4.
Sexually Transmitted Infections
(STIs)
Study Session 4 Sexually Transmitted Infections (STIs)..............................................3
Introduction................................................................................................................3
Learning Outcomes for Study Session 4....................................................................3
4.1 Why are young people at risk from sexually transmitted infections?.................3
Question.................................................................................................................4
Answer...................................................................................................................4
Biological factors:..................................................................................................4
Psychosocial factors:..............................................................................................4
4.2 Impact of STIs (including HIV) on young people..............................................6
Question.................................................................................................................6
Answer...................................................................................................................6
4.3 STI prevention strategies for young people........................................................7
4.4 Young people with HIV......................................................................................8
4.4.1 Prevention of the HIV epidemic..................................................................9
4.4.2 Who has a role in HIV prevention?..............................................................9
Young people.........................................................................................................9
Parents and other adults in the community............................................................9
Public idols who are role models for young people.............................................10
Government leaders and the media......................................................................10
People living with HIV........................................................................................10
1
4.4.3 Key HIV prevention strategies for young people that you can offer at
health posts...........................................................................................................10
Question...............................................................................................................12
Answer.................................................................................................................12
Summary of Study Session 4...................................................................................12
Self-Assessment Questions (SAQs) for Study Session 4.........................................13
Case Study 4.1 The marriage of Tessema and Meselech....................................13
SAQ 4.1 (tests Learning Outcomes 4.1 and 4.2)..................................................14
Answer.................................................................................................................14
SAQ 4.2 (tests Learning Outcome 4.4)................................................................14
Answer.................................................................................................................14
SAQ 4.3 (tests Learning Outcome 4.3)................................................................14
Answer.................................................................................................................15
SAQ 4.4 (tests Learning Outcome 4.4)................................................................15
Answer.................................................................................................................15
2
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
3
women. HIV, in its turn, facilitates the transmission of some STIs and worsens the
complications of STIs because it weakens the immune system.
Question
Why do you think young people have a high risk of contracting STIs including HIV?
Answer
There are many biological, psychological and social reasons that put young people at
a high risk of acquiring STIs. The major ones are listed below.
End of answer
Biological factors:
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:
4
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.
5
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.
Question
Why should this be so?
Answer
6
This is because, women and girls are less likely to experience symptoms, and so many
STIs go undiagnosed until a serious health problem develops.
End of answer
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.
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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
8
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.
Young people
HIV prevention must focus on young people because young people have an essential
role in slowing the epidemic. Many young people listen to their peers and believe
their peers. Young people can be trained to spread messages and promote responsible
behaviour among their friends and colleagues. This is known as peer education and
is discussed in Study Session 12. As a Health Extension Practitioner you can help by
raising the awareness of young people about STIs including HIV through peer
education and education in schools.
Parents and other adults in the community
9
All adults have a role to play in their personal capacity as parents, members of
extended families and adult role models. They may also have a professional role as
teachers, sports coaches and religious leaders. Studies have identified that having a
positive relationship with parents, teachers and other adults in the community and
having spiritual beliefs helps adolescents avoid behaviour that puts them at risk of
HIV.
Targeted strategies must be available that focus on individual needs. (E.g. safer sex
information and free condoms for young prostitutes; outreach information
programmes for young people who have left school).
Public idols who are role models for young people
Musicians, film stars and sports figures provide role models for young people through
their personal lives and through their performances. The images and messages they
portray should encourage young people to adopt and maintain healthy behaviours.
You can use known examples to help you deliver safer sex messages and to
discourage risky behaviour.
Government leaders and the media
Politicians, journalists and public servants can affect the social, economic, and
political factors that determine the risk environments for HIV infection in which
young people live and work. Public images of sexual behaviour and HIV in the media
influence young people. You should look out for those that can help you achieve the
aims of HIV prevention.
People living with HIV
People living with HIV and those with AIDS have a role in HIV prevention. They
have a personal role to ensure they do not transmit HIV to any other person. People
living with HIV are frequently subject to discrimination and human rights abuses. A
strong movement of people living with HIV and AIDS can develop a network that
provides mutual support and a voice at local and national levels and can be a
particularly effective method of tackling HIV stigma. If there are such people living in
your community you can work with them to teach young people about ways of
preventing HIV infection and also offer your support by showing that you are not
judgemental in your dealings with such people.
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
10
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.
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
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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.
Question
What is meant by dual protection?
Answer
Dual protection is the simultaneous protection against unwanted pregnancy and the
possible transmission of STIs including HIV.
End of answer
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.
12
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.
13
Case Study 4.1 The marriage of Tessema and Meselech
Tessema (23 years) and Meselech (16 years) had been attracted to each other for some
time. Meselech had to drop out from school when she was a 5th grade student as her
parents felt she was not safe going to school alone; Tessema only completed 4th grade
as his father decided that he had to take care of the farm and domestic animals. When
they finally began to date, things moved very quickly and they decided to have sex.
They were married 6 months later. Neither of them had any information about
contraceptive use or STIs.
Almost a month later Tessema comes to see you because he has developed a small
sore (blister) on his penis.
A year later Meselech comes to you complaining of having an unusual vaginal
discharge and pain during urination. She thinks her problems may be related to the
problem Tessema had because she has had similar symptoms many times in the
preceding year. She says she has not seen any health worker but has been buying
some (unidentified) antibiotics from the nearby drug shop but there has been little
improvement. She is also concerned because she has not become pregnant even
though she was expecting to conceive any time. She is particularly worried that her
inability to conceive might damage her marriage. In addition, she is worried about the
possibility of having HIV.
SAQ 4.1 (tests Learning Outcomes 4.1 and 4.2)
Tessema and Meselech may have an STI. Suggest factors that could have put them at
risk.
Answer
Tessema and Meselech are young and uneducated. They did not know about dual
protection or STIs. They may have contracted STIs from previous partners or
Tessema might have visited a prostitute to prove his sexual powers.
End of answer
SAQ 4.2 (tests Learning Outcome 4.4)
What should Tessema do and what help can you offer?
Answer
Tessema should go to a health facility that can offer treatment and counselling. Since
you are not trained to provide this treatment you need to refer Tessema to seek care
from the nearest health facility (health centre or hospital) where the service is
available. You can advise Tessema not have intercourse before he gets treatment for
his illness. You can also explain that he may have an STI and you can provide
condoms and tell him about their proper use.
14
End of answer
SAQ 4.3 (tests Learning Outcome 4.3)
Explain whether any of Meselech’s problems could be a consequence of having an
STI.
Answer
Meselech seems to have one of the STIs characterised by vaginal discharge. She may
also be infertile as a consequence of this and if she does not conceive she risks
divorce which will affect her social status in the community.
End of answer
SAQ 4.4 (tests Learning Outcome 4.4)
What advice would you now give to Meselech and Tessema to prevent such problems
in the future?
Answer
Meselech appears to have an STI so you need to refer her to the appropriate health
facility (health centre or hospital) where she can get treatment. Both Meselech and
Tessema should be advised to go for HIV testing and counselling. You need to
educate them on the prevention of STIs.
Meselech should also be advised to avoid taking medications without consulting a
health professional.
End of answer
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