Book Review

Sexually Transmitted Infections and AIDS in the Tropics

N Engl J Med 2000; 342:1375-1376May 4, 2000

Article

Sexually Transmitted Infections and AIDS in the Tropics
Edited by O.P. Arya and C.A. Hart. 462 pp., illustrated. New York, CABI, 1998. $110. ISBN: 0-85199-262-5

In 1492, Columbus discovered the New World; one year later, the Old World discovered a new disease. And what a disease it was — starting with “painful pustules on private parts spreading to body and face, rashes, ulcers, buboes, black pustules, carbuncles, agonizing and swollen joints, lassitude, fever, rotting flesh, blindness and death . . . the symptoms lingering for years in survivors.” In graphic detail, Nicolo Leoniceno (1428 to 1524), a professor of physic in Ferrara, Italy, thus portrayed syphilis, the first international sexually transmitted disease.

Could Leoniceno have imagined the costs of sexually transmitted diseases 500 years after Columbus's crew members discharged their pestilent cargo? Today, the toll is measured in fetal wastage, premature births, congenital infections, blindness, ectopic pregnancies, infertility, genital cancers, and deaths, especially in tropical countries. In 1992, Wasserheit and Holmes estimated that nearly 80 percent of cases of female infertility in low-income countries resulted from infections of the reproductive tract, including sexually transmitted diseases. In 1993, the World Bank identified sexually transmitted diseases other than human immunodeficiency virus (HIV) infection as the second leading cause of morbidity and mortality among women of reproductive age. In 1995, the World Health Organization estimated that there were 333 million new cases in adults of four leading curable sexually transmitted diseases — gonorrhea, chlamydia, syphilis, and trichomoniasis — with the majority in developing countries in South and Southeast Asia (45 percent), sub-Saharan Africa (20 percent), and Latin America and the Caribbean (11 percent). Add the calamity of HIV infection in sultry realms, and a 15th-century physician gazing on the future might quit medicine altogether, relying solely on prayer for the preservation of mankind.

So much for history and hand wringing. Despite tragic losses, there is still hope for the current battle against HIV infection and other sexually transmitted diseases in low-income countries, thanks to energetic public health programs, modern diagnostics, and antimicrobial therapies. Nonetheless, the clinical management of HIV infection and other sexually transmitted diseases has become increasingly complex. When one considers the typical facility for the treatment of sexually transmitted diseases in the tropics — a bare-bones government or nonprofit clinic lacking personnel, equipment, and drugs — the challenges are great.

That is where this comprehensive book with an international group of authors comes in. Starting with the trends of the 1980s and 1990s — for example, the demographic and socioeconomic substrates of sexually transmitted diseases, their effect on the health of mothers and children and on reproduction, the contribution of classic sexually transmitted diseases to the transmission of HIV infection, new diagnostic laboratory tests, and the growing problem of antibiotic resistance among pathogens — the book offers both theory and practical guidance to doctors and nurses who care for patients with sexually transmitted diseases. The book also has a superb color atlas with 141 photographs to aid in the identification of specific syndromes and pathogens.

There are up-to-date chapters on all the viral, bacterial, fungal, and protozoal microorganisms and arthropods transmitted by sexual contact. The chapter on syphilis, with its lucid summary of diagnostic pitfalls, reactions to treatment, and clinical syndromes in both otherwise healthy and HIV-infected hosts, deserves special mention. Less useful are the three pages aimed at a moving target: state-of-the-art antiretroviral therapy. There is no discussion of lamivudine as an emerging therapy for selected hepatitis B carriers throughout the world. But these are minor flaws, given the breadth of the text. Although the book is not an antiviral primer, its coverage of the epidemiology, pathogenesis, and complications of HIV infection is excellent. And with respect to practical problems from managing herpes in pregnant women to designing tiers of laboratory services for a village, district health center, regional hospital, and national laboratory, the discussions are on target.

Social research aimed at the prevention of sexually transmitted diseases is a field unknown to many front-line physicians. Future editions of Sexually Transmitted Infections and AIDS in the Tropics should include a chapter by a social scientist on the promotion of sexual health. I know Professor Nicolo Leoniceno would approve.

Claire B. Panosian, M.D.
UCLA School of Medicine, Los Angeles, CA 90095