Research and Development Agenda
Priorities for global STI research include the following:
-
The development and evaluation of therapeutic (drug treatment or vaccines), behavioral, and structural interventions to prevent or reduce STIs and their sequelae. Given the spread of drug-resistant strains of gonorrhea and other STIs, new pharmaceutical products and new combination therapies are needed to prevent and treat STIs.
-
The development and evaluation of mechanisms to accurately quantify the disease burden in order to prioritize activities.
-
The development and evaluation of inexpensive and practical rapid diagnostic tests to permit early detection and treatment of STIs.
-
The conducting of studies to evaluate effective prevention modalities for persons at highest risk for STIs.
-
The undertaking of health services research to gain an understanding of practical and cost-effective STI prevention strategies or systems that ideally can be integrated into existing public health infrastructure. When an individual is treated for an STI, this treatment has both positive and negative spillover effects (externalities). The right combination of patient and provider incentives needs to be found that will maximize the beneficial spillovers while minimizing the harmful ones.
-
The implementation of studies in support of global elimination programs.
Because of the clandestine nature of most sexual behavior, STIs are probably massively underreported, which in turn leads to an underestimation of their importance. New survey and measurement tools have been developed. They now need to be applied to populations in poor countries to improve these estimates.
In addition, randomized controlled trials need to be conducted in different settings to test the hypothesis that treating or preventing STIs in high-risk individuals has beneficial spillover effects by preventing infections among low-risk individuals. An improved understanding of the determinants of high-risk sexual behavior and the role that such behavior can sometimes play in helping women to escape from poverty and helping men to cope with it is also needed, as is a better understanding of the full range of benefits of effective STI interventions for high-risk individuals and their dependents.
As concerns disease modeling and surveillance, further improvements are needed in understanding the implications for interventions of different kinds of local, regional, and international sex networks.
Tools
Because of the difficulty of persuading patients to adhere to a course of medication for the prescribed period, single-dose therapy would be valuable. Rapid, point-of-care diagnostics are also a high priority, so that drugs can be targeted at pathogens more accurately. New approaches for treating chronic STIs should be incorporated into prevention strategies, and blister packs of antibiotics that can be sold over the counter for syndromic management of STIs should be available.
Vaccines would be particularly valuable, both for preventing and for potentially treating chronic viral STIs and chlamydial infection, which is often asymptomatic but is responsible for considerable morbidity.
Diagnostics tests that could be used at home or at social meeting spots may help people decide whether to engage in risky sex. Packages of diagnostic tests that change color when the contents expire would also be useful.
Intervention Methods
Syndromic management algorithms have now existed for more than a decade. However, treatment algorithms are sensitive to changes in the relative prices of pharmaceuticals and diagnostic reagents, in the prevalence of the various STIs, in pathogens' resistance, and so on. Thus, every country needs some ability to respond to local changes by developing or modifying algorithms as needed.
As concerns intervention packaging, many policy makers continue to believe that the most sexually active people are hard to find. This belief hampers efforts to target these people with STI prevention programs. The PLACE methods developed at the University of North Carolina offer an opportunity to correct that impression and should be packaged with other urban public health functions. Packaging sex education into school curricula is a challenge in most of the world. As enrollment rates for poor children, especially girls, rise, the presence of a strong, culturally appropriate, sex education curriculum will lay the foundation for strong STI prevention and treatment campaigns.
As this chapter has argued, the determinants of the unit costs of STI treatment and prevention are largely unknown. We recommend health services and operations research to study the determinants of the unit costs of STI prevention and treatment services. The purpose of this research would be to learn not only how to deliver care in the most cost-effective ways, but also how to build systems that achieve that technological frontier in a high percentage of public and private facilities and pass those cost savings on to the government and to patients. Given the beneficial spillover effects from effective STI prevention and treatment among those who are most sexually active, research is needed to learn how the PLACE approach to targeting can be implemented most cost-effectively in different cultural contexts.
Finally, improved understanding of the best way to design an STI treatment system, including the rewards and penalties that best motivate providers (to be polite, discrete, prompt, efficient, and accurate in following best practice, evidence-based treatment protocols) and patients (to seek and then to adhere to treatment) is a priority. Improved data on the costs of each STI intervention at the pilot stage and after scaling up to the national level are also necessary.
