Sarah Hawkes

Global control of sexually transmitted infections

Sexually transmitted infections other than HIV are important global health issues. They have, however, been neglected as a public-health priority and control efforts continue to fail. Sexually transmitted infections, by their nature, affect individuals, who are part of partnerships and larger sexual networks, and in turn populations. We propose a framework of individual, partnership, and population levels for examining the effects of sexually transmitted infections and interventions to control them. At the individual level we have a range of effective diagnostic tests, treatments, and vaccines. These options are unavailable or inaccessible in many resource-poor settings, where syndromic management remains the core intervention for individual case management. At the partnership level, partner notification and antenatal syphilis screening have the potential to prevent infection and re-infection. Interventions delivered to whole populations, or groups in whom the risks of infection and onward transmission are very high, have the greatest potential effect. Improvements to the infrastructure of treatment services can reduce the incidence of syphilis and gonorrhoea or urethritis. Strong evidence for the effectiveness of most other interventions on population-level outcomes is, however, scarce. Effective action requires a multifaceted approach including better basic epidemiological and surveillance data, high quality evidence about effectiveness of individual interventions and programmes, better methods to get effective interventions onto the policy agenda, and better advocacy and more commitment to get them implemented properly. We must not allow stigma, prejudice, and moral opposition to obstruct the goals of infectious disease control.

Global Estimates of Syphilis in Pregnancy and Associated Adverse Outcomes: Analysis of Multinational Antenatal Surveillance Data

Using multinational surveillance data, Lori Newman and colleagues estimate global rates of active syphilis in pregnant women, adverse effects, and antenatal coverage and treatment needed to meet WHO goals.

Untreated maternal syphilis and adverse outcomes of pregnancy: a systematic review and meta-analysis

OBJECTIVE To perform a systematic review and meta-analysis of reported estimates of adverse pregnancy outcomes among untreated women with syphilis and women without syphilis. METHODS PubMed, EMBASE and Cochrane Libraries were searched for literature assessing adverse pregnancy outcomes among untreated women with seroreactivity for Treponema pallidum infection and non-seroreactive women. Adverse pregnancy outcomes were fetal loss or stillbirth, neonatal death, prematurity or low birth weight, clinical evidence of syphilis and infant death. Random-effects meta-analyses were used to calculate pooled estimates of adverse pregnancy outcomes and, where appropriate, heterogeneity was explored in group-specific analyses. FINDINGS Of the 3258 citations identified, only six, all case-control studies, were included in the analysis. Pooled estimates showed that among untreated pregnant women with syphilis, fetal loss and stillbirth were 21% more frequent, neonatal deaths were 9.3% more frequent and prematurity or low birth weight were 5.8% more frequent than among women without syphilis. Of the infants of mothers with untreated syphilis, 15% had clinical evidence of congenital syphilis. The single study that estimated infant death showed a 10% higher frequency among infants of mothers with syphilis. Substantial heterogeneity was found across studies in the estimates of all adverse outcomes for both women with syphilis (66.5% [95% confidence interval, CI: 58.0-74.1]; I(2) = 91.8%; P < 0.001) and women without syphilis (14.3% [95% CI: 11.8-17.2]; I(2) = 95.9%; P < 0.001). CONCLUSION Untreated maternal syphilis is associated with adverse pregnancy outcomes. These findings can inform policy decisions on resource allocation for the detection of syphilis and its timely treatment in pregnant women.

Reproductive-tract infections in women in low-income, low-prevalence situations: assessment of syndromic management in Matlab, Bangladesh

