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Control of Sexually Transmitted Infections and Prevention of HIV

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Control of Sexually Transmitted Infections and Prevention of HIV Control of sexually transmitted infections and prevention of HIV transmission: mending a fractured paradigm Richard Steen,a Teodora Elvira Wi,b Anatoli Kamali c & Francis Ndowa d Abstract Control of sexually transmitted infections (STIs) is feasible, leads to improved sexual and reproductive health and contributes to preventing HIV transmission. The most advanced HIV epidemics have developed under conditions of poor STI control, particularly where ulcerative STIs were prevalent. Several countries that have successfully controlled STIs have documented stabilization or reversal of their HIV epidemics. STI control is a public health outcome measured by reduced incidence and prevalence. The means to achieve this include: (i) targeting and outreach to populations at greatest risk; (ii) promoting and providing condoms and other means of prevention; (iii) effective clinical interventions; (iv) an enabling environment; and (v) reliable data. Clinical services include STI case management, screening and management of STIs in sex partners. Syndromic case management is effective for most symptomatic curable STIs and screening strategies exist to detect some asymptomatic infections. Presumptive epidemiologic treatment of sex partners and sex workers complement efforts to interrupt transmission and reduce prevalence. Clinical services alone are insufficient for control since many people with STIs do not attend clinics. Outreach and peer education have been effectively used to reach such populations. STI control requires effective interventions with core populations whose rates of partner change are high enough to sustain transmission. Effective, appropriate targeting is thus necessary and often sufficient to reduce prevalence in the general population. Such efforts are most effective when combined with structural interventions to ensure an enabling environment for prevention. Reliable surveillance and related data are critical for designing and evaluating interventions and for assessing control efforts. الرتجمة العربية لهذه الخالصة يف نهاية النص الكامل لهذه املقالة. .Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español Introduction to general lung health within the Stop TB partnership and in- tegrated vector management in malaria efforts. The rationale In the history of sexually transmitted infection (STI) control, is that sustainable disease control requires coordinated efforts as with other communicable diseases, the pendulum swings to address common conditions that may facilitate transmis- between vertical disease-specific and broader horizontal sion or impede access to prevention, case detection, diagnosis approaches, from a narrow focus on pathogens and their and treatment.4,5 treatment to the wider needs of populations who host and This paper describes a unified paradigm of STI control transmit them. where HIV is an important focus. The approach is analytical Since the emergence of HIV in the 1980s, STI control and programme-oriented, with attention to public health efforts have increasingly been defined in relation to HIV outcomes and means. We start by reviewing definitions and 1 programme priorities. Although HIV is itself an STI, efforts outlining basic components of STI control, and then exam- to prevent its transmission are largely managed through ine empirical evidence of the feasibility and benefits of STI programmes that are funded, implemented and evaluated control under different conditions. We also consider what independently of other STI control efforts. Such a fractured happens to HIV under different scenarios and look at the paradigm has had unfortunate consequences. Too often, overlap and potential synergies between HIV prevention and neglected STI programmes – the foundation upon which STI control efforts. HIV prevention efforts were built – collapse due to reduced funding. As a result, STI clinics and services are understaffed, Defining STI control understocked or disappearing altogether; pregnant women may be offered HIV tests but are no longer screened for STI control is a public health outcome, measured as re- syphilis; and STI reporting, an important marker of sexual duced incidence and prevalence, achieved by implementing transmission trends, has largely collapsed.2,3 strategies composed of multiple synergistic interventions. In other areas of communicable disease control, the In the literature, the term “STI control” is frequently used pendulum is moving in a different direction towards strate- interchangeably with “STI treatment”, yet these are quite gies that aim for broad public health benefit while pursuing different things.6,7 Control of any communicable disease is a disease-specific control objectives. Examples include attention public health outcome, measured as reduced prevalence (total a World Health Organization Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi, 110 002, India. b World Health Organization Regional Office for the Western Pacific, Manila, Philippines. c Medical Research Council, Entebbe, Uganda. d Reproductive Health and Research, World Health Organization, Geneva, Switzerland. Correspondence to Richard Steen (e-mail: [email protected]). (Submitted: 9 January 2009 – Revised version received: 22 August 2009 – Accepted: 31 August 2009 ) 858 Bull World Health Organ 2009;87:858–865 | doi:10.2471/BLT.08.059212 Special theme – Strengthening linkages between sexual and reproductive health and HIV Richard Steen et al. Sexually transmitted infection control and prevention of HIV infections) or incidence (new infections) bination HIV prevention” and “back to cal infections. STI screening and case in a population. Treatment is a biomedi- basics” approaches to HIV emphasize finding are time-tested approaches for cal intervention that, unless part of a the use of combinations of feasible and identifying asymptomatic infections. broader control strategy, usually does proven interventions.10,11 Although feasible, screening to detect not result in lower transmission rates or A recent review listed priority STI cervical infection remains problematic disease burden. control interventions to include “STI since sensitive tests for detecting gonor- STI control can be measured in treatment of high-risk sub-populations, rhoea and chlamydial infection remain absolute or relative terms, for example, comprehensive case management of too expensive for widespread use. as elimination of chancroid or 50% symptomatic STIs, antenatal syphilis Breaking the chain of infection reduction of the prevalence of gonor- screening and treatment and ophthal- also involves treating as many sexual rhoea. Monitoring trends of common mia neonatorum prophylaxis, condom partners of people with STIs as can curable STIs, etiologically or syndromi- promotion and risk reduction coun- be identified. Several partner treat- cally, can provide evidence of changing selling” with increased emphasis on ment strategies have been described incidence. Where STI surveillance is the role of STI clinics in identifying with success rates as high as 30–50% supported and functioning (often it and counselling HIV-infected persons (of index patients).14 Due to frequent is not), these data also reflect general and in diagnosing and managing their uncertainty about STI diagnoses in 12 sexual transmission trends and can be STIs. The review pragmatically pro- women and potentially serious social used to assess the adequacy of overall vides evidence for the effectiveness of consequences of notification, partner STI/HIV prevention efforts.8 Since individual intervention components strategies should focus on identifying HIV shares many aspects with other within the fragmented domains of STI symptomatic men who should then be STIs – including modes of transmis- control and HIV prevention, while offered counselling and assistance with sion, behavioural and other cofactors making a case for better alignment of notifying their partners. and potential control measures – HIV efforts. Other interventions aim to in- prevention can logically be situated What would such aligned control terrupt transmission through epide- within the larger, encompassing do- efforts include? Historical experience miologic targeting and presumptive main of STI control. argues for coordinated effort in five treatment. Asking STI patients about main areas: (i) appropriate epidemio- the location of recent contacts can logic targeting; (ii) primary prevention help direct prevention efforts to epi- Back to basics and access to means of prevention; demiologically important “hot-spots” A comprehensive STI control strategy (iii) provision of effective clinical ser- where incidence may be high. Pre- includes targeted community-based in- vices to shorten the duration of infec- sumptive treatment has been used to terventions, promotion and provision tivity; (iv) an “enabling environment” rapidly reduce STI prevalence among of the means of prevention and effec- for prevention; and (v) reliable data to populations at highest risk, such as sex 15 tive clinical services within an enabling guide decision-making. workers. environment, as well as reliable data to A relatively new area for STI clini- guide the response. Clinical services cal services is identification and early The science and methods of STI intervention with people living with Clinical interventions can be broadly control build on several centuries’ HIV, particularly those recently in- categorized as STI management ap- experience
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