By: Samantha Dulak BS and Heather McClintock PhD MSPH MSW
This is the first part of a IH Blog series featured this summer, Sexually Transmitted Infections in Sub-Saharan Africa: Determinants, Outcomes, and Interventions.
Part I: Sexually Transmitted Infections in Sub-Saharan Africa
Sexually transmitted infections (STIs) are common acute conditions that while exacting a tremendous toll on health and well-being currently receive minimal media coverage and attention. This is likely due to resources being allocated to other new and emerging conditions, the stigma associated with people who are perceived to be able to contract STIs, and a lack of education about STI symptoms and treatment. STIs range from curable (syphilis, gonorrhea, chlamydia, and trichinosis) to incurable (HPV and HIV/AIDS) infections. The nearly 30 STIs are most commonly transmitted through sexual encounters, but contact with blood and mother to child transmission during pregnancy are other ways STIs can be spread (Newman et al., 2015). Comparing the four curable STIs globally, sub-Saharan Africa had the highest incidence and prevalence of syphilis and gonorrhea (Chesson, Mayaud, & Aral, 2017). Unfortunately, STIs can raise HIV transmission up to four times which is why controlling STIs is at the top of the public health professional’s radar (Stillwaggon & Sawers, 2015). The highest prevalence of HIV is found in sub-Saharan Africa with 53% of the world’s HIV population living there and 56% of those individuals being women (UNAIDS, 2018). Although incidence rates are falling globally, 1.8 million people were newly diagnosed in sub-Saharan Africa in 2017; there is much more work to be done to reach the 2020 goal of less than 500,000 new cases in this region (UNAIDS, 2018). The current estimates state that 66% of all new global HIV infections occur in sub-Saharan Africa (UNAIDS, 2018).
STIs affect people of all socioeconomic classes in every country. Without proper precautions, no one is immune from these infections. STIs in sub-Saharan Africa are particularly important because the largest estimates are reported in this region and public health advances can provide insight and hope to other countries that are affected. Combating the negative stigma around STIs will increase the amount of people who will know their status, subsequently increasing treatment for those infections that are treatable. Furthermore, globalization perpetuates the spread of STIs across geographic boundaries highlighting the importance of acknowledging and addressing STIs on a broad scale.
STIs cause major pregnancy complications such as ectopic pregnancies, infertility, and spontaneous abortions (Chesson, Mayaud, & Aral, 2017). In both men and women, liver cancer, central nervous system diseases, and arthritis are all common comorbidities (Aral, Over, Manhart, & Holmes, 2006). Due to insufficient diagnosis and treatment in many lower and middle income countries, the rates of complications are much higher. This inadequacy can be attributed to the asymptomatic nature of some STIs, lack of education on the topic, or poor care-seeking behaviors (Mayaud & Mabey, 2004).
There are many at-risk groups for contracting STIs, including men who have sex with men, female sex workers, children born to women with STIs, and intravenous drug users. An interesting connection to be made exists for women who experience intimate partner violence (IPV). IPV can include physical or sexual violence, stalking, and psychological control over one’s spouse or dating partner (Centers for Disease Control, 2019). Women are already disproportionately affected by STIs, and these rates are greatest in women who also have reported cases of IPV. One answer for this is that women who have experienced IPV are more likely to have high-risk partners (Miller, 1999). Abusive partners may express coercive behaviors both within and outside of the relationship (Miller, 1999). Additionally, people experiencing IPV can suffer psychological trauma leading them to have impaired decision-making skills and experience increased risk-taking behavior (Miller, 1999).
As of 2018, the World Health Organization has been utilizing the Joint United Nations Programme on HIV/AIDS (UNAIDS) Global AIDS Monitoring system to quantify cases of STIs at the country level and the Gonococcal Antimicrobial Surveillance Programme (GASP) to follow antimicrobial resistance for the treatable STI, gonorrhea (Wi et al., 2017). For GASP to have continued success, international collaboration must be strengthened to develop advanced screening procedures and novel antibiotic treatments. By continually improving both monitoring systems, there may be hope for new vaccines for STIs we are still not protected from. Since antimicrobial resistance is not evolving at the same time across all countries, sharing data and laboratory methods for new pharmaceutical development is imperative to control the spread of STIs in sub-Saharan Africa (Wi et al., 2017).
