Controlled studies show that HIV risk reduction counseling significantly increases condom use, reduces unprotected sex and prevents sexually transmitted infections. Nevertheless, without evidence of reducing HIV incidence, these interventions are generally discarded. One trial, the EXPLORE study, was designed to test whether 10 sessions of risk reduction counseling could impact HIV incidence among men who have sex with men in six US cities. Based on epidemiologic models to define effective HIV vaccines, a 35% reduction in HIV incidence was set a priori as the benchmark of success in this behavioral intervention trial. Results demonstrated a significant effect of the intervention, with more than a 35% reduction in HIV incidence observed during the initial 12 to 18 months following counseling. Over an unprecedented 48-month follow-up, however, the effect of counseling on HIV incidence declined to 18%. The current review examined how the scientific literature has thus far judged the outcomes of the EXPLORE study as well as the policy implications of these judgments. We identified 127 articles that cited The EXPLORE Study since its publication. Among articles that discuss the HIV incidence outcomes, 20% judged the intervention effective and 80% judged the intervention ineffective. The overwhelmingly negative interpretation of the EXPLORE study outcomes is reflected in public policies and prevention planning. We conclude that using a vaccine standard to define success led to a broad discrediting of the benefits of behavioral counseling and, ultimately, adversely impacted policies critical to the field of HIV prevention.
This study examined the efficacy of an enhanced intervention to reduce sexual risk of HIV/STI and harmful alcohol use among female sex workers in Mongolia. Women (n = 166) were recruited and randomized to either (1) a relationship-based HIV sexual risk reduction intervention; (2) the same sexual risk reduction intervention plus motivational interviewing; or (3) a control condition focused on wellness promotion. At three and six month follow-up, both treatment interventions and the wellness promotion condition were effective in reducing the percentage and the number of unprotected acts of vaginal sex with paying partners in the past 90 days. All three conditions demonstrated efficacy in reducing harmful alcohol use. No significant differences in effects were observed between conditions. Findings suggest that even low impact behavioral interventions can achieve considerable reductions of HIV/STI risk and harmful alcohol use with a highly vulnerable population in a low resourced setting.
HIV; Prevention; Sex work; Alcohol; Mongolia