Holistic actions are essential to combat the global public health burden of non-viral sexually transmitted infections: challenges and future perspectives.

Sexually transmitted infections (STIs) represent a significant international public health burden. These infections result in substantial morbidity, mortality and economic costs globally, and require more attention and resources internationally. This special focus issue of Expert Review of Anti Infective Therapy invited key opinion leaders to review and discuss the challenges associated with the diagnosis and treatment of non-viral STIs. The issue also elucidates the future perspectives, ways forward and holistic actions imperative to effectively combat these STIs.

Effectiveness and cost-effectiveness of traditional and new partner notification technologies for curable sexually transmitted infections: observational study, systematic reviews and mathematical modelling.

BACKGROUND: Partner notification is essential to the comprehensive case management of sexually transmitted infections. Systematic reviews and mathematical modelling can be used to synthesise information about the effects of new interventions to enhance the outcomes of partner notification. OBJECTIVE: To study the effectiveness and cost-effectiveness of traditional and new partner notification technologies for curable sexually transmitted infections (STIs). DESIGN: Secondary data analysis of clinical audit data; systematic reviews of randomised controlled trials (MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials) published from 1 January 1966 to 31 August 2012 and of studies of health-related quality of life (HRQL) [MEDLINE, EMBASE, ISI Web of Knowledge, NHS Economic Evaluation Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA)] published from 1 January 1980 to 31 December 2011; static models of clinical effectiveness and cost-effectiveness; and dynamic modelling studies to improve parameter estimation and examine effectiveness. SETTING: General population and genitourinary medicine clinic attenders. PARTICIPANTS: Heterosexual women and men. INTERVENTIONS: Traditional partner notification by patient or provider referral, and new partner notification by expedited partner therapy (EPT) or its UK equivalent, accelerated partner therapy (APT). MAIN OUTCOME MEASURES: Population prevalence; index case reinfection; and partners treated per index case. RESULTS: Enhanced partner therapy reduced reinfection in index cases with curable STIs more than simple patient referral [risk ratio (RR) 0.71; 95% confidence interval (CI) 0.56 to 0.89]. There are no randomised trials of APT. The median number of partners treated for chlamydia per index case in UK clinics was 0.60. The number of partners needed to treat to interrupt transmission of chlamydia was lower for casual than for regular partners. In dynamic model simulations, >10% of partners are chlamydia positive with look-back periods of up to 18 months. In the presence of a chlamydia screening programme that reduces population prevalence, treatment of current partners achieves most of the additional reduction in prevalence attributable to partner notification. Dynamic model simulations show that cotesting and treatment for chlamydia and gonorrhoea reduce the prevalence of both STIs. APT has a limited additional effect on prevalence but reduces the rate of index case reinfection. Published quality-adjusted life-year (QALY) weights were of insufficient quality to be used in a cost-effectiveness study of partner notification in this project. Using an intermediate outcome of cost per infection diagnosed, doubling the efficacy of partner notification from 0.4 to 0.8 partners treated per index case was more cost-effective than increasing chlamydia screening coverage. CONCLUSIONS: There is evidence to support the improved clinical effectiveness of EPT in reducing index case reinfection. In a general heterosexual population, partner notification identifies new infected cases but the impact on chlamydia prevalence is limited. Partner notification to notify casual partners might have a greater impact than for regular partners in genitourinary clinic populations. Recommendations for future research are (1) to conduct randomised controlled trials using biological outcomes of the effectiveness of APT and of methods to increase testing for human immunodeficiency virus (HIV) and STIs after APT; (2) collection of HRQL data should be a priority to determine QALYs associated with the sequelae of curable STIs; and (3) standardised parameter sets for curable STIs should be developed for mathematical models of STI transmission that are used for policy-making. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Cost-effectiveness of treatment strategies for cervical infection among women at high risk in Madagascar.

BACKGROUND: According to the national guidelines developed in 2001, a woman at high risk of gonorrhea and chlamydia in Madagascar is treated presumptively at her first sexually transmitted infection clinic visit; risk-based treatment (RB) is subsequently used at 3-month visits. OBJECTIVES: To compare health and economic outcomes for a 2-stage Markov process with the following 3 cervical infection treatment policies at baseline and at 3-month follow-up visit: presumptive treatment (PT), RB, and an interim laboratory/risk-based policy. STUDY DESIGN: Cost-effectiveness analysis was used to compare the 9 treatment strategies. RESULTS: When 3-month incidence of cervical infection is <20%, the national guidelines are less costly and less effective than both RB followed by PT, and PT at both visits. CONCLUSIONS: The national guidelines are a reasonable strategy, especially in the context of resource constraints, relatively low reinfection rates, and local preferences.

