Sexually Transmitted Infections in Developing Countries

Why address STIs in developing countries?

Sexually transmitted infections (STIs) are among the world’s most common diseases, with an annual incidence exceeded only by diarrheal diseases, malaria, and lower respiratory infections. Every day nearly 1 million people acquire a new STI, and worldwide, more than 340 million new cases of curable STIs and even more new viral (non-curable) infections occur each year. Up to 80% of curable STIs occur in developing world settings, and adolescents and young adults have the highest rates of these STIs.

The burden of STIs on the health care system and healthcare expenditure is great. Even excluding HIV, STIs are consistently among the most common con-ditions leading to health care visits. In all nations, but particularly in developing countries, STIs result in substantial productivity losses for individuals and communities. In developing countries, STIs are among the leading causes of disability adjusted life years (DALYs) lost for women of reproductive age, exceed-ed only by maternal causes and HIV.

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Consequences of untreated STIs

If not identified and treated promptly, STIs can cause serious long term consequences, and most morbidity and mortality occurs in women and infants (WHO, 2006).

• Infertility, tubal pregnancy, and maternal mortality. Untreated bacterial STIs in women result in pelvic inflammatory disease in up to 40% of infections; and 1 in every 3 of these will result in infertility. Tubal damage from STIs can lead to ectopic (tubal) pregnancy, the cause of up to 10% of maternal mortality in settings with high STI prevalence. Chronic pelvic pain from untreated bacterial STIs is an important cause of health care visits among women.
• Infant blindness. Up to 4000 newborn babies become blind every year because of eye infections that are attributable to untreated maternal STIs, and that could be easily prevented with topical infant eye medications.
• Perinatal deaths. Syphilis is one of the most important causes of adverse pregnancy outcomes globally, estimated to account for up to 1,500,000 perinatal deaths each year—equal or exceeding the perinatal mortality associated with either HIV or malaria. In Africa and Latin America, 2 to 15% of all pregnancies are in women with untreated syphilis. Infected women will experience an overall perinatal mortality of 40%—including stillborn infants and early neonatal deaths.
• Chronic liver disease and death. Chronic infection with hepatitis B virus (HBV) is the most important cause of disability and death from liver disease in developing world settings—causing 1 in 40 deaths among adults globally each year. Most HBV is transmitted from mother to child at birth. Existing HBV vaccine if provided for neonates could prevent 30 to 70% of all deaths related to liver cancers and cirrhosis among adults living in developing settings.
• Cervical cancer and death. Cervical cancer is the most common cause of cancer mortality among African women, and its frequency and progression are increased with HIV infection. New vaccines against human papillomavirus (HPV) infection could stop the early death of approximately 240,000 women from cervical cancer every year in resource poor settings.

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Available, affordable solutions exist

The tragedy of the health and economic burden of STIs is that many of the serious consequences related to STIs could be prevented using available and af-fordable interventions that already exist. Early screen-ing and treatment (a penicillin injection) for pregnant women infected with syphilis is simple and can cost as little as 1 USD and can also eliminate the associ-ated perinatal mortality (including stillbirths) due to syphilis. But maternal syphilis screening, among the most cost-effective of all public health interventions, is still not effectively applied in many nations. Likewise, viral STIs such as hepatitis B virus (HBV) and human papillomavirus (HPV) can be prevented with vaccines; and antiviral drugs such as acyclovir can reduce the spread of genital herpes infection (the most common cause of genital ulcer disease) and potentially prevent new HIV infections. Most STIs (including those caused by viruses) can be prevented with male latex con-doms used consistently and correctly. Many common STIs can be cured with affordable antibiotic drug.

A number of evidence-based and effective strategies have emerged and become widely accepted over the past two decades:

Prevention through treatment: Prompt identification and treatment of bacterial STIs remains a cornerstone of STI control. Treating STIs reduces prevalence and breaks the chain of transmission in the community, and is therefore the most effective form of prevention in the absence of a vaccine. However, facility-based case management alone is not enough to control STIs. Core components of STI control involves a series of interventions working together:

• Clinic-based management of symptomatic STIs. Syndromic management has been demonstrated to be effective in the absence of laboratory capacity to support etiologic diagnosis.
• Identification and treatment of sex partners prevents re-infection and breaks the chain of transmission in the community.
• Screening asymptomatic persons (particularly women) at risk for serious STI-related outcomes can prevent serious consequences such as congenital syphilis and cervical cancer.
• Sustained, targeted control strategies for “core” high risk groups who have high likelihood of infection and high rates of partner change (e.g. sex workers); populations that “bridge” to the general population (e.g. clients of sex workers, truckers, and other mobile populations); and highly vulnerable groups (e.g., adolescents) reduces morbidity and STI prevalence in the community.
• STI vaccines against HBV and HPV hold the promise of eliminating a substantial proportion of the world’s STI-related cancers and chronic liver disease.

