The three direct determinants of the rate of spread of sexually transmitted diseases (STDs) are sexual behaviors, the mean duration of infectiousness, and the mean efficiency of sexual transmission of each STD. Underlying ecological and behavioral factors that operate through one or more of these direct determinants lie on a continuum, ranging from those most proximate back to those more remote (in time or mechanism) from the direct determinants. Most remote and least modifiable are the historical stages of economic development that even today conspicuously influence patterns of sexual behavior. Next are the distribution and changing patterns of climate, hygiene, and population density; the global population explosion and stages of the demographic transition; and ongoing changes in human physiology (e.g., menarche at younger age) and culture (e.g., later marriage). More proximate on the continuum are war, migration, and travel; and current policies for economic development and social welfare. Most recent or modifiable are technologic and commercial product development (e.g., oral contraceptives); circumcision, condom, spermicide, and contraception practices; patterns of illicit drug use that influence sexual behaviors; and the accessibility, quality, and use of STD health care. These underlying factors help explain why the curable bacterial STDs are epidemic in developing countries and why the United States is the only industrialized country that has failed to control bacterial STDs during the AIDS era.
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