TITTLE: STDs set to be the new accelerator for the prevalent HIV.

INTRODUCTION
As time goes on, countries around the world become more industrialized and
modernized. As part of it, life of people became more easy when modern
technologies introduced to them. However, as these continue to multiply problems
unbalancing the society exists too. Nowadays, issues regarding reproductive health
are being published in newspapers to television and radios around the world. People
around the world are aware about the existence of this pandemic infections, but do
they really know how this diseases being acquired? How aware they are? This
became a public health problem to both industrialized and developing countries
around the globe (Marr, 2006). Mostly in many developing countries like South Africa
and other neighbouring countries had their rampant cases of Sexually Transmitted
Infections (STI’s) due to exploitation and human trafficking and considering the poor
management of National Health Department in implementing different programs to
control the spread of this infection.
Sexually transmitted disease also known as Sexually Transmitted Infection (STI) or
Venereal Disease (VD) is an illness that has significant of transmission between
humans or animals by means of human sexual behaviour, including vaginal
intercourse oral sex and anal sex. While in the past, these illnesses have mostly
been referred to us STD or VD, in recent years the term sexually transmitted
infection has been preferred, as it has a broader range of meaning; a person may be
infected and may potentially infect others, without showing signs of disease. Some
STI’s can also be transmitted via the use of needles after its use by an infected
person.
World health organisation WHO stated that sexually transmitted infections (STIs) are
infections that are spread primarily through person-to-person sexual contact.
Sexually transmitted infections have impact in all dimensions of person’s life. STI can
negatively influence a person’s self-concept and may profoundly affect a person’s
entire life and his family. Society, often associate STI’s with discrimination and
socially unacceptable behaviours. This makes most persons afflicted with STI
hesitate immediate treatment and often the disease is on its progress stage before
the infected individual finally decides to consult health care practitioners. Therefore,
health organizations need to educate high risk individuals on prevention of STI’s.
Furthermore, health practitioners need to be alert to indicators of STI’s since
prognosis can be influenced by early diagnosis and treatment (Butler,1997).
Sexual assault is defined as unlawful sexual intercourse with a woman by force or
against her will. It includes penetration of the vagina or anus with a penis or other
objects, touching the perineum, vagina, anus or oral sex. Sexual violence/ assault
can have a profound impact on the physical, psychological, and social wellbeing of
rape survivors. In addition to immediate genital and bodily injuries, risks include HIV
and other sexually transmitted infections, unwanted pregnancy, urinary tract
infections, chronic pelvic pain, miscarriage, depression, substance abuse, post-
traumatic stress disorder, and suicide. International guidelines specify the central
role of the health sector in providing comprehensive clinical care after sexual assault
(Handsfield , 1991).
There are more than 30 different sexually transmissible bacteria, viruses and
parasites. The most common conditions they cause are gonorrhoea, Chlamydia
infection, syphilis, trichomoniasis, chancroid, genital herpes, genital warts, human
immunodeficiency virus (HIV) infection and hepatitis B infection.
SYPHILIS
Is a sexually transmitted genital ulcerative disease caused by the bacterium
Treponema pallidum. It can also spread to a foetus from an infected mother during
pregnancy causing congenital syphilis. Syphilis presents in four different stages:
primary, secondary, latent and tertiary. In Nairobi province syphilis prevalence rate is
1.7% among reproductive age group 11. A positive syphilis test in survivors of sexual
assault indicates a prior infection and therefore puts the perpetuator at risk of getting
infected.
PRIMARY SYPHILIS: is acquired via direct sexual contact with the infectious lesions
of another person. Approximately 3 to 90 days after initial exposure, a skin lesion
appears at point of contact which is a firm, painless, non-itchy skin ulceration with a
clean base and a sharp border between 0.3 and 3 cm in size. This lesion may persist
for 3 to 6 weeks without treatment. SECONDARY SYPHILIS: Occurs 4 to 10 weeks
after primary infection. It may be asymmetrical reddish pink non itchy rash on the
trunk and extremities including sores and palms. Other manifestations are fever,
sore throat, malaise, weight loss and headaches. Rare presentations include
hepatitis, optic neuritis, uveitis, kidney disease, arthritis and interstitial keratitis. Acute
symptoms resolve in 3 to 6 weeks.
TRICHOMONAS VAGINALIS
Trichomonas vaginalis is the causative agent of trichomoniasis. It accounts for 4 to
35 percent of vaginitis diagnosed in symptomatic women presenting in primary care
settings.The prevalence of trichomonas vaginalis infection in reproductive aged
women in the US was best illustrated by a study in which 3754 women aged 14 to 49
years selfcollected vaginal swab specimens that were subsequently evaluated for
the presence of T. Vaginalis using PCR. The overall prevalence of T. vaginalis was
3.1 percent, and increased with age. Prevalence was highest in non-Hispanic black
women (13.3 percent) and lowest in non-Hispanic white women (1.3 percent) 5 The
annual incidence in the United States has been estimated to be three to five million
cases 9 In Kenya a study done on STIs among sex workers in 1999 found a
prevalence rate of 13.95 % for trichomoniasis. In another study by (J Grimes, 2008).
the prevalence of trichomoniasis among pregnant women was 23%.12 It is a
flagellated protozoan which is found in the vagina, urethra and Para urethral glands
of infected women.The classical signs and symptoms include purulent malodorous
thin vaginal discharge associated with burning sensation, pruritus, dysuria,
dyspareunia and even post coital bleeding. In 10% to 30% of symptomatic women,
the PV discharge is green frothy foul smelling.
Physical examination reveals erythematous vulva and vaginal mucosa, punctuate
haemorrhages with straw berry cervix. Complications of untreated trichomonas’s
include tubal infertility, cervical neoplasm, PPROM, preterm labour and increases
risk of HIV infection

