Oral Transmission of Sexually Transmissable Infections: A Narrative Review.

Over the last few decades, behavioral changes in sexual practices have made oral transmission of traditional sexually transmissible infections increasingly recognized. Patients harboring a sexually transmissible infection may first present lesions on the oral cavity, as these may be visible and interfere with basic functions such as speech or swallowing. Moreover, the oral cavity may function as a reservoir for future spread of these infections. In order to successfully control this problem, a greater focus on oral sex should be persued, along with promotion of the use of condom and education on safe oral sex practices. Furthermore, examination of the oral cavity should is essential when evaluating any patient suspected of harboring a sexually transmissible infection. In this article, oral transmission of several viral and bacterial infections is reviewed, including human papillomavirus infection, genital herpes, syphilis and gonorrhea, among others.

Com as alterações comportamentais nas práticas sexuais verificadas nas últimas décadas, a transmissão oral de infeções sexualmente transmissíveis tem vindo a ser progressivamente mais reconhecida. As lesões na cavidade oral podem ser visíveis ou interferir com funções básicas como a fala ou deglutição, sendo por isso o motivo de apresentação de muitos destes doentes. Além disso, a cavidade oral pode funcionar como um reservatório para a disseminação futura dessas infecções. Para um controlo adequado deste problema, deve ser prestada uma maior atenção às práticas de sexo oral, à promoção do uso do preservativo e à educação relativamente a práticas sexuais seguras. Por outro lado, o exame da cavidade oral deve ser parte integrante da avaliação de qualquer indivíduo com suspeita de uma infecção sexualmente transmissível. Neste artigo, a transmissão oral de várias infeções virais e bacterianas é revista, nomeadamente a infeção pelo vírus do papiloma humano, herpes genital, sífilis e gonorreia, entre outras.

Knowledge of AIDS among secondary school pupils in Bagamoyo and Dar-Es-Salaam, Tanzania.

We assessed knowledge of AIDS among pupils in selected schools in Tanzania in August 1989. Four hundred and eight-one pupils from four randomly selected secondary schools, two from Dar-Es-Salaam (a city) and two from Bagamoyo (a semi-rural town), were interviewed using a structured questionnaire. Of these, 476 (99.0%) had heard of AIDS, and 447 (92.9%) were able to mention spontaneously at least one sexually transmitted disease (STD), of whom 374 (83.7%) mentioned AIDS. Knowledge was found to increase with age and tended to be higher among women in Dar-Es-Salaam than in Bagamoyo. These data suggest that communication channels directed at women in rural areas should be strengthened. While knowledge of sexual transmission of HIV was generally high, and prevalence of reported misconceptions about modes of transmission was very low, knowledge of non-sexual means of transmission (transfusions, injections, vertical) was lacking. Although 80% of pupils mentioned reduction of number of sexual partners as a means of AIDS prevention, only 22% mentioned condom use, and less than 5% reported that they had ever used a condom. Future research should concentrate on means of promoting sexual behavior change, the ultimate aim of any AIDS prevention strategy.

HIV and HTLV-I infections in the Americas: a regional perspective.

With over 143,000 cases of AIDS reported to the World Health Organization from 145 countries and with an estimated 5 to 10 million people worldwide infected with HIV, AIDS has become firmly established as a global pandemic. In the region of the Americas over 100,862 cases of AIDS have been reported with indigenous transmission documented in 45 to 46 countries. While North America has the highest annual number of AIDS cases per population, with 72 cases/million, the Caribbean subregion has a disproportionately high number of cases, with annual rates as high as 200 to 300 cases/million population for some countries. Despite differences in absolute number of cases, there has been a remarkable similarity in the temporal rate of increase of AIDS in the countries of the Americas, reflecting delayed introduction of the virus to some areas with an early exponential increase similar to that observed initially in the United States. Although the modes of transmission of HIV are the same throughout the region, evidence of increasing bisexual and heterosexual transmission, particularly in the Caribbean subregion, has resulted in a lower male-to-female ratio of AIDS cases and increased perinatal transmission. Clinically, a resurgence of diarrheal diseases, respiratory infections, and tuberculosis has been documented in association with HIV infection in many tropical countries of the Americas. With relatively high rates of HTLV-I infection already established in the Caribbean subregion, the overall public health problems of the Americas will be markedly potentiated by further spread of these 2 human retroviruses. If HIV infection continues to penetrate the poor and less advantaged populations in Latin America and the Caribbean, the potential exists for a massive epidemic in the Americas that may rapidly parallel the situation in Africa.

