STIs and HIV
The presence of an untreated ulcerative or non-ulcerative (those STIs which cause ulcers or those which do not) infection increases the risk of both acquisition and transmission of HIV by a factor of up to 10. Thus, prompt treatment for STIs is important to reduce the risk of HIV infection. Controlling STIs is important for preventing HIV in people at high risk, as well as in the general population.
Prevention of STIs
The most effective means to avoid becoming infected with or transmitting a sexually transmitted infection is to abstain from sexual intercourse (i.e., oral, vaginal, or anal sex) or to have sexual intercourse only within a long-term, mutually monogamous relationship with an uninfected partner. Male latex condoms, when used consistently and correctly, are highly effective in reducing the transmission of HIV and other sexually transmitted infections, including gonorrhoea, chlamydial infection and trichomoniasis.
STIs without symptoms
Some sexually transmitted infections often exist without symptoms. For example, up to 70% of women and a significant proportion of men with gonococcal and/or chlamydial infections may experience no symptoms at all. Both symptomatic and asymptomatic infections can lead to the development of serious complications, as outline above.
STI syndromes and the syndromic approach to patient management
Although many different pathogens cause STIs, some of them give rise to similar or overlapping clinical appearances, known as signs (what the individual or the health-care provider sees on examination) and symptoms (what the patient feels, such as pain or irritation). Some of these signs and symptoms are easily recognizable and consistent, giving what is known as a syndrome that signals the presence of one or a number of pathogens. For example, a discharge from the urethra in men can be caused by gonorrhoea alone, chlamydia alone or both together.
The main syndromes of common STIs are:
- Urethral discharge
- Genital ulcers
- Inguinal swellings (bubo, which is a swelling in the groin)
- Scrotal swelling
- Vaginal discharge
- Lower abdominal pain
- Neonatal eye infections (conjunctivitis of the newborn)
The traditional method of diagnosing STIs is by laboratory tests. However, these are often unavailable or too expensive. Since 1990 WHO has recommended a syndromic approach to diagnosis and management of STIs in patients presenting with consistently recognized signs and symptoms of particular STIs.
The syndromic approach is a scientifically derived approach and offers accessible and immediate treatment that is effective. The syndromic approach using flowcharts to guide diagnosis and treatment is more accurate than diagnosis based on clinical judgment alone, even in experienced hands, and more cost-effective for some syndromes than use of laboratory tests. However, the specificity of this approach for vaginal discharge is low for gonorrhoea and chlamydia and treating all women with vaginal discharge for cervical infection (as if they have a sexually transmitted cause for the discharge) has led to unacceptable levels of over-treatment in some settings. Women with abnormal vaginal discharge should be treated primarily for vaginal infections, and treatment for gonorrhoea and chlamydia only included according to the prevalence of or risk for these pathogens. The organisms causing any particular syndrome need to be determined locally and flow charts adapted accordingly.
Furthermore, regular monitoring of the organisms causing each syndrome should be conducted on a regular basis to validate the treatment recommendations.
The global strategy for the prevention and control of STIs
The control of STIs remains a priority for WHO. The World Health Assembly endorsed the global strategy for the prevention and control of STIs in May 2006. The strategy urges all countries to control the transmission of STIs by implementing a number of interventions, including the following:
- Prevention by promoting safer sexual behaviours;
- General access to quality condoms at affordable prices;
- Promotion of early recourse to health services by people suffering from STIs and by their partners;
- Inclusion of STI treatment in basic health services;
- Specific services for populations with frequent or unplanned high-risk sexual behaviours - such as sex workers, adolescents, long-distance truck-drivers, military personnel, substance users and prisoners;
- Proper treatment of STIs, i.e. use of correct and effective medicines, treatment of sexual partners, education and advice;
- Screening of clinically asymptomatic patients, where feasible; (e.g. syphilis, chlamydia);
- Provision for counselling and voluntary testing for HIV infection;
- Prevention and care of congenital syphilis and neonatal conjunctivitis; and
- Involvement of all relevant stakeholders, including the private sector and the community, in prevention and care of STIs.
Source: World Health Organization