MODULE I
INTRODUCTION TO STI
1
Module Objectives
Identify common STIs and the factors that
influence STI prevention and control
Explain:
the magnitude of STI
the public health impact of STI
The relationship of STIs and HIV/AIDS
Strategies on prevention and control of STI
Challenges in the STIs prevention and control
2
Brain storming session
What is STI?
3
STIs are infectious disease that are
transmitted by intimate contact mainly
sexual intercourse .
STIs are caused by more than 30 different
pathogens including bacteria, viruses,
protozoa, fungus and ecto-parasites.
4
THE TRANSMISSION OF STIs
5
STI transmission dynamics at population level
General population
Bridging population
Core
transmitters
6
How STIs disseminate?
Basic Reproductive
rate
Ro = B x c x D
Transmission Rate of Duration
Efficiency(infectiousness) sex partner of
change infectiousness
7
The Transmission of STIs
The most common mode of transmission
is unprotected sex
Other forms of transmission are
Mother to child
During pregnancy (HIV & syphillis)
At delivery (gonorrhea ,chlamydia &HIV)
Through breast feeding
8
Transmission cont…
Unsafe (unsterile ) use of needles or
injections
Contact with blood or blood products
(syphilis, HIV &hepatitis )
9
Factors increasing transmission of STIs
• Biological factors
– Age, young age more susceptible
– Gender, women more easily infected than males
– Immune status
• Behavioral factors
– changing sexual partners frequently
– having more than one sexual partner
– having sex with ‘casual’ partners, sex-workers
or their clients
– having unprotected penetrative sexual
intercourse in a situation where either partner
has an infection
– use of alcohol or other drugs before or during
sex
10
Factors increasing transmission of STIs
• Socio-cultural factors
– in most cultures women have very little decision
making power over sexual practices and choices,
including use of condoms
– women tend to be economically dependent on
their male partners and are therefore more likely
to tolerate men’s risky behaviour
– in some societies the girl-child tends to be
married off to an adult male at a very young age,
thus exposing the girl to infections
11
Socio-cultural factors cont..
in some societies a permissive attitude is taken
towards men allowing them to have more than
one sexual partner.
Harmful traditional practices
skin-piercing
the use of unsterile needles to give injections or tattoos
scarification or body piercing
circumcision using shared knives
12
EPIDEMIOLOGY OF STIs
13
Epidemiology of STIs
• Global
• STIs are a major public health problem in all
countries, but are especially in developing countries
where access to adequate diagnostic and treatment
facilities is very limited or non-existent.
• According to 2008 WHO estimates, 499 million new
cases of curable STIs (syphilis, gonorrhea, chlamydia
and trichomoniasis) occur annually throughout the
world in adults aged 15-49 years.
• Geographically, the largest proportion of patients is in
the region of south and south-east Asia followed by
sub Saharan Africa (SSA), and Latin American and the
Caribbean.
14
Epidemiology continued
• Ethiopia
• According to 2011EDHS
• 1 percent, each, of Ethiopian women and men reported
having had an STI in the past 12 months.
• 3% of women and 2 % of men reported having
had an abnormal genital discharge, and
• 1% each of women and men reported
having had a genital sore or ulcer in the
12 months preceding the survey.
• These numbers may be underestimates
because respondents may be embarrassed or
ashamed to admit to having STIs.
15
Epidemiology continued
Another STI sentinel surveillance study done in 2013 at 8
health facilities located in three regions (Amhara, Oromia
and Addis Ababa) by EPHI and CDC-Ethiopia, a total of 636
STI cases were reported.
•The commonest syndrome was
• Vaginal discharge 50%
• Urethral discharge 31%,
• Genital ulcerative disease 9%
• Lower abdominal pain 7.3%and
• Presented with two syndrome.3%
16
Epidemiology continued
• About 16% of the STI patients were co-infected
with HIV(8.1% male and 21%female) and HIV
prevalence is higher on STI patients with lower
abdominal pain (41% ) and genital ulcer (24.5%).
• Young people (20-34yrs) are highly affected
(68.2%), with a larger proportion of
females( 61%).
1
Epidemiology continued
According to the 2012 ANC sentinel
surveillance the prevalence of syphilis is 1%
which shows a reduction in trend as compared
to (2.7% in 2007 and 2.3% in 2009 surveillance
report
According to the single point HIV prevalence
estimate for the year 2014, the adult HIV
prevalence is 1.14%.
Taking syphilis and HIV as proxy indicators, the
STI prevalence is in a declining trend.
1
Epidemiology continued
Prevalence higher in urban than rural
Higher in unmarried & young adults (15-44
yrs)
More frequent among females
19
Epidemiology continued
There is increasing evidence that a large
proportion of STIs are asymptomatic and most
symptomatic patients seek treatment from
traditional healers, pharmacies, drug vendors,
shops and marketplaces.
According to 2011 EDHS,
34% each, of women and men sought care for the STIs or
symptoms of STIs from a clinic, hospital, or health
professional.
1% of women and 6 % of men sought advice or
medicine from a shop, pharmacy, or drug vendor.
63% of women and 56 %of men who had STIs or STI
symptoms in the 12 months preceding the survey did not
seek any advice or treatment.
20
Operational model of STI in the
community
2
Epidemiology continued
Implications of the model for STI
Control:
Reduce risk through education to
communities and specific groups
Condoms promotion through improving their
availability to the sexually active
Case finding through partners’ notification
and screening programs
Promotion of health seeking behavior
through early STI symptom recognition.
22
Epidemiology continued
Provision of user friendly services
Innovative approaches for STI service
delivery e.g. training
pharmacists,traditional healers, in STI
recognition and referral.
