FEMS Immunology and Medical Microbiology 24 (1999) 431^435
Sexually transmitted diseases (STDs) in the world1
Ali Aḡac°¢dan a; *, Peter Kohl
a
b
b
Istanbul Faculty of Medicine, Department of Microbiology, 34390 C°apa, Istanbul, Turkey
Department of Dermatology and Venerology, Neuko«lln Academic Hospital, Berlin, Germany
Received 17 July 1998; revised 1 October 1998; accepted 5 October 1998
Abstract
Sexually transmitted diseases (STDs) represent a major public health problem in the world and the advent and increase of
human immunodeficiency virus infection during the last decade has highlighted the importance of infections spread by the
sexual route. The World Health Organization estimates that the global incidence in 1995 of new cases of selected curable STDs,
which are gonorrhea, chlamydial infection, syphilis and trichomoniasis, was 333 million. Control programs for STDs must
prevent the acquisition of STDs, their complications and sequelae and interrupt and reduce transmission. ß 1999 Federation
of European Microbiological Societies. Published by Elsevier Science B.V. All rights reserved.
Keywords : Sexually transmitted disease; Gonorrhea; Chlamydial infection; Syphilis ; Human immunode¢ciency virus
1. Introduction
Sexually transmitted diseases (STDs) are a major
health problem in the world. These diseases, including human immunode¢ciency virus (HIV) infection,
represent some of the most complex ones in modern
medicine. STDs exhibit a higher incidence and prevalence, an alarming rate of antimicrobial resistance,
a higher rate of serious complications and interaction with HIV infection in developing countries.
Failure to diagnose and treat traditional infections,
such as gonorrhea, chlamydial infections and syphilis
* Corresponding author.
1
From the conference ``Recent Advances in the Diagnosis
of Sexually Transmitted Diseases'', Istanbul, Turkey, June 10^
13, 1998.
which can have deleterious e¡ects during pregnancy
and on the newborn, is also common in these countries. Other complications especially in women, such
as pelvic in£ammatory disease, ectopic pregnancy,
infertility and cervical cancer, are large health and
social problems. In most developing countries, the
incidence and prevalence of STDs may be 20 times
higher than those in developed countries [1].
Point-prevalence studies are employed most widely
in the developing world. Such information is useful
but limited since it is not totally representative of the
whole population as it is obtained mostly from high
risk groups of individuals and/or patients. The developing world is a heterogeneous community, but it
has at least one common feature, that the STDs in
this community are expected to occur among those
between 20 and 40 years of age, in contrast to the
population of developed countries. The consequence
of this is not only a higher absolute incidence of
0928-8244 / 99 / $20.00 ß 1999 Federation of European Microbiological Societies. Published by Elsevier Science B.V. All rights reserved.
PII: S 0 9 2 8 - 8 2 4 4 ( 9 9 ) 0 0 0 6 0 - 7
FEMSIM 1049 23-6-99
432
A. Aḡac°¢dan, P. Kohl / FEMS Immunology and Medical Microbiology 24 (1999) 431^435
STDs in the developing countries but also a potentially worsening situation in the future [1^3].
2. Frequency of STDs in the world
STDs may be subdivided into curable and noncurable STDs. Curable STDs are Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum,
and Trichomonas vaginalis infections while non-curable STDs are of viral (HIV, herpes simplex virus
(HSV), human papilloma virus (HPV) and hepatitis
B virus) origin.
