Sexually Transmitted Diseases in Lebanon: Observations and Status of Art

Lebanese health system lacks of organization and almost all of those dispensaries are private ones; thus, reporting encountered diseases has never been accomplished. Furthermore, there is no available recent data about prevalence of STD in Lebanon. To date, there is no fund for any research in STD area and prevalences are usually based on specialists’ feedback.

Since 2011, beside my Dermatology residency, I have been challenged to deal with sexually transmitted diseases (STD) in many dispensaries in Beirut-Lebanon. Some observations might be found according to these consultations over 4 years. Human papilloma virus (HPV) infection is definitely prevalent in Lebanon like all countries. Anal warts are present in more than 50% of MSM patients who consulted those dispensaries. Warts are more frequently treated with cryotherapy as available Imiquimod 5% cream is expansive. Chlamydia trachomatis is also prevalent especially in oro-pharyngeal locations of MSM population. Asymptomatic chlamydia infection is the rule.

Neisseria gonorrhea is less prevalent, more frequent in highly active population. To date, no cases of resistant Gonorrhea were found in Lebanon.

Syphilis is extremely rare, and 5 cases were reported recently: all participants had more than five sexual partners per month [1]. They all reported receptive anal sex. Four participants reported consistent condom use during anal sex, while only one patient used condoms irregularly. All participants practiced unprotected fellatio. In their previous six months, the five patients had been living in Lebanon, but all of them reported various short-term travels (New York, London, Montreal, Paris, Cairo and Dubai) during that time period with sexual contact with non-Lebanese partners. Only one participant was co-infected with HIV. All participants had a prior diagnosis of at least one sexually transmitted infection (excluding HIV). Four participants reported the use of recreational drugs, alcohol, or both, before or during sex. The clinical presentation of syphilis was primary with genital ulcer in only one patient. The four others discovered their syphilitic status on screening tests. In the Middle East and North Africa regions, the annual incidence of syphilis is 2.2 per 1000 [2]. In Saudi Arabia, among 3270 women tested at King Khalid University Hospital in Riyadh, only one was found syphilitic [3]. The prevalence was 0.0% in women from different areas in Jordan [4].

A single case of Lymphogranuloma venereum has been recently reported in a patient who travels a lot [5]. This infection is exceptional in Lebanon. Herpes infection is definitely prevalent however; those patients are usually treated by general physicians or pharmacists and are rarely seen in dispensaries. Other STD diagnoses such as Molluscum contagiosum infection, pubic lice, or scabies are frequently diagnosed in dispensaries, especially in active population, HIV-positive not diagnosed patients, and immigrants.

HIV status in Lebanon is not known, however there are more and more cases of HIV positive young aged MSM.

Hepatitis B and C are usually treated and followed by infectious diseases specialists. STD is treated in Lebanon by general physicians, family medicine physicians, pharmacists and by self-prescribed treatments. Prescribed treatments rarely rely on international societies guidelines. The vast majority of patients who consulted in dispensaries have usually been informed by browsing the web. Many MSM populations have reported discrimination by physicians.

Concerning laboratory tests, many nongovernmental organizations (NGO) offer free of charge HIV, Hepatitis B and C rapid tests. They are usually financed by international NGO or United Nations organizations. However, there is always a neglect of the 3 months delay between unprotected sexual intercourse and those rapid tests. Other more sophisticated tests such as polymerase chain reaction (PCR) based studies of Chlamydia trachomatis, Neisseria gonorrhea, Mycoplasma genitalium are rarely prescribed because of the high costs of these tests and because of the lack of knowledge of the indication of the test.

Vaccines (Hepatitis B, HPV) are rarely advised for patients who consult for STD. Local dispensaries do not offer these vaccines and they remain expansive and not covered by public/private health care systems.

Genital dermatoses are frequently confused with STD, especially by General physicians, unless the patient is referred to a Dermatologist.

References

1. Maatouk I, Fahed M, Moutran R. Five cases of syphilis from an urban university hospital in Lebanon. Int J STD AIDS. 2014; 25: 973-974.
2. Kenyon C, Buyze J and Colebunders R. Classification of incidence and prevalence of certain sexually transmitted infections by world regions. Int J Infect Dis. 2014; 18: 73–80.
3. Shakoor Z. Antenatal screening for syphilis at a tertiary care hospital in Riyadh. Ann Saudi Med. 2004; 24: 262–264.
4. Mahafzah AM, Al-Ramahi MQ, Asa’d AM, El-Khateeb. Prevalence of sexually transmitted infections among sexually active Jordanian females. Sex Transm Dis. 2008; 35: 607–610.
5. Maatouk I, Moutran R. Lymphogranuloma venereum: the first case in Lebanon. Int J STD AIDS. 2014; 25: 971-972.