Treating Sexually Transmitted Infections (STIs)

A systematic review and meta-analysis of 1,064 reports between 1998 and 2000 found that genital ulcerative disease appears to have a greater impact than nonulcerative disease on the susceptibility to HIV. Men were more affected than women by the effects of STIs Untreated concurrent STIs in an HIV-positive individual increases the rate of progression towards AIDS. “A better and more quantitative understanding of the interactions between HIV infection and classic STDs is needed ...Sexual behavior is the common risk factor for contracting both HIV and STDs”.

A review of 2,101 articles in Medline and International Conferences on AIDS found that both ulcerative and non-ulcerative STIs promote HIV transmission. Risk estimates found in prospective studies from four continents ranged from two to over 23. “Owing to the greater frequency of non-ulcerative STIs in many populations, these infections may be more responsible for more HIV transmission than genital ulcers”.

A 2004 to 2006 cross-sectional survey study of female sex workers in India found that of the 976 women who had symptoms of an STI, more than 78% sought medical treatment; behavior that was protective for both HIV and STIs. HIV infection was strongly associated with lifetime and active syphilis.

In a study where 109,500 samples were tested during a nine-month period from patients in STI clinics in the US, Malawi and South Africa, 1 to 2 percent had acute HIV infection, which greatly increases the risk for transmission of HIV.

A retrospective study of 174 monogamous couples in Uganda in which one partner was HIV-positive, found that higher viral load and genital ulceration are the main determinants of HIV transmission per coital act. Transmission probabilities increased from .001 per act at viral loads of less than 1,700 copies/mL to .0023 per act at 38,500 copies/mL or more and were .0041 with genital ulceration versus .0011 without.

Ulcerative STIs, particularly chancroid, herpes simplex virus type 2 and syphilis are the most important STI cofactors for HIV transmission. Control of curative genital ulcers – chancroid and syphilis – is highly feasible and correlates well with stabilization of HIV epidemics. Effective antibiotic treatment of gonorrheal or chlyamydial infection reduces HIV viral load to normal levels. “Evidence supporting the role of STIs as HIV cofactors is extensive and indisputable”.

A study of 495 people living with HIV in South Africa, of whom more than 70% were women, found that 59% had a validated STI symptom assessed by STI symptom algorithm.

A retrospective medical review of 1,457 deliveries and 1,071 aborted pregnancies among HIV-positive women in Russia from 2003 to 2005 found that 37% of postpartum and 21% of abortion clients had STIs. Approximately 20% of those with STIs did not receive treatment for their STIs.

The prevalence of genital shedding of herpes simplex virus (HSV)-2 and related risk factors was evaluated in a prospective population of 355 women attending the Maternity Joséphine Bongo, in Libreville, Gabon. Researchers found a high prevalence (66%) of HSV-2 seropositivity, with a high proportion, 14%, of women harboring HSV-2 DNA shedding in their genital secretions. HSV-2 genital shedding was positively associated with previous episodes of genital blisters, current genital ulcer, current genital blister, HIV seropositivity and HSV-2 seropositivity.

A randomized trial was conducted over two years in rural Tanzania. STI treatment was provided in the intervention communities to assess the impact on HIV transmission. Strong evidence indicates that the STI intervention program had a substantial effect on HIV incidence in this rural African population. Six communities received the intervention immediately following the baseline survey, while six comparison communities received the intervention after the follow-up survey two years later. HIV incidence was consistently lower in the intervention community than the comparison community in all six matched pairs. After two years of the intervention, there were 48 seroconversions (1.2%) in the intervention group and 82 (1.9%) in the comparison group. HIV incidence was approximately 42% lower in the intervention group. Prevalence and incidence of STIs was measured in a random cohort consisting of 1,000 adults in each community. STI services were based on syndromic algorithms recommended by WHO . The intervention program had five components: 1) Establishment of an STI reference clinic and laboratory to monitor the effectiveness of treatment algorithms; 2) Existing staff from health centers received one week of classroom training and two weeks of practical training at the STI clinic. Staff also were trained to provide patients with health education and to offer free condoms; 3) A special delivery system of drugs was established to supplement the national essential drugs program supplies; 4) Regular supervisory visits by a program officer were conducted to provide in- service training and to check drug supplies and patient records; 5) Periodic visits by health educators to villagers were conducted to provide information on STIs, inform villagers of available treatment, and encourage prompt attendance for treatment of symptomatic STIs. Men with a positive LED test and those reporting or found to have urethral discharge were asked to provide a urethral swab. Urethral swabs were tested for Neisseria gonorrhea by pram stain and for Chlamydia trachoatis by antigen capture immunoassay. HIV was tested by ELISA assay. Positive samples received a second ELISA assay, and in case of discrepant or indeterminate ELISA results, a western blot test. Serological tests for syphilis were conducted using RPR and TPHA. Evaluation of the impact of the intervention on the prevalence of STIs was based on the seroprevalence of active syphilis and on the prevalence of confirmed urethritis, N gonorrhea and C traehomanis infection in men. Surveys indicated that condom use did not increase nor did sexual behavior change during the course of the intervention (Grosskurth et al., 1995).