SEXUALLY TRANSMITTED INFECTIONS (STI)

MSF counsellor counselling patient on STI and HIV prevention in Bagratashen area of Armenia. © Ruben Mangasaryan

In countries where MSF works, the prevalence of sexually transmitted infections (STI) is very high. On a worldwide scale, the WHO estimates more than 340 million new cases of curable sexually transmitted infections each year for men and women aged between 15 and 49 years.

Women are more vulnerable to STIs than men. For social and physiological reasons women are more exposed to STIs than men. Diagnosis of STIs is also more complicated as in most women they are asymptomatic. In fact, around 70% of women with STIs present no symptoms at all (as opposed to only 10% of men). Furthermore, the consequences of STIs can be very serious for women, and sometimes fatal (cervical cancer, sterility, extra-uterine pregnancies, septicaemia). They can also be transmitted to the fetus resulting in miscarriages, stillbirths and neonatal deaths. Finally, genital tract infections are linked to increase risk of HIV transmission through the presence of an ulcer or discharge.

MSF’s APPROACH
In preventing and treating STIs MSF faces two major obstacles: stigma, which explains why patients hesitate to seek treatment and are reluctant to encourage their sexual partners to do the same; and diagnosis: the asymptomatic character of certain STIs and the absence of testing programmes or rapid, inexpensive diagnostic tests, leads to numerous people living with undetected, untreated infections which they continue to transmit.

MSF combines the diagnosis and effective treatment of sexually transmitted infections with information sessions including availability of testing for HIV, the promotion of condom use and an active partner tracing. Special attention is given to STIs in MSF’s prenatal consultations, family planning services and the framework of care offered to rape victims. When possible, diagnosis is confirmed by a laboratory test, however many of the currently available tests are not very sensitive or specific so they are not useful in the field. There are many new tests becoming available which will hopefully improve the management of infections in the field. Furthermore patients should be treated at their first encounter and not sent home to await results hence any tests need to give an immediate diagnosis. In the absence of rapidly available and reliable laboratory tests, the 'syndromic'* approach is used.
MSF tries to ensure that effective drugs are used and where possible a single dose regimen is preferred in order to improve compliance (it’s easier to take a single treatment than a course over several days).

*In syndromic approach – patients with a consistent group of signs and symptoms are treated according to the most likely causative pathogens.

THE FEMINISATION OF HIV/AIDS
AIDS affects increasing numbers of women and girls. According to WHOAIDS, the HIV/AIDS infection rate is constantly on the rise in women. In Africa, women represent 59% of adults living with the AIDS virus and three quarters of HIV positive women live in Sub-Saharan Africa. On a worldwide scale, 17.3 million women aged 15 years or more live with HIV, making up 48% of the world’s total. In Asia, Eastern Europe and Latin America, there is a growing number of women and girls living with HIV/AIDS.

The inequality between the sexes and the low status of women in certain societies has contributed to the feminization of this pandemic. In the field, MSF teams see how women are more vulnerable to the virus for biological, social and economic reasons.

"To start with, it should be noted that biologically, women are more at risk of being contaminated by the virus than men during unsafe sex," points out Line Arnould, the AIDS technical advisor within MSF’s medical department.

Over and above these biological factors, other inequalities make women more vulnerable to HIV, from prevention through to treatment, with the impact of contamination bearing heavier consequences.

Social and cultural norms can make it difficult for many women to take preventative measures. "In most of the contexts where we work, condoms remain a means of prevention chosen and used by men," Line Arnould reminds us. "Women rarely have the power to impose their use." Sexual violence, of which numerous women are victims, further increases women’s vulnerability to HIV/AIDS.

Through its AIDS programmes, MSF has observed how women fear revealing their status, or having their status revealed without their consent, exposing them to the risk of stigma, discrimination or loss of financial support from their husband, family or community. They therefore avoid HIV services, including critical programmes limiting the transmission of the virus from mother to newborn child.

Although it seems women have the same access to anti-retroviral treatment as men, their reluctance to disclose their status is often an obstacle to follow up treatment. Our teams hear of numerous cases of women who do not dare reveal their status to their partners through fear of being rejected and abandoned, and losing the economic support they depend on for their own survival and that of their family.

MSF has witnessed how women whose partners die of AIDS suffer discrimination, rejection and violence, because they are also suspected of carrying the virus. The precariousness of these women’s situation obliges them to turn to means of survival which, in the case of prostitution for example, may increase the risk of contracting HIV.

Women are also the principal carers for families and community members suffering from HIV/AIDS and diseases associated with HIV/AIDS, even though they may be infected themselves.

MSF’s APPROACH
MSF has developed HIV/AIDS activities and projects in over 30 countries, and so far more than 100,000 patients are receiving antiretroviral treatment (ARVs) – July 2007. At present, around 60% of patients receiving ARVs in our programmes are women. "The majority of our programmes are located in sub-Saharan Africa where the epidemic affects women more than men. The large number of women under treatment in MSF projects reflects this," explains Line Arnould.

Most programmes supported by MSF include a component limiting the virus’ transmission from the mother to the child during pregnancy (Prevention of Mother to Child Transmission). This component is either offered by MSF or women are referred to existing programmes elsewhere.
Through its prenatal consultations, MSF offers HIV testing to all pregnant women and, for those found positive, will provide treatment for the mother (where required for her disease) or treatment to prevent the disease being transmitted to her child (if she is currently healthy). This type of programme is critical given that without such intervention there is up to a 40% risk of the mother transmitting the virus to her child.

For MSF, women’s access to this type of programme constitutes a major challenge. "The implementation of mother-child transmission programmes represents a real operational challenge," explains Line Arould. "This includes the complexity of protocols, the lack of qualified staff, and women’s access to pre and post natal care allowing us to supply them with the medicines and information necessary to prevent the transmission of the virus from mother to child."

In some programmes, MSF tries to encourage the use of female condoms as an alternative to male condoms. For women whose partners do not wish to, or cannot, use the male condom, the female condom constitutes the only method of preventing HIV that depends entirely on women.

Women's Health index