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Updates on Sexually Transmitted Infections in the Philippines

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Abstract

Sexually transmitted infections (STIs) remain a public health problem worldwide, with more than 1 million people acquiring an STI every day. In the Philippines, the total number of people with STIs other than human immunodeficiency virus (HIV) infection is not known. Hence, the Philippine Dermatological Society (PDS) has taken the initiative to document STI cases in its institutions since 2011. Syphilis, human papillomavirus (HPV), herpes simplex virus (HSV) and HIV infections are some of the common STIs in our country. A total of 665 syphilis patients, 2,053 HPV-infected patients and 977 patients with herpes have been seen and treated in PDS institutions throughout the country from 2011 to 2018. The number of HIV cases on the other hand, have already reached 58,181 from January 1984 to August 2018. In August 2018 alone, 1,047 new cases of HIV have been reported to the HIV/AIDS & ART Registry of the Philippines (HARP). The rates of STI infections like HIV, syphilis, HPV and herpes may be on the rise but clinicians can have a significant impact on this trend. With effective counselling, early and accurate detection, diagnosis and treatment, the threat and burden of STIs can be greatly reduced.
LET’S HEAR FROM A COLLEAGUE
Updates on Sexually Transmied Infecons in the Philippines
Emmerson Gale S.Vista, MD, FPDS, FPSVI
Sexually transmied infecons (STIs) remain a public health problem worldwide, with more than 1 million people acquiring an STI every
day. In the Philippines, the total number of people with STIs other than human immunodeciency virus (HIV) infecon is not known.
Hence, the Philippine Dermatological Society (PDS) has taken the iniave to document STI cases in its instuons since 2011.
Syphilis, human papillomavirus (HPV), herpes simplex virus (HSV) and HIV infecons are some of the common STIs in our country. A
total of 665 syphilis paents, 2,053 HPV-infected paents and 977 paents with herpes have been seen and treated in PDS instuons
throughout the country from 2011 to 2018. The number of HIV cases on the other hand, have already reached 58,181 from January
1984 to August 2018. In August 2018 alone, 1,047 new cases of HIV have been reported to the HIV/AIDS & ART Registry of the Philip-
pines (HARP).
The rates of STI infecons like HIV, syphilis, HPV and herpes may be on the rise but clinicians can have a signicant impact on this
trend. With eecve counselling, early and accurate detecon, diagnosis and treatment, the threat and burden of STIs can be greatly
reduced.
Keywords: Sexually transmied infecon, syphilis, human papillomavirus, herpes simplex virus, human immunodeciency virus,
updates
INTRODUCTION
exually transmied infecons (STIs) remain a public health
problem worldwide. According to the World Health Orga-
nizaon (WHO), more than 1 million people acquire an STI
every day. Unfortunately, there is currently no available data on
the number of STI cases in the Philippines except for HIV. There
are also few local journals on STI. Hence in 2011, the Philippine
Dermatological Society (PDS) started to document STI cases in all
its instuons.
One major barrier to STI prevenon and control is the
sgma associated with STIs. Sgmasing beliefs and fears of dis-
criminaon have been shown to inuence decisions to seek STI
tesng and treatment. , STI counselling in primary care can help
encourage paents to undergo STI tesng, treatment and partner
referral.2 It may also help promote safe sex and reduce risky be-
havior.
HIV
In 2017, the Philippines has registered the fastest-grow-
ing HIV/AIDS epidemic in the Asia-Pacic. One thousand forty-
seven new cases of HIV have been reported to the HIV/AIDS &
ART Registry of the Philippines (HARP) in August 2018 alone. This
brings up the total number of reported HIV cases in the Philip-
pines since January 1984 to 58,181.6
The risk of HIV infecon may be reduced by abstaining from sex,
liming the number of sexual partners or scking to a monoga-
mous relaonship, using condoms the right way when engaging in
sex and avoiding sharing of needles. There is also a newer tool for
HIV prevenon, which is pre-exposure prophylaxis (PrEP) or the
use of a daily anretroviral medicaon such as tenofovir-emtric-
itabine by HIV-negave individuals. PrEP was introduced in the
Philippines in 2017 through a pilot project led by experts from
S
the WHO, the Research Instute for Tropical Medicine (RITM) and
non-governmental organizaons. Two hundred HIV-negave men
who have sex with men (MSM) and transgender women were
enrolled in the project. Results of this two-year study are set to
inform naonal policies and the possible wider implementaon
of PrEP in the Philippines.
