Sexual Health in Developing Countries: Do we need more testing?
As of November 2021, WHO data has revealed that more than 1 million sexually transmitted infections (STIs) are acquired every day, worldwide. Most of these infections are unfortunately asymptomatic.
More than 30 different bacteria, viruses and parasites are known to be transmitted through sexual contact, however, eight of these pathogens are classically described using the term STIs. These eight STIs are primarily caused by bacteria and viruses, of which the four bacterial infections (syphilis, gonorrhoea, chlamydiosis, and trichomoniasis) are completely curable with antibiotic treatment. If detected and treated early, these can be cured without any sequelae or complications.
The other four STIs are caused by viruses (HIV, human papillomavirus, hepatitis B, and herpes). Although antivirals are available to treat them, these infections cannot be completely cured. Additionally, we have vaccines that are very effective against HPV and hepatitis B and prevent infections with the same.
In spite of the above advancements in medical science, STD rates have been found to be increasing worldwide over the past few decades. It is estimated that, globally, more than 500 million people aged 15 to 49 years are estimated to have a genital infection with herpes simplex virus (HSV). Additionally, it is estimated that there are 374 million new infections with 1 of the 4 STIs: chlamydia, gonorrhoea, syphilis, or trichomoniasis.
From the above data, one can estimate the huge burden of STIs in the world at present. And while effective treatments are available for so many of these infections, why have we been unable to reduce transmission rates and incidences?
This is because of the strong psychosocial factors and the longstanding stigma associated with STIs. The World Health Organization states that – “STIs have a direct impact on sexual and reproductive health through stigmatization, infertility, cancers and pregnancy complications, and can increase the risk of HIV.”
WHO data on syphilis reveals that in 2019, of 78 reporting countries, an average of 3.2% (range 1.1% to 10.9%) of antenatal care attendees tested positive for syphilis. Syphilis in pregnancy is the second leading cause of stillbirth globally and results in various complications in newborns. However, if diagnosed with a simple test during pregnancy, it can be completely treated. Most countries now have laws to provide a test for syphilis and HIV during pregnancy to every pregnant woman who accesses healthcare.
Worldwide, syphilis is a highly prevalent infection among men who have sex with men (MSM). The increasing numbers of MSMs have contributed to the increasing rates of STIs. Syphilis infects an average of 11.8% (range 5.2% to 19.6%) of MSM of the 25 reporting countries in 2019, as per WHO data. There have been reports in many countries of increasing trends. Untreated syphilis can lead to serious complications in 25% of infected individuals that do not receive diagnosis and treatment. The complications can be severe and even life-threatening and can increase the risk of HIV acquisition and transmission.
HPV infection causes cervical cancer. Cervical cancer is the fourth most common cancer among women globally. Hepatitis B resulted in an estimated 820 000 deaths in 2019, mostly from cirrhosis and hepatocellular carcinoma (primary liver cancer).
In 2020, the global number of people living with HIV was 37.7 million, compared to 25.5 million in 2000. This reflects the continued transmission of HIV despite reductions in incidence. Sub-Saharan Africa remains the most severely affected region, with nearly 1 in every 25 adults (3.6%) living with HIV and accounting for more than two-thirds of the people living with HIV worldwide.
The sexual health of adolescents in developing countries is another major problem. There are more than 1 billion teenagers worldwide, with 70 per cent of them living in developing countries. In Sub-Saharan Africa, where AIDS is an epidemic, about two-thirds of those infected are adolescents.
STD rates are more difficult to determine in underdeveloped or developing countries because of the lack of access to health care and the lack of STD testing. The strong stigma against STDs in these countries further delays testing, as many try to avoid getting themselves checked despite symptoms. Pregnant women do not always have access to adequate healthcare facilities, and when available, these are geographically inaccessible and thus testing and treatment is delayed. In developed countries, however, STD testing is more easily available and widely used, which reflects in the data.
Additionally, it is noted that many doctors or healthcare professionals in low- or middle-income countries rely on identifying consistent, easily recognizable clinical signs and symptoms to guide STI diagnosis and treatment, without relying on testing, as most people would not be able to bear the additional cost of a test.
Based on the author’s experience in India, when there is a choice between prescribing a test or prescribing a treatment that will likely cure the patient (once the diagnosis has been established clinically), the doctors often prefer the latter. Additionally, it is quite difficult to send the patient away to get a test, as many of them would not follow up with the results and the treatment would thus remain incomplete. However, these are some of the reasons which contribute to low reported incidences of STIs in developing countries.
This approach of diagnosing and treating STIs based on clinical features is called syndromic management. This method relies on clinical flowcharts and allows health workers to diagnose a specific infection based on observed syndromes (e.g., vaginal discharge, urethral discharge, genital ulcers, abdominal pain).
Syndromic management is simple, assures rapid, same-day treatment, and avoids expensive or unavailable diagnostic tests for patients that present with symptoms. However, one disadvantage is that this approach results in overtreatment and missed treatment as the majority of STIs are asymptomatic. Thus, WHO recommends that countries enhance syndromic management by gradually incorporating laboratory testing to support the diagnosis.
In addition, STI screening with adequate testing remains important in high risk and vulnerable groups such as pregnant women, adolescents, men having sex with men, commercial sex workers, etc. The need of the hour is to step up testing facilities in developing countries and to improve accessibility to the same.
While most cities in India now have routine access to good quality labs, with even home-based testing being easily available, the situation in the remote villages is not so good. These residents often must travel long distances, sometimes hours, to reach the nearest testing centre, and this leads to very low testing rates.
And the burden of asymptomatic STIs, which contributes to their continued transmission in the population, can only be addressed with widespread screening and testing. The development and availability of rapid and reliable tests for STIs is the need of the hour, with presently rapid tests only being available easily for Syphilis and HIV.
Thus, as medical advancements are made and new tests are being developed around the world, it may be time to improve testing and accessibility to testing in the developing nations in Asia, Sub-Saharan Africa, and Latin America, where a major burden of STIs is being felt presently.
- Sexually transmitted infections (STIs) (who.int)
- Data on syphilis (who.int)
- Estimated number of people (all ages) living with HIV (who.int)
- Sexual Health of Adolescents in the Developing World (borgenproject.org)
- STD Rates by Country (worldpopulationreview.com)
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