Sexually Transmitted Infections (STIs)

Key facts

  • More than 1 million sexually transmitted infections (STIs) are acquired every day worldwide, the majority of which are asymptomatic.
  • Each year there are an estimated 374 million new infections with 1 of 4 curable STIs: chlamydia, gonorrhoea, syphilis and trichomoniasis.
  • More than 500 million people 15–49 years are estimated to have a genital infection with herpes simplex virus (HSV or herpes) (1).
  • Human papillomavirus (HPV) infection is associated with over 311 000 cervical cancer deaths each year (2).
  • Almost 1 million pregnant women were estimated to be infected with syphilis in 2016, resulting in over 350 000 adverse birth outcomes (3).
  • STIs have a direct impact on sexual and reproductive health through stigmatization, infertility, cancers and pregnancy complications and can increase the risk of HIV.
  • Drug resistance is a major threat to reducing the burden of STIs worldwide.

Overview

More than 30 different bacteria, viruses and parasites are known to be transmitted through sexual contact, including vaginal, anal and oral sex. Some STIs can also be transmitted from mother-to-child during pregnancy, childbirth and breastfeeding. Eight pathogens are linked to the greatest incidence of STIs. Of these, 4 are currently curable: syphilis, gonorrhoea, chlamydia and trichomoniasis. The other 4 are incurable viral infections: hepatitis B, herpes simplex virus (HSV), HIV and human papillomavirus (HPV).

In addition, emerging outbreaks of new infections that can be acquired by sexual contact such as monkeypox, Shigella sonneiNeisseria meningitidis, Ebola and Zika, as well as re-emergence of neglected STIs such as lymphogranuloma venereum. These herald increasing challenges in the provision of adequate services for STIs prevention and control.

Scope of the problem

STIs have a profound impact on sexual and reproductive health worldwide.

More than 1 million STIs are acquired every day. In 2020, WHO estimated 374 million new infections with 1 of 4 STIs: chlamydia (129 million), gonorrhoea (82 million), syphilis (7.1 million) and trichomoniasis (156 million). More than 490 million people were estimated to be living with genital herpes in 2016, and an estimated 300 million women have an HPV infection, the primary cause of cervical cancer and anal cancer among men who have sex with men. An estimated 296 million people are living with chronic hepatitis B globally.

STIs can have serious consequences beyond the immediate impact of the infection itself.

  • STIs like herpes, gonorrhoea and syphilis can increase the risk of HIV acquisition.
  • Mother-to-child transmission of STIs can result in stillbirth, neonatal death, low-birth weight and prematurity, sepsis, neonatal conjunctivitis and congenital deformities.
  • HPV infection causes cervical and other cancers.
  • Hepatitis B resulted in an estimated 820 000 deaths in 2019, mostly from cirrhosis and hepatocellular carcinoma. STIs such as gonorrhoea and chlamydia are major causes of pelvic inflammatory disease and infertility in women.

Prevention of STIs

When used correctly and consistently, condoms offer one of the most effective methods of protection against STIs, including HIV. Although highly effective, condoms do not offer protection for STIs that cause extra-genital ulcers (i.e., syphilis or genital herpes). When possible, condoms should be used in all vaginal and anal sex.

Safe and highly effective vaccines are available for 2 viral STIs: hepatitis B and HPV. These vaccines have represented major advances in STI prevention. By the end of 2020, the HPV vaccine had been introduced as part of routine immunization programmes in 111 countries, primarily high- and middle-income countries. To eliminate cervical cancer as a public health problem globally, high coverage targets for HPV vaccination, screening and treatment of precancerous lesions, and management of cancer must be reached by 2030 and maintained at this high level for decades.

Research to develop vaccines against genital herpes and HIV is advanced, with several vaccine candidates in early clinical development. There is mounting evidence suggesting that the vaccine to prevent meningitis (MenB) provides some cross-protection against gonorrhoea. More research into vaccines for chlamydia, gonorrhoea, syphilis and trichomoniasis are needed.

Other biomedical interventions to prevent some STIs include adult voluntary medical male circumcision, microbicides, and partner treatment. There are ongoing trials to evaluate the benefit of pre- and post-exposure prophylaxis of STIs and their potential safety weighed with antimicrobial resistance (AMR).

