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Without adequate surveillance it will not be possible to monitor the situation
Physicians in the affluent, industrialised countries of western Europe probably pay little attention to directives from the World Health Organization (WHO). They investigate and treat their patients as they see fit and they see little attraction, for instance, in the WHO’s advocacy of syndromic management for sexually transmitted infections (STIs).1 The WHO has a series of policies and principles in relation to STIs which cover prevention, control policies including surveillance and care programmes.2 However, knowledge about the state of affairs in relation to STIs is sketchy for most European countries and those of the central Asia republics, all of which come under the Regional Office for Europe in Copenhagen. There, an STI task force has been established to address the situation in eastern Europe and central Asia.
The paper by Dehne et al3 in this issue of STI (380) is the first survey of these policies across the region. The authors used an adapted WHO model questionnaire which was sent to officials in ministries of health in all 46 countries of Europe and central Asia; 45 replied. This was part of ongoing efforts by the WHO/UNAIDS to survey the situation in all regions of the world.
Replies from officials in ministries of health, who are not involved usually at the clinical coalface, may not absolutely reflect the reality on the ground. Overall, however, the replies are likely to be reasonably consistent. The study was conducted in 1998 and it is a pity that there has been such a delay before publication. For instance, some countries now have national management guidelines, such as the United Kingdom,4 and the International Union against Sexually Transmitted Infections (IUSTI) and the WHO have produced model European guidelines.5 The United Kingdom also now has a national sexual health strategy.6
The newly independent states (NIS) of the former Soviet Union have experienced a spectacular epidemic rise in syphilis, gonorrhoea, and other STIs in recent years, which may now be coming under control.7–11 In western Europe, too, there has been a rise in incidence12 with trend data showing that the numbers of new diagnoses of sexually acquired HIV infections increased by 20% between 1995 and 2000.13 The situation in some countries of eastern Europe may be worse.14
It is against this background that the results of this survey must be viewed. In western Europe much provision of care is at the primary care level and is usually free of charge. Responsibility is largely left to the individual patient and, apart from in the United Kingdom and some Scandinavian countries, there are no national STI control plans or programmes. In about half of the NIS countries, there is some degree of public STI programme. STI services are provided mainly by dedicated clinics, often part of a polyclinic. In some countries, such as the Baltic states, care may be provided privately,3,15 but this type of provision may be more widespread than is realised, particularly when doctors need to supplement a low state salary. While consultation and investigation may be free in these public services, patients in some countries may have to pay for their medication. It seems extraordinary, with outbreaks of syphilis in some Western countries16 and the high incidence in the east with people moving extensively around the continent, that Denmark, Greece, Iceland, and Ireland do not screen donated blood for syphilis and only 75% of countries routinely screen pregnant women. Drug sensitivity monitoring, particularly for the gonococcus, is not universal.
Few countries have STI services designed to reach specific vulnerable groups. Condoms are freely available in western European countries where their provision may be part of the consultation, but are not so readily available in the east and in central Asia.
Ministry of health officials reported to Dehne et al that all European countries, except Greece, have an STI surveillance system. This may be true but the information provided through these systems is almost certainly a considerable underestimate of the real problem and fairly unreliable because it is difficult to ensure reporting of cases from primary care. On the other hand in the NIS, except in Georgia, STI reporting is universal, most cases being seen in dedicated clinics which are often part of polyclinics. Germany and the Netherlands have virtually abandoned STI surveillance,17,18 although the Germans feel that sentinel surveillance will be adequate for their needs. While physicians in genitourinary medicine clinics in the United Kingdom are well programmed to produce reliable returns, which are soon to be enhanced, it is unrealistic to expect the non-specialist to do this. Yet without adequate surveillance it will not be possible to monitor the situation. The reality is that, in most countries, the best that is going to be possible is a sentinel system; this will allow capture of data on sexual orientation, ethnic group, and country of origin as well as details of the condition(s) diagnosed.19 Nevertheless, ordinary STI surveillance is poor in western Europe, although HIV surveillance is much better.
HIV infection is, in the main, a sexually acquired condition. So it was surprising that in Dehne et al’s article it was barely mentioned. With the incidence of this infection increasing across Europe, this is of great concern. Given that other STIs may facilitate HIV transmission20 it is obviously of the greatest importance to have adequate, competent services available and, preferably, free of charge. While most patients in western Europe can access free care, in many of the countries of the former Soviet Union, including Russia itself, the consultation may be free but not necessarily the medications required for treatment—which may not always be available in some countries. Care of HIV cases is provided in Europe, in the main, by infectious diseases physicians, and management of the traditional STIs often is not a major part of their remit. In Italy, there are some interesting developments by infectious diseases physicians.21 In the United Kingdom, it is the STI physicians who provide the bulk of the HIV care, and it is interesting to note that some of the recent outbreaks of syphilis in HIV infected men occurred in areas where this was not the case.22,23 This is illustrative of a certain disconnection of service provision and it does indicate that the potential presence of ordinary STIs should not be overlooked by the non-STI specialist.
There was considerable political interest in the HIV epidemic when it emerged in the 1980s and some HIV prevention programmes were undertaken with a degree of impact,24,25 which has probably now been lost. STIs, in general, are not perceived as a major public health priority by many national governments. The fact that in the NIS governments have programmes in place, however rudimentary, is not surprising. These countries have emerged from Soviet rule where the state attempted to supervise every aspect of life. In relation to the control of STIs, a degree of compulsion always existed—for instance, with partner notification. There is no such interference from an overbearing state in western Europe where a state of laissez faire exists. STIs are just not high enough up the medicopolitical agenda and, in some countries, are barely registered on it. Even in the United Kingdom, where the government has been persuaded to produce a national sexual health strategy, its recommendations are to be implemented only in a limited way.
HOPE FOR THE FUTURE
Despite these comments and Dehn et al’s gloomy findings there are some heartening aspects. The overarching specialist body for European dermatovenereologists is the European Academy of Dermatology and Venereology (EADV). At its annual congresses, originally, the STI tracks were very limited but gradually these have been built up with considerable input from the United Kingdom and Ireland, from Germany and from IUSTI-Europe. While few European countries have active STI societies/associations, with the reactivation of IUSTI-Europe, regular pan-European meetings are now held and two new national societies have been formed, one in Hungary and another in Estonia. European STI management guidelines have been produced and these can be adapted locally in many of the countries, particularly in western Europe. The guidelines may not be so suitable for central Asia but a US grant giving body is interested in supporting development of guidelines and westernisation of care in that region.26 It would be good if these meetings and other IUSTI activities could become a focus for progress in the field in Europe. They could be a forum for discussion about the needs of Europe and its adjacent states, in relation to STIs. Perhaps, using the national societies that do exist and the WHO, it might be possible to move the matter of STIs further up the political agenda across the wider Europe than is presently the case27 and, hopefully, increase the resources available. As Winston Churchill memorably said, when lobbying America for materiel assistance, early in the second world war, “give us the tools and we shall finish the job.”
Without adequate surveillance it will not be possible to monitor the situation