Overview

More than 30 different bacteria, viruses and parasites are known to be transmitted through sexual contact, including
vaginal, anal and oral sex. Some STIs can also be transmitted from mother-to-child during pregnancy, childbirth and
breastfeeding. Eight pathogens are linked to the greatest incidence of STIs. Of these, 4 are currently curable: syphilis,
gonorrhoea, chlamydia and trichomoniasis. The other 4 are incurable viral infections: hepatitis B, herpes simplex virus
(HSV), HIV and human papillomavirus (HPV).

In addition, emerging outbreaks of new infections that can be acquired by sexual contact such as
monkeypox, Shigella sonnei, Neisseria meningitidis, Ebola and Zika, as well as re-emergence of neglected STIs such as
lymphogranuloma venereum. These herald increasing challenges in the provision of adequate services for STIs prevention
and control.

Scope of the problem

STIs have a profound impact on sexual and reproductive health worldwide.

More than 1 million STIs are acquired every day. In 2020, WHO estimated 374 million new infections with 1 of 4
STIs: chlamydia (129 million), gonorrhoea (82 million), syphilis (7.1 million) and trichomoniasis (156 million). More than
490 million people were estimated to be living with genital herpes in 2016, and an estimated 300 million women have an
HPV infection, the primary cause of cervical cancer and anal cancer among men who have sex with men. An estimated
296 million people are living with chronic hepatitis B globally.

STIs can have serious consequences beyond the immediate impact of the infection itself.

 STIs like herpes, gonorrhoea and syphilis can increase the risk of HIV acquisition.
 Mother-to-child transmission of STIs can result in stillbirth, neonatal death, low-birth weight and prematurity, sepsis,
neonatal conjunctivitis and congenital deformities.
 HPV infection causes cervical and other cancers.
 Hepatitis B resulted in an estimated 820 000 deaths in 2019, mostly from cirrhosis and hepatocellular carcinoma.
STIs such as gonorrhoea and chlamydia are major causes of pelvic inflammatory disease and infertility in women.

Prevention of STIs
When used correctly and consistently, condoms offer one of the most effective methods of protection against STIs,
including HIV. Although highly effective, condoms do not offer protection for STIs that cause extra-genital ulcers (i.e.,
syphilis or genital herpes). When possible, condoms should be used in all vaginal and anal sex.

Safe and highly effective vaccines are available for 2 viral STIs: hepatitis B and HPV. These vaccines have
represented major advances in STI prevention. By the end of 2020, the HPV vaccine had been introduced as part of routine
immunization programmes in 111 countries, primarily high- and middle-income countries. To eliminate cervical cancer as a
public health problem globally, high coverage targets for HPV vaccination, screening and treatment of precancerous
lesions, and management of cancer must be reached by 2030 and maintained at this high level for decades.

Research to develop vaccines against genital herpes and HIV is advanced, with several vaccine candidates in early
clinical development. There is mounting evidence suggesting that the vaccine to prevent meningitis (MenB) provides some
cross-protection against gonorrhoea. More research into vaccines for chlamydia, gonorrhoea, syphilis and trichomoniasis
are needed.
 Other biomedical interventions to prevent some STIs include adult voluntary medical male circumcision,
microbicides, and partner treatment. There are ongoing trials to evaluate the benefit of pre- and post-exposure prophylaxis
of STIs and their potential safety weighed with antimicrobial resistance (AMR).

Diagnosis of STIs
STIs are often asymptomatic. When symptoms occur, they can be non-specific. Moreover, laboratory tests rely on
blood, urine or anatomical samples. Three anatomical sites can carry at least one STI. These differences are modulated by
sex and sexual risk. These differences can mean the diagnosis of STIs is often missed and individuals are frequently
treated for 2 or more STIs.

Accurate diagnostic tests for STIs (using molecular technology) are widely used in high-income countries. These
are especially useful for the diagnosis of asymptomatic infections. However, they are largely unavailable in low- and middle-
income countries (LMICs) for chlamydia and gonorrhoea. Even in countries where testing is available, it is often expensive
and not widely accessible. In addition, the time it takes for results to be received is often long. As a result, follow-up can be
impeded and care or treatment can be incomplete.

On the other hand, inexpensive, rapid tests are available for syphilis, hepatitis B and HIV. The rapid syphilis test
and rapid dual HIV/syphilis tests are used in several resource-limited settings.

Several other rapid tests are under development and have the potential to improve STI diagnosis and treatment,
especially in resource-limited settings.

Treatment of STIs
Effective treatment is currently available for several STIs.

 Three bacterial (chlamydia, gonorrhoea and syphilis) and one parasitic STIs (trichomoniasis) are generally curable
with existing single-dose regimens of antibiotics.
 For herpes and HIV, the most effective medications available are antivirals that can modulate the course of the
disease, though they cannot cure the disease.
 For hepatitis B, antivirals can help fighting the virus and slowing damage to the liver.

AMR of STIs – in particular gonorrhoea – has increased rapidly in recent years and has reduced treatment options.
The Gonococcal AMR Surveillance Programme (GASP) has shown high rates of resistance to many antibiotics including
quinolone, azithromycin and extended-spectrum cephalosporins, a last-line treatment (4).

AMR for other STIs like Mycoplasma genitalium, though less common, also exists.

STI case management

 LMICs rely on identifying consistent, easily recognizable signs and symptoms to guide treatment, without the use of
laboratory tests. This approach – syndