Sexually Transmitted Diseases Control Research Articles

Sexually Transmitted Disease Control in the Armed Forces, Past and Present

Sexually transmitted diseases (STDs) present a challenge for military medical personnel in their efforts to maintain a ready and healthy force. Many tactics have been used in military STD control programs. This paper is a review of the literature outlining some past strategies used in the United States military and how they have shaped current STD policy. These efforts have included financial and administrative penalties, stigmatization and shame, screening programs, and sharing of resources with other government agencies. Punishments and stigmatization have not proven to be useful strategies and have been eliminated from current policy. Cooperation with other government agencies and screening programs are examined as tactics that have been found useful and are part of the program used by the military today to control not only the traditional STDs, but also the more recently discovered human immunodeficiency virus.

Risk factors for sexually transmitted diseases among women attending family planning clinics in Dar-es-Salaam, Tanzania.

BACKGROUND: Identification of risk factors for sexually transmitted diseases (STDs) assists in development of treatment algorithms, which are potentially important components of STD control when microbiologic facilities are limited. METHODS:...

Sexually transmitted diseases in mobile populations.

Introduction STDs and travel: an ancient association Sexually transmitted diseases have been associated with travel, and indeed blamed on travellers (particularly foreigners) since they were first described. The history of...

Health seeking behaviour and the control of sexually transmitted disease.

What people do when they have symptoms or suspicion of a sexually transmitted disease (STD) has major implications for transmission and, consequently, for disease control. Delays in seeking and obtaining diagnosis and treatment can allow for continued transmission and the greater probability of adverse sequelae. An understanding of health seeking behaviour is therefore important if STD control programmes are to be effective. However, taboos and stigma related to sex and STD in most cultures mean that gaining a true picture is difficult and requires considerable cultural sensitivity. At the moment relatively little is known about who people turn to for advice, or about how symptoms are perceived, recognized or related to decisions to seek help. It is argued that such knowledge would assist programme planners in the development of more accessible and effective services, that studies of health seeking behaviour need to include a combination of qualitative and quantitative methods, and that studies should include data collection about people who do not present to health care facilities as well as those who do. A pilot protocol for studying STD-related health seeking behaviour in developing countries is briefly presented.

Public Health Departments Providing Sexually Transmitted Disease Services

Results of a 1995 survey reveal that 1,437 local health departments-half of those in the country-provide sexually transmitted disease (STD) services and receive about two million client visits each year. Their clients are predominantly individuals with incomes of less than 250% of the poverty level (83%), women (60%) and non-Hispanic whites or blacks (55% and 35%, respectively); 36% of clients are younger than 20, and 30% are aged 20-24. On average, 23% of clients tested for STDs have chlamydia, 13% have gonorrhea, 3% have early-stage syphilis, 18% have some other STD and 43% have no STD. Virtually all public STD programs offer testing and treatment for gonorrhea and syphilis; only 82% test for chlamydia, but 97% provide treatment for it. Some 14% offer services only in sessions dedicated to STD care, 37% always integrate STD and other services, such as family planning, in the same clinic sessions, and 49% offer both separate and integrated sessions. STD programs that integrate services with other health care typically cover nonmetropolitan areas, have small caseloads, serve mainly women and provide a variety of contraceptives. In contrast, those that offer services only in dedicated sessions generally are in metropolitan areas and have large caseloads; most of their clients are men, and few provide contraceptive methods other than the male condom.

Human immunodeficiency virus infection and other sexually transmitted diseases in developing countries: public health importance and priorities for resource allocation.

The health programs of developing countries have not traditionally given high priority to the prevention and control of sexually transmitted diseases (STDs). However the HIV pandemic and the realization that a significant proportion of reproductive and maternal morbidity and mortality result from STDs have generated renewed interest in STD control. The authors develop and apply a population-based analytical approach to modeling the cost-effectiveness of alternative STD interventions. They find that the cost-effectiveness of individual interventions is highly sensitive to the circumstances of implementation. In particular targeting interventions to the subset of the population with the highest rates of sex partner change markedly improves the cost-effectiveness of all interventions analyzed.