Other Supporting Elements for Prevention and Control

In addition to the core components of STI prevention and control, six additional supporting elements have proven important in ensuring the core programs can be effectively provided:

• Leadership and advocacy to ensure an environment supporting STI control and prevention.
• STI surveillance to track burden of disease and track program impact.
• STI laboratory capacity that is sufficient to monitor critical diseases and support programs.
• Training around STI clinical management and prevention.
• Monitoring and evaluation of STI programs to assess progress and make needed changes.
• Community education around STI risks and prevention, especially important for youth along with availability of preventive options such as male and female latex condoms.

Globally, the populations most vulnerable to STIs are those who are disproportionately affected by other health and social issues: adolescents, pregnant women and their unborn children, migrant populations, and other economically or socially marginalized groups.

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Do's and Don'ts

• DO involve leaders in supporting STI prevention and control. Stigma around STIs exists in virtually every society, but people are often unaware of the consequences of acquiring an STI or of not seeking prompt treatment. Keeping leaders informed about the burden and consequences of STIs and involved in programs allows them to advocate for a supportive environment for STI prevention and control, including supportive polices, laws and initiatives related to stigma reduction and disease prevention and treatment.
• DO ensure comprehensive STI clinical management for symptomatic individuals. Prompt and effective treatment of curable STIs reduces adverse health complications in individuals and breaks the chain of transmission in the community because—for STIs—treatment is prevention. Nonetheless, treatment alone is not enough. An adequate STI clinical encounter should include education about drug compliance and abstaining from sex while symptoms persist, STI risk reduction counseling (preferably using non-judgmentally, client-centered approaches), discussion of partner management, provision of condoms and how to use them, counseling (as appropriate) around contraception and recommendation of HIV testing—this is especially critical in settings with high or rising HIV prevalence.
• DO involve the private sector. Most STI care is done by private providers, whether in formal or informal sectors. Including private providers, prac-titioners and pharmacists, as part of the STI control program improves coverage of quality of STI care and surveillance.
• DO include STI surveillance as a key component of STI program. Surveillance systems allow clarification of disease burden and epidemiology, monitoring of STI trends useful in evaluating program impact over time, and help in projecting resource needs. Basic components of STI surveillance should at least include case reporting by syndrome (if etiology unavailable) disaggregated by age and sex, prevalence assessments in defined populations, linking of related program data and limited laboratory studies assessing STI etiologies.
• DO invest in laboratory capacity. While extensive laboratory capacity is unnecessary at all local levels, capacity should exist at the national level to ensure quality of lower level services, ensure ad-equacy of treatment protocols and support surveil-lance to guide national programs.
• DO prioritize targeted interventions for high risk and vulnerable populations. Adolescents, along with young adults, have high risk for STIs but are often hard-to-reach. Specialized user-friendly, affordable clinical and prevention services for adolescents can reduce STI burden and subsequent serious health care consequences for young people.
• DO ensure affordable, effective interventions are scaled up. Syphilis screening in pregnant women is among the most cost-effective health interventions that exist in developing nations, but is often not universally applied in remote settings despite availability of rapid point-of-care diagnostics. Hepatitis B vaccine is safe and affordable and recommended routinely in infant immunization programs, but is often overlooked—probably because the significant morbidity and mortality associated with HBV occurs among adults.
• DON’T overlook STIs in HIV-infected individuals. A new STI in an HIV-infected patient represents behavioral and biologic likelihood of HIV transmission to other partners and should be considered an urgent situation. Genital ulcer disease (GUD) is the STI syndrome most strongly associated with HIV transmission and acquisition. Individuals with genital ulcers should be promptly treated and counseled, with strong emphasis on the importance of partner management regardless of whether the individual’s HIV status is known. If HIV status is negative or unknown, HIV testing should be strongly encouraged.
• DON’T forget the importance of ongoing program monitoring and evaluation. Lack of periodical on-site monitoring of STI programs was highlighted in the WHO Global Strategy for STI Control: 2006–2015 as an important gap for STI control that should be addressed. Program Indicators, such as measure of adequate STI management and of adequate prevention counseling and condom distribution go a long way in ensuring program quality.
• DON’T miss opportunities for integration of services. Although vertical programs may increase focus and expertise for a particular health issue, more often men and women presenting for specific services leave with important health issues unaddressed. Integrating STI, HIV, and reproductive health services at point of care increase patient access, improves efficiencies and improves health outcomes. Incorporating syphilis screening into routine antenatal care services, and HIV testing and counseling into STI clinical encounters are examples of opportunities for service integration.
• DON’T overlook new information. Public health researchers are continually identifying new and effective prevention strategies, and these should be incorporated into programs when possible. For example, increasing global antimicrobial resistance to gonorrhea strains means national treatment protocols may need to be updated. Recent development of safe and effective vac-cines against HPV mean programs should begin to consider possible ways to roll out this intervention. Findings that herpes treatment may help prevent HIV means that antiviral drugs against herpes should be made available, especially in high HIV prevalence settings. Findings of substantial HIV prevention benefits and subsequent focus on development of specialized men’s health care facilities offers an opportunity to incorporate STI screening and control for men who do not access primary health care services.

