Sexual Health &

STI

05/26/2024
Sexually Transmitted Infections (STI)

• STIs refer to the infectious organisms transmitted

primarily through sexual activity.
• STIs are among the many related factors that affect the
broad continuum of reproductive health.
• They are major global cause of acute illness, infertility,
long term disability and death, with severe medical
and psychological outcome.
• STIs remain a significant public health problem
largely unrecognized by the public, policymakers and
professionals.
…cont’d

• STIs are part of the broader group of infections

known as Reproductive Tract Infections (RTIs).
• RTIs include STIs as well as other infections of the
RT that are not transmitted through sexual
intercourse.

• Not all STIs are RTIs and not all RTIs are sexually
transmitted.
…cont’d

• STI refers to the way of transmission whereas RTI

refers to the site where the infections develop.
RTIs include:
1. STIs
2. Endogenous infections
3. Iatrogenic

05/26/2024
1. Sexually transmitted infections (STIs)
• also known as sexually transmitted diseases
(STDs)
• caused by viruses, bacteria, or parasitic organisms
that are passed through sexual activity from an
infected partner.
• More than 40 STIs have been identified, including
chlamydia, gonorrhea, hepatitis B and C, herpes,
human papillomavirus, syphilis (Treponema
pallidum), trichomoniasis, and HIV.
2. Endogenous infections

• Infections that result from an overgrowth (imbalance)

of organisms normally present in the vagina.

• These infections are not usually sexually transmitted,

and include bacterial vaginosis and candidiasis.
3. Iatrogenic

• Infections introduced into the reproductive tract by a

medical/surgical procedure such as induced abortion,
IUD insertion, or childbirth.

• This can happen if surgical instruments used in the

procedure are not properly sterilized, or if an
infection already present in the lower reproductive
tract is pushed through the cervix into the upper
reproductive tract.
Epidemiology and Trends

• Over 340 million curable, and many more

incurable, STIs occur each year.
• Nearly one million new cases of curable STIs
occur each day
• Majority of the infection occurs in sub‐
Saharan Africa and some parts of Asia.
…cont’d

• The prevalence and incidence of STIs may

vary widely, between urban and rural
population.

• These differences reflect a variety of social,

cultural, and economic factors.
• The prevalence of STIs tend to be high in
unmarried individuals, and in young adults.
…cont’d

• STIs tend to occur at a younger age in females than in

males.
• In developing countries, STIs and their complications
are amongst the top five disease categories for which
adults seek health care.

• In women of childbearing age, STIs (excluding HIV)

are the second causes of disease, death and healthy
life lost.
Causes

1. Bacterial
2. Viral
3. Fungal
4. Parasitic
…cont’d

• The main sexually transmitted bacteria are:

– Neisseria gonorrhea (causes gonorrhoea)
– Chlamydia trachomatis (chlamydial infections)
– Treponema pallidum (causes syphilis)
– Hemophilus ducreyi (causes chancroid)
…cont’d

• The main sexually transmitted viruses are:

– Human immunodeficiency virus

– Herpes simplex virus
– Human papilloma virus
– Hepatitis B virus
– Cytomegalovirus
…cont’d

• Protozoal infections
– Trichomonas vaginalis

• Fungal infections
– Candida albicans
• Parasitic infestations
– Phthirus pubis (pubic lice infestation)
– Sarcoptes scabiei (scabies)
Mode of transmission

• Unprotected sexual intercourse

• Other possible methods of transmission include

mother-to-child, blood transfusion, contact with
blood or blood product
Prognostic classification of STDs

• Curable (mostly bacterial)

– Gonorrhea, Syphilis
– Chlamydia, Trichomoniasis
• Incurable (virus)
– HIV/AIDS
– Hepatitis
– Herpes
– Human papilloma virus
…cont’d
• Women have a greater risk of suffering from STIs/RTIs
than men b/c women are:
– biologically more susceptible than men;
– usually infected at a younger age than men;
– more likely to suffer from complications;
– limited in their ability to protect themselves from
high-risk sex or to negotiate condom use;
– more to suffer from asymptomatic infections and
remain untreated; and
– less likely to seek treatment, even for symptomatic
infections.
STIs and sexually transmitted HIV