The World Health Organization (WHO) has been
responsible for surveying problems represented by
STDs and HIV infection. It estimates an annual total
of 333 million of new STD infections in adults. The
number of new cases is 12 million for syphilis, 62
million for gonorrhea, 89 million for chlamydial infections and 170 million for trichomoniasis [4], excluding genital papilloma virus infection which
WHO itself had previously estimated at 30 million
new cases per year and herpetic infection at 20 million (Table 1). Genital ulcers show a relatively higher
frequency among STDs, and chancroid followed by
syphilis is a major cause of genital ulcers in the developing countries. WHO projections for HIV infection show a current range of 15^20 million cumulative infections worldwide and it is projected that
cumulative worldwide totals of HIV infections will
reach 30^40 million by the year 2000 [1]. STDs were
concentrated in South East Asia with approximately
150 million new cases in 1995 and in sub-Saharan
Africa with 64 million. There was a signi¢cant deTable 1
The annual total of sexually transmitted diseases (excluding HIV)
Disease
Bacterial
Genital chlamydia
Gonorrhea
Syphilis
Chancroid
Viral
Genital papilloma virus
Genital herpes
Protozoan
Trichomoniasis
Total (million)
89
62
12
7
30
20
170
cline in the incidence of curable STDs such as syphilis and gonorrhea in developed countries during
1980^1991 [4]. These infections were either at a negligible rate in general or particularly absent in some
localities in these countries. In developing countries
in contrast, for example in the eastern part of Europe and especially in the recently independent states
of the former USSR, the situation was quite di¡erent. There has been an extremely rapid rise in the
noti¢cation of syphilis in the Russian Federation
reaching 86 per 100 000 in 1994 and 172 in 1995
with a 40-fold increase from 1989 to 1995. In contrast to the low prevalence of HIV infection in some
developing countries, such as those in Eastern Europe and the Middle East, the numbers of reported
HIV cases were considerably high in Poland and
Ukraine in 1994^1995 [5].
The prevalence of common STDs in developing
countries is very high in particular risk groups. Prevalence of gonorrhea can reach 50% among commercial sex workers (CSWs) and syphilis ranges from 23
to 32% for acute or previous infection, while C. trachomatis positivity can be as high as 25%. Prostitution is a particular driving force for STDs and HIV;
for example in Kenyan urban STD clinics, 60% of
men with a gonococcal urethritis or chancroid reported commercial sexual exposure as the probable
source of infection [1]. Prevalence rates of gonococcal infections among pregnant women range from
2 to 20% in Africa [6,7]. Although this infection is
a common STD in many developing countries, its
prevalence rate is very small in the developed world.
The prevalence rates of syphilis in pregnant women in some developing countries ranges from 1 to
20% [8]. Several African surveys showed that high
rates of trichomoniasis among pregnant women
were found, ranging from 10 to 30%. The prevalence
rates of this infection among CSWs were not signi¢cantly di¡erent from those in pregnant women.
Women and men attending STD clinics constitute
another high risk group and levels of infection are
considerably high as should be expected. Syphilis is a
treatable disease which can be diagnosed with a very
simple test, the fact that it is still prevalent in many
developing countries is unacceptable [2].
Most developing countries have also undertaken
HIV seroprevalence studies, particularly among
CSWs, intravenous drug users and pregnant women.
FEMSIM 1049 23-6-99
A. Aḡac°¢dan, P. Kohl / FEMS Immunology and Medical Microbiology 24 (1999) 431^435
High levels of infection in these groups are found in
most sub-Saharan African and South-East Asian
countries. There is a high rate of concurrent infection for HIV and other well known STDs in patients.
Rates as high as 70% of HIV infection are found in
African patients with STD, whereas the rates are
reaching 15^20% in patients with STD in Thailand
[9,10].
N. gonorrhoeae and C. trachomatis can now be
easily screened for by modern ampli¢cation techniques, even by self-obtained swabs and home-obtained urine specimens. 11.5% of female and 27.2%
of male STD clinic attenders in Baltimore, MD,
USA were positive for N. gonorrhoeae and 10.8%
and 13.8% respectively for C. trachomatis by COBAS
Amplicor System [11]. Sexually active female adolescents (1.5%) were positive for C. trachomatis in Antwerp, Belgium in a population-based study [12]. In
contrast in adolescents in the USA, the prevalence of
C. trachomatis was 13.3% among non-Hispanic
Blacks, 10.7% among Mexican Americans, and 5%
among non-Hispanic Whites. For syphilis the incidence rate is 1.4/100 000 in Germany, although
85% of the infections are not reported [13].