PIP: The article describes in detail the extent and nature of HIV and HTLV-1 infections, and AIDS in the Americas. Surveillance statistics are provided for general populations, homosexual and bisexual men, IV-drug users, female prostitutes, hemophiliacs, heterosexual partners of HIV-infected persons, blood donors, and pregnant women. As of publication, over 100,862 AIDS cases have been reported in the region, with indigenous transmission documented in 45-46 countries. Clinical manifestations of HIV infection and AIDS are discussed. North America claims the highest annual AIDS cases per population at 72/million, while the Caribbean subregion has a disproportionately high number of cases, with annual rates reaching 200-300/million for some countries. The temporal rate of increase of AIDS cases has, however, been fundamentally comparable for all countries of the Americas. While HIV transmission modes are the same throughout the region, increasingly lower male-female ratios of AIDS cases, and more cases of perinatal transmission especially in Caribbean countries. Diarrheal disease, respiratory infections, and tuberculosis have also been documented as associated with HIV infection in many tropical countries of the Americas. Further, relatively high rates of HTLV-1 infection in the Caribbean will only exacerbate already significant public health problems faced by some countries of the region. Should HIV continue infiltrating poor, disadvantaged populations of Latin America and the Caribbean, HIV infection levels and AIDS could reach epidemic proportions similar to that witnesses in Africa.

Knowledge of AIDS and other sexually transmitted diseases among women attending a family planning clinic in Nairobi, Kenya.

We interviewed 1,716 women attending a family planning clinic in Nairobi between January 1990 and May 1991 about their knowledge of the acquired immunodeficiency syndrome (AIDS) and other sexually transmitted diseases (STDs). When participants in the study were asked to name spontaneously the STDs they knew, more than 90% of the women named gonorrhea and AIDS, and 75.0% named syphilis; 65.4% could name two or more signs of AIDS; and 96.9%, 66.5%, and 58.3% mentioned sexual transmission, transmission via blood transfusion, and perinatal transmission, respectively, as routes of transmission of AIDS. Knowledge of most symptoms and routes of transmission of AIDS, as well as knowledge of gonorrhea and syphilis, was significantly positively associated with level of education. Unmarried women were significantly less likely to know symptoms and routes of transmission of AIDS than were married women. Level of knowledge of gonorrhea and syphilis was significantly positively associated with number of lifetime sexual partners. Although awareness of AIDS was very high, detailed knowledge of signs of AIDS and routes of transmission was deficient, particularly among less educated women. This positive association of detailed AIDS knowledge with level of education suggests a need to design AIDS prevention activities that are more accessible to, and better understood by, women who have little education.

PIP: Between January 15, 1990 and May 6, 1991, in Kenya, family planning workers interviewed 1716 women who attended 2 peri urban family planning clinics in Nairobi to identify predictors of knowledge about AIDS and other sexually transmitted diseases (STDs). 16.3% of the women reported to have or have had an STD. The majority of the women had spontaneously mentioned gonorrhea, syphilis, and AIDS (95%, 75% and 94.2%, respectively). Reference to syphilis increased with education level (65.3% for none, 71.4% for upper primary, 85.8% for upper secondary; p .001). Few women mentioned herpes, chancroid, chlamydia, warts, and trichomoniasis (2% each) and candidiasis (11.7%). 65.4% of the women were able to correctly name at least 2 signs of AIDS. Knowledge of at least 2 signs of AIDS increased steadily with educational level (50.5% for none, 59.6% for lower primary, 71% for lower secondary; p .001) as it did for infection and diarrhea. The most well-known sign was weight loss regardless of education level (87.7%). Essentially everyone knew that AIDS was transmitted sexually (96.9%). Education level was positively associated with knowledge of its transmission perinatally and through a blood transfusion (p .001). Single women were less likely to be familiar with AIDS signs, perinatal transmission of AIDS, and transmission of AIDS by blood transfusions. The more lifetime sexual partners women had the more likely they were to know about gonorrhea and syphilis. These findings demonstrated the important role education plays in AIDS knowledge and the need to design accessible and easily understood AIDS prevention activities for women with limited education.

Awareness of sexually transmitted disease among women and service providers in rural Bangladesh.