• HIV is transmitted in the same way as other STIs

• Prevention of STIs also prevents sexual transmission of

HIV
• STIs increase the risk of acquiring as well as
transmitting HIV for several reasons:
• HIV can easily pass through breaks in the skin or
mucus membrane caused by genital ulcers (disrupt
mucosal barrier)
…cont’d

• HIV can attach to the many white blood cells that are
present in genital discharges (Increase number of
receptors in genital track)
• Large amounts of HIV are found in ulcers and genital
fluid of people with certain STIs (increased viral load )
• Effective treatment of STIs decreases the amount of HIV
in genital secretions and makes HIV transmission less
likely
Risk Factors for STIs

• Differences in vulnerability and sequelae are

attributable to:
– biological susceptibility,
– gender differentials such as power inequalities,
–behavioral factors including sexual practices and
health‐care seeking behavior
–poor access to care and low levels of education
Complications of STIs

1. Reproductive system problems (PID, chronic

pelvic pain, ectopic pregnancy and infertility)
2. Fetal and perinatal health problems (blindness,
stillbirth)
3. Cancer (cervical ca, genito-anal cancers)
4. Causal chain of events in the sexual transmission
of HIV infection
Impact of STIs
• Impose an enormous burden of morbidity and mortality
in developing countries:

– Directly through their impact on reproductive and

child health (medical complications of STIs)

– Indirectly through their role in facilitating the sexual

transmission of HIV infection
Social:
– Stigmatization
– Divorce & family disruption as a result of infertility
STI Prevention and Control Interventions

• According to the WHO and UNAIDS, STI control

programs have three objectives:
–interrupt the transmission of STIs;
–prevent the development of diseases and
complications; and
– reduce the transmission of HIV
Primary prevention of STI

1. Behavioral interventions (promoting healthy

sexual behavior)
• providing accurate and explicit information on safer
sex
– correct and consistent use of male and female
condoms
– Abstinence
– delay in onset of sexual activity
– keeping to one sexual partner or reducing the
number of sexual partners
…cont’d

• Increased delays in first sex and reduction of the

number of partners account for some of the most
impressive reductions in HIV prevalence and
incidence rates observed in Uganda
2. Health services for STI
– Health education/Counseling about STIs for both
infected and uninfected people
– VCT for HIV
…cont’d
3. Providing condoms and other barrier
methods
• Latex condom ‐ the single, most efficient, available
technology to reduce the sexual transmission of HIV
and other STIs
• Tests are currently under way to assess the
effectiveness of diaphragms to protect the cervix from
HIV and other STIs
…cont’d
4. Vaccines
– Hepatitis B is the only potentially sexually
transmissible pathogen for which an effective vaccine
is currently available

– Recent report of an efficacious vaccine against

human papilloma virus (HPV)
Secondary Prevention

A. Screening and case finding

– Universal serological testing of antenatal clinic
attendants for syphilis as recommended by the WHO

– Screening of blood donors at least for hepatitis,

syphilis, and HIV

– and if possible screening populations such as

military recruits and company employees
…cont’d
• simple and cheap diagnostic tests to identify
women with asymptomatic or poorly
symptomatic cervical infections for
– Women undergoing trans-cervical
procedures (insertion of IUD, uterine
curettage in abortion clinics) or
– pregnant women, at risk of transmitting
infections to their babies
– adolescents and sex workers
…cont’d
B. STI case management
• Early diagnosis and effective treatment of STIs is an
essential component of STI control programs
Three approaches:
1. Etiologic – done by identifying causative agent

2. Clinical – using clinical experience and giving treatment

targeted to suspected pathogens

3. Syndromic – identification of clinical syndromes and

giving treatment targeting all the locally known
pathogens which can cause the syndrome
Syndromic management of STIs
• Designed in 1980 by WHO for resource poor
countries
• relies on sign and symptom and risk assessment,
not laboratory investigation
 Principles of Syndromic Approach
• STI signs and symptoms are rarely specific to a
particular causative agent
• Laboratories are either non-existent or non functional
due to lack of resources
• Dual infections are quite common and both clinician
and laboratory may miss one of them
• Waiting time for lab. results may discourage some
patients
• Failure of cure at first contact
…cont’d

