Classical Sexually Transmitted Diseases Drive the Spread of HIV-1: Back to the Future
TLDR
The results offered a stark reality for HIV-1 prevention and demonstrate yet again that STDs represent a “hidden epidemic,” the title of a compelling Institute of Medicine report published more than a decade ago.Abstract:
The transmission of human immunodeficiency virus type 1 (HIV-1) depends on the infectiousness of the index case (ie, vector) and the susceptibility of the host [1]. The probability of the transmission event has been extensively studied [1–3], and the risk is often described as about 1 in 1000 coital events [4]. However, large numbers of exposures like these are often derived from studies of stable, heterosexual, discordant couples [4, 5]. By definition, the HIV-1–negative partners in these couples can be defined as “exposed and uninfected” at the time of enrollment. The transmission of HIV-1 is almost certainly often more efficient than reflected in studies of couples and is likely enhanced by amplifying factors [6]. Perhaps no other HIV transmission cofactor has attracted as much attention as sexually transmitted diseases (STDs). More than 20 years ago, Wasserheit and colleagues described the transparent and omnipresent relationship between classical STDs and HIV-1, coining this unfortunate marriage of pathogens “epidemiologic synergy” [7].We subsequently showed that infection with Neisseria gonorrhoeae greatly increased shedding of HIV-1from the male genital tract in seminal plasma, offering a biological view of such synergy [8]. In recent years, however, interest in the relationship between STDs and HIV-1 has waned, primarily because it has proven nearly impossible to reduce the spread of HIV-1 through directed or empirical treatment of STDs [9]. In this issue of The Journal of Infectious Diseases, Mlisana et al [10] contribute to this consideration. Because of the limited laboratory infrastructure in lowand middle-income countries, treatment of STDs in women often depends on the recognition of signs and symptoms of vaginal discharge, leading to empirical treatment with antibiotics [11, 12]. Syndromic management is important but often suboptimal since a substantial number of people using this method are overor undertreated [11, 12]. Mlisana and colleagues [10] have further expanded our concerns about syndromic management. Two-hundred forty-two women at risk for HIV-1 infection were enrolled in a prospective cohort. Four things were measured: the presence or absence of a vaginal discharge, detection of ≥1 STD pathogens, vaginal cytokine concentrations, and HIV-1 acquisition. The results offered a stark reality for HIV-1 prevention and demonstrate yet again that STDs represent a “hidden epidemic,” the title of a compelling Institute of Medicine report published more than a decade ago [13]. Only 12.3% of women infected with a pathogen that might cause a vaginal discharge had signs or symptoms of infection. Women with STDs were >3-fold more likely to acquire HIV-1 than those who harbored no pathogens. Women with gonococcal infections, among the most inflammatory of the classical STD agents [14], had had an eye-opening 7fold increased risk of HIV-1 acquisition, bringing us full circle to earlier reports [8]. Surprisingly, inflammatory cytokines were not significantly different in women with symptomatic STDs, compared with asymptomatic infections, although they were greater than in women with no STDs or with bacterial vaginosis. Passmore et al [15] have reported that some unique inflammatory cytokine profiles predict risk for HIV acquisition. How can we fit these observations into sensible HIV-1 prevention strategies? Padian et al [9] have provided an exhaustive summary of interventions designed to prevent HIV-1 transmission, emphasizing the general lack of prevention benefit with treatment of classical STDs. The failure of this approach, in my opinion, is not because STDs are not critically important. Rather, we are simply unable to treat the right infections with the right drugs at the right times, and so the results of the interventions prove disappointing. Sadly, except for hepatitis B virus vaccine and HPV vaccine, STD vaccines are not available. Received 10 February 2012; accepted 13 February 2012; electronically published 19 April 2012. Correspondence: Myron S. Cohen, MD, 130 Mason Farm Rd, CB 7030, University of North Carolina, Chapel Hill, NC 27599-7030 (mscohen@med.unc.edu). The Journal of Infectious Diseases 2012;206:1–2 © The Author 2012. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@ oup.com. DOI: 10.1093/infdis/jis303read more
Citations
More filters
Journal ArticleDOI
State of HIV in the US Deep South
Susan Reif,Susan Reif,Donna Safley,Carolyn McAllaster,Elena Wilson,Kathryn Whetten,Kathryn Whetten +6 more
TL;DR: This manuscript synthesizes recent data on HIV epidemiology, care financing, and current research literature on factors that predispose this region to experience a greater impact of HIV to inform efforts to effectively address HIV in the South.
Journal ArticleDOI
Diagnosing sexually transmitted infections in resource-constrained settings: challenges and ways forward.
Teodora Wi,Francis Ndowa,Cecilia Ferreyra,Cassandra Kelly-Cirino,Melanie M Taylor,Igor Toskin,James Kiarie,Nancy Santesso,Magnus Unemo +8 more
TL;DR: The diagnostic accuracy of syndromic case management and existing point-of-care tests, including those in the pipeline, to diagnose STIs in resource‐constrained settings are reviewed.
Journal ArticleDOI
High prevalence and incidence of sexually transmitted infections among women living in Kwazulu-Natal, South Africa.
TL;DR: These results confirm the extremely high prevalence and incidence of STIs among women living in rural and urban communities of KwaZulu-Natal, South Africa, where the HIV epidemic is also particularly severe and suggest an urgent need to allocate resources for STI and HIV prevention that mainly target younger women.