Sexually transmitted disease (STD) in rural Bangladesh is currently a topic of great concern. To date, little information is available in the literature regarding its prevalence. It is now known, however, that the current level of STD awareness among the rural population with regard to modes of transmission and means of prevention is inadequate. In 1994, the MCH-FP Extension Project (Rural) of ICDDR, B surveyed 8674 married women of reproductive age (MWRA) in 4 rural thanas to examine their awareness of STDs. The association between socio-demographic and programmatic factors (variables which affect STD information availability) and awareness of STDs was examined by both bivariate and multivariate analyses. Seven focus group discussions were conducted among groups of government health and family planning workers and paramedics to assess their knowledge of STDs and attitudes about their prevention. Only 12% of the original group had even a basic understanding about STDs and how to protect themselves from them. Twenty-five per cent of the women surveyed had ever heard of either syphilis or gonorrhoea. Of these women, less than half could mention specific mechanisms involved in the transmission of these diseases. Seven per cent reported that syphilis and gonorrhoea are transmitted through sexual intercourse. Thirteen per cent reported that the infections are transmitted from spouses to their partners. Four per cent reported that STDs can be spread by having multiple sexual partners. The results of logistic regression analysis indicate that awareness of STDs was higher among relatively older women than among younger women. Awareness of STDs was most strongly and positively associated with the education of both the women and their husbands. Awareness of STDs was also found to be higher among women who were more socially mobile (e.g. those who frequent cinemas or mothers' clubs). The findings of focus group discussions indicate that family planning and health care service providers have a moderate level of STD awareness. Modes of transmission and means of prevention, however, were areas of weakness. It will, therefore, be necessary, whether to prevent a potential STD epidemic or to combat current STD prevalence, to implement culturally acceptable and affordable means of disseminating knowledge in rural areas of Bangladesh. Training of health care providers will be an essential first step.

PIP: Both a 1994 survey of 8674 married women of reproductive age from four rural thanas (Abhoynagar, Bagherpara, Keshobpur, and Sirajganj) of Bangladesh and focus group discussions conducted among government health and family planning providers in the same thanas revealed inadequate awareness of sexually transmitted diseases (STDs) and their transmission. Only 12% of survey respondents were considered to have a basic understanding of STDs and how to protect themselves from infection. Even after probing, only 25% of married women had ever heard of syphilis or gonorrhea; of these, just half knew the mechanisms of disease transmission. In the logistic regression analysis, awareness of STDs and their transmission was significantly associated with older age, higher educational level, Muslim religion, attendance at a family health and welfare center, current contraceptive use, and women's mobility outside the home. Although service providers had moderate levels of STD knowledge, there were many misconceptions (e.g., that STDs could be transmitted by wearing the clothes of an infected person). Providers agreed couples should be counseled to use condoms and avoid brothels. Awareness of AIDS was even lower than knowledge of syphilis and gonorrhea among both married women and health care workers. Training of health care providers is recommended as a first step in a national campaign aimed at disseminating accurate, culturally acceptable knowledge about STDs throughout rural Bangladesh.

Migrant labor and sexually transmitted disease: AIDS in Africa.

Acquired immune deficiency syndrome (AIDS) is worldwide, but the clinical and epidemiological pattern of the disease in Africa is different from that in developed areas. "Type 1 AIDS" occurs in industrialized North America and Europe; it has a distinctive sex ratio (16:1) and risk pattern of IV drug use and sexual practices. "Type 2 AIDS" occurs in Third World countries, particularly in eastern, southern, and central Africa. It is characterized by an entirely different sex ratio (1:1) and by distinctively different risk patterns. Both epidemics are caused by the HIV-1 virus. The key concept for understanding the origins of the differences between Type 1 and Type 2 AIDS is the migratory labor system in eastern, central, and southern Africa. This system causes long absences, increased family breakdown, and increased numbers of sexual partners. Historically the organization of this labor market has created a population which suffers from epidemics of sexually transmitted diseases. These historical patterns are presented as evidence for the contemporary transmission of AIDS. When contemporary AIDS and HIV-1 seropositivity prevalence data are examined, a systematic temporal and geographic pattern emerges for the AIDS epidemic in Africa. Despite a paucity of good data, the prevalence data from eastern, central, and southern Africa support the thesis of migrant labor's role in the transmission of AIDS.