In HIV-posive individuals, early iniaon of anretrovi-
ral therapy (ART) is said to improve their overall health and re-
duce the risk of HIV transmission. Anretroviral (ARV) drugs are
commercially available but the Department of Health (DOH) also
provides free ARV drugs or ART in treatment hubs throughout
the country. The number of such treatment facilies has been in-
creased in recent years such as in Central Visayas, where the num-
ber has increased from three hospitals to six in this year alone.
Despite increased government support and availability of free
treatment, only 30,004 people living with HIV (PLHIV) in the Phil-
ippines were enrolled in free ART as of July 2018.6 The DOH said
that “the low percentage of ART enrollees is due to the sgma and
fear of knowing one’s HIV status”.
PhilHealth is in full support of these STI prevenon and
control measures of DOH. There is a PhilHealth Outpaent HIV/
AIDS Treatment (OHAT) package that covers up to P30,000-worth
of anretroviral treatment and laboratory exams, which can be
availed of at any accredited HIV treatment facility. PhilHealth also
provides hospitalizaon benets for PLHIV, which ranges from
P11,000 to P20,000 depending on the case.
Government support is not merely limited to treatment
but includes HIV tesng and screening as well. Accurate HIV diag-
nosc tesng however, can be challenging. The most sensive and
reliable method for tesng, which is nucleic acid tesng, is expen-
sive and oen limited to centralized tesng facilies. Outpaent
HIV test kits are now commercially-available but the reliability of
these may not be high. Another obstacle to early detecon is the
seronegave window period or WP, the me between infecon
and the producon of detectable levels of anbodies (seroconver-
sion). WP is esmated to be about 3 months. If an HIV anbody
test is done during the WP, the result will be negave even if the
person is infected and could transmit the virus to others. There-
fore, if an HIV test is negave, a follow-up test should be done
aer 2-3 months to conrm the results.
Syphilis
Syphilis, an STI caused by the spirochete bacteria Trepo-
nema pallidum, is another chronic STI that may cause major com-
plicaons, if not detected and treated properly. It is also known as
the great imitator because its symptoms are oen similar to many
other diseases. A total of 665 paents have been seen and
treated for syphilis in PDS instuons since 2011.
Syphilis paents oen seek dermatologic evaluaon for
signs and symptoms such as chancre (primary stage) or diuse
rash (secondary stage). In the latent stage, the paent has acve
infecon but may be asymptomac.
Screening for syphilis should be performed when pa-
ents show signs or symptoms of the disease or when they are
highly at risk from acquiring the infecon. Screening may be done
through a direct test or a serological test. The direct test is very
specic but the serological test is more popular and more roune-
ly performed. However, there are some challenges with the inter-
pretaon of results in serological tesng such as the possibility
of a false negave or a false posive result. False negave results
may be due to the prozone eect, prior treatment or the specic
stage of infecon upon tesng (early stage or latent stage may
test negave). Prozone eect is the false negave result due to
high levels of anbodies to cardiolipin cholesterol lecithin angen
in an infected person. False posive results on the other hand,
are aributed to other clinical condions and other factors like
repeated infecon and laboratory error.
Treatment of primary or secondary syphilis with penicil-
lin or other anbiocs is necessary to prevent progression into
neurosyphilis or the life-threatening terary stage and to mini-
mize the risk of HIV acquision.
HPV
Human papillomavirus (HPV) infecon characterized by
anogenital and oropharyngeal disease is sll very common. Ac-
cording to PDS data, 2,053 paents with HPV infecon have been
seen in its instuons since 2011. Diagnosis of HPV is mostly clini-
cal but when diagnosis is uncertain, a biopsy may be required.
There is no cure for HPV infecon; only reduc-
on of infecvity and removal of visible and symptomac warts.
Treatment may be topical or surgical. Imiquimod and chemical
peel are the only widely available topical methods for HPV treat-
ment in the Philippines. These can be quite expensive and based
on a systemac review of treatment modalies, most topical
methods do not yield a high success rate of clearance and recur-
rence is common. Among the surgical methods, electrocautery is
most commonly performed locally. It is also the most appropriate
as it immediately clears lesions.
