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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa
11
Sexually Transmitted Diseases and HIV Infection
In Sub-Saharan Africa, sexually transmitted diseases (STDs) are among the most common reasons that adults, as a group, seek health care (Hira et al., 1992b; Meheus et al., 1990; Zimbabwe, 1989). Yet this statistic refers primarily to males. Most women with STDs will not seek medical care at all, or will only present late for treatment, when complications have already developed, complications that have devastating physical, psychological, and social consequences, particularly for women and their children (Carty et al., 1972; Latif, 1981). These consequences for individuals, in turn, have serious repercussions for the societies of which they are part.
Human immunodeficiency virus (HIV) infection is considered by many to be the most serious STD because of its multiple debilitating manifestations, its high fatality rate, and the severe stigma and discrimination that surround it in communities around the globe. In Sub-Saharan Africa, where the infection is acquired sexually in most cases, HIV seriously affects, and will spread among, the very same women and men who already have very high rates of other STDs.
Table 11-1 depicts the gender-related burden of HIV infection and the STDs reviewed in this chapter. As the table indicates, both are of unique significance to female health because of their capacity for transmission from mother to offspring during pregnancy and birth and, in the case of HIV infection, through breast milk. In contrast to HIV infection, which in Sub-Saharan Africa is a disease of both women and men, the other STDs disproportionately affect women, who bear 80 percent of the disability-adjusted life years (DALYs) lost to these diseases (World Bank, 1993). In addition, compared with HIV infection, which has stimulated extensive research, including research related to the women of Sub-Saharan Africa (de Bruyn, 1992; Mane et al., 1994; Mann et al., 1992; Orubuloye et al., 1993; Temmerman et al., 1994; Ulin, 1992; WHO, 1993, 1994), relatively little attention has been paid to the other STDs. We therefore choose to consider HIV and other STDs together, and to place greater emphasis on non-HIV STDs.
This chapter first provides a conceptual framework for thinking about STDs and HIV infection. It then highlights the gender differences that make all STDs a critical women's health concern and examines special issues that are unique to the different stages of women's lives. Next, the chapter describes the magnitude of the problem in Sub-Saharan Africa, analyzing existing data, explores the geographic distribution and clustering of five common STDs, including HIV infection. The chapter proceeds to an examination of societal factors that may influence STD and HIV prevalence, and closes with a discussion of implications for research, policy, and programs.
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TABLE 11-1 HIV Infection and Other Sexually Transmitted Diseases in Sub-Saharan Africa: Gender-Related Burden
Disorder
Exclusive to Females
Greater for Females than for Males
Burden for Females and Males Comparable, but of Particular Significance for Females
HIV infection
Xa
Other STDs
Xa
NOTE: Significance is defined here as having impact on health that, for any reason—biological, reproductive, sociocultural, or economic —is different in its implications for females than for males.
a Both HIV infection and other STDs have the capacity to be passed on from an infected mother to her offspring through congenital, perinatal, or neonatal transmission.
OVERVIEW
STDs, Including HIV Infection, and their Complications
One of the simplest and most useful ways to classify STDs is based on their two most common syndromes: genital discharge and genital lesions. STDs such as gonorrhea, chlamydia, and trichomoniasis cause genital discharge. Others cause genital lesions that can be further categorized as ulcerative diseases such as syphilis, chancroid, and genital herpes, or as nonulcerative diseases such as genital warts. In addition, a few STDs, such as human immunodeficiency virus (HIV) infection, do not fit this syndromic classification. The final stage of HIV infection, acquired immunodeficiency syndrome (AIDS), develops after a variable period of time, with onset generally following initial infection within approximately 10 years, during which it remains largely asymptomatic. The symptomatic stages of AIDS are characterized by the onset of opportunistic infections or cancers, some of which, such as cervical cancer, affect the genital tract.
This chapter refers to studies from Africa whenever they are available. When African data do not exist, or when comparison is appropriate, data are presented from other countries, particularly Sweden, which has accumulated a substantial and unique body of data on STDs in women.
Complications of STDs
Untreated or inappropriately treated, STDs may lead to severe complications, which account for most of their morbidity. Such complications occur most frequently in populations that lack ready access to effective treatment. Furthermore, both the anatomy of the female genital tract —prone to ascending infections—and reproductive events and related medical procedures—childbirth, stillbirth, abortion, uterine curettage, and intrauterine device insertion—are additional risk factors for STD complications particular to women (Meheus et al., 1990). The main STD complications include pelvic inflammatory disease (PID) and its sequelae, and the most important of these are impaired fertility and adverse pregnancy outcomes, enhanced HIV transmission, and cervical cancer.
The clinical manifestations associated with HIV infection depend on several factors, including the pathogens to which an individual has been exposed; the susceptibility of the host; possibly, the strain of HIV; and access to medical care. Most studies have not highlighted significant gender differences in disease progression. In the United States, however, one study indicated that, compared with men, HIV-infected women were at increased risk of death, which may reflect differential access to health care or different socioeconomic status and social support for women compared with men (Melnick et al., 1994). In Africa, little information is available on the natural history of HIV infection, particularly among women. The clinical picture of HIV infection in Sub-Saharan Africa
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TABLE 11-2 Sexually Transmitted Diseases in Women
Potential Complications
Syndrome
Etiology
Infertility/Ectopic Pregnancya
Adverse Pregnancy Outcomea
Cervical Cancera
Enhanced HIVa Transmission
Discharge
Chlamydia
X
X
X
Gonorrhea
X
X
X
Trichomonas
X
X
Lesions
Genital ulcers
Syphilis
X
X
Chancroid
X
Herpes
X
X
Other
HPV infection and genital warts
X
X
a Potentially fatal.
appears to be dominated by dermatological and gastrointestinal manifestations and by tuberculosis (De Cock et al., 1993; Kreiss and Castro, 1990).
