1ST AUTHOR: DR. (MRS) CHINWEUBA, A.U. RN, RM, BSc, MSc., PHD, FWACN.
2ND AUTHOR: MISS OZOUDE, AMARACHUKWU BENEDETTE
3RD AUTHOR: MRS OBI, THERESA
UNIVERSITY OF ENUGU
Sexually transmitted infections (STIs), also referred to as sexually transmitted diseases (STDs), are infections that are commonly spread by sexual activity, especially vaginal intercourse, anal sex and oral sex (Murray, 2013). Many times STIs initially do not cause symptoms. This results in a greater risk of passing the disease on to others. Symptoms and signs of disease may include vaginal discharge, penile discharge, ulcers on or around the genitals, and pelvic pain. STIs can be transmitted to an infant before or during childbirth and may result in poor outcomes for the baby. Some STIs may cause problems with the ability to get pregnant.
This paper aims to:
Explain the concept of sexually transmitted infection.
Discuss the psychosocial implications of STI incidence.
Discuss the implications to healthcare seeking behavior.
CONCEPT OF SEXUALLY TRANSMITTED INFECTIONS
Sexually transmitted disease can be defined as any disease transmitted by sexual contact; caused by microorganisms that survive on the skin or mucus membranes of the genital area or transmitted via semen, vaginal secretions or blood during intercourse. Because the genital area provide a moist, warm environment that is especially conducive to the proliferation of bacteria, viruses and yeasts, a great many diseases can be transmitted this way. They include: AIDS, Chlamydia, genital herpes, genital warts, gonorrhea, syphilis and some forms of hepatitis (Goering, 2012).
Until the 1990s, STIs were commonly known as venereal diseases, the word venereal being derived from the Latin word “venereus” meaning relating to sexual intercourse or desire, ultimately derived from Venus, the Roman goddess of love. STIs have been euphemistically referred to as "blood diseases" and "social diseases" in the past.
The World Health Organization (WHO) has recommended the more inclusive term sexually transmitted infection since 1999.Public health officials originally introduced the term sexually transmitted infection, which clinicians are increasingly using alongside the term sexually transmitted disease in order to distinguish it from the former.
The main types of sexually transmitted infections include:
1.Chlamydia is a sexually transmitted infection caused by the bacterium Chlamydia trachomatis. In women, symptoms may include abnormal vaginal discharge, burning during urination, and bleeding in between periods, although most women do not experience any symptoms (Demirezen et al., 2005).Symptoms in men include pain when urinating, and abnormal discharge from their penis. If left untreated in both men and women, Chlamydia can infect the urinary tract and potentially lead to pelvic inflammatory disease (PID). PID can cause serious problems during pregnancy and even has the potential to cause infertility. It can cause a woman to have a potentially deadly ectopic pregnancy, in which the egg implants outside of the uterus. However, Chlamydia can be cured with antibiotics.
2.The two most common forms of herpes are caused by infection with herpes simplex virus (HSV). HSV-1 is typically acquired orally and causes cold sores, HSV-2 is usually acquired during sexual contact and affects the genitals, however either strain may affect either site (Weinstein, 2014). Some people are asymptomatic or have very mild symptoms. Those that do experience symptoms usually notice them 2 to 20 days after exposure which last 2 to 4 weeks. Symptoms can include small fluid-filled blisters, headaches, backaches, itching or tingling sensations in the genital or anal area, pain during urination, Flu like symptoms, swollen glands, or fever. Herpes is spread through skin contact with a person infected with the virus. The virus affects the areas where it entered the body. This can occur through kissing, vaginal intercourse, oral sex or anal sex. The virus is most infectious during times when there are visible symptoms, however those who are asymptomatic can still spread the virus through skin contact. The initial infection and symptoms are usually the most severe because the body does not have any antibodies built up. After the primary attack, one might have recurring attacks that are milder or might not even have future attacks. There is no cure for the disease but there are antiviral medications that treat its symptoms and lower the risk of transmission (Valtrex). Although HSV-1 is typically the "oral" version of the virus, and HSV-2 is typically the "genital" version of the virus, a person with HSV-1 orally can transmit that virus to their partner genitally. The virus, either type, will settle into a nerve bundle either at the top of the spine, producing the "oral" outbreak, or a second nerve bundle at the base of the spine, producing the genital outbreak.
3.The human papilloma virus (HPV) is the most common STI in the United States (Kennedy, et al 2017). There are more than 40 different strands of HPV and many do not cause any health problems. In 90% of cases the body's immune system clears the infection naturally within 2 years. Some cases may not be cleared and can lead to genital warts (bumps around the genitals that can be small or large, raised or flat, or shaped like cauliflower) or cervical cancer and other HPV related cancers. Symptoms might not show up until advanced stages. It is important for women to get pap smears in order to check for and treat cancers. There are also two vaccines available for women (Cervarix and Gardasil) that protect against the types of HPV that cause cervical cancer. HPV can be passed through genital-to-genital contact as well as during oral sex. It is important to remember that the infected partner might not have any symptoms.
