Reducing South Africa’s hidden epidemic of sexually transmitted infections

D Wilkinson, ¹ G Ramjee, ¹ Sturm AW, ² SS Abdool Karim ¹

¹ Centre for Epidemiological Research in Southern Africa, Medical Research Council, PO Box 187, Mtubatuba 3935. Tel 035 5500607; fax 035 5501436; email davewilk@iafrica.com.
² Department of Medical Microbiology, University of Natal, Durban / MRC Genital Ulcer Disease Research Unit

Sexually transmitted infections (STI) are a major public health concern in developing countries. Their impact is greatest among women and unborn children, causing acute illness and chronic complications that include infertility, ectopic pregnancy and death. STIs also facilitate the transmission of HIV, and improved treatment of symptomatic STIs in Mwanza, Tanzania reduced new HIV infections by 42%. STIs are common in South Africa: in the Hlabisa district of KwaZulu-Natal we have shown that around 10% of young adults have at least one STI each year and that repeat episodes are frequent.

With rapidly rising HIV prevalence (20-30% among women attending antenatal clinics in KwaZulu-Natal) it is important to understand better the burden of STIs in different groups, to recognise what form infection takes, and also how it is being spread. Disease control strategies can then be better formulated.

In Hlabisa a wide range of studies have been done including STI surveillance by clinic nurses and family doctors, microbiological studies among women attending antenatal and family planning clinics, household surveys, and quality of care surveys in the public and private sectors. In and around Ladysmith in the Natal Midlands, a large study among sex workers is underway that aims to determine if a vaginal microbicide (nonoxynol-9) is effective in preventing HIV infection and oMajor findings ther STIs.

• prevalence of STIs (either gonorrhoea, chlamydial infection, trichomoniasis or recent/active syphilis) is high. Among sex workers 77% had at least one STI and 33% had multiple infection; among pregnant women corresponding rates were 52% and 18%; and among women attending family planning clinics rates were 27% and 10%
• prevalence of HIV infection is also high. Sex workers 50%, pregnant women 16% and women attending family planning clinics 24%
• sex workers reported an average of 20 clients each week and only 10% reported using a condom in more than half of all episodes of intercourse
• symptoms and signs associated with STIs (lower abdominal pain, burning urine, vaginal discharge, genital itch, genital ulceration) were frequently not recognised or not acted upon
• infection was frequently asymptomatic or unrecognised: 60% of infected women in the family planning clinic were asymptomatic and 14% of sex workers had unrecognised genital ulcers
• quality of treatment was poor: only 10 - 40% of patients presenting with an STI to family doctors or primary care clinics were given correct drugs
• a "Syndrome Packet" that contains the recommended drugs, condoms, partner treatment cards and a patient information leaflet made it easier for clinics to correctly treat patients with an STI

Using these data we can also estimate the burden of STI in the community and gain some insight into what form this burden takes:

• in the general community, 25% of women have at least one STI
• about half of these are asymptomatic and hence remain undetected and untreated
• most of the remaining women with symptomatic infections delay or defer seeking treatment
• only about 2% of infections are treated within a reasonable time
• only about a quarter of those treated actually receive the correct drugs
• reinfection rates are likely to be high as partner treatment strategies are inadequate

Conclusion
South Africa suffers a huge -and largely hidden - burden of STIs. Rates are highest among women who engage in high risk behaviour such as sex work, but rates are also high among women in the general community who would normally be considered lower risk. Underlying factors include poor quality services, low rates of partner treatment, poor understanding of and response to symptoms, sex work, and high levels of population mobility and migration.

Policy recommendations

• The high level of STI and HIV - much of it hidden - needs to be acknowledged as a major public health threat in South Africa and political commitment to a support strategy is required
• Immediate priority is to ensure that patients with an STI who seek care are treated correctly, the first time. Correct treatment includes being given the right drugs, being counselled, receiving partner notification cards and receiving condoms
• Quality of STI management in both public and private health sectors requires urgent improvement - this could be facilitated by the use of "Syndrome Packets" in both public and private sectors
• Large scale media promotion of the following messages:
  • STIs are common in the community
  • STIs are treatable if you go to the clinic or doctor
  • it is important for your partner to be treated too
  • condoms prevent STIs
• Consideration should be given to decriminalising sex work and regulating the industry to achieve high standards of health and hygiene.
• Research into strategies to reduce the large asymptomatic burden of STIs, such as how to improve partner treatment, microbicides, and mass treatment

Bibliography

1. Wilkinson D, Connolly AM, Harrison A, Lurie M, Abdool Karim SS. Sexually Transmitted Disease Syndromes In Rural South Africa: Results From Health Facility Surveillance. Sexually Transmitted Diseases 1997 (in press).
2. Wilkinson D. Syndromic management of sexually transmitted diseases in developing countries: what role in the control of the STD and HIV epidemics? (Editorial). Genitourinary Medicine 1997 (in press).
3. Sturm AW, Wilkinson D, Ndovela N, Bowen S, Connolly S. Pregnant women as a reservoir of undetected sexually transmitted diseases in rural South Africa: implications for disease control. American Journal of Public Health 1998 (in press).
4. Wilkinson D, Ndovela N, Kharsany A, Connolly C, Sturm AW. Tampon-sampling to diagnose bacterial vaginosis. A potentially useful way to detect genital infections? Journal of Clinical Microbiology 1997;35:2408-2409.
5. Wilkinson D, Ndovela N, Harrison A, Lurie M, Connolly C, Sturm AW. Family planning services in developing countries: an opportunity to treat asymptomatic and unrecognised genital tract infections? Genitourinary Medicine 1997 (in press).
6. Wilkinson D, Sach M, Connolly C. Epidemiology of syphilis in pregnancy in rural South Africa: opportunities for control. Tropical Medicine and International Health 1997; 2: 57-62.