Human immunodeficiency virus infection and self-treatment for sexually transmitted diseases among northern Thai men

Accounting for variation in and overuse of antibiotics among humans

Worldwide, antibiotic use is increasing, but many infections against which antibiotics are applied are not even caused by bacteria. Over-the-counter and internet sales preclude physician oversight. Regional differences, between and within countries highlight many potential factors influencing antibiotic use. Taking a systems perspective that considers pharmaceutical commodity chains, we examine antibiotic overuse from the vantage point of both sides of the therapeutic relationship. We examine patterns and expectations of practitioners and patients, institutional policies and pressures, the business strategies of pharmaceutical companies and distributors, and cultural drivers of variation. Solutions to improve antibiotic stewardship include practitioners taking greater responsibility for their antibiotic prescribing, increasing the role of caregivers as diagnosticians rather than medicine providers, improving their communication to patients about antibiotic treatment consequences, lessening the economic influences on prescribing, and identifying antibiotic alternatives.

The burden of HIV infection among men who purchase sex in low- and middle-income countries - a systematic review and meta-analysis

Background

Since the start of the HIV epidemic, transactional sexual relationships have been considered to present a high risk of HIV transmission to both the client and the person offering the sexual service. However, prevention research and programs have focused predominantly on sex workers rather than on their clients, who are generally men. To support effective and targeted interventions, we undertook a systematic review and meta-analysis of the evidence of the prevalence of HIV infection among men who purchase sex (MWPS) in low- and middle-income countries (LMICs), and the association between HIV infection and purchase of sex.

Methods

We included articles that reported from LMICs on the prevalence of HIV in MWPS and those that reported on HIV prevalence among both MWPS and non-MWPS in the same study, or any information which allowed calculation of the prevalence. We defined MWPS as heterosexual males (not men who purchase sex or individuals of other sexual orientation) who purchased sex mostly from women (and not men), or who have had sexual contact with female sex workers (FSWs). We searched Medline, Global Health, Scopus, Embase and Cinahl for articles published up until 1 March 2020. Meta-analysis was conducted using a random effects model to estimate the pooled HIV prevalence and the relative risk (RR) of HIV infection associated with purchasing sex.

Results

Of 34862 studies screened, we included 44 studies (59515 men, 47753 MWPS) from 21 countries. The pooled HIV prevalence among MWPS was 5% (95%CI: 4%-6%; I² = 95.9%, p < 0.001). The pooled HIV prevalence calculated from studies that reported data collected pre-2001 was highest, i.e. 10% (95% CI: 6%-14%; I² = 91.2%, p < 0.001), compared to studies whose data was collected between 2001–2010, i.e. 4% (95%CI: 2%-6%; I² = 96.6%, p < 0.001), and from 2011 and beyond, i.e. 3% (95% CI: 2%-5%; I² = 94.3%, p < 0.001). For studies which included comparisons of HIV infection among MWPS and non-MWPS, the relative risk of HIV infection was consistently higher among MWPS than among non-MWPS within the same study, with the overall pooled relative risk of 1.95 (95%CI: 1.56–2.44; I² = 84.3%, p < 0.001), and 2.85 (95%CI: 1.04–7.76; I² = 86.5%, p < 0.001) for more recent studies.

Conclusions

This review represents the first comprehensive assessment of the burden of HIV among MWPS in LMICs. We found that HIV prevalence was elevated compared to the population as a whole, and that there was a strong association between purchasing sex and HIV prevalence. Despite a reduction over time in prevalence, these data highlight that MWPS need better access to HIV preventive interventions.

Halting and reversing HIV epidemics in Asia by interrupting transmission in sex work: experience and outcomes from ten countries

HIV epidemics spread rapidly through Asian sex work networks two decades ago under conditions of high vulnerability, low condom use, intact male foreskins and ulcerative STIs. Experiences implementing interventions to prevent transmission in sex work in ten Asian countries were reviewed. All report increasing condom use trends in sex work. In the seven countries where condom use exceeds 80%, surveillance and other data indicate declining HIV trends or low and stable HIV prevalence with declining STI trends. All four countries with national-level HIV declines among sex workers have also documented significant HIV declines in the general population. While all interventions in sex work included outreach, condom programing and STI services, the largest declines were found in countries that implemented structural interventions on a large scale. Thailand and Cambodia, having controlled transmission early, are closest to providing universal access to HIV care, support and treatment and are exploring HIV elimination strategies.