Journal ArticleDOI
A novel intravaginal ring to prevent HIV-1, HSV-2, HPV, and unintended pregnancy.
Shweta R. Ugaonkar,Asa Wesenberg,Jolanta Wilk,Samantha Seidor,Olga Mizenina,Larisa Kizima,Aixa Rodriguez,Shimin Zhang,Keith Levendosky,Jessica Kenney,Meropi Aravantinou,Nina Derby,Brooke Grasperge,Agegnehu Gettie,James Blanchard,Narender Kumar,Kevin Roberts,Melissa Robbiani,José A. Fernández-Romero,Thomas M. Zydowsky +19 more
TL;DR: Proof-of-concept of a novel core-matrix intravaginal ring (IVR) for sustained and simultaneous delivery of diverse molecules for the prevention of HIV, HSV-2 and HPV acquisition, as well as unintended pregnancy is demonstrated.
Journal ArticleDOI
Factors associated with amplified HIV transmission behavior among American men who have sex with men engaged in care: implications for clinical providers.
Kenneth H. Mayer,Kenneth H. Mayer,Margie R. Skeer,Margie R. Skeer,Conall O'Cleirigh,Conall O'Cleirigh,Brett M. Goshe,Steven A. Safren,Steven A. Safren +8 more
TL;DR: HIV primary care providers should routinely assess patients for potential HIV transmission behaviors, particularly those who are younger and more recently diagnosed with HIV, who drink alcohol heavily, and who use any nonprescription drugs, particularly stimulants, in order to decrease the spread of HIV.
References
More filters
Journal ArticleDOI
Prevention of HIV-1 Infection with Early Antiretroviral Therapy
Myron S. Cohen,Ying Q. Chen,Marybeth McCauley,Theresa Gamble,Mina C. Hosseinipour,Nagalingeswaran Kumarasamy,James Hakim,Johnstone Kumwenda,Beatriz Grinsztejn,José Henrique Pilotto,Sheela Godbole,Sanjay Mehendale,Suwat Chariyalertsak,Breno Santos,Kenneth H. Mayer,Irving F. Hoffman,Susan H. Eshleman,Estelle Piwowar-Manning,Lei Wang,Joseph Makhema,Lisa A. Mills,Guy de Bruyn,Ian Sanne,Joseph J. Eron,Joel E. Gallant,Diane V. Havlir,Susan Swindells,Heather J. Ribaudo,Vanessa Elharrar,David N. Burns,Taha E. Taha,Karin Nielsen-Saines,David D. Celentano,Myron Essex,Thomas R. Fleming +34 more
TL;DR: In this article, Antiretroviral therapy that reduces viral replication could limit the transmission of human immunodeficiency virus type 1 (HIV-1) in serodiscordant couples.
Journal ArticleDOI
Prevention of HIV-1 infection with early antiretroviral therapy
TL;DR: The exciting evidence generated by this paper – that antiretroviral treatment of HIV-1 infection definitively reduces the risk of onward transmission of the virus by 96% – was rightly dubbed Science magazine's ‘Breakthrough of the Year’ in 2011.
Journal ArticleDOI
Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases.
TL;DR: Preliminary data from 83 reports on the impact of HIV infection on STDs suggest that, at a community level, HIV infection may increase the prevalence of some STDs (e.g., genital ulcerative and nonulcerative STDs), and if the same STDs facilitate transmission of HIV, these infections may greatly amplify one another.
Journal ArticleDOI
Sexual transmission of HIV
TL;DR: The epidemiology and biology of the host-related factors that affect the sexual transmission of HIV and the host susceptibility and infectiousness environment biologic agent are discussed.
Related Papers (5)
Symptomatic Vaginal Discharge Is a Poor Predictor of Sexually Transmitted Infections and Genital Tract Inflammation in High-Risk Women in South Africa
Koleka Mlisana,Koleka Mlisana,Koleka Mlisana,Nivashnee Naicker,Lise. Werner,Lindi Roberts,Francois van Loggerenberg,Cheryl Baxter,Jo-Ann S. Passmore,Jo-Ann S. Passmore,Jo-Ann S. Passmore,Anna Christina. Grobler,A. Willem Sturm,Carolyn Williamson,Carolyn Williamson,Carolyn Williamson,Katharina Ronacher,Gerjard. Walzl,Salim S. Abdool Karim,Salim S. Abdool Karim +19 more
From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection.
Prevention of HIV-1 Infection with Early Antiretroviral Therapy
Myron S. Cohen,Ying Q. Chen,Marybeth McCauley,Theresa Gamble,Mina C. Hosseinipour,Nagalingeswaran Kumarasamy,James Hakim,Johnstone Kumwenda,Beatriz Grinsztejn,José Henrique Pilotto,Sheela Godbole,Sanjay Mehendale,Suwat Chariyalertsak,Breno Santos,Kenneth H. Mayer,Irving F. Hoffman,Susan H. Eshleman,Estelle Piwowar-Manning,Lei Wang,Joseph Makhema,Lisa A. Mills,Guy de Bruyn,Ian Sanne,Joseph J. Eron,Joel E. Gallant,Diane V. Havlir,Susan Swindells,Heather J. Ribaudo,Vanessa Elharrar,David N. Burns,Taha E. Taha,Karin Nielsen-Saines,David D. Celentano,Myron Essex,Thomas R. Fleming +34 more