title: Structural and community-level interventions for increasing condom use to prevent the transmission of HIV and other sexually transmitted infections.
abstract: BACKGROUND
  Community interventions to promote condom use are considered to be a valuable tool to reduce the transmission of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). In particular, special emphasis has been placed on implementing such interventions through structural changes, a concept that implies public health actions that aim to improve society's health through modifications in the context wherein health-related risk behavior takes place. This strategy attempts to increase condom use and in turn lower the transmission of HIV and other STIs.
  
  
  OBJECTIVE
  To assess the effects of structural and community-level interventions for increasing condom use in both general and high-risk populations to reduce the incidence of HIV and STI transmission by comparing alternative strategies, or by assessing the effects of a strategy compared with a control.
  
  
  METHODS
  We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, from 2007, Issue 1), as well as MEDLINE, EMBASE, AEGIS and ClinicalTrials.gov, from January 1980 to April 2014. We also handsearched proceedings of international acquired immunodeficiency syndrome (AIDS) conferences, as well as major behavioral studies conferences focusing on HIV/AIDS and STIs.
  
  
  METHODS
  Randomized control trials (RCTs) featuring all of the following.1. Community interventions ('community' defined as a geographical entity, such as cities, counties, villages).2. One or more structural interventions whose objective was to promote condom use. These type of interventions can be defined as those actions improving accessibility, availability and acceptability of any given health program/technology.3. Trials that confirmed biological outcomes using laboratory testing.
  
  
  METHODS
  Two authors independently screened and selected relevant studies, and conducted further risk of bias assessment. We assessed the effect of treatment by pooling trials with comparable characteristics and quantified its effect size using risk ratio. The effect of clustering at the community level was addressed through intra-cluster correlation coefficients (ICCs), and sensitivity analysis was carried out with different design effect values.
  
  
  RESULTS
  We included nine trials (plus one study that was a subanalysis) for quantitative assessment. The studies were conducted in Tanzania, Zimbabwe, South Africa, Uganda, Kenya, Peru, China, India and Russia, comprising 75,891 participants, mostly including the general population (not the high-risk population). The main intervention was condom promotion, or distribution, or both. In general, control groups did not receive any active intervention. The main risk of bias was incomplete outcome data.In the meta-analysis, there was no clear evidence that the intervention had an effect on either HIV seroprevalence or HIV seroincidence when compared to controls: HIV incidence (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.69 to 1.19) and HIV prevalence (RR 1.02, 95% CI 0.79 to 1.32). The estimated effect of the intervention on other outcomes was similarly uncertain: Herpes simplex virus 2 (HSV-2) incidence (RR 0.76, 95% CI 0.55 to 1.04); HSV-2 prevalence (RR 1.01, 95% CI 0.85 to 1.20); syphilis prevalence (RR 0.91, 95% CI 0.71 to 1.17); gonorrhoea prevalence (RR 1.16, 95% CI 0.67 to 2.02); chlamydia prevalence (RR 0.94, 95% CI 0.75 to 1.18); and trichomonas prevalence (RR 1.00, 95% CI 0.77 to 1.30). Reported condom use increased in the experimental arm (RR 1.20, 95% CI 1.03 to 1.40). In the intervention groups, the number of people reporting two or more sexual partners in the past year did not show a clear decrease when compared with control groups (RR 0.90, 95% CI 0.78 to 1.04), but knowledge about HIV and other STIs improved (RR 1.15, 95% CI 1.04 to 1.28, and RR 1.23, 95% CI 1.07 to 1.41, respectively). The quality of the evidence was deemed to be moderate for nearly all key outcomes.
  
  
  CONCLUSIONS
  There is no clear evidence that structural interventions at the community level to increase condom use prevent the transmission of HIV and other STIs. However, this conclusion should be interpreted with caution since our results have wide confidence intervals and the results for prevalence may be affected by attrition bias. In addition, it was not possible to find RCTs in which extended changes to policies were conducted and the results only apply to general populations in developing nations, particularly to Sub-Saharan Africa, a region which in turn is widely diverse.
authors: Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
authors: Ralfh
authors: R
authors: Moreno
authors: Herfina Y
authors: HY
authors: Nababan
authors: Erika
authors: E
authors: Ota
authors: Windy M V
authors: WM
authors: Wariki
authors: Satoshi
authors: S
authors: Ezoe
authors: Stuart
authors: S
authors: Gilmour
authors: Kenji
authors: K
authors: Shibuya
mesh_terms: D000328:Adult; D002690:Chlamydia Infections / Q000453:epidemiology / Q000517:prevention & control; D017280:Condoms / Q000706:statistics & numerical data*; D006069:Gonorrhea / Q000453:epidemiology / Q000517:prevention & control; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control; D006293:Health Promotion / Q000458:organization & administration*; D006558:Herpes Genitalis / Q000453:epidemiology / Q000517:prevention & control; D018258:Herpesvirus 2, Human; D006801:Humans; D015994:Incidence; D015995:Prevalence; D016032:Randomized Controlled Trials as Topic; D012749:Sexually Transmitted Diseases / Q000453:epidemiology / Q000517:prevention & control*; D013587:Syphilis / Q000453:epidemiology / Q000517:prevention & control; D014245:Trichomonas Infections / Q000453:epidemiology / Q000517:prevention & control