Improve STI case management in health
facilities
Provision of full package of STI case
management including partner notification
23
The accuracy of STI statistics
• Reasons for underestimation:
– people with asymptomatic STIs do not seek
treatment
– health facilities offering treatment for STIs
may be too far away for many people
– people seeking other health care such as
antenatal services may not be routinely
screened for STIs
– many patients perceive a stigma in attending
clinics
24
The accuracy of STI statistics
Reasons continued….
many people may choose to go to alternative
providers, both in the formal and informal
sectors, who do not report case numbers.
Lack of uniformity of reporting
Cost of services
25
The accuracy of STI statistics cont….
Symptomatic
Asymptomatic
26
Public health impacts of STI
27
Public health impacts of STI
• Failure to diagnose and treat STIs at an early stage may
result in serious
complications and sequelae.
• The most serious health consequences of STIs, other
than HIV/AIDS, tend to occur in women and newborn
children.
• Complications in women include
• cervical cancer, pelvic inflammatory disease ,
• infertility, chronic abdominal pain,
• ectopic pregnancy, preterm labor and related
2 maternal mortality.
Public health impacts of STI continued
• Complications in newborns include
• congenital syphilis,
• gonococcal infection of the conjunctiva - a
potentially blinding condition,
• chlamydial pneumonia and perinatal hepatitis
B infection,
• premature deliveries, low birth weight,
growth retardation.
2
Public health impacts of STI
continued
• Complications in men:
• Urethral stricture
• infertility
• Majority of the complications of STIs are
preventable if the patient is diagnosed and
treated early.
30
Public health impacts of STI
continued
• STIs have also enormous social and economic
consequences.
• In developing countries it account for 17% of economic
losses.
• Marital disharmony may occur when one partner develops
STI or infertility.
• The costs of STI drugs may place a heavy financial burden
on families, communities and the country at large.
• Antimicrobial resistance has rendered some low-cost
regimens ineffective
31
The relation ship between STI and
HIV AIDS
3
The relation ship between STI and
HIV AIDS
• The relationship between STIs and HIV/transmission
has been described as an epidemiological
synergy and share the same risk factors.
[Link] enhance the sexual transmission of HIV
through:
• STIs that primarily cause ulcers disrupt the
integrity of the skin barrier enabling HIV easy
access through such defects in the skin.
• The presence of genital ulcers is known to increase the risk
of HIV transmission 3-5 folds
• STIs that primarily cause inflammation such as
gonorrhea, trichomoniasis, and chlamydial
infections present a weak barrier to HIV.
3
The relation ship between STI
and HIV AIDS continued
• infected lymphocytes among HIV infected
individuals are attracted to the lesions and
hence increase likelihood of infection to the
partner
• STIs Increase viral shedding (reported in
genital fluids of patients with STIs) and STIs
increase susceptibility to HIV.( STI treatment
has been demonstrated to significantly
reduce viral shedding).
34
The relation ship between STI
and HIV AIDS continued
2. HIV infection affects STIs through:
• Increased susceptibility to STIs among immuno suppressed
individuals
•Altering susceptibility of STI pathogens to antibiotics
→decreasing effectiveness of treatment. (This has been
reported for chancroid and syphilis)
•The clinical features of various types of STIs are influenced by
co-infection with HIV.
3
STRATEGIES FOR STIs
PREVENTION AND CONTROL
36
The Main Aims of STIs Prevention
and Control are:-
Interrupting the transmission of STIs
Prevent development of disease and
complications
Reducing the risk of acquiring and
transmitting HIV
37
Prevention and Control of STIs Involves
Early diagnosis and treatment
Promotion of safer sexual behavior
Promotion of health care-seeking
behavior,
Targeting vulnerable groups
38
Primary prevention
Safer sexual behaviors
abstinence from sexual activity
altogether/ delaying the age of sexual
debut
life-long mutual monogamy
Correct and consistent use of condoms .
39
Secondary prevention
promoting STI care-seeking behaviour,
through:
public education campaigns
providing non-stigmatizing and non-
discriminatory health facilities
providing quality STI care
ensuring a continuous supply of highly
effective drugs
ensuring a continuous supply of condoms
40
Secondary prevention
continued
• Early diagnosis and prompt and correct treatment
using comprehensive STI syndromic management
• case finding and screening:
– examining minimally symptomatic women attending
clinics for maternal and child health and family planning
– partner notification and treatment
– education, investigation and treatment of targeted
population groups who may have placed themselves at
risk of infection
– testing of blood donors for syphilis, HIV and hepatitis B
• Integration of STI services within primary care
41
CHALLENGES OF
CONTROLLING STIs
42
Brainstorming session
• What makes the control of STI so
difficult? What can we do to control STI?’’
43
Challenges are due to:
Health system factors
Biological factors
Socio-cultural & behavioral factors
44
Health System Factors
Health service may be unavailable,
too far away,
expensive,
ill equipped,
not user friendly or considered stigmatizing
There may be little emphasis on education
Health services may not have effective drugs
Difficulty of partner management
Services may not be integrated within primary
care clinics: maternal, child health, family
planning and ART clinics
45
Socio-cultural & behavioral factors
Reluctance to seek health care
Ignorance or misinformation
A preference for alternative health care
service
Reluctance to follow safe sex practices
The social stigma often attached to STI
46
Socio-cultural & behavioral factors
continued
Failure to take full prescribed course of
treatment
Difficulty of notifying sexual partners
47
Biological factors
70%-80% of infected women may be
asymptomatic and so will not seek
treatment
Such people will continue to be infected,
risking complications and perhaps infecting
others
48