A recent study strongly suggests that a sexually transmitted herpes virus causes Kaposi's sarcoma, one of the clinical manifestation of AIDS (Chang, 1994). In Africa, while this cancer has always been endemic, predominantly affecting men, with the spread of HIV its incidence has risen notably, and it is affecting an increasing number of women. In Zambia, the proportion of women among persons with Kaposi's sarcoma increased from 9 percent in 1983 to 30 percent in 1990–1992 (Ebrahim et al., 1993).
The onset of AIDS may be delayed by antiretroviral drugs. Because of their high cost, however, it is unlikely that these drugs will become widely available in the near future in Sub-Saharan Africa. Most important, several AIDS-indicative diseases may be prevented. Indeed, some opportunistic infections can be prevented by the use of chemoprophylaxis, and invasive cervical cancer can be prevented by proper recognition and treatment of cervical dysplasia or early cervical cancer.
The syndromic classification of STDs described above also suggests the kinds of complications that may occur. For example, fertility impairment is primarily associated with the genital discharge syndromes, and both genital discharges and genital ulcers may be prodromal to poor pregnancy outcomes and enhanced risk of sexual HIV transmission (Table 11-2).
In men, STD complications do not have the frequency, severity, or consequences they have in women. They result mainly from urethral infections, and include urethral strictures and epididymitis, an inflammation of the excretory duct of the testicle and the leading cause of male infertility in parts of Sub-Saharan Africa (Berger, 1990).
Pelvic Inflammatory Disease and Its Sequelae In women, pathogens that cause genital discharge, such as gonococci and chlamydiae, tend to rise into the upper genital tract and cause pelvic inflammatory disease. As many as 10 to 20 percent of women with untreated gonorrhea or chlamydia develop PID (Hook and Handsfield, 1990; Weström and Mårdh, 1984), the most common of the complications of sexually transmitted diseases.
Although the acute clinical manifestations of pelvic inflammatory disease may be quite severe, their public health significance resides primarily in their long-term sequelae. The partial or total occlusion of the fallopian tubes that can ensue from ID produces harsh and irreversible sequelae: infertility, ectopic pregnancy, chronic pelvic pain, and recurrent infection. Both gonococcal and chlamydial PID may be associated with those sequelae, but manifest differently. PIDs of chlamydial origin generally produce less severe symptoms than those of gonococcal cause, and they appear to produce more tubal damage and correspondingly higher rates of infertility
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and ectopic pregnancy. In part, this may be caused by the more indolent character of chlamydia, which makes women with chlamydial PID less likely to seek timely treatment than women with gonococcal PID (Hillis et al., 1993).
Rates of infertility consequent to a pelvic inflammatory disease are high, even in developed countries. In a landmark study of Swedish women treated for one episode of PID, 11.4 percent became involuntarily infertile, with the risk of infertility roughly doubling with each subsequent episode; 23.1 percent of women became infertile after two episodes of PID; and 54.3 percent became infertile after three or more episodes (Weström and Mårdh, 1990). In the absence of timely, effective treatment, which is the normative circumstance in Sub-Saharan Africa, this risk becomes even greater: according to data from the preantibiotic era, 45–75 percent of women who had suffered from PID became infertile (Weström and Mårdh, 1990). Delay in PID treatment is a critical risk factor for impaired fertility; women who wait to seek health care for more than two days after onset of symptoms have a threefold increase in risk of infertility or ectopic pregnancy compared with those who seek care promptly. This risk is highest for women with chlamydial infection: 17.8 percent of those who delayed seeking health care developed impaired fertility; none of those who sought prompt treatment became so afflicted (Hillis et al., 1993).
Ectopic pregnancy is caused by partial occlusion of the fallopian tubes, in which the damaged tube hampers the passage of the fertilized ovum into the uterus. Absent emergency care, it is frequently fatal. In Sweden, women with a history of any pelvic infection have a risk of ectopic pregnancy 6 to 10 times greater than women with no such history, and the first conception following an infection leads to ectopic pregnancy in almost 10 percent of women (Weström et al., 1992). In Africa, studies from Zimbabwe and Gabon implicate both gonorrhea and chlamydia in the development of ectopic pregnancy (De Muylder et al., 1990; Ville et al., 1991), although the Gabon study shows a stronger association between chlamydia and ectopic pregnancy, which is consistent with the pattern of association suggested by the Swedish data.
While chronic pelvic pain has neither the emotional significance of infertility nor the fatal character of ectopic pregnancy, it is the most disabling of all PID sequelae, often so insidious and severe that it interferes with daily activities. It affects 15 to 18 percent of all women who have had a pelvic inflammatory disease and is often associated with infertility (Weström, 1980). In industrialized countries, up to one-third of women who have had a single episode of PID develop recurrent infections because of inadequate treatment, increased vulnerability of damaged tubes, repeated exposure to sex partners who remain untreated, or unaltered risky behaviors (Weström and Mårdh, 1990). This risk, as is the case for all the other sequelae of PID, may be much greater in Sub-Saharan Africa simply because of the pervasive lack of access to effective care.
Adverse Pregnancy Outcomes Adverse pregnancy outcomes, which include congenital or perinatal infection, low birthweight, and fetal death, are a major public health problem in Sub-Saharan Africa, and linked to both genital discharge syndromes and genital ulcer diseases. When STDs occur during pregnancy, a mother may pass the infection to her child, either during pregnancy or at the time of delivery Thus, not only the pregnant woman herself but her entire family is affected, so that she becomes the unwitting, critical link between horizontal and vertical transmission.
Congenital infections occur during pregnancy; perinatal infections occur around the time of birth. Either may result in transient illness, permanent disability, or neonatal death. In Sub-Saharan Africa, the most common and best-documented congenital or perinatal infections caused by STDs include ophthalmia neonatorum, congenital syphilis, and congenital HIV infection. Ophthalmia neonatorum, an eye infection that develops within the first month of life, is one of the most common infections of newborns related to maternal STDs, and may be caused by gonorrhea, chlamydia, or both. Easily preventable by instillation of medication in the eye at birth, untreated it may result in blindness. In a Nairobi hospital where ocular prophylaxis at birth had been discontinued, ophthalmia neonatorum occurred in 42 percent of infants whose mothers were infected with gonorrhea, and in 31 percent of infants whose mothers had chlamydia (Laga et al., 1986).
