Despite recognition in the prevalence of sexually transmitted illnesses (STIs) in developing countries, actions taken to minimize transmission of these diseases over the years have not been effective. According to the World Health Organization (WHO), despite being curable, the majority of STIs still occur in developing countries with high mortality rates.
A troubling statistic in modern times
STIs still pose as a major health issue in the developing world even after years of attempted management and control. In the past decade, up to 85% of the 350 million cases of STIs occurred in developing countries. Most of these cases are treatable STIs such as gonorrhoea and syphilis, but still have high mortality rates. The prevalence of STI transmission plays a significant role in HIV incidents in Africa. Females and infants are most affected as STIs constitute the second highest reason to life years lost by young women. These statistics may, in fact, be an underestimate as there has yet to be a comprehensive data collection covering the transmission of STIs in the census of developing countries. Data collected from few countries and the disparity of the groups surveyed are common issues in studying STI prevalence in the developing world. High transmission rates of STIs are attributed to factors such as less access to birth control, more prostitution due to economic hardship, limited access to treatment, and exposure to antibiotic resistant bacteria.
Traditional methods and aims of STI prevention
STI prevention programs are designed by organizations such as WHO and UNAIDS with the goal of interrupting the transmission of STIs, preventing the development of diseases, and reducing the transmission of HIV infection. Primary prevention methods in developing countries involve behaviour, barriers, vaccines, and clinical diagnosis. Encouragement of abstinence and monogamous relationships are examples of behavioural interventions of STI preventions. Condoms are an invaluable tool as a barrier method to prevent spread of STI and HIVs. In fact, condom programs implemented in Thailand contributed to increased rates of safer sex and decreased transmission of STIs in the military. Vaccines would also be an effective method for STI prevention. Moreover, access to health clinics may allow for more treatment opportunities after accurate diagnoses.
The reality of STI prevention in the developing world
Although the methods listed above may theoretically seem effective in controlling STIs, there are many limitations that prevent these methods from working effectively. The effectiveness of behavioural interventions have not been thoroughly studied. Additionally, many of the few studies on behavioural interventions for STIs and HIVs have reported little to no changes in infection rates. Results seem to vary depending on the country as encouragement of delayed sex and less partners resulted in less HIV incident rates observed in Uganda, but the impact on STIs transmission has not been investigated.
Problems for condom use include unaffordable prices, no availability, and little education on usage. Even without these limitations, higher incidents of rape and forced unprotected sex on women also pose as serious constraints to condom use.
Next, the only successfully developed vaccine is for hepatitis B while vaccines for other STIs and HIVs are still a long way from being developed. However, even if more vaccines were available, factors such as little access to healthcare and perceived fear of vaccination may also prevent the protection of STIs through vaccines.
Finally, clinical laboratory diagnosis is often complex, time-consuming, and economically costly. It is unlikely that people can have access or can afford to go to clinics for a diagnosis.
These issues point to a larger reason why these methods often failed in developing countries. First, STI prevention seems as a low priority in the government funding because of failure to realize the magnitude of the issue. With many constraints in the developing world not considered before, it is now important to develop new protocols.
New ideas to match a modern world
Novel approaches have been developed with these limitations in mind. To address the difficulty and inconvenience of traditional clinical diagnosis, WHO has created a syndromic approach. This management system is based on characterizing a syndrome (a set of symptoms) for a particular STI. Treatments will be simplified to established protocols and prescriptions to address each syndrome. The major advantage of syndromic management of STIs is that it does not require expensive diagnostic tools or clinics. Most importantly, treatment is given immediately after the syndrome is identified and is cost effective.
Data collected from developing countries also supports the effectiveness of the syndromic approach. In South Africa, the syndromic approach was found to successfully treat more than 90% of the population infected with genital ulcers. The syndromic approach also resulted in lower costs per diagnosis and treatments for gonococcal and chlamydial urethritis infections. More importantly, the cure rate for these STIs under syndromic management was 99%.
However, there are also limitations to the syndromic approach that need to be addressed. For one, it was found to be ineffective in treating and controlling cervical infections in women. Furthermore, there may be infected women who fall into the category of “asymptomatic” where they are misdiagnosed because they exhibit little to no signs of infection. In addition, although treatment plans are immediate with the syndromic approach, women may still be unable to access and afford prescriptions. More importantly, this method relies more on treatment and diagnosis rather than prevention. It fails to consider other factors that may control transmission of STIs such as sexual behaviour and birth control.
Thus, the syndromic approach also needs to be revised to address these issues. To combat the issues of cervical infections and asymptomatic cases, simple and accessible diagnostic tests should be developed. Moreover, use of these tests should be encouraged to the high-risk population such as pregnant women or sex workers. Data should also be collected to identify groups with high infection rates. Recently, the WHO started doing exactly that by testing rapid point of care (POC) tests in developing countries. These tests have been shown to have at least a moderate sensitivity and accuracy in STI diagnosis and usage of these tests have shown promising results.