Successful eradication of sexually transmitted diseases in the People's Republic of China: implications for the 21st century.

The global control of sexually transmitted diseases (STDs) represents a daunting task, and there have been very few examples of success. The scope of the STD problem in China before the formation of the People's Republic and the effects of a governmental STD control program were reviewed. In major cities, 10% of the population had syphilis, reaching 50% prevalence in some rural minorities. By 1964, STDs in China were virtually eliminated through a program that destigmatized STDs, provided an infrastructure for case finding and therapy, and eliminated prostitution. The People's Republic of China demonstrated the possibility of eliminating STDs, at least for some period of time. Although the Chinese approach may not be ideal for Western democracies, understanding some features of the Chinese program may help in designing a strategy for the eradication of human immunodeficiency virus when or if treatment becomes available.

Health care systems in transition: People's Republic of China. Part II: The Chinese health care system's response to HIV-AIDS.

Since the diagnosis of the first AIDS case in China in 1985 by the first half of 1995 1774 patients had been diagnosed as being HIV positive some of whom now also have AIDS. Between 1985 and 1993 more than 300 HIV-infected people had been identified through quarantine offices along the borders making up one-quarter of the reported infections during that period. Until now more than 75 per cent of the reported HIV cases are drug users. Within the Southwest border region most of the infected individuals are injecting drug users. In the coastal cities and interior provinces HIV-infected individuals are also found among returned expatriate workers. In the large cities HIV-infected individuals are found among patients attending sexually transmitted diseases (STD) clinics prostitutes and those with multiple sexual partners. Recently introduced routine screening has also diagnosed HIV-infected individuals among blood donors. The Chinese Government takes HIV prevention very seriously. Within the health care system groups of professionals who specialize in HIV-related control surveillance education treatment and research are being formed. A quarantine service is currently operated as one of the supplementary approaches though its role within HIV-related containment strategies is being evaluated. These strategies are centred around prevention centres involving all tiers from central to local government. In addition a number of community organizations research agencies and nongovernment organizations have become involved in HIV prevention. Multiple agencies and scientists representing multiple disciplines are working together to formulate appropriate HIV prevention policies. The best known non-government organizations which have made important contributions to the work performed to date include the China Association of STD and AIDS Prevention and Control and China AIDS Network. (excerpt)

Association of sexually transmitted diseases and infection with the human immunodeficiency virus: biological cofactors and markers of behavioural interventions.

Sexually transmitted diseases (STDs) interact uniquely with HIV infection, regardless of the form of sexual transmission of HIV. Both STDs and HIV infection are behaviorally and biologically intertwined with one another. This concept is called epidemiologic synergy since they facilitate the sexual transmission of one another. Assuming that one accepts this concept, innovative and comprehensive STD control programs along with community and individual-based prevention programs should provide a more effective HIV control program by reducing the efficiency of HIV transmission in high-risk individuals. Public health workers can assess the effectiveness of these programs by monitoring incident STDs in high-risk groups. Other benefits of using incident STDs as markers for HIV prevention include: biological validation of self-reported behavioral change, possible association between self-reports of behavioral change and recall or social desirability bias, representation of a major target population for HIV programs by people at risk for STDs, and sensitive, specific, and noninvasive STD-assays. Disadvantages of using incident STDs as markers for HIV prevention are: incident STDs are unreliable for detecting deficiencies in one individual component (i.e., condom use), they can be used only in areas with a high STD prevalence and high transmission probability, STD diagnostic assays are not 100% sensitive and specific, and untreated/undetected STDs at enrollment may be mislabeled as incident STDs at follow-up. Questions remain about the validity of self-reported condom use and the use of STDs to evaluate individual intervention measures, e.g., condom use within a short period of time. Monitoring of HIV incidence would be ideal, but it may take too long. Valid measures of condom use and other risk behavior are needed to determine risk status and changes in risk status over time. Thus, further research is needed to develop more accurate measures.

