STIs and AIDS: Meeting the challenges

Published here are extracts from the speech made by Dr. K. A. M. Ariyaratne, President of the College of Venereologists of Sri Lanka on the occasion of the inauguration of their 11th annual scientific sessions

Venereal diseases were named after the mythical goddess “Venus” and have been in existence since antiquity. During ancient times important archaeological discoveries brought to light medical artefacts, papyri and mummies that established the prevalence of STIs. The French Venereologist Philippe Ricord made the cryptic comment that the first sentence of the Bible should have been “In the beginning God created the heaven, the earth, man and venereal diseases”. At present they are known as sexually transmitted infections (STIs).

Earliest recordings dating back to about 1550 BC, include descriptions of STIs. Shortly after the Second World War there were hopes that the sexually transmitted infections were nearing extinction. Physicians had been confident that penicillin and other antibiotics would eliminate the problem of STIs. However, the development of antibiotic resistance and the advent of the human immunodeficiency virus infection which causes AIDS shattered this widely held belief. The prevalence and incidence of most STIs have increased rather than decreased in both developed and developing countries. STIs continue to be a major problem throughout the world and Sri Lanka is no exception.

It might seem simple enough to define STIs as those infections that can be acquired through sexual contact. Yet, they vary enormously in their manifestations. Some like herpes and warts infections are often a nuisance due to their recurring nature adding a psychological dimension. Others, like cervical cancer secondary to human papilloma virus can appear decades after the moment of transmission. Pelvic inflammatory disease secondary to sexually transmitted pathogens like Chlamydia can have dramatic acute courses, as well as long term health consequences. Today, HIV has become a leading cause of death among young adults and it is estimated that around 16,000 new infections occur daily around the globe.

We in Sri Lanka are living in turbulent times and also passing through the effects of a new globalised economy. Therefore we as medical professionals ought to have a broader view of behaviours which promote the acquisition and transmission of STIs and work with others such as legislators, social scientists and policy makers to come up with comprehensive social and health strategies to mitigate the ill effects of STIs including AIDS. This multidisciplinary approach is an enormous challenge but it is the responsibility of the professionals to execute that responsibility in the service of humanity.

I would like to take you through a few important STIs and look at the challenges for their prevention, especially in relation to Sri Lanka.

The name Syphilis was first given to the disease in 1530, when Dr. Fracaster, a physician and poet in Venice in Italy wrote a poem about a young swine-herd called syphilis, who angered God Apollo. Apollo inflicted a terrible disease on the swine-herd as a punishment in which ulcers on the skin or buboes were the main features. It is interesting to note that Francastor gave the disease a second name the “French disease” as the Italians claimed the disease was introduced by the French whom they disliked.

In Sri Lanka, the prevalence of infectious syphilis is declining over the years but our challenge is to develop cost effective interventions targeting control and elimination of congenital syphilis.

The true global burden of congenital syphilis is difficult to determine. It is estimated that, annually, at least half a million infants are born with congenital syphilis. In addition, maternal syphilis causes another half million stillbirths and miscarriages annually.

It is possible to eliminate congenital syphilis as a public health problem by testing women for syphilis early in pregnancy, treating those who are sero-positive, and preventing reinfection. Treating the mother with a single dose of penicillin is nearly always effective in preventing or treating infection in the foetus.

Simple and effective screening tests for syphilis are now available. These can be used even at the lowest levels of health care service delivery. A simple strip of paper, impregnated with treponemal antigen, is used to test blood obtained by a fingerprick. Results are available in just a few minutes.

Unlike earlier diagnostic tests, they do not require access to a laboratory or a refrigerator. These tests have the potential to change the whole approach to syphilis testing even in isolated clinics. Because the results are available immediately, women can be tested and receive treatment on the same visit. A challenge is to introduce these tests at field level.

The building blocks for elimination of congenital syphilis are already available in Sri Lanka including policy guidelines for universal antenatal syphilis screening, high levels of antenatal attendance, low cost screening test, treatment with penicillin which is cheap. What is required is increased motivation at all levels of health service including policy makers, public health care providers and obstetricians to work in a coordinated manner to achieve the desired results.

Gonorrhoea is one of the oldest known diseases of humans. Humans are the only natural host for the gonococci. Gonorrhoea undoubtedly was known to the authors of the Bible. The book of Leviticus describes a person with urethral discharge.

Neisseria gonorrhoeae, the causative organism of gonorrhoea was discovered by Albert Neisser in 1879. Penicillin had been the effective treatment for gonorrhoea for many years; however the rapid emergence of resistant strains has led to this being withdrawn as a suitable treatment. In recent years, the gonococcus has acquired resistance to many other antibiotics including quinalones.

If not adequately and correctly treated, gonorrhoea infection is not always without complications. In females, pelvic inflammatory disease can lead to fertility problems and chronic pelvic pain. In males, transurethral spread of the organism can lead to an infection of the epididymis. Disseminated infections can result from prolonged untreated gonorrhoea.

The standard procedure for diagnosing symptomatic disease in men with urethritis is the Gram stain. In asymptomatic men or in women with genital infection the Gram stain is less useful and a bacterial culture is a necessity.

Bacterial culture is both sensitive and cheap to perform. It has the added advantage that further tests can be carried out to determine antimicrobial susceptibility. Continuous laboratory monitoring of the antibiotic sensitivity pattern and the dissemination of information to primary care providers are a priority. In fact this information is a sine qua non for successful implementation of syndromic management of STDs at primary health care level.

