STDs: Flushing out the hidden epidemic’
Dateline 1982: The term AIDS appears for the first time in the Morbidity and Mortality Weekly Report.1 Fast-forward to the present. Researchers have identified HIV as the causative organism of the disease, developed highly effective multidrug regimens to treat HIV infection and limit transmission from mother to child, and examined behavioral intervention — both at the individual and community levels — to promote condoms for HIV prevention.
The impact of the HIV pandemic ranks as the most significant event in the arena of sexually transmitted diseases (STDs) in the past two decades, says Willard Cates, MD, MPH, president of Family Health International, a reproductive health research organization in Research Triangle Park, NC. In making strides against HIV/AIDS, public health officials now look to confront what has been termed "the hidden epidemic" of STDs.2
Getting a grip on STDs is important because research has shown that STDs increase the risk of HIV infection.3 While HIV has opened the dialogue about infectious organisms that are acquired in sexual ways, there continues to be a large burden of stigma and shame that is "amazingly disproportionate" to the actual morbidity and mortality associated with STDs, notes Linda Alexander, PhD, president and CEO of the American Social Health Association in Research Triangle Park. Until people are ready to talk about STDs in a rational, pragmatic way, no headway will be made in stemming them, she says.
Judith Wasserheit, MD, MPH, director of the division of STD prevention in the National Center for HIV, STD, and TB Prevention at the Atlanta-based Centers for Disease Control and Prevention (CDC), agrees. "As a society, we’ve got to be able to talk about these issues," she says. "We’ve got to be able to find the common ground and accommodate the diversity of cultural and other backgrounds, but we also must use strong science as our point of departure."
Progress made in detecting infections
On the research side, important progress has been made in diagnosing and treating STDs, says Penelope Hitchcock, DVM, MS, chief of the STD branch of the National Institute of Allergy and Infectious Diseases of the National Institutes of Health in Bethesda, MD. Diagnostic advances such as urine-based screening for gonorrhea and chlamydial infection and the advent of testing to detect human papillomavirus (HPV) and herpes simplex virus-2 (HSV-2) have aided clinicians in detecting infection. "As far as treatment goes, we have seen the development of single-dose therapy for the treatable STDs," she says. "Every one of them can be treated with a single dose of a drug, with the exception of syphilis, and we are in the process of studying that now."
With improved diagnosis and treatment, public health officials have moved to increase chlamydia screening and treatment, thereby reducing the incidence of pelvic inflammatory disease, the leading preventable cause of infertility in women, says Wasserheit. "Given the fact that, on average, 75% of chlamydial infections in women are asymptomatic; screening is essential for prevention of further spread of chlamydia and its consequences in terms of infertility."
While there is no cure for HSV-2, the arrival of antiviral treatments such as acyclovir, famciclovir, and valacyclovir offer suppressive therapy to minimize HSV-2 outbreaks. Research continues into development of an effective vaccine for the virus. (See STD Quarterly in Contraceptive Technology Update, May 1999, for a review of research on HSV-2 vaccine development.)
Syphilis rates continue to decline, reaching an all-time low national rate of 2.6 cases per 100,000 population.4 In October 1999, the CDC targeted 33 states and cities with a heavy burden of syphilis or a high potential for re-emergence in an effort to eliminate the disease.
"We do know that syphilis epidemics move in seven- to 10-year cycles, and we are 10 years out from the peak of the last syphilis epidemic in 1990," states Wasserheit. "We really do have a very narrow window of opportunity to do this, and if we don’t take advantage of it, we may not have the opportunity again for a long time, if ever." (STD Quarterly in the September 1997 and August 1998 CTU reviews efforts to eliminate syphilis in the United States.)
As progress is made on bacterial STDs, viral STDs become more important, Wasserheit says. The balance already is tipping, as viral STDs make up more than half of the current burden of STDs in the United States, she says. Public health officials will need to be prepared to deal with such STDs as HPV and HSV-2 in the coming years.
"I think vaccines and microbicides loom large for us," says Hitchcock. "We have either completed or are in the process of completing the genome sequences of many of the organisms that cause STDs, and we are very hopeful that those genome sequences will inform us, both in terms of specific diagnostic probes as well as vaccine development."
References
1. Centers for Disease Control and Prevention. Update on acquired immune deficiency syndrome (AIDS) — United States. MMWR 1982; 31:507-514.
2. Eng TR, Butler WT, eds. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: Institute of Medicine, National Academy Press; 1997.
3. Wasserheit JN. Epidemiologic synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sex Transm Dis 1992; 9:61-77.
4. Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention. Syphilis Continues to Retreat: Nation Sets Sights on Elimination. Atlanta; 1999.
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