Tables

Table 1. Natural History of STDs
Table 2. Examples of Successful STD Programs, 1970–1992
Table 3. Treatment Costs for Syndromic Diagnosis
Table 4. Contraceptives and STDs: What Are the Choices?
Table 5. Estimated Costs of an Antenatal Syphilis Screening Program

Table 1. Natural History of STDs
Disease and Pathogen	First Symptoms	Incubation Period	Natural History/Sequelae	Transmissibility
Chancroid Haemophilus ducreyi	Women: Painful, irregularly shaped ulcers at entrance to vagina and around anus. May cause pain on urination or defecation, rectal bleeding, pain on intercourse, or vaginal discharge. May have no symptoms. Men: Painful, irregularly shaped ulcers on penis or tenderness in groin.	Usually 3 to 7 days; up to 10 days.	Ulcers disappear without treatment usually in about a month but may last to 12 weeks (335). Causes inguinal buboes (swollen lymph nodes in the groin) in up to one-half of cases (256).	People are infectious as long as they have ulcers. No transmission from mother to fetus or during delivery (256).
Chlamydia Chlamydia trachomatis	Women: Vaginal discharge, pain on urination, spotting after sexual intercourse, lower abdominal pain. Men: Urethral discharge, pain on urination. Often both men and women have no symptoms.	7 to 21 days	Women: Can cause PID (salpingitis1 and endometritis2), cervicitis3, urethritis4, and Bartholinitis5. In pregnant women may cause premature rupture of membranes and preterm delivery (47). Men: Can cause urethritis and epididymitis6. Accounts for 35% to 50% of nongonococcal urethritis in heterosexual men (282)	In one study 45% of women and 30% of men whose sexual partners had chlamydia were infected (171)7. Mother to infant: 60% to 70% of infants exposed at birth develop respiratory infection, pneumonia, or chlamydial ophthalmia (eye infection) (269).
Donovanosis (Granuloma inguinale) C. granulomatis	Nodules below the skin that break through to form a beefy lesion. In women lesions usually from on the labia; in men, on the prepuce or glans of the penis. Women may have no symptoms.	8 to 80 days	Without treatment, may erode genitalia or block urethra.	NA
Gonorrhea Neisseria gonorrhoeae	Women: Vaginal discharge, pain on urination, spotting after sexual intercourse, lower abdominal pain. May have no sypmtoms. Men: Urethral discharge of pus, pain on urination.	1 to 14 days. Most symptoms develop within 2 to 5 days.	Women: Leads to salpingitis in 10% to 20% of cases. Other sequelae include endometritis, cervicitis, urethritis, and Bartholinitis (123). Men: Urethritis and epididymitis. Without antibiotics up to 20% of infected men develop epididymitis (123)8.	50% to 90% of female sexual partners of infected men are infected after one exposure (231). Once urethritis has disappeared, most men are not infectious. 20% of men are infected after one exposure; 60% to 80% after four exposures (122, 123). Mother to infant: 2% to 50% of infants exposed during birth develop eye infections (109, 159, 255).
Herpes Herpes simplex virus (HSV) tpes 1 and 2	Women: First episode: Painful blisterlike lesions in and around vagina, around anus, or on thighs. Pain may be more severe than in men. may cause painful urination or vaginal discharge. Systemic symptoms may include headache, backache, fever, and malaise. As many as 70% may have no symptoms (144). Men: first episode: Painful penile lesions. May cause urethral discharge or pain on urination. Same systemic symptoms as in women. Women and men: Recurrent episodes: Half of those infected have recurrences. Compared with first episode, recurrent episodes invovle smaller and fewer lesions, and systemic symptoms are less common. pain, numbness or tingling in buttocks, legs, or hips may precede outbreak (61, 65).	1 to 26 days; average 6 to 7 days.	In both men and women primary infection can affect central nervous system, causing stiff neck, headache, and abnormal sensitivity to light. Can lead to cervicitis in women and proctitis9 in both sexes.	In a study of 144 couples with one partner infected, followed for a median of 344 days, 17% of women and 4% of men became infected (196). HSV can be transmitted while person is without symptoms. Mother to infant: If mother has first episode, 20% to 50% of infants are infected at birht; during recurrent episode, 3% to 5%. Most transmission occurs while mother has no symptoms (65).
Lymphogranu- loma venereum Chlamydia trachomatis	Women: No symptoms or lower abdominal or back pain; 20% to 30% have inguinal bubo (223). Men: Inguinal bubo that may be preceded by a small genital lesion. Anal intercourse may lead to rectal infection.	3 to 12 days for genital lesion; 10 to 30 days for inguinal bubo.	Two-thirds of buboes shrink and form figrous masses. One-third rupture and leave scars. In 20%, inguinal lymph nodes separate from femoral lymph nodes to form inguinal groove. Other sequelae include fistula, chronic inflammation of lymph nodes, cervicitis, urethritis, and enlargement of genitalia (223, 283).	Not known, but probably less transmissible than gonorrhea (223).
Syphilis Treponema pallidum	Painless lesion on vulva, cervix, penis, nose, mouth, or anus. In women internal lesions may be missed, and first apparent symptoms may be rash of secondary syphilis.	10 to 90 days; mean 21 days.	Two stages: Early syphilis:—primary, secondary and early latent, (when infectious): genital lesion heals in a few weeks, followed by rash, malaise, fever, general lymph-node enlargement, hepatitis, arthritis, and/or hair loss usually beginning days, weeks, or months after lesion disappears and lasting several weeks or months. Late syphilis: (not infectious): Gummas (large lesions) in soft tissue or viscera, neurosyphilis,10 and cardiovascular syphilis11 beginning 1 to 20 years later. Untreated symptomatic neurosyphilis is usually fatal within 5 years (292)..	30% to 60% of sexual partners become infected after one exposure (202, 294). Mother to infant: May pass throught the placenta as early as ninth week of pregnancy in two-thirds or more of pregnancies, causing spontaneous abortion, stillbirth, or neonatal death in 40% of cases (68, 334).
Trichomoniasis Trichomonas vaginalis	Women: Green or yellow, abundant, frothy vaginal discharge with foul odor, itching, pain on urination, pain on intercourse. Men: Usually without symptoms but may involve urethral discharge, pain on urination, or itching.	3 to 28 days	Women: Without treatment initial symptoms may persist for years. Symptoms worsen during or after menses. No complications or sequelae in most cases. Men: Most cases resolve spontaneously. Sequelae may include urethritis, prostatitis, and infertility (336).	Up to 85% of the female sexual partners of infected men are infected. 30% to 40% of male partners of infected women are infected. Mother to infant: About 5% of girls born to infected women are nfected during birth (248).
NA = Not available PID = Pelvic inflammatory disease 1Salpingitis: Inflammatory disease 2Endometritis: Inflammation of the uterine endometrium 3Cervicitis: Inflammation of the cervix 4Discharge, pain on urination, and itching of the urethra 5Bartholinitis: Inflammation of Bartholin's gland 6Epididymitis: Inflammation of the epididymis. Usually causes unilateral testicular pain and swelling. 7The risk of transmission of C. trachomatis is uncertain because, compared with N. gonorrhoeae, it is more difficult to isolate, and chlamydial infection has a longer incubation period and produces fewer symptoms than gonorrheal infection (282). 8Gonorrhea becomes systemic in at most 3% of cases, causing arthritis, tendonitis, and dermatitis. 9Proctitis: Inflammation of the mucous membrane of the rectum. 10Neurosyphilis: Infection of the central nervous system causing degeneration and paralysis. 11Cardivascular syphilis: Infection of the heart, aorta, and coronary artieries.