PIP: Acquired immune deficiency syndrome (AIDS) is worldwide, but the clinical and epidemiological pattern of the disease in Africa is different from that in developed areas. "Type 1 AIDS" occurs in industrialized North America and Europe; it has a distinctive sex ratio (16:1) and risk pattern of intravenous (IV) drug use and sexual practices. "Type 2 Aids" occurs in 3rd World countries, particularly in eastern, southern, and central Africa. It is characterized by an entirely different sex ratio (1:1) and by distinctively different risk patterns. Both epidemics are caused by the HIV-1 virus. The key concept for understanding the origins of the differences between Type 1 and Type 2 AIDS in the migratory labor system in eastern, central, and southern Africa. This system causes long absences, increased family breakdown, and increased numbers of sexual partners. Historically the organization of this labor market has created a population that suffers from epidemics of sexually transmitted diseases. These historical patterns are presented as evidence for the contemporary transmission of AIDS. When contemporary AIDS and HIV-1 seropositivity prevalence data are examined, a systematic temporal and geographic pattern emerges for the AIDS epidemic in Africa. Despite a paucity of good data, the prevalence data from eastern, central, and southern Africa support the thesis of migrant labor's role in the transmission of AIDS. The Western press and (to some extent) the Western scientific establishment have attempted to locate the origins of the HIV-1 virus, the biologically causative agent for AIDS, in Africa. This attempt is based on "victim-blaming" mentality and is fundamentally racist. The "African origins" theory is based on many weak arguments; almost all have been disproved, including the genetic relationship of the HIV-1 virus to the simian variety of retrovirus in the green monkey of equatorial Africa.

The use of mail reminders in STD contact tracing in Ibadan, Nigeria.

Contact tracing has become the most important tool in the control of sexually transmitted diseases (STDs) world-wide, and different strategies have been introduced into it in recent years to improve its effectiveness. Of all these strategy components, index patient counselling and co-operation to do their own contact tracing by themselves has been identified as the most important one. In Ibadan, it is the only component of the contact tracing strategies that has proven worthwhile. This study has assessed the contribution of supplementary mail reminders to defaulting index patients and their defaulting contacts to our control efforts in the first two years of its usage. It demonstrates that, like the other components of the contact tracing strategies, it is not successful in improving the contact or defaulting index patient attendance, thus only contributing to success in 7 of 141 patients. The intensification of efforts towards encouraging the index patient in contact tracing must therefore be ever more strongly emphasised as the top priority in STD control in Nigeria and similar developing countries for the success of this strategy.

PIP: Contact tracing has become the most important tool in the control of sexually transmitted diseases (STDs) world-wide and different strategies have been introduced in recent year to improve its effectiveness. Of all these strategy components, index patient counselling and co- operation to do their own contact tracing by themselves has been identified as the most important one. In Ibadan, it is the only component of the contact tracing strategies that has proven worthwhile. This study has assessed the contribution of supplementary mail reminders to defaulting index patients and their defaulting contacts to our control efforts in the first 2 years of its usage. It demonstrates that, like other components of the contact tracing strategies, it in not successful in improving the contact or defaulting index patient attendance, thus only contributing to success in 7 of 141 patients. Of the 141 letters sent to defaulting index patients, 38% and 19% of them were returned as untraceable addresses by the postal services in 1985 and 1986. The remaining 103 letters were assumed to have reached their correct destination. Only 7 of these 103 index patients attended the clinic on account of mail reminders, while non of the 39 contacts to whom slips were sent came for follow-up. 11 of the non-responding 96 index patients were later traced physically. 7 of these 11 were found, 6 of whom would not return to the clinic because they felt cured. Efforts must be intensified towards involving index patients in contact tracing as a top priority in STD control in Nigeria. (Author's modified).

Helping patients to reduce their risk of acquiring sexually transmitted disease.

This monthly series was developed from the AOA Task Force on AIDS Writers' Workshop, held August 16 to 18, 1991, in New York. The workshop was sponsored by an education grant from Burroughs Wellcome. It will provide brief clinical updates and perspectives on the human immunodeficiency virus (HIV). Readers may request tear sheets from the AOA editorial offices.

PIP: Counseling patients about sexually transmitted disease (STD) prevention is imperative to primary care. Physicians have a tendency not to discuss STDs, however. The AIDS epidemic makes STD counseling very essential. In the US, heterosexual adolescents and heterosexual women suffer from the highest increase in HIV infections rates. AIDS 1st struck the homosexual community which has reduced the incidence of all STDs including HIV infection by counseling and condom use. Thus physicians should speak to their patients frankly about STD prevention including the details of how to use a condom properly regardless of their STD and HIV status. They should also promote sex education of younger people before they become sexually active. The only way to not acquire STDs is to practice sexual abstinence. Another safe way to prevent STDs is a monogamous relationship between uninfected partners. If a partner was sexually active in the past, he/she should undergo serologic testing to determine STD and HIV status. Each sexually active individual not in a monogamous relationship must practice risk reduction behavior to prevent transmission of STDs and HIV. The best condom to use is a latex condom with a tip and lubricated with the spermicide nonoxynol-9. Users must put on the condom on an erect penis before it comes in contact with any mucus regardless of the mucous origin. The man should withdraw the condom protected penis while still erect. Physicians should stress to younger or sexually less experienced people the difference between contraception and prophylaxis. They should also inform all patients that anal intercourse is the riskiest sexual activity. Vaginal intercourse, fellatio, and cunnilingus also pose sizable risk of STD and HIV transmission. Physicians must remind patients to be extra careful during oral or anal intercourse and that condoms can leak. They must remember that low risk groups do not exist, but low risk behaviors do.