4.Gonorrhea is caused by bacterium that lives on moist mucous membranes in the urethra, vagina, rectum, mouth, throat, and eyes. The infection can spread through contact with the penis, vagina, mouth or anus. Symptoms of gonorrhea usually appear 2 to 5 days after contact with an infected partner. However, some men might not notice symptoms for up to a month. Symptoms in men include burning and pain while urinating, increased urinary frequency, discharge from the penis (white, green, or yellow in color), red or swollen urethra, swollen or tender testicles, or sore throat. Symptoms in women may include vaginal discharge, burning or itching while urinating, painful sexual intercourse, severe pain in lower abdomen (if infection spreads to fallopian tubes), or fever (if infection spreads to fallopian tubes); however, many women do not show any symptoms(Kennedy et al, 2017). There are some antibiotic resistant strains for Gonorrhea but most cases can be cured with antibiotics.
5.Syphilis is an STI caused by a bacterium. Untreated, it can lead to complications and death (Kennedy et al, 2017). Clinical manifestations of syphilis include the ulceration of the uro-genital tract, mouth or rectum. If left untreated the symptoms worsen. In recent years, the prevalence of syphilis has declined in Western Europe, but it has increased in Eastern Europe (former Soviet states). A high incidence of syphilis can be found in places such as Cameroon, Cambodia, Papua, New Guinea. Syphilis infections are increasing in the United States.
6.Trichomoniasis is a common STI that is caused by infection with a protozoan parasite called Trichomonas vaginalis (Kennedy et al, 2017). Trichomoniasis affects both women and men, but symptoms are more common in women. Most patients are treated with an antibiotic called metronidazole, which is very effective.
7.HIV (Human Immunodeficiency Virus) damages the body's immune system, which interferes with its ability to fight off disease-causing agents. The virus kills CD4 cells, which are white blood cells that help fight off various infections. HIV is carried in body fluids, and is spread by sexual activity. It can also be spread by contact with infected blood, breast feeding, childbirth, and from mother to child during pregnancy( Moyer et al, 2014). When HIV is at its most advanced stage, an individual is said to have AIDS (Acquired Immunodeficiency Syndrome). There are different stages of the progression of HIV infection. The stages include:
Symptomatic infection and
In the primary infection stage, an individual will have flu like symptoms (headache, fatigue, fever, muscle aches) for about 2 weeks. In the asymptomatic stage, symptoms usually disappear, and the patient can remain asymptomatic for years. When HIV progresses to the symptomatic stage, the immune system is weakened, and has a low cell count of CD4+ T Cells. When the HIV infection becomes life-threatening, it is called AIDS. People with AIDS fall prey to opportunistic infections and die as a result. When the disease was first discovered in the 1980s, those who had AIDS were not likely to live longer than a few years. There are now antiretroviral drugs (ARVs) available to treat HIV infections. There is no known cure for HIV or AIDS but the drugs help suppress the virus. By suppressing the amount of virus in the body, people can lead longer and healthier lives. Even though their virus levels may be low they can still spread the virus to others.
DIAGNOSIS OF SEXUALLY TRANSMITTED INFECTIONS
Accurate diagnostic tests for STIs are widely used in high-income countries. These are especially useful for the diagnosis of asymptomatic infections. However, in low- and middle-income countries, diagnostic tests are largely unavailable. Where testing is available, it is often expensive and geographically inaccessible and patients often need to wait a long time (or need to return) to receive results. As a result, follow up can be impeded and care or treatment can be incomplete.
The only inexpensive, rapid tests currently available for STIs are for syphilis and HIV. The syphilis test is already in use in some resource-limited settings. The test is accurate, can provide results in 15 to 20 minutes, and is easy to use with minimal training. Rapid syphilis tests have been shown to increase the number of pregnant women tested for syphilis. However, increased efforts are still needed in most low- and middle-income countries to ensure that all pregnant women receive a syphilis test.
Several rapid tests for other STIs are under development and have the potential to improve STI diagnosis and treatment, especially in resource-limited settings.
STI tests may be used for a number of reasons:
As a diagnostic test to determine the cause of symptoms or illness.
As a screening test to detect asymptomatic or presymptomatic infections.
As a check that prospective sexual partners are free of disease before they engage in sex without safer sex precautions (for example, when starting a long term mutually monogamous sexual relationship, in fluid bonding, or for procreation).
As a check prior to or during pregnancy, to prevent harm to the baby.