BACKGROUND In the control of reproductive-tract infections, including sexually transmitted infections (STIs), in low-income and middle-income countries, WHO recommends syndromic management for individuals with symptoms. This intervention was initially developed in areas where prevalence of such infections is high. We investigated the clinical effectiveness and cost of this approach among a group of women with a low prevalence of infection. METHODS During a 5-month period, we investigated all women complaining of abnormal vaginal discharge and seeking care at maternal and child health/family-planning centres in Matlab, Bangladesh, for the presence of laboratory-diagnosed reproductive-tract infections and STIs. Syndromic diagnoses made by trained health-care workers were compared with laboratory diagnosis of infection. We then calculated the costs of treating women by means of the recommended WHO algorithm and an adapted algorithm incorporating use of a speculum and simple diagnostic tests. FINDINGS The prevalence of endogenous infections among 320 women seen was 30%. Cervical infections (Neisseria gonorrhoeae and Chlamydia trachomatis) were found in only three women. The WHO algorithm had a high sensitivity (100%) but a low specificity (zero for bacterial vaginosis, candida, and Trichomonas vaginalis). The speculum-based algorithm had a low sensitivity (between zero and 59%) but a higher specificity (79-97%). Between 36% and 87% of costs would have been spent on uninfected women. INTERPRETATION The high rate of overtreatment in the population studied carries both financial and social costs--the latter in potentially exposing women misdiagnosed as having an STI to threats of domestic disruption or even violence. We make recommendations for management programmes in areas of low STI prevalence and low income.

Effectiveness of interventions to improve screening for syphilis in pregnancy: a systematic review and meta-analysis

BACKGROUND About 2·1 million pregnant women have active syphilis every year. Without screening and treatment, 69% of these women will have an adverse outcome of pregnancy. The objectives of this study were to review the literature systematically to determine the effectiveness of screening interventions to prevent congenital syphilis and other adverse pregnancy outcomes. METHODS We searched four electronic databases and selected studies to examine evidence for effectiveness of interventions on three outcomes: increased uptake of syphilis testing, increased treatment rates, and reduction in adverse pregnancy outcomes. We used fixed effects meta-analysis to estimate pooled relative risks if no or little evidence of heterogeneity between trials existed. FINDINGS Ten studies met the inclusion criteria, including two randomised trials. Only two studies aimed to encourage women to seek care earlier in pregnancy. Nine studies included decentralisation of screening and treatment. The effects of the interventions on uptake of testing for antenatal syphilis and receiving at least one dose of penicillin were variable and could not be combined statistically. Study interventions were associated with a reduction in perinatal death (pooled risk ratio [RR] from three studies 0·46, 95% CI 0·26-0·82) and stillbirth (pooled RR from three studies 0·42, 95% CI 0·19-0·93). The incidence of congenital syphilis was reduced in all four studies that measured this outcome with heterogeneous results. INTERPRETATION Interventions to improve the coverage and effect of screening programmes for antenatal syphilis could reduce the syphilis-attributable incidence of stillbirth and perinatal death by 50%. The resources required to roll out antenatal screening programmes would be a worthwhile investment for reduction of adverse pregnancy outcomes and improvement of neonatal and child survival. FUNDING None.

Risk behaviour and HIV prevalence in international travellers

ObjectiveTo assess risk factors for infection and to determine HIV prevalence in a sample of international travellers. DesignA cross-sectional survey of new patients attending a hospital outpatient clinic, and self-completion of an anonymous questionnaire on sexual behaviour prior to and during travel. Urine samples were tested for the presence of antibodies to HIV. SettingThe Hospital for Tropical Diseases, London, UK. SubjectsAll new patients over a 6-month period. ResultsOf 782 people approached, 757 (97%) agreed to participate: 141 (18.6%) had had new sexual partners during their most recent trip abroad. Almost two-thirds of those having sex abroad did not use condoms on every occasion with a new partner, and 5.7% contracted a sexually transmitted disease (STD) during their most recent trip; 26% of men from World Health Organization Pattern I countries who had new sexual partners abroad paid for sex. Sixteen out of 731 (2.2%) participants were HIV-antibody-positive. HIV positivity was associated with being born in east, central or southern Africa, having symptoms of an STD since arriving in the United Kingdom and being treated for an STD since arrival. ConclusionThe rates of unsafe sex and payment for sex abroad reported by these international travellers indicate the potential for contracting and transmitting STD, including HIV, in both their foreign and domestic sexual partnerships. With the increasing HIV incidence in Asia (the most common destination for UK travellers after sub-Saharan Africa), the number of cases of HIV contracted abroad may rise in the future.

The need and plan for global elimination of congenital syphilis.