Congenital syphilis is a very serious condition, often debilitating when it is not fatal. Approximately one-third of women with syphilis are delivered of live infants with syphilis, who then go on to suffer the ravages of that disease; untreated, the disease can proceed to fatality (Schultz et al., 1990). HIV-infected babies have an even
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worse prognosis, since no good therapeutic options are yet available. In a Rwanda study, 38 percent of HIV-infected infants had died by the age of 6 months (Lepage and Van de Perre, 1988a,b).
HIV-infected mothers have a risk of transmitting HIV to their babies ranging from 13 to 45 percent, with a tendency toward higher rates in Africa (Blanche et al., 1989; Hira et al., 1989; Lallemant et al., 1994; Lepage et al., 1993; Newell, 1992; Ryder et al., 1989; St. Louis et al., 1993; Tovo et al., 1988). One reason that has been postulated for the difference in transmission rates between countries is that, compared with those from industrialized countries, African HIV-infected women are generally in poor health because of poor nutritional status and frequent infections, and thus are at greater risk of transmutting HIV to their infants (Lepage et al., 1993). HIV may be transmitted during pregnancy, during birth, or through breast milk, but the relative contribution of these different modes of transmission to infection is still unclear in most African countries. A collaborative French-American study showed that the uptake of zidovudine by HIV-infected pregnant women reduces the risk of mother-to-child transmission by approximately one-third (Connor et al., 1994). The complexity of the regimen used in this study and the cost of the drug, however, make it unlikely that this kind of therapy will become available to most of the HIV-infected women of Sub-Saharan Africa in the near future.
Low birthweight, defined as live birth below 2,500 grams, occurs because of intrauterine growth retardation, premature delivery, or both. Many factors, both infectious and noninfectious—such as diet, smoking, and hypertension—may cause low birthweight. The relative contribution of each of these factors remains to be determined, and undoubtedly varies substantially according to their local prevalence. In developing countries, up to 30 percent of infants are below 2,500 grams at birth, compared with only 2 to 10 percent of infants in industrialized countries (Barnes, 1979). Because 70 percent of mortality and morbidity during the first month of life occurs among low birthweight babies (Barnes, 1979), STDs would appear to be an important factor in child survival.
Syphilis and genital herpes appear to be associated with both intrauterine growth retardation and premature delivery, while gonorrhea, chlamydia, and trichomoniasis induce premature delivery without affecting intrauterine growth (Brunham et al., 1990a; Cotch, 1990). In a study in Nairobi, Elliot and colleagues suggested that treatment of maternal gonorrhea may reduce prematurity rates by 14 percent (Elliot et al., 1990). Studies from Kenya, Rwanda, Zaire, and Zambia have identified a significant association between HIV infection and low birthweight (Braddick et al., 1990; Bulterys et al., 1991; Hira et al., 1989; Ryder et al., 1989; Temmerman et al., 1992b), which appears to derive from intrauterine growth retardation.
Fetal death, occurring either before 20 weeks of gestation (spontaneous abortion), or at or after 20 weeks of gestation (stillbirth), also appears to be associated with several types of sexually transmitted infections. Studies from industrialized countries suggest that spontaneous abortion is more frequently associated with gonorrhea or genital herpes, with stillbirth more often linked with chlamydia or syphilis (Brunham et al., 1990a; Cooper-Poole, 1986; Mtimavalye and Belsey, 1987). Schulz and his colleagues have estimated that at least 50 percent of women with untreated syphilis may lose the fetus they are carrying (Schulz et al., 1990). In Zambia, pregnant women with untreated syphilis had a risk of bearing a stillborn child 28 times higher than pregnant women without syphilis (Watts et al., 1984). In another Zambian study, 42 percent of stillbirths were attributed to syphilis (Ratnam et al., 1982), and in Ethiopia, data suggest that 5 percent of all pregnancies are lost to that disease (Bishaw et al., 1983).
Enhanced HIV Tranmission The relationships between HIV infection and other STDs are complex, intriguing, and in large measure speculative. STDs may enhance HIV transmission either by increasing the infectivity of HIV-infected persons or by increasing the susceptibility to HIV infection of non-HIV-infected persons. Several studies, mostly from Africa, indicate that both genital ulcers and genital discharge syndromes enhance the risk of HIV transmission (Cameron et al., 1989; Laga, 1990; Laga et al., 1990; Plummer et al., 1991; Wasserheit, 1992). HIV also may alter the natural course of other STDs, including their response to treatment. In Zimbabwe and Kenya, HIV-infected persons have an increased risk of treatment failure for chancroid (Latif, 1989; MacDonald et al., 1989). All of these interactions are worrisome. If co-infection with HIV prolongs or increases the infectivity of individuals with genital ulcers, and if genital ulcers facilitate transmission of HIV infection, then at the community level the two infections have the potential to greatly amplify each other (Wasserheit, 1992).
Cervical Cancer Cervical cancer is a major public health problem throughout the world, and it is the most
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common cancer in Africa (Parkin et al., 1988; see also Chapter 7). It is strongly associated with several types of human papillomavirus (HPV), the etiologic agent of genital warts (WHO, 1987) and increasingly recognized as important human carcinogens.
HIV-infected women are at increased risk for cervical dysplasia, a precursor lesion for cervical cancer (Laga et al., 1992; Schafer et al., 1991; Wright et al., 1994a). Furthermore, HIV infection may adversely alter the course and treatment of cervical dysplasia and cancer (Frutcher et al., 1992; Klein et al., 1992; Maiman et al., 1990; Rellihan et al., 1990; Schwartz et al., 1991; Wright et al., 1994b). Compared with women of unknown HIV serostatus, HIV-infected women have a ninefold greater risk of recurrent or persistent cervical intraepithelial neoplasia following loop electrosurgical excision (Wright et al., 1994b).