Sexually transmitted diseases control in developing countries.

Sexually transmitted diseases (STDs) are a major public health problem now compounded by the advent of AIDS and HIV infection. The size of the problem represented by STDs and HIV is unknown however it is estimated that there are 333 million new cases of STD per annum and currently 15-20 million people infected worldwide with HIV. Control programmes for STDs must prevent the acquisition of STDs, their complications and sequelae and interrupt and reduce transmission. They can also reduce the incidence of HIV infection. Such programmes must place emphasis on health education, condom usage, altering health seeking behaviour and providing case management. The syndromic approach currently offers the most realistic, and cost effective, way in which to treat patients.

In Response: Cost-Effectiveness of Contact Tracing Versus Screening to Find Syphilis Cases: Further Study Is Needed

In Response: Cost-Effectiveness of Contact Tracing Versus Screening to Find Syphilis Cases: Further Study Is Needed

Providers of syphilis care in the southern United States.

The nadir in syphilis incidence in the 1950s provided evidence that current control methods could eliminate the transmission of syphilis. Planning such an effort will require information on the current state of the public and private infrastructure for the control of sexually transmitted disease (STD). To evaluate the accessibility, acceptability, and quality of delivery of clinical and preventive outreach services for syphilis control in the southern United States. A telephone-and-questionnaire survey of the 7 largest southern city, 10 state, and 9 nonsouthern comparison state STD control programs. The gender-race composition of public-sector STD providers is very different from their clients. Median ratio of STD clinicians per 1994 infectious syphilis patient was 0.08 (0.01-0.25) in southern states and 0.50(0.07-1.00) in comparison states. The proportion of clients treated within one day of care-seeking in southern states was 58% to 100%; regions with inadequate access were common. A median of 45% to 50% of patients with presumptive congenital syphilis underwent recommended diagnostic procedures. Serious deficiencies exist in the accessibility of STD care in the south that make the elimination of syphilis transmission difficult using current clinic-based diagnosis and treatment. A more community-based program of case finding and presumptive treatment may be indicated.

Incidence and Predictors of Human Immunodeficiency Virus Type 1 Seroconversion in Patients Attending Sexually Transmitted Disease Clinics in India

The first estimates of the seroincidence of human immunodeficiency virus type 1 (HIV-1) and of the risk factors for seroconversion in a cohort of high-risk patients attending sexually transmitted disease (STD) clinics in India are reported. Between 1993 and 1995, 851 HIV-1-seronegative persons were evaluated prospectively every 3 months for HIV infection and biologic and behavioral characteristics. The overall incidence of HIV-1 was 10.2/100 person-years (95% confidence interval, 7.9-13.1). The incidence among commercial sex workers (CSWs) was 26.1/100 person-years, compared with 8.4 among non-CSWs. Recurrent genital ulcer disease and urethritis or cervicitis during the follow-up period were independently associated with a 7- (P < .001) and 3-fold (P = .06) increased risk of HIV-1 seroconversion, respectively. Because of the association of recurrent ulcerative and nonulcerative STDs with HIV-1 seroconversion in this setting, behavioral and biologic measures directed at the prevention and control of STDs would be expected to greatly reduce the transmission of HIV-1 infection in similar high-risk groups.

STD control for HIV prevention—it works!