In every society, congenital syphilis (CS) has significant medical, economic, societal and emotional burdens; these are poorly characterized but high. Inexplicably, the elimination of CS has failed to attract international attention. Yet, the cornerstones of programs to do this universally are in place, the recent development of new diagnostic tools offers the now-practical possibility of testing every pregnant woman, testing is cost-effective, and programs for the elimination of CS can be joined with other programs to enhance efficiency. The magnitude of the CS burden, globally, rivals that of HIV infection in neonates yet receives little attention. The newly proposed World Health Organization Strategy for the Global Elimination of Congenital Syphilis aims to mobilize resources and provide a plan to address this underrecognized health problem.

Gender and global health: evidence, policy, and inconvenient truths

In this article the authors survey the evidence for the role of gender in health status analyze responses to gender by key global health actors and propose strategies for mainstreaming gender-related evidence into policies and programs. Using the WHO definition of gender the article attempts to disentangle and quantify the exact contributions that sex and gender make to health status which often interact with other social determinants of health. The authors analyzed the recent Global Burden of Disease (GBD) from a gender perspective. Data from this study are intended to help policy makers to set priorities and allocate resources according to population health needs. Evidence shows that gender – a social construct – has a substantial effect on health behaviors access to health care and health system responses. The tendency to underplay or misunderstand the role of gender or to equate the gender dimensions of health solely with the specific health needs of women has led to a failure to address the evidence of gendered determinants that affect and drive the burden of ill health of both men and women.

Missing men's messages: does the reproductive health approach respond to men's sexual health needs?

Following the 1994 International Conference on Population and Development, the world has seen a shift in paradigm away from focused family planning programmes towards reproductive and sexual health more generally. This paper considers how the traditional emphasis on womens health and family planning can result in mens sexual health needs being overlooked. A biomedical rationale to target men with health services evolved from the rising interest in control programmes for HIV and sexually transmitted infections (STIs). To plan appropriate health interventions more needs to be known about how men perceive their sexual health. Unique data from Orissa (India) and rural Bangladesh illustrate mens perceptions of their sexual health problems and demonstrate that men are willing to seek care. While public sector programmers and health planners may be focusing their attention on the control of STIs, men in both studies indicated that their major concerns relate more to matters of psychosexual disorders. The failure of public sector programmes to take cognisance of male sexual health problems may lead to men continuing to seek care for all their sexual health problems (including STIs) in the unregulated and possibly ineffective private sector. If programmes addressing the sexual health needs of men are to be effective, they will need to be comprehensive in their scope and coverage, just as they are now aiming to be for women.

HIV and other sexually transmitted infections among men transgenders and women selling sex in two cities in Pakistan: a cross-sectional prevalence survey.

Objectives: The extent and possibilities of spread of the HIV epidemic are not fully understood in Pakistan. A survey was conducted among men, women and transgender populations selling sex in Rawalpindi (Punjab) and Abbottabad (North West Frontier Province) in order to inform evidence-based programme planning. Methods: A cross-sectional survey was performed with participants recruited through respondent-driven sampling. Male and transgender sex workers were analysed in three gender groups; women were analysed as one group. Behavioural surveys were conducted and clinical specimens collected. Laboratory tests looked for evidence of acute infection (gonorrhoea, Chlamydia, syphilis, Trichomonas) and infection over the lifetime (HIV, herpes simplex virus-2, syphilis). Predictors of infection were explored using univariable and multivariable logistic regression. Results: The prevalence of HIV was low in 917 male and transgender sex workers and absent in 533 female sex workers in the study. High levels of current sexually transmitted infections were found, predominantly among transgender sex workers. Risk behaviours were common and knowledge of HIV was extremely low. Multivariable analysis found a large number of factors associated with higher levels of infection, including experience of forced first sex. Protection against risk was low, but those sex workers who reported using condoms at last sex had lower rates of infection. Conclusions: The HIV epidemic is currently in its early stages among people who sell sex, but there may be potential for a much greater spread given the levels of other sexually transmitted infections found and the concomitant low levels of both protective knowledge and risk-reducing behaviours. Action is needed now to avert an epidemic. Framing interventions by upholding the recognition and protection of human rights is vital.