Diagnosis and Treatment of Sexually Transmitted Infections


  1. Definition of the Prevention Area

    Sexually transmitted infections (STIs) likely facilitate HIV transmission and acquisition. STI treatment activities have been used as an HIV prevention approach, but have achieved mixed outcomes. This prevention strategy may be most effective in settings with a high burden of STIs, and when targeted to members of key populations and their sexual partners. However, randomized trials have found STI treatment to have little to no effect on HIV incidence.

  2. Epidemiological Justification for the Prevention Area

    The role of STIs in the transmission dynamics of HIV epidemics is paradoxical and complex. Population-based studies have found that both the prevalence and incidence of HIV were substantially higher among people with STIs. Both curable STIs and chronic infections, such as herpes simplex virus type-2 (genital herpes), can increase vulnerability to HIV infection by disrupting skin and mucosal barriers and/or by causing inflammation, which brings HIV-susceptible immune cells to the genital tract. STIs are biological markers for risky sexual behaviors, which are also risk factors for HIV acquisition. 

    Also, a number of studies in HIV-serodiscordant couples report that HIV-positive individuals with herpes or genital ulcer disease are significantly more likely to transmit HIV to their partners. Some STIs appear to increase the risk of HIV transmission by boosting viral shedding in the genital secretions of both men and women who are HIV-positive. Other studies of HIV-positive individuals on antiretroviral therapy suggest that STIs may increase the infectiousness of HIV, even when an individual has an undetectable viral load.

    Despite these data, numerous clinical trials have been unable to demonstrate a decline in HIV incidence as a result of STI treatment. Some hypothesize that treated STIs may still cause inflammation and other changes in the genital mucosa, even after the initial symptoms have disappeared. Ongoing inflammation and changes in the genital mucosa following treatment may explain why STI treatment has no effect on HIV incidence; other possible factors include epidemic stage, prevalence of viral versus bacterial STIs, and type of treatment.

  3. Core Programmatic Components

    Even though STI treatment does not seem to have a significant impact on HIV incidence, effective management of STIs is an essential public health activity, especially for improved maternal and child health outcomes. Data linking the prevalence of STIs with increased risk of HIV transmission and acquisition underscore the importance of STI prevention, which can best be achieved through a comprehensive STI control program. 

    A 2009 review of STI control and HIV prevention in the Bulletin of the World Health Organization concluded that the core elements of a comprehensive STI control program should include:

    • Reaching out to populations at greatest risk, particularly those who change partners frequently and thus may propel transmission within the population
    • Promoting safer sex by providing condoms and conducting other prevention activities
    • Offering effective clinical interventions (including STI screening, treatment, and case management)
    • Initiating structural interventions to ensure an environment that supports safer sexual behavior and care- and treatment-seeking behaviors
    • Collecting reliable data to monitor disease trends and the effectiveness of interventions.
  4. Current Status of Implementation Experience

    Research on how STIs modify HIV transmission is ongoing. Development of improved screening strategies to detect some asymptomatic STIs in resource-limited settings remains a research priority. Currently, STI treatment as a stand-alone HIV prevention intervention in generalized epidemics is not supported by scientific data.

    The approach for STI control for HIV prevention depends on the type of HIV epidemic and the populations at highest risk. A number of resource-limited countries, including Cambodia, Kenya, Senegal, Sri Lanka, and Thailand, have demonstrated that it is feasible for programs to expand STI control services. Several countries that have successfully controlled STIs have also reported stabilization or reversal of their HIV epidemics. For instance, in India, the Avahan Initiative reported a reduction in STI and HIV incidence after it included improved delivery of STI management to key groups as part of its comprehensive prevention interventions. Thailand’s 100% Condom Programme appears to have contributed to both STI reduction and HIV prevention by requiring condom use in brothels.

    The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) supports several approaches for STI control for HIV prevention, depending on epidemic type and population. In concentrated epidemics, the population focus should be on key populations, individuals with symptomatic STIs, HIV-positive persons with high-risk behaviors, and other groups that may be at high risk for STI acquisition. In generalized epidemics, PEPFAR supports STI control programs for high-risk subpopulations, including key populations, individuals with symptomatic STIs, HIV-positive persons, and sexually active adolescents. STI screening, management, and treatment are key components of the PEPFAR comprehensive package of services for key populations. PEPFAR also supports HIV testing services for STI patients.

UPDATED 6/2016

Prevalence of Sexually Transmitted Co-infection in People Living with HIV/AIDS: Systematic Review with Implications for Using HIV Treatments for Prevention

Kalichman, S., Pellowski, J., and Turner, C. Sexually Transmitted Infections (April 2011), 87(3): 183–190.