GONORRHEA
Gonorrhoea is a bacterial infection. It is a sexually transmitted infection caused by
Neisseria gonorrhoea. This infection remains a significant cause of preventable and
treatable morbidity and mortality in women. This infection present post rape indicates
a high possibility of having been acquired during rape. It affects any part of the
female reproductive system with the cervix being the commonest site. Other sites
include the pharynx and anorectal region. WHO estimates that 62.35 million cases of
gonococcal infections are diagnosed annually worldwide. An estimated 700,000 new
gonococcal infections occur annually in United States with higher rates in developing
countries. The prevalence of gonorrhoea in Kenya in 2001 was estimated to be 1.8%
to 11. It is usually asymptomatic infection in 50% women with gonococcal urethritis
accounting for 10% of cases of dysuria among urban women in absence of PID. The
main symptoms of gonorrhoea in women are PV discharge, dysuria, dyspareunia,
lower abdominal pains and intermentrual bleeding. The commonest complications
are PID in 10% - 40% of women with cervicits, chronic pelvic pains, ectopic
pregnancy, infertility, pelvic abscess and gonococcal 19 arthritis. In pregnancy it
causes PROM, preterm labour and ophthalmia neonatorum to the newborn.
Gonococcal infection increases risk of HIV infection by 3-5 times (Lipchitz ,2007).
HEPATITIS B INFECTION
Hepatitis is an infectious infection caused by Hepatitis B virus (HBV) which infects
human liver. Approximately 2 billion people in the world have been infected with
hepatitis B virus; this includes 350 million chronic carriers of the virus. Its
transmission is through exposure to infectious blood or body fluids including semen
and vaginal fluids. A positive Hepatitis B test in a sexual assault survivor indicates a
prior infection and hence the perpetuator is at risk of infection.
SIGNS AND SYMPTOMS
ACUTE ILLNESS: acute infection with GBV causes liver inflammation, vomiting,
jaundice and acute liver failure leading to death. Hepatitis B has also been linked to
development of membranous glomerulonephritis (MGN).
CHRONIC INFECTION: chronic hepatitis B causes liver cirrhosis and liver cancer- a
fatal disease with poor response to current chemotherapy (Lanham ,2014).

HIV
Human immunodeficiency virus infection is non curable retro viral disease spread
through sexual intercourse, blood products and other body fluids. It can also be
transmitted from mother to child during pregnancy or breastfeeding. An estimate of
5.7 million people are living with HIV in South Africa according to (Judith A,2007).
TRANSMISSION: HIV is transmitted through exchange of infected blood and blood
products or other body fluids which include semen, vaginal secretions and breast
milk. Sexual intercourse is the highest mode of transmission followed by shared
needles in drug abusers. Receptive vaginal intercourse presents a risk of 0.1 to 0.2%
HIV transmissions. HIV increases the risk of lower genital malignancies Several, in
particular HIV and syphilis, can also be transmitted from mother to child during
pregnancy and childbirth, and through blood products and tissue transfer (Feinstein
S, 2003).

