International Journal of Gynecology and Obstetrics 123 (2013) 183–184

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Sexually transmitted infections and women’s sexual and reproductive health Sami L. Gottlieb ⁎, Lori M. Newman, Avni Amin, Marleen Temmerman, Nathalie Broutet Department of Reproductive Health and Research, WHO, Geneva, Switzerland

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Keywords: Prevention and control Reproductive health Sexually transmitted infections Women’s health

a b s t r a c t Sexually transmitted infections (STIs) are widespread globally and result in a large burden of sexual and reproductive health consequences that disproportionately affect women, including pregnancy complications, cancer, infertility, and enhanced HIV transmission. A new WHO publication, available online, outlines key points of action and new and future technologies for global STI prevention and control. Highlights from the WHO publication are described in the present article. © 2013 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.

1. Sexually transmitted infections: A call for action WHO estimates that 499 million new cases of curable sexually transmitted infections (STIs)—namely, gonorrhea, chlamydia, syphilis, and trichomoniasis—occurred in 2008 [1]. In addition, 536 million people are estimated to be living with incurable herpes simplex virus type 2 (HSV-2) infection [2] and approximately 291 million women have a human papillomavirus (HPV) infection at any point in time [3]. These data indicate that more than 1 million people acquire an STI every day. Complications of STIs have a profound impact on sexual and reproductive health and they disproportionately affect women, especially in resource-poor settings. Syphilis infection during pregnancy results in 305 000 fetal and neonatal deaths each year [4]. Infection with HPV causes an estimated 530 000 cases of cervical cancer annually [5]. Gonorrhea and chlamydia infections are important causes of pelvic inflammatory disease, ectopic pregnancy, and female infertility, while HSV-2 infection triples the risk of acquiring HIV infection [6]. In 2010, the UN Secretary-General’s Global Strategy for Women’s and Children’s Health included STI prevention in the comprehensive package of essential services for women [7]. A new WHO publication on STIs [8] outlines key points of action to ensure provision of these essential services and describes new and future technologies for STI prevention. Highlights from the WHO publication are presented here to encourage broad implementation and support for these critical prevention measures. 2. Current technological advances New rapid diagnostic tests for syphilis now make it feasible to eliminate a substantial proportion of the adverse outcomes of syphilis in pregnancy, which currently affect more than half a million women each year [4]. These tests are cheap, accurate, and easy to use in remote ⁎ Corresponding author at: Department of Reproductive Health and Research, WHO, 20 Avenue Appia, 1211 Geneva 27, Switzerland. Tel.: +41 22 791 33 36. E-mail address: [email protected] (S.L. Gottlieb).

settings, and enable women with syphilis to be identified and treated in a single visit. Basic prenatal care packages should be scaled-up to include syphilis testing for all pregnant women. Integration of syphilis and HIV testing, perhaps with new dual rapid tests, could help to achieve the goal of eliminating mother-to-child transmission of both infections. Safe and efficacious HPV vaccines have already shown benefit in some high-income countries but they have not yet been implemented in the countries with the most cervical cancer deaths [5,8]. Providing HPV vaccination to at least 70% of girls in low- and middle-income countries over the next decade could prevent 4 million deaths [9]. The GAVI Alliance has approved initial funding for HPV vaccination in selected lower-income countries but strong and consistent commitment will be needed at all levels to ensure universal access to the HPV vaccine.