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Table 2. Examples of Successful STD Programs, 1970–1992
Program	Ref. No.	Country	Year	Population Addressed	Effect
National STD program; increased STD clinics from 2 to 54, trained 140 clinical officers, treated high-risk populations, increased public awareness	119, 290	Zambia	1980–	General public	New STD cases at University Teaching Hospital in Lusaka declined from 18,000 in 1985 to 5,000 in 1991.
Free STD diagnosis and treatment, partner notification, sex education in schools, publicity about high gonorrhea rates, condom promotion	12, 37	Sweden	1970–	General public	Incidence of gonorrhea decreased from 487 to 31 cases per 100,000 population between 1970 and 1987; number of cases of chlamydia almost halved between 1986 and 1991.
Chlamydia screening in family planning clinics	304	US	1988–	Women attending 150 family planning clinics in northwest US	Decrease in prevalence of chlamydia from 11% to 5% between 1988 and 1992.
Health education for pregnant women; prenatal syphilis screening and treatment	116	Zambia	1986–87	5,000 women attending prenatal clinics in 3 health centers. Effect measured on 806 infnats from study cneters and 1,274 from control cneters.	In treatment clinics 28% of syphilitic pregnancies were affected: the pregnancy spontaneously aborted or ended in stillbirth, or the baby was born prematurely or had low birthweight or congenital syphilis. In control clinics 72% of syphilitic pregnancies were affected.
Diagnosis and treatment of STDs and promotion of condom use among prostitutes	201, 255	Kenya	1985–	Over 1,000 female prostitutes in low-income areas of Nairobi	Decrease in annual incidence of genital ulcers amoung prostitutes from 3 episodes per woman in 1986 to less than 1 per woman in 1989; prevented an estimated 6,000 to 10,000 HIV casesa.
Peer education of prosititutes about AIDS and STDs; condom distribution	112	Dominican Republic	1990–92	2,300 prostitutes working in the bars, streets, and brothels of Santo Domingo	Increase in reported condom use among new and regular clients and regular partners. Among prostitutes working in borthels, for example, 65% always used condoms with regular partners in 1992 copared with 56% in 1990.
AIDS, STD, and family planning education; STD screening of prostitutes	218, 219	Thailand	1991–	About 300 prostitutes in 3 districts of Chiang Rai province	In 3 districts gonorrhea prevalence declined from 10% to 1% , from 14% to 5%, and from 73% to 20% between April and August 1991.
aThis esitmate is based on the following assumptions: 80% of prostitutes have an average of four clints per day; 90% of clients do not have HIV; clients have a 1% chance of being infected each time they have intercourse with a prostitute; condoms are 90% effective in preventing HIV transmissions; and an infected client infects two more people. Six thousand cases would be prevented if prostitutes used condoms with 50% of sexual contacts , and 10,000 would be prevented if they used condoms with 80% of contracts.