The review examined the role that sexually transmitted infections (STIs) play in people living with HIV (PLHIV) and how the co-infections of STIs and HIV affect the prevention potential of antiretroviral therapy (ART) in limiting HIV transmission rates. The 37 eligible studies, published from 2000 to 2010, reported on STIs in PLHIV, specifically those showing HIV shedding in the genital tract (syphilis, chancroid, and gonorrhea). Mean overall prevalence of STI co-infection was 16.3 percent. The most common STIs co-infections were syphilis, gonorrhea, chlamydia, and trichomoniasis. The highest prevalence of STI/HIV co-infections were in people newly diagnosed with HIV, but STI co-infections occur throughout the course of HIV infection. People taking ART also were diagnosed with STI co-infections to a high degree; there was no significant difference in the prevalence of co-infections between PLHIV who were or were not on ART. The authors discussed the limitations of forecast data on the overall effect of ART on reducing transmission rates in HIV epidemics. Forecasting models often do not include the effect of STI co-infections, which would reduce the success of those results. They concluded that STI co-infections should be included in future models and forecasts that examine ART as a prevention strategy.  

The Presentation, Diagnosis, and Treatment of Sexually Transmitted Infections

Wagenlehner, F.M., Brockmeyer, N.H., Discher, T., et al. Deutsches Ärzteblatt International (January 2016), 113:11–22, doi: 10.3238/arztebl.2016.0011.

This continuing medical education review drew together information from key articles, guidelines, and systematic reviews to enable readers to recognize the clinical features of common sexually transmitted infections (STIs); apply currently recommended diagnostic tests; and understand treatment in the event of antibiotic resistance. The authors referred to the global scale of STIs while including diagnostics and treatment available in Germany. The review covered STIs that present with ulcers (genital, anal, perianal, or oral), urethritis, cervicitis, urethral or vaginal discharge, or genital warts, as well as HIV and hepatitis C (HCV). For each STI it provided a description and photograph, and outlined the route of transmission, diagnostic tests, and treatment, also including tables summarizing clinical features and associated pathogens, diagnostic tests, and treatment options. The authors stressed that STIs increase the risk of other STIs, and so patients presenting with one STI should be assessed for others. They discussed partner treatment, which is indicated for most STIs; and noted the growing problem of antibiotic resistance and late diagnosis of HIV and HCV as challenges to effective treatment. 

Acyclovir and Transmission of HIV-1 from Persons Infected with HIV-1 and HSV-2

Celum, C., Wald, A., Lingappa, J.R., et al. New England Journal of Medicine (February 2010), 362(5): 427–439.

This randomized, placebo-controlled clinical trial of acyclovir focused on whether the drug could reduce the transmission of HIV from partners co-infected with HIV and herpes simplex virus type 2 (HSV-2) to their serodiscordant partners. The study was conducted among over 3,400 serodiscordant couples in 14 sites in Southern and Eastern Africa. Although daily therapy with acyclovir reduced mean plasma concentrations of HIV and the occurrence of genital ulcers due to HSV-2, it did not cut the risk of HIV transmission, the study found. However, it proved the feasibility of conducting trials among HIV-serodiscordant couples.

Global Estimates of the Prevalence and Incidence of Four Curable Sexually Transmitted Infections in 2012 Based on Systematic Review and Global Reporting

Newman, L., Rowley, J., Vander Hoorn, S. et al. PLOS ONE (December 2015), 10(12): e0143304. doi: 10.1371/journal.pone.0143304. eCollection 2015.

This article reported on the 2012 World Health Organization (WHO) estimates of prevalence and incidence of four curable sexually transmitted infections (STIs): chlamydia, gonorrhea, trichomoniasis, and syphilis. The authors conducted a meta-analysis and developed global estimates based on literature reviews of prevalence data from 2005 through 2012 in general populations. Estimated prevalence in absolute numbers and percentages for men and women aged 15–49 were:

  • Chlamydia: 131 million (4.2% in women, 2.7% in men)
  • Gonorrhea: 78 million (0.8% in women, 0.6% in men)
  • Trichomoniasis: 143 million (5.0% in women, 0.6% in men)
  • Syphilis: 6 million (0.5% in women, 0.48% in men).

Regional incidence estimates were derived from prevalence estimates adjusted for duration of infection. Africa had the highest estimated prevalence rates for gonorrhea, trichomoniasis, and syphilis. Estimated chlamydia prevalence was highest in the Americas and Western Pacific region. The authors noted that nearly one million new curable STIs occur each day, underscoring STIs as an important public health problem. They urged wider access to available interventions for STI prevention, screening, diagnosis, and treatment, along with better methods for estimation, so that a more diverse array of data sources can be incorporated into future analyses and used to generate national-level estimates.

Selecting HIV Infection Prevention Interventions in the Mature HIV Epidemic in Malawi Using the Mode of Transmission Model

Maleta, K., and Bowie, C. BMC Health Services Research (August 2010),10: 243.