If detected and treated early, cervical cancer is almost always curable; in the absence of early treatment, it is almost always fatal. In Sub-Saharan Africa, many women die from cervical cancer because their disease is only diagnosed at an advanced, incurable stage.
Gender Differentials in STDs and HIV Infection
Gender is linked to biological and behavioral factors that contribute to crucial differences in the acquisition, course, and consequences of STDs. Compared with men, women are less likely to have control over the circumstances of their sexual activity. If they have sex with an infected partner, they are more likely to acquire an STD, including HIV infection; if they have an STD or HIV infection, they are less likely to seek health care; if they seek health care, they are less likely to be treated effectively, are more likely to develop complications, and, finally, frequently pay a heavier social toll for STDs, including HIV and their sequelae. These individual factors operate against a backdrop of such societal features as the low-status of women and the high ratios of males to females in urban areas. These societal factors clearly influence sexual behavior and are discussed in greater detail below.
Control Over the Circumstances of Sexual Intercourse
Gender typically influences economic and social status and, in most societies, women's roles are defined primarily by their sexual and reproductive relationships with men, relationships that place severe limitations on the extent of women's control of their own sexuality (Aral, 1990). Compared with men, in most societies women also have fewer options about when, where, how, and with whom they will have sex.
Acquisition of STDs and HIV Infection and Development of Complications
Gender affects the efficiency of transmission of some STDs. Transmission of STD pathogens that produce discharge or are present in genital secretions—such as gonococci, chlamydiae, trichomonads, and HIV—appears to be more efficient from male to female than vice versa, at least partly because of the prolonged exposure to organisms when infected ejaculate is retained in the vagina. In contrast, the transmission of syphilis, chancroid, and genital herpes, all of which cause genital ulcers, differs little by gender. This may be because transmission of these STDs depends on small breaks in the genital skin that probably occur in both sexes during vigorous coitus. Sexual behaviors may also synergize with biological factors to promote STD transmission. For example, the practice of ''dry sex" (use of intravaginal desiccants to increase friction during coitus) in some parts of Sub-Saharan Africa—such as Malawi, Zaire, and Zambia (Brown et al., 1992; Dallabetta et al., 1990; Nyirenda, 1992)—frequently causes breaks in the vaginal surface (Brown et al., 1992), which may enhance the risk of acquiring HIV infection and other STDs. Finally, unavailability of female-controlled barrier methods of birth control restricts women's ability to protect themselves against all STDs, including HIV infection.
Health-Seeking Behavior
Another gender-related consequence of STDs is the exacerbation of their sequelae brought about by differences in health-seeking behavior. Although in some industrialized countries women are more likely than men to
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seek health care and subsequently receive appropriate treatment, this is rarely the case in Sub-Saharan Africa (Ehrhardt and Wasserheit, 1991). First, women may not suspect that they have an STD. Indeed, women with STDs are more frequently asymptomatic than men: 50 to 80 percent of women infected with gonorrhea are asymptomatic (Jones and Wasserheit, 1991), compared with 20 to 40 percent of men (Rothenberg and Potterat, 1990). In addition, when STD symptoms are present in women, they are often subtle, and may resemble changes that normally occur during the menstrual cycle, such as increased vaginal discharge, lower abdominal pain, and vaginal bleeding. Finally, cultural factors may influence the way women perceive the significance of their symptoms. For example, in regions where women are circumcised, practice "dry sex," or where STDs are widespread, pain during coitus, irregular vaginal bleeding, or pelvic pain may be considered the norm.
Another major reason for gender differentials in seeking care for STDs is the female-specific, stigmatizing character of STDs, including HIV infection. Women face very strong sociocultural barriers to STD care, which are frequently fueled by the judgmental attitudes of health care providers. Finally, financial barriers for accessing care for HIV and other STDs may be stronger for women than for men, because women are frequently either of lower socioeconomic status than men or do not have independent financial resources.
Detection and Treatment of STDs
Even if they do seek health care for STDs, women are less likely than men to receive correct diagnosis and adequate treatment, for several reasons. First, most health care providers have limited expertise in STD management in women; they also share a common misconception that STDs affect only promiscuous women and prostitutes. Second, as discussed earlier, because STD signs and symptoms in women are often subtle and nonspecific, clinical diagnosis is not reliable. Third, in many Sub-Saharan African settings, laboratory tests are not available, even though it is women who would benefit most from laboratory tests because of the poor predictive value of female STD syndromes, particularly for vaginal discharge. Finally, the increased antimicrobial resistance of many pathogens to older antibiotics such as penicillin requires that new, more expensive drugs be used. Once again, women may be disproportionately affected: most sexually active women in Sub-Saharan Africa are either pregnant or breastfeeding at any given time, yet antibiotics that are effective and safe under those conditions may be neither available nor affordable.
The Social Implications of STDs and HIV Infection
Both STDs and their complications have far greater social significance for women than they do for men. Uncomplicated STDs typically cause personal embarrassment and domestic conflicts, but whoever is responsible for bringing a given infection into the relationship, it is the woman who is typically blamed and who endures the most serious consequences; these may include violence, divorce, and social ostracism. The complications of STDs, especially impaired fertility, are even more devastating. Although male infertility scientifically explains about one-third of all infertility, women are customarily blamed when a couple cannot have children. In parts of Africa, it is not uncommon for the female of an infertile couple to look for another male to make her pregnant (Rob et al., 1987), out of fear of being rejected by her husband and in-laws and becoming a social outcast. As a result, many infertile men may never become aware of their infertility. For women, childlessness, whether through infertility or poor pregnancy outcome, can be a major tragedy. Not only does it cause personal pain for the women themselves, but it becomes a paramount infirmity in a society that values women primarily for their ability to produce healthy offspring. Infertile women may be divorced by the same husbands who infected them with the STD that produced the infertility. The same is true of HIV-infected women, who are at risk of abandonment by the very men who transmitted the infection (de Bruyn, 1992). Ostracized by society, divorced women have few survival options other than prostitution, which increases STD transmission and the risk of infertility in the larger community, creating a vicious cycle of disease; misery; and, increasingly, death.
