World trends in sexually transmitted infections, HIV and AIDS: what is coming up next for specialists in this field
World trends in sexually transmitted infections, HIV and AIDS: what is coming up next for specialists in this field |
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My discourse starts a long way from Europe. The world has grown smaller time-travel wise, through instant communication and fast airline travel. This has made us more aware of the gap between resources and research in the well capitalised countries and the developing world. There is an awful problem of HIV/AIDS in Africa and South Asia especially. It is estimated that 34 million people were living with HIV/AIDS at the end of 1999. Twenty-three million were living in sub Saharan Africa - 69% of the worlds AIDS in an area of the world with only 10% of the total population. The area with a very fast rising prevalence is South Africa but many countries like Swaziland, Namibia, Zambia all have 30 to 40% of their population affected. There is evidence that HIV is spreading fast in West Africa - Ghana and Nigeria being affected. In the latter that is a tragedy in an already chaotic country affected by civic strife. There is no doubt that coexisting STDs, genital ulcer disease and genital inflammatory disease make the situation worse and that passage of HIV is enabled this way. Practices such as multiple sex partners without condoms, marriage of widows of men who have died of AIDS to their brothers, HIV and STIs passing via truck drivers along traffic routes all add to the epidemic. Tuberculosis is common, malnutrition and tropical disease such as malaria, onchocerciasis and filiarisis all add to misery. These countries are very poor and there are very few medical resources.
There are many other problems stemming from the AIDS epidemic in Africa. As a result of early mortality, mothers dying soon there will be millions of AIDS orphans. Who is going to feed them? Who is going to care for them? The professional classes of countries affected also die of AIDS and there is a shortage of any form of technocrat.
Primary prevention in most countries has not been very successful. Senegal in West Africa seems to have been a success and the epidemic in Uganda may be abating. These are however only two examples. At Mwanza, it was shown that reducing the incidence of STDs also decreased HIV infection rates, but the Rakai trial in Uganda has not been quite so fortunate. Antibiotic mass medication does not seem to have had the same effect. World Health Organisation has put forward Syndromic Management as a means of controlling STDs in resource poor settings. There are now many examples of successes and their utility published from some parts of Africa. However it does depend on symptomatic populations. We do know that most STDs are symptomless to begin with and supplies of antibiotics and personnel are in short supply.
ASIA - my personal view is that the HIV epidemic may be potentially more dangerous there because of a much larger population. On the other hand intelligence from governmental public health sources is better in many countries. However there are problems of regimes such as Burma which are militaristic, secretive and not following good international practice. In the middle and near east countries, we do know from Task Force that
syphilis has increased in the former Islamic parts of the former Soviet Union. There is very little data and much taboo on collecting any information about anything to do with sex from these countries. There are potential threats in not knowing about potential AIDS in a large region of the world.
India has an enormous population, much movement of populations, enormous poverty, and many STIs. There is evidence from such cities as Mumbai (Bombay), Madras and Calcutta of rising prevalences of HIV over the last 10 years. The government is waking up to this fact slowly and bringing in prevention programs. In Assam in north east India, near to Burma, there has been much evidence that intravenous drug use with contaminated equipment is a source of HIV spread.
Thailand, I know this country well and have visited and taught there many times. It has a population of 57 million and at the beginning of the 1980s it had high prevalences of all STDs. From about 1984 HIV infection in many different sub groups was observed. It was realised that the economy of the country was in jeopardy as the younger population the main tax earners would be the main group infected. About a million Thais have been infected. For this reason the Thai 100% Condom Campaign was started and this has been very successful. Reports have shown that STDs have decreased enormously and it is hoped that HIV will diminish in prevalence. Much research has been carried out in Thailand and there is very good post graduate teaching. Thai teaching resources are being used by neighbouring countries as models to control their epidemics of HIV.
China remains the enigma for HIV/AIDS. There is some evidence of HIV spreading and public health authorities are concerned.
EUROPE:
Most of you will only be too aware during the past ten years of the rise of syphilis, and to a lesser extent gonorrhoea in Estonia, the other Baltic countries, Russia and former countries of the former Soviet Empire. There are very many reasons for this complex issue. The reasons include so called sexual freedom in a population knowing little about sexual health; mobility of populations; criminality; breakdown of social orders and currency compound the problem. Also in many of these countries, necessary up to date medical care is lacking in modern training and technical expertise. There is some evidence that the syphilis epidemic in Russia and neighbouring countries may have peaked but there are observed worrying increases of congenital syphilis, and increasing forecasts of rising levels of HIV infection. The Ukraine, Belorussia, and Russian cities such as St. Petersburg and Kalingrad seem to have been severely affected.
Important trends in STDs
I have just mentioned the resurgence of syphilis and its recognition often not realised by doctors who see little of it in Western Europe. We need to recognise the increasing trends for antimicrobial resistant in gonorrhoea and the importance of having reference centres to monitor the trend. For all STDs there needs to be national protocols of treatment structured on evidence based medicine not just on anectodal accounts. We need to constantly audit our work, and have postgraduate training to keep with new advances. We need to have research and very importantly epidemiology. None of us can plan for adequate resources unless we know facts concerning our speciality. We need not only to understand microbial STDs especially Chlamydial infection but a full understanding of viral STDs like herpes genitalis, human papilloma virus, and Hepatitis B/C is needed. We need to understand problems related to young people, adolescence, sexuality, issues related to contraception, an understanding of homosexuality, and a tolerance for all, irrespective of sexuality or ethnicity. A good venerologist is amoral not immoral. In Europe at the present time we have to understand what it feels like not to be in ones own country. To be a migrant and if young to be lonely and more liable to get STDs. The suffering your own country has gone through will make you very sensitive to the suffering of others. We need to integrate STDs into services aimed at young people such as sexual health, contraception and psychological counselling. We need very much to help in preventative education at all levels and give expert advice. We need to explain to those we teach at University how important STDs are, and how contact tracing, partner notification is essential to cut back STDs.
In the next few years there will be new treatments, new vaccines, new ideas. We should be open to all and be able to critically evaluate them. Our speciality is one of intense interest in human nature, in human beings. A life long journey.
Keynote address to the Estonian STD Society read on June 9th 2000.
©2000 Sexual Health Matters. Published Quarterly by Express Print Works, Middlesbrough,
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