Conundrum of sexually transmitted infections – One patient, many diseases

The recognition that sexually transmitted infections (STI) facilitate HIV transmission among heterosexuals has led to a rejuvenated focus on improving STI control as a component of HIV prevention programmes in developing countries. While efforts so far have focused mainly on all STI, there is increasing evidence that genital ulcers facilitate a considerable proportion of HIV transmission among heterosexuals and that this effect has been underestimated. This paper focuses on the epidemiology of genital herpes in developing countries past and present. To review the scientific literature about the epidemiology of genital herpes in developing countries and discuss the implications of the findings for STI control and HIV prevention programmes. SEARCH METHODOLOGY: A Medline search for June 1966 to August 1999 using the keywords, genital herpes, STD and developing countries, and genital ulcers in MeSH and free text. Abstract books from recent international AIDS conferences and other international STD conferences were reviewed. The annual reports of the medical officers of heath for Harare 1982-1998 and Durban 1989-1997 were reviewed to detect trends in genital herpes diagnoses. Genital herpes, formerly regarded as a minor STI in most developing countries, has now emerged as a leading cause of genital ulceration in many countries where syphilis and chancroid were more prevalent previously. This increased recognition of genital herpes reflects both a change in the pattern of STI epidemiology through a decline in syphilis and chancroid as a response to HIV control programmes and improved techniques for diagnosing herpetic infection. Countries with significant heterosexual HIV epidemics also appear to have rapidly increasing numbers of genital herpes cases. The emergence of this herpes epidemic must be addressed through innovative strategies that will be viable, sustainable, acceptable, and effective in developing countries. In countries where genital herpes is a significant problem, local adaptation of WHO treatment algorithms should be made. STI service providers should be trained about issues around the transmission of herpes and how best to advise clients about dealing with, and recognising, recurrences. The effectiveness of antiviral treatment for genital herpes should be investigated in core groups at high risk of HIV.

To address the ongoing epidemic of sexually transmitted infections (STIs) in the United States, the National Academies of Sciences, Engineering, and Medicine (National Academies) conducted a consensus study on STI control and prevention in the United States to provide recommendations to the Centers for Disease Control and Prevention and the National Association of County and City Health Officials. The culminating report identified military personnel as one of the priority groups that require special consideration given the high prevalence of STIs and their associated behaviors (e.g., concurrent sexual partners and infrequent condom use) that occur during active duty service. Universal health care access, the relative ease and frequency of STI screening, and the educational opportunities within the military are all assets in STI control and prevention. The report offers a comprehensive framework on multiple and interrelated influences on STI risk, prevention, health care access, delivery, and treatment. It also provides an overview of the multilevel risk and protective factors associated with STIs that could be applied using a sexual health paradigm. The military context must integrate the multilevel domains of influences to guide the effort to fill current gaps and research needs. The Department of Defense, with its large clinical and preventive medicine workforce and its well-established universal health care system, is well positioned to enact changes to shift its current approach to STI prevention, treatment, and control. STI control based on highlighting behavioral, social, cultural, and environmental influences on service members' sexual health and wellness may well drive better STI care and prevention outcomes.

Control of sexually transmitted infections for HIV prevention

From the Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD; and HIV Clinic, Naval Medical Center San Diego, San Diego, CA. Reprints: Nancy Crum-Cianflone, MD, MPH, c/o Clinical Investigation Department (KCA), Naval Medical Center San Diego, 34800 Bob Wilson Dr, Suite 5, San Diego, CA 92134-1005. E-mail: [email protected]. Support for this work was provided by the Infectious Disease Clinical Research Program, a Department of Defense program executed through the Uniformed Services University of the Health Sciences. This project has been funded in whole, or in part, with federal funds from the National Institute of Allergy and Infectious Diseases, National Institutes of Health, under Inter-Agency Agreement Y1-AI-5072. The content of this publication is the sole responsibility of the author and does not necessarily reflect the views or policies of the National Institutes of Health or the Department of Health and Human Services, the Department of Defense, or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the US Government. This work is original and has not been published elsewhere.

There is limited evidence from randomised controlled trials for STI control as an effective HIV prevention strategy. Improved STI treatment services have been shown to reduce HIV incidence in an environment characterised by an emerging HIV epidemic (low and slowly rising prevalence), where STI treatment services are poor and where STIs are highly prevalent. There is no evidence for substantial benefit from treatment of all community members. The addition of the Kamali trial to the existing evidence supports the data from the Rakai trial of no effect. There are, however, other compelling reasons why STI treatment services should be strengthened, and the available evidence suggests that when an intervention is accepted it can substantially improve quality of services provided. The Kamali trial shows an increase in the use of condoms, a marker for improved risk behaviors. Further community-based randomised controlled trials that test a range of alternative STI control strategies are needed in a variety of different settings. Such trials should aim to measure a range of factors that include health seeking behaviour and quality of treatment, as well as HIV, STI and other biological endpoints.