In this way, STDs and their complications affect individuals, communities, and, eventually, whole societies. In some areas, notably the so-called "infertility belt," which extends from Gabon in the west of Africa to southwestern Sudan in the east, STDs have had a dramatic impact on fertility rates. Brunham estimates in a mathematical
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model that a 20 percent gonorrhea prevalence in sexually active adults may produce up to a 50 percent reduction in net population growth, an estimate consistent with fertility levels actually observed in some parts of Uganda (Brunham et al., 1991). The consequences of HIV infection are even more striking. In another mathematical model, Anderson predicts that in some Sub-Saharan African countries, HIV infection may reverse demographic growth from positive to negative over a few decades (Anderson et al., 1988).
Yet another dramatic—and paradoxical—effect of STDs on society is their potential for jeopardizing family planning programs. STDs may decrease acceptance and continuation of contraceptive methods in two ways: directly, by creating the perception of a contraceptive side effect, and indirectly, by creating a fear of fertility impairment in the face of complications of STDs. Numerous studies in Bangladesh have found that the most common reason given for discontinuing a contraceptive method is the perception of a method-associated side effect (Akbar et al., 1981; Bhatia, 1982; Jain and Sivin, 1977; Rob et al., 1987). Similar findings have turned up all over the globe and can be extrapolated comfortably to other settings. Absent accurate diagnosis and effective education and therapy, it is far easier for a woman to blame a vaginal discharge on her current contraceptive method than to confront the possibility of having been infected by her husband—who is then, by definition, unfaithful. The net result is that the woman stops using her contraceptive method in the mistaken belief that if caused the unrelated infection (Wasserheit, 1989).
The indirect impact of STDs on family planning is equally important. Several authors have postulated that high levels of infertility or frequent adverse pregnancy outcomes might result in a compensatory decrease in acceptance of family planning methods (O'Reilly, 1986; Rosenberg et al., 1986). In societies that value children highly, couples are unlikely to undertake voluntary fertility regulation unless they are confident that they will be able to raise as many healthy children as they desire (Wasserheit, 1989).
STDs and HIV Infection Throughout the Female Life Span
The relative contribution of different risk factors for STDs, including HIV infection, varies with age. Increased vulnerability to STDs may be the result of biological or behavioral factors, and these may go in the same or in the opposite direction. In adolescence, for example, biological and behavioral factors act concurrently to increase dramatically the risk of HIV infection and other STDs and their complications. In later years, however, these factors may have different weights. In the adult, biological factors tend to decrease in importance and to be outweighed by behavioral factors. In the elderly, while physiological changes may facilitate the transmission of HIV and other STDs, behavioral factors tend to be protective (Ehrhardt and Wasserheit, 1991).
The striking changes that occur in cellular morphology in the vagina and cervix over the female life span have a direct effect on susceptibility to STDs and on the spectrum of infections found at each stage. During the first few weeks of life, the vagina and cervix of the newborn are lined by squamous epithelial thick cells that are relatively resistant to infection. From one month until menarche, changes in this lining increase susceptibility to STDs, especially to chlamydia and gonorrhea. Then, beginning at puberty, under hormonal influence, the cervico-vagina vault will again be covered by a thicker layer of squamous cells that are more resistant to some infections. The junction between squamous cells and the columnal cells that are the site of attachment for chlamydial and gonococcal infection is called the zone of ectopy. In the adolescent, the zone of ectopy is found on the surface of the cervix, where it is particularly susceptible to chlamydia, gonorrhea, and HIV. In young adulthood, the zone will usually migrate from the surface of the cervix to a less-exposed position in the cervical canal, reducing susceptibility to those infections (Cohen et al., 1985).
Sexuality and sexual behavior are forbidden subjects in many societies. As a result, real data on these topics are quite limited, particularly in developing countries. Most of our knowledge about sexual behavior comes from studies in industrialized countries, and it may not be applicable to Sub-Saharan Africa. In addition, sexual behavior in Sub-Saharan Africa is likely to vary a great deal across its many cultures and countries. At the same time, biological factors are more likely to be similar across cultures. This section enlarges upon the key biological and behavioral risk factors that are unique to each stage of the female life span.
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Infancy, Childhood, and Adolescence
Infancy During infancy, STDs, including HIV infection, are rarely transmitted sexually unless sexual abuse has occurred. Instead, they result from intrauterine or perinatal transmission of maternal infections. Behavioral risk factors for congenital infections therefore concern the infant's mother.
The consequences of congenital and perinatal infections associated with STDs and HIV infection include, at the extreme, blindness and other physical disabilities, mental retardation, and death. All the morbidities may have continuous, severe consequences throughout childhood, adulthood, and senescence. In addition, congenital infections affect not only the baby, but also its mother, who has to care for the sick or disabled child, perhaps for her remaining lifetime. Also, the children born to HIV-infected mothers, whether infected themselves or not, will, if they outlive their parents, become orphans, representing an extra burden for the older members of the community, often the grandmothers.
Childhood STDs and HIV infection during childhood are relatively rare, and result almost entirely from sexual abuse. Sexual activities during childhood are exploratory and sporadic; while such sexual play between children of the same age is normative, sexual behavior between adults and children is not. Sexual abuse of children by strangers or by family members has received very little attention in Sub-Saharan Africa, and may well merit more. There are no studies of the region that would permit evaluation of the extent of emotional injury and long-term impact on the subsequent psychosexual development of sexually abused children or the magnitude of the problem. Studies from industrialized countries indicate that the extent of trauma varies and that the effects are nonspecific and may influence later sexual, emotional, or substance abuse behavior (Browne and Finkelhor, 1986). Sexual abuse of children may be more likely than rape of adult women to result in STD and HIV transmission because penetration is more likely to be traumatic in children.
