Holmes K K
Department of Medicine, University of Washington, Seattle 98122.
Proc Natl Acad Sci U S A. 1994 Mar 29;91(7):2448-55. doi: 10.1073/pnas.91.7.2448.
The three direct determinants of the rate of spread of sexually transmitted diseases (STDs) are sexual behaviors, the mean duration of infectiousness, and the mean efficiency of sexual transmission of each STD. Underlying ecological and behavioral factors that operate through one or more of these direct determinants lie on a continuum, ranging from those most proximate back to those more remote (in time or mechanism) from the direct determinants. Most remote and least modifiable are the historical stages of economic development that even today conspicuously influence patterns of sexual behavior. Next are the distribution and changing patterns of climate, hygiene, and population density; the global population explosion and stages of the demographic transition; and ongoing changes in human physiology (e.g., menarche at younger age) and culture (e.g., later marriage). More proximate on the continuum are war, migration, and travel; and current policies for economic development and social welfare. Most recent or modifiable are technologic and commercial product development (e.g., oral contraceptives); circumcision, condom, spermicide, and contraception practices; patterns of illicit drug use that influence sexual behaviors; and the accessibility, quality, and use of STD health care. These underlying factors help explain why the curable bacterial STDs are epidemic in developing countries and why the United States is the only industrialized country that has failed to control bacterial STDs during the AIDS era.
性传播疾病（STD）传播速度的三个直接决定因素是性行为、平均传染期以及每种性传播疾病的平均性传播效率。通过这些直接决定因素中的一个或多个起作用的潜在生态和行为因素处于一个连续统一体上，范围从最接近直接决定因素的那些因素到（在时间或机制上）离直接决定因素更远的那些因素。最遥远且最难改变的是经济发展的历史阶段，即使在今天，它仍显著影响性行为模式。其次是气候、卫生和人口密度的分布及变化模式；全球人口爆炸和人口转变阶段；以及人类生理（例如初潮年龄提前）和文化（例如晚婚）的持续变化。在连续统一体上更接近的是战争、移民和旅行；以及当前的经济发展和社会福利政策。最近或可改变的是技术和商业产品开发（例如口服避孕药）；包皮环切术、避孕套、杀精剂和避孕措施；影响性行为的非法药物使用模式；以及性传播疾病医疗保健的可及性、质量和使用情况。这些潜在因素有助于解释为什么可治愈的细菌性性传播疾病在发展中国家流行，以及为什么美国是艾滋病时代唯一一个未能控制细菌性性传播疾病的工业化国家。