LITERATURE REVIEW
STIs continue to be a major concern in public health because of their high incidence
and prevalence. Globally WHO reported that an estimated half a billion-people aged
15-49 are infected each year with curable STIs including Syphilis, Gonorrhea,
Chlamydia and Trichomoniasis (WHO, 2015). Moreover, STIs are not only a
common cause of severe complications leading to infertility but also increase the
probability of HIV transmission. In particular Syphilis infections can considerable
increase the risk of HIV transmission by more than 40% (WHO, 2007). In recent
research done by WHO syphilis is said to increase the risk of HIV acquisition three-
fold more. It is also estimated that there are 357 million new infections each year
with 1 of the top for STIs, Chlamydia (131 million), Gonorrhea (78 million), Syphilis
(5.6 million), Trichomoniasis (143 million), on average daily more than 1 million
people acquire a new STI (WHO, 2015)
Although the above statistics are shocking, the reported STIs are however just a tip
of the iceberg because most infections are entirely asymptotic or unrecognized
especially for women (Petermen et al., 2006). Moreover because of the difficulty in
accessing high risk groups with high prevalence of STIs, insufficient information
about their sexual risk behaviors have boosted the STIs rates significantly (Laaman,
1994). Additionally, the distribution of these STIs is not static but depends on the
changing patterns in the transmission between and within various subpopulations
(WHO, 2007). More specifically, STIs are transmitted between high risk persons with
high prevalence and frequent changes in sex partner such as female sex workers ().
In terms of epidemic STIs are spread rapidly from a higher to a lower risk person.
Since AIDS was first recognized in the early 1980s about 35 million people have died
of AIDS and nearly 70 million have been infected with HIV. Consequently HIV/AIDS
has become one of the worst global epidemics. Despite many HIV treatment and
prevention programs, the number of people living with HIV has increased gradually
from around 8 million in 1990 to 36.9 [34.3- 41.4] million at the end of 2014.
Moreover, it was estimated about 2 million people were newly infected with HIV in
2014 (UNAIDS, 2015). HIV remains the deadliest pandemic that has resulted in
increase in many countries death rate.
Ongoing research however reveals more shocking statistics, providing the link
between STI and HIV. According to a survey conducted by WHO in 1999,
epidemiological studies have shown that persons with ulcerative and non-ulcerative
STI are more susceptible to HIV. People with HIV and non-ulcerative STI have
increased shedding of HIV-infected cells and greater efficiency in transmitting the
virus. In particular, genital ulcer disease (GUD) has been shown as a co-factor in the
transmission of HIV. Sexually transmitted infections that cause genital inflammation
have been shown to increase the efficiency of HIV transmission as much as fivefold.
Treatments of STI and health education, including correct condom use, are efficient
and cost effective ways to prevent HIV epidemics.
There is a strong association between bacterial and viral sexually transmitted
infections and both the acquisition and transmission of HIV infection. This was first
demonstrated in case series and retrospective studies that showed an association
between previous sexually transmitted infections (STI) and human immunodeficiency
virus (HIV) (Weber et al., 1986). Prospective studies strengthened this observation
by showing a link between STI and incident HIV infection, with the strongest relative
risks for genital ulcer disease but potentially large attributable risks from more
common inflammatory conditions such as trichomoniasis (Cameron et al.,
1989).Such evidence has continued to accumulate over the decades, but has
remained difficult to interpret because of confounding due to shared risk factors,
particularly sexual behavior, and difficulties in determining temporal relationships
(Rottingen et al., 2001)
In addition to the epidemiological evidence, biological findings support the
mechanisms for STI increasing HIV acquisition and transmission through direct
mucosal disruption, recruitment of HIV target cells to the genital tract, and by
increased HIV load in plasma and genital secretions. Further synergies are
described whereby HIV can alter the natural history of some STI (Fox & Fidler,
2010). These observations, together with the fact that HIV itself is a sexually
transmitted infection, have underpinned calls for STI management to be an essential
part of HIV control programs. However, results of intervention studies have been
disappointing. Several large, well conducted trials of enhanced STI treatment and
care have failed to show a consistent impact on HIV incidence.
Wadd and Ronn confirmed the association between STI and HIV as they base their
research on that evidence of the association comes from ecological, cross sectional,
case control and cohort studies (Wadd and Ronn, 2010). However, most of these
designs, with the exception of cohort studies, are unable to distinguish between
causation, reverse causation and confounding due to a common causal pathway,
(Rottingen et al., 2001) although some have tried to do this through using innovative
designs. The ecological association between HIV and STI has been reported in the
USA, where higher rates of HIV occur in African American than white or Hispanic
populations (Hall et al., 2008) which is thought to be in part due to the
disproportionate burden of STI in this group (Adimora et al., 2009).
In Belgium there are also overlapping epidemics in men who have sex with men
(MSM) where there are high numbers of HIV diagnoses and of incident STI (Sasse &
Defraye, 2009). Such associations are subject to ecological fallacy, but similar
findings are reproduced in individual-based cross sectional studies, including in
African American drug using women in the USA and clients of female sex workers in
Mexico (Miller et al., 2008) Braunstein and colleagues reviewed data around HIV
incidence in sub-Saharan Africa; 18 of 22 studies looking at the impact of current or
recent STI found an increased HIV risk, the remaining 4 found no association. The
highest STI risk was found for HSV-2 seropositivity (Braunsten et al., 2009).
Globally, the most frequent cause of STD-related GUD is genital herpes, followed by
syphilis, then chancroid. While lymphogranuloma venereum (LGV) has recently
emerged (or been increasingly recognized) in the U.S. and Western Europe.
Syphilis
It is caused by Treponema pallidum. The primary lesion of syphilis, called a
“chancre”, is the stage characterized by genital ulcer disease. Multiple chancres are
possible though much less common. A syphilitic chancre occurs at the site of
inoculation, which is dependent upon the type of sexual activity engaged in by the
patient. Therefore, a primary chancre may be found at the oral, anal or perianal site
(and other sites as well). Recent research reveals that rates of syphilis continue to
rise, particularly among men who have sex with men (MSM), and most significantly
among MSM co-infected with HIV and black MSM
Genital herpes
The majority of genital and perianal herpetic outbreaks in the U.S. are caused by
HSV-2, though 10-50% of first episodes are due to HSV-1. HSV-2 seroprevalence
rates show a correlation with level of sexual activity (e.g., number of lifetime sexual
partners). Research also reveals that, HSV-2 is more common in HIV-infected
persons and adults of lower socioeconomic status.
Chancroid
Infection caused by Haemophilus ducreyi. Very low incidence in the U.S. Most
current cases in the U.S. are acquired from foreign sources. Demographic and
behavioral factors associated with a higher incidence of chancroid include, lower
socioeconomic status, commercial sex work or contact with commercial sex workers,
male gender (male: female ratio is 10:1), and uncircumcised men. Chancroid
infection is endemic in regions of Africa, Southeast Asia, India, South America and
the Caribbean
The above research reveals the interaction between certain STIs and HIV. It is clear
from the above information that the highlight common cause of the prevalence rates
of these STIs increasing is due to impacts considered as boredom in society like
commercial sex workers and males having sex with males. Consequently because of
stigma and discrimination they are reluctant to access health services for
examination and treatment. Such barriers increase the risk of contracting STI and
increase the risk thereof of HIV (Khuat et al., 2004).
If the following statistics continue to increase, it will thus imply that all STI patients
are positive for HIV especially if they have gonorrhea, syphilis, herpes or chancroid.
PROBLEM STATEMENT
The increase in HIV prevalence rate in recent years is analogous to increase in STIs
prevalence rate.

