioral intervention effect.
These were interventions among men in the workplace or men joining the military
after a nationwide mass media and structural intervention to reduce HIV risk
in Thailand. This suggests that it is possible to reduce the burden of sexual
risk and consequent ill health for men in the general population—the
section of men likely to have the largest population-attributable risk for
the burden of STI and HIV in men and women in many
settings.
There is clearly a pressing need to identify successful programs to
reduce HIV and STI transmission and morbidity among heterosexual men. However,
it will only be possible to measure reduced incidence of HIV in heterosexual
men in circumstances of high population prevalence of the infection. In other
situations, including those where incident STIs are high, it may be necessary
to use reductions in non-HIV morbidity as a proxy marker of program efficacy.
There are problems in using bacterial infections such as Chlamydia trachomatis and Neisseria gonorrhoeae
as indicators of risk for viral infections such as HIV because of biological
differences in transmission dynamics, but they remain good markers of exposure
to sexually transmitted pathogens. Also, transmission of these bacterial infections
is prevented in the same way as HIV infections are prevented, notably through
protected sex or sexual intercourse between uninfected partners.
The results of the present systematic review suggest that the following
factors are important for future research agendas to prevent the spread of
STIs and HIV in heterosexual men:
- Research needs to focus on morbidity outcomes (eg, incident infection)
rather than only behavioral or social psychological outcomes.
- Interventions need to target heterosexual men or at least ensure
that heterosexual men participate in single-sex intervention groups, and then
evaluations can identify the approaches that are best suited to this population.
- More research needs to be carried out in regions of the world
where rates of STI and HIV are high among heterosexual men (such as sub-Saharan
Africa) and where they are increasing (such as Asia, Eastern Europe, and Central
Asia).
- Studies other than RCTs can identify promising interventions;
the effectiveness of these interventions requires further rigorous evaluation
before widespread implementation.
- Studies should have the statistical power to demonstrate effectiveness,
and this should be calculated prior to research being funded and implemented.
AUTHOR INFORMATION
Accepted for publication April 24, 2002.
Corresponding author and reprints: Graham J. Hart, PhD, Medical Research
Council Social and Public Health Sciences Unit, University of Glasgow, 4 Lilybank
Gardens, Glasgow G12 8RZ, Scotland (e-mail: graham{at}mrc.msoc.gla.ac.uk).
From the Medical Research Council, Social and Public Health Sciences
Unit, University of Glasgow, Glasgow, Scotland (Drs Elwy, Hart, and Petticrew),
and the London School of Hygiene and Tropical Medicine, London, England (Dr
Hawkes).
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