Adolescent and Youth Reproductive Health Module: 4. Sexually Transmitted Infections (STIs)

Study Session 4  Sexually Transmitted Infections (STIs)

Introduction

In this study session, you will learn why young people are at risk of developing sexually transmitted infections (STIs), and the long-term health consequences of acquiring these infections. You will learn about the major STI syndromes, what biological and social factors influence their transmission and what advice to offer on how individuals can protect themselves from STIs.

STIs, including HIV are discussed in Study Session 28 in Part 3 of the Module on Communicable Diseases, but in this session you will learn about the peculiar features of these infections among young people. Note that you are not expected to treat STIs. The Ethiopian Ministry of Health has recommended that treatment of STIs using the syndromic approach will only be given at a health centre or hospital. You are, however, expected to identify young people with STIs and refer them to the appropriate health facility.

Learning Outcomes for Study Session 4

When you have studied this session, you should be able to:

4.1  Define and use correctly all of the key words printed in bold. (SAQ 4.1)

4.2  Explain why young people are at risk of acquiring STIs. (SAQ 4.1)

4.3  Describe the impact of STIs (including HIV) on young people. (SAQ 4.3)

4.4  Describe how you can work with young people to ensure that they understand prevention strategies that can be used to stop the transmission of STIs, including HIV. (SAQs 4.2 and 4.4)

4.1  Why are young people at risk from sexually transmitted infections?

According to the World Health Organization (WHO), the highest reported rates of STIs are found among 15–24 year olds, while about half of all of the people infected with HIV and 60% of all new HIV infections are also in that age group. WHO also estimates that in 2008 there were around one million Ethiopians living with HIV.

The most widely known STIs are gonorrhoea, syphilis and HIV – but there are more than 30 STIs and disease syndromes that result from STIs. It is important to note that certain STIs substantially increase the risk of transmission of HIV for both men and women. HIV, in its turn, facilitates the transmission of some STIs and worsens the complications of STIs because it weakens the immune system.

• Young women are biologically more susceptible to STIs than older women. This is because their vaginal mucosa and cervical tissue are immature, and this makes these tissues more vulnerable to STIs.
• Boys and girls may have immune systems that have not previously been challenged and have not mobilised defences against STIs and HIV.
• Young people may also be more prone to infection because of anaemia or malnutrition.

Another biological factor, though not exclusive to young people, is that women often do not show symptoms of chlamydia and gonorrhoea (the most common STIs), so they do not seek treatment. For example, up to 70% of women and 30% of men infected with chlamydia have no symptoms. Similarly, up to 80% of women and 10% of men infected with gonorrhoea also have no symptoms.

Psychosocial factors:

Figure 4.1  Young boys and girls may not think beyond their love about the possible risks of unprotected sexual activity.

• Adolescents often lack basic information concerning their sexual health, or the symptoms, transmission and treatment of STIs.
• Often there is poor communication between young people and their elders, and there are few learning materials (books, magazines) designed for young people.
• Sexual intercourse is often unplanned and spontaneous among young people.
• They often have multiple, short-term sexual relationships and do not consistently use condoms.
• Young people may feel peer pressure to have sex before they are emotionally ready to be sexually active and they often confuse sex with love and engage in sex before they are ready in the name of ‘love’ (see Figure 4.1).
• Young men sometimes have a need to prove their sexual powers. Young men may have their first sexual experiences with prostitutes (commercial sex workers), while young women may have their first sexual experiences with older men, both of which increase the chance of getting STIs including HIV.
• Sexual violence and exploitation, lack of formal education (including sex education), inability to negotiate with partners about sexual decisions (in some cultures, girls are not empowered to say ‘No’) and lack of access to reproductive health services together put young women at especially high risk.
• Some adolescents are subject to early marriage, forced sex, trafficking and poverty, and may engage in sex work for money or favours.
• Substance abuse or experimentation with drugs and alcohol is common among young people, which often leads to their making irresponsible decisions such as having unprotected sex.

Even when young people realise that they are infected they may be afraid to seek treatment for STIs and so go on to infect others unnecessarily.

