Sexually transmitted infections - the challenge

10 World Health • SlstYear, No. 6, November-December 1998 Sexually transmitted infections - the challenge Antonio Gerbase, Shanthi Noriega-Minichiello & Bea Vuylsteke An awareness campaign in the streets of Hanoi sensitizes people to the fact that sexually transmitted diseases encourage the transmission of HIV, so it is all the more important to practise safe sex. Photo Keystone/Hoang Oinh Nom © The prevention and prompt effective treatment of sexually transmitted infections will significantly improve the reproductive health of a population. Such actions also have the potential to slow down the HIV epidemic. Sexually transmitted infections (STis) are so called because they are mainly transmitted through unprotected sexual contact with an infected partner. Some of them, such as syphilis and HIV infection, can also be transmitted through blood and from mother to child. STis are caused by more than 20 microorganisms; some of these are bacterial (such as those causing gonorrhoea and chlamydial infec- tion) and can be treated by common antibiotics; others, such as HIV, are viral and at present have no cure. The most common signs of infection include discharge from the penis in men, abnormal discharge from the vagina in women, blisters and sores in or outside the genitals, and swollen glands in the groin. However, because many STis cause no- or only mild- symptoms, many people don't even realize that they are infected. Every day, about one million people are infected with an STI, not even counting HIV; in other words, ten people are infected every second. Most of these infections occur in developing countries where the access to good quality health services is limited. When untreated, STI may cause serious complications, such as chronic abdominal pain, infertility and ectopic pregnancy in women, a potentially life-threatening condi- tion. Syphilis, for instance, may be passed on to a developing baby in the womb, and cause premature birth, congenital syphilis and even the death of the baby. Higher risk of HIV STis facilitate the transmission of the human immunodeficiency virus (HIV). A person infected with an STI (especially one where lesions occur) is at higher risk of getting HIV from an infected partner, and an HIV-infected person eo-infected with another STI will pass the HIV virus more easily to his or her part- ner during unprotected intercourse. This has important implications for HIV prevention. A study in Mwanza, United Republic of Tanzania, demonstrated that im- proved STI care at the primary health care level reduced the number of new HIV infections. Preventing infection is critical since there is no effective treatment for viral STis, including HIV. Mass education campaigns contribute to improved knowledge of STis and to safer behaviour, by promoting fidelity and condom use. Projects involving the social marketing of condoms have been successful in making condoms available and encouraging their use in many devel- oping countries. Prompt treatment of STis reduces their infectiousness for sexual part- ners and hence the spread of new infections; it also lowers the risk of complications and of HIV infection. WHO has developed simple treat- ments based on "the syndromic approach". A syndrome is a group of symptoms and easily recognized signs, and a syndromic approach World Health • SlstYear, No. 6, November-December 1998 A health worker visits a woman at home in Uganda . Health programmes for women, including family planning projects, offer an ideal framework for the prevention of sexually transmitted infections. Photo Format Photographers Ltd/}. Chapman © provides treatment for the most common causative organisms for that syndrome. A health care worker can make a correct diagnosis in most STI patients without sophisticated labora- tory tests and without the need for a repeat visit by the patient. This approach is currently being used in primary health care settings in a large number of developing countries. One of the major challenges to STI control is the fact that many infections show no symptoms. This is especially true for women, who are at the same time most at risk of reproductive health complications. The integration of STI services into other health programmes for women (such as family planning pro- grammes) could make these services more accessible to women, but a major drawback is the absence of simple STI screening tests. Even if infected people are symp- tomatic, they often do not go to the health centre. Many patients prefer to consult traditional healers , and self- medication for STI is very common everywhere in the world, since peo- ple are often too poor to pay for transport, for a consultation or for prescribed drugs. Another important reason is the lack of privacy at the health centre and the stigma that arises from having an STI. In some societies, women dare not tell their husbands they have an STI for fear of being accused of infidelity. Vulnerable youngsters Another challenge is to design preventive and curative services for particular vulnerable groups. Adolescents are such a group. They are more vulnerable to infection than adults because of behavioural char- acteristics such as frequently chang- ing partners, social factors such as the difficulty of saying "no" to unsafe sex (especially with aii older partner), and biological characteris- tics such as an immature genital tract. Moreover, they are among the groups least likely to use preventive health care services. Finally, the increasing mobility of populations, urbanization, poverty, demographic changes, displaced populations in war situa- tions, and the migration of men seeking work are all factors that increase the risk of STis. These are issues that go beyond health care in the strict sense, making it difficult for health care professionals to improve the situation without sup- port from other sectors. 11 The prevention and prompt effective treatment of STI will have a major impact on improving the reproductive health of a population. It also has the potential to slow down the HIV epidemic. Many success stories of behavioural change result- ing from prevention campaigns and of improvements in the quality of STI care have been reported, in both developing and industrialized coun- tries. Lessons learned from these experiences should serve as a frame- work, on the basis of which the most effective interventions can be adapted and put into effect on a wider scale. Adoption of a syn- dromic approach to STI care will make good quality services widely available. Adolescent-friendly services are also needed to improve access. A set of well-coordinated activities, in which classic strategies are in balance with innovative ap- proaches, is essential if real success is to be achieved. • Or Antonio Gerbase is Medical Officer and Shanthi Noriega-Minichiello is a Short-Term Professional with the Initiative on HIV /AIDS & STI, World Health Organization, 121 1 Geneva 27, Switzerland. Or Bea Vuylsteke is with the Department of Infection and Immunity at the WHO Collaborating Centre on AIDS, Institute of Tropical Medicine, Nationaleslraat 155, B-2000 Antwerp 1, Belgium .