Background Information to Lesson 10

Protect yourself: STIs and HIV/AIDS

1.Introduction

The majority of young people worldwide are sexually experienced by the age of twenty[1]. Many youngsters abstain from sex or sexual intercourse, but a great part of them cannot or do not want to wait until marriage before they engage in sexual activity. If both partners feel ready for sex and practise it in a healthy, safe and consensual way, sex can be a satisfactory and pleasant part of a relationship. Unfortunately, sex can have negative consequences if it is unprotected, coerced or forced. Unsafe sex can result in unintended pregnancies (see the Background Information to Lesson ------) or it can cause the transmission of Sexually Transmitted Infections (STI), including HIV/AIDS. Practicing safe and protected sex can prevent both pregnancy and STIs. To decide on these measures, young people need adequate information and skills to choose one of the ABC methods (Abstinence, Be faithful and use Condoms) that suit their lifestyles.

The WHO estimated that, worldwide, nearly 340 million new cases of sexually transmitted infections occur each year, of which one-third in people under 25[2]. Worldwide, one in twenty adolescents contract a sexually transmitted infection each year, and half of all new HIV infections each year occur among young people[3]. While most STIs are treatable, many are undiagnosed and go untreated due to fear of stigmatisation or lack of accessible services (youth friendly services) for young people. Untreated STIs can have severe consequences. They are an important cause of infertility.[4] In addition, STIs that go untreated can increase the risk of HIV infection and transmission by up to ten times.[5]The largest of the new cases of HIV infection each day, worldwide, are sexually transmitted.[6]

2.STIs in Ethiopia

Sexually Transmitted Infections

Sexually transmitted infections (STIs) remain a major public health problem in Ethiopia. Stigma is associated with sexually transmitted infections, which discourages clients from seeking timely and appropriate care.

Available data[7] show that even though rates of STIs remain much higher in high risk groups such as commercial sex workers and urban populations the infections are also quite prevalent among women in what would be seen as low risk groups including antenatal and women seeking family planning services

In such Family planning clinics, rates for gonorrhoea, Chlamydia and syphilis were recorded high. With continued unprotected sexual relations among young people, the risk and the spread of STIs remains potentially high.

3.What are STIs and how are they transmitted?

Sexually Transmitted Infections (STIs) are infections that can be passed on from one person to another by way of sexual contact. Previously, they were also called venereal diseases (VD) or sexually transmitted diseases (STDs). STIs can be caused by parasites, bacteria, fungal infections and viruses. Most STIs can be cured if diagnosed and treated in time, with the exception of viral infections. Viral infections may not be lethal – only HIV/AIDS, Hepatitis B and C may be lethal if untreated – but the virus causing the disease will stay present in the body, causing the symptoms of the infection to return. This means that treatment of symptoms of viral STIs is possible, but there is no cure yet. Hepatitis B and C, for that matter, do not always develop into chronic diseases, and a percentage of patients clear the virus spontaneously or after treatment.

The most common STIs caused by parasites are public lice, scabies and trichomonas. The most common bacterial STIs are Chlamydia, gonorrhoea and syphilis. Hepatitis, herpes and warts (papiloma virus) are the most common viral STIs, and HIV is the best known viral STI. HIV will be dealt with separately in this Background Information section and is also discussed in the Background Information to Lesson ------, because of its high prevalence among young people and its more severe consequences.

Candidacies, a fungal infection, is a very common and quite harmless vaginal infection. It can be compared with the common cold: if a person’s resistance is low, such an infection can occur. Candidacies, therefore, is not necessarily a sexually transmitted infection though its similar symptoms can easily be confused with those of STIs. It is estimated that 75% of women has the symptoms of candidacies at least once in their lives[8].

Types and symptoms of STIs:You cannot tell from the outside whether someone has an STI or HIV. STIs often do not present symptoms. Someone may be infected without having symptoms for months or years; or the symptoms can be very mild and disappear by themselves after a few days. This does not mean STIs need not be treated. In general, if there are any symptoms, they include: unusual smelly or coloured vaginal fluid; pus coming from the penis or, in the case of anal sex, from the anus; or sores, itching, blisters or warts in the genital area or anus[9]. The infected person can also experience pain when urinating or during sexual activities.

If untreated, more serious STIs can result in infections in the abdomen, causing abdominal pain and possibly fever. Chlamydia often does not show any symptoms at all but can damage the tubes and cause infertility. Not all symptoms will occur in the genital or anal area: warts and blisters sometimes occur in other parts of the body. Symptoms of candidacies, not necessarily sexually transmitted, may be similar to other STIs: itching and burning. If someone suspects he/she may have contracted an STI or if there are symptoms, it is important to seek medical advice at a clinic immediately. More information about each particular STI can be found in Annex 1.