The authors used Joint United Nations Programme on HIV/AIDS Mode of Transmission Model spreadsheet and data available from Malawi to assess the impact of various HIV prevention interventions, taking into account the country’s high prevalence of partner concurrency and serodiscordancy. Interventions in the model included increased condom use, more circumcisions, and conversion of all multiple concurrent partnerships into monogamous partnerships. The model showed that most new cases were among low-risk heterosexual groups (i.e., those who were part of serodiscordant couples or those who had casual sex (and their partners). Condom use by discordant couples, a monogamy policy such as Uganda’s Zero Grazing campaign, and abstinence were the most effective prevention measures; improved treatment of sexually transmitted infections had only a limited effect.

Disentangling Contributions of Reproductive Tract Infections to HIV Acquisition in African Women

van de Wijgert, J.H.H.M., Morrison, C.S., Brown, J., et al. Sexually Transmitted Diseases (June 2009),36(6): 357–364.

The authors of this study examined the prevalence and incidence of reproductive tract infections (RTIs) and HIV over a five-year period, and investigated the relationship between RTIs and HIV infection in Uganda and Zimbabwe. Study subjects comprised more than 4,400 women attending family planning clinics in those countries. Even though the women received regular counseling on risk reduction, screening, and treatment for RTIs, the incidence of HIV and RTIs did not diminish during the study period. Almost all types of RTI were associated with increased risk of HIV infection, especially herpes simplex virus type 2 and altered vaginal flora. The authors still concluded that aggressive efforts to control RTIs may contribute significantly to HIV prevention, and recommended continued research to find more effective treatments and interventions.

Persistence of HIV-1 Receptor–Positive Cells After HSV-2 Reactivation is a Potential Mechanism for Increased HIV-1 Acquisition

Zhu, J., Hladik, F., Woodward, A., et al. Nature Medicine (August 2009),15(8): 886–892, doi:10.1038/nm.2006.

This small study offered an explanation of why treating herpes simplex virus type-2 (HSV-2) does not lead to a reduction in HIV acquisition, even though infection with HSV-2 is associated with increased risk of HIV infection. Examining biopsies from eight subjects infected with HSV-2, the authors found that beneath healed herpes lesions, there is profound localized inflammation that persists even after prolonged antiviral therapy. They concluded that future interventions to break the association between HSV-2 and HIV should strive to reduce this inflammation or lead to the development of a HSV-2 vaccine.

Effect of Acyclovir on HIV-1 Acquisition in Herpes Simplex Virus 2 Seropositive Women and Men Who Have Sex With Men: A Randomized, Double-Blind, Placebo-Controlled Trial

Celum, C., Wald, A., Hughes, J., et al. The Lancet (June 2008), 371(9630): 2109–2119.

This randomized, double-blind, placebo-controlled trial examined whether controlling herpes simplex virus 2 (HSV-2) with acyclovir could protect against acquisition of HIV. The 3,172 participants included HIV-negative, HSV-2 seropositive women in Africa and men who have sex with men in Peru and the United States. Participants were given either acyclovir or placebo for 12 to 18 months. The primary endpoint was HIV acquisition, and the study showed that suppression of HSV-2 infection did not lead to a reduction in incidence of HIV. The authors found this result disappointing, given that infection with HSV-2 is associated with significantly higher risk of HIV acquisition. They recommended further studies to reexamine whether higher doses of acyclovir or other antiviral drugs would yield better results. 

Population-Based Biomedical Sexually Transmitted Infection Control Interventions for Reducing HIV Infection

Ng, B.E., Butler, L.M., Horvath, T. et al. Cochrane Database Systematic Reviews (March 2011), 16(3): CD001220, doi: 10.1002/14651858.CD001220.pub3.

This article updated a previous Cochrane review. The update used more rigorous search criteria to focus specifically on population-based biomedical interventions for controlling sexually transmitted infections (STIs), with change in HIV incidence as the outcome. These stricter criteria yielded four randomized controlled trials of one or more biomedical interventions in general populations, where the community or facility was the unit of randomization. One trial assessed mass treatment of the entire population in a defined community in rural Uganda; after three rounds of STI treatment, the study found no effect on HIV incidence. The other three studies evaluated interventions that combined improved syndromic management of STIs, counseling, and treatment. An intervention in northern Tanzania to strengthen STI treatment in primary health clinics showed a 42 percent reduction in HIV incidence in the intervention group (1.2%) compared with the control (1.9%). In this setting, the HIV epidemic was just emerging and STI treatment services were very poor, while STI incidence was very high. The two remaining studies, in rural Uganda and Zimbabwe, showed no effect by either intervention on HIV incidence. An analysis pooling data from the four studies also showed no effect on HIV incidence. This review did not support the hypothesis that community-based STI control is effective for HIV prevention. 

Control of Sexually Transmitted Infections for HIV Prevention

White, R., Celum, C., Wasserheit, J., et al. The Lancet (October 2008),372(9646): 1297.