[Contraceptives, HIV, and other sexually transmitted diseases]. / Anticonceptivos, VIH y otras enfermedades de transmisión sexual.

The large majority of women who acquire Human Immuno-Deficiency Virus (HIV) and other sexually transmitted diseases (STDs) are in their childbearing years and are current or potential users of contraceptive methods. Certain STDs augment women's risk for HIV due to damage which these diseases produce in the integrity of the epithelial lining of the vagina and the vulva. There also exists evidence that some contraceptive methods, such as the intrauterine device and certain hormonal products, may increase the risk of HIV and other STDs. Condoms and spermicides offer good levels of protection against these diseases, but are not highly effective contraceptives. The interrelations among these risks are important and create a great problem for women's reproductive health. Moreover, the high vulnerability of the female population for these diseases is also related to a variety of social factors which are referred to as gender relations (power of females in society relative to that of females). Among the gender-related inequalities which affect women are their lack of power to successfully control many aspects of sexual relations. Another problem has to do with the fact that there are no highly reliable female controlled methods for preventing infection by HIV and other STDs. Improvement in the reproductive health care of women depends on the development of new disease prevention products and structural changes in the delivery of care, as well as continued research efforts on the interrelations among contraceptive methods, HIV and other STD.

PIP: Until recently, some behaviors were viewed as entailing a high risk of HIV infection, but HIV is now considered a great risk for the female population in general. The number of HIV infected women is increasing rapidly even in areas such as Mexico and South America where women form a minority of AIDS patients. Most women infected with HIV and other sexually transmitted diseases (STDs) are sexually active and at risk of pregnancy. Some STDs, notably those producing genital ulcers, increase the risk of HIV infection. It is not yet known whether STDs not producing ulcers also increase the risk. There is controversy over the extent to which specific contraceptive methods increase or perhaps reduce the risk of HIV infection. Some unconfirmed assumptions are that the cervical ectopy produced by oral contraceptives (OCs) results in affected zones more vulnerable to trauma and thus perhaps to HIV infection, and that combined OCs by reducing menstrual bleeding also reduce risk of infection. OCs containing only progestins may increase the risk of transmission by inducing irregular bleeding, thickening the cervical mucus, and thinning the vaginal epithelium. Injectables may increase risk by increasing bleeding, thinning the vaginal epithelium, or through use of contaminated needles in application. IUDs may increase menstrual bleeding and are not advisable in any event for women at high risk of other STDS. Condoms and spermicides offer some protection against STDs, but are not highly effective contraceptives. The interrelations between risk of pregnancy and of disease are a great and largely unresolved problem in women's reproductive health. Few family planning services are able to address prevention of STDs and especially AIDS adequately. Methodological and logistical problems impede study of the interrelations between contraception and STDs, and resources are limited. Studies of commercial sex workers in different countries have offered a partial solution. Women's lack of power to negotiate successfully concerning sexual relations and their lack of access to a means of preventing STDs under their own control are factors in their vulnerability. Improved reproductive health of women will require development of new products to control disease, structural changes in health services, and continued research.

What blame can teach us about sexual health promotion.

PIP: While references to sexually transmitted infections (STIs) can be found back as far as biblical times, women have traditionally taken most of the blame for the spread of such diseases. There is no evidence to suggest that men were blamed or stigmatized in the same way as women until the panic over AIDS in the 1980s shifted some of the blame to groups such as gay and bisexual men, IV drug users, and Africans. Throughout history, heterosexual men have escaped blame for STIs. Maybe it is this latter population subgroup which should be targeted in future sexual health promotion programs. This paper reviews the history of blame for STIs dating from the book of Leviticus, in which men with urethral discharge are urged to wash after copulation, to female prostitutes during the past 400 years, and recent groups with the advent of HIV/AIDS.^ieng

Health education needed to improve public STD awareness in Somalia.

PIP: To study public sexually transmitted disease (STD) awareness among sexually active individuals in Mogadishu, Somalia the authors interviewed 183 patients who presented at an STD clinic and 29 controls. Only 2 of 3 patients with proven STD knew that diseases can be transmitted through sexual intercourse, and only 1 of 3 non-STD controls had this knowledge. Schools were listed as the source for their STD information by only 15%, and health providers by only 5% of the STD-aware individuals. Moreover, STD awareness did not seem to impact on people's life style, since more STD-aware persons were sexually promiscuous than their unaware counterparts. The authors conclude that STD awareness is very low among the general public in Somalia. Urgent health education campaigns are necessary to slow the spread of STDs. The epidemic of HIV, the latest addendum on the list on modern STDs, could then perhaps be halted, since educating the public on how to avoid exposure to the AIDS virus presently remains the only successful strategy against this killer disease.^ieng

STDs and the pill.

