A systematic review of the epidemiologic interactions between classic sexually transmitted diseases and HIV - How much really is known?

Background: Many studies have explored the role of "classic" sexually trans mitted diseases (STDs) in determining the pattern of HIV epidemics. However , the many different STDs may contribute in different ways, at different ma gnitudes. Goal: To review available studies on the bidirectional interactions of HIV and STDs to explore the extent of current knowledge on the different influe nces of the varied STDs in heterosexual HIV epidemics. Methods: Longitudinal studies on susceptibility and controlled studies on i nfectiousness and duration of disease identified on electronic databases th rough reference lists and citation indices up to the end of 1999 were syste matically reviewed, including meta-analyses assessing the influence of STDs on susceptibility to HIV. Results: Studies have a clear publication bias with a significant result th at hinders robust interpretation. However, genital ulcerative disease appea rs to have a greater impact than nonulcerative disease, and men are more af fected than women by the effects of STDs on susceptibility to HIV. There is evidence that STDs increase the infectiousness of HIV from men to women, w hereas the evidence is more equivocal for the infectiousness of women. Few studies identify the impact of different STDs, and there is a marked lack o f studies investigating the impact of HIV infection on the transmission of other STDs. Conclusions: A large body of work has measured the association between STDs and HIV. However, publication bias and gaps in the focus of studies mean t hat a detailed, quantitative understanding of the interaction requires much more attention.