The commentary responded to the view expressed by Gray and Wawer in “Reassessing the Hypothesis on STI Control for HIV Prevention,” (Lancet 2008) that HIV prevention strategies should be adjusted based on the results from two randomized controlled trials showing that control of sexually transmitted infections (STIs) had no effect on HIV acquisition. The authors disagreed with this view. They supported STI control in HIV prevention based on the results of modeling studies. Reducing funds for STI diagnosis, treatment, and control could have adverse and unexpected effects on the HIV epidemic, the authors said; and STI control measure should not be relaxed.

Treating Curable Sexually Transmitted Infections to Prevent HIV in Africa: Still an Effective Control Strategy?

White, R.G., Orroth, K.K., Glynn, J.R., et al. Journal of Acquired Immune Deficiency Syndromes (March 2008),47(3): 346–353.

This study used a mathematical model to examine whether or not interventions to treat sexually transmitted infections (STIs) are cost-saving in populations with generalized HIV epidemics. The model was applied to the population characteristics of four cities in West Africa and East Africa: two with high HIV prevalence and two where prevalence was relatively low. Findings showed that syndromic management had a high impact in three of the four cities, with a cost of between USD$321 and USD$1,665 per HIV infection averted. The authors stated that in settings where there is a generalized HIV epidemic, even though the proportion of HIV infections attributable to curable STIs is likely to fall, interventions targeting these diseases are still highly cost-effective and potentially cost-saving, assuming that STIs were not controlled by changes in risk behavior. 

The Expedited Partner Therapy Continuum: A Conceptual Framework to Guide Programmatic Efforts to Increase Partner Treatment

Schillinger, J.A., Gorwitz, R., Rietmeijer, C., et al. Sexually Transmitted Diseases (February 2016), 43(2 Suppl 1): S63–75, doi: 10.1097/OLQ.0000000000000399.

The authors reviewed published articles about expedited partner therapy (EPT) published after 2006, and randomized controlled trials before 2006. In EPT, health care providers give patients antibiotics or a prescription to treat their sex partners, without examining the partner. EPT was endorsed by the U.S. Centers for Disease Control and Prevention in 2006 and is included in current guidelines for treatment of sexually transmitted infections. It has been implemented with different models, and the evidence base is drawn from studies using a range of populations, settings, and outcome measures. The authors described steps in what they termed the “EPT continuum,” which starts with a patient diagnosis and continues through treatment of the patient’s sex partner(s) with antibiotics. All the interventions assessed focused on these steps. Providers’ uptake and offer of EPT were the most significant barriers; patient acceptance also limited EPT uptake and use. The authors recommended removing legal obstacles and uncertainty; making free EPT available in settings with a high volume of patients with chlamydia and gonorrhea; and developing clear information for providers and patients. Future efforts should continue to focus on provider uptake, and on monitoring and ensuring partner use of EPT using population-based measures. 

Randomized Trial of Presumptive Sexually Transmitted Disease Therapy During Pregnancy in Rakai, Uganda

Gray, R.H., Wabwire-Mangen, F., Kogozi, G., et al. American Journal of Obstetrics and Gynecology (November 2001), 185(5): 1209–1217.

This study looked at the impact of presumptive treatment of sexually transmitted infections (STIs) on both HIV transmission and pregnancy outcomes. The study randomized over 4,000 pregnant women in Uganda to either one presumptive treatment for STIs during pregnancy or vitamin and mineral supplements, with confidential notification and treatment referral for those diagnosed with syphilis during the study. The intervention resulted in fewer cervical and vaginal infections and fewer cases of infant ophthalmia, as well as significantly lower rates of low birth weight and neonatal mortality. However, there was no change in maternal HIV acquisition or in mother-to-child HIV transmission.

Trichomonas Vaginalis: A Review of Epidemiologic, Clinical and Treatment Issues

Kissinger, P. BMC Infectious Diseases (August 2015), 15:307, doi: 10.1186/s12879-015-1055-0.

This article reviewed the epidemiology, diagnosis, and treatment of trichomonas vaginalis (TV). TV is not a reportable disease, so its precise extent is not known, but it may be the most common non-viral sexually transmitted infection (STI) globally. Rates vary significantly by population and geography, with studies indicating ranges among antenatal clients from 3.2–52 percent in resource-limited settings and 7.6–12.6 percent in the United States. TV is strongly associated with other STIs. Women with TV are at higher risk of both acquiring and transmitting HIV, and of acquiring herpes simplex virus and human papillomavirus. The most commonly used diagnostic test is inexpensive and available at the point of care, but it is not sensitive, especially in men. Several newer testing approaches may be promising for use in resource-poor settings. World Health Organization guidelines include a single dose of metronidazole to treat TV, with a seven-day regimen as the alternate. Treatment of sex partners is also recommended. Persistent and repeat infections are common, but the sources are less clear. The author concluded that TV is an important source of reproductive morbidity that also contributes to acquisition and transmission of HIV. Better diagnostics and treatment are needed to understand and address repeat infections. 