The global problem of STDs is in£uenced by a
number of factors: di¡erent infecting agents with
di¡erent host relationships and susceptibilities to
therapy, age group, social status, sexual orientation
and sexual behavior of infected persons in di¡erent
continents, countries and cultures in di¡erent time
periods, absence or presence of national prevention
programs and therapy guidelines, di¡erent medical
specialities dealing with STDs and last but not least
reliability of registry data. Pregnant women, sex
workers, recruits, STD clinic attenders and prisoners
are often studied populations.
3. STDs in Turkey: `as a model among developing
countries'
Nowadays in Turkey, knowledge of the epidemiology of STDs is very limited, except for reportable
diseases such as syphilis and HIV/AIDS, the reportable diseases for which contact tracing and treatment
of infected partners are enforced by law and also free
of charge, if patients cannot a¡ord the due cost in
Turkey. However, genital chlamydial infections
433
caused by C. trachomatis are not reportable and
the diagnostic tests are not free of charge [14].
Almost all case-¢nding activities on STDs have
centred around tertiary health care centers such as
university hospitals in metropolitan areas. The results of the ¢rst STD clinic set up at the DermatoVenerology Department, Istanbul Faculty of Medicine in Turkey were reported in 1989 [15]. According
to these results, a total of 586 STDs were diagnosed
in 495 patients. Among 81 patients, more than one
STD existed. No STD was found in 451 persons. The
frequently encountered diseases in female patients
were candidial and Gardnerella vaginalis vaginitis.
The most frequently encountered disease in male patients was syphilis. This disease was the fourth most
common infection among females. In males, the incidence of non-gonococcal urethritis followed syphilis and Ureaplasma urealyticum was found more frequently than C. trachomatis. Anti-HIV antibody was
found positive only in two male patients living
abroad.
The prevalence studies on STDs are generally focused on CSWs in Turkey. For instance, HSV infection prevalence was 3% [16]. In another study, syphilis prevalence among CSWs was reported to be 8^
21.1% [17]. This prevalence was found to be 16.6%
among Romanian CSWs in Turkey. The prevalence
of C. trachomatis was 12% in Turkish CSWs and
14.4% in Romanian CSWs in Turkey [18].
With the breakdown of communist rule in Eastern
European countries in the 1980s and the subsequent
disruption in socioeconomic conditions, there have
been substantial population shifts across national
borders. In Turkey, these shifts have included increases in the number of visitors from Bulgaria, Romania, Hungary, Poland and the countries formerly
known as Czechoslovakia, Yugoslavia and the
USSR. Due to recent changes in social migration,
the number of unregistered CSWs in Turkey has increased [18,19]. However, studies on STDs are very
limited among these groups. Further surveys for this
population are needed to determine the prevalence of
STDs.
The ¢rst case of AIDS was reported in 1985 in
Istanbul. The prevalence of HIV seropositivity
showed that it was very low in Turkey. According
to the Ministry of Health of Turkey, a total of 753
seropositive cases were reported from 1985 until De-
FEMSIM 1049 23-6-99
434
A. Aḡac°¢dan, P. Kohl / FEMS Immunology and Medical Microbiology 24 (1999) 431^435
cember 31, 1997 [20]; 254 of these 753 cases were
AIDS patients. When we evaluated the seropositivity
prevalence according to risk groups, homosexual and
bisexual cases were 68, intravenous drug users 84,
hemophiliac cases 14, transfusion recipients 34, heterosexual cases 333, in utero transmission 7 and unknown cases 213. The seropositivity distribution for
gender was determined as 563 for men and 190 for
women. As a center for AIDS/HIV con¢rmatory laboratory in Istanbul, Department of Microbiology,
Istanbul Faculty of Medicine, 23 844 people were
screened for HIV antibody from 1985 to 1987 [21];
200 sera out of these were found positive for HIV
antibody. In the same Department, a total of 235 698
sera were studied for HIV infection, 149 out of these
sera were positive [22].
