Diagnosis of sexually transmitted infections in developing nations using syndromic management: Is it working?

Sexually transmitted infections (STIs) are a major public health problem, and controlling their spread is a priority. According to the World Health Organization (WHO), there are 340 million new cases of treatable STIs among 15–49 year olds that occur yearly around the world (1). Infection with STIs can lead to several complications such as pelvic inflammatory disorder (PID), cervical cancer, infertility, ectopic pregnancy, and even death (1). Additionally, STIs and associated complications are among the top disease types for which healthcare is sought in developing nations (1), and according to the UNAIDS report, there is a strong connection between STIs and the sexual spread of HIV infection (2). In fact, it is estimated that the presence of an untreated STI can increase the likelihood of contracting and spreading HIV by a factor up to 10 (2). In addition, developing countries are poorer in resources and lack inexpensive and precise diagnostic laboratory tests for STIs, thereby exacerbating the problem. Thus, the WHO recommends syndromic management of STIs for delivering care where lab testing is scarce or unattainable (1). This approach utilizes the use of an easy to use algorithm to help healthcare workers recognize symptoms/signs so as to provide treatment for the likely cause of the syndrome. Furthermore, according to the WHO, syndromic management offers instant and legitimate treatment compared to clinical diagnosis, and that it is also more cost-effective for some syndromes over the use of laboratory testing (1). In addition, even though it has been shown that the vaginal discharge syndrome has low specificity for gonorrhea and Chlamydia and can lead to over treatment (1), this is the recommended way to manage STIs in developing nations. Thus, the purpose of this paper is to specifically address the following questions: is syndromic management working to lower the STI burden in developing nations? How effective is it, and should it still be recommended? To answer these questions, a systematic literature review was conducted to evaluate the current effectiveness of syndromic management in developing nations. This review examined published articles over the past 5 years that compared syndromic management to laboratory testing and had published sensitivity, specificity, and positive predicative value data. Focusing mainly on vaginal discharge, urethral discharge, and genital ulcer algorithms, it was seen that though syndromic management is more effective in diagnosing and treating urethral and genial ulcer syndromes in men, there still remains an urgent need to revise the WHO recommendations for managing STIs in developing nations. Current studies have continued to show decreased specificity, sensitivity and positive predicative values for the vaginal discharge syndrome, and high rates of asymptomatic infections and healthcare workers neglecting to follow guidelines limit the usefulness of syndromic management. Furthermore, though advocate d as cost-effective by the WHO, there is a cost incurred from treating uninfected people. Instead of improving this system, it is recommended that better and less expensive point of care and the development of rapid test diagnosis kits be the focus and method of diagnosis and treatment in developing nations for STI management. ^

HIV incidence estimates and HIV/AIDS concurrent diagnosis in Houston/Harris County

The purpose of this dissertation was to estimate HIV incidence among the individuals who had HIV tests performed at the Houston Department of Health and Human Services (HDHHS) public health laboratory, and to examine the prevalence of HIV and AIDS concurrent diagnoses among HIV cases reported between 2000 and 2007 in Houston/Harris County. ^ The first study in this dissertation estimated the cumulative HIV incidence among the individuals testing at Houston public health laboratory using Serologic Testing Algorithms for Recent HIV Seroconversion (STARHS) during the two year study period (June 1, 2005 to May 31, 2007). The HIV incidence was estimated using two independently developed statistical imputation methods, one developed by the Centers for Disease Control and Prevention (CDC), and the other developed by HDHHS. Among the 54,394 persons who tested for HIV during the study period, 942 tested HIV positive (positivity rate=1.7%). Of these HIV positives, 448 (48%) were newly reported to the Houston HIV/AIDS Reporting System (HARS) and 417 of these 448 blood specimens (93%) were available for STARHS testing. The STARHS results showed 139 (33%) out of the 417 specimens were newly infected with HIV. Using both the CDC and HDHHS methods, the estimated cumulative HIV incidences over the two-year study period were similar: 862 per 100,000 persons (95% CI: 655-1,070) by CDC method, and 925 per 100,000 persons (95% CI: 908-943) by HDHHS method. Consistent with the national finding, this study found African Americans, and men who have sex with men (MSM) accounted for most of the new HIV infections among the individuals testing at Houston public health laboratory. Using CDC statistical method, this study also found the highest cumulative HIV incidence (2,176 per 100,000 persons [95%CI: 1,536-2,798]) was among those who tested in the HIV counseling and testing sites, compared to the sexually transmitted disease clinics (1,242 per 100,000 persons [95%CI: 871-1,608]) and city health clinics (215 per 100,000 persons [95%CI: 80-353]. This finding suggested the HIV counseling and testing sites in Houston were successful in reaching high risk populations and testing them early for HIV. In addition, older age groups had higher cumulative HIV incidence, but accounted for smaller proportions of new HIV infections. The incidence in the 30-39 age group (994 per 100,000 persons [95%CI: 625-1,363]) was 1.5 times the incidence in 13-29 age group (645 per 100,000 persons [95%CI: 447-840]); the incidences in 40-49 age group (1,371 per 100,000 persons [95%CI: 765-1,977]) and 50 or above age groups (1,369 per 100,000 persons [95%CI: 318-2,415]) were 2.1 times compared to the youngest 13-29 age group. The increased HIV incidence in older age groups suggested that persons 40 or above were still at risk to contract HIV infections. HIV prevention programs should encourage more people who are age 40 and above to test for HIV. ^ The second study investigated concurrent diagnoses of HIV and AIDS in Houston. Concurrent HIV/AIDS diagnosis is defined as AIDS diagnosis within three months of HIV diagnosis. This study found about one-third of the HIV cases were diagnosed with HIV and AIDS concurrently (within three months) in Houston/Harris County. Using multivariable logistic regression analysis, this study found being male, Hispanic, older, and diagnosed in the private sector of care were positively associated with concurrent HIV and AIDS diagnoses. By contrast, men who had sex with men and also used injection drugs (MSM/IDU) were 0.64 times (95% CI: 0.44-0.93) less likely to have concurrent HIV and AIDS diagnoses. A sensitivity analysis comparing difference durations of elapsed time for concurrent HIV and AIDS diagnosis definitions (1-month, 3-month, and 12-month cut-offs) affected the effect size of the odds ratios, but not the direction. ^ The results of these two studies, one describing characteristics of the individuals who were newly infected with HIV, and the other study describing persons who were diagnosed with HIV and AIDS concurrently, can be used as a reference for HIV prevention program planning in Houston/Harris County. ^