As a check after birth, to check that the baby has not caught an STI from the mother.
To prevent the use of infected donated blood or organs.
As part of the process of contact tracing from a known infected individual.
As part of mass epidemiological surveillance.
Early identification and treatment results in less chance to spread disease and for some conditions may improve the outcomes of treatment. There is often a window period after initial infection during which an STI test will be negative. During this period, the infection may be transmissible. The duration of this period varies depending on the infection and the test. Diagnosis may also be delayed by reluctance of the infected person to seek a medical professional. One report indicated that people turn to the Internet rather than to a medical professional for information on STIs to a higher degree than for other sexual problems (Osbom, et al 2002).
PREVENTION OF STIS
1.Counseling and behavioral approaches
Counseling and behavioral interventions offer primary prevention against STIs (including HIV), as well as against unintended pregnancies. These include:
comprehensive sexuality education,
STI and HIV pre- and post-test counseling
safer sex/risk-reduction counseling, condom promotion
In addition, counseling can improve people’s ability to recognize the symptoms of STIs and increase the likelihood they will seek care or encourage a sexual partner to do so. Unfortunately, lack of public awareness, lack of training of health workers, and long-standing, widespread stigma around STIs remain barriers to greater and more effective use of these interventions.
Vaccines are available that protect against some viral STIs, such as Hepatitis A, Hepatitis B, and some types of HPV. Vaccination before initiation of sexual contact is advised to assure maximal protection. The development of vaccines to protect against gonorrhea is ongoing (Moyer et al, 2014)
3.Use of Condoms
Male condoms and female condoms only provide protection when used properly as a barrier, and only to and from the area that they cover. Uncovered areas are still susceptible to many STIs. In the case of HIV, sexual transmission routes almost always involve the penis, as HIV cannot spread through unbroken skin; therefore, properly shielding the penis with a properly worn condom from the vagina or anus effectively stops HIV transmission.
Other STIs, even viral infections, can be prevented with the use of latex, polyurethane or polyisoprene condoms as a barrier. Some microorganisms and viruses are small enough to pass through the pores in natural skin condoms, but are still too large to pass through latex or synthetic condoms.
Proper male condom usage entails:
Not putting the condom on too tight at the tip by leaving 1.5 centimetres (0.6 inch) room for ejaculation. Putting the condom on too tightly can and often does lead to failure.
Wearing a condom too loose can defeat the barrier.
Avoiding inverting or spilling a condom once worn, whether it has ejaculate in it or not
If a user attempts to unroll the condom, but realizes they have it on the wrong side, then this condom may not be effective.
Being careful with the condom if handling it with long nails
Avoiding the use of oil-based lubricants (or anything with oil in it) with latex condoms, as oil can eat holes into them
In order to best protect oneself and the partner from STIs, the old condom and its contents are to be treated as infectious and properly disposed of.
A new condom is used for each act of intercourse, as multiple usage increases the chance of breakage, defeating the effectiveness as a barrier.
In case of female condoms, the device consists of two rings, one in each terminal portion. The larger ring should fit snugly over the cervix and the smaller ring remains outside the vagina, covering the vulva. This system provides some protection of the external genitalia (Gavin et al, 2014).
4.Cap and cervical diaphragm
The cap was developed after the cervical diaphragm. Both cover the cervix and the main difference between the diaphragm and the cap is that the latter must be used only once, using a new one in each sexual act. The diaphragm, however, can be used more than once. These two devices partially protect against STDs (they do not protect against HIV).
Specific age groups, persons who participate in risky sexual behavior or those have certain health conditions may require screening. The CDC recommends that sexually active women under the age of 25 and those over 25 at risk should be screened for chlamydia and gonorrhea yearly. Appropriate times for screening are during regular pelvic examinations and preconception evaluations. Nucleic acid amplification tests are the recommended method of diagnosis for gonorrhea and chlamydia This can be done on either urine in both men and women, vaginal or cervical swabs in women, or urethral swabs in men. Screening can be performed:
To assess the presence of infection and prevent tubal infertility in women during the initial evaluation before infertility treatment.
To identify HIV infection.
For men who have sex with men.
For those who may have been exposed to hepatitis C.
TREATMENT OF STIS
Low- and middle-income countries rely on identifying consistent, easily recognizable signs and symptoms to guide treatment, without the use of laboratory tests. This is called syndromic management. This approach, which often relies on clinical algorithms, allows health workers to diagnose a specific infection on the basis of observed syndromes (e.g., vaginal discharge, urethral discharge, genital ulcers, and abdominal pain).
Syndromic management is simple, assures rapid, same-day treatment, and avoids expensive or unavailable diagnostic tests. However, this approach misses infections that do not demonstrate any syndromes - the majority of STIs globally.
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