PIP: During World War II, venereal disease was regarded as a problem for men in uniform. At that time there were only three common sexually transmitted diseases (STDs): syphilis, gonorrhea, and venereal warts, along with crab lice. Today, there are two dozens STDs, and almost all of them are caused by viruses. They include AIDS, herpes, human papilloma virus, and also chlamydia. In explaining the emergence of the new sexual diseases, STOPP Planned Parenthood has suggested in its November 1987 newsletter that " ...because the contraceptive pill lowers the acid level of the vaginal area it may be a contributing factor to the development and transmission of AIDS." The December 1993 issue of Family Planning Perspectives has reported that "women who test positive for HIV virus and who also use the pill are more likely than non-users to have the virus present in their cervical and vaginal secretions and may be more likely to infect their sex partner... The presence of HIV virus in cervical secretions was nearly 12 times as likely among pill users as among non-users." The newsletter further states that infected women who were taking the pill were also more likely to transmit AIDS to a baby they delivered. Researchers should thoroughly investigate if the contraceptive pill has contributed to the emergence of STDs.^ieng

The other epidemic.

PIP: Sexually transmitted diseases cause more problems for women, than AIDS causes for men, children, and women combined. Yet, the cure for this problem is simple contraceptive prevention. In developing countries women can be abandoned, abused, and even murdered for being infertile, yet 70% if female infertility is caused by the STDs they contracted from their husbands. Men are the agents that transmit STDs, not wives, not prostitutes. Men seeking commercial sex can infect a prostitute who then goes on to infect many other men who then infect their wives. In overview, STD rates are that same for men and women. STDs cause 750,000 deaths annually and 75 million illnesses among women yearly. By 2000, estimates are double.^ieng

Heterosexual relationships and condom-use in the spread of sexually transmitted diseases to women.

OBJECTIVES: To examine the effect of patient-defined non-regular heterosexual relationships on the incidence of sexually transmitted diseases and other genital infections in women and the role of condom use in the prevention of their spread. DESIGN: A cross-sectional study of sexual behaviour reported by a standardised self-administered questionnaire in new patients who presented for screening and diagnosis. SETTING: A genitourinary medicine clinic in West London. SUBJECTS: 938 consecutive newly attending women who completed a sexual behaviour questionnaire in 1992. MAIN OUTCOME MEASURES: Variables relating to socio-demographic status, sexual behaviour, condom use, sexually transmitted diseases and other genital infections stratified by the reporting of non-regular partners. RESULTS: We found that women who reported non-regular sexual partners were more likely to be single (p = 0.0001), white (p < 0.0001), have had coitarche before 17 years of age (p = 0.003) and many more sexual partners both in the last year and in their life-time (p < 0.0001) and were more likely to practise fellatio (p < 0.0001), anal penetration (p = 0.004) and to be smokers (p < 0.0001). Paradoxically, the incidence of sexually transmitted diseases and other genital infections was no higher in this group than in the group of women who did not have non-regular partners. Increasing condom use with regular partners correlated with decreasing incidence of gonorrhoea (p < 0.001), chlamydial infection (p < 0.01) and trichomoniasis (p < 0.02), but increasing condom use with non-regular partners did not show this trend. CONCLUSIONS: Regular heterosexual partners play the major role in transmission of bacterial sexually transmitted diseases to women. This is significantly influenced by use of condoms.

PIP: The authors investigated the effect of patient-defined non-regular heterosexual relationships upon the incidence of sexually transmitted diseases (STD) and other genital infections in women and the role of condom use in preventing their spread. Findings are based upon responses to a 1992 sexual behavior questionnaire among 938 consecutive newly attending women presenting at a genitourinary medicine clinic in West London for screening and diagnosis. It was found that women who reported non-regular sex partners were more likely to be single, White, have had coitarche before age 17 years and many more sex partners both during the last year and in their lifetime, and were more likely to practice fellatio, anal sex, and smoke cigarettes. The incidence of STDs and other genital infections was no higher in this group than among women who did not have non-regular partners. Increasing condom use with regular partners correlated with decreasing incidence of gonorrhea, chlamydial infection, and trichomoniasis, but increasing condom use with non-regular partners did not show a similar trend. The authors conclude that regular heterosexual partners play the major role in transmitting bacterial STDs to women.