Pharmacy workers' sexually transmitted diseases/human immunodeficiency virus knowledge in Fuzhou, China: implications for human immunodeficiency virus testing, treatment, and prevention strategies

BACKGROUND

Pharmacies play a special role in providing treatment services for patients with sexually transmitted diseases (STDs) in China. There is a need to study the STD/human immunodeficiency virus (HIV) knowledge among pharmacy workers in retail pharmacies.

METHOD

A total of 200 pharmacy workers were recruited from 120 randomly selected retail pharmacies in Fuzhou, China. A self-administrated questionnaire was used to collect information of demographics, working experience, pharmacy structure and clientele profile, and pharmacy workers' attitudes toward traditional Chinese folk remedies and their STD/HIV knowledge.

RESULTS

Work-related training during the past 6 months, holding pharmacist license, and years of being a pharmacy worker showed significant association with STD/HIV knowledge. Work-related training also significantly associated with provision of consultation. Years of education and medical training, however, failed to show significant association with STD/HIV knowledge.

CONCLUSIONS

In order to improve service quality and avoid misdiagnosis and inappropriate treatment of STD/HIV, on-the-job training or continuous education for pharmacy workers should be required, implemented, and monitored as part of the national effort for STD control and treatment.

Inconsistent condom use with steady and casual partners and associated factors among sexually-active men who have sex with men in Bangkok, Thailand

HIV/STD risk behavior has not been examined in community samples of men who have sex with men (MSM) in Thailand. The sexually-active sample (n=927) was recruited from bars, saunas, and parks; 20% identified as bisexual and 17% tested HIV-positive. Inconsistent (<100%) condom use was reported by 45% of those with steady partners and 21% of those with casual partners in the prior three months. 21% had heard of effective HIV treatments (n=194), among whom 44% believed HIV was less serious and 36% said their risk behavior had increased after hearing about the treatments. In multivariate analysis, HIV-positive status, gay-identification, getting most HIV information from the radio, believing HIV can be transmitted by mosquito bite, and concern about acquiring an STD were associated with inconsistent condom use during anal sex; slightly older age (25-29 vs. 18-24 years) was associated with more consistent condom use. HIV/STD risk-reduction strategies for MSM in Bangkok should clearly state sexual risk to individuals in this population.

Sex-work harm reduction

Sex work is an extremely dangerous profession. The use of harm-reduction principles can help to safeguard sex workers' lives in the same way that drug users have benefited from drug-use harm reduction. Sex workers are exposed to serious harms: drug use, disease, violence, discrimination, debt, criminalisation, and exploitation (child prostitution, trafficking for sex work, and exploitation of migrants). Successful and promising harm-reduction strategies are available: education, empowerment, prevention, care, occupational health and safety, decriminalisation of sex workers, and human-rights-based approaches. Successful interventions include peer education, training in condom-negotiating skills, safety tips for street-based sex workers, male and female condoms, the prevention-care synergy, occupational health and safety guidelines for brothels, self-help organisations, and community-based child protection networks. Straightforward and achievable steps are available to improve the day-to-day lives of sex workers while they continue to work. Conceptualising and debating sex-work harm reduction as a new paradigm can hasten this process.

Approaches to the control of sexually transmitted infections in developing countries: old problems and modern challenges

Sexually transmitted infections (STIs) constitute a huge health and economic burden for developing countries: 75-85% of the estimated 340 million annual new cases of curable STIs occur in these countries, and STIs account for 17% economic losses because of ill health. The importance of STIs has been more widely recognised since the advent of the HIV/AIDS epidemic, and there is good evidence that the control of STIs can reduce HIV transmission. The main interventions which could reduce the incidence and prevalence of STIs include primary prevention (information, education and communication campaigns, condom promotion, use of safe microbicides, and vaccines), screening and case finding among vulnerable groups (for example, pregnant women), STI case management using the syndromic approach, targeted interventions for populations at high risk (for example, sex workers), and in some circumstances (targeted) periodic mass treatment. The challenge is not just to develop new interventions, but to identify barriers to the implementation of existing tools, and to devise strategies for ensuring that effective STI control programmes are implemented in the future.

Herpes simplex virus type 2 and heterosexual spread of human immunodeficiency virus infection in developing countries: hypotheses and research priorities

Herpes simplex virus type 2 (HSV-2) infection is almost always sexually transmitted, and causes genital ulceration. Significant progress in our understanding of HSV infection has occurred over the last decade, in part related to the development of accurate and sensitive laboratory tests to study HSV-2. The application of PCR and type-specific serology to individual cases and in population-based studies has enabled the identification of a potentially important role for HSV-2 infection as a cofactor in the sexual transmission of HIV. This is a particular issue in developing countries. This review describes the epidemiology of HSV-2 infection in the HIV era, the hypotheses regarding HSV-HIV interactions, and research priorities for the developing world.