There is limited evidence from randomised controlled trials for STI control as an effective HIV prevention strategy. Improved STI treatment services have been shown to reduce HIV incidence in an environment characterised by an emerging HIV epidemic (low and slowly rising prevalence), where STI treatment services are poor and where STIs are highly prevalent. There is no evidence for substantial benefit from treatment of all community members. There are however other compelling reasons why STI treatment services should be strengthened and the available evidence suggests that when an intervention is accepted it can substantially improve quality of services provided. Further community based randomised controlled trials that test a range of alternative STI control strategies are needed in a variety of different settings. Such trials should aim to measure a range of factors that include health seeking behaviour and quality of treatment as well as HIV, STI and other biological endpoints.

To the Editor: We published a 1999 review of studies exploring whether sexually transmitted infections (STIs) are causally associated with human immunodeficiency virus (HIV) infection among men who have sex with men (MSMs),1 finding few studies and no convincing evidence for associations. This contrasted with evidence then emerging of several STIs (especially ulcerative infections) being risk factors for HIV among the general population. We speculated that our findings might be explained by higher exposure to HIV among MSM and relatively higher transmission of HIV in anal than vaginal sex. A more recent review/meta-analysis by Freeman et al. focusing on herpes simplex virus (HSV)-22 reported a significant association of HSV-2 with HIV among MSMs [RR = 1.7; 95% confidence interval (CI) 1.2–2.4] but smaller than among the general population. This difference is plausible for the reasons above but does suggest STI control may nonetheless be important in MSM HIV prevention efforts. Another recent review/meta-analysis3 suggests other STIs, including syphilis, gonorrhoea, and chlamydia, may be risk factors for HIV among the general population but reports no findings for MSMs. We therefore decided to update our review to assess whether other STIs not merely HSV-2 might be important to address within HIV prevention for MSMs. We searched PubMed for relevant articles published 1998 to 2007 using MeSH/non-MeSH search terms covering STIs, HIV, and MSM; abstracts from the most recent International Acquired Immune Deficiency Syndrome conference and International Society for Sexually Transmitted Disease Research conference; and reference lists of found articles. We identified 10,681 potentially relevant articles. Titles and abstracts were reviewed for possible pertinence and where this was the case, full articles obtained (46 in all) and reviewed against criteria of reporting association(s) between HIV and one or more STIs, or between exposure/allocation to an STI control programme and HIV; assessing incident HIV infections serologically/via medical case notes; assessing prior STI infections serologically/via medical case notes; and adjusting, matching, or otherwise controlling for age and measure(s) of sexual risk behavior. Four adequate studies were identified. Two reported on data from the same cohort,4,5 so only the more complete of these was included. Three reported on HSV-25–7 and one on HSV-1.6 None examined other STIs. None reported the effects of STI control. One study5 did not appear in Freeman et al.'s review and this reported a significant association between HIV and HSV-2 detected >24 months previously (hazard ratio = 1.5, 95% CI 1.1–2.1) but not HSV-2 detected <24 months previously (hazard ratio = 1.7, 95% CI 0.8–3.3), i.e., in line with Freeman et al.'s meta-analysis. A further study reviewed by Freeman et al. regarding its findings for HSV-2 also included data on HSV-16 finding no association with HIV. Thus, current evidence suggests HSV-2 is a risk factor for HIV infection among MSMs but does not tell us whether STIs other than HSV-2 exert effects on HIV that are negligible; smaller than those found for the general population but not negligible; or possibly even comparable to the general population. Our review also identified an absence of research on STI control programmes effects on HIV among MSMs. This is surprising given the high prevalence of many STIs among MSMs worldwide. To assess the importance of addressing STIs other than HSV-2 within HIV prevention for MSMs we recommend further research on this question. Observational studies could be nested within studies of behavioural interventions or repeat clinic attenders. Alternatively, given the variability in contents, targeting, and intensity of STI control for MSMs as well as the uncertainty regarding impact on HIV incidence, it would be ethical and useful for experimental evaluations of pilot-enhanced STI control programmes targeting MSM to assess effects on HIV incidence.

The global burden of sexually transmitted infections

AAUS guidelines 2021 revision sexually transmitted infection (STIs) diagnostic strategy for STI

A special edition on sexually transmitted diseases (STD) of the anus and rectum was planned by a mediator to identify differences of STD among five specific institutes such as rural clinics, speciality coloproctological hospitals, and general hospitals. According to the data of national health care authorities and author's papers, STD has become prevalent among those in their 20s and 30s, especially young women.In general, recent STDs include gonococcal infection, genital Chlamydia infection, genital herpes, condyloma ac-cuminatum, syphilis, and AIDS. Although gonococcal infection and genital Chlamydia infection have been decreasing in number, genital herpes and condyloma accuminatum have been increasing steadily.The recent tendency of STD indicates higher prevalence among young women aged 15 to 20 then men, except for gonococcal infection. Further more, not only a single infection but also double or triple infections are characteristic. STD has extended not only to the genito-anal region but also the oral cavity and pharyngeal site, so the upper or lower digestive tract should be investigated hereafter.