Control of Sexually Transmitted Diseases for AIDS Prevention in Uganda: A Randomised Community Trial

Wawer, M.J., Sewankambo, N.K., Serwadda, D., et al. The Lancet (February 1999),353(9152): 525–535.

This study tested the hypothesis that controlling sexually transmitted infections (STIs) at the population level would reduce the incidence of HIV, as had been found in the first clinical trial conducted in rural Tanzania. The study was conducted in clusters of villages that encompassed social, and therefore sexual, networks in a rural district in southwestern Uganda with high rates of both HIV and STIs. The intervention group participants were given mass treatment with antibiotics, while the control group participants were given vitamins and treatment for parasitic worms. The prevalence and incidence of some STIs significantly diminished in the intervention group versus the control group. Also, pregnant women in the intervention group had significantly lower prevalence of STIs than their control counterparts. However, there was no difference in HIV incidence.

Impact of Improved Treatment of Sexually Transmitted Diseases on HIV Infection in Rural Tanzania: Randomised Controlled Trial

Grosskurth, H., Mosha, F., Todd, J., et al. The Lancet (August 1995), 346:8974: 530–536.

This was the first randomized controlled clinical trial to test the hypothesis that treating sexually transmitted infections (STIs) would reduce HIV infection. Over 8,800 participants from 12 large communities took part in the STI intervention program, which included setting up a reference clinic and laboratory, providing diagnosis and treatment training for existing staff, supplying drugs, and visiting villages served by each health facility to encourage people to seek prompt treatment for STIs. The study found that in the intervention group, HIV incidence fell by more than two-fifths over two years, with the greatest impact among women aged 15 to 24 and men aged 25 to 34. The authors concluded that STI treatment led to significant reductions in HIV incidence. However, subsequent clinical trials have not been able to replicate these results.

Quality Assurance and Quality Improvement Using Supportive Supervision in a Large-Scale STI Intervention with Sex Workers, Men Who Have Sex with Men/Transgenders and Injecting-Drug Users in India

Mogasale, V., Wi, T.C., Das, A., et al. Sexually Transmitted Infections (February 2010),86(Suppl. 1): i83–i88.

This article reported the approach and results of an evaluation to monitor the performance of Avahan, the India AIDS Initiative. The authors developed a supportive supervision tool to analyze outcomes from three perspectives: clinical, community, and management. The tool assessed the accessibility, acceptability, and contact coverage of sexually transmitted infection clinical services. It looked at barriers to access and monitored the quality of individual service components, including correct treatment, infection control, confidentiality, and counseling. The tool was used during supportive supervision visits, and visits were repeated at three-month intervals to assess response to feedback. The monitoring demonstrated that Avahan improved and sustained quality in terms of coverage, quality, technical support, community involvement, and networks of referrals. In the 292 clinics assessed, overall quality indicators improved by a factor of between three and seven over 45 months. The authors concluded that the monitoring tool provides timely and useful feedback, but was time-consuming and expensive to implement.

Changes in Risk Behaviours and Prevalence of Sexually Transmitted Infections Following HIV Preventive Interventions Among Female Sex Workers in Five Districts in Karnataka State, South India

Ramesh, B.M., Beattie, T.S.H., Shajy, I., et al. Sexually Transmitted Infections (October 2010), 86(Suppl. 1): i17–i24.

This study used biological and behavioral surveys to assess the impact of a large HIV prevention program targeted at female sex workers (FSWs) in India's Karnataka State. A total of 4,712 FSWs received either baseline surveys, or follow-up surveys conducted between 28 and 37 months later. Prevention activities included peer outreach, behavior change communication, and provision of clinical services including syndromic and presumptive management of sexually transmitted infections (STIs). By follow-up, almost all participants had been visited by a peer educator; at least three-quarters had visited a drop-in center or sexual health clinic; and two-thirds had received presumptive treatment for chlamydia and gonorrhea. Rates of condom use with clients improved, but were static with regular partners. The prevalence of HIV diminished significantly across the board. Street-based FSWs had a reduced prevalence of curable STIs at follow-up, but prevalence of these STIs did not decrease for brothel- and home-based FSWs. The authors called for stronger strategies to increase FSWs' condom use with regular partners, and also to reduce the vulnerability of FSWs in brothels to HIV.

Uptake and Population-Level Impact of Expedited Partner Therapy (EPT) on Chlamydia Trachomatis and Neisseria Gonorrhoeae: The Washington State Community-Level Randomized Trial of EPT

Golden, M.R., Kerani, R.P., Stenger, M., et al. PLOS Medicine (January 2015), 12(1): e1001777, doi: 10.1371/journal.pmed.1001777, eCollection 2015.