A well-designed community randomized trial in rural Mwanza Tanzania demonstrates that improved sexually transmitted disease (STD) case-management reduces the incidence of HIV infection. STD care activities integrated into primary health care services included training of health care workers in STD syndrome management securing available effective antibiotics for STDs through a separate distribution system and promoting health- seeking behavior. Essentially the reduced duration of self-reported STDs (especially in men) led to a 42% reduction in HIV infection incidence. The HIV infection incidence would have been even higher if health workers had implemented even more aggressive strategies (e.g. case-finding of asymptomatic STD cases among vulnerable groups). In both intervention and control villages sexual behavior and condom use were the same. The interventions had the greatest impact on HIV infection incidence among women 15-24 years old. Integration of STD services in family planning and maternal and child health services does not serve this very vulnerable age group or another very vulnerable group sex workers. Lack of simple technical tools to detect gonococcal and chlamydial infections in women presents an obstacle for providing accessible and effective STD care for vulnerable groups. Outreach activities as opposed to waiting for clients to come to a clinic community involvement and low-threshold services are means to reach vulnerable populations. These findings highlight the role of STDs as cofactors in HIV infection incidence and the need for health workers to discuss safe sex and promote condom use with STD patients. Health personnel should focus reaching vulnerable groups.

Neutrophils from human immunodeficiency virus (HIV)-seronegative donors induce HIV replication from HIV-infected patients' mononuclear cells and cell lines: an in vitro model of HIV transmission facilitated by Chlamydia trachomatis.

Infection with a sexually transmitted disease (STD) increases the risk for human immunodeficiency virus (HIV) infection. Polymorphonuclear leukocytes (PMNs) are recruited into the genital tract by STD pathogens, such as Chlamydia trachomatis. Semen of HIV-infected men contains HIV associated with mononuclear cells. This study investigated the interaction among PMNs from HIV-uninfected persons, C. trachomatis, and HIV-infected cells and examined the mechanisms for enhanced HIV replication. We demonstrated that PMNs from HIV-seronegative donors induced HIV replication in mononuclear cells from 17 HIV-infected patients in medium without exogenous IL-2. HIV in the cell-free supernatants from cocultures of PMNs and patients' peripheral blood mononuclear cells (PBMCs) was replication competent, as indicated by their capacity to propagate HIV in a second round of culture using PBMCs from HIV-seronegative individuals and by the fact that proviral DNA was found in these cells. PMNs from HIV-seronegative donors increased HIV replication over 100-fold in chronically HIV-infected cell lines of the monocytic, T, and B cell lineages. Moreover, PMNs increased U1 cells' production of p24 antigen by as much as ninefold when compared with U1 cells cocultured with PBMCs. The addition of C. trachomatis to PMN and U1 coculture increased HIV replication by an additional ninefold at 24 h, whereas C. trachomatis alone had no effect on p24 antigen production by U1 cells. Thus, C. trachomatis serves not only to recruit PMNs, but also to interact with PMNs to increase HIV replication. HIV replication is triggered by contact of HIV-infected cells with PMNs, by the generation of reactive oxygen intermediates (ROIs), and by soluble factors such as TNF-alpha and IL-6. This is based on the findings that production of p24 antigen, IL-6, and TNF-alpha induced by PMNs is abrogated by disrupting or partitioning PMNs from HIV-infected cells; is inhibited by superoxide dismutase and catalase, enzymes that destroy ROIs; is enhanced by differentiated HL60 cells capable of producing ROIs; and is induced by PMNs tested negative for CMV. Furthermore, the production of ROIs is independent of HIV infection of mononuclear cells, since PMNs cocultured with HIV-uninfected parental monocytic and T cell lines generated ROIs. Therefore, the increased risk for acquiring HIV infection associated with chlamydia cervicitis may be related to the local recruitment of PMNs by C. trachomatis and the induction of infectious virus from mononuclear cells present in semen. These observations provide a rationale for strategies to reduce HIV transmission by control of STD.

The American Social Health Association celebrates 80 years of fighting sexually transmitted diseases.

