To the Editor: Dr Kaul and colleagues1 again confirm that sexually transmitted infections (STIs) are important human immunodeficiency virus (HIV) cofactors and, with new insights on potential pathways, reinforce the importance of STI control at the population level. Notably, the study may say more about the impact of cumulative public health efforts on local STI/HIV transmission than about the effectiveness of any specific intervention.
The rationale for treating sex workers presumptively for STIs is based on 2 assumptions. First, sex workers are frequently exposed to STIs and can transmit infection to many partners, particularly when condom use is low. Second, STIs in women are difficult to identify without sensitive laboratory tests.
These factors are dynamic and the potential benefit of presumptive treatment is setting-specific. The greatest effect can be expected where STI transmission is intense and access to services poor. Sexually transmitted infections, particularly genital ulcers, spread easily under such conditions. In eastern and southern Africa and parts of Asia, these factors drove initial rapid growth of heterosexual HIV epidemics and continue to exert high transmission pressure where they persist.
The above conditions certainly have existed in Nairobi and have motivated pioneering work on HIV, sex work, and genital ulcers.2 - 3 By the time of the study by Kaul et al, however, interventions had already had marked impact on both epidemics.4 The prevalence of HIV was in decline and rates of curable STIs, particularly genital ulcers, fell to low levels. Chancroid, once the major cause of genital ulcers, had all but disappeared.
The study by Kaul et al confirmed these trends by demonstrating a low incidence of ulcerative STIs, limited to incurable herpes simplex virus type 2 and comparable in the intervention and control groups. Consequently, instead of a 15% to 50% HIV incidence expected from previous experience with Nairobi sex workers, much lower incidence (4%) was measured. As the authors point out, several interpretations of their results are possible. These should include recognition that a high level of STI control had already been achieved in Nairobi. Targeted presumptive treatment may quickly help reduce high rates of curable STI in some settings.5 Where STI rates have decreased and sustainable services are in place, however, we believe that there is little need for such an approach.
Trials to assess effectiveness of STI control on HIV transmission should be evaluated under conditions in which STI rates are highest, carefully matching interventions to epidemiologic conditions. The situation in Nairobi illustrates that interventions for sex workers that strengthen peer networks, enable higher condom use, and improve access to effective STI services work, even in established HIV epidemics.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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