What Works for Women and Girls

transmit HIV. Providing male circumcision only to HIV-negative men may discourage allmen from accessing male circumcision and women may falsely conclude that if a man iscircumcised, there is no risk of HIV acquisition.Gap noted, for example, in Uganda (Wawer et al., 2009); Southern Africa (Anderssonet al., 2009); sub-Saharan Africa (Hallett et al., 2008a); Kenya (Agot et al., 2007); SouthAfrica (Taljaard et al., 2008); Uganda and Zimbabwe (Matovu et al., 2007).3D. Prevention for Women: Treating SexuallyTransmitted Infections (STIs)Worldwide, the burden of sexually transmitted infections in women is more than five timesthat in men (Sciarra, 2009). The prevention and treatment of the other sexually transmittedinfections may also play a role in HIV prevention for women.Multiple observational studies have found an association between STIs and HIV (Cohen,2009). Modeling exercises suggest that increases in the HIV viral burden in the genital tractcan increase the efficiency of HIV transmission. STIs generally increase the concentration ofHIV-1 in the genital tract. Thus, treating STIs in HIV-infected men was suggested as a wayto reduce transmission to women. In addition, treating STIs in HIV-uninfected women washoped to decrease their susceptibility to acquiring HIV.However, the evidence that treating STIs can reduce the spread of HIV to women has beengenerally disappointing (Padian, 2010; Celum et al., 2010). A Cochrane review from 2004noted: “There is limited evidence from randomized controlled trials for STI control as an effectiveHIV prevention strategy” (Sangani et al., 2004). The only study to have shown an impacton HIV incidence from STI treatment has been the Mwanza trial in Tanzania. A combinationof improved STI treatment services was shown to reduce HIV incidence in an environmentcharacterized by an emerging HIV epidemic (low and slowly rising prevalence), where STItreatment services are poor, and where STIs are highly prevalent (Grosskurth et al., 1995). Theother eight trials of STI treatment have shown no effect on HIV acquisition (Padian, 2010).However, using STI services as a point of access to reach women at high risk of acquiringHIV is important. These services “contribute to the achievement of universal access to HIVprevention by promoting condom use, behavioral change and the empowerment of vulnerablepopulations” (Chersich and Rees, 2008: S35). “Even if in the end it is found that STDs haveonly a limited impact on HIV transmission, we cannot afford to miss the potentially costeffectivechance of controlling HIV through their treatment. Additionally, STDs are importantdiseases, which by themselves cause major morbidity and reduced fertility, demandingcontrol” (Rottingen et al., 2001: 594).[See also Chapter 8. Meeting the Sexual and Reproductive Health Needs of Women Living WithHIV for additional sexual and reproductive health interventions]70 CHAPTER 3 PREVENTION FOR WOMEN