Control of Sexually Transmitted Infections and Prevention of HIV Transmission: Mending a Fractured paradigm/Lutte Contre Les Infections Sexuellement Tranmissibles et Prevention De la Transmission Du VIH: Reconstitution D'un Dispositif deteriore/Control De Las Infecciones De Transmision Sexual Y Prevencion De la Transmision del VIH: Reparar la Fractura

Introduction In the history of sexually transmitted infection (STI) control, as with other communicable diseases, the pendulum swings between vertical disease-specific and broader horizontal approaches, from a narrow focus on pathogens and their treatment to the wider needs of populations who host and transmit them. Since the emergence of HIV in the 1980s, efforts have increasingly been defined in relation to HIV programme priorities. (1) Although HIV is itself an STI, efforts to prevent its transmission are largely managed through programmes that are funded, implemented and evaluated independently of other efforts. Such a fractured paradigm has had unfortunate consequences. Too often, neglected programmes--the foundation upon which HIV prevention efforts were built--collapse due to reduced funding. As a result, clinics and services are understaffed, understocked or disappearing altogether; pregnant women may be offered HIV tests but are no longer screened for syphilis; and reporting, an important marker of sexual transmission trends, has largely collapsed. (2,3) In other areas of communicable disease control, the pendulum is moving in a different direction towards strategies that aim for broad public health benefit while pursuing disease-specific objectives. Examples include attention to general lung health within the Stop TB partnership and integrated vector management in malaria efforts. The rationale is that sustainable disease requires coordinated efforts to address common conditions that may facilitate transmission or impede access to prevention, case detection, diagnosis and treatment. (4,5) This paper describes a unified paradigm of where HIV is an important focus. The approach is analytical and programme-oriented, with attention to public health outcomes and means. We start by reviewing definitions and outlining basic components of control, and then examine empirical evidence of the feasibility and benefits of under different conditions. We also consider what happens to HIV under different scenarios and look at the overlap and potential synergies between HIV prevention and efforts. Defining is a public health outcome, measured as reduced incidence and prevalence, achieved by implementing strategies composed of multiple synergistic interventions. In the literature, the term STI control is frequently used interchangeably with STI treatment, yet these are quite different things. (6,7) Control of any communicable disease is a public health outcome, measured as reduced prevalence (total infections) or incidence (new infections) in a population. Treatment is a biomedical intervention that, unless part of a broader strategy, usually does not result in lower transmission rates or disease burden. can be measured in absolute or relative terms, for example, as elimination of chancroid or 50% reduction of the prevalence of gonorrhoea. Monitoring trends of common curable STIs, etiologically or syndromically, can provide evidence of changing incidence. Where surveillance is supported and functioning (often it is not), these data also reflect general sexual transmission trends and can be used to assess the adequacy of overall STI/HIV prevention efforts. (8) Since HIV shares many aspects with other STIs--including modes of transmission, behavioural and other cofactors and potential measures--HIV prevention can logically be situated within the larger, encompassing domain of control. Back to basics A comprehensive strategy includes targeted community-based interventions, promotion and provision of the means of prevention and effective clinical services within an enabling environment, as well as reliable data to guide the response. The science and methods of build on several centuries' experience backed by evidence of progressively declining incidence and prevalence, particularly in developed countries? …