This study reported on a community-level randomized trial to determine whether EPT increases partner treatment and decreases reinfection rates for gonorrhea and chlamydia in women. EPT refers to treating sex partners of people with sexually transmitted infections (STIs) without requiring medical evaluation for the partner. An EPT approach called patient-delivered partner therapy (PDPT) has been shown to be effective but has not been widely used or evaluated. Twenty-three local health jurisdictions (LHJs) in Washington State were randomized into four study waves to measure a population-level impact. Study outcomes, measured at the community level, were positive chlamydia tests in women ages 14–25 and incidence of reported gonorrhea in women. The intervention increased the percentage of people receiving both PDPT and partner services, and was associated with a reduction in both chlamydia positivity and gonorrhea incidence of about 10 percent. Potential study limitations included inadequate statistical power, crossover between LHJs, and contamination from a new state policy to increase partner services. The authors concluded that promotion of free PDPT in public-sector facilities substantially increased its use, and may have resulted in population-level decreases in chlamydia and gonorrhea. Taken with other evidence, the authors recommended increased promotion of EPT. 

Patient-Delivered Partner Treatment for Chlamydia, Gonorrhea, and Trichomonas Infection Among Pregnant and Postpartum Women in Kenya

Unger, J.A., Matemo, D., Pintye, J., et al. Sexually Transmitted Diseases (November 2015), 42(11): 637–42, doi: 10.1097/OLQ.0000000000000355.

This prospective cohort study evaluated patient-delivered partner treatment (PDPT) for sexually transmitted infections (STIs) among pregnant and postpartum women. It compared PDPT acceptability and barriers, and STI reinfection, between women whose partners did or did not receive PDPT. The study cohort was from a larger study of peripartum HIV acquisition; participants with diagnosed chlamydia, gonorrhea, and/or trichomonas were screened for eligibility. Questionnaires explored acceptability and barriers related to PDPT. Women were re-evaluated to assess whether their partners had been treated and whether the women had been reinfected with STIs. PDPT outcome data were collected for 51 women; 37 (73%) reported that their partners were treated with PDPT, and 14 (27%) refused or did not deliver treatment to their partners. Overall acceptability was high. The few reported barriers to PDPT included fear of partner's anger/abuse, and accusations they were the source of the STI. Reinfection rates were low, though the numbers in the study are too small to assess differences. Overall, PDPT was acceptable and feasible in this population, and may reduce recurrent STIs in pregnancy. The authors noted that PDPT is not recommended with syndromic diagnosis used in resource-limited settings, but may be more applicable with availability of new STI diagnostics. They called for further research to confirm the findings of this small study. 

Linking Sexual and Reproductive Health and HIV/AIDS, Gateways to Integration: A Case Study From Haiti

World Health Organization, United Nations Population Fund, Joint United Nations Programme on HIV/AIDS, and International Planned Parenthood Federation (2008).

This report was one of a series of documents describing country-based activities to integrate sexual and reproductive health (SRH) services. In Cité de Dieu, and later in two other neighborhoods in Port au Prince, voluntary HIV counseling and testing (VCT) became a gateway to providing comprehensive SRH services for a population of about 1.5 million. Services included condom use promotion, family planning, maternal child health services, and services specifically for young people and survivors of sexual violence. Integration made sense because most HIV infections in Haiti are transmitted sexually, mother-to-child transmission is common, and people living with HIV face stigma and discrimination in accessing health services. Services evolved as needs were identified. Requests for VCT by all clients increased by a factor of 62 between 1985 and 1999; and between 1999 and 2003, the number of pregnant women seeking VCT increased from an average of 7 to 120 per month. Although such integration requires great efforts to overcome the stigma associated with HIV, providing access to a range of health services greatly improves uptake of HIV counseling and testing.

Monthly Antibiotic Chemoprophylaxis and Incidence of Sexually Transmitted Infections and HIV-1 infection in Kenyan Sex Workers

Kaul, R., Kimani, J., Nagelkerke, N., et al. Journal of the American Medical Association (June 2004), Vol. 291(21): 2555–2562.

This randomized double-blinded and placebo-controlled trial enrolled 466 Kenyan female sex workers to test whether the use of antibiotic prophylaxis to treat common sexually transmitted infections (STIs) would also reduce the rate of HIV acquisition. All women received risk-reduction counseling, condoms, treatment of symptomatic STIs, and biannual screening and treatment for asymptomatic STIs. Half of participants received oral azithromycin, and the other half received a placebo. STI incidence diminished significantly in the intervention group, but HIV incidence remained unchanged. Out of 35 seroconversion cases, 19 were in the treatment group and 16 were in the placebo group. There was a strong association between prior STI and incident HIV-1 infection, and a significant positive effect of azithromycin on the reduction of incidence and prevalence of bacterial STIs. Both groups showed a reduction in risky sexual behaviors. Condom use with all clients increased from less to 20 percent to more than 50 percent within one month. The number of clients per week decreased from more than 16 to less than 6 within 6 months. There was a correlation between HIV-1 infection and risky sexual behaviors within the year of seroconversion. The authors offered several possible reasons for the lack of effectiveness in reducing HIV-1 acquisition with azithromycin treatment in this population.