Adolescence This is the period when behavioral and biological factors combine to maximize the risk for STDs and HIV infection. As noted, during puberty and adolescence, several physiological changes occur in the female genital tract that result in a particularly high-risk. In addition, adolescence is a period of life in which many women have their first sexual encounter, and it is the time when sexual behavior patterns become established. Furthermore, when the initial sexual encounter is traumatic, it may be a high-risk event for male-to-female HIV transmission (Bouvet et al., 1989). Age at sexual debut (time of first sexual intercourse) and sexual activities during adolescence follow secular trends and also vary greatly according to culture. Studies indicate that an earlier age of sexual debut is associated with higher total numbers of sex partners over a lifetime. In Ethiopia, where child marriage is practiced, half of 2,111 women surveyed had experienced their first sexual intercourse before the menarche (Duncan et al., 1990). That same early sexual activity was associated with an increased prevalence of STDs, PID, and cervical cancer later in life. The study also indicates that the younger the age at first marriage or first coitus, the shorter the duration of the marriage and the greater the likelihood of divorce (Duncan et al., 1990).
The extent of sexual assault in Sub-Saharan Africa is unknown. As in other parts of the world, rapes are rarely reported (see also Chapters 2 and 8). Instead, the incident is often settled between the families involved through compensation, in cash or goods, by the perpetrator to the family of the woman raped. There is evidence that rape is a serious problem in parts of Sub-Saharan Africa. In Kenya, when 71 teenage girls were raped during one night in the dormitory of a boarding school, a Kenyan newspaper described the incident as a common occurrence, and as sanctioned by the principal and his staff (Heise et al., 1994). There is a good chance that sexual abuse is a menace for African women throughout their lives. In South Africa, as one example, the incidence of rape appears to exceed rates in the United States, with an annual incidence of 34 rapes per 1,000 women, compared with 18 per 1,000 women in the United States (Heise et al., 1994).
Finally, the limited health knowledge and constrained health-seeking behavior of adolescents compound the impact of physiological factors on STD and HIV infection morbidity. Many adolescents are unable to recognize or to understand the significance of STD or HIV symptoms and have little or no independent access to health care, or are afraid to utilize existing services.
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Adulthood In adulthood, behavioral factors dominate the risk for STDs and HIV infection and are characteristically tied to the sex partner's sexual behavior. The physiological changes that affect the risk for STDs, including HIV infection, during the adult reproductive years are related primarily to the menstrual cycle, pregnancy, and contraceptive use.
The menstrual cycle seems to play a key role in the risk of PID. Symptomatic gonococcal and chlamydial PID appear to occur more frequently during the first week of the menstrual cycle, probably because of the retrograde flow of menstrual blood from the uterus into the fallopian tubes. During pregnancy, although the lower genital tract, particularly the cervix, may be more susceptible to infections, the upper genital tract appears to be protected from infections by gestational anatomical changes.
Sex during menses has been hypothesized, although not shown, to be a risk factor for female-to-male transmission (De Vincenzi, 1994). Although there is no evidence thus far to suggest that pregnancy aggravates the course of HIV infection, several studies have documented the occurrence of serious HIV-related infections during pregnancy (Selwyn and Antoniello, 1993).
Contraceptives may play a prominent part in altering the risk of HIV and other STDs during the reproductive years, and even beyond. Barrier contraceptive methods such as condoms and diaphragms serve as a mechanical barrier to pathogens. Oral contraceptive pills seem to increase risk of cervical chlamydial infection, but appear to decrease the frequency and severity of PID. Users of intrauterine devices have increased risk of developing PID, particularly during the first four months following insertion, and this risk varies by geographic area; Africa has the highest rates of all the world's regions (Farley et al., 1992).
Behavioral risk factors for STDs include sexual and health-seeking behavior. Because men tend to have more partners and engage in riskier sexual behavior than women, women's risk for STDs, including HIV infection, is more closely related to their husbands' sexual behavior than their own. Nonsexual transmission of STD pathogens present in the blood—such as HIV, treponemes (which cause syphilis), and hepatitis B virus—may be a concern for health workers, particularly for midwives and traditional birth attendants, who are usually women and who frequently come into contact with abundant quantities of blood.
The lifelong impacts of STDs and their long-term sequelae are tremendous, and were described earlier. Obviously, the earlier in life those sequelae occur, the longer women have to bear their consequences. In addition, women may be more susceptible to such consequences, notably the psychological and social repercussions, in part because they are affected by HIV and other STDs at an earlier age than men.
Maturity and Senescence As people become older, their sexual activity often decreases as a result of physiologic changes and societal influences. During senescence, increased biological risk for STDs compensates for decreased behavioral risk.
The physiologic changes that occur in women include atrophic changes in the vagina, with thinning of the epithelium, reduced lubrication, and narrowing and shortening of the vaginal canal. A vagina that is dry can be injured more easily by penile penetration (Holmes, 1990; Mooradian and Greiff, 1990), placing a woman at greater risk for transmission of HIV infection and other STDs from an infectected partner.
Sexual behavior at older ages is determined by sexual interest, which is influenced, in turn, by the hormonal environment and sociocultural factors. The level of sexual activity among older people, particularly women, varies greatly across cultures. While sexual activity is socially acceptable or desirable for older men, it may not be so for older women. In Sub-Saharan Africa, for example, the limited available evidence suggests that many women cease to be sexually active at menopause.
A different, yet major aspect of the burden of the HIV epidemic on women, including older women, is the care of the sick. Indeed, it is women who—as health care workers, community members, or family members—provide most of the care for people with chronic illnesses, including HIV infection and AIDS (Richardson, 1989).
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MAGNITUDE OF THE PROBLEM
Morbidity
This section provides general information on the extent of the problem of sexually transmitted diseases, including HIV infection, in Sub-Saharan Africa and estimates the prevalence of five common STDs across the countries of the region.
