These worrying trends were discussed at a meeting of the University of Nairobi STD/AIDS Collaborative Research Group in January. Dr Kevin De Cock, head of CDC Kenya and former head of WHO's HIV/AIDS Division, opened a session on STIs that laid out the burgeoning STI epidemic, with particular reference to the US and Europe, where good data is available.
Levels of STIs are particularly high among men who have sex with men (MSM), and have been on the increase throughout this century. For example, the percentage of urethral gonorrhoea among MSM attending STI clinics in the US almost doubled between 2000 and 2016 (GISP 1989-2016).
There is little data on STIs among MSM in eastern and southern Africa, and indeed many clinicians and health workers in the region are ill-equipped to diagnose and treat (or even consider in their diagnosis) rectal or oral gonorrhoea and chlamydia. Two of EHPSA's studies in Kenya and South Africa will shed light on the situation here: preliminary results are showing a significant burden of STIs, including herpes and hepatitis.
De Cock described how STIs were high on the global agenda in the early days of the HIV epidemic, when evidence was supporting an association between AIDS and STIs, particularly among sex workers and MSM. The 1995 Mwanza study in Tanzania showed that improved STI treatment services substantially reduced HIV incidence. However, since then there has been a significant divergence between the fields of STI's and HIV.
This was partly due to a later study in Rakai, Uganda, that failed to support the findings from Mwanza. Researchers concluded that differences in the phases and speed of the two epidemics were to blame. Two additional trials later confirmed the Rakai finding (1). However, there is a paucity of epidemiological and other types of research on this important topic. In this resounding silence the "AIDS community" seems to have lost interest in STIs, which were not identified as priority areas by the new AIDS architecture of the "noughties".
So, while the response to HIV surged, - with new funding, global targets and national commitments - the response to STIs failed to keep pace. Without the advocacy, research and visibility of the HIV struggle, the STI epidemic is now out of control.
The lack of evidence that treating STIs reduces HIV incidence is not a good enough reason to neglect STIs. Dr Larry Gelmon, a visiting lecturer at University of Nairobi and Associate Professor of University of Manitoba, says it makes sense for the HIV community to pay attention to STI's for two main reasons: firstly, the presence of STIs are usually an indication of unprotected sex; and secondly, STIs that cause lesions (such as syphilis and herpes) have been proven to increase the risk of HIV transmission.
In the final analysis there is a compelling reason for strengthening STI services - to reduce a growing public health threat. It is critical that we return attention to STIs. De Cock argues that one way to do this is to broaden the mandate of HIV programmes to include STIs - donor agencies should be challenged to fund research and programmatic activity on STIs. The STI community also needs to find its voice and mimic the strategies used by AIDS activists. Synergies and networks - in antimicrobial resistance, microbiome research, molecular epidemiology, hepatitis and SDGs to name a few - must also be explored and strengthened.
The question remains, who is to make the call to action on STIs that is so needed in the 21st century?
1. A 2011 Cochrane review looked at the evidence from four trials and was unable to support the hypothesis that STI control is an effective HIV prevention strategy. Ng BE, Butler LM, Horvath T, Rutherford GW. Population-based biomedical sexually transmitted infection control interventions for reducing HIV infection. Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No.: CD001220. DOI: 10.1002/14651858.CD001220.pub3.