The Cost-Effectiveness of 10 Antenatal Syphilis Screening and Treatment Approaches in Peru, Tanzania, and Zambia

Terris-Prestholt, F., Vickerman, P., Torres-Rueda, S. et al. International Journal of Gynaecology and Obstetrics (June 2015), 130(Suppl 1): S73–80, doi: 10.1016/j.ijgo.2015.04.007. 

Syphilis diagnosis in pregnant women is important to avert the risk of adverse outcomes in infants, but antenatal care clinics often lack the laboratory capacity to implement traditional diagnostic tests such as rapid plasma reagin (RPR). This study assessed the cost-effectiveness of different approaches to screening pregnant women for syphilis. In addition to RPR, rapid strip tests are now available that detect only one type of antibodies (single RSTs) or two types of antibodies (dual RSTs). The authors used costs from 20 clinics in Peru, Tanzania, and Zambia to model the cost-effectiveness of different testing approaches—examining combinations of RPR, single RSTs, dual RSTs, no treatment, and mass treatment. RPR screening was relatively inexpensive, but more than 70 percent of cases were not treated. Single RSTs, followed by dual RSTs, were the most cost-effective; dual RSTs became the most cost-effective if the test cost was cut in half. Single-test algorithms dominated most testing algorithms that used more than one test, although the sequential algorithms reduced overtreatment. In settings without screening supplies, mass treatment was relatively inexpensive and effective, but many women were treated who did not have syphilis. The authors concluded that introducing RSTs conferred advantages in the settings assessed, and these advantages should be applicable in other settings as well.

Impact of a Brief Intervention for Substance Use on Acquisition of Sexually Transmitted Diseases Including HIV: Findings From an Urban Sexually Transmitted Disease Clinic Population

Rogers, M., Johnson, K., Yu, J. et al. Sexually Transmitted Diseases (October 2015), 42(10): 569–74. doi: 10.1097/OLQ.0000000000000339.

Substance abuse is associated with sexually transmitted diseases (STDs) including HIV. This retrospective study assessed whether patients at STD clinics in New York City who received a brief intervention (BI) aimed at reducing substance use had lower rates of new STD/HIV infections than patients who did not receive this intervention. The study considered 7,665 patients (65% men and 35% women) for one year. The analysis focused on whether there were significant demographic differences between patients who received BI and those who did not, and whether BI was associated with STD or HIV incidence. Overall, 44.6 percent of the eligible study population had received BI. There were no statistically significant differences in newly diagnosed HIV between the two groups. Incidence of newly acquired bacterial STDs diminished by 20 percent in the BI group compared to the control group; this reduction was statistically significant in men. The sample size of women may have been too small to detect a difference. The authors recommended a randomized controlled trial to further test whether BI reduces incidence of STD and HIV in this population. Any such trial should include screening to differentiate severity of alcohol and drug use, to identify the mechanisms through which BI may reduce STD acquisition.

Guidance for the Prevention of Sexually Transmitted HIV Infections

U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) (2011).

The Office of the Global AIDS Coordinator guidance provides PEPFAR country teams with the latest scientific data on prevention programs to increase the impact of their country portfolios. Prevention programs should be tailored to the epidemiological and social context of the country as well as optimizing on current programs implemented by other partners to help fill gaps. The guidance highlights the importance of knowing the country’s epidemic, context, response, and costs, as well as ensuring that HIV prevention is part of the overall country continuum for the response. It also outlines current evidence and program activities that PEPFAR funds will support in relation to the diagnosis and treatment of sexually transmitted infections.

A Strategic Approach to Strengthening Control of Reproductive Tract and Sexually Transmitted Infections: Use of the Programme Guidance Tool

World Health Organization (2009).

National- and regional-level decisionmakers can use this Programme Guidance Tool to set goals and priorities for interventions to address reproductive tract infections. The tool has 10 steps, 7 of which are for strategic situation analysis, followed by development of recommendations, implementation of new measures, and expansion of those found to be successful. The document gives detailed guidance about what items should be covered at each stage. It includes a section on how to conduct a rapid assessment, as well as details on who should be interviewed and what interview tools can be used. There is also a suggested funding proposal outline for financing the first stage of the tool.

Training Modules for the Syndromic Management of Sexually Transmitted Infections

World Health Organization (2007).

This sexually transmitted infection (STI) management training program can be used for in-service training of health care workers in health centers, district hospitals, STI clinics, or other first-level health facilities. Seven modules cover STI prevention and control, syndromic case management, history-taking and examination, diagnosis and treatment, patient counseling and education, partner management, and recording and development. The material includes a trainer’s guide; and a CD-ROM is available that can be used for self-learning or in conjunction with conventional training. The program is also available in French and Spanish.

