HIV care should include routine STI screens, finds study

A significant proportion of women receiving antiretroviral therapy from public health facilities in Bangkok have a sexually transmitted infection (STI), according to a study published in the April 15^th edition of the Journal of Acquired Immune Deficiency Syndromes. Based on the findings of this study, the Thai public health ministry has expanded its provision of sexual health services for HIV-positive individuals.

Access to antiretroviral therapy has expanded greatly in Thailand in recent years. Anti-HIV treatment can reduce viral load in genital fluids, but improved health resulting from successful antiretroviral therapy can increase levels of sexual activity and risk taking. Although HIV prevention initiatives are increasingly being incorporated into routine HIV care in richer countries, there are limited data on the HIV transmission risks of individuals receiving antiretroviral therapy in resource-limited countries.

It is well known that sexually transmitted infections increase the risk of an HIV-positive individual transmitting the infection to others during unprotected sex, and it is estimated that 25% of HIV transmissions could be averted by treatment for sexually transmitted infections with sexual health screens now recommended as part of routine HIV care in the United States.

In Thailand, however, few individuals receive sexual health services as part of their HIV care. Accordingly, investigators in Bangkok scaled-up the level of service they provided, and screened HIV-positive women attending an infectious diseases clinic and a sexual health clinic for sexually transmitted infections between 2003 and 2004. The women who underwent screening were also asked about their sexual risk activities and condom use.

A total of 272 HIV-positive women were invited to have a sexual health screen and 210 agreed. Most of the women (150) were receiving their HIV care at the infectious diseases clinic.

Sexually transmitted infections were detected in 30 women (14%), the most common being genital ulcerative disease. Unsurprisingly, there was a higher prevalence of sexually transmitted infections amongst women attending the sexual health clinic (30%) than the infectious diseases clinic (8%; difference highly significant, p < 0.001).

The prevalence of genital ulcers was significantly higher amongst women with a CD4 cell count below 200 cells/mm³ (11% versus 1%, p = 0.004) and the investigators speculate that these ulcers were caused by herpes simplex virus-2. The provision of aciclovir therapy would, the investigators write, not only improve the quality of life of these women, but also significantly reduce the risks of onward HIV transmission.

Sexual activity in the preceding three months was reported by 116 (55%) women. Of these, 42 (36%) said that they did not use a condom at least once during the last three months. All but three of the sexually active women had a regular partner and 64 women (54%) reported that they knew the HIV infection status of their partner, with 20 (31%) saying their partner was HIV-negative.

Antiretroviral use was significantly associated with increased condom use (82% versus 58%, p < 0.01). The investigators note that this result is in contrast to some studies involving gay men in western countries where the use of antiretroviral therapy was associated with more sexual risk-taking.

“Almost 10% of women attending the infectious disease clinic had an STI, and it seems appropriate to screen these women as part of their initial HIV evaluation, with intervals depending on risk factors”, write the investigators. Although few clinics will have the resources to test for infections such as gonorrhoea and chlamydia using the most sensitive tests, the investigators note that all clinics should be able to conduct visual examinations for genital ulcers.

The high rate of unprotected sex between couples was noted by the investigators. They comment, “this emphasises the need for strengthening prevention of HIV transmission among couples.”

HIV treatment and care provided by the Thai government now includes sexual health screening and “data on STIs and risk behaviours are to be routinely collected in the context of antiretroviral treatment and used to plan a national strategy for prevention of HIV transmission among HIV-infected persons.”