STD rates began rising long ago, say researchers

Study shows at-risk behavior is long-term trend

Although recent increases in some sexually transmitted diseases (STDs) have worried public health officials about how this could signal a rise in new HIV cases, a new study shows that risk behavior among HIV-positive people has been a problem for at least a decade.

"Recent trends in syphilis have provided data that made people think we need to focus more on prevention among positives," says Emily J. Erbelding, MD, MPH, chief of clinical services for the Baltimore City Health Department and assistant professor in the division of infectious diseases of the department of medicine at Johns Hopkins University School of Medicine in Baltimore.

Unfortunately, prevention programs targeting HIV-infected people would have been a good strategy to start even before the introduction of highly active antiretroviral therapy, which some health care officials suspect has led to increasing risk behaviors among those at risk for HIV, as well as among those who already are infected.

The study found that 13.9% of 796 men with HIV who were seen between 1993 and 1998 at STD clinics in Baltimore developed an STD after their first HIV diagnosis. The same was true of 11.9% of the 354 women included in the clinical cohort.1

"These were people who came to the STD clinics and were diagnosed HIV-positive through routine counseling and testing," Erbelding says. "These were just people coming in for clinical care, and after learning they were HIV-positive, they were counseled, and later came back to the clinic with a new STD."

This suggests that a significant percentage of HIV-positive people continued their risky behavior despite knowing their positive serostatus and despite being counseled on how to prevent transmission to others, Erbelding says.

"Among men who have sex with men [MSM], we’re seeing rising rates [of syphilis], and in many cities we’re noticing these epidemics," Erbelding says. "Syphilis is a biological marker of risk behavior, and we think it’s a change, because there’s a shift to seeing more in MSM."

Because there is a lack of good behavioral surveillance on the national level, public health officials use syphilis data to draw conclusions about behavior, Erbelding says.

Prevention programs targeting HIV-positive people are fairly new, but those who have been working in the STD field have known all along that many HIV-positive people struggle with behavior change after learning their serostatus, says Patricia Ann Coury-Doniger, FNP. She is director of the Center for Health and Behavioral Training and the STD/HIV Program at the University of Rochester (NY). The Monroe County Health Department collaborates with the university to provide the services.

"It was taboo to talk about it within the HIV field," Coury-Doniger says. "Nobody could talk about the fact that some people with HIV were not practicing safer sex."

But STD health care officials regularly saw evidence of risk behavior among HIV-positive patients.

"Within the STD world, we saw HIV-infected people coming to our clinic who told us they were not practicing safe sex, and they had infections, so you couldn’t ignore the evidence," Coury-Doniger says. "From a behavioral standpoint, it only made sense."

Research has consistently shown that about 30% of HIV-positive people reduce their risk behaviors after learning their serostatus, but that leaves a large number of people who haven’t made that behavioral shift, Coury-Doniger says.

One solution would be to integrate STD and HIV services to meet the need for intensive interventions aimed at co-infected populations, she says. 

What the Baltimore study suggests is that the whole issue of funding HIV prevention vs. HIV treatment is a false dichotomy, and clinicians working with HIV populations need to think differently now, Erbelding says.

"By improving prevention efforts, we can decrease the chance that HIV-positive people will transmit HIV to others," Erbelding says.

"I think young gay men, particularly racial minority groups at high risk or young men who don’t identify as gay but have MSM experiences, and young injection drug users, are the groups I’d try to focus prevention services on," Erbelding says. "They probably have other STDs, so their chances of transmitting to others is enhanced because of the fact of their having STDs."

Researchers are working on developing prevention strategies for seropositive people that can be implemented during brief clinical visits, Erbelding says.

Another strategy is for clinicians to regularly screen HIV patients for STDs, which would provide an opportunity for continued prevention counseling and could help prevent public health problems that occur when HIV-positive people engage in risk behaviors and have STDs that can increase the risk of HIV transmission, Erbelding says.

The cost of screening for most STDs is less than $20, while the HIV viral load test costs a minimum of $80-$90, so an annual screening for syphilis, gonorrhea, and chlamydia should not be cost-prohibitive, Erbelding adds.


1. Erbelding EJ, Chung SE, Kamb ML, et al. New sexually transmitted diseases in HIV-infected patients: Markers for ongoing HIV transmission behavior. JAIDS 2003; 33: 247-252.