2. Learning Objectives
• Discuss the over view of STIs
• Explain the Basic terms used in STI
• Describe the three modes transmission of STIs
• Explain the links between HIV and other STI
• Describe factors contributing to the spread of STIs
• Describe the complications of STIs
• Discuss the challenges to STI prevention and Management
3. Background
• Over 1 million STIs are acquired every day worldwide (WHO 2019)
• Of the estimated 1 million new STIs that occur in the world every year, at least one
third occur in young people under 25 years.
• STI is a major public health problem for developing and developed countries
• Increases risk of HIV acquisition 3x or more
• Can be transmitted from Mother to child (syphilis, gonorrhoea, chlamydia)
• May lead to Pelvic Inflammatory Disease (PID), infertility and cervical cancer
4. STIs in Malawi
• Malawi adopted the STI syndromic case management in 1992
• Policy endorsement in 1996
• First review of STI treatment guidelines in 1997
• Subsequent reviews - 2003, 2008
5. Cont…
2003 DFID committed its STI activities through SWAP (STI left out of
initial Global Fund proposal of 2002)
March 2008, relocation of STI program from RHU to HIV & AIDS
department with few baseline information
2008 edition- HTC & STI service integration, and change of treatment
algorithms
6. Self reported STIs among young people in
Malawi (MDHS 2015/16)
• According to the 2015/2016 M DH Survey, 15% of women and 10% of
• men (15-49 years) experienced STI symptoms in the past 12 months.
• Only 41% of these sought treatment from a health care professional.
• Based on a total population of 8 million adults (15-49 years), this translates into 1 million STI
cases, 430,000 of whom reported accessing professional care.
• MoH service data show only 264,397 STI patients treated in 2016, which is 62% of the
population who reported seeking professional STI care.
• The prevalence is higher in rural areas compared to urban areas
• Within regions, the prevalence of STIs is higher in the southern region especially in the districts
of Zomba, Mulanje, Thyolo and Blantyre
7. STI burden in Malawi
• 386,346 STI cases reported in 2020
• 59% patients were female vs 41% males
• 19% of STI patients HIV positive
• 23% of STI patients previously treated for another STI
• STI is the fourth common reason for out patient visit.
• Asymptomatic nature of some STI remains a challenge ( 80% of STIs are
asymptomatic esp in women)
10. Explain the Basic terms used in STI
• STIs?
• RTIs
• HIV?
• AIDS?
• Safer Sex?
11. Definitions
• The Term RTI means: Refers to any infection of the reproductive tract.
• In women, it includes infections of the external genitals, vagina, cervix,
uterus, fallopian tubes, and or ovaries. Whilst in men it involves the penis,
testes, scrotum, and or prostate.
• STIs are infections caused by germs such as bacterias, viruses, protozoa that
are passed from one person to another through sexual contact.
• RTIs in both Men and Women include STIs.
12. Cont..
• Safer sex; it refers to those practices that allow couples to reduce chances
of getting pregnancy as well as transmitting STI. Generally, safer sex prevent
contact with genital sores as well as the exchange of body fluids such as
semen, blood and vaginal secretions.
13. Modes of STIs Transmission
1. Unprotected penetrative sexual intercourse
• (vaginal or anal): all STIs (Main mode – >80%)
2. Mother-to-child:
• – During pregnancy: HIV – Syphilis
• – At delivery: HIV – Gonorrhoea – Chlamydia – Herpes
• – After birth (lactation): esp HIV+ mothers.
3. Transfusion or other contact with blood (Syphilis – HIV)
14. HIV and STIs
• The risk of transmitting HIV is 5-10 times higher is someone who has an STI. A
person with a STI is at much higher risk of acquiring HIV - Treating STIs is therefore a
very important step in HIV prevention programmes.
• HIV may influence manifestation of STIs and may cause treatment failure.
• STIs may cause HIV viral load increase.
• Even if you are faithful you can get STI/HIV if your partner has other sex partners
– Don’t forget that in Malawi a majority of women are in monogamous relationships
• Treating STI reduces the transmission of HIV
15. Factors affecting spread of STIs
• Socio-Economic Factors
• Social mobility
• Stigma and denial
• Political and social instability
• Cultural factors
• Poverty
– Early marriage
– Delay in getting STIs treatment
– Non-compliance to treatment
• • Drug abuse
16. Cont…
• Behaviors Factors
• Having more than one partner
• Frequent partner change
• Having sex with casual partners
• Having sex with those known to have many partners
17. Cont…
• Cultural Issues
• Providers are often embarrassed to talk about STIs
• Counseling is rarely done
• Partners are often not treated, nor counseled
• Condoms are not promoted, nor demonstrated
• Results:
– Failure to follow safe sex practices, such as using condoms
– Failure to bring in sexual partners for treatment
18. Who is at increased risk of STIs?
• Adolescents (socially & biologically)
• Individuals with multiple partners
• Individuals whose partners have multiple partners
• Commercial sex workers
• Individuals involved in unprotected sex
• Men having sex with men
• Street children
19. STIs and Women
• STIS can be difficult to detect in women and consequently a lot of women have
untreated STIs.
• Women are at higher risk of contracting STIs than men because;
Biological differences: thin lining of vaginal mucosa, larger exposed area, genital
fluids stay in contact for a longer time, immature genital tract in younger women.
• Use of vaginal douches
• Influences of hormonal contraceptives
• Economic dependence of women on men
• Traditional practices such as wife inheritance and Fisi
20. Complications of untreated STIs
• Infertility in women and men
• Ectopic pregnancy
• Complications during pregnancy (stillbirths / preterm births)
• Effects on the baby – congenital diseases
• Carcinoma of cervix which is caused by HPV
• Increased susceptibility to HIV
• Stigma and embarrassment
21. Cont…
• 55-85% of women with PID may become infertile
• PID increases the risk of ectopic pregnancy by 7-10 folds
• 10-30% of men with gonorrhea develop epididymitis
• 20-40% of the epididymitis cases become infertile
• Neonatal conjunctivitis may cause permanent damage of
• vision of 1-6% of the affected infants
22. Challenges to STI prevention and
Management
• Health systems and providers challenges.
• Failure by HCWs to recognize the STIs
• Poor attitude
• Less emphasis on patient education and counselling
• Poor management
• Lack of medical supplies
23. Cont…
• Client related factors
• Lack of knowledge
• Misconceptions
• Asymptomatic infections
• Seeking other treatments
• Reluctant to discuss sexual matters
• Stigma attached to STIs