Aral, S.O., Over, M., Manhart, L., Holmes, K.K. (2006). Sexually Transmitted Infections. In Jamison, D.T., Breman, J.G., Measham, A.R, Alleyne, G., Claeson, M., Evans, D.B., Jha, P., Mills, A., Musgrove, P. (Eds), Disease Control Priorities in Developing Countries, second edition. 311–30. Washington (DC): World Bank and Oxford University Press.
Center for Disease Control [CDC]. (2019). Preventing Intimate Partner Violence. Retrieved May 27, 2019, from https://www.cdc.gov/violenceprevention/intimatepartnerviolence/fastfact.html
Chesson, H.W., Mayaud, P., & Aral, S.O. (2017). Sexually Transmitted Infections: Impact and Cost-Effectiveness of Prevention. In Holmes, K.K., Bertozzi, S., Bloom, B.R., & Jha, P. (Eds.), Major Infectious Diseases, third edition. Washington (DC): The International Bank for Reconstruction and Development and The World Bank.
Mayaud, P., Mabey, D. (2004). Approaches to the Control of Sexually Transmitted Infections in Developing Countries: Old Problems and Modern Challenges. Sexually Transmitted Infections, 80(3), 174–182. doi: 10.1136/sti.2002.004101
Miller, M. (1999). A model to explain the relationship between sexual abuse and HIV risk among women. AIDS Care, 11(1), 3-20. doi:10.1080/09540129948162
Newman, L., Rowley, J., Hoorn, S. V., Wijesooriya, N. S., Unemo, M., Low, N., . . . Temmerman, M. (2015). Global Estimates of the Prevalence and Incidence of Four Curable Sexually Transmitted Infections in 2012 Based on Systematic Review and Global Reporting. PLos One, 10(12). doi:10.1371/journal.pone.0143304
Stillwaggon, E., & Sawers, L. (2015). Rush to judgment: The STI-treatment trials and HIV in sub-Saharan Africa. Journal of the International AIDS Society, 18(1), 19844. doi:10.7448/ias.18.1.19844
UNAIDS. UNAIDS: Data 2018. 2018. https://www.unaids.org/sites/default/files/media_asset/unaids-data-2018_en.pdf (accessed 26 May 2019).
Wi, T., Lahra, M. M., Ndowa, F., Bala, M., Dillon, J. R., Ramon-Pardo, P., . . . Unemo, M. (2017). Antimicrobial resistance in Neisseria gonorrhoeae: Global surveillance and a call for international collaborative action. PLoS Medicine, 14(7). doi:10.1371/journal.pmed.1002344
Samantha Dulak is a recent graduate from Arcadia University. She received her Bachelor of Science in Biology and a Minor in Global Public Health. Her enthusiasm for medicine and disease prevention perfectly intertwine these two fields of study. Her current public health interests are in maternal and child health and nutrition. Since graduation, Samantha has applied to naturopathic medical school with a goal of becoming a pediatric physician. In her free time, she enjoys reading, playing sports, and baking.
Dr. Heather F. McClintock PhD MSPH MSW
Dr. McClintock is an IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. She earned her Master of Science in Public Health from the Department of Global Health and Population at the Harvard School of Public Health. Dr. McClintock received her PhD in Epidemiology from the University of Pennsylvania with a focus on health behavior and promotion. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and reduce the burden of intimate partner violence in Sub-Saharan Africa. Prior to completing her doctorate she served as a Program Officer at the United States Committee for Refugees and Immigrants and a Senior Project Manager in the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania. At the University of Pennsylvania she led several research initiatives that involved improving patient compliance and access to quality healthcare services including the Spectrum of Depression in Later Life and Integrating Management for Depression and Type 2 Diabetes Mellitus Studies.