Trichomoniasis and candidiasis in consorts of females with vaginal discharge.

PIP: The prevalence of trichomoniasis and candidiasis in partners of 59 women with candidiasis and 33 with trichomoniasis was determined in relation to condom use and personal hygiene. Overall 60.1% of male partners of women with candidiasis, and 47.5% of partners of women with trichomonas harbored the respective infections. 85.6% of partners who had coitus 4 or more times weekly, compared to 24% of those who did so less frequently, were infected. 6 of 39 who used condoms (14.6%), compared to 45 of the 53 who did not (85.4%) were infected. 20.8% of the men who washed and voided after intercourse, as opposed to 79.2% who did not, were infected.^ieng

Sexual bridging by Cambodian men: potential importance for general population spread of STD and HIV epidemics.

BACKGROUND: Linkages between sexual networks influence STD and HIV epidemics. GOAL: This study quantifies male sexual "bridging" and associated factors in Cambodia's 1997 behavioral surveillance survey. STUDY DESIGN: Among persons randomly selected from clusters of military, police, and motorcycle taxidrivers in five cities, associations between individual characteristics, behaviors, social context, and "active bridging" were tested using logistic regression analyses. RESULTS: The authors defined 20.5%, 15.7%, and 14.7% of military, police, and motorcycle taxidrivers as active bridgers (men who have unprotected sex with high and low risk partners). Among the military and police, logistic regression revealed that age (odds ratio [OR], 1.05), age of first sexual intercourse (OR, 0.89), having friends who frequent sex workers (OR, 3.31), and residence in the port city (OR, 3.34) were associated with active bridging. Among motorcycle taxidrivers, residence in the border city (OR, 2.23) or the port city (OR, 2.84) was associated with active bridging. Sexually transmitted disease symptoms during the past year were significantly associated with active bridging. CONCLUSIONS: Social characteristics influence sexual bridging more than individual ones. The pervasiveness of bridging and the association with sexually transmitted disease symptoms underscore the potential of men who are active bridgers to spread sexually transmitted disease and HIV in Cambodia beyond high-risk groups.

Douching and sexually transmitted diseases in pregnant women in Surabaya, Indonesia.

OBJECTIVE: Our purpose was to investigate the association between douching (douching agents and timing) and sexually transmitted disease. STUDY DESIGN: A cross-sectional survey of sexually transmitted diseases and habits of vaginal douching was performed on 599 pregnant women who visited a prenatal clinic in Surabaya, Indonesia. RESULTS: Of the 599 pregnant women, 115 (19.2%) had at least one sexually transmitted disease (gonorrhea, chlamydia, syphilis, trichomoniasis, or herpes simplex virus-2). Most women had douched with water (19%) or water and soap (63%) at least once in the preceding month. Approximately 10% of the women had douched in the preceding month with a commercial agent (2%) or betel leaf (8%). Douching with water alone after sex was not associated with sexually transmitted disease. Douching with water and soap or with a betel leaf or commercial agent after sex was associated with sexually transmitted disease; adjusted odds ratios were 2.6 (95% confidence interval 1.0 to 7.1) and 2.7 (95% confidence interval 0.5 to 14.5), respectively. The association was enhanced if the women douched before sex or both before and after sex; adjusted odds ratio were 2.7 (95% confidence interval 1.0 to 7.3) for douching with water and soap and 5.2 (95% confidence interval 1.6 to 16.7) for douching with betel leaf or a commercial agent. Compared with women who never douched, women who always douched with betel leaf or a commercial agent had a substantially increased risk for sexually transmitted disease (adjusted odds ratio 9.4, 95% confidence interval 1.8 to 50.3). CONCLUSIONS: We found a significant association between sexually transmitted disease and douching habits (douching with betel leaf, commercial agents, or water and soap). However, further prospective investigations are needed to evaluate the temporal relationship between douching and sexually transmitted disease.

Prostitutes are a major reservoir of sexually transmitted diseases in Nairobi, Kenya.

Prostitutes are a major reservoir of sexually transmitted diseases in many developing nations. In Nairobi we found that 16%, 28%, and 46%, respectively, of upper-, middle-, and lower-social strata prostitutes were infected with Neisseria gonorrhoeae. Genital ulcers and infections with Haemophilus ducreyi were more prevalent among prostitutes of the middle and lower social strata. A group of 97 prostitutes of the lower social strata were followed longitudinally to determine the rate of reinfection with N. gonorrhoeae. The mean time to acquisition of a new infection was 12.0 +/- 9.2 days. These results show that in Nairobi prostitutes are a readily identifiable group of high-frequency transmitters of gonococcal infection. Strategies based on intervention in the prostitute reservoir could prove to be an effective means of control of gonococcal infections in developing nations.

