[e-drug] Mass STD treatment should be used to reduce HIV transmission

["KC Team" <kcteam@aids2000.com>]

E-drug: Mass STD treatment should be used to reduce HIV transmission
---------------------------------------------

Mass treatment of sexually transmitted diseases (STDs) to prevent HIV
transmission will be the theme of a special debate session at the 
World AIDS Conference to be held in Durban in July 2000.  Whether you 
will attend or not, this is your opportunity to ensure that the 
existing views and evidence are made available to the debate 
organisers and the panellists who will discuss (and probably argue) 
the issue - for and against.

IF YOU HAVE SOMETHING TO SAY, please write to the ProCaare forum at:
procaare@usa.healthnet.org

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Mass STD treatment should be used to reduce HIV transmission

Sexually transmitted diseases (STDs) continue to be a major and growing
public health problem in many parts of the world, with an estimated 330
million new cases each year.  Studies indicate that treatment of STDs,
particularly those such as syphilis or gonorrhoea that create sores, can
significantly reduce the transmission of another STD - HIV/AIDS. These
observations have led to calls for improved treatment of curable STDs 
as a major component of HIV prevention.

Sounds simple, right?  Simply treat common STDs with existing antibiotics
and HIV transmission should drop. Wrong! - unfortunately the situation is
not that simple.  Although there are antibiotic drugs available that cure
STDs like syphilis and gonorrhoea, most cases occur in developing 
countries where services for accurate detection and diagnosis do not 
exist. To add to the problem, in many instances STDs do not create 
visible symptoms - particularly in women - so many people suffer from 
STDs without realising it.

About 8 years ago, the World Health organization came up with a solution:
they recommended that doctors should not worry about identifying 
precisely which STD somebody has, but should base their diagnosis on 
a set of easily observed symptoms or conditions - such as vaginal 
discharge or scrotal swelling - and then prescribe broad spectrum 
drugs aimed at treating all the possible infections that might bring 
about those symptoms. This is the so-called 'syndromic approach' to 
treating STDs, and does not need costly and sometimes slow laboratory 
tests.

But syndromic management is not without its pitfalls too. One of the 
biggest is due to the high numbers of STDs cases that do not show any 
symptoms. This means that unless you show signs of having an STD, you 
will not be identified and will remain untreated - falling through 
the syndromic treatment safety net. As a result, many people - and 
again, women in particular - may not receive treatment.

An alternative and more radical approach, and one which specifically 
treats STDs among non-symptomatic people, is to administer treatment 
to the entire population.  This might be considered as most 
appropriate in places where STDs are very common, and could have the 
following advantages:
 - Facilities and resources for diagnostic tests are not required
 - Asymptomatic people are treated
 - A substantial impact on STD & HIV prevalence is theoretically possible
 - Training needs are modest
 - Attendance at health centres may not even be necessary.

There is only limited evidence to indicate whether or not such an approach
works to reduce STDs, and even less whether it indirectly reduces HIV
transmission. Results of a recent study in the Rakai district of Uganda
showed that STDs can be significantly reduced through a mass treatment
approach, but that impact on HIV transmission may only be seen in areas
where the AIDS epidemic is in its early stages.

Of course there are also ethical concerns because many people without 
STDs would be at risk of possible side-effects, drug costs for such a 
mass
approach are very high, and there may also be increased risk of inducing
antibiotic resistance as a result of widespread use.

Theoretically at least, mass treatment approaches may work best:
 - in settings with high STD prevalence and early stage HIV/AIDS epidemics
 - where asymptomatic STDs are particularly common
 - when STD treatment is simple (i.e., a single oral dose), cheap and safe
to administer.

In 1998, in the journal 'Sexually Transmitted Infections', a team of people
from the Population Council, Johns Hopkins University, UNAIDS and WHO 
asked the question:  "At what level of [STD] infection does 
presumptive [mass] treatment become a cost-effective as well as an 
ethically and
programmatically acceptable intervention?"*

It seems that, however important it is in terms of HIV prevention, that
question remains to be fully addressed. The ethical concerns about 
mass STD treatment are closing the door to one of our few feasible 
means of slowing down the spread of HIV.

AIDS2000 Key Correspondent Team
Email: kcteam@aids2000.com

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(and look under ëArchivesí)

*Van Dam C.J., Becker K.M., Ndowa F., Islam M.Q. (1998)
Syndromic Approach to STD Case Management - Where Do We Go From Here?
Sexually Transmitted Infections; Vol. 74 (Suppl. 1): S175 - S178

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B  R  E  A  K     T  H  E     S  I  L  E  N  C  E

13th International World AIDS Conference,
Durban, South Africa, 9 - 14 July 2000
Internet: www.aids2000.com/interactive

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