Treatment of curable sexually transmitted infections (STIs), a relatively inexpensive, simple, and effective intervention, should be promoted as an essential component of HIV control programs in communities with a high incidence of STIs. The authors derived this from reviewing the observational studies and nine randomized controlled trials (RCTs) evaluating the impact of STI treatment interventions on HIV incidence. Although only one of nine RCTs has demonstrated an effect on HIV incidence, the authors conclude that issues in trial design and conduct—including HIV epidemic phase, STI prevalence, and intervention in comparison groups—affected several of the trials. The RCTs examined three different management approaches to a broad spectrum of curable and incurable STIs in varying populations, with different levels of risk behaviors and STI prevalence, in both concentrated and generalized HIV epidemic settings. Four of the trials focused on population-level effects of STI treatments, with only one focusing on populations with high STI prevalence. Three trials, focusing on herpes suppressive therapy, found that antivirals for herpes simplex virus suppression were insufficient to control the cofactor effect of herpes simplex virus type-2 on HIV transmission. The authors advocate for future research examining the biological mechanisms responsible for the STI-HIV interactions, testing new STI control strategies that target these interactions, and developing point-of-care STI diagnostics and evaluation of alternative partners service approaches (e.g., patient-delivered partner therapy).

This study used confidential computerized interviews to ask people living with HIV about recent history of sexually transmitted infections (STIs) as well as their sexual behaviors and infectiousness beliefs. It found that one in seven respondents had been diagnosed with an STI over a six-month period, most commonly herpes simplex virus and syphilis. There was a strong association between belief that viral load was undetectable and diagnosis with an STI. The authors advocate integration of STI diagnosis and treatment into routine clinical HIV care. It is also crucial to correct false beliefs about infectiousness and provide education about STI symptom recognition and the importance of early detection and aggressive treatment, they write.

The prevalence and incidence of reproductive tract infections (RTIs) and HIV over a five-year period and the relationship between RTIs and HIV infection were examined in this study of more than 4,400 women attending family planning clinics in Zimbabwe and Uganda. 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 and almost all types of RTI were associated with increased risk of HIV infection. The authors still conclude that aggressive efforts to control RTIs may contribute significantly to HIV prevention and recommend continued efforts to find more effective treatments and interventions.

This randomized, double-blind, placebo-controlled trial enrolled HIV-negative, herpes simplex virus type 2 (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. This is disappointing, the authors comment, given that infection with HSV-2 is associated with significantly higher risk of HIV acquisition. They recommend further studies re-examine this assumption derived from observational studies and whether higher doses of acyclovir or other antiviral drugs would yield better results.

The commentary is in response 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 no effect of STI control on HIV acquisition. The authors disagree with this view and support sexually transmitted infection control in HIV prevention founded on the results of modeling studies. Reducing funds to sexually transmitted infection diagnosis, treatment, and control could have adverse and unexpected effects on the HIV epidemic and should not be relaxed.

This study compared the impact of three scenarios—behavioral interventions with or without syndromic management of sexually transmitted infections and routine medical care—on incidence of HIV in rural Ugandan communities. Awareness of herpes simplex virus type-2 (HSV-2) symptoms improved in the behavioral intervention group and HSV-2 incidence decreased in the group that also received syndromic sexually transmitted infection management. The study took reported condom use with the last casual partner as a proxy for high-risk sexual encounters and found that the behavioral interventions were associated with increased condom use. However, there was no measurable reduction in the incidence of HIV in any of the groups.

This 2001 meta-analysis combined the best available evidence to date to examine the effect of sexually transmitted infections (STIs) on HIV susceptibility. It found that many studies had been done in this area, but that a quantitative understanding of the interaction between the two was still lacking. Although randomized controlled trials are the gold standard for proving causation, most studies on HIV and STIs were observational. The authors recommend that future studies should strive to quantify the extent to which treating STIs has an impact on HIV prevention.

This study used biological and behavioral surveys to assess the impact of HIV prevention programs targeted at female sex workers, such as peer outreach and behavior change communication and provision of sexual health clinic 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 reduced significantly across the board, but for curable STIs, only street-based female sex workers had a reduced prevalence at follow-up. Rates of curable STIs did not decrease for brothel- and home-based female sex workers.

This paper argues that the “fractured paradigm” of HIV prevention separate from programs to tackle sexually transmitted infections (STIs) is counterproductive for both, given that weak control of STIs may undermine HIV prevention efforts. The paper reviews the components, benefits, and feasibility of STI control and offers an alternative, unified paradigm to tackle HIV together with other STIs. A useful table lays out the epidemiological parameters for integrating HIV prevention and STI control, detailing which target groups and diseases should get priority in which settings and when STI interventions are most effective in preventing HIV transmission.

The randomized double-blinded and placebo-controlled trial enrolled 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. Four hundred and sixty-six seronegative sex workers were enrolled in the study. All women were provided with risk-reduction counseling, condoms, treatment of symptomatic STIs, and biannual screening and treatment for asymptomatic STIs. Oral azithromycin was given to half of the participants and the other half was given a placebo. There was no statistically significant difference between the treatment and placebo groups on HIV-1 incidence. 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. A reduction in risky sexual behaviors in both groups was found. 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 six months. There was a correlation between HIV-1 infection and risky sexual behaviors within the year of seroconversion. The authors provide plausible reasons for the lack of effectiveness in reducing HIV-1 acquisition with azithromycin treatment in this population.

National- and regional-level decision makers 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. It gives detailed guidance about what items should be covered at each stage. There is a section on how to conduct rapid assessment, including 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.

These guidelines present sexually transmitted infections grouped by presenting symptom, with a section each for infections characterized by vaginal discharge, urethritis and cervicitis, and genital ulcers. Each section gives the range of recommended treatment regimens. The guidelines also cover partner management and special issues such as sexually transmitted infections during pregnancy; infections in babies, children, and adolescents; and, where applicable, treatment of drug-resistant disease strains. These guidelines are based on laboratory diagnosis rather than the syndromic management method that is used in resource-constrained settings.