Sexually transmitted infections case notification rates in the Kingdom of Saudi Arabia , 2005 – 2012

Introduction: Sexually transmitted infections (STIs) are major public health concerns around the world. This study describes the epidemiology of reported STI cases from 2005 to 2012 in the Kingdom of Saudi Arabia. Methodology: The annual registry was the main source of data as reported by healthcare providers. Case definitions were based on positive human immunodeficiency virus (HIV) antibodies detectable by enzyme-linked immunosorbent assay (ELISA) and confirmed by western blot test for HIV cases. The definitions of other STIs were based on published Centers for Disease Control and Prevention (CDC) definitions. Results: During the study period, 68,886 new cases were reported, with nongonococcal urethritis being the highest STI (25.4) per 100,000 population (25.4), followed by trichomoniasis (9.1), HIV (7), human papillomavirus (HPV) infection (2.9), and syphilis (1.3). The cases included nongonococcal urethritis (n = 35,613; 51.7%), trichomoniasis (n = 12,679; 18.4%), gonococcal urethritis (n = 3,006; 4.4%), syphilis (n = 1,769; 2.6%), HIV (n = 9,843; 14.3%), genital warts (n = 4,018; 5.8%), genital herpes (n = 1,508; 2.2%), and chancroid (n = 450; 0.7%). Saudi contribution to HIV cases increased from 28.9% in the preceding decade to 43.5% in the current study. Conclusions: Nongonococcal urethritis, trichomoniasis, and HIV were the most commonly reported STIs in the Kingdom of Saudi Arabia.


Introduction
Sexually transmitted infections (STIs) constitute a major health problem worldwide, especially in developing countries [1,2].According to the World Health Organization (WHO), 499 million new cases of curable syphilis, gonorrhea, chlamydia, and trichomoniasis occur annually in adults [3].In general, the prevalence of STIs tends to be higher in urban residents, unmarried individuals, and young adults [3][4][5].Serious complications result from late diagnosis or ineffective treatment of STIs.These complications include infertility, ectopic pregnancy, anogenital cancer, and premature death [3,4].
The precise burden of STIs is generally unknown.Passive STI surveillance systems are present in some countries, and the credibility of these data and estimates depend on the quality of STI services, the degree to which patients ask for healthcare, the severity of cases, the diagnostic test(s) used, and the excellence of reporting [5].Data on STIs in Islamic countries are limited due to cultural and religious concerns [6,7].The Kingdom of Saudi Arabia (KSA) is a conservative Islamic country where Islamic rules are strictly followed.The concept of being infected with STIs is not totally accepted by culture and society.The stigma is associated with the sense of being blamed, especially in the case of human immunodeficiency virus (HIV) infection [4,8].Thus, we attempted to present the epidemiology of STIs in KSA and provide an estimate of the burden of these diseases.

Methodology
The

Discussion
The main finding of our study was that over an eight-year period, STIs in KSA remained low, with an annual incidence of 92.1/100,000.Shame and stigmatization may lead affected individuals to seek help outside established healthcare systems by visiting traditional healers, self-treating, or not seeking care at all.Thus, STI surveillance based on reporting of symptomatic individuals may underestimate the total number of new cases [5].Social stigma of STIs is known to occur in various societies and contributes to under-detection and underreporting [11,12].
Non-Saudi patients accounted for 56.5% of the HIV cases, and the percentage of Saudis increased, from 15.8% in 1995-1999 to 28.9% in 2000-2009 [6,8], to 43.5% in the current study.In a previous report, the percentage of Saudis among all HIV cases increased from 20% in early 2001 to 40% in 2009 [8].The difference in the percentage of Saudis with HIV infection in these studies may be related to a source of data or a true change in the epidemiology of diagnosed HIV patients.The overall increase in the number of reported HIV cases may be related to the availability of HIV testing and counseling clinics throughout KSA as well as pre-marital testing [8].Other possible contributing factors include improvement in the reporting system and better education and awareness.Despite such an increase in the reported cases, the overall prevalence of HIV/AIDS (acquired immunodeficiency syndrome) in KSA is consistently low (< 0.2%) [8].Proper prevention programs for STIs remain a challenge.Strategies to prevent STIs in KSA should regenerate the Islamic values [6,8,11].In addition, health education, early diagnosis and treatment, and comprehensive contact tracing should be applied [9,10].

Conclusions
Nongonococcal urethritis, trichomoniasis, and HIV were the most commonly reported STIs.Additionally, the Saudi contribution to HIV cases increased from 28.9% in the preceding decade to 43.5%.The total number of reported cases based on STI surveillance could be substantially underestimated due to the social stigma associated with STIs.Appropriate preventive programs in accordance with Islamic values should be put into operation.
The definitions of the STIs were based on the Centers for Disease Control and Prevention (CDC) definitions[9,10].HIV infection was defined as positive HIV antibodies detected by enzyme-linked immunosorbent assay (ELISA) and confirmed by western blot test.The presence of a painful genital ulceration and inflammatory inguinal lymphadenopathy defined chancroid.Gonococcal urethritis was based on the presence of urethral discharge with the presence of Gram-negative diplococci on Gram stain and/or the isolation of Neisseria gonorrhoeae.Syphilis was based on the presence of a reactive nontreponemal serologic test (Venereal Disease Research Laboratory [VDRL] or rapid plasma reagin [RPR]) and a reactive specific treponemal serologic test (Treponema pallidum hemagglutination test [TPHA] or fluorescent treponemal antibody absorbed [FTA-ABS]).Each case is counted once, as the Saudi MOH mandates that genital herpes and genital warts should be reported only once per patient, regardless of the number of recurrent episodes.

Figure 1 .
Figure 1.Annual total number of sexually transmitted infection cases from 2005 to 2012.

Table 1 .
Total number and annual incidence of sexually transmitted infections per 100,000 population in Saudi Arabia from 2005 to 2012.

Total number of infections (%) Annual incidence of infection per 100,000 population
Figure 2. Annual number of reported sexually transmitted infections.

Table 2 .
Comparison between the total number of sexually transmitted infections between1995-1999 and 2005-2012.