Gray RH, Wawer MJ. Reassessing the hypothesis on STI control for HIV prevention

Johns Hopkins University, Baltimore, MD 21205, USA.
The Lancet (Impact Factor: 45.22). 07/2008; 371(9630):2064-5. DOI: 10.1016/S0140-6736(08)60896-X
Source: PubMed
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    • "Studies suggest the possibility of women with untreated urogenital schistosomiasis also present with similar adverse outcomes [8-11]. According to Gray et al. [12], CT and NG facilitate the susceptibility of women to HIV infection. "
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    ABSTRACT: Many studies have shown an overlap in the epidemiology of sexually transmitted infections (STIs) and urogenital schistosomiasis among young women living in schistosomiasis endemic areas. Yet we found no study assessing the prevalence of STI infections in urogenital schistosomiasis endemic areas in Ghana. As part of an epidemiological study on urogenital schistosomiasis and HIV, we sought to assess the prevalence of both Chlamydia trachomatis (CT) and Neisseria gonorhoeae (NG) infections among women living in schistosomiasis endemic communities and explore the relationship between the sexually transmitted infections (STIs) and demographic characteristics, sexual behaviour and self-reported symptoms. This was a cross-sectional study in which endocervical samples were collected from 191 women aged 15–49 years from October 2005 to March 2006. Samples were examined for CT and NG using Polymerase Chain Reaction (PCR). A structured questionnaire was also used to elicit information on study participant’s gynaecological and obstetric history and symptoms for genital infection. Chi-square test and binary logistic regression were used to assess association between CT and NG and other variables such as age, sexual behaviour and self-reported symptoms. The overall prevalence of CT and NG were 6.3% and 2.6% respectively.The highest prevalence rates of CT were in the 15 to 19 year group while only individuals between 15 and 39 years were positive for NG. There was no association between CT and age, contraceptive use and the other variables assessed. NG on the other hand was found to be associated with age, number of births and number of sexual partners only by chi-square test. Our research revealed higher prevalence of CT and NG infections when compared to previous studies conducted among higher risk groups in non-urogenital schistosomiasis areas in Ghana. We therefore recommend further studies of these STIs in urogenital schistosomiasis endemic areas in the country.
    Full-text · Article · Jun 2014 · BMC Research Notes
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    • "Certainly, biologic evidence of both increased infectiousness and susceptibility, as well as some epidemiologic evidence, indicates that particularly ulcerative STIs play some role [54]. However, the preponderance of randomized trials have failed to show an impact of STI treatment at both the individual and community level on HIV transmission [55]. Of course, these other STIs are also profoundly influenced by sexual behaviour and have their own literature implicating a crucial role of concurrency in their transmission [56,57]. "
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    ABSTRACT: Multiple sexual partnerships must necessarily lie at the root of a sexually transmitted epidemic. However, that overlapping or concurrent partnerships have played a pivotal role in the generalized epidemics of sub-Saharan Africa has been challenged. Much of the original proposition that concurrent partnerships play such a role focused on modelling, self-reported sexual behaviour data and ethnographic data. While each of these has definite merit, each also has had methodological limitations. Actually, more recent cross-national sexual behaviour data and improved modelling have strengthened these lines of evidence. However, heretofore the epidemiologic evidence has not been systematically brought to bear. Though assessing the epidemiologic evidence regarding concurrency has its challenges, a careful examination, especially of those studies that have assessed HIV incidence, clearly indicates a key role for concurrency. Such evidence includes: 1) the early and dramatic rise of HIV infection in generalized epidemics that can only arise from transmission through rapid sequential acute infections and thereby concurrency; 2) clear evidence from incidence studies that a major portion of transmission in the population occurs via concurrency both for concordant negative and discordant couples; 3) elevation in risk associated with partner's multiple partnering; 4) declines in HIV associated with declines in concurrency; 5) bursts and clustering of incident infections that indicate concurrency and acute infection play a key role in the propagation of epidemics; and 6) a lack of other plausible explanations, including serial monogamy and non-sexual transmission. While other factors, such as sexually transmitted infections, other infectious diseases, biological factors and HIV sub-type, likely play a role in enhancing transmission, it appears most plausible that these would amplify the role of concurrency rather than alter it. Additionally, critics of concurrency have not proposed plausible alternative explanations for why the explosive generalized epidemics occurred. Specific behaviour change messaging bringing the concepts of multiple partnering and concurrency together appears salient and valid in promoting safer individual behaviour and positive social norms.
    Full-text · Article · Jun 2011 · Journal of the International AIDS Society
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    • "For example, the role of STIs is now questioned, and some speculate that they were only important during the early years of the epidemic (Korenromp et al. 2005). Similarly, the association between HSV and HIV may be due to shared risk factors only, and HSV suppression with acyclovir may have been inadequate (Gray & Wawer 2008). The science behind potential interventions requires thorough interrogation before trials, and this was lacking in some of the early trials. "
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    ABSTRACT: Southern Africa continues to shoulder a disproportionate burden of the HIV epidemic with the number of new infections outstripping treatment initiation two- to threefold. Current prevention strategies have had a limited impact on the trajectory of the epidemic so far. The history of HIV prevention research is dominated by failed approaches, but recent developments have provided reason for hope. These include the successful male circumcision outcomes in trials in South Africa, Kenya and Uganda, the recent protective outcome of a tenofovir vaginal gel trial in South Africa and the proof that pre-exposure prophylaxis with oral combination tenofovir/emtricitabine can work in men. The latter positive outcome has however been shattered by the early closure of FEM-PrEP for futility. The challenge now is on how to best integrate emerging prevention methods with established strategies, recognising that some of the older methods have never been scaled up to saturation level. El sur de África continúa soportando una carga desproporcionada de la epidemia del VIH con el número de nuevas infecciones sobrepasando la iniciación de tratamiento entre dos y tres veces. Hasta ahora las estrategias de prevención disponibles han tenido un impacto limitado en la trayectoria de la epidemia. En la historia de la investigación en prevención del VIH abundan las estrategias fallidas, aunque desarrollos recientes han dado razones para tener esperanzas. Estos incluyen resultados exitosos en los ensayos de circuncisión masculina en Sudáfrica, Kenia y Uganda; el reciente resultado de protección del ensayo con el gel vaginal tenofovir en Sudáfrica y la prueba de que la profilaxis pre-exposición con una combinación oral de tenofovir/emtricitabina puede funcionar en hombres. Sin embargo, el último resultado positivo ha sido destrozado por el cierre anticipado del estudio FEM-PrEP. Ahora el reto es encontrar la mejor forma de integrar los métodos de prevención emergentes con estrategias establecidas reconociendo que algunos de los métodos más antiguos no se han llevado a escala hasta sus niveles de saturación.
    Full-text · Article · Jun 2011 · Tropical Medicine & International Health
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