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• Missing the path: time to reconceptualise STD prevention
  Concepcion Tomas
  Published on: 25 June 2014

• Published on: 25 June 2014

  Missing the path: time to reconceptualise STD prevention

  • Concepcion Tomas, Professor
  • Other Contributors:
    • Guillermo Matinez, Angel Gasch

  The highlights of a strategy endorsed by the World Health Organization (WHO) in 2010 for Sexually Transmitted Infections (STI) screening, testing and early initiating into treatment (TnT) to Men that have Sex with Men (MSM) and transgender people are discussed by Cohen et al. in their editorial letter entitled "WHO guidelines for HIV/STI prevention and care among MSM and transgender people: implications for policy and p...

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  The highlights of a strategy endorsed by the World Health Organization (WHO) in 2010 for Sexually Transmitted Infections (STI) screening, testing and early initiating into treatment (TnT) to Men that have Sex with Men (MSM) and transgender people are discussed by Cohen et al. in their editorial letter entitled "WHO guidelines for HIV/STI prevention and care among MSM and transgender people: implications for policy and practice" (1,2). In the same line as WHO, the authors call for improved access to STI screening services for people in low and middle- income settings regardless of their sexual identity, sexual orientation or their cultural and socioeconomic characteristics (1,2) Due to the higher prevalence of STI among these vulnerable groups, compared to the general population, the uptake of this guideline is recommended to prevent the transmission of STI and ensure that sexual minorities enjoy their right to access quality provision of STI healthcare (1,2).

  The advantages of this strategy are understandable. This, regardless of the scarcity of data on the cost-effectiveness, cost-benefit and impact on community incidence of STI of routine TnT to asymptomatic MSM and transgender people that the WHO recommends (1). As the raison d'etre of a public health approach being informed by the evidence seems disregarded, in this letter we intend to highlight some gendered aspects that also derive from the WHO guideline and that, in our opinion, Cohen et al. may have given the same relevance as they had given to the WHO-endorsed TnT strategy.

  STI screening is a secondary prevention strategy. In the scenario we are discussing, it may be assumed that all MSM and transgender people may eventually engage in sexual risky behaviours and, as consequence, be infected with an STI. Hence, the recommendation to screen those targets populations for STI even if asymptomatic. The pitfall of this recommendation is that these vulnerable groups may end up dealing with healthcare providers with prejudices towards them. The first assumption healthcare providers should have in mind is that these groups adhere to key messages on how to lead a healthy sexual life. Hence, Routine STI screening should not be the first step in the cascade to prevent, detect and treat STI. It can be ventured that STI TnT approach might result being less cost-effective, potentially more stigmatizing, and, more distanct from the goal of equity that the traditional primary prevention strategies hold (2,4).

  On the other hand, women are not listed among the beneficiaries of this prevention strategy. The significance of understanding the motivations and other factors contributing to sexual risk taking among MSM that also have sexual intercourse with Women (MSMW) have been highlighted elsewhere (5,6,7). It must be acknowledged that in many low and middle- income countries, in order to fulfil with social expectations, many MSM may also engage, in an casual or in a permanent manner, in heterosexual relationships (7). To effectively reduce the community-level prevalence of STI, all asymptomatic women should also be targeted as beneficiaries of this TnT. In a context where cultural taboos and social stigma, judgemental attitudes from health workers towards sexual minorities, repressive policies, and anti-gay legislation, it is very unlikely that their MSMW might disclose to their female partners or their healthcare providers that they occasionally engage in unprotected same-sex sexual intercourse.

  Fear to being stigmatized acts as a driving force that leads MSM to becoming MSMW, keeping their sexual orientation hidden, and hindering them from accessing and demanding STI healthcare. Acknowledging this leads us to another worrisome issue that should not be neglected from the umbrella of responsibilities that lie within the scope of the public health arena; how many countries with pandemic HIV/AIDS infection figures have actually decriminalized homosexuality in the last decade? According to the International Lesbian and Gay Association Report, there were 76 countries prosecuting people because of their sexual orientation as recent as in 2010. Eleven countries still include death penalty for homosexuals in their penal code (8). To effectively inform and carry out any health promotion campaign targeting MSM and transgender people, beyond advocating for the implementation of massive TnT strategies that capitalize the potential of new nucleid acid amplification testing technologies, the international community should move the focus to advocate for low and middle-income countries? governments to abolish their pre-colonial 'anti- sodomy laws', build the capacity of their healthcare providers to better address the health needs of MSM and transgender people, and raise awareness among the general population to respect the sexual rights of the most vulnerable ones (9,10).