IntroductionThe extraordinarily high incidence of HIV in sub-Saharan Africa led to the search for cofactor infections that could explain the high rates of transmission in the region. Genital inflammation and lesions caused by sexually transmitted infections (STIs) were a probable mechanism, and numerous observational studies indicated several STI cofactors. Nine out of the ten randomized controlled trials (RCTs), however, failed to demonstrate that treating STIs could lower HIV incidence. We evaluate all 10 trials to determine if their design permits the conclusion, widely believed, that STI treatment is ineffective in reducing HIV incidence.DiscussionExamination of the trials reveals critical methodological problems sufficient to account for statistically insignificant outcomes in nine of the ten trials. Shortcomings of the trials include weak exposure contrast, confounding, non-differential misclassification, contamination and effect modification, all of which consistently bias the results toward the null. In any future STI-HIV trial, ethical considerations will again require weak exposure contrast. The complexity posed by HIV transmission in the genital microbial environment means that any future STI-HIV trial will face confounding, non-differential misclassification and effect modification. As a result, it is unlikely that additional trials would be able to answer the question of whether STI control reduces HIV incidence.ConclusionsShortcomings in published RCTs render invalid the conclusion that treating STIs and other cofactor infections is ineffective in HIV prevention. Meta-analyses of observational studies conclude that STIs can raise HIV transmission efficiency two- to fourfold. Health policy is always implemented under uncertainty. Given the known benefits of STI control, the irreparable harm from not treating STIs and the likely decline in HIV incidence resulting from STI control, it is appropriate to expand STI control programmes and to use funds earmarked for HIV prevention to finance those programmes.

Purpose: The purpose of this study was to estimate the incidence and the direct medical cost of sexually transmitted infections (STIs) among young persons in California and each of its 58 counties, and to better inform discussions about statewide policies and local resources needed for STI prevention and control efforts. Methods: On the basis of the methods developed at the Centers for Disease Control and Prevention we estimated the statewide number of new cases of eight major STIs among young persons aged 15 to 24 years in California in 2005: chlamydia, gonorrhea, syphilis, genital herpes, human papillomavirus (HPV), hepatitis B, trichomoniasis, and HIV. We also calculated the direct medical cost of these STIs using national cost-per-case estimates. To inform local policy discussions about STI control efforts, the statewide estimates were allocated by county. Results: An estimated 1.1 million new cases of STIs occurred among young persons in California in 2005, with a direct medical cost of $1.1 billion. The estimated number of new cases within counties ranged from a low of 82 in Alpine and Sierra counties, at a cost of $38,000, to a high of about 360,000 in Los Angeles County, at a cost of $390 million. Conclusions: These estimates illustrate the widespread and frequently underreported incidence and costs of youth STIs in California and its counties, and provide the foundation for a comprehensive assessment of youth STI prevention needs.

Toward global prevention of sexually transmitted infections (STIs): The need for STI vaccines

Artificial intelligence and sexual health in the USA

The increasing incidence of sexually transmitted infections (STIs) is a global health concern, but research on proportions of sexually transmitted coinfection in large populations remains limited. This study estimated the proportions of coinfections among various STIs using a health care nationwide claims database. This descriptive epidemiologic study analyzed data from the National Database of Health Insurance Claims and Specific Health Checkups of Japan from April 2013 to December 2020. Five STIs were included: syphilis, genital chlamydia (Chlamydia trachomatis), gonococcal infection (Neisseria gonorrhoeae), genital herpes (herpes simplex virus), and genital warts. Coinfection was defined as the presence of multiple STIs, and proportions were calculated for individuals aged 15 to 49 years. Coinfection proportions were higher among individuals aged 15 to 19 and 20 to 29 years across all STIs. From 2017 to 2020, 3.4% to 6.4% of females with gonococcal infections had syphilis, rising to 8.9% to 9.0% among females aged 15 to 19 years. Among males, 5.4% to 6.1% with genital herpes had syphilis. Genital chlamydia occurred with gonorrhea in 33.8% to 38.1% of males and 37.9% to 40.8% of females. Coinfection proportions for syphilis with genital herpes ranged from 2.5% to 3.0% in males, and genital warts with chlamydia ranged from 2.0% to 2.3% in males and 3.1% to 4.1% in females. The findings underscore the need for targeted STI screening and early diagnosis to manage and reduce coinfections. These results provide actionable insights for clinicians and public health policy makers to strengthen STI prevention and control strategies.