STD history, self treatment, and healthcare behaviours among fishermen in the Gulf of Thailand and the Andaman Sea

OBJECTIVE

Migrant populations are at higher risk for HIV infection. Access to health care and STD treatment is thought to lower this risk. This study aims to examine determinants of STD history and treatment and healthcare behaviours among fishermen in the Gulf of Thailand and the Andaman Sea.

METHODS

A cross sectional survey of fishermen working on commercial fishing trawlers was conducted in four provinces in Thailand in early 1998.

RESULTS

Of the 818 fishermen interviewed, 30% reported a history of STD, of which 31% reported self treatment of the last STD. 32% reported self care for general health while ashore. In multivariate analyses, a history of STD was significantly more often reported by older men compared with younger men, by owners and skippers compared with lower positions on the boat, and by men who have ever visited female sex workers. Self treatment of the last STD was related to being Burmese compared with being Thai, and to working as a steersman or ship hand compared with as a skipper. Self care for general health while ashore was significantly related to being Burmese or Khmer compared with being Thai, and to being unmarried compared with married.

CONCLUSION

Burmese migrant fishermen and their needs should be targeted for culturally specific interventions to increase their understanding of STD treatment and improve their access to health care.

Interventions against sexually transmitted infections (STI) to prevent HIV infection

STIs have taken on a more important role with the advent of the HIV/AIDS epidemic, and there is good evidence that their control can reduce HIV transmission. The challenge is not just to develop new interventions, but to identify barriers to the effective implementation of existing tools, and to devise ways to overcome these barriers. This 'scaling-up' of effective strategies will require an international and a multisectoral approach. It will require the formation of new partnerships between the private and public sectors and between governments and the communities they represent.

The repertoire of human efforts to avoid sexually transmissible diseases: past and present. Part 2: Strategies used during or after sex

BACKGROUND/OBJECTIVE

Despite the focus by public health programmes on condoms, chastity, or monogamy, people use a much wider variety of strategies to minimize their personal risk of sexually transmissible disease (STD). The objective of this study was to compile a comprehensive list of personal and societal STD avoidance strategies.

METHODS

Data from clinical and research observations, computer searches, and historical texts were pooled.

RESULTS

A variety of behaviours during or after sex, other than condoms, were identified that have been perceived to alter STD risk. STD avoidance strategies were often poorly documented and difficult to disentangle from other drives such as aesthetics, sexual variety, and contraception. They also varied in popularity in time and place. Some examples were douching; systemic and topical prophylactic antimicrobials; non-penetrative sexual practices, post-coital urination; and examining sexual partners' genitalia. Interest in some practices has been recently revived--for example, vaginal microbicides and post-exposure chemoprophylaxis, while others--for example, withdrawal and non-penetrative sexual practices, receive scant attention but may be much more widely used.

CONCLUSION

The full spectrum of STD avoidance strategies warrants further study because some are ubiquitous across cultures and because they have the potential to complement or undermine safer sex programmes. Because of their greater acceptability, some less efficacious strategies may have greater public health importance than less popular but more efficacious strategies such as condoms.

The repertoire of human efforts to avoid sexually transmissible diseases: past and present. Part 1: Strategies used before or instead of sex

BACKGROUND/OBJECTIVE

Despite the focus by public health programmes on condoms, chastity, or monogamy, people use a much wider variety of strategies to minimise their personal risk of sexually transmissible disease (STD). The objective of this study was to compile a comprehensive list of personal and societal STD avoidance strategies.

METHODS

Data from clinical and research observations, computer searches, and historical texts were pooled.

RESULTS

In addition to discriminating between potential sexual partners, a variety of behaviours before or instead of sex were identified that have been perceived to alter STD risk. Traditional STD avoidance strategies were often poorly documented and difficult to disentangle from other drives such as the maintenance of social order, paternity guarantee, and eugenics. They also varied in popularity in time and place. Some examples were displacement activities such as masturbation or exercise, circumcision, infibulation, shaving, vaccination, or requiring partners to be tested for infection. Social and moral forces typically discourage non-marital sex, and this affects most people most of the time but few people all of the time.

CONCLUSION

The full spectrum of STD avoidance strategies warrants further study because some are ubiquitous across cultures and because they have the potential to complement or undermine safer sex programmes. Because of their greater acceptability, some less efficacious strategies may have greater public health importance than less popular but more efficacious strategies such as condoms.

