A compelling body of evidence shows that STD treatment and prevention can be an important HIV prevention strategy for young women. Therefore, CDC recommends that HIV prevention programs develop strong linkages with STD testing and treatment programs. While researchers have long recognized the common behavioral risk factors for HIV and other STDs, recent evidence points to several new reasons to consider STD treatment and prevention efforts as a means to help reduce HIV infections, especially among young women.

• There are now epidemiological, biological, and intervention trial data linking HIV and other STDs. Well-designed studies from four continents, including North America, have confirmed at least a three- to fivefold increased risk of new HIV infection associated with other STDs. Researchers have now documented not only that STDs facilitate sexual transmission and acquisition of HIV, but also that treatment of STDs reduces the spread of HIV.

• While the heterosexual spread of HIV among young women in the United States is strongly associated with the epidemic among injecting drug users, it also is associated with the prevalence of other sexually transmitted diseases.

• The spread of HIV infection among women in the United States through heterosexual transmission has closely paralleled other STD epidemics. For example, most of the health districts with the highest rates of syphilis and gonorrhea are concentrated in the South, where HIV prevalence among childbearing women also is highest in the country.

• Heterosexual HIV transmission is increasing at a faster rate than any other transmission category. Young women are particularly vulnerable to heterosexual HIV transmission. For example, in 1996, 54 percent of women under age 25 with diagnosed AIDS became infected with HIV through heterosexual transmission.

The Biological Link Between HIV and Other STDs

The presence of other STDs increases the likelihood of both transmitting and acquiring HIV.

Increased likelihood of acquiring HIV. Women who are infected with other STDs have an increased number of HIV target cells (e.g., CD4+ cells) present in cervical secretions. Researchers believe that having a larger number of these cells increases a woman's likelihood of acquiring HIV infection if she is exposed to HIV. The genital ulcers caused by some bacterial and viral STDs are an efficient portal of entry for HIV.

Increased ability to transmit HIV infection to others. Studies have shown that when HIV-infected individuals also are infected with other STDs, they are more likely to shed HIV in both ulcerative and inflammatory genital secretions, and they also are more likely to shed HIV in greater amounts compared to people infected with HIV alone. Studies conducted in Africa demonstrate that individuals who are infected with both HIV and other STDs (e.g., gonorrhea, chlamydia, genital ulcers) were more than twice as likely to have HIV genetic material detectable in their genital secretions than were those who were infected with only HIV.

STD Treatment May Slow the Spread of HIV

When STDs are detected and treated, HIV transmission is substantially reduced.

STD treatment reduces how much and how often HIV is shed. Studies from three African countries have shown that STD treatment of individuals who are coinfected with HIV and another STD decreases both the amount and how often the individual sheds the virus in genital secretions.

STD treatment reduces the spread of HIV infection in communities. A landmark community-level randomized trial in a rural area of Tanzania demonstrated a 42 percent decrease in new heterosexually transmitted HIV infections in communities with improved treatment of symptomatic STDs as compared to communities with minimal STD services.

The Challenge of Improving STD Treatment Services

High-quality, easily accessible STD clinical services are not readily available in all parts of the United States. In fact, only half of local public health departments provide STD services as compared to other services, such as immunizations, which are provided in 97 percent of the clinics. Even where public STD services do exist, capacity to provide timely care and access for critical populations, such as young women, are limited. For example, 40 percent of local health departments providing STD services cannot see a new patient on the same day she or he presents for care. Furthermore, the operating hours of public health clinics typically do not accommodate working schedules, and lack of child care is a particular barrier to health care for young mothers.

In the private sector, access to STD services does not necessarily equate with quality. In one state with a strong health care infrastructure and where HMO enrollees have more annual preventive care visits than the national average, only an estimated 21 percent of sexually active teenaged women are screened for STDs.

In addition, most people are unaware of the connection between HIV and other STDs. In the recent Kaiser Family Foundation Survey on Public Knowledge and Attitudes about STDs other than HIV, 56 percent of the respondents did not know that STDs make a person more vulnerable to becoming infected with HIV. Furthermore, the high percentage of asymptomatic STDs in women decreases the likelihood that an infected woman will seek care.

The Importance of STD Treatment in HIV Prevention

Strong STD treatment and control is one of the few well-documented biomedical tools that clearly works to help prevent heterosexually transmitted HIV infection. It is an important component of model comprehensive HIV prevention programs, particularly for young women.

As part of an overall strategy, comprehensive HIV prevention programs should develop linkages with STD diagnostic and treatment services to incorporate (1) community-based efforts to improve STD care-seeking behavior, (2) high-quality on-site STD detection and treatment services at a variety of settings for HIV-infected persons, other persons at risk for HIV or other STDs, and their partners, (3) improved STD treatment for sex partners of infected persons, and (4) expanded STD surveillance systems. HIV Prevention Community Planning Groups have an important role in strengthening these linkages.

For further reading...

Grosskurth H, et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial. Lancet. 1995;346:530-536

Institute of Medicine. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. 1996. Washington, DC: National Academy Press

St. Louis ME, Wasserheit JN, Gayle HD. Editorial: Janus considers the HIV pandemic -- harnessing recent advances to enhance AIDS prevention. AJPH 1997;87:10-12

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