Why are sexually transmitted infections on the rise?

One afternoon, after waiting for over three hours to get treatment, patients with sexually transmitted infections are turned away from Kochilira Rural Hospital in Mchinji district in central Malawi because the institution is out of antibiotics used to treat STIs. One of the patients, Maria Thole, said she traveled for four kilometers (2.5 miles) to reach the facility and was visibly disappointed about being turned away without medication. The medical officer at the clinic, Psyela Kaunda, said drug shortages have increased over the last few years, and at times the hospital lacks essential drugs including those used to treat STIs. Incidentally, this is the time Malawi and other countries experienced the burden of COVID-19 cases. She added that even when the medicines arrive, they only last for some weeks or a month due to the high demand for the therapy. According to the World Health Organization, STI cases have been on the rise since the COVID-19 pandemic when many countries reported low coverage for preventive, testing, and treatment services as they focused on the pandemic. The development, according to WHO, led to a resurgence of STIs and the emergence of new variants of STIs such as herpes simplex and mycoplasma genitalium. While globally STIs are rising, sub-Saharan Africa has the highest yearly prevalence. The agency estimates that globally more than 1 million STIs are acquired every day, with an estimated 374 million new infections recorded in 2020 alone. Africa records 3.5 million instances of syphilis, 15 million cases of chlamydial illness, 16 million cases of gonorrhea, and 30 million cases of trichomoniasis each year. "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 warned. Despite having high instances of STIs, countries in sub-Saharan Africa, including Malawi, are faced with a lack of products to diagnose and treat STIs, which results in a surge of infections, said Moctar Menta, media advisor at the International Planned Parenthood Federation Africa Region. He said inefficient supply chain management, delays in procurement, poor forecasting, and storage and distribution issues are among the causes of unavailability of STI medication at health facilities in sub-Saharan Africa. Additionally, a disproportionate supply of some STI drugs impacts the access to STI medications in poorer sub-Saharan African countries that depend on drug donations — resulting in a surge of infections when the donations are unpredictable or when STI treatment is not prioritized. Untreated STIs can cause infertility, birth defects, mental illness, and heart disease, and increase the risk of HIV infection, and the periodic STI drug shortages mean that many infected patients go without medication for extended periods, posing a public health concern as they can infect others. For instance, at Kochilira, according to Kaunda, the hospital gets 600 STI cases every month on average, and during periods of STI drug stockouts, patients are encouraged to seek treatment at private pharmacies. This is not an ideal situation as some patients turn to traditional healers to avoid high costs. "The area is faced with a huge STI problem because of lack of knowledge on STIs which creates a web of STI infections. There is an urgent need for awareness on STIs, mostly among men who prefer to go for traditional cures to hide an STI infection from their wives," she said. Menta said while STI drug stockouts could contribute to a surge of STIs in sub-Saharan Africa, there are factors contributing to the shortages including inadequately resourced health systems, limited comprehensive sexuality education, and siloed approaches to STI management. He said that under-resourced and failing health systems are unable to address STI service needs, leading to an overreliance on syndromic care of STIs, which focuses solely on signs and symptoms, risking overtreatment and subsequent anti-microbial resistance among treated populations. While there is a direct link between an increase in STIs and poverty, South Africa and Botswana — which are upper-middle-income countries — continue to have high rates of STI cases due to income inequalities that sustain sexually risky behaviors through transactional sex and partnerships with individuals of higher socioeconomic status, Menta said. "Stigma continues to be a barrier to obtaining sexual health services." he said, "There is insufficient partner notification and treatment, which propagates transmission chains." To address the ongoing issues, countries need to create an environment that encourages people to discuss STIs, adopt safer sexual practices and seek treatment, and increase integration of STI services with primary health care, he said. Menta also stressed that ongoing government commitments, community mobilization, and wise investments in the health system can hasten success against STIs. He said that integrating STI management with related health care services like antenatal, HIV and AIDS services, and other youth-related health care services was the best way to approach STI management. "Prevention of STIs other than HIV has historically taken a back seat in high HIV burden countries which focused on HIV prevention," Menta explained. Maziko Matemba, a Malawian health rights activist, added that one of the challenges countries face in tackling STIs is a lack of partner organizations. “While we have many partners in HIV and AIDS prevention, STI coverage is funded entirely by local resources," Matemba said. In Malawi for instance, according to a recent STI landscape analysis by JournAids Malawi, several factors, including a lack of STI treatment advocacy by NGOs, are driving the surge in STIs. The desk review also establishes that while Malawi has developed policies and plans, including the implementation of programs on sexual reproductive health and rights and HIV and AIDS, the documents under these initiatives contain general statements and strategic actions on sexual reproductive health and gender without specifically mentioning STIs. "It appears that STIs have long been ignored because the HIV and AIDS pandemic seems to have overshadowed the response to sexually transmitted infections," said Dingani Mithi, a project officer at JournAids Malawi. According to Mithi, since HIV and AIDS came into the public health spectrum, little attention has been paid to STIs, hence the rise in preventable and treatable infections like syphilis and gonorrhea. Adamson Muula, professor and head of the Department of Community and Environmental Health at Kamuzu University of Health Sciences, on the other hand, said STIs have gained public health significance since they are related to HIV, and that any health system strengthening resources directed at supporting HIV and AIDS prevention, care, and support are also used for STI prevention, treatment, and care. He said that the health care system has improved as a result of HIV and AIDS. While there is limited data on STI prevalence in Malawi, the country's 2015 to 2016 Demographic and Health Survey self-monitoring report on STIs indicated that 15% of women and 10% of men in the age group 15-49 reported having an STI or symptoms of an STI in the 12 months before the survey, against an average of 41.5% treatment coverage for both genders.