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Table 3. Treatment Costs for Syndromic Diagnosis
Syndrome	Drug choices	Course of Treatment	Cost (US$)
Urethral Discharge
For gonorrhea	Cefixime Ceftriaxone Ciprofloxacin Spectinomycin Kanamycin Co-trimoxazolea	400 mg by mouth as a single dose 250 mg IM as a single dose 500 mg by mouth as a single dose 2 g IM as a single dose 2 g IM as a single dose 10 tablets once daily for 3 days	3.00 4.00 2.25 5.00–8.00   .50   .40
For chlamydia	Doxycycline Tetracycline Erythromycin	100 mg by mouth 2 times daily for 7 days 500 mg by mouth 4 times daily for 7 days 500 mg by mouth 4 times daily for 7 days	.43   .88b 2.45
	Range of total cost to treat syndrome		.83–10.45
Vaginal Discharge
For gonorrhea and chlamydia	see above	see above
For trichomoniasis and bacterial vaginosis	Metronidazole	2 g by mouth as a single dose	.05
For candidiasis	Miconazole Clotrimazole Nystatin	200 mg vaginally once daily for 3 days 200 mg vaginally once daily for 3 days 100,000 U vaginally once daily for 14 days	3.78b   .73b 1.09b
	Range of total cost to treat syndrome For vaginitis and cervitisc For baginitis onlyd		1.61–14.28   .78–3.83
Genital Ulcer
For syphilis	Benzathine penicillin Procaine penicillin	2.4 million U IM during one visit 1.2 million U IM daily for 10 days	.40 3.22e
For chancroid	Erythromycin Ciprofloxacin Ceftriaxone Co-trimoxazolea	500 mg by mouth 3 times daily for 7 days 500 mg by mouth as a single dose 250 mg IM as a single dose 2 tablets two times daily for 7 days	1.84 2.25 4.00   .37
For herpes (first episode)	Acyclovir	200 mg by mouth 5 times daily for 7 days	38.87b
	Range of total cost to treat syndrome (excluding herpes)		.77–7.22
Vaginal Discharge
For gonorrhea and chlamydia	see above	see above
For anaerobic bacteria	Metronidazole	400 mg by mouth 2 times daily for 10 days	.20
	Range of total cost to treat syndrome		1.03–10.65
Note: Costs are drawn from several listings and are approximate. IM = Intramuscularly U = Units aTrimethoprim, 80mg/sulphamethoxazole, 400 mg bAverage cost calculated from International Drug Price Indicator (175) cTreatment for gonorrhea, chlamydia, trichomoniasis, bacterial vaginosis, and condidiasis. dTreatment for trichomoniasis, bacterial vaginosis, and candidiasis. eCost of 12 one-million-unit vials of powder supplied by UNICEF (175) Source: WHO/GPA (328)