The American Social Health Association (ASHA) can look back on 80 years of service as the only national nongovernmental organization devoted exclusively to prevention of sexually transmitted diseases (STDs). The valuable contributions made by physicians since the agency's founding in 1914 are noted and gratefully acknowledged. To commemorate its 80th anniversary, ASHA recently published a history that discusses the movements leading to ASHA's founding, the organization's work with the military during the World Wars, the changing face of STD control once penicillin became widely available in the 1940s, and the response to newly identified infections in recent decades. It also lists ASHA's founders, board presidents, executive directors, and recipients of the William Freeman Snow Award for outstanding contributions in the field of sexually transmitted diseases. The history was written by Kay Flaminio and David Klaassen of the ASHA Archive. This article summarizing ASHA's history was written especially for the Journal by Sam A. Nixon and Kay Flaminio. Nixon, a long-time member of the Southern Medical Association, recently retired as an associate network medical director of BlueCross BlueShield of Texas. He has maintained an interest in STD prevention and the work of the ASHA for many years, currently serving as the vice chair of ASHA's board of directors. Kay Flaminio is a member of the staff of ASHA.

STDs and AIDS in Ghana.

Gonorrhea and other infectious diseases were introduced to Ghana prior to the colonial period by European settlers. By the 1920s, both gonorrhea and syphilis were widespread in southern Ghana (3760 and 1503 cases, respectively, in 1925-26) and soon disseminated throughout the country. By 1946, there were 82,430 cases of gonorrhea and 9340 cases of syphilis--an increase exacerbated by the influx of laborers and troops during World War II. Although there was no government department responsible for the control of sexually transmitted diseases (STDs), sulpha drugs were widely utilized and distributed through the black market. It was not until 1986, when the first case of acquired immunodeficiency syndrome (AIDS) was diagnosed in Ghana, that government health officials gave serious attention to STDs. At that time, the most prevalent STDs were gonorrhea, chlamydia, and trichomonas. By 1992, 10,285 AIDS cases had been reported to the National AIDS Control Program and high rates of human immunodeficiency virus (HIV) infection existed in prostitutes and blood donors. Awareness of the role that STDs play as co-factors in HIV acquisition prompted in 1993 the decision to integrate AIDS and STD control programs. Campaigns to train health workers in AIDS/STD detection, treatment, and prevention were initiated. Women's subordinate socioeconomic status, which renders them unable to insist on condom use and denies them access to STD treatment, remains a major obstacle.

VACCINES FOR CLASSIC SEXUALLY TRANSMITTED DISEASES

Sexually transmitted diseases (STDs) can substantially increase the morbidity and mortality of exposed adults and children. Despite the advent of new antibiotics and focus on behavioral interventions such as condom use, attempts to limit the spread of STDs have been largely unsuccessful. Vaccines have received increasing attention as a potential strategy for STD control. This article focuses on the current status of vaccine research for five classic STDs: gonorrhea, genital herpes, syphilis, chancroid, and chlamydia.

STD knowledge and behaviours among clients of female sex workers in Bali, Indonesia.

This study investigated knowledge, beliefs, and practices related to STDs and AIDS among clients of low price sex workers in Bali, Indonesia. These men are at high risk of STD and HIV transmission. They have poor knowledge of the basic concepts of STD and HIV transmission and prevention, and they practice a variety of ineffective prevention strategies including partner selection and the prophylactic use of antibiotics. They report a mean of 1.9 paid sexual partners in the previous week and very low frequencies of condom use. Over 25% had experienced an STD symptom in the previous 6 months, with self treatment with antibiotics reported by a third. Recent experience of an STD was related to the number of sex worker partners in the previous month and to ever having used a condom with a sex worker. The implications of the study findings for the development of comprehensive STD control programs including educational campaigns, condom promotion, and the strengthening of STD case management by health care providers are discussed.

EPIDEMIOLOGICAL CONSIDERATIONS OF SEXUALLY TRANSMITTED DISEASES IN UNDERSERVED POPULATIONS

Although unexplained declines in the number of bacterial sexually transmitted diseases (STDs) are currently being documented on a national level, increasing rates among minority populations and among adolescents in general, present challenges for STD prevention and control. By contrast, little evidence has been presented to suggest declines in rates of incident viral STDs in any population. Unique approaches to prevention and control based on the epidemiological heterogenicity of STDs are discussed.