However, since culture facilities are at present available only in Colombo, Kandy, Kurunegala and Badulla, the challenge is to provide this facility to other peripheral areas in the future. In developed countries a variety of molecular tests are being used to detect gonococci antigen and DNA hybridization, polymerase chain reaction and ligase chain reaction tests. The high cost prevents using these tests in most of the developing countries.

In Sri Lanka an extraordinary increase in the incidence of gonorrhoea has been observed since 2002. This is an important risk marker as well as a risk factor for an impending HIV epidemic. The increased incidence of gonorrhoea in spite of all our efforts at behaviour change and promotion of safe sex is a matter of great concern. We need to control and prevent the spread of gonorrhoea among high risk groups such as commercial sex workers and men who have sex with men. Penetrating into these hard to reach population groups for prevention activities is a challenge.

The change in the antibiotic sensitivity pattern of gonococcus is posing a challenge for prompt and effective treatment and elimination of the infection.

Warty lesions of the ano-genital area have been described as early as the first century AD. The venereal origin of the disease was described in the 1950s. Intracellular virus particles in the wart tissue were demonstrated in 1968. In the 1970s, further work attributed these cellular changes to human papilloma virus (HPV) infection.

Recent epidemiologic and molecular studies have conclusively shown the association of some HPV types with the development of genital tract and anal cancers. Virtually all cervical cancer cases (99%) are linked to genital infection with HPV.

Cervical cancer is the second most common malignancy in women worldwide, and it remains a leading cause of cancer-related death for women in developing countries.

In Sri Lanka, the central STD clinic, Colombo performs cytology screening and this facility has to be extended to the peripheral STD clinics. The Well Woman Clinics conducted at the primary health care institutions provide this service and in 2005 a total of 53,287 smears were examined. The continuing of the integration of cervical cytology screening in reproductive health programmes is a challenge.

In Sri Lanka, herpes is one of the commonest sexually transmitted diseases reported from STD clinics.

Infection with Herpes Simplex Virus type 2 causes most of genital herpes infections and is responsible for almost all recurrent herpes episodes. A majority of people infected are asymptomatic and do not report a history of symptoms or awareness that they are infected, yet they can still transmit the infection. Those with frequent recurrences may have substantial psychological and psychosexual morbidity. Widespread misconceptions around herpes infection add to the trauma of infected and affected people. Hence addressing the psychosocial and sexual morbidity through in-depth counselling is a challenge to care providers.

The interaction and synergy between herpes virus and HIV have strong implications for the control of STIs and AIDS. Herpes simplex virus-2 infection facilitates transmission and acquisition of HIV. A number of recent studies have demonstrated that levels of HIV in the plasma and genital secretions can be reduced by suppressive therapy for HSV-2 infection. In such a scenario, control of HSV-2 infection is emerging as a major theme in the global effort to prevent HIV transmissions.

Twenty five years into the global HIV/AIDS epidemic, HIV infection rates are alarmingly high and more than 4 million people become infected every year. It is estimated that 40 million people are living with HIV infection and about 3 million people die each year.
Three decades into the epidemic, there is still no vaccine and no permanent cure. However, social and economic conditions that facilitate the spread of HIV are well known. Despite this, risk behaviours and risk environments persist, and HIV continues to spread among individuals and across national and regional borders.

Currently, Sri Lanka is considered to be a country with a low prevalence of HIV. However, most of the risk behaviours that facilitate the spread of HIV exist within the country. In response to the 3x5 initiative of the WHO, Sri Lanka initiated the ART programme in December 2004.

As of June 2006, 85 HIV infected persons have been treated with antiretroviral therapy. With antiretroviral therapy AIDS has now been transformed into a chronic disease similar to diabetes or hypertension. The challenge is to scale up provision of ARV to cover all those who are eligible for treatment.

Presence of vulnerable populations such as sex workers, drug users, men who have sex with men and, internal and external migrants potentially promote the spread of HIV. In relation to HIV AIDS I would like to draw your attention to a few aspects of the present challenge.

From ancient times, prostitution or sex work has been associated with high levels of STIs. Sex workers are rated as high frequency transmitters of sexually transmitted infections and are the reservoirs of infection. In Asia the engine of growth of the HIV infection is considered to be the sex industry.

Although prostitution in Sri Lanka is illegal, it is estimated that around 30,000 women and girls are engaged in the commercial sex industry in the country. Due to their poor health seeking behaviours they do not get the services of regular health screening. The available data show that 45% of female sex workers have experienced multiple STIs.

It is estimated that 5-10% of all HIV infections in the world are transmitted by sex between males. In Asia, HIV prevalence is estimated to be 5-15 times higher among MSM than in the general population. A significant proportion of men who have sex with men also have sex with women making a wider population vulnerable to HIV. However, due to widespread stigma and discrimination, MSM are less likely to utilize preventive programmes. A recent report by TREAT Asia states that prevention programmes were available to only 2 percent of men who have sex with men in the 16 Asia-Pacific countries surveyed. HIV prevention programmes have to understand issues on sexuality, freedom of expression and appreciate the diversity in sexual issues.

The foreign employment industry is the second largest foreign exchange earner for Sri Lanka. An estimated 1.2 million Sri Lankans work in the Middle East and 79.1% of unskilled migrants are women.

Internal migration for employment is a common situation in Sri Lanka. Thousands of women and men live away from their families as workers in the Sri Lankan Free Trade Zones. The vulnerability of these women is indicated by the reports of the high rate of unwanted pregnancies and high prevalence of STDs.

Migrant populations are at higher risk of contracting HIV because of the situation they face in their migration such as poverty, exploitation, and separation from families and partners.

The failure to limit the spread of HIV/AIDS is too fearful to contemplate. Currently we are a low prevalence country and a concerted effort could make a difference.