• The main Syndromic algorism includes:

• Vaginal discharge

• Urethral discharge

• Genital ulcer

• Inguinal bubo

• Scrotal swelling

• Lower abdominal pain

• Neonatal eye discharge

05/26/2024
 Syndromic: Treat the seven syndromes
SYNDROME MOST COMMON CAUSE

Vaginal discharge Vaginitis (trichomoniasis,

candidacies)
Cervicitis (gonorrhea, Chlamydia)
Urethral discharge in men Gonorrhea, chlamydia
Genital ulcer Syphilis, chancroid, herpes
Lower abdominal pain Gonorrhea, chlamydia, mixed
anaerobes
Scrotal swelling Gonorrhea, chlamydia
Inguinal bubo LGV, Chancroid
Neonatal conjunctivitis Gonorrhea, Chlamydia
Main Features of Syndromic Management

• Classification of the main causal pathogens by the

clinical syndromes they produce
• Use of flow charts to manage a particular syndrome

• Treatment for all important causes of the syndrome

…cont’d

• Reduction or prevention of further risk ‐taking

behavior through age‐appropriate education and

counseling;
• promotion and provision of condoms, with clear
messages for correct and consistent use;

• notification and treatment of STIs in sexual

partners, where applicable
STIs in Ethiopia

• Major public health problem

• There is, however, little information regarding the
incidence and prevalence of these diseases
• The characteristic of risk behaviors include:
– Wide spread prostitution
– Postponement of marriage
– Urbanization
– Socio‐cultural change resulting in risky sexual
behavior
– Increasing unemployment and streetism
…cont’d

• There is an underreporting of STI cases:

– Large proportion of STIs are asymptomatic

– There is no national estimate on the
prevalence of STIs, except for syphilis
– There is no uniform pattern of reporting system and
the surveillance system is weak
• Some reports indicate that there is a decline in the
number of syphilis cases compared to other STIs
…cont’d
• STI case reporting is important for:
– Planning and decision making
– Predicting the trend of HIV and STI infections and
people’s change in sexual behavior over time
…cont’d

• Traditionally, STI control efforts have focused on

diagnosis and treatment in the clinic setting.

• However, to have the greatest community impact, it is

necessary to implement prevention activities and to
find and treat cases as early as possible
 Unwanted pregnancy
&Abortion

05/26/2024
Unwanted pregnancy

• An unintended pregnancy is a pregnancy that is

mistimed, unplanned, or unwanted at the time of
conception.
 Unintended pregnancy is a worldwide problem that
affects women, their families and societies at large.
Unintended pregnancy results from:
. none-use of contraceptives
. contraceptive failure and rape
Abortion Concepts

• Abortion is expulsion of the fetus before it reaches

viability (ability to survive outside the uterus).

• can be spontaneous (miscarriage) or induced

(terminated on purpose).
Unsafe Vs Safe Abortion

• Unsafe abortion (WHO) is defined as a procedure

for terminating pregnancy either by persons lacking
the necessary skills or in an environment lacking
the minimal medical standards or both.

• Any abortion that does not occur under any of the

above conditions is considered a safe abortion
Legal Vs Illegal Abortion

• A legal abortion is an induced abortion that meets

the legal requirements of the country in which it takes
place

• An illegal abortion is an abortion that does not meet

such requirements
• The legality and safety of abortion are closely related
but not synonymous
• Generally, legal abortions are mostly safe and illegal
abortions are mostly unsafe
Public Health Importance of Abortion

• major public health problem in many countries.

• approximately 210 million women become pregnant

every year
• 42 million pregnancies are voluntarily terminated
each year;
• 20 million undergo unsafe abortion

• 55, 000 unsafe abortions and more than 200 women

deaths every day.
…cont’d

• Unsafe abortion causes approximately 13% of all

maternal deaths (68,000 maternal deaths each year)
and about 5 million disabilities.

