STI/HIV Synergies and Implications for Sexual Health Globally
A lot of progress has been made in recognizing sexual health as a human right in the past twenty years, but social stigma remains a barrier to screening and treatment for sexually transmitted infections (STIs) even with substantial resources to improve service provision. STIs are of major public health importance as a top contributor to avoidable mortality in women worldwide just after maternal mortality and morbidity (Bosu, 1999). Globally, increased attention has been brought to reducing rates of HIV incidence to address rising rates of maternal mortality. However, other STIs, which contribute just as significantly to maternal mortality, have been neglected in the global conversation on STI preventative programming primarily due to stigmatization of these diseases and moral opposition to their primary prevention measures in many societies (Low et al., 2006). Gender and sex differences as they impact experiences of receiving healthcare and education on STIs also prevent timely treatment. Here, I hope to reflect on the history of sexual health and human rights frameworks’ myopic focus on HIV as it has impacted STI prevention efforts globally and how gender constructs and stigma have created barriers to early STI detection and treatment, and based on these factors, propose future directions for the prevention and treatment of STIs.
Changing global attitudes towards infections of the reproductive tract have been reflected in the evolution of definitions of sexual health and rights to health, which have shaped approaches to STI treatment and prevention over time. One of the first milestones in addressing sexual and reproductive health issues on a global scale was the development of the Millenium Development Goals (MDGs) in 2000, goals agreed upon at the Millenium Summit by world leaders gathered at the United Nations Headquarters in New York (United Nations, 2020). The MDGs were time-bound goals with benchmark targets to reach by 2015 to reduce extreme poverty globally (United Nations, 2020). These goals, while calling attention to issues which may be caused by poor sexual health such as stopping the spread of HIV, improving maternal health, and promoting gender equality, were still lacking in that they did not identify sexual health as a primary area of focus (Haslegrave & Bernstein, 2005). It was not until the adoption of the Sustainable Development Goals (SDGs) by the United Nations in 2015 that sexual health was defined and made a priority within the scope of human rights (Heidari, 2015). In the SDGs, sexual health was given a more broad definition to include a “pleasurable, fulfilling, and safe sexual life,” establishing the lack of resources to do so as a human rights violation (Heidari, 2015). This was an incredibly progressive definition, especially for more conservative member states.
Reviewing current literature on STI prevention and treatment globally as it functions today, there is evidence that this history may have influenced how strategies and policies have developed. While HIV was named as a disease of focus in the MDGs, no other STIs were named, and subsequently lost focus for investment, including genital human papillomavirus (HPV) (Low et al., 2006). Today, interventions targeting prevention of other STIs are agreed upon as low-cost, effective strategies for improving population health, but only as a means for preventing HIV transmission, framing their importance only in relation to HIV (Low et al., 2006). This highlights how the MDGs may have skewed global prioritization of STI prevention, considering other sexual and reproductive tract infections are just as impactful to maternal morbidity, contribute to the spread of HIV, and reflect gender inequalities in their overall population burden.
The global reluctance to address other sexual and reproductive tract infections is reflected in current misunderstandings of the prevalence of HPV infections. In the United States, HPV is the most common sexually transmitted virus, yet its prevalence and long term consequences are largely misunderstood as demonstrated by CDC focus group studies (Friedman & Shepeard, 2007). In these focus groups, participants did not identify STIs as being of major concern, except for HIV/AIDS. Upon learning of the high prevalence and long term consequences of HPV, participants demonstrated a desire for information regarding prevention, but still identified stigma as a concern in seeking treatment (Friedman & Shepeard, 2007). It is possible that the neglect of the MDGs to evenly prioritize all STIs as being of public health concern and the delay in establishing sexual health as a human right until only recently has contributed to the lack of accurate risk assessment in the general population. Many governments are still reluctant to provide HIV-specific interventions to those most at risk (men who have sex with men, injection drug users, sex workers, etc.), but it is interesting to speculate the impact of this history on sexual health interventions in the United States and other Western nations.
Gaining an understanding of how sex and gender differences impact STI transmission, prevention, and treatment is critical to developing effective public health programming, but also to inform how these differences, when coupled with existing gender inequalities, have been greatly influential on global health priorities. From a biological standpoint, those with female reproductive anatomy are disproportionately affected by STIs in part because of the uniquely vulnerable squamocolumnar junction on the cervix (Low et al., 2007; Anderson, 2019). The high rate of cell division and metabolic activity make this tissue especially susceptible to infection, and in the case of HPV, can lead to development of cervical cancers. Additionally, many STIs remain asymptomatic in women until later stages of disease, when it may be too late to prevent irreversible damage, putting those with a cervix at higher risk for developing serious complications (Low et al., 2006). Adding to these inherent vulnerabilities are the cultural and social forces which both cause higher rates of incidence of infection and prevent women from detecting infections early on. Structurally, women may not be permitted to receive medical care without a family member or partner’s permission. They are less likely to visit health centers and transportation factors have a greater impact on their ability to seek treatment than for men (Vlassoff & Moreno, 2002). Additionally, women are differentially impacted by social stigma surrounding sexual and reproductive tract infections. Women who can seek treatment may be blamed for infection due to sexual promiscuity, face isolation, and are at greater risk of intimate partner violence (Low et al., 2006; Friedman & Shepeard, 2007). This stigma is also preventative of making STIs other than HIV, which may disproportionately impact women, a priority in health programming and development. These factors are all important to consider when developing programs to treat infections earlier, as they create substantial barriers to health equity.