4.2  Impact of STIs (including HIV) on young people

Sexually transmitted infections are of public health concern because of their potential to cause serious and permanent complications in infected people who are not treated in a timely and effective way. These can include cervical cancer, pelvic inflammatory disease, chronic pelvic pain, fetal death, ectopic pregnancy (pregnancy outside the uterus) and related maternal mortality. Chlamydial infections and gonorrhoea are important causes of infertility, particularly in women, with far-reaching social consequences including break-up of marriages. Chlamydial infection is an important cause of pneumonia in infants. Neonatal gonococcal infections of the eyes can lead to blindness. Congenital syphilis is an important and significant cause of infant morbidity and mortality. In adults, syphilis can cause serious cardiac, neurological and other consequences, which can ultimately be fatal.

Generally, the long-term health consequences of STIs are more serious among women.

People who become ill from STIs may face loss of community credibility and even health workers sometimes treat them badly, being judgemental and refusing to provide services. It is important that you provide a good role model and become known for being sympathetic and non-judgemental.

4.3  STI prevention strategies for young people

As a Health Extension Practitioner, you should advise and encourage young people to adopt the following healthy behaviours:

• Delay onset of sexual activity. Abstain from sexual intercourse until married or in a stable relationship.
• Learn how to use condoms. If young people are already sexually active, it is important to make sure they know how to use condoms correctly. You should demonstrate the proper use of condoms in your education sessions related to sexually transmitted infections either individually or in group meetings (in schools, at the health post or in the community).
• Condoms should always be used except when pregnancy is desired or when partners in a stable relationship know for certain they are both disease-free.
• Avoid any kind of risky behaviour; try to stick with one partner. Boys should avoid having contact with prostitutes.
• Discuss sexual issues. Young men and women must feel comfortable communicating with their partners and family about sex and their sexual histories. A communicative relationship is essential to emotional and physical health.

Figure 4.2  A girl having pelvic pain which might be indicative of an STI and a boy having pain during urination caused by an STI.

When you discuss these sexual issues with young people it is also a good idea to tell them how to recognise the symptoms of STIs (Figure 4.2). For example, you should explain that if they experience burning with urination, have a discharge from the penis/vagina, and/or have genital sores then they and their partner should not have sex but should go to the higher level health facility for treatment.

4.4  Young people with HIV

There are two groups of young people living with HIV: those who were infected around birth and have survived into adolescence and those young people who have been infected during adolescence, usually through unprotected sex. This infection history has an impact on many features of how HIV affects a young person, including prevention strategies and their HIV care and management (e.g. progression of HIV disease, treatment with antiretroviral therapy (ARV drugs), knowledge and disclosure of HIV status, access to care). For example, young people who have acquired the HIV infection at birth will have symptoms earlier than those infected after adolescence.

Young people who are infected before entering puberty often grow slowly and enter puberty later than is normal. Girls have irregular menstrual periods. This delay in growth and sexual maturation may also have an impact on the psychosocial development of the individual.

For young people infected after puberty, the infection can remain asymptomatic for a longer period of time than for adults. The younger the age at infection (after puberty), the longer the virus remains asymptomatic.

4.4.1  Prevention of the HIV epidemic

HIV prevention among young people is the key to reducing infection rates and slowing the epidemic. Those between the ages of 15 and 24 are at the greatest risk of acquiring and transmitting HIV. They are both the most threatened and the greatest hope for reversing the HIV epidemic, by changing attitudes and behaviours. The future epidemic will be shaped by the action and behaviour of young people.

The major aims of HIV prevention include:

• Prevent transmission of HIV for all people (HIV-negative, HIV-positive or of unknown status), to reduce the number of new infections.
• Help people who are HIV negative to stay negative.
• Promote testing and counselling for people who do not know their status.

Young people everywhere report that the education they receive about HIV and sexual reproductive health is too little and too late. Adults are often hesitant to provide young people with the facts about HIV prevention and sexual health, often because they fear this will encourage sexual activity. But there is convincing evidence from studies in many different cultures that, in fact, sex education encourages responsibility. Knowledgeable young people tend to postpone intercourse or, if they do have sex, to use condoms.

4.4.2  Who has a role in HIV prevention?

HIV prevention requires active involvement from all members of society to ensure an environment where young people feel safe and supported and able to protect themselves from HIV at home, school and work and in their community.

4.4.3  Key HIV prevention strategies for young people that you can offer at health posts

HIV prevention services must be offered to young people whenever they come for health services (STI, antenatal care, family planning, etc). Key prevention strategies for young people cannot be the same for all but need to be adapted to their different needs. For example for boys and girls in primary school (early adolescence age 10–14), it is appropriate to talk about the changes during puberty and the benefits of abstinence and delaying sexual activity. By contrast, for post-adolescents (aged 20–24) education about faithfulness and safer sex using condoms is relevant as they are likely to have started sexual activity anyway. Similarly, you need to provide appropriate messages for adolescents in and out of school and young people both married and unmarried based on their needs for information and services.

