HIV Infection and Other STDs

Commentary:Although its history can be traced back further, the modern version ofSexually Transmitted Diseasesappeared in 1974 under the nameJournal of the American Venereal Disease Association.The name was changed toSTDin 1977, and the society's name was changed to the American Sexually Transmitted Diseases Association. During that 25 year history, the most cited publication was the 1992 article by Dr. Judith Wasserheit on the enhanced transmission of HIV that appeared to be caused by other sexually transmitted diseases. In recognition of the fact that this was the most cited article in the journals' history, Dr. Wasserheit was asked to provide the following commentary. I WAS SURPRISED and honored to learn that the review of interrelationships between human immunodeficiency virus (HIV) infection and other sexually transmitted diseases (STDs), which was published in Sexually Transmitted Diseases in 1992, has become the most frequently cited article in the journal's history.1 Popularity is often a function of relevance and timing, spiced with a new twist. I suspect that this article was no exception. By the beginning of this decade, a large number of cross-sectional studies and a few prospective studies already provided fairly strong evidence for a potentially explosive, mutually reinforcing spiral of infection between HIV infection and other STDs. Just as HIV prevention efforts were entering their second decade, the 1992 article highlighted this information by pulling together the work of many outstanding researchers, and by giving that unique interrelationship a name (epidemiological synergy) and a visual image with a new twist (the loops). During the subsequent 10 years, our understanding of STD-HIV interactions has greatly expanded; particularly our understanding of the ways in which other STDs facilitate HIV transmission.2 Numerous prospective studies from four continents have confirmed that there is at least a two-to fivefold increased risk of HIV transmission associated with the presence of other STDs. A growing body of data suggest that several biological mechanisms are responsible; HIV susceptibility and infectiousness are probably increased by inflammatory mediators and target cell recruitment in response to ulcerative and nonulcerative STDs, and by the “portal of entry” created by genital ulcers. The prevalence and magnitude of HIV shedding in genital secretions are increased by other STDs; STD treatment restores HIV shedding to baseline levels. Community-level, randomized, controlled trials of two different approaches to STD treatment have demonstrated that a substantial reduction in HIV incidence can be achieved by assuring access to syndromic treatment of symptomatic STDs; however, in at least one population, intermittent mass treatment administered at relatively long intervals compared with the frequency of intercourse had no impact on HIV spread.3,4 These trials also suggest that the contribution of STD treatment to HIV prevention may be greatest in populations experiencing earlier stage HIV epidemics. The question is no longer whether, or even how, to begin to incorporate early detection and treatment of STDs as a routine part of our national HIV prevention strategy. In 1998, based on the compelling data that were available, the Advisory Committee for HIV and STD Prevention of the Centers for Disease Control and Prevention published guidelines for policy makers, HIV program managers, and providers focusing on three key areas: 1) improving access to and quality of STD clinical services; 2) promoting early and effective STD-related health care behaviors; and 3) establishing surveillance systems to monitor STD and HIV trends and their interrelationships.5 Yet in both the public and private sectors, STD detection and treatment are still rarely a part of comprehensive HIV prevention and care services. For example, of the health department HIV and STD prevention programs that are not fully combined at the clinical level, less than one in five HIV clinics provide STD-related services.6 As STD rates surge among men who have sex with men, many of whom are HIV infected,7–10 and the rates of growth of the AIDS epidemic among women and in communities of color outstrip those in other subpopulations,11 the question is, what will it take to accelerate the pace at which we translate more than a decade of scientific insights into policy and practice? How do we move fields that seem ever closer, and yet remain so far apart?