By Samantha Dulak BS and Heather F. McClintock PhD MSPH MSW
This is the second part of a IH Blog series featured this summer, Sexually Transmitted Infections in sub-Saharan Africa: Determinants, Outcomes, and Interventions.
Part II: Outcomes and Interventions for Sexually Transmitted Infections in sub-Saharan Africa
Sexually transmitted infections (STIs) are a significant public health burden globally and are a leading cause of mortality in lower middle income countries (LMICs). In 2016, there were 988,000 women infected with syphilis worldwide, resulting in 350,000 deaths and delivery complications (Korenromp, Rowley, Alonso, et al., 2019). Human papillomavirus (HPV), an incurable STI, leads to over half a million new cases of cervical cancer every year (Bray, Ferlay, Soerjomataram, et al., 2018). Cervical cancer can be the result of other factors, however, in 90% of all cervical cancer cases that resulted in death, the cancer was caused by HPV (WHO, 2018). Of the 1.8 million newly diagnosed HIV infections each year, 940,000 individuals died globally from AIDS related factors (UNAIDS, 2019a). Unfortunately, a third of those deaths (302,700) are among females aged 15-49 living in sub-Saharan Africa (UNAIDS, 2019b). Higher rates of complications are found in sub-Saharan Africa because of inadequate clinician training, delayed diagnosis, and limited care seeking behaviors (Mayaud & Mabey, 2004). STI surveillance systems are absent or poorly functioning in Africa causing unreliable data on the prevalence of these infections.
STIs are common in low resource settings and their impact can be catastrophic on the lives of individuals. The list of potential complications is extensive. Untreated gonorrhea and chlamydia are associated with the development of arthritis, hepatitis B with liver cancer, and syphilis with central nervous system disorders (Aral, Over, Manhart, & Holmes, 2006). While all individuals are at risk, women and children are disproportionately affected by a greater burden of disability, as assessed by disability adjusted life years. Women suffering without treatment can experience chronic pelvic and abdominal inflammation leading to infertility, spontaneous abortions, and many adverse pregnancy outcomes (Chesson, Mayaud, & Aral, 2017).
International attention on STI outcomes is imperative to reducing the incidence of STIs not only in sub-Saharan Africa, but globally. Most attention has focused on HIV due to the public health crisis we are experiencing now. The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) reported that Africa has the highest burden of STIs compared to all other continents (Lewis, 2011). The UNAIDS 2018 report on the global AIDS epidemic found that there are 37.9 million people living with AIDS in the world and 20.6 million of them live in eastern and southern Africa (UNAIDS, 2019a).
Prevention strategies in sub-Saharan Africa place a heavy emphasis on sexual health education. A meta analysis of 51 papers reported that while school-based sexual health education significantly increased condom usage, there was no significant effect on the incidence of STIs (Sani, Abraham, Denford, & Ball, 2016). This information is promising, though. School aged children are experiencing positive behavior changes through the use of physical protection methods. Some studies even report a change of attitude towards persons living with HIV/AIDS (Paul-Ebhohimhen, Poobalan, & van Teijlingen, 2008). However, a focus on at-risk groups is missing. Sex workers, men who have sex with men, and intravenous drug users all have high susceptability to contracting an STI and greater attention needs to be directed towards prevention in these populations to reduce the incidence of STIs.
To address the vast number of cases of cervical cancer caused by HPV, many sub-Saharan countries now qualify for assistance from the Global Alliance for Vaccines and Immunization. As of 2018, eight countries have HPV vaccine programs for school aged children, with pilot programs implemented in nearly 16 additional countries (Black and Richmond, 2018). Data for all 8 countries is not public as of now, but of the five countries with available data, the success rate for at least one dose of the vaccine is 83% (Black and Richmond, 2018). Rwanda was the only country to successfully complete three doses, covering 98.7% of girls (Black and Richmond, 2018).
From a global perspective, Sustainable Development Goals (SDGs) aim to ensure access to sexual and reproductive care and end the AIDS epidemic by 2030 (UN General Assembly, 2015). Primary prevention strategies have become popular among many countries to promote these goals. In 2018, the WHO reported on global STI surveillance, indicating that 44% of countries have HPV vaccines in their immunization programs (WHO, 2018). To reach those who are not benefiting from immunization initiatives, the 2016 Global STI Strategy, along with strategies for HIV and viral hepatitis, fight to meet the SDG 2030 agenda (WHO, 2018). The Global STI Strategy focuses on creating affordable interventions for at-risk individuals and adolescents in all countries. These plans are financed and delivered by promoting universal health care coverage to keep costs low (WHO, 2018). Additionally, the Gonococcal Antimicrobial Surveillance Programme (GASP) has improved national monitoring of antimicrobial resistance to gonorrhea in order to provide stronger data for new treatment research (Wi et al., 2017).
Samantha Dulak BS
Ms. Dulak was a biology major and global public health minor at Arcadia University. She has a strong interest in nutrition as well as maternal and child health. She now hopes to attend graduate school for public health and pediatrics.
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.
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Black, E., Richmond, R. (2018) Prevention of Cervical Cancer in Sub-Saharan Africa: The Advantages and Challenges of HPV Vaccination. Vaccines, 6(3), 61. doi: https://doi.org/10.3390/vaccines6030061
Bray, F., Ferlay, J., Soerjomataram, I., Siegel, R.L., Torre, L.A., Ahmedin, J. (2018). Global Cancer Statistics 2018: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: A Cancer Journal for Clinicians, 68: 394–424.
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Paul-Ebhohimhen, V.A., Poobalan, A., van Teijlingen, E.R. (2008). A systematic review of school-based sexual health interventions to prevent STI/HIV in sub-Saharan Africa. BMC Public Health, 8(4). doi: 10.1186/1471-2458-8-4
Sani, A.S., Abraham, C., Denford, S., & Ball, S. (2016). School-based sexual health education interventions to prevent STI/HIV in sub-Saharan Africa: a systematic review and meta-analysis. BMC Public Health, 16, 1069. doi: 10.1186/s12889-016-3715-4
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