AIM OBJECTIVE
To determine why sexually transmitted diseases are set to be the new accelerator of
the prevalent HIV, and what are the consequences of this acceleration. Due to the
impact of growing population of people with STI’s what can be done to prevent/ solve
this problem.

SPECIFIC OBJECTIVE
 To determine the type of STDs that leads to HIV infection.
 To determine how HIV and other STDs are so closely linked.
 To determine how these STDs can increase both a HIV-negative person’s
risk of becoming infected with HIV and an HIV-positive person’s risk of
transmitting HIV to someone else.
 To determine how STDs may be undermining our HIV prevention strategies,
and what we can do about it.

RESEARCH HYPOTHESIS

 Sexual transmitted diseases enhance HIV transmission

 A sexual transmitted disease increases the risk of acquisition of HIV.

METHODOLOGY
An STI prevalence assessment is a determination of the number of person Infected
with an STI among persons screened in defined populations. A prevalence rate is a
measure of frequency of existing disease at a given time in a specific population, and
is defined as:
P = total number of cases of disease at a given time
Total population at the same time

Once a decision is made to conduct the prevalence study, a principal investigator will
need to be identified. The primary role of the principal investigator will be to organize
and conduct the prevalence study. The principal investigator needs to have past
research experience in conducting epidemiological studies and a Clinical, laboratory
or management background in sexual or public health.

