Treating Sexually Transmitted Infections (STIs)
Worldwide, the burden of sexually transmitted infections in women is more than five times that in men (Sciarra, 2009). The prevention and treatment of the other sexually transmitted infections 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 tract can increase the efficiency of HIV transmission. STIs generally increase the concentration of HIV-1 in the genital tract. Thus, treating STIs in HIV-infected men was suggested as a way to reduce transmission to women. In addition, treating STIs in HIV-uninfected women was hoped to decrease their susceptibility to acquiring HIV.
However, the evidence that treating STIs can reduce the spread of HIV to women has been generally disappointing (Padian, 2010; Celum et al., 2010). A Cochrane review from 2004 noted: “There is limited evidence from randomized controlled trials for STI control as an effective HIV prevention strategy” (Sangani et al., 2004). The only study to have shown an impact on HIV incidence from STI treatment has been the Mwanza trial in Tanzania. A combination of improved STI treatment services was shown to reduce HIV incidence in an environment characterized by an emerging HIV epidemic (low and slowly rising prevalence), where STI treatment services are poor, and where STIs are highly prevalent (Grosskurth et al., 1995). The other 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 acquiring HIV is important. These services “contribute to the achievement of universal access to HIV prevention by promoting condom use, behavioral change and the empowerment of vulnerable populations” (Chersich and Rees, 2008: S35). “Even if in the end it is found that STDs have only a limited impact on HIV transmission, we cannot afford to miss the potentially cost-effective chance of controlling HIV through their treatment. Additionally, STDs are important diseases, which by themselves cause major morbidity and reduced fertility, demanding control” (Rottingen et al., 2001: 594).
[See also Chapter 8. Meeting the Sexual and Reproductive Health Needs of Women Living With HIV for additional sexual and reproductive health interventions]