Treating the whole syndrome

Abstract

For over a decade, epidemiological studies have addressed the issue of sexually transmitted diseases (STDs) as cofactors in transmission of HIV with the most convincing documentation from a nested casecontrol study in Zaire (AIDS 1993; 7: 95-102) and a community-based intervention trial in Tanzania (Lancet 1995; 346: 530). Biological evidence for this cofactor effect was provided this year by two studies done in Africa (Cohen, Ghys) on viral load in genital secretions. The presence of HIVwas strongly correlated in both semen and vaginal secretions with gonococcaJ and chlamydial infections, and more compellingly, of these STDs resulted in a decrease of genital shedding. The concentation of HIV in genital secretions is likely to be a key determinant of HIV sexual infectiousness and the finding that with antibiotics can reduce genital shedding of HIV has marked implications for HIV-prevention programmes. Since the 1980s it has also been hypothesised that the clinical spectrum and response to of STDs differs in the presence of HIV infection. Of particular concern was the impact of HIV on syphilis. Rolfs and colleagues reported the results of multicentre randomised trial of clinical and serological response of patients with syphilis (of all stages) with and without HIV, comparing standard with enhanced regimens (Rolfs). HIV-positive patients did not differ from HIVnegative patients with regard to clinical presentation, presence of Treponema pallidum in cerebrospinal fluid (positive in at least a quarter of all patients), or clinical response to treatment. HIV-positive patients responded less well serologically, but whether this reflects treatment failure or simply modified immunological response as a result of HIV infection, is unclear. Enhanced did not improve clinical outcomes. While symptomless genital shedding of herpes simplex virus (HSV) seems much higher than initially thought, it is not yet clear what the implications for infectiousness to sexual partners are. Should safe sex for ever be promoted to all those who are serologically confirmed (10-30% of the adult population in the West)? At least transmission from mother to child and related perinatal complications are very rare. Only acquisition of HSV near the time of labour was associated with neonatal herpes and perinatal morbidity (Brown) in a large study from Seattle. Despite these advances, the large knowledge-base about and prevention of STDs, and the impact of STDs on HIV infectiousness and acquisition and overall reproductive health, STD control continues to be limited by programmatic, resource, and service issues