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Weighing the gold in the gold standard: challenges in HIV prevention research

Padian, Nancy Sa,b; McCoy, Sandra Ib; Balkus, Jennifer Ec; Wasserheit, Judith Nd

doi: 10.1097/QAD.0b013e328337798a
Editorial Review

Objective(s): Few HIV prevention interventions have been evaluated in randomized controlled trials (RCTs). We examined design, implementation, and contextual considerations that may limit detection of a positive or adverse effect in HIV prevention trials.

Design: A systematic review of late phase RCTs for prevention of sexual transmission of HIV that randomly allocated intervention and comparison groups; evaluated interventions to prevent sexual transmission in nonpregnant populations; and reported HIV incidence as the primary or secondary outcome.

Methods: PubMed/MEDLINE, other electronic databases, and electronic conference proceedings of recent HIV/AIDS-related conferences were searched to identify published or unpublished trials meeting the inclusion criteria. Descriptive, methodological, and contextual factors were abstracted from each trial.

Results: The review included 37 HIV prevention RCTs reporting on 39 unique interventions. Only six RCTs, all evaluating biomedical interventions, demonstrated definitive effects on HIV incidence. Five of the six RCTs significantly reduced HIV infection: all three male circumcision trials, one trial of sexually transmitted infection treatment and care, and one vaccine trial. One microbicide trial of nonoxynol-9 gel produced adverse results. Lack of statistical power, poor adherence, and diluted versions of the intervention in comparison groups may have been important issues for the other trials that demonstrated ‘flat’ results.

Conclusion: Almost 90% of HIV prevention trials had ‘flat’ results, which may be attributable to trial design and/or implementation. The HIV prevention community must not only examine evidence from significant RCTs, but must also examine flat trials and address design and implementation issues that limit detection of an effect.

aSchool of Public Health, USA

bInstitute of Business and Economic Research, University of California, Berkeley, California, USA

cDepartment of Epidemiology, USA

dDepartment of Global Health, University of Washington, Seattle, Washington, USA.

Received 7 August, 2009

Revised 18 December, 2009

Accepted 22 December, 2009

Correspondence to Nancy S. Padian, MPH, PhD, Adjunct Professor, School of Public Health, Center of Evaluation for Global Action, University of California, Berkeley, F508 Haas Building, Berkeley, CA 94720-1922, USA. Tel: +1 510 926 1387; fax: +1 510 642 5018; e-mail:

© 2010 Lippincott Williams & Wilkins, Inc.