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Table 4. Contraceptive and STDs: What Are the Choices?
Method	Advice
Condom	The best method for protection against STDs, but the condom must always be on the penis before any contact between penis and vagina. Condoms do not protect against infection from lesions in the groin that are not covered.
Spermicides	Reduce the risk of many STDs and pelvic inflammatory disease (PID). Protection against HIV has been demonstrated but needs further study. May be a good choice if condom use is not possible.
Diaphragm, cervical cap, sponge	Used with spermicides, these methods reduce the risk of many STDs and PID. Protection against HIV has been demonstrated but needs further study. May be a good choice if condom use is not possible.
IUD	Does not protect against STDs. Women at risk for STDs need to use condoms in addition or, if they cannot, spermicides. Risk of PID is higher in IUD users thean in women not using contraception, especially just after IUD insertion. Therefore, where STDs and infertility are common, programs may want to help a woman carefully assess her STD risk before advising her about IUD use.
Oral contraceptives	Do not protect against STDs in the lower reproductive tract. Women at risk for STDs need to use condoms in addition or, if they cannot, spermicides. Provide some protection against PID.
Injectables	Do not protect against STDs in the lower reproductive tract. Women at risk for STDs need to use condoms in addition or, if they cannot, spermicides. Provide some protection against PID.
Norplant	Does not protect against STDs in the lower reproductive tract. Women at risk for STDs need to use condoms in addition or, if they cannot, spermicides. Provide some protection against PID.
Voluntary femal sterilization	Does not protect against STDs. Women at risk for STDs need to use condoms in addition or, if they cannot, spermicides. May provide some protection against PID. Women with STDs or pelvic infection should be treated before undergoing sterilization.
Vasectomy	Does not protect against STDs. Men at risk for STDs need to use condoms in addition. Men with STDs should be treated before undergoing vasectomy.

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Table 5. Estimated Costs of an Antenatal Syphilis Screening Program Serving 1,000 Women (in US$), Based on a Pilot Project in Zambia
Measure	Prevalence of Infection
	1%	10%	15%
Two RPR tests per woman at $0.10 each.	$200	$200	$200
Treatment of all infected women at first visit, at $1 per treatment	$10	$100	$150
Treatment at next visit, at $1 per treatment, assuming 20% will be retreated	$2	$20	$30
Treatment of spouses, at $1 per treatment, assuming that 67% of spouses of infected women at first and second visits will be treated	$8	$80	$120
Amortized cost for development and printing of educational material	$100	$100	$100
Amortized cost for microcentrifuges and lamps	$100	$100	$100
Total	$420	$600	$700
Adverse outcomes averted	6	50	75
Cost per adverse outcome averted	$70.00	$12.00	$9.28
RPR = Rapid plasma reagin Sources: Hira et al. 1990 (116), Schultz et al. 1992 (271)

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