• Unsafe abortion is one of the most easily preventable

causes of maternal death and ill-health.
Unsafe abortion in Ethiopia

• Accurate estimates are difficult to get.

• It is estimated that there are 3.27 million pregnancies
every year of which approximately 500,000 end in
either spontaneous or unsafely induced abortion

• the leading cause of maternal mortality

 Methods and Procedures to Induce Abortion
• over 100 traditional methods of inducing abortion
• can be broadly classified in to 4 categories:
– Oral and injectable medicines
– Vaginal preparations
– Introduction of a foreign body in to the uterus
– Trauma to the abdomen
 Causes of Unsafe abortion
Individual factors
– Age
– Educational status
– Economic status
– Marital status
Social Factors
– Stigma of extramarital pregnancy
– Unwanted/ Unplanned Pregnancy
– Violence‐ In studies in Ethiopia rape was cited as
the reason for seeking an abortion in 20 ‐25%
 …cont’d
Legal restriction
– Not available on demand
– Lack of knowledge of the penal code
• Only 29% of the health workers were able to state
the Penal Code of abortion
Limited and costly safe abortion services
– Abortion services in private facilities are expensive
Provider/ Service factors
• unplanned pregnancy
• method failure or ineffective use
 …cont’d
Ethiopia
• Over 45% of all abortions occurred in adolescents and
the younger age group who have limited access to RH
services

• Contraceptive method failure was responsible for 18%

of all the pregnancies that resulted in unsafe abortion
– Currently EDHS2016 the unmet need for family
planning is 22%.
 Prevention of unsafe abortion
I. Educating communities
• HE messages should be sensitive to people’s beliefs,
attitudes and practices.
• The information should include:
– the legal status of abortion;
– preventing unwanted pregnancy;
– avoiding unsafe abortion; and
– recognizing and seeking appropriate treatment for
abortion complications
…cont’d
II. Universal access to Contraceptive services and information
• priority should be given to the prevention of unwanted
pregnancy through comprehensive, client-oriented
reproductive health services.
• Provide universal access to a full range of safe and
reliable family planning information and services,
including emergency contraception.
• Ensure a continuing improvement in the quality of
services and remove all the major remaining barriers to
the utilization of family-planning services.
 …cont’d
III. Improve access to high quality post abortion care
(PAC)
PAC generally includes:
• Clinical treatment for complications of incomplete abortion

• provision of counseling and contraceptive supplies

• referral to other RH care services

• community education to improve RH and to reduce

unwanted pregnancy and the need for abortion.
IV. Supportive laws and policies
• Policies and laws can contribute to unsafe

abortion by impeding women’s ability to

protect their sexual and reproductive
health.

• Eg. Prohibitions on contraceptive delivery

to unmarried women and adolescents
 …cont’d
• Evidence shows that restrictive legislation is associated with
higher rates of unsafe abortion and correspondingly high
mortality.

– Up to 23/1000 women unsafe abortion in restrictive laws

compared to 2/1000 in permissive laws
– 34/1000 mortality in restrictive countries compared to 1 or
less per 1000 in liberal laws

Eg. In Romania, abortion-related deaths increased sharply when

the law became very restrictive in 1966 (to 148/100,000), and
fell after 1990 with a return to less restrictive legislation
(9/100,000) in 2002.
 Legal Framework of abortion

• Restrictive ‐ abortion is not allowed for any reason

• Liberal‐ abortion is allowed for selected reasons
• Non restrictive – abortion is available on demand
 Legal framework of abortion in Ethiopia

• Previous penal code:

‘performing, receiving or referring someone to an
abortion except to save a mother's life could result in
five years of imprisonment’

The penal code was revised in 2005.

Grounds on Which Abortion is Permitted in
Ethiopia
• According to the revised penal code, abortion is legal if:
the pregnancy is as a result rape/ incest sex
the pregnancy threatens the mother’s/the fetus life
the fetus has a major deformity
the mother has a mental/physical defect or if she is underage
(<18 years) and if she is not psychologically ready to have the
child
the mother doesn’t have the economic capacity to bring up
the child
05/26/2024 prepared by Robel.D (PHO)