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Useful Websites

• Millennium Development Goals 
• WHO Guidelines for STI management
• WHO Fact Sheet, STDs and young people
• WHO Fact Sheet, Women and STIs
• WHO STI Diagnostics Initiative (SDI)
• WHO Vaccine Preventable Diseases (VPD)
• CDC STD Program Operations Tools
• CDC 2005 CDC STD Treatment Guidelines
• HIV/AIDS Integration Partners Working Group
• UN, 1994 Conference on Population Development, Cairo
• Alliance for Microbicide Development
• Demographic and Health Surveys

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Resources

• World Health Organization. Global Strategy for the Prevention and Control of Sexually Transmitted Infections, 2006–2015; WHO: Geneva, 2006
• Agosti, J. M., and S. J. Goldie, 2007, Introducing HPV vaccine in developing countries--key challenges and issues: N.Engl.J Med, v. 356, no. 19, p. 1908–1910.
• Berman, S., and M. Kamb, 2007, Biomedical Interventions, in SO Aral, JM Douglas, and JA Lipshutz eds., Behavioral Interventions for Prevention and Control of Sexually Transmitted Diseases: New York, Springer Science and Busi-ness Media, LLC, p. 60–101.
• Dallabetta, G., M. L. Field, M. Lage, and Q. M. Islam, 2006, STDs: Global Burden and Challenges for Control, in G Dallabetta, M Laga, and Lamptey P. eds., Control of Sexually Transmitted Diseases: A handbook for the design and management of programs: Durham, North Carolina, Family Health Inter-national/ The AIDS Control and Prevention Project(AIDSCAR), p. 23–52.
• Fleming, D. T., and J. N. Wasserheit, 1999, From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmis-sion of HIV infection: Sex Transm.Infect., v. 75, no. 1, p. 3–17.
• Manhart, L. E., and K. K. Holmes, 2005, Ran-domized controlled trials of individual-level, population-level, and multilevel interventions for preventing sexually transmitted infections: what has worked?: J Infect.Dis., v. 191 Suppl 1, p. S7–24.
• Peeling RW, Mabey D, Fitzgerald DW, Watson-Jones D, 2004, Avoiding HIV and dying of syphilis. Lancet, v. 364 (9445), p. 1561–3.
• Meheus, A., 1992, Women’s health: importance of reproductive tract infections, pelvic inflammatory disease and cervical cancer, in A Germain, KK Holmes, P Piot, and JN Wasser-heit eds., Reproductive tract infections: global impact and priorities for women’s reproductive health: New York, Plenum Press, p. 61–91.
• Wasserheit, J. N., 1992, Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases: Sex Transm.Dis., v. 19, no. 2, p. 61–77.

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PDF Versions

• English (PDF 302kb)

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Prepared with technical assistance from the Division of STD Prevention and Division of Reproductive Health, Centers for Disease Control and Prevention