Supplement

Advances in control of sexually transmitted diseases in developing countries

Despite being recognized as an important challenge at the 1994 International Conference on Population and Development (ICPD), sexually transmitted ınfections (STIs) other than HIV are one of the most neglected dimensions of sexual and reproductive health. STIs, often undiagnosed and untreated, have especially harmful consequences for women and their neonates.

During the last two decades, substantial knowledge and experience have accumulated in behavior change programming during the global response to the HIV epidemic which can also be used for prevention of STIs. There has been progress in development and implementation of vaccines against certain STIs such as hepatitis B and the human papilloma virus. Development of a rapid, point-of-care test for syphilis has opened the door to control this infection.

The estimated annual incidence of non-HIV STIs has increased by nearly 50% during the period 1995–2008. The growth in STIs has been aggrevated by a combination of factors: lack of accurate, inexpensive diagnostic tests, particularly for chlamydia and gonorrhea; lack of investment to strengthen health systems that can deliver services for diagnosis and management of STIs; absence of surveillance and reporting systems in the majority of countries; political, socioeconomic and cultural barriers that limit recognition of STIs as an important public health problem; and failure to implement policies that are known to work.

Governments, donors and the international community should give higher priority to preventing STIs and HIV; fully implementing behavior change interventions that are known to work; ensuring access of young people to information and services; investing in development of inexpensive technologies for STI diagnosis,treatment and vaccines; and strengthening STI surveillance, including of microbial resistance.

The term ‘sexually transmitted diseases (STDs)’ refers to a number of distinct infections caused by a variety of organisms, including bacteria, viruses, protozoa, and ectoparasites, which are typically transmitted through sexual contact and result in an array of clinical manifestations. The clinical syndromes associated with infection by one or more of these organisms can range from asymptomatic infection to severe life-threatening disease. The acquisition and transmission of STDs depend primarily on sexual behavior, but some infections, such as hepatitis B and cytomegalovirus, can also be acquired through nonsexual contact in areas with poor living conditions. Some can be transmitted from mother to child during pregnancy and childbirth, and can be sometimes associated with significant infant morbidity and mortality. Others, including syphilis and human immunodeficiency virus (HIV), can be transmitted through blood products and organ transplantation. Over the last two decades, there have been tremendous advances in our understanding of STDs. These include a recognition of new pathogens, new clinical syndromes, emerging antimicrobial resistance, the increasing importance of viral pathogens, and a better understanding of the epidemiology of many STDs, and progress has been made in the field of prevention including vaccine development. This article summarizes some important epidemiological trends among the more common STDs, and reviews the clinical syndromes, diagnosis, treatment, and pathogenesis of selected STDs.

Sexually transmitted infections other than HIV are important global health issues. They have, however, been neglected as a public-health priority and control efforts continue to fail. Sexually transmitted infections, by their nature, affect individuals, who are part of partnerships and larger sexual networks, and in turn populations. We propose a framework of individual, partnership, and population levels for examining the effects of sexually transmitted infections and interventions to control them. At the individual level we have a range of effective diagnostic tests, treatments, and vaccines. These options are unavailable or inaccessible in many resource-poor settings, where syndromic management remains the core intervention for individual case management. At the partnership level, partner notification and antenatal syphilis screening have the potential to prevent infection and re-infection. Interventions delivered to whole populations, or groups in whom the risks of infection and onward transmission are very high, have the greatest potential effect. Improvements to the infrastructure of treatment services can reduce the incidence of syphilis and gonorrhoea or urethritis. Strong evidence for the effectiveness of most other interventions on population-level outcomes is, however, scarce. Effective action requires a multifaceted approach including better basic epidemiological and surveillance data, high quality evidence about effectiveness of individual interventions and programmes, better methods to get effective interventions onto the policy agenda, and better advocacy and more commitment to get them implemented properly. We must not allow stigma, prejudice, and moral opposition to obstruct the goals of infectious disease control.

Although syndromic management of sexually transmitted diseases in highly endemic areas provides a short-term benefit to the individuals treated, it has no impact on decreasing prevalence rates. The numerous factors that contribute to this are discussed. Rapid reinfection from a large pool of infected symptomatic and asymptomatic individuals as well as the non-specific nature of presenting symptoms in women with vaginal discharge syndrome are major causes.