Risk pathways for gonorrhea acquisition in sex workers: can we distinguish confounding from an exposure effect using a priori hypotheses?

The population distribution of sexually transmitted infections (STIs) varies broadly across settings. Although there have been many studies aiming to define subgroups at risk of infection that should be a target for prevention interventions by identifying risk factors, questions remain about how these risk factors interact, how their effects jointly influence the risk of acquisition, and their differential importance across populations. Theoretical frameworks describing the interrelationships among risk determinants are useful in directing both the design and analysis of research studies and interventions. In this article, we developed such a framework from a review looking at determinants of risk for STI acquisition, using gonorrhea as an index infection. We also propose an analysis strategy to interpret the associations found to be significant in uniform analyses of observational data. The framework and the hierarchical analysis strategy are of particular relevance in the understanding of risk formation and might prove useful in identifying determinants that are part of the causal pathway and therefore amenable to prevention strategies across populations.