Aspectos biológicos, socioeconömicos e culturais de mulheres com corrimento vaginal / Biologycals socio-cultural-economics aspects women with vaginal discharge

Apesar do corrimento vaginal ser uma das mais antigas e frequentes afecçöes que acometem a saúde física e emocional da mulher, do diagnóstico laboratorial ser relativamente fácil e de baixo custo, das recidivas e reinfecçöes serem constantes, ainda na atualidade, sua abordagem é feita de maneira simplista e empírica, tanto para o diagóstico como para a terapêutica. Este estudo objetiva enfatizar a importåncia de uma abordagem holística no atendimento à mulher com corrimento vaginal, pois acreditamos que tal afecçäo, suas recidivas e reinfecçöes näo estäo exclusivamente associadas a infectividade e virulência do patógeno envolvido, mas também ao contexto socioeconömico e cultural em que a mulher está inserida

STD treatment for men in rural and urban Zimbabwe: choice of practitioner, perceptions of access and quality of care.

STD treatment choices and perceptions of treatment services (access, quality of care) by Zimbabwean men are examined in 2 settings: Mbare, a district within the capital city Harare, and Gutu, a rural town. Data collection included a survey of 457 men 18 years of age or older (from a stratified systematic sample), focus groups and key informant interviews. Of 220 cases of self-reported genital symptoms, 81.4% were treated by allopathic practitioners, 9% by traditional/faith healers, 8.6% by the subject, a friend or another person; 1.4% were not treated. Traditional/faith healers were consulted primarily for symptoms involving pain or discomfort rather than ulcers or exudation. Disrespect by the health care provider and consultations that were not private were cited as problems by a small minority of subjects. Significantly more respondents in Mbare than in Gutu had been prevented from obtaining the STD treatment they desired at some point in their life because of cost of treatment (chi(2)=5.23, P=0.02). Given the current deteriorating economic situation in Zimbabwe, cost of treatment may become an even more important impediment in the future.

The legal framework covering the practice of genitourinary medicine in the UK: the Venereal Diseases Regulations.

The legal framework governing the practice of genitourinary medicine is traced from 1916 to the present. The first legislation, the Public Health (Venereal Diseases) Regulations of 1916 was comprehensive, and accompanied by guidance on setting up outpatient clinics and their supporting laboratories with practical advice on taking samples to support clinical diagnosis. Confidentiality was emphasized. The regulations led to the development of a nationwide network of clinics providing free care, open at times convenient to the public, and situated in general hospitals in large centres of population. Most of the principles still apply. Subsequent legislation centred on maintaining the confidentiality of all information obtained in relation to persons examined or treated for venereal disease, but allows transfer of details between healthcare providers to facilitate care and contact tracing. While the initial regulations stated that the venereal diseases were syphilis, gonorrhoea and chancroid, the legislation now covers all sexually transmitted diseases.

Which resources pay for treatment? A model for estimating the informal economy of health.

The model proposed is a means for (i) documenting the resources a woman deploys to choose, seek, find, get and pay for treatment; (ii) comparing what she has/does with a neighbour facing similar symptoms and problems, and (iii) understanding which difference between them makes most difference to the way they manage illness. In a narrow economic perspective, only tangible items with easily enumerated values are called resources, and only the formal economy counts. This model allows assessment of the value of both formal and informal resources in the household system. It will not establish the absolute or market worth of households in the sample, but does offer a framework for comparing households which have the same access to a given set of treatment options when faced with the same symptoms. Its application improves the possibility of understanding which resources, or combinations of resources, make most difference to a household's capacity to seek and get the treatment it has decided it needs. The paper is one element of a multi-layered and multi-disciplinary study of 'The Informal Economy of Health in African Cities'. The overall project aims are (i) to map the cultural, infrastructural and clinical factors affecting the treatment-seeking behaviour of women in low-income urban areas; (ii) to compare their effect(s) on the management of symptoms of adult venereal infection (STD) and crisis symptoms in children under five. The project mapped the social context of illness management in a district of Kampala. Important dimensions of that context are: the infrastructure of the area, and the treatment options available in or around it; women's assessments of how good/kind/shameful/private/feasible/ appropriate those options are, and the social and physical signs which trigger the conclusion that a symptom is 'serious enough' to need treatment outside the home in the first place. The focus here is the value of resources mobilized after the 'serious enough' assessment has been made.