Sexually Transmitted Infections in Sub-Saharan Africa

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).

References

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

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.

Global News Round Up

Politics & Policies

The House Appropriations Committee on Thursday approved the fiscal year 2020 Department of State and Foreign Operations (SFOPs) appropriations bill, which includes funding for international development, global health, gender equality, and humanitarian assistance programs.

Alabama passed a near-total ban on abortion this week, strict enough to rival abortion rules in countries like Brunei, Guatemala and Syria.

The Trump administration pushed the G-7 nations to water down a declaration on gender equality last week as part of its broad effort to stamp out references to sexual and reproductive health in international institutions, according to people involved in the process and drafts reviewed by Foreign Policy.

Health Ministers from G7 countries wrapped up a two-day meeting today in Paris that focused on strengthening primary health care, health inequalities for developing countries and the elimination of HIV/AIDS, tuberculosis and malaria.

The increase in the number of infectious-diseases outbreaks (e.g., Ebola, Zika, and yellow fever) around the world and the risk posed by an accidental or deliberate release of dangerous pathogens highlight the need for a sustained, multi-sectoral, and coordinated United States response. U.S. Agency for International Development (USAID) is proud to be working with more than ten other Federal Departments and agencies in this critically important effort.

Today, May 18, 2019, Health and Human Services Secretary Alex Azar participated in a meeting with the Pasteur Institute.  He and other U.S. health officials met with Stewart Cole, President of the Pasteur Institute, and other members of the Pasteur Institute, and other members of the Institute’s senior leadership team.

Programs, Grants & Awards

Since childhood, Cynthia Luo knew she wanted to be a physician. In high school, she discovered a passion for cancer immunology research while working in the lab of a biotech company.  After spending part of a gap year volunteering at a rural health clinic in Uganda, she aspired to have an impact on global health.

Research

The World Health Organization (WHO) reports there are more than 112,000 confirmed cases of measles worldwide, as of this month – a 300% increase from the 28,124 cases this time last year.

New research suggests that coxsackievirus decreases the number of insulin-producing beta cells, raising the risk for type 1 diabetes in lab mice, according to findings published Wednesday in Cell Reports.

The legalization of recreational marijuana is associated with an increase in its abuse, injury due to overdoses, and car accidents, but does not significantly change healthcare use overall, according to a new study.

Avian malaria parasites (genus Plasmodium) are cosmopolitan and some species cause severe pathologies or even mortality in birds, yet their virulence remains fragmentally investigated. Understanding mechanisms and patterns of virulence during avian Plasmodium infections is crucial as these pathogens can severely affect bird populations in the wild and cause mortality in captive individuals.  The goal of this study was to investigate the pathologies caused by the recently discovered malaria parasite Plasmodium homocircumflexum (lineage pCOLL4) in four species of European passeriform birds.

Diseases & Disasters

There have now been 880 measles cases reported in this year’s outbreak, already the largest since 1994, federal health officials said on Monday.  An additional 41 cases were reported last week, according to the Centers for Disease Control and Prevention. Of those, 30 were in New York State, which is having the country’s most intense outbreak, largely in Orthodox Jewish communities.

Tuberculosis (TB) may be an ancient disease, but it is still the leading cause of infectious death worldwide, affecting more than 10 million people and killing 1.6 million in 2017 alone. Last year, the UN held the first High-Level Meeting on TB. As part of that meeting’s final political declaration, member states committed to fill the $1.3 billion annual funding gap in TB research & development, and to increase overall global investments to 2 billion dollars with the aim of enabling the development and introduction of life-saving scientific innovations for those impacted by TB around the world.

The government is to send new funding and expert personnel to the Democratic Republic of Congo (DRC) amid fears the rapidly escalating Ebola crisis there is spiralling out of control and could spread into neighbouring countries.

Chad’s worst measles outbreak in years will soon spread to all parts of the country as vaccination rates are too low to stop an epidemic that has already hit thousands, the World Health Organization (WHO) said on Thursday.

Technology

Last year’s high-level political declaration on the fight against tuberculosis committed to mobilizing sufficient and sustainable financing for universal access to quality prevention, diagnosis, treatment and care of tuberculosis (TB). To achieve this, we need new ideas and innovation to end TB.

In theory, a terrorist could mass disseminate the hemorrhagic virus by small particle aerosol. It is a possible but unlikely scenario because executing such an attack would take an incredible amount of technology and financing.  However, someone g executing such an attack would take an incredible amount of technology and financing. However, someone with basic skills in virology could infect only a few people with Ebola, and the event would cause worldwide havoc.

Confronting an Ebola outbreak spiraling out of control in the Democratic Republic of Congo, the World Health Organization announced ola s on Tuesday to change its vaccination strategy, offering smaller doses and eventually introducing a second vaccine.

