Sexually transmitted infections: prevention and management.

In the early 21st century, STI and HIV have been linked inextricably. Although the focus of this article is STI, some discussion on the diagnosis and management of individuals with HIV infection is necessary. The history of HIV diagnosis in the workplace is checkered. The authors have seen cases of prospective workers being subjected to HIV testing without their knowledge as part of a pre-employment medical examination. If the test came back positive, the men were told that they would not be employed without explanation. This approach is a breech of the human rights of the individual being tested and cannot be condoned. Any HIV testing must be done with the full and informed consent of the individual, with counseling given before and after testing to enable individuals with HIV infection to seek care and protect their families and to give individuals without HIV infection counseling on risk reduction. Men and women who present with an STI are at risk for HIV infection. With increasing options for management and secondary prevention, it is important to recognize people who are at risk. This identification should be done through HIV VCT. The location, funding, and supervision of VCT sites related to workplace populations should be a subject for serious debate. Although fears of mass layoffs after HIV testing largely have been unfounded, it is natural for workers to be fearful, unless there is a clearly articulated policy stating that the company observes and enforces nondiscriminatory practices. The workplace examples show that syndromic STI management, allied to comprehensive prevention programs, can have a genuine and measurable impact on STI prevalence. The potential interventions and partners are listed in Table 2. A community-based, randomized study in Tanzania showed that the institution of a well-managed STI syndromic management program can reduce HIV incidence by up to 40%, in the context of a rising HIV epidemic. Presumptive STI treatment for female sex workers (see Box 1) may prove useful as a short-term measure to reduce high STI prevalence rates while more sustainable preventive and curative services are established. The laboratory diagnosis of STIs remains problematic in the face of commonly available technologies of limited sensitivity and specificity and often substandard quality-assurance practices. For these and other reasons, syndromic management became the recommended strategy for treating STIs. The availability of rapid, accurate, and inexpensive diagnostics, especially for cervical infections for women, would alter management recommendations. Work is being done by the WHO and others to develop and assess low-cost diagnostics. Managing STIs and altering the behavior that leads to STIs are essential elements of any HIV prevention and management program. The issues surrounding a practical, compassionate, and comprehensive HIV program can be difficult. Numerous publications exist to help program managers navigate these issues and appropriately tailor a program to the needs of individual organizations. Some of these publications are listed in the next section.