Ethics of mass STD treatment [letter]

Heiner Grosskurth and colleagues conclude their review of the divergent results of the Mwanza and Rakai trials with a call for trials of single or multiple rounds of mass treatment for sexually transmitted diseases (STDs). Such a call is disingenuous given the negative findings of the Rakai trial and furthermore ignores those who believe mass treatment will have an adverse effect on public health. In addition there is the unexplained increase in HIV-1 incidence over time in Rakai which the authors suggest is related to increased unsafe sexual behavior in the face of a biomedical intervention. An increase in STD prevalence was seen in Mwanza probably for the same reason. Again an uncomfortable fact is conveniently overlooked. We have argued elsewhere that trials of biomedical interventions should take place in cohorts of stable HIV-1 discordant couples before they are extended to the general population. This approach applies to HIV-vaccine trials mass STD treatment antiretroviral treatments and circumcision. At the XIII International AIDS Conference in Durban there was much discussion about the latter. Circumcision of the male partner seems to be protective for male-female and female-male heterosexual HIV-1 transmission but only in discordant couples. Those working in Africa need to be more strident in resisting those who suggest mass biomedical interventions while becoming supportive of biomedical interventions in discordant couples. (full text)