Vaccines that protect against inial HPV infecon have
been developed and proven eecve. In fact in some countries,
it is now included in their mass vaccinaon program for young
people who are not yet sexually acve. HPV vaccinaon has also
been shown to increase natural HPV immunity in people who
have been previously infected with HPV.
Genital Herpes
Genital herpes is another STI that is highly prevalent and
has a signicant impact on sexual health and the risk of HIV acqui-
sion and transmission. It is usually caused by herpes simplex vi-
rus-2 (HSV-2) but may also be due to herpes simplex virus-1 (HSV-
1). WHO esmated more than 500 million people to be infected
with HSV worldwide in 2016.1 In the Philippines, 977 paents
have been seen and treated for herpes in PDS instuons since
2011.
Herpes is characterized by frequent viral shedding
throughout the genital tract that leads to inammaon. People
suspected to have genital herpes should undergo laboratory tests
such as PCR analysis to conrm the diagnosis.
Like HPV, HSV infecon is incurable. However, interven-
ons that suppress viral shedding may prevent transmission of
HSV and the risk of HIV acquision.14 Treatment also reduces
pain, duraon of shedding and healing me. Treatment may be
episodic or chronic suppressive. Chronic suppressive therapy is
usually oered to paents who experience six or more clinical
episodes per year or those who experience signicant anxiety or
distress due to the clinical recurrences.
The rates of STI infecons like HIV, syphilis, HPV and her-
pes may be on the rise but clinicians can have a signicant impact
on this trend. With eecve screening, counselling, early and ac-
curate diagnosis and treatment, the threat and burden of STIs can
be greatly reduced.
ABOUT THE AUTHOR
Dr. Emmerson Gale Silverio Vista is a consultant and
faculty member at the Research Instute for Tropical Medicine
(RITM), Department of Dermatology. He is also a consultant at
St. Luke’s Medical Center in Bonifacio Global City and a vising
consultant at Cavite Medical Center. He nished his dermatology
residency training at RITM and parcipated in the dermatology
fellowship observership program at the Naonal Skin Centre in
Singapore and dermatology mentorship training on STD-HIV at
the Ludwig Maximilian University of Munich, Department of Der-
matology and Allergy in Germany. His current research interests
include knowledge, atudes and pracces of dermatology pa-
ents or health care workers regarding HIV/AIDS and other STIs.
*You may contact the author at:
esvdermatology@gmail.com
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Thesis
In the UK, research has highlighted the need for improved education in alcohol and sexual health in the adolescent population. Consequently, Relationships and Sex Education and Health Education were made compulsory in 2019. However, preceding research highlighted that school-based alcohol and sexual health education was ill-suited to building associated health skills and competencies. Health literacy as a concept aims to address these issues by providing a framework within which health related competencies and outcomes can be developed. Consequently, the aim of this research was to develop models of alcohol and sexual health literacy in adolescents and further interrogate the use of such models in education, exploring the barriers to developing alcohol and sexual health literacy in adolescents though formal education. A pragmatic, mixed methods approach was utilised to explore the research questions. The study contributed to the field of research by creating robust, theory-based models of alcohol and sexual health literacy and discovering the following: • Current measures of adolescent health literacy are poorly designed, often only accounting for functional health literacy. • There are many barriers that need to be overcome to effectively deliver alcohol and sexual health education in schools, specifically, that competencies in alcohol and sexual health are perceived as challenging to teach and measure within a school setting. • Internationally, curriculum guidelines tend to focus on the risks associated with alcohol and sexual health and fall short in building competencies over knowledge and in aiding educators with instruction. • Introduction of compulsory Relationships and Sexual Health Education and Health Education in the UK will have little significant impact if it is not supported with more training and support for educators. These findings and the models produced have significant connotations for the design and delivery of alcohol and sexual health education in schools.
