Q&A: Halting the burden of STIs in Africa

The burden of sexually transmitted infections remains high. According to the World Health Organization estimates, one million new infections are acquired globally each day. And a large share of those goes unnoticed, undiagnosed, and untreated.

While few STIs are immediately life-threatening, the consequences of not treating them can be severe. Left untreated, the chances of contracting HIV rise almost tenfold. Populations in low- and middle-income countries are particularly vulnerable, with a higher prevalence of STIs due to factors such as lack of awareness and access to diagnostics and treatment.

“In Africa, there are many gaps and challenges to reduce the burden of STIs, but there are no well-formulated, consolidated national responses,” says Dr. Francis J. Ndowa, director and physician at the Skin & Genito-Urinary Medicine Clinic in Harare, the regional director of Africa, the Middle East and North Africa branch of the International Union against Sexually Transmitted Infections, and a member of WHO’s sexual and reproductive health/human reproduction scientific and technical advisory group.

“It's a complex problem that requires complex measures,” he says, “that will need to be tackled on multiple fronts.”

Speaking with Devex, he elaborated on the burden of STIs in Africa, how women and girls are disproportionately affected, and what actions are needed to meet WHO’s targets to reduce STIs.

This conversation has been edited for length and clarity.

According to WHO estimates for 2016, there were approximately 376 million new infections globally of the four curable STIs – chlamydia, gonorrhea, syphilis, and trichomoniasis. What do we know about the current state of STIs in Africa?

WHO estimates the prevalence of STIs to be higher in Africa than in other regions, but it is important to note that these are really just estimates. There is a lack of good, systematic surveillance in Africa that gives a reliable grasp of the burden of STIs in the region. Aside from HIV/AIDS, with cases being well documented, there is a need for improved STI surveillance both in different populations and in the general population. The current estimates are based on the existing, often anecdotal, data that are fleshed out with formulae and modeling to give a more realistic overview.

How do STIs impact women, and young women aged 15-24 years in particular?

Women in this age group are in their early phases of sexual exploration, and many of them are impacted by STIs partly because of ignorance since they are not aware of the problems the infections impose. By the time they find out, it may already be too late — with consequences ranging from psychological, to physical, to social. They may experience lower abdominal pain, pelvic inflammatory disease, infertility, and stigma associated with having an STI. In the African context, you are generally expected to have children if you get married, so infertility creates marital disharmony.

Women are also disproportionately affected by HIV. But, to my knowledge, there is no country looking at young women as a special group heavily impacted by HIV or other STIs. They are treated just like the general population, aside from perhaps in HPV vaccination programs for young people. There are, however, some anecdotal projects run by NGOs targeting adolescent girls and boys, including young women who practice sex work, and projects that are focusing on having rapid diagnostic tests accessible and acceptable at the community level.

What are some of the current gaps and challenges to reduce the burden of STIs and how are you overcoming them in practice?

At the height of HIV, there were population-based campaigns for prevention, for condom promotion, for HIV awareness, testing, and so on. Over the years, these campaigns have disappeared, which is a pity, given HIV and other STIs are becoming a “silent epidemic,” with young people unaware of the dangers of unprotected sex. HIV rates have gone down, but we still see new infections in young people, and the risk is that we will be unable to meet the demand for treatment. So, there is a need to bring back and strengthen prevention and awareness campaigns, promoting the use of condoms, and other barrier methods for preventing STIs, including HIV.

There are also gaps and challenges related to existing interventions. We have interventions such as the HPV vaccine available, but the funding is not adequate for governments to implement it to scale. Same thing goes for the hepatitis B vaccine, which has existed for many years but is not being adequately used.

The COVID-19 pandemic may have worsened the situation further, although its impact is more speculative than evidence-based. Lockdowns made it difficult for people to access health care services. In a country like Zimbabwe, for example, an HIV-positive person would be given about three months’ supply of antiretroviral therapy due to limited supplies. With movement being limited, access to treatment was definitely impacted. And we don’t know yet if that led to an increase in HIV and other STIs. But generally speaking, we should not blame gaps and challenges on COVID-19. They were already there.

WHO has set targets to drastically reduce the number of STIs by 2030, aiming for a 90% global reduction in gonorrhea, less than 50 cases of congenital syphilis per 100,000 live births in 80% of countries, and 90% national coverage of human papillomavirus vaccines. What concrete actions/interventions are needed to achieve these ambitious goals?

They are good targets to aim for. But the problem with STI prevention and control, including HIV, in the context of Africa is the reliance on episodic, nonconsistent, donor-funded programs. Country programs and interventions need to be sustained, which require government commitments and financing. It is difficult to see how these goals are going to be met unless national governments allocate more financial and human resources into STI prevention and control. And getting them to commit will require a lot from WHO as an advocacy platform. Governments have actually committed to abide by these goals [at the World Health Assembly], but when following up at government level, hardly any low- and middle-income country has allocated the required resources. So, there is still a lot of work to be done.

Overwhelming clinical evidence has firmly established that HIV Undetectable=Untransmittable, or U=U, meaning that HIV-infected people with an undetectable viral load cannot transmit the virus sexually. What impact does U=U have on the transmission of STIs?

In the context of Africa, I am not sure that it makes much of a difference since U=U is only known by a few people living with HIV. Where people are given the information, as with preexposure prophylaxis or PrEP interventions for HIV prevention, there may be an impact. However, studies done in other regions have shown that other STIs, such as syphilis, gonorrhea, and chlamydia have been high among PrEP users — probably because they are using it [U=U] instead of condoms or other barrier prevention methods. But no such study that I am aware of has focused on Africa. So U=U may not have that large of an impact on STI transmission, since the use of prevention methods is low anyway.

Final call to action: What’s the one thing that health or development practitioners should do to reduce the burden of STIs when designing programs or interventions?

During my time at WHO, I was often asked by donors to outline a main problem or solution. But there is not one single magic bullet. It is a complex problem, just like the infections themselves. Environmental, social, and financial issues are all playing a role, and they all need to be responded to. However, I can mention a few things. Enhancing prevention is key. We need to make people aware of STIs and of how they can protect themselves. We need to provide access to protection as well as vaccines available, accessible, and affordable to the population that needs them the most. Diagnostics must be readily available, and we must provide affordable, effective treatment.

Then we also need a public health approach that encompasses all the public health elements of preventing disease, but especially communicable diseases. So I cannot just mention one thing — it's a complex problem that requires complex measures. But it can be simplified into prevention, diagnosis, vaccines, and awareness.