Sexually transmitted infections: challenges ahead

TLDR: Overall, this Commission aims to enhance the understanding of some of the key challenges facing the field of STI treatment and control, and outlines new approaches to improve the clinical management of STIs and public health.

Abstract: WHO estimated that nearly 1 million people become infected every day with any of four curable sexually transmitted infections (STIs): chlamydia, gonorrhoea, syphilis, and trichomoniasis. Despite their high global incidence, STIs remain a neglected area of research. In this Commission, we have prioritised five areas that represent particular challenges in STI treatment and control. Chlamydia remains the most commonly diagnosed bacterial STI in high-income countries despite widespread testing recommendations, sensitive and specific non-invasive testing techniques, and cheap effective therapy. We discuss the challenges for chlamydia control and evidence to support a shift from the current focus on infection-based screening to improved management of diagnosed cases and of chlamydial morbidity, such as pelvic inflammatory disease. The emergence and spread of antimicrobial resistance in Neisseria gonorrhoeae is globally recognised. We review current and potential future control and treatment strategies, with a focus on novel antimicrobials. Bacterial vaginosis is the most common vaginal disorder in women, but current treatments are associated with frequent recurrence. Recurrence after treatment might relate to evidence that suggests sexual transmission is integral to the pathogenesis of bacterial vaginosis, which has substantial implications for the development of effective management approaches. STIs disproportionately affect low-income and middle-income countries. We review strategies for case management, focusing on point-of-care tests that hold considerable potential for improving STI control. Lastly, STIs in men who have sex with men have increased since the late 1990s. We discuss the contribution of new biomedical HIV prevention strategies and risk compensation. Overall, this Commission aims to enhance the understanding of some of the key challenges facing the field of STIs, and outlines new approaches to improve the clinical management of STIs and public health.

Figures

Figure 12: Percentage of tests positive for HIV, primary and secondary syphilis and 1995 gonorrhoea, 2005-2014, and mean number of sexual partners in last three months, 2008-1996 2013, San Francisco, USA. Source: San Francisco Department of Health. 1997

Table 3: Point-of-care tests for sexually transmitted infections currently on the market with available sensitivities and specificities

Table 1: Novel antimicrobials in different stages of clinical trial evaluation for treatment of gonorrhoea

Table 2: Actions to control the emergence, spread and impact of antimicrobial resistance (AMR) in Neisseria gonorrhoeae (public and private sectors)

Frequently asked questions

Q1. What are the elements of this panel?

The elements of this panel assume that other elements of an effective STI control program are already in place including; sound sex education programme throughout school, strong partner notification programmes that use the latest information technology systems and legislative changes for partner delivered antibiotic treatment where appropriate, legalised frameworks for sex work, active targeted health promotion, accurate surveillance programmes. 

Q2. What is the definition of the main diagnosis?

The main diagnosis is defined as the conditiondiagnosed at the end of the hospitalisation period, primarily responsible for the patient’s need for treatment or examination at the hospital. 

Q3. What is the responsibility of the Federal Public Service of Health?

Coverage: - The Federal Public Service of Health, DG 1 "Organisation of health institutions" is responsible for the registration of the Minimal Hospital Data. 

Q4. What is the definition of main diagnosis?

- Data include: - Inpatient discharges - Day-cases discharges - All patients (including uninsured, foreigners) - Long duration stays in hospitals - Palliative care in hospitals - Healthy newborn babies (since 2003) Definition of main diagnosis: the main diagnosis is defined as that which was responsible for the patient’s admission at the hospital, which best reflects the main reason for admission, or that which is the main reason for treatment. 

Q5. What are the main symptoms of syphilis?

inflammatory disease, ectopic pregnancy and infertility Develop non-invasive tools to detect upper genital tract infection and diseaseDevelop and implement effective partner treatment Robust trials of innovative partner treatment strategies with biologicaloutcomes (e.g. reinfection rates)New antimicrobials and/or other treatments for gonorrhoeaFund research into new antimicrobials and treatments for gonorrhoeaReduce gonorrhoea prevalence Identify key drivers of gonorrhoeaprevalence and effective interventions to reduce itvaginosis (BV) with low relapse ratesExplore new agents that target the biofilm; re-evaluate the role of treatment of male sex partnersEvaluate partner treatment for BV New partner treatment trials and identifythe transmissible agent(s) responsible for BVEnsure 100% of pregnant women are screened and treated for syphilis at the first prenatal visitIncrease implementation research to strengthen health systems to effectively identify and manage syphilis using simple and rapid POC testsPoint-of-care (POC) tests for STIsIdentify the key health systems required for effective use of POC tests, Develop new POC tests for STIs, Evaluate the use of POC tests for STIsPre-exposure prophylaxis (PrEP) and STI testingIdentify the effect that frequent STI screening has on STI incidenceVaccines for STIs150Undertake the laboratory and subsequent clinical research necessary for successful vaccines150Footnote. 

Q6. How many provinces and territories reported their data in 2001/02?

In 2001/02, five provinces and one territory provided their data for the first time, according to ICD-10-CA; in 2002/03 twomore provinces and two more territories reported according to ICD-10-CA. 

Q7. What is the definition of the hospital discharge?

- Data are for acute care hospitals only, except for the data on mental and behavioural disorders which include psychiatric hospitals starting in 2013/14. 

Q8. What is the main classification of discharges?

1) Discharges according to ICD-10 main chapters by sex and age groups include deceased patients but not bed-days; 2) Hospital discharges by selected ICD-10 subgroups/single diagnoses and corresponding bed-days. 

Q9. What is the definition of a hospital discharge?

Database contains all inpatient hospitalisations, including iterative care, and ambulatory cases except haemodialysis, chemotherapy, radiotherapy and other iterative treatments. 

Q10. what is the definition of a hospital discharge?

http://www.cdc.gov/nchs/about/maj or/hdasd/nhds.htm.civilian non-institutionalised population. - The National Hospital Discharge Survey (NHDS) defines a hospital discharge as the formal release of an inpatient by a hospital, terminating of the period of hospitalisation (including stays of 0 nights) by death or by disposition to the place of residence, nursing home, or another hospital; survey of discharges from non-federal hospitals in which the Average Length of Stay is less than 30 days. 

Q11. What is the definition of hospital days for inpatients?

- Hospital days for inpatients concern only acute admissions in acute hospitals (with at least 1 overnight stay in the hospital). 

Q12. What is the classification used for diagnoses in HIPE?

The HMT shortlist is based on ICD9 and ICD-10 codes, but the classification used for diagnoses in HIPE was changed from ICD-9-CM to ICD-10-AM including theAustralian Coding Standards. 

Q13. What is the code for HIPE discharges from 2005?

All HIPE discharges from 2005 are now coded using ICD-10-AM (The Australian Modification of ICD-10 incorporating the Australian Classification of Health Interventions). 

Q14. What is the status of the data?

Estonia Ministry of Social Affairs, Departmentof Health Information and Analysis, routinely collected aggregate hospital statistics.