Postponing the first sexual activity and reducing the number of sexual partners can significantly protect young people from HIV. Behavioural change communication can help young people to develop positive behaviours. Behavioural change communication is the process of using communication approaches and tools to develop the skills and capabilities of individuals to promote and manage their own health and development. It promotes positive change in their behaviour, as well as in their knowledge and attitudes. The messages and the way the messages are given are very important for young people, as they do not want to only hear what they cannot do, but also what they can do. Figure 4.3 shows the stages of behaviour change that an individual passes through, from being completely unaware to making positive behaviour changes.

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Figure 4.3  Stages of behaviour change.

As you can see in Figure 4.3, behaviour change doesn’t immediately follow awareness. It takes some time for individuals to change their behaviour even after they have the necessary knowledge. Hence, whenever you counsel young people who are already engaged in some form of risky behaviours (such as having multiple sexual partners, chewing khat, or drinking alcohol), it is important that you tell them they shouldn’t expect everything to change overnight. Behaviour change is a process that needs to be continuously supported and reinforced in order to bring the desired change.

Provider-initiated testing and counselling and voluntary counselling and testing (VCT) services need to be available at all health facilities and in the community. These methods can be used both for giving information on sexual behaviour and HIV and also for opening the discussion on many sensitive issues faced by young people (e.g. peer pressure, condom negotiation, unwanted pregnancy, decision making, how to be an adult, disclosure of HIV status). There are more details on provider-initiated testing and counselling in Study Session 26 of the Communicable Diseases, Part 2 Module.

The use of latex condoms to prevent the exchange of body fluids during sex is an essential element of all HIV prevention activities. Safer sex depends on the correct and consistent use of condoms, so condom provision must be accompanied by clear instructions on condom use for every act of penetrative sex. Female condoms offer women an option that may give them more control but they also require more counselling and assistance with respect to their proper use and they are also more expensive and less available. Condom promotion also supports dual protection.

STIs greatly facilitate HIV transmission and acquisition between sexual partners, so treating and preventing them is an important step in HIV prevention. Effective and early treatment of STIs is an essential part of HIV prevention. Hence, it’s important that you refer adolescents with STIs to minimise the risk of transmission and complications.

Summary of Study Session 4

In Study Session 4, you have learned that:

1. STIs including HIV are common among young people for biological and psychosocial reasons. Biologically, young women are more susceptible to STIs than older women because of their immature vaginal mucosa and cervical tissue.
2. Adolescents are likely to engage in unsafe sexual practices (including having multiple sexual partners, using prostitutes and not using condoms), which predisposes them to STIs including HIV. This is because they often lack basic information concerning their sexual health, including ignorance of the symptoms, transmission, and treatment of STIs.
3. In most rural areas girls are married at a very early age and they are not empowered to say ‘No’. As a result, young women may have their first sexual experiences with older men while young men may have their first sexual experiences with prostitutes; both behaviours increase the chance of getting STIs including HIV.
4. STIs in young people can lead to multiple long-term negative consequences for their health and social life and can even result in early death. Health problems include pelvic inflammatory disease, chronic pelvic pain, fetal death, ectopic pregnancy, cervical cancer and related maternal mortality. Chlamydia and gonorrhoea can also result in infertility, particularly in women. Chlamydia can cause pneumonia in infants, while neonatal gonococcal infections of the eyes can lead to blindness. Syphilis in adults can cause serious heart and brain disease which can be fatal.
5. Young people can acquire HIV in two ways through infection from their mothers at birth or through unprotected sex during adolescence. This infection history has an impact on how HIV affects a young person and on their HIV care and management.
6. HIV prevention requires active involvement from all members of society including young people themselves, parents, role models, government leaders, the media and people living with HIV and those with AIDS.
7. In general, behaviour changes take time and don’t always automatically follow awareness. Hence, it is important that you provide continuous support whenever you counsel young people who are already engaged in some form of risky behaviours to adopt healthy behaviours.
8. In addition to awareness raising and education of young people on ways of STI prevention, there is a need to provide condoms and refer them for appropriate counselling and HIV testing.

Self-Assessment Questions (SAQs) for Study Session 4

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

First read Case Study 4.1 and then answer the questions that follow it.