There are noteworthy differences in the magnitude of the STD burden between the industrialized and the developing countries. First, sexually transmitted diseases including HIV infection are much more prevalent in most developing countries, particularly in Sub-Saharan Africa, than in the majority of industrialized countries. Second, developing countries, again particularly those in Sub-Saharan Africa, have a higher incidence of complications of STDs than industrialized countries experience, and these complications are often more severe. Third, different kinds of STDs predominate in developing and industrialized countries. For example, the proportion of STDs characterized by genital ulcers is greater in developing countries than in industrialized countries; in Sub-Saharan Africa, chancroid and syphilis account for the majority of genital ulcers, while in industrialized countries, herpes is the main cause of those lesions (Meheus et al., 1990). Finally, while in industrialized countries HIV infection is often transmitted through homosexual contact and injecting drug use, and affects predominantly males, in Sub-Saharan Africa, HIV infection is almost exclusively transmitted heterosexually and affects both women and men equally, except for substantial mother-to-child transmission.
The following statistics highlight the severity of the problem in Sub-Saharan Africa.
STDs are among the top five reasons for clinic attendance in many Sub-Saharan African countries (Meheus, 1990). For example, STDs account for 13 percent of adult outpatient visits in Zimbabwe (Zimbabwe, 1989), and for 5 to 10 percent of outpatient visits in Zambia (Hira et al., 1992b). In some countries, PID is the most common diagnosis among women attending STD clinics. In Zimbabwe, 47 percent of women attending an STD clinic had a pelvic inflammatory disease (Latif, 1981), and in Ethiopia at least 39 percent of gynecological outpatients had signs or symptoms suggestive of PID (Perine et al., 1980). Even though many women with PID are never diagnosed and the majority are not hospitalized (Carty et al., 1972), it is one of the leading causes of gynecological admission (Brown and Cruickshank, 1976; De Muylder, 1989; Perine et al., 1980; Ratnam et al., 1980b; Zacarias and Aral, 1985).
In many countries of Sub-Saharan Africa, where the prevalence of syphilis among pregnant women is at least 10 percent, Schulz and colleagues estimate that 5 to 8 percent of all pregnancies that last beyond 12 weeks will fail to produce a healthy infant because of congenital syphilis, or syphilis-related fetal death or infant death (Schulz et al., 1987).
In some Sub-Saharan African countries—for example, Cameroon, Ethiopia, and Kenya—as many as 4 to 6 percent of newborn babies develop gonococcal ophthalmia, a condition that, untreated, leads to blindness (Galega et al., 1984; Lepage and Van de Perre, 1988a; Muhe and Tafari, 1986).
In Sub-Saharan Africa, HIV infection has not only reached high levels of prevalence—overall, affecting one in 40 adults, and in certain cities as many as 30 percent of pregnant women (see Appendix, Table 11-8)—but is also rapidly spreading, particularly in urban areas and among selected subgroups, such as prostitutes (Nkowame, 1991).
In several African cities, AIDS is the leading cause of death among young women and men.
Prevalence
Estimates of the prevalence of HIV infection and other STDs among women in Sub-Saharan Africa must be made cautiously. Although more information on STDs is available in Sub-Saharan Africa than in other parts of the developing world, the quantity, quality, and heterogeneity of data across countries and populations limit the ability to precisely define the extent of STD morbidity in the region. There is virtually no surveillance system in Sub-Saharan
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APPENDIX
TABLE 11-6 Genital Discharge Syndrome
Country
Year
Population
N
Ref.
GC
CT
TV
Low-risk population
Cameroon
1977
PP
296
87
14
1980
AN (asymptomatic)
110
180
14
15
1980
FP (asymptomatic)
53
180
2
8
1980
PP (asymptomatic)
296
180
10
1986a
AN
234
9
Central African Republic
1980
AN
268
10
Ethiopia
1973–75
PP (asymptomatic)
200
209
9
Gabon
1981
AN
530
270
6
1988
PP (asymptomatic)
598
137
10
1987–89
AN
2,305
82
19
Gambia, The
1982
AN
87
145
7
7
1982
AN (asymptomatic)
100
144
7
7
32
Ghana
1983
AN
213
3
1988a
AN (asymptomatic)
110
74
4
Kenya
1973
FP
200
111
18
26
1981
AN
54
188
0
6
1981
FP
57
188
17
4
1984
PP
728
131
7
23
1984
PP
845
212
7
21
1985
PP
175
99
4
17
1985–86
PP
2,732
127
6
9
1985–87
Trachoma area
168
35
4
1988–89
AN
549
161
3
2
1990
AN
269
242
7
1990
FP
80
6
11
1992
AN
5,674
178
10
Malawi
1973
AN
100
162
19
1990
AN
6,483
57
5
3
32
Nigeria
1971
AN
208
203
3
21
1971–75
Gyn (IUD users)
282
256
5
27
1971–75
Asymptomatic housewife
130
256
5
15
1983–85
FP
500
196
4
1988
AN
80
253
11
1988
Infertile
20
253
15
1989a
FP
150
189
0–8
0–8
1989a
No FP
50
189
6
4
1989a
AN
46
6
6
1991a
AN (rural)
250
195
25
1991a
AN (urban)
250
195
38
Rwanda
1987
AN + FP
199
236
5
1987
AN + FP
198
236
16
Senegal
1983
AN
213
19
1987
AN
236
176
2
1990
511
93
30
Senegal
1987
AN
200
68
2
7
1989–92
AN
781
227
1
8
16
Somalia
1987
All village
200
115
0
18
South Africa
1980a
AN
105
110
10
23
1980a
AN
80
110
90
1981
AN (asymptomatic)
1,200
260
11
1983
AN
213
10
1986
AN
88
12
13
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa
Country
Year
Population
N
Ref.