In developing countries, the most important problem is insu¤cient sexual education. In Turkey as a
model among developing countries, sex and STDs
were taboo until the last few decades. However,
there are still some cultural values in this country
[15].
b
In order to manage these activities, national control programs, consisting of intervention strategies
and support components, are developed and implemented. These interventions in developing countries
include:
b
b
b
b
b
b
b
b
Prostitution, free sex and homosexuality are usually rejected by society. On the other hand, these
are very common in Turkey, especially in metropolitan areas;
To be a virgin is still an important factor for marriage;
To have an STD is still regarded as shameful;
Most STD patients prefer to hide their illnesses
and hardly ever consult a physician;
Most STD patients usually ask for drugs from
their friends or pharmacies;
Most STD patients go to a physician when serious
complications occur.
Actually the above-mentioned cultural values are
still problems in most developing countries [23^26].
Health promotion to change sexual behavior and
adoption of `safer sex' practices;
Adequate management of patients with STDs and
their sex partners;
Screening for HIV, gonorrhea, syphilis, and chlamydia in high risk groups known to have a high
prevalence of infection.
The control programs for STDs in developing
countries play an important role in the prevention
of these diseases. The control programs in the prevention of STDs in these countries should include:
b
b
Reducing duration of infectivity of those responsible for spread of disease.
b
b
b
b
b
b
b
Professional training;
Social, political and economic reforms;
Research projects (early detection programs);
Laboratory services (speci¢c laboratory technology);
Counselling centers;
Safer sex behavior models;
Treatment regimens;
Cost-bene¢t analysis.
In conclusion, in developing countries, in contrast
to developed ones, more funds for STD screening,
diagnosis, treatment and of course education are
needed. These should include the right combination
of medical, behavioral and social interventions.
References
4. STD control activities and programs
STD control activities can be classi¢ed into three
distinct categories:
b
b
Reducing rates of new sex partner acquisition;
Reducing susceptibility of exposed individuals;
[1] Adler, M.W. (1996) Sexually transmitted diseases : control in
developing countries. Genitourin. Med. 72, 83^88.
[2] Laga, M. (1994) Epidemiology and control of sexually transmitted diseases in developing countries. Sex. Transm. Dis. 21,
545^550.
[3] Cathpole, M.A. (1996) The role of epidemiology and surveillance systems in the control of sexually transmitted diseases.
Genitourin. Med. 72, 321^329.
FEMSIM 1049 23-6-99
A. Aḡac°¢dan, P. Kohl / FEMS Immunology and Medical Microbiology 24 (1999) 431^435
[4] World Health Organization (1995) WHO/64 Sexually Transmitted Diseases Three Hundred and Thirty-three Million New
Curable Cases in 1995. World Health Organization, Geneva.
[5] World Health Organization (1996) Epidemic of Sexually
Transmitted Diseases in Eastern Europe; Report on a WHO
Meeting. EUR/ICP/CMDS 08 01 01.
[6] Brunham, R.C. and Embree, J.E. (1992) Sexually transmitted
diseases: Current and future dimensions of the problem in the
Third World. In: Reproductive Tract Infections. Global Impact and Priorities for Women's Reproductive Health (Germanie, A., Holmes, K.K., Piot, P. and Wasserheit, J.N., Eds.),
pp. 35^58. Plenum Press, New York.
[7] Wasserheit, J.N. and Holmes, K.K. (1992) Reproductive tract
infections: Challenges for international health policy, programs and research. In: Reproductive Tract Infections: Global Impact and Priorities for Women's Reproductive Health
(Germanie, A., Holmes, K.K., Piot, P. and Wasserheit, J.N.,
Eds.), pp. 7^33. Plenum Press, New York.
[8] Mehaus, A. and De Schrijver, A. (1991) Sexually transmitted
diseases in the Third World. In: Recent Advances in Sexually
Transmitted Diseases and AIDS (Harris, J.R.W. and Forster,
S.M., Eds.), pp. 201^217. Churchill Livingstone, London.
[9] Over, M. and Piot, P. (1991) Health sector priorities review.
HIV infection and sexually transmitted diseases. In: Diseases
Control Priorities in Developing Countries (Jamison, D.T.
and Mosley, W.H., Eds.). Oxford University Press, New
York.