HIV/AIDS: HIV is an STI. HIV stands for Human Immunodeficiency Virus and is the cause of AIDS. The virus damages the cells of the immune system of the person it lives in. The immune system is a group of cells and organs that protect the body by fighting viruses and infections. The body's immune system usually finds and kills viruses quickly. The HIV virus, however, attacks the immune system itself, limiting the body’s capacity to fight infections. The body becomes increasingly vulnerable, not just to the HIV virus, but also to other viruses. Over time, an infected person becomes ill more frequently and more severely. At that point, a person has developed AIDS, the Acquired Immune Deficiency Syndrome[10].

The difference between HIV and AIDS: HIV is the virus that causes AIDS. Some first symptoms of an HIV infection may be noted, such as a flu-like illness. These symptoms may disappear without the HIV-infected person noticing them.

AIDS, on the other hand, is the name of the syndrome that arises once the symptoms of one or more diseases are becoming manifest. A simple boil or wart may spread all over the body. The mouth may be infected with thrush (a thick white coating). People may develop severe shingles (painful blisters in a band of red skin), or herpes. They may feel very tired all the time, run high temperatures, have drenching night sweats, lose more than 10% of their body weight and have diarrhoea for more than a month. When no other cause is found, a blood test will usually indicate infection with HIV. People with AIDS may also suffer from infection of the lungs, Tuberculosis, infections of the nervous system, skin cancer, et cetera. At this stage, AIDS has fully developed as a syndrome.

Window period:Someone who has been infected with HIV may still be a healthy-looking person. People who have been infected are called HIV positive, meaning that antibodies against HIV can be found in their blood, while HIV virus has not yet attacked most white blood cells and they may feel healthy. After HIV infection has taken place, people start producing antibodies against the HIV virus, mostly within about twelve weeks. As an HIV test is unable to detect the HIV viruses themselves but only the antibodies against the HIV virus, an HIV test can only show a reliable result after these twelve weeks. The process of the blood test changing from negative to positive is called ‘sero-conversion’. The time between infection (when the virus is present in the blood) and sero-conversion (when anti-bodies against the virus can be demonstrated in the blood) is called the ‘window period’. In this window period, when an HIV test will still be negative, there are a lot of HIV viruses in the blood, and this person is highly infectious.

After a certain time, all HIV-infected people will develop AIDS. However, the time between HIV infection and the onset of AIDS varies. Some HIV-positive people may live a long time after they get infected, even up to 15 years or more, without getting any symptoms of AIDS, whereas other people may show symptoms within some months or years. There is no answer to the question how long someone with HIV can continue to live. The number of years an infected person will survive, depends on many factors. For example, it depends on the immune system itself, his or her diet, the number of viruses in the body, whether other diseases are treated fully and immediately whenever they occur and whether he or she takes specific drugs for HIV.

Ways of STI transmission:STIs are transmitted in various ways. All STIs can be transmitted through unprotected sexual contact, particularly sexual intercourse. Unprotected sex is called unsafe sex, that is, sex without proper use of a condom. Parasites can also be transmitted by sleeping in infected bedclothes, sharing clothes with someone who is infected or by intimate contact. Genital warts and herpes can be transmitted by sexual intercourse and by intimate bodily contact without having sexual intercourse. HIV and hepatitis can be transmitted sexually but also through blood contact, for example, when intravenous drug users share contaminated needles. In addition, HIV can be transmitted from mothers to their babies through pregnancy, labour, delivery or breastfeeding.[11]

Transmission of all STIs can be prevented by abstaining from sexual, vaginal and anal intercourse and/or by using a condom during all sexual intercourse. There is a risk of contracting STIs via oral sex, but this is quite low, and is even lower for HIV transmission (see below: prevention of STIs).

Transmission of HIV:HIV is present in all bodily fluids. However, the concentration of HIV viruses in saliva, tears and sweat is too low to cause infection in a partner. Vaginal fluid is particularly infectious if menstruation blood is present. HIV is only transmitted through blood-blood contact and sperm-blood contact: HIV in infected people’s blood or sperm may enter the blood stream of their sexual partner through small bruises and scratches in and around the private parts. This is why STIs (which often show wounds on private parts) and rape (which is often accompanied by force and violence and usually involves unprotected intercourse) increase the risk of HIV infection.