  A behavioural change approach, with the aim to promote adoption of safer sexual practices and an active demand of HIV/STI healthcare services, needs to be effectively integrated with any proposed TnT strategy. Health promotion is a basic public health tool that we find that it is not referred to in Cohen et al. missive. There is scientific evidence that behavioural change-based education, community awareness and advocacy approaches targeting sexual minorities may have a positive impact -even in budget-constrained settings- in terms of adoption of safer sexual practices with the ultimate goal to reduce incidence of HIV/STI (11). Why for Cohen et al. the cornerstone of the cascade of "solutions" to the high prevalence of STI may lie in targeted routine TnT when there is evidence on the benefits primary prevention strategies?.

  From a primary prevention point of view, other approaches should be recommended. A public health approach to tackle HIV/STI is necessarily gendered. The structural gender system has to be taken into account, including in low and middle-income countries, when designing and endorsing these types of prevention strategies. It is crucial to understand how gender constructions are determinant in populations adopting sexual risk practices, in impeding or facilitating their access to HIV/STI diagnostic and treatment services, and in influencing government and institutional policy and decision making processes (12). To have a more comprehensive picture to inform approaches such as the STI TnT discussed in this letter, it can be suggested that other subjects such as "masculinities, transactional sex, infrastructural deficits in health and education (at all levels), fragile states and global governance" (13) should be studied and that sexual risk practices should be tackled in a broader context in which gender equity is pursued and stigma and discrimination are combatted.

  REFERENCES

  1. Cohen J, Lo Y, Caceres CF, Klausner JD, for the WHO guideline working group. WHO guidelines for HIV/STI prevention and care among MSM and transgender people: implications for policy and practice. Sex Transm Infect 2013;89:536-538. 2. Gerbase A. Prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender People: Recommendations for a public health approach. Geneva, Switzerland: WHO, Programme HIV/AIDS, 2011. Report No.: ISBN 978 92 4 150175 0. 3. Starfield B, Hyde J, Gerv?s J, Heath J. The concept of prevention: a good idea gone astray? J Epidemiol Community Health 2008;62:580-583. 4. Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. Milbank Quaterly 2005;83:457-502. 5. Maulsby C, Sifakis F, German D, et al. HIV risk among men who have sex with men only (MSMO) and men who have sex with men and women (MSMW) in Baltimore. J Homosex 2013;60:51-68. 6. Harawa NT, McCuller WJ, Chavers C, et al. HIV risk behaviours among Black/African American and Hispanic/Latina Female partners of men who have sex with men and women. AIDS Behav 2013;17:848-55. 7. Eaton LA, Pitpitan EV, Kalichman SC, et al. Men who report recent male and female sex partners in Cape Town, South Africa: an understudied and underserved population. Arch Sex Behav 2013;42:1299-308. 8. Ottoson D. State-Sponsored Homophobia. A world survey of laws prohibiting same sex activity between consenting adults. ILGA (International Lesbian, Gay, Bisexual, Trans and Intersex Association). 2010. 9. Joint United Nations Programme on HIV/AIDS (UNAIDS). UNAIDS Action Framework: Universal Access for Men who have Sex with Men and Transgender People. WHO Library Cataloguing-in-Publication Data. 2009. 10. Ripley J, Lauer K, Hebert P, et al. Speaking Out: A Toolkit for MSM- led HIV/AIDS Advocacy. Levi Strauss Foundation. The Global Forum on MSM and HIV (MSMGF). 2010. 11. McDaid LM, Hart GJ. Sexual risk behaviour for transmission of HIV in men who have sex with men: recent findings and potential interventions. Curr Opin HIV AIDS 2010;5:311-5. 12. Connell R. Gender, health and theory: Conceptualizing the issue, in local and world perspective. Social Science and Medicine 2012;74:1675- 1683. 13. Phillips AF, Pirkle CM. Moving beyond behaviour: advancing HIV risk prevention epistemologies and interventions (A report on the state of the literature). Glob Public Health 2011;6:577-92.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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