[10] Laga, M. (1993) STD control for HIV prevention. Abstract,
Ninth International Conferences on AIDS, 6^11 June, Berlin.
[11] Crotchfelt, K.A., Welsh, L.E., Pare, B. and Quinn, T.C.
(1997) Detection of C. trachomatis and N. gonorrhoeae by
the Cobas Amplicor system in female and male genitourinary
specimens. International Congress of Sexually Transmitted
Diseases, Seville (Abstract P811).
[12] Vandenbruaene, M., Vandenbulcke, P., Vuylsteke, B., Van
Dyck, E., Colebunders, R. and Laga, M. (1997) Prevalence
of Chlamydia trachomatis among secondary school students in
Antwerp. International Congress of Sexually Transmitted Diseases, Seville (Abstract P777).
[13] Mertz, K.J., McQuillan, G., Levine, W.C., Candal, D., Bullard, J. and Black, C.M. (1997) A pilot study of the prevalence
of chlamydial infections in a national household survey. International Congress of Sexually Transmitted Diseases, Seville
(Abstract P774)
435
ë . (1996) Gen[14] Aḡac°¢dan, A., Genc°, M., Badur, S. and Anḡ, O
ital chlamydial infections in Turkey. Proceedings of the Third
Meeting of the European Society for Chlamydia Research,
11^14 September, p/403.
ë zarmaḡan, G., Altinok, T., Yeḡenoḡlu, Y., Saylan, T. and
[15] O
Baransu, O. (1989) The results of the ¢rst STD clinic in Turkey. In: Dermatology in Europe, Proceeding of the 1st Congress of the European Academy of Dermatology and Venerology (Panconesi, E., Ed.), pp. 754^757.
[16] Yilmaz, G., Bozkaya, E., Tu«rkoḡlu, S., Badur, S. and C°etin,
E.T. (1991) Detection of prevalence of the herpes simplex
virus infection by cell culture and immunoassay. Klimik
Derg. 4, 72^73.
ë . (1993) Syphilis
[17] Aḡac°¢dan, A., Badur, S. and Gerikalmaz, O
prevalence among unregistered prostitutes in Istanbul, Turkey. Sex. Transm. Dis. 20, 237^27.
ë zarmaḡan, G.
[18] Aḡac°¢dan, A., Chow, J.M., Pashazade, H., O
and Badur, S. (1997) Screening of sex workers in Turkey for
Chlamydia trachomatis. Sex. Transm. Dis. 24, 573^575.
ë . and Mardh, P.A.
[19] Genc°, M., Aḡac°¢dan, A., Gerikalmaz, O
(1995) A descriptive study on Rumanian women prostituting
in Istanbul. Med. Derg. 104, 45^48.
[20] Anon. (1997) AIDS, Savas°|m Bu«lteni 25.
[21] Yilmaz, G., Badur, S. and C°etin, E.T. (1995) Seroprevalence
of HIV infection among people attending the HIV/AIDS Diagnostic laboratory for HIV antibody test since 1985 in Istanbul. Med. Derg. 104, 43.
ë zkan, E., Yilmaz, G. and Badur, S. (1998) HIV seropositives
[22] O
by transmission group in Istanbul since 1995. FEMS Symposium on Recent Advances in the Diagnosis of Sexually Transmitted Diseases, Program and Abstracts, p. 38.
[23] Temmerman, M. (1994) Sexually transmitted disease and reproductive health. Sex. Transm. Dis. 21 (Suppl. 2), S55^58.
[24] Galavotti, C. and Schnell, D. (1994) Relationship between
contraceptive method choice and beliefs about HIV and pregnancy prevention. Sex. Transm. Dis. 21, 5^7.
[25] Piot, P. and Islam, M.Q. (1994) Sexually transmitted diseases
in the 1990s. Global epidemiology and challenges for control.
Sex. Transm. Dis. 21, S7^13.
[26] Meheus, A. (1991) Diagnosis of STD in developing countries.
Uppsala J. Med. Sci. 50, 14^17.
FEMSIM 1049 23-6-99