The situation in Africa.

More than three million women world-wide are infected with HIV, and women will constitute 40% of the new AIDS cases in 1990-1991. Unlike in the industrialized world, HIV in Africa is heterosexually transmitted and thus affects at least as many women as men. Already the leading cause of death in a major African city, HIV may be spreading to rural areas. In spite of improvement in surveillance, under-reporting makes it difficult to project trends, document differences within and between urban and rural areas, and identify at-risk groups. Increasing evidence shows that STDs play a major role in spreading the HIV epidemic. Male-to-female transmission is more efficient owing to factors related to the pathogen and the host. Ulcerative STDs such as chancroid, syphilis and herpes facilitate HIV entry through mucosal discontinuation and recruitment of HIV target cells. The role of non-ulcerative STDs such as gonorrhoeal, chlamydial and trichomonal infections needs further elucidation. Lack of circumcision, traditional healing practices and oral contraceptives may affect the risk of viral transmission, but may not be major or modifiable risk factors. Pregnancy and pregnancy-associated immune alterations do not seem to affect the clinical course of HIV/AIDS in African women or impair immunocompetence. Maternal HIV can adversely affect pregnancy outcome in Africa, causing low birth-weight, prematurity, intrauterine and intrapartum fetal death. The risk for these outcomes is likely to depend on the degree of immunological and clinical deterioration. Breast-feeding does not appreciably increase the risk of HIV transmission to the infant and should be actively promoted in Africa. Control of HIV/AIDS in Africa, in the absence of an effective vaccine, will focus on behavioural changes through health education and condom use. High frequency STD transmitter core groups, mainly prostitutes and their clients, are currently the target of prevention campaigns which are proving to be successful and affordable.

PIP: More than 3 million women are infected with HIV worldwide. Further, 40% of new cases in 1990-91, will be among women. HIV and AIDS are overwhelmingly heterosexually related in Africa and affect similar proportions of both sexes. AIDS may, in fact, be the leading cause of death in some cities, and is thought to be spreading to rural areas through a highly mobile work force, multiple partners, and high rates of sexually transmitted disease (STD). Other biological and behavioral factors also contribute to the existence of the pattern of HIV transmission predominantly seen in Africa. Women and children are at particular risk of infection in African countries. STDs such as chancroid, syphilis, herpes, and gonorrhea; traditional healing practices and sexual behavior; lack of circumcision; and the use of oral contraceptives may all support HIV infection to varying degrees. Of STDs, chancroid, syphilis, and herpes are known to facilitate HIV entry by effecting mucosal discontinuation and recruiting HIV target cells. Pregnancy and pregnancy-associated immunal changes most likely do not affect the clinical course of HIV/AIDS in African women or harm their immune status. Maternal HIV may, however, cause newborns to be of low birth weight or premature, or increase the probability of intrauterine or intrapartum fetal death. Breast feeding does not significantly increase the risk of vertical HIV transmission and should continue to be promoted.

Urbanisation and the epidemic of sexually transmitted diseases in South Africa.

PIP: This article describes the nature and extent of sexually transmitted diseases (STDs) in South Africa, the spread of STDs, and recommended STD prevention and control approaches. Gonorrhea, chlamydia, syphilis, and chancroid are in the top 25 causes of healthy days of life lost in sub-Saharan Africa. In South Africa, an estimated 40% of women attending family planning clinics were diagnosed with an STD. 15% of women attending prenatal clinics in urban areas had latent syphilis. The World Bank estimates that over 3 million in South Africa, are infected with at least 1 STD/year. 1 in 10 sexually active persons in South Africa, may be infected with an STD every year. STDs cause morbidity, infertility, abortions, ectopic pregnancies, stillbirths, prematurity, and cervical cancer. The presence of a genital ulcer increases the risk of AIDS up to tenfold. The presence of a urethral or vaginal discharge increases the AIDS risk fivefold. An estimated 1200 HIV infections could be prevented over the next 10 years by curing or preventing 100 cases of syphilis. In 1995, 1 in 10 women who attended prenatal clinics was infected with HIV. The incidence of STDs among women are underestimates due to the greater chance that women are without STD symptoms or may be embarrassed to report symptoms. High rates of urbanization are linked to 9 factors that contribute to the spread of AIDS. STD prevention programs should create awareness, provide accessible and user-friendly services integrated within primary health care, provide simple and effective STD management, and detect/manage STD carriers.^ieng