Environmental Health

Concentrations of antibiotics found in some of the world’s rivers exceed ‘safe’ levels by up to 300 times, the first ever global study has discovered.

Māori culture is at risk due to predicted changes in the ranges of two culturally important native plants, kuta and kūmarahou.

Equity & Disparities

In San Francisco, a hub of homelessness in the US, researchers have observed firsthand how living on the streets can accelerate aging. With an average age of 57, homeless study participants suffered strokes, falls, and incontinence at rates more typical of people in their 70s and 80s.

More people on the planet have access to electricity than ever before, however, the world is on pace to fall short on the goal of affordable and sustainable energy for all by 2030, according to an international report on the state of international energy.

Women, Maternal, Neonatal & Children’s Health

Over 20 million babies around the world – about 1 out of every 7 – were born underweight in 2015, a slight improvement over rates in 2000 but not enough to meet goals and prevent global health consequences, according to a new study.

In the eastern Democratic Republic of the Congo, ongoing armed conflict increases the incidence of gender-based violence (GBV) and presents a distinct and major barrier to care delivery for all survivors of GBV. To address the multiple barriers to providing time-sensitive medical care, the Prevention Pack Program was implemented. The Prevention Pack Program was able to provide timely and consistent access to emergency contraception, HIV prophylaxis and treatment for sexually transmitted infections for rape survivors in the eastern Democratic Republic of the Congo.

Global News Round Up

Politics & Policies

At the urging of the White House, Germany nixed language referring to “sexual and reproductive health” in a signature UN resolution taking aim at rape in conflict situations, Foreign Policy reports.

Programs, Grants & Awards

The DMU Department of Global Health’s Distinguished Global Health Internships are highly selective research opportunities that enable students to explore global health research topics at various organizations. Students have the opportunity to work with researchers on projects such as conducting systematic reviews to create evidence-based educational materials for worldwide distribution.

Research

A swarm of micro-robots, directed by magnets, can break apart and remove dental biofilm, or plaque, from a tooth. The innovation arose from a cross-disciplinary partnership among dentists, biologists, and engineers.

Diseases & Disasters

Imagine your house is gone. And yet the TV set is still standing.  That’s one of the scenes that photojournalist Tommy Trenchard documented as he visited parts of Mozambique hit by Cyclone Kenneth on Thursday.

Measles continues to spread in the United States, federal health officials said on Monday, surpassing 700 cases this year as health officials around the country sought aggressive action to stem the worst outbreak in decades.

Nearly three weeks since fighting began near the Libyan capital Tripoli, the UN health agency warned on Tuesday that “large numbers” of people are sheltering in medical clinics, while civilians continue to be killed or injured, and refugees and migrants remain exposed to clashes.

Students are currently being quarantined in Los Angeles. Mandatory-vaccination policies have been implemented in Brooklyn. Even President Donald Trump, contrary to prior assertions, today urged people to get children vaccinated.

The Democratic Republic of the Congo (DRC) today reported another double-digit rise in Ebola cases, as local leaders such as traditional chiefs and provincial representatives stepped up their efforts to convince community members to support the response efforts to end the outbreak.

In South Sudan mind-bending horrors abound of war, ethnic violence, rape, hunger and displacement.  But for civilians living in the shadow of conflict, the greatest danger is often being cut off from health services, whether due to violence or lack of development in the vast, remote areas that make up much of the country.

Technology

The CDC is issuing new guidance to clinicians for the treatment of severe cases of malaria.  The action follows discontinuation of quinidine, the only FDA-approved intravenous (IV) antimalarial drug in the United States.

Devout parents who are worried about vaccines often object to ingredients from pigs or fetuses. But the leaders of major faiths have examined these fears and still vigorously endorse vaccination.

Ghana’s long unsung health tech sector is getting global validation with two of its most promising startups being named among five winners for one of the most prestigious social enterprise awards in the world.

Environmental Health

Dozens of cities across the world have declared a climate emergency. Now, students behind the school climate strikes are bringing the movement to Switzerland and Germany. But what does that mean exactly?

Equity & Disparities

Sometimes it is important to go back to basics. For human interaction, one of the basics is language, the system of communication that, when applied at its best, allows us to understand each other, share, cooperate, and pull each other towards a better place. When on a collective journey towards a common objective such as the Sustainable Development Goals, with a rallying cry of “leaving no one behind” and a central aim of “reaching the furthest behind first”, this system of communication is fundamental to move beyond just the rhetorical: to be truly reached, the furthest one behind will need to understand what she is being told, and most likely, that exchange will have to be done in her own language. That principle should apply to all aspects of development, including global health.

The Sustainable Development Goals (SDGs) set by the United Nations (UN) would “remain beyond reach” without adequate financing, an International Monetary Fund (IMF) official said.