GC
CT
TV
Low-risk population
South Africa
1986a
AN
231
14
1
1986a
FP
62
14
16
1987
AN
193
193
6
11
49
1991a
AN (white, high SES)
41
261
7
1992a
AN (asymptomatic)
170
72
4
5
1992a
AN
206
249
7
11
Swaziland
1973
OPD (all women)
179
39
29
1973
AN
215
39
50
1978
AN
51
167
4
23
1978
FP
52
167
2
15
Tanzania
1978
FP (asymptomatic)
341
147
8
1983
AN
213
8
1986a
AN
69
6
1991–92
AN
2,009
237
5
14
Uganda
1971–72
Community (Ankole)
168
9
2
1971–72
Community (Teso)
295
9
22
1980
Low fertil. district
336
10
18
1980
High fertil. district
246
10
2
1992a
AN
450
101
1
7
43
Zaire
1985
AN
208
64
2
4
1988
AN
101
17
9
1990
AN
701
142
2
6
17
1991
AN
1,875
174
1
5
16
Zambia
1977a
AN
218
102
39
1979
AN (asymptomatic)
161
216
11
Zimbabwe
1976
AN
50
259
2
1976
FP
100
259
12
1983
AN
199
154
31
1986–87
PP (asymptomatic)
111
155
5
6
14
High-risk population
Cameroon
1980
AN (symptomatic)
610
180
15
21
1980
FP (symptomatic)
81
180
21
7
1980
PP (symptomatic)
42
180
21
2
Côte d'Ivoire
1986a
Symptoms
73
10
Ethiopia
1973–75
PP (puerperal sepsis)
67
209
28
1973–75
PID (outpatient)
100
209
19
1973–75
PID (hospital)
46
209
15
Gabon
1980–82
Symptomatic (vaginal D/C)
261
270
15
23
1988a
Symptomatic (vaginal D/C)
252
137
18
1988a
Symptomatic (LAP)
265
137
14
Gambia, The
1982
Gyn (symptomatic)
23
145
14
Ghana
1985
Gyn
162
20
3
5
1985
Gyn (LAP)
40
20
0
10
1985
PP (hospitalized)
148
20
3
1985
PP (hospitalized)
39
20
8
Kenya
1981
STD (symptomatic)
58
188
23
7
1982
STD (vaginal D/C)
122
171
26
34
1982
STD (vaginal D/C)
58
171
7
1985
PP (preterm)
166
99
11
13
1992
STD
80
4
11
1992
STD+FP
212
80
11
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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa
Country
Year
Population
N
Ref.
GC
CT
TV
High-risk population
Malawi
1992
STD
505
58
15
26
1992
STD
175
58
5
1990
STD
255
57
25
36
Nigeria
1971–75
Gyn (symptomatic)
228
256
17
19
1977–81
STD
435
19
13
11
1988a
Gyn
120
114
15
Senegal
1990
Gyn
250
68
4
8
1989–92
Gyn
795
227
2
8
16
South Africa
1980
STD
135
19
13
1980a
AN (symptomatic)
127
110
9
31
1980a
Gyn
100
252
11
1986a
STD
135
14
13
Sudan
1976
Gyn (symptomatic)
147
224
1
12
1977
STD (symptomatic)
613
199
7
20
1976–78
STD (vaginal D/C)
132
200
4
1976–78
STD (vaginal D/C)
144
200
1976–78
STD (vaginal D/C)
114
200
20
1985a
STD
404
201
8
1985a
STD
613
199
20
Zambia
1977a
Gyn
518
102
31
1979
STD (nonpregnant)
1,000
216
19
1979
STD (pregnant)
170
216
23
1979
PID (hospitalized)
100
216
46
Zimbabwe
1976
Gyn
118
259
11
1979–80
STD
234
200
23
1982
STD (pregnant)
160
133
26
38
1983
STD
156
154
37
1986–87
PP (puerperal sepsis)
95
155
19
16
12
1990a
STD
100
153
19
8
32
Very-high-risk population
Burkina Faso
1990
CSW
127
59
20
17
Cameroon
1991a
CSW
168
122
39
Côte d'Ivoire
1988a
CSW
228
65
Ethiopia
1991a
CSW
282
90
30
24
1992
CSW
46
28
30
6
Kenya
1981
CSW (upper SES)
60
16
1981
CSW (middle SES)
60
28
1981
CSW (lower SES)
60
46
Madagascar
1987
CSW
298
175
39
1987
CSW
40
175
18
Malawi
1990
CSW (STD)
274
57
29
27
Senegal
1989–92
CSW
397
227
13
17
18
1989–92
CSW
653
70
16
14
24
Somalia
1990a
CSW
89
38
11
Tanzania
1991a
CSW
106
185
51
1991a
CSW
47
185
25
1992a
CSW
70
156
Zaire
1989a
CSW
801
130
23
14
22
NOTE: GC, gonorrhea; CT, chlamydia; TV, trichomoniasis; AN, antenatal; PP, postpartum; FP, family planning; LAP, lower abdominal pain; D/C, discharge; CSW, commercial sex worker; SES, socioeconomic status.
a No study date.
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TABLE 11-7 Syphilis
Country
Year
Population
N
Ref.
Non-T
Trep
Non-T + Trep
GUD
Low-risk population
Botswana
1985–87
AN
113
238
17
3
Burkina Faso
1973a
Village (Karba)
208
217
18
1973a
Village (Dedougo)
239
217
32
1973a
Village (Moko)
133
217
8
Cameroon
1989–90
AN
544
184
16
1990a
AN
608
272
24
1990a
AN
900
121
10
Central African Republic
1980
AN
268
10
Ethiopia
1974–75
AN
2,717
208
18
17
1977a
AN
337
86
13
11
11
1990a
AN
1,719
240
7
1992a
AN
100
83
9
Gabon
1983
AN
527
165
12
1984
AN
715
165
13
1985
AN
623
165
14
1986
Urban
211
77
15
1987
Semi-rural
277
77
9
Gambia, The
1986a
AN (rural)
100
143
15
11
1986a
AN
238
143
26
13
1982
AN (urban)
100
144
9
1
1
Kenya
1984
PP
1,013
131
11
4
1985
PP
133
99
5