Lower genital tract infections among HIV-infected and high-risk uninfected women: findings of the Women's Interagency HIV Study (WIHS)

BACKGROUND AND OBJECTIVES

Few comparisons of factors associated with sexually transmitted diseases (STDs) and HIV are available for representative samples of American women.

GOAL OF THE STUDY

To compare factors associated with STDs in a large sample of women infected with HIV and women not infected with HIV.

STUDY DESIGN

A cross-sectional analysis of STDs in 2,058 women seropositive (HIV+) for HIV and 567 women seronegative (HIV-) for HIV.

RESULTS

HIV + women were more likely than HIV- women to report previous STDs, with the exceptions of chlamydia and bacterial vaginosis. Both HIV status and CD4 lymphocyte count were associated with evidence of genital ulcerations, warts, and vaginal candidiasis (p <0.001 for all). HIV- women were more apt to report recent vaginal intercourse (p <0.001), a factor that was independently associated with the occurrence of bacterial and protozoan infections. CD4 lymphocyte depletion was the factor most closely associated with the expression of chronic viral infections.

CONCLUSIONS

In this North American cohort, HIV+ women were more likely than HIV- women to report previous genital tract infections and symptoms. However, the HIV+ women reported less recent sexual activity and few gonococcal or chlamydial infections.

Decreasing incidence of HIV and sexually transmitted diseases in young Thai men: evidence for success of the HIV/AIDS control and prevention program

OBJECTIVE

To determine whether HIV and sexually transmitted disease (STD) incidence rates among young men in northern Thailand have declined since the establishment of the '100% Condom Program', and to prospectively document changes in the association between behavioral risk factors and incident HIV and STD infections.

SETTING

Thirteen military bases in northern Thailand.

METHODS

Serial prospective cohorts of 19-23-year-old male conscripts (n = 4086) inducted into military service from six northern Thai provinces between 1991 and 1993 were followed at 6-month intervals for incident HIV and STD through May 1995. HIV incidence was determined by serology, and incident STD were reported by conscripts as diagnosed by health-care providers.

RESULTS

HIV incidence declined from a rate of 2.48 per 100 person-years during 1991-1993 to 0.55 per 100 person-years during 1993-1995. STD incidence showed an even greater decline, with a 10-fold decrease from 1991-1993 to 1993-1995. Behavioral risk factors for incident STD infections included a history of prior STD and sex with girlfriends and sex workers. Inconsistent condom use remained a strong predictor of incident STD among brothel visitors. Other previously-reported risk factors in 1991-1993 such as illicit drug use, frequency and cost of brothel visits, and low socioeconomic status were not associated with incident STD or HIV in 1993-1995.

CONCLUSIONS

Although several studies have recently reported decreased prevalence of HIV and STD infections in Thailand, these data demonstrate that a dramatic decrease in the incidence rates of STD, including HIV infection, has occurred among young men in military service in northern Thailand. The Thai AIDS prevention and control program might be implemented by other countries experiencing major epidemics of heterosexually transmitted HIV infections. Similar prevention programs targeted at other populations in Thailand and elsewhere in Asia are needed to decrease the spread of the HIV epidemic.

Medication use by female sex workers for treatment and prevention of sexually transmitted diseases, Chiang Rai, Thailand

BACKGROUND

Female sex workers (FSWs) in Thailand are at high risk for sexually transmitted diseases (STDs). Although regular attendance at public STD clinics is required, FSWs may frequently use medications obtained in the community for STDs.

OBJECTIVES

To determine the frequency of use of medications for STDs from sources other than public STD clinics among FSWs in Thailand and to describe factors associated with such medication use.

METHODS

A cross-sectional survey of FSWs attending the public STD clinic in Chiang Rai, Thailand, was performed.

RESULTS

Of the 200 FSWs interviewed, 55% had ever used medications to treat or prevent STDs from a source other than a public STD Clinic, and 36% had done so in the prior year. Most use (79%) was to treat STD symptoms, and medication was most frequently obtained directly from a pharmacy (54%). This use of community medication for STDs was associated with younger age, non-Thai ethnicity, seeking STD treatment during the current clinic visit, and brothel-based sex work.

CONCLUSIONS

Use of medications from various sources in the community was common among these FSWs. Further research is needed to determine the appropriateness of this treatment. Innovative methods to ensure adequate quality STD care by community providers and to improve the health-care-seeking behaviors of these high-risk women are needed.