RECOMMENDED STI FOR INCLUSION IN THE SURVEY

Treponema pallidum (syphilis), Neisseria gonorrhoea (gonorrhoea), Chlamydia
trachomatis (chlamydia), Trichomonas vaginalis (trichomonas) and HIV have all
been classified as high priority for inclusion in the STI prevalence survey. The first
four STI are curable, because considerable adult and infant morbidity and mortality
are spread primarily by sexual transmission and are often asymptomatic in women.
HIV testing will also often be included in the survey.

INFORMATION TO BE COLLECTED
The minimum information needed for the prevalence study is listed below. Additional
data elements can be collected at some sites which will provide more detail of
patient demographics, risk characteristics and diagnoses. Minimum data elements
for an STI prevalence study are:
 study identification number;
 study site;
 date of specimen collection;
 sex; and
 Date of birth or age to be determined by study population.

STUDY DESIGN
The most appropriate study design for the STI prevalence survey is a cross-
Sectional study. Cross-sectional studies are observational studies in which a sample
of subjects in a population (e.g., pregnant women attending an antenatal Clinic) are
investigated for specific characteristics, in this instance laboratory confirmed STI.
Prevalence studies do not establish causality.
The proposed sample frame should include persons aged 15-49 years. Ideally, there
should be over-sampling of persons aged less than 25 years so that half the sample
is aged 15-25 years. The aim of over-sampling young persons is to determine
disease prevalence in those who are most recently sexually active. This also
provides a baseline for monitoring the impact of the STI and HIV epidemic in that
population.
DATA ANALYSIS
Data obtained from the interviews and the results of the laboratory tests should be
entered into and analysed using Epi-Info or appropriate computer software. The
principal investigator should be responsible for the development of a data entry
protocol and data entry template. To minimize data entry errors, a data entry
template should be developed that restricts the range of values that can be entered
for any data item and requires mandatory entry for all data fields. At a minimum, 10%
of the data should be double entered to review the level of data entry error. If the
error is higher than 10% then data entry procedures will need to be reviewed and the
accuracy of the data entry checked. This is critical because for some of the infections
the absence or presence of additional positive laboratory results may have wider STI
programme planning implications.
The results of the study should be analysed as follows for each study site:
1. number and proportion of persons with positive test results for each STI and
HIV;
2. Prevalence of the surveyed STI and HIV pathogens; and
3. Stratified by the population subgroup and where applicable by:
a. Age - which should be stratified into equal age groups such as 5-year or 10-
year age groups depending on the sample size?
b. Sex
4. Where indicated odds ratios should be calculated with 95% Confidence
intervals and/or the chi-square tests to assess the Association of variables
with a particular ST.
STUDY POPULATION
TABLE 1: POTENTIAL POPULATION FOR PREVALENCE STUDIES OF STI

Sample frame - proposed Risk category of Characteristics of

types of population population subgroup population subgroup
subgroup

Female sex workers Core (high-risk) infection High rates of

•Brothel transmission subgroup – a
•Massage parlours/bars small subgroup of people
•Casual freelance experiencing infections
Injecting drug users in who
specific populations are responsible, either
directly
Male sex workers or indirectly for a large
•Casual freelance number
•Sex with men/women of
STIs in the general
population.
STIs compared
to the general population;
high rates of partner
change;
longer duration of
infection;
poorer access to health
care
facilities; very efficient
transmission of STI per
sexual
exposure

STI clinic (equivalent) Bridging (medium-risk) Assumed to include clients

clients subgroups that are of sex workers and/or sex
(usually males) characterized by sexual workers.
•Military contact with both the core
•Police transmission population
•Mobile populations and the low risk general
(e.g. transport workers, population.
fishermen) Often males who frequent
FSW and have at the
same
time a wife or girlfriend

Women attending Maintenance (low-risk) Low-risk sexually active

antenatal population subgroup who population. Equivalent to
clinics are the general sexually active
characterized by relatively population rate, gives an
lower rates of sexual indication of the level of
partners disease burden.
and concurrent
relationships, smaller
numbers of sexual
linkages, and relatively
limited contact with other
population subgroups.
Represent this population.
In most settings the likely high-risk (STI core transmission) subgroups will include
female and/or male sex workers and some mobile populations including fishermen,
transport drivers, seasonal labourers and the military. Another low-risk group are
pregnant women attending antenatal services, a convenient group similar to the
general sexually active population.