Diagnosis of STIs

STIs are often asymptomatic. When symptoms occur, they can be non-specific. Moreover, laboratory tests rely on blood, urine or anatomical samples. Three anatomical sites can carry at least one STI. These differences are modulated by sex and sexual risk. These differences can mean the diagnosis of STIs is often missed and individuals are frequently treated for 2 or more STIs.

Accurate diagnostic tests for STIs (using molecular technology) are widely used in high-income countries. These are especially useful for the diagnosis of asymptomatic infections. However, they are largely unavailable in low- and middle-income countries (LMICs) for chlamydia and gonorrhoea. Even in countries where testing is available, it is often expensive and not widely accessible. In addition, the time it takes for results to be received is often long. As a result, follow-up can be impeded and care or treatment can be incomplete.

On the other hand, inexpensive, rapid tests are available for syphilis, hepatitis B and HIV. The rapid syphilis test and rapid dual HIV/syphilis tests are used in several resource-limited settings.

Several other rapid tests are under development and have the potential to improve STI diagnosis and treatment, especially in resource-limited settings.

Treatment of STIs

Effective treatment is currently available for several STIs.

  • Three bacterial (chlamydia, gonorrhoea and syphilis) and one parasitic STIs (trichomoniasis) are generally curable with existing single-dose regimens of antibiotics.
  • For herpes and HIV, the most effective medications available are antivirals that can modulate the course of the disease, though they cannot cure the disease.
  • For hepatitis B, antivirals can help fighting the virus and slowing damage to the liver.

AMR of STIs – in particular gonorrhoea – has increased rapidly in recent years and has reduced treatment options. The Gonococcal AMR Surveillance Programme (GASP) has shown high rates of resistance to many antibiotics including quinolone, azithromycin and extended-spectrum cephalosporins, a last-line treatment (4).

AMR for other STIs like Mycoplasma genitalium, though less common, also exists.

STI case management

LMICs rely on identifying consistent, easily recognizable signs and symptoms to guide treatment, without the use of laboratory tests. This approach – syndromic management – often relies on clinical algorithms and allows health workers to diagnose a specific infection based on observed syndromes (e.g., vaginal/urethral discharge, anogenital ulcers, etc). Syndromic management is simple, assures rapid, same-day treatment, and avoids expensive or unavailable diagnostic tests for patients with symptoms. However, this approach results in overtreatment and missed treatment as the majority of STIs are asymptomatic. Thus, WHO recommends countries to enhance syndromic management by gradually incorporating laboratory testing to support diagnosis. In settings where quality assured molecular assays are available, it is recommended to treat STIs based on laboratory tests. Moreover, STI screening strategies are essential for those at higher risk of infection, such sex workers, men who have sex with men, adolescents in some settings and pregnant women.

To interrupt transmission and prevent re-infection, treating sexual partners is an important component of STI case management.

Controlling the spread

Behaviour change is complex

Despite considerable efforts to identify simple interventions that can reduce risky sexual behaviour, behaviour change remains a complex challenge.

Information, education and counselling can improve people’s ability to recognize the symptoms of STIs and increase the likelihood that they will seek care and encourage a sexual partner to do so. Unfortunately, lack of public awareness, lack of training among health workers, and long-standing, widespread stigma around STIs remain barriers to greater and more effective use of these interventions.

Health services for screening and treatment of STIs remain weak

People seeking screening and treatment for STIs face numerous problems. These include limited resources, stigmatization, poor quality of services and often out-of-pocket expenses.

Some populations with the highest rates of STIs – such as sex workers, men who have sex with men, people who inject drugs, prison inmates, mobile populations and adolescents in high burden countries for HIV – often do not have access to adequate and friendly health services.

In many settings, STI services are often neglected and underfunded. These problems lead to difficulties in providing testing for asymptomatic infections, insufficient number of trained personnel, limited laboratory capacity and inadequate supplies of appropriate medicines.

Dr Nassim Sherif is the brains behind the company. Originally from Botswana with an interest in Internal Medicine and Community health, Nassim wishes to take hard to understand information and disperse it freely amongst our audience. He currently works as a medical officer at Hillbrow Community Health Centre. He doesn’t say much but when he does he’s dropping evidence based medicine throughout the podcast to correct or substantiate the teams opinions.