While the primary focus of this discussion on gender and health has highlighted the ways in which women’s health is impacted by gender differences, gendered discussions of health have a negative impact on all members of a given society. Being that men are the primary transmitters of STIs, adequate consideration must be given to their sexual health care. While men tend to seek sexual health treatment, it is often in the private sector when they do (Low et al., 2007). This is not regulated in terms of public health intervention measures making it difficult to target them for prevention-based or educational initiatives (Low et al., 2007). Reflecting on past studies of gendered health-seeking behaviors, ideals of hegemonic masculinity affect health-seeking behaviors when looking at men’s sexual health. As discussed in a lecture given by Dr. Halley Crissman on gender and health, hegemonic masculinity is defined against positive health behaviors, prompting men to forego treatment for health issues out of fear of appearing “weak” (Crissman, 2019). Is this a prevalent factor contributing to men being the primary transmission agents of STIs? This dynamic could be informative for health education efforts, as in situations where health is threatened, men tend to fear losing sexual functioning more than they fear social stigmatization as compared to women, providing evidence that interventions may need to be differentially framed for the best effectiveness (Vlassoff & Moreno, 2002).
Taking into account the current state of sexual health in human rights considerations and gender dynamics in diverse populations, certain interventions can be ruled out as ineffective strategies, while others stand out as being particularly attractive moving forward. This discussion will begin with syndromic management, or the practice of treating STIs based on their symptoms and determining treatment plans based on the organism most commonly responsible for producing the symptoms present (World Health Organization, 2005). While this may be an acceptable treatment model in the absence of other options, this approach is not a sustainable method of reducing STI prevalence for all populations. To begin with, it requires that symptoms be present for any kind of treatment. As alluded to previously, this does not permit early intervention for infections in biological females, as symptoms usually do not present until the infection is severe (Low et al., 2007; Bosu, 1999). This approach is also a poor predictor of STIs like chlamydia and gonorrhea due to lack of specificity, warranting large-scale misuse or overuse of resources (Low et al., 2007). To best decrease the prevalence of STIs, gender dynamics of the community must be taken into consideration in program development. For example, opportunistic screening may be an effective option over proactive screening if social stigma is widely influential in seeking testing and treatment. Opportunistic screening integrates STI testing as an option during other medical consultations, not necessarily related to or prompted by a suspicion of infection (National Screening Unit, 2014). Making this practice routine may help alleviate concerns that testing is done only on individuals who are deemed high risk by medical professionals, which tend to be the same populations at highest risk for stigmatization (Low et al., 2007). An additional recommendation to improve the specific testing of STIs in women is more widespread development and implementation of rapid point-of-care tests. Tests that are quick, accurate, and specific would greatly impact women’s sexual health care in diverse settings by providing a quick diagnosis that would prompt treatment and not require returning to the health center at which it is administered (Low et al., 2007). This takes into account barriers due to transportation and could be administered using the same opportunistic screening approach, removing the need for symptoms to present or to be labeled as “high-risk”.
STIs are a pressing public health issue globally and continue to be due to societal reluctance to adequately address them as a problem, human rights frameworks which do not specify the need for specific sexual health promotion with regards to STIs, and issues of gender inequities which put women at a disadvantage for good sexual health. Future interventions must work to incorporate gender considerations specific to the communities where the program will be implemented. To achieve equitable sexual health globally, it will be necessary that specific goals are set with regards to STI prevention for the benefit that comprehensive education and healthy sexual lives can bring to a population.
Anderson, F. (2019, November). Ann Arbor, MI.
Bosu, W. K. (1999). Syndromic management of sexually transmitted diseases: is it rational or scientific?. Tropical Medicine & International Health, 4(2), 114-119.
Crissman, H. (2019, October). Ann Arbor, MI.
Friedman, A. L., & Shepeard, H. (2007). Exploring the knowledge, attitudes, beliefs, and communication preferences of the general public regarding HPV: findings from CDC focus group research and implications for practice. Health Education & Behavior, 34(3), 471-485.
Haslegrave, M., & Bernstein, S. (2005). ICPD goals: Essential to the millennium development goals. Reproductive Health Matters, 13(25), 106-108.
Heidari, S. (2015). Sexual rights and bodily integrity as human rights.
Low, N., Broutet, N., Adu-Sarkodie, Y., Barton, P., Hossain, M., & Hawkes, S. (2006). Global control of sexually transmitted infections. The Lancet, 368(9551), 2001-2016.
National Screening Unit. (2014, December 5). Organised and opportunistic screening. Retrieved November 05, 2020, from https://www.nsu.govt.nz/about-us-national-screening-unit/what-screening/organised-and-opportunistic-screening
United Nations. (2020). United Nations Millennium Development Goals. Retrieved November 05, 2020, from https://www.un.org/millenniumgoals/bkgd.shtml
Vlassoff, C., & Moreno, C. G. (2002). Placing gender at the centre of health programming: challenges and limitations. Social science & medicine, 54(11), 1713-1723.
World Health Organization. (2005). Sexually transmitted and other reproductive tract infections: A guide to essential practice. Geneva: World Health Organization.