Sexual behaviour in LA

A recent analysis of sexual behaviour around the world revealed that age at first sexual intercourse in LA varies from a median of 16.5 to 17.5 years for men and 15.5 to 17.5 years for women.3 From analyses of demographic and health surveys from eight countries (Bolivia, Brazil, Colombia, Dominican Republic, Guatemala, Nicaragua, Paraguay and Peru) conducted between 1990 and 2000, researchers have found that premarital sexual activity has been increasing.4 There is a trend towards increased uptake of contraception, which varies from 6% for Guatemala to 27% in Colombia. These results also show that condom use increased, although the contribution of condom use to contraceptive protection represents only 10–20% of all contraceptive methods. However, the increase in contraceptive use is not sufficient to decrease the risk of pregnancy due to increased sexual activity, nor other risks associated with unsafe sex (eg, STIs). In 1990, a Brazilian study showed that 30% of sexually active adolescent males from low-income areas reported having had an STI at least once.5 In Peru, from a 2006 population-based survey of asymptomatic men 18–29 years old, we found 28% reported having had urethral discharge, genital ulcers or genital warts in the 12 months before the survey (P J Garcia, personal communication, 2008).

Data on sexual partnerships in LA shows over-reporting of partners by men and under-reporting by women.3 Estimates of proportions of men who have sex with men vary from 6% to 20%.6

Epidemiological situation of STIs

All countries have mandatory reporting of AIDS and HIV infection, except Brazil and Uruguay, which do not require reporting of HIV infection. Mandatory reporting of other STIs, however, varies greatly across countries (table 1).

It is not easy to characterise accurately the epidemiological situation of STIs in the LA region from the data collected by the national STI programmes; in contrast with HIV/AIDS, the surveillance and reporting systems differ considerably from one country to another with regard to definitions—clinical versus syndromic versus laboratory based—and even those using laboratory-based diagnosis differ with regard to the type of tests available.

A total of 539 063 STI cases, including syndromic notifications, were reported by the 19 countries for 2006 (table 2). Compared with 1999 WHO estimates of 38 million new cases of five curable STIs in LA,7 the numbers reported from the national STI programmes represent a very small proportion of the expected incident STI cases. Several STIs are not reported because of difficulties with STI diagnosis and recognition of cases. Studies in LA have shown that private physicians provide a substantial proportion of health delivery for STIs, and such cases are not reported at the national level.8–10 In addition, patients with STI often bypass formal healthcare systems and seek care in the informal sector (eg, pharmacies), as has been documented for LA.11 Members of the national STI programmes of 10 of the 19 countries responding to our survey estimated that 25–50% of STI cases are seen at pharmacies.

Organisational aspects of STI programmes in LA

All the countries surveyed reported that STI management is integrated into primary care services. In addition, they reported 241 ‘specialised’ STI clinics in the 19 LA countries. Syndromic management of STIs is now universally accepted as the standard of care throughout the region, although acceptance of this policy took much longer in countries such as Uruguay and Ecuador (2006) than in Brazil (1994). General practitioners, as well as specialists in infectious diseases, gynaecology, urology and dermatology, are responsible for treating STI cases in most of the countries, although nurses and midwives also see and manage cases.12

Most countries reported providing services to all individuals seeking care for an STI through ministry of health clinics, where consultations for STIs are free of charge for any patient (general or high-risk population) in 14 of 19 countries and STI drugs are offered free of charge in 17 of 19 countries (Colombia and Uruguay do not offer free treatment for STIs). Paraguay and Bolivia reported that condoms are not regularly offered as part of STI management.

All countries except Colombia, El Salvador and Paraguay offer partner notification services. Most of the countries (12 of 19) have implemented partner notification solely by asking patients to notify their partners; only four used a combined patient and health provider notification strategy. National STI programme staff estimated that notification reaches <25% of the partners in STI cases.

STI screening and services for specific populations

As shown in table 3, STI screening is almost universal for female sex workers (conducted in 16 of 19 countries) and mostly includes HIV and syphilis testing, although five countries also report screening for gonorrhoea. STI screening of pregnant women is also common and includes syphilis and HIV testing. STI screening for other groups is less common.

Dedicated STI services for specific populations are also common in the LA region, and were reported by all countries except Colombia—which provides no differentiated care—and Argentina—which did not respond to the question. Female sex workers are the most common beneficiaries of differentiated services, although there are also services for male sex workers, prisoners and truck drivers in some countries.

Antibiotic resistance and Neisseria gonorrhoeae

Only nine of the countries surveyed (47%) have implemented surveillance of resistance of Neisseria gonorrhoeae strains to antibiotics currently used. In the region, strains resistant to penicillin and tetracycline are widely disseminated, and strains with intermediate resistance to ciprofloxacin are also circulating. Four countries, Chile, Costa Rica, Mexico and Panama, no longer recommend ciprofloxacin for gonococcal infections; instead, the current recommendation is ceftriaxone, which is much more costly and logistically more difficult because it requires parenteral administration.