Women, Maternal, Neonatal & Children’s Health

Anyone following international development is probably familiar with “stunting” — which in nontechnical terms means children being too short for their age. Over the past decade, as the world has focused unprecedented attention on undernutrition, stunting has taken center stage.

Help is needed urgently from the international community to help some 2,500 apparently stateless “foreign children” at a camp for the displaced, in north-east Syria, a top UN official said on Thursday.

Malnutrition is detrimental to the health of children. As a result of malnutrition, a child’s growth can be stunted. Additionally, both brain damage and physical impairments can arise from malnutrition.

Rates of sexual violence in El Salvador rose by a third last year, with the majority of cases involving teenage girls.

Over 19 million children in Bangladesh are vulnerable to the forces of climate change, says a new study released this month (April) by the UNICEF.

Children in some disaster-prone regions are twice as likely to be living in chronic poverty, according to new research.

2019 Membership Engagement Survey Results

Every year, the membership committee conducts a membership engagement survey to help us better understand how we can engage our members and track how we are improving this effort. On February 12th, we sent out a survey to all members over the APHA Connect list-serv. The response rate was 10.44% (n=237) which is a decrease from last year’s 12% response rate.

Of the members who responded, 38% were regular members (full, discounted, or affiliate), 26.6% were students, 22.8% were Early Career Professionals (ECPs), and 12.7% were retired. Almost half of the respondents 46.4%, have been an IH member for less than a year, 29% have been a member for 1 to 3 years, 7.6% of them for over 20 years. The majority (85.2%) indicated that they intend to renew their APHA membership and 89% of them intend to remain with the IH section.

The most common reason listed as the primary reason for joining APHA was: connecting/networking with other professionals (40.5%), followed by professional collaboration with other researchers/professionals (20.7%). About one-third of respondents indicated that they joined to either attend (11.8%) or present (11.4%) or advocate/lobby (11.4%) at the Annual Meeting.

Respondents were asked how easy it is to get involved with Section activities. On a scale of 1 to 5, with 1 being the most difficult and 5 being the easiest, the percentage of respondents were; 1=6.6% (most difficult), 2=19.7%, 3=42.8%, 4=21%, and 5=10% (easiest). Most (79.5%) of the respondents have never been involved with the section committees or working groups.

A clear majority of survey respondents indicated that they were unaware of the Section’s communications platforms: the section website (65.5%), quarterly newsletter (62%), social media (67%) and APHA Connect (59.4%). A quarter of the respondents are aware of the section website, social media and APHA Connect but do not read. And a quarter of the respondents read the quarterly newsletter regularly. Many of the respondents (71.2%) are interested in using communications platforms to network with other section members and discuss global health research and advocacy programs outside of the Annual Meeting. Most of the respondents (81.7%) are also interested in attending regional meet-up event outside of the Annual Meeting.

Members were asked to indicate if they were interested in learning more about the Section’s committees and working groups and to provide their e-mail address so they can be contacted by our committees with information on how to get involved. Committees that generated the most interest among respondents were Policy/Advocacy (71.2%), Program (31.9%), Student (24.5%) and Mentorship (31.3%). Working groups with the largest number of interested respondents included Global Health Connections (70%), Maternal and Child Health (39.5%), Community-Based Primary Health Care (39.5%), and Climate Change and Health (37.9%).

If you have any questions about the survey or have an interest in additional analysis, please feel free to reach out to Jay Nepal or Rose Schenider of the Membership Committee.

It’s National Public Health Week!

From the National Public Health Week Website: http://www.nphw.org/

We hope you’ll take advantage of all National Public Health Week 2019 has to offer as we celebrate public health and highlight key issues. During these seven days of inspiring events, conversations and celebrations nationwide, don’t miss:

  • Our annual Twitter chat, a conversation with public health leaders from around the country. Mark your calendar for April 3, and don’t forget to RSVP.
  • The NPHW Forum on April 1 featuring grassroots organizers sharing how they’ve activated their communities to improve health right where they live. You can register to attend in person or watch the event via webcast.
  • NPHW’s Student Day discussion on April 4, when public health professionals will share tips on how to break into the field. You can join us in D.C. or watch the webcast to ask questions about getting that first job out of school.
  • Our Shareables page featuring images you can post on social media and NPHW logos to help you spread the word about NPHW 2019.
  • NPHW events in your community, from fundraising fitness walks to health fairs to educational workshops. You can search by state on our Events page.

Our fact sheets are available year-round on the NPHW website so we can keep the momentum and learning going. Learn more about this year’s daily themes and how you can be part of the movement for science, action and health.

Why do we celebrate National Public Health Week? APHA Executive Director Georges Benjamin explains that perfectly in his NPHW 2019 Welcome Letter.