If people share shaving blades or needles for drug injection with an HIV-infected person, this may involve blood-blood contact and HIV transmission. Traditional customs such as circumcision or body tattooing with non-sterilized blades or knives can spread HIV as well. Wife inheritance and wife sharing can contribute to the spread of HIV if unsafe sex is practised. Risky traditional customs, therefore, should be avoided to stop the spread of HIV.

4. Misconceptions about STIs and HIV

There are a lot of misconceptions about STIs and the spread of HIV. However, it is important for people to know the facts and the truth about STI infection, including HIV, to protect themselves and other people from getting infected. Below, we address some common misconceptions.

Misconception:If the male withdraws his penis before ejaculating, STIs and HIV cannot be transmitted.

Truth:many viruses and bacteria can be present in vaginal fluids; HIV may be present in the woman’s menstrual blood or the man’s pre-cum fluids. STIs can be transmitted easily. HIV/AIDS can also be transmitted if one of the lovers has sores or small cuts in or on his or her sexual organs (usually caused by an STI). Withdrawing the penis from the vagina or anus before ejaculation, therefore, is not a way of preventing the transmission of STIs and HIV.

Misconception:oral sex is safe sex.

Truth:STIs can be transmitted during oral sex. However, the risk of HIV transmission is low. For HIV transmission to take place, there needs to be blood-blood or blood-sperm contact. Oral HIV infection can only take place, therefore, if partners have cuts or wounds in their mouths or if infected sperm or vaginal fluid with menstrual blood comes into contact with cuts or wounds in the mouths or genitals of their sexual partners. If people are really concerned about STI and HIV transmission during oral sex, they can decide to use a condom when they have oral sex. In any case, sperm or vaginal fluid during menstruation should be prevented from entering the mouth.

Misconception:kissing can transmit STIs, including HIV.

Truth:Kissing will not cause an infection, neither with STIs nor with HIV. In case of deep kissing or French kissing, the probability of getting an STI or HIV is very small. Exchanging saliva during kissing alone does not cause STI or HIV infection. Transmission is possible, however, if both partners have small wounds or cuts in their mouths, which would involve blood-blood contact.

Misconception:safe sex means using any method of contraception, for example, contraceptive pills.

Truth:Contraceptive pills prevent pregnancy but do not protect against STIs and HIV infection. Only condoms protect people against both pregnancy and STIs, including HIV.

Misconception:Having sex with a virgin cures HIV infection or AIDS.

Truth:HIV and AIDS cannot be cured. HIV infection is caused by having unprotected sexual intercourse with anyone who is already carrying HIV, as sexual intercourse involves exchanging risky body fluids such as seminal fluid and vaginal fluid that may contain menstrual blood. Having unprotected sex with a virgin puts this girl at risk of HIV infection, especially when very young girls are involved and if they are forced into having sex.

Misconception: Being married protects against STIs or HIV.

Truth:One of the partners may have been infected before or outside marriage and can transmit this infection to their spouse. Only a test for STIs and HIV can tell whether either one of the partners has been infected or not. Marriage will only protect against STIs and HIV when both partners have been tested negative and are completely faithful to one another.

4.High-risk situations and behaviours

STI and HIV transmission may happen to anyone who practises unsafe sex, that is, sexualintercourse without using a condom. There are several situations and behaviours that increase the risk of STI or HIV transmission through unprotected sexual intercourse. These include:[12]

-Unprotected sexual intercourse due to lack of adequate knowledge about STIs and HIV; or misconceptions, for example, the mistaken idea that sexual intercourse can cure an STI; or the idea that the STI has been cured when the symptoms disappear.

-Unprotected sexual intercourse due to lack of negotiation skills. In a social sense, young girls are more vulnerable to STI transmission because they often lack skills in negotiating safe sex. In a biological sense, young girls are more vulnerable to infections with STIs or HIV than boys and adult women because the mucous cells of the vagina and cervix are not yet fully developed and thinner, providing a less effective barrier to viruses.

-Unprotected sexual intercourse because young men and women may find it difficult to use condoms. They may feel too embarrassed to purchase or ask for condoms, to have condoms with them, to talk about condom use before having sexual intercourse and to use condoms correctly and consistently. This may be more difficult for girls than for boys. However, having condoms available whenever they have sexual intercourse is a responsibility for both girls and boys.

-Unprotected sexual intercourse after discontinued treatment of STIs. People often stop the treatment of a disease as soon as the symptoms disappear, before confirming that the STI has actually been cured. If they then have unprotected sex, they may transmit the STI while also being more vulnerable to HIV infection. If they discontinue treatment too early, they may also build up resistance towards the antibiotics that can treat and cure STIs, which means that STIs will be more difficult to cure in future.