Laboratory Diagnosis of Sexually Transmitted Infections, Including Human Immunodeficiency Virus

World Health Organization (2013).

This manual, issued by the World Health Organization, updates a manual issued in 1999. Experts from around the world revised, added to, and reviewed the manual to ensure that it reflects the most current and relevant information. Key advances in the field have included diagnostic procedures, especially nucleic acid amplification and rapid point-of-care tests, and testing and recommendations on antimicrobial susceptibility. The manual is designed to provide a basic practical understanding of the principles of laboratory tests as they apply to screening and diagnosis as components of sexually transmitted infection (STI) control. The main intended audience is microbiologists and medical technologists in laboratories at different levels of health systems, but the document is also relevant to administrators, managers, and medical providers, since it informs areas such as procurement. The manual begins with chapters on choosing tests and laboratory quality management, followed by a separate updated chapter on each of the main diseases. Each covers practical topics including specimen collection, transport, and laboratory testing. New chapters examine point-of-care tests for STIs and laboratory quality management; and annexes address specific elements of equipment, tests, media, reagents, and stains. Although the manual is comprehensive, the editors advise consulting additional sources for information on complementary topics, such as national policies, antimicrobial susceptibility testing, and STI testing in minors. 

WHO Guideline for Brief Sexuality-Related Communication: Implications for STI/HIV Policy and Practice

Toskin, I., Cooper, B., Troussier, T. et al. Reproductive Health Matters (November 2015), 23(16): 177–184. doi: 10.1016/j.rhm.2015.11.009. 

This article summarized the implications of 2012 World Health Organization (WHO) guidelines on brief sexuality-related communication (BSC) for work on sexually transmitted infections (STI) and HIV. BSC is a patient-centered communication approach to help patients discuss sexual concerns with trained providers and motivate behavior change to reduce risk and enhance sexual wellbeing. In primary health care (PHC), the time for providing BSC ranges from 5–60 minutes. A 2012 WHO systematic review examined evidence on use of BSC and training programs for providers. It concluded that BSC had some effect on reducing and preventing STIs and HIV, with less strong evidence showing improved sexual wellbeing (few studies assessed this outcome). The review identified BSC as a promising approach to STI/HIV prevention in PHC settings, but noted that few studies came from low- and middle-income countries. The guidelines recommended that where BSC is introduced, providers and policymakers ensure that it “respects, protects and fulfills their clients’ human rights.” They recommended BSC for prevention of STIs among adults and adolescents in primary health services, and training for providers is using BSC. The authors concluded that BSC has great potential, and that implementing it will require advocacy and additional research to develop and test a clinical tool, provide in-service training, and address barriers.

Integrating STI/RTI Care for Reproductive Health. Sexually Transmitted and Other Reproductive Tract Infections: A Guide to Essential Practice

World Health Organization (2005).

This guide is a reference manual for use in reproductive health care settings such as family planning and maternal and child health care clinics. It focuses on women, since they are the typical users of such clinics and are less likely to use sexually transmitted infection (STI) clinics. There are sections giving basic information on STIs and other reproductive tract infections (RTIs), improving prevention and treatment services, and the clinical management of RTIs. HIV is mentioned in the guide, but is not covered extensively because it is not a disease of the reproductive tract.

Periodic Presumptive Treatment for Sexually Transmitted Infections: Experience from the Field and Recommendations for Research

World Health Organization (2008).

This report describes experiences from the field in periodic and one-time presumptive treatment for sexually transmitted infections (STIs) among sex workers and their clients. The report followed a technical consultation on global experiences of presumptive STI treatment programs among high-risk populations. The consultation identified the conditions needed for effective STI control using presumptive treatment, and produced recommendations for research. Both topics are covered in this report, as is the effect of presumptive treatment on specific STIs. The report presents case studies and offers brief guidance on operating programs for presumptive treatment.

Global Strategy for the Prevention and Control of Sexually Transmitted Infections 2006–2015: Breaking the Chain of Transmission

World Health Organization (2007).

This document makes the case for a global strategy to tackle sexually transmitted infections (STIs), describing the public health burden and the opportunities for an accelerated response, such as the emergence of new and cost-effective technologies. The strategy aims to provide a framework for this response. The document targets managers of national HIV prevention and STI control programs as well as other health sector stakeholders including health care providers, health ministers, and donors. It details both the technical strategy for STI prevention and control and an advocacy strategy for mobilizing resources and political and social leadership.

Guidelines for the Management of Sexually Transmitted Infections

World Health Organization (2003).

These guidelines lay out the standardized treatment recommendations for syndromes associated with sexually transmitted infections (STIs) using at-a-glance flowcharts and tables. There are also treatment recommendations for each specific STI. The guidelines detail the main considerations in choosing a treatment, such as cost, efficacy, treatment compliance, and availability. There is a chapter covering practical considerations in case management of STIs, and another on treatment of STIs in children and adolescents.