3. Future technologies for prevention of sexually transmitted infections Rapid point-of-care diagnostics for gonorrhea and chlamydia are likely to become available soon, and are urgently needed in settings without laboratory infrastructure. Most gonorrhea and chlamydia infections have few or no symptoms and are largely missed by current symptom-based STI management strategies in resource-poor settings, leading to millions of pelvic infections and infertility. Continued development, validation, and implementation of new rapid STI tests are critical. Vaccines and microbicides against HSV-2 could have a major impact on HIV spread, given the strong synergy between these 2 infections [6]. Development and evaluation of new HSV-2 vaccines are ongoing. A tenofovir-containing microbicide gel halved the risk of HSV-2 infection in 1 trial, and data from additional trials are keenly awaited [10]. Multipurpose technologies preventing HIV, other STIs, and unintended pregnancies are highly desirable. Investment is also needed in the development of new drug regimens to treat gonorrhea. Antimicrobial resistance to cephalosporins, the last available class of first-line drugs effective against gonorrhea, is being increasingly reported. Without attention to the problem of drug-resistant

0020-7292/$ – see front matter © 2013 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. http://dx.doi.org/10.1016/j.ijgo.2013.09.013

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S.L. Gottlieb et al. / International Journal of Gynecology and Obstetrics 123 (2013) 183–184

gonorrhea, there may soon be no first-line treatment options for the estimated 106 million cases occurring each year [1].

4. Moving forward All of these STI prevention interventions will need to be implemented within a broad framework of sexual and reproductive health [8]. Sexual health education and condom promotion, especially for adolescents and young adults, provide the foundation for STI prevention and should continue to be strengthened. With advocacy to normalize conversations about sex and sexuality, fight stigma associated with STIs, address gender inequality and gender-based violence, and promote human rights, STI services can be implemented and framed as what they are: essential components of routine healthcare.

Conflict of interest The authors have no conflicts of interest. The authors alone are responsible for the views expressed in the article, which do not necessarily represent the decisions or policies of WHO.

References [1] WHO. Global prevalence and incidence of selected curable sexually transmitted infections – 2008. http://www.who.int/reproductivehealth/publications/rtis/ stisestimates/en/index.html. Published 2012. Accessed June 11, 2013. [2] Looker KJ, Garnett GP, Schmid GP. An estimate of the global prevalence and incidence of herpes simplex virus type 2 infection. Bull World Health Organ 2008;86(10):805–12. [3] de Sanjosé S, Diaz M, Castellsagué X, Clifford G, Bruni L, Muñoz N, et al. Worldwide prevalence and genotype distribution of cervical human papillomavirus DNA in women with normal cytology: a meta-analysis. Lancet Infect Dis 2007;7(7):453–9. [4] Newman L, Kamb M, Hawkes S, Gomez G, Say L, Seuc A, et al. Global estimates of syphilis in pregnancy and associated adverse outcomes: analysis of multinational antenatal surveillance data. PLoS Med 2013;10(2):e1001396. [5] GLOBOCAN. Cervical cancer incidence and mortality worldwide in 2008. http://globocan.iarc.fr/factsheets/cancers/cervix.asp. Accessed June 11, 2013. [6] Freeman EE, Weiss HA, Glynn JR, Cross PL, Whitworth JA, Hayes RJ. Herpes simplex virus 2 infection increases HIV acquisition in men and women: systematic review and meta-analysis of longitudinal studies. AIDS 2006;20(1):73–83. [7] UN Secretary-General. Global Strategy for Women’s and Children's Health. http://www. who.int/pmnch/topics/maternal/20100914_gswch_en.pdf. Accessed June 11, 2013. [8] WHO. Sexually transmitted infections (STIs): the importance of a renewed commitment to STI prevention and control in achieving global sexual and reproductive health. http://www.who.int/reproductivehealth/publications/rtis/rhr13_02/en/index. html. Published 2013. Accessed June 11, 2013. [9] Goldie SJ, O'Shea M, Diaz M, Kim SY. Benefits, cost requirements and costeffectiveness of the HPV16,18 vaccine for cervical cancer prevention in developing countries: policy implications. Reprod Health Matters 2008;16(32):86–96. [10] Tan D. Potential role of tenofovir vaginal gel for reduction of risk of herpes simplex virus in females. Int J Womens Health 2012;4:341–50.

Sexually transmitted infections and women's sexual and reproductive health.

Sexually transmitted infections (STIs) are widespread globally and result in a large burden of sexual and reproductive health consequences that dispro...
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