Control of bacterial sexually transmitted diseases in the developing world is possible.

Paz-Bailey et al. [1] provide evidence from yet another country of the feasibility of moving from a situation of poor sexually transmitted disease (STD) control, characterized by high prevalences of curable bacterial and protozoan STDs, to one of lower prevalences. An important feature of this change is a decrease in the number of cases of genital ulcers and a predictably changing etiology; as control measures (most effective against bacteria) decrease the proportion of genital ulcers due to Haemophilus ducreyi (in particular) and Treponema pallidum, ulcers of herpetic origin become predominant. This transition toward STD patterns typical of industrialized countries is good news, in that interventions are having an impact on STD transmission and, surely, their sequelae (e.g., infertility), and are likely decreasing the rate of HIV transmission as well. The decreased prevalences of gonorrhea (68.1%), chlamydial infection (55.0%), and trichomoniasis (65.4%) in the cross-sectional surveys of persons practicing family planning between 1993 and 2002 was considerable, whereas the decrease in the seroprevalence of syphilis (91.7%) was spectacular. For genital ulcers, because only proportional data regarding individuals seeking care were available, one can ask, " Did the number of cases of genital ulcers with a bacterial etiology decrease, or did the number of cases with a viral etiology increase? " A decrease in the absolute number of cases of genital ulcers is supported only by surveillance data, which is often of uncertain quality in the developing world. But control of bacterial genital ulcers is apparent from the magnitude of change in the relative proportions of etiologies of genital ulcers. Chancroid was the most common cause of genital ulcer disease in 1993, yet it became a rare event by 2002; meanwhile, syphilis was disappearing among all patient groups. Bringing chancroid to near extinction is possible [2]. Because it is characterized by very painful lesions and asymptomatic carriage is rare, it exists only in communities where access to health care services is extremely poor; individuals with chan-croid simply will not tolerate the disease unless they have no alternative. Indeed, chancroid can be seen as the riskiest of all STDs (the core of the core), associated with the highest risk behavior. Chancroid thrives under conditions of risky sexual behavior, in which use of condoms is infrequent and sex workers have limited access to preventive and curative services. A high prevalence of chancroid in a community is an indicator of high-risk sexual behavior and the …