Article
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Although licensed human papillomavirus (HPV) vaccines are most efficacious in persons never infected with HPV, they also reduce infection and disease in previously infected subjects, indicating natural immunity is not entirely protective against HPV re-infection. The aim of this exploratory study was to examine the B cell memory elicited by HPV infection and evaluate whether vaccination merely boosts antibody (Ab) levels in previously infected subjects or also improves the quality of B cell memory. Toward this end, the memory B cells (Bmem) of five unvaccinated, HPV-seropositive subjects were isolated and characterized, and subject recall responses to a single HPV vaccine dose were analyzed. Vaccination boosted Ab levels 24- to 930-fold (median 77-fold) and Bmem numbers 3- to 27-fold (median 6-fold). In addition, Abs cloned from naturally elicited Bmem were generally non-neutralizing, whereas all those isolated following vaccination were neutralizing. Moreover, Ab and plasmablast responses indicative of memory recall responses were only observed in two subjects. These results suggest HPV vaccination augments both the magnitude and quality of natural immunity and demonstrate that sexually active persons could also benefit from HPV vaccination. This study may have important public policy implications, especially for the older ‘catch-up’ group within the vaccine's target population.
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When learning of a positive HIV test, individuals face a host of psychological and social stresses. HIV-related stigma is associated with psychological distress and can interfere with coping, adjustment, and management of HIV disease. Effective management of HIV disease requires timely testing for HIV infection so that persons who are infected can learn of their serostatus and gain access to care, therefore benefiting from available treatment options. This article discusses the impact that HIV-related stigma has on HIV testing and care. Specifically, problems associated with delays in testing, disclosure of seropositive status, and implications for health care are presented.
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Herpes simplex virus 2 (HSV-2) is a DNA virus that is efficiently transmitted through intimate genital tract contact and causes persistent infection that cannot be eliminated. HSV-2 may cause frequent, symptomatic self-limited genital ulcers, but in most persons infection is subclinical. However, recent studies have demonstrated that the virus is frequently shed from genital surfaces even in the absence of signs or symptoms of clinical disease and that the virus can be transmitted during these periods of shedding. Furthermore, HSV-2 shedding is detected throughout the genital tract and may be associated with genital tract inflammation, which likely contributes to increased risk of HIV acquisition. This review focuses on HSV diagnostics, as well as whatwehave learned about the importance of frequent genital HSV shedding for (i) HSV transmission and (ii) genital tract inflammation, as well as (iii) the impact of HSV-2 infection on HIV acquisition and transmission.Weconclude with discussion of future areas of research to push the field forward. © 2015, American Society for Microbiology. All Rights Reserved.
Article
Stigma has long accompanied sexually transmissible infections (STI) and hindered prevention and control efforts. It not only acts as a formidable barrier to STI testing, treatment and disclosure, but has a multitude of consequences for the health and quality of life of infected individuals. This review summarises the literature related to STI stigma and offers practical approaches to counter STI-associated stigma through multi-level efforts. Specifically, it describes the key sources that breed and perpetuate stigma, outlines how STI-associated stigma has been conceptualised and measured in the literature, documents the impact of stigma on infected and uninfected individuals, and summarises the stigma reduction strategies recommended in the literature. Gaps in the literature are identified and areas for further research are suggested, along with practical strategies for moving forward.
HIV testing attitudes, AIDS stigma, and voluntary HIV counselling and testing in a black township in Cape Town, South Africa
HIV testing attitudes, AIDS stigma, and voluntary HIV counselling and testing in a black township in Cape Town, South Africa. Sex Transm Infect 2003; 79: 442-447.
Stigma, social risk, and health policy: public attitudes toward HIV surveillance policies and the social construction of illness. Health Psych (in press)
  • G M Herek
  • J P Capitanio
  • K F Widaman
Herek GM, Capitanio JP, Widaman KF. Stigma, social risk, and health policy: public attitudes toward HIV surveillance policies and the social construction of illness. Health Psych (in press). In: Kalichman SC, Simbayi LC. HIV testing attitudes, AIDS stigma, and voluntary HIV counselling and testing in a black township in Cape Town, South Africa. Sex Transm Infect 2003; 79: 442-447.
HIV pre-exposure prophylaxis
  • M Sharma
  • Dhs Tan
Sharma M, Tan DHS. HIV pre-exposure prophylaxis. CMAJ 2014; 186(15): E588.
Syphilis: Screening and diagnostic testing
  • C B Hicks
  • M Clement
Hicks CB, Clement M. (2018, Aug). Syphilis: Screening and diagnostic testing.