EXPECTED OUTCOME
Identification of skills needed to prevent STI transmission and optimal mechanisms
to impart those skills (i.e., what is the best way to increase consistent condom use
among individuals with STI’s who may be asymptomatic but shedding virus).
Determination of key norms that govern behaviours associated with STI transmission
and development of strategies to modify them (i.e., what are the norms governing
sexual intercourse during treatment for a bacterial STI, how do they vary by
subpopulation, and what intervention strategies would be effective to modify them).
Increase the adoption and diffusion of new and existing technologies to prevent
STI’s, such as barrier methods, that are compatible with human skills, dispositions,
and perceptions related to STI’s, including those technologies that can be controlled
exclusively by women (i.e. what characteristics of vaginal suppositories enhance or
discourage use among women, and which should be considered in the development
of new topical microbicides to prevent STI’s). Behavioural research is needed to
increase appropriate use of diagnostic tests. Given the high prevalence of
asymptomatic disease, effective strategies should encourage individuals to seek
STD screening on the basis of recognition of risk-related behaviour rather than
symptoms, which may not be present or recognized.

TIME FRAME

TASK WEEKS OR DAYS

TITTLE Wed-24

INTRODUCTION AND LITERATURE REVIEW Thur- 25-26

PROBLEM STATEMENT AND MAIN OBJECTIVES Sut- 26

SPECIFC OBJECTIVES AND RESEARCH Sut-26

HYPOTHESIS
METHODOLOGY Mon-28

EXPECTED OUTCOME Mon-28

REFFERENCES

 Adimora AA, Schoenbach VJ, Floris-Moore MA. Ending the epidemic of

heterosexual HIV transmission among African Americans. American Journal
of Preventive Medicine. 2009;37(5):468–471
 Braunstein SL, van de Wijgert JH, Nash D. HIV incidence in sub-Saharan
Africa: a review of available data with implications for surveillance and
prevention planning. AIDS reviews. 2009 Jul-Sep;11(3):140–156.
 Cameron DW, Simonsen JN, D’Costa LJ, Female to male transmission of
human immunodeficiency virus type 1: risk factors for seroconversion in
men. Lancet. 1989;ii:403–407
 Fox J, Fidler S. Sexual transmission of HIV-1. Antiviral Res. 2010
Jan;85(1):276–85. A comprehensive recent review of determinants of sexual
transmission of HIV.
 Grosskurth H, Mosha F, Todd J, et al. Impact of improved treatment of
sexually transmitted diseases on HIV infection in rural Tanzania: randomised
controlled trial. Lancet. 1995;346:530–536.
 H. Hunter Handsfield, 1991, Color Atlas and Synopsis of Sexually Transmitted
Diseases, page 83-88.
 Hall HI, Song R, Rhodes P, et al. Estimation of HIV incidence in the United
States. Jama. 2008;300(5):520–9.
 Jill Grimes, 2008, seductive delusions, vol 1, page 82-93
 Joe McIlhaney, Lanham B, Maryland Rowman & LIttlefield, 2014, what you
don’t know can kill you, page 87-92
 Laneen Haniah ,2013, STDs: Sexually Transmitted Demons vol 3 , page 230-
238,
 Lisa Marr M D, 2006, a johns Hopkins health text book ,2 nd edition, page 700-
702.
 Miller M, Liao Y, Wagner M, Korves C. HIV, the clustering of sexually
transmitted infections, and sex risk among African American women who use
drugs. Sexually transmitted diseases. 2008 Jul;35(7):696–702.
 Sasse A, Defraye A. HIV infections and STI co-infections in men who have
sex with men in Belgium: sustained increase in HIV diagnoses. Euro Surveill.
2009;14(47)
 Sevgi O. Aral, Judith A. Lipchitz , 2007, Behavioral Interventions for
Prevention and Control of Sexually Transmitted diseases , page 502-530.
 Stephen Feinstein, 2003, Sexuality and Teens: What You Should Know about
Sex, Abstinence and Birth Control, page 206-209.
 UNAIDS 2015, How AIDS changed everything : Global Strategies Fact 2004
 Weber JN, McCreaner A, Berrie E, et al. Factors affecting seropositivity to
human T cell lymphotropic virus type III (HTLV-III) or lymphadenopathy
associated virus (LAV) and progression of disease in sexual partners of
patients with AIDS. Genitourin Med. 1986;62(3):177–180.
 WHO 2007, Global Strategy for the prevention and control of STI 2006-2015:
factsheets STIs
 WHO 2015 Fact sheets STIs
 William T. Butler, R Eng and William T Thomas, 1997, the Hidden Epidemic:
Confronting Sexually Transmitted Diseases, Page 99-102.