COMMENTARY

HIV and STIs: Interactions in Resource-Limited Settings

Edsel Maurice T. Salvana, MD, DTM&H; Robert A. Salata, MD

Disclosures

December 06, 2011

In This Article

Epidemiologic Synergy and Global Sexually Transmitted Infections

Epidemiologic synergy between sexually transmitted infections (STIs) means that multiple concurrent STIs in a person is not an uncommon phenomenon.[1] Acquisition and transmission of HIV is affected by co-infection with other STIs, and vice-versa. A negative impact on CD4 count and viral load in persons living with HIV (PLWH) has been demonstrated for some STIs; and the immunosuppression associated with advanced HIV infection can make concurrent STIs more difficult to treat and control.[2] In the context of a global AIDS epidemic, bidirectional interactions between HIV and these diseases is a potentially lethal combination.

From a worldwide perspective, the largest burdens for both HIV and most STIs fall squarely in resource-limited settings, particularly sub-Saharan Africa and South/Southeast Asia.[3] The dearth of modern diagnostics and treatment in these areas means that otherwise manageable infections continue to produce unnecessary suffering and death. Rollout of antiretroviral treatment has been moderately successful, but access to quality and competent care remains unsatisfactory in most of these countries.

Foremost among the factors that increase the risk for HIV acquisition are those associated with ulcerative STIs, including genital herpes, lymphogranuloma venereum, primary syphilis, and chancroid.[4] The mechanism of increased risk is primarily the breakdown in the skin and mucosa, resulting in higher recruitment and exposure of susceptible cell targets. Fragile blood vessels can rupture and serve as portals of entry for the virus to infect susceptible cells by means of the circulation. However, other factors have been found, including an increase in the absolute number of HIV-susceptible cells, and higher viral loads in the genital secretions of persons co-infected with HIV.[2,5]

Nonulcerative STIs interact with HIV as well. Because untreated HIV eventually leads to a severe immunocompromised state, disease progression for most STIs is faster and more severe, and susceptibility to new infection is probably higher. Nonulcerative STIs have likewise been shown to increase the risk of acquisition of HIV, and increase HIV viral shedding.[2]

Although data exist for other STIs, the purpose of this article is to review the most common STIs that interact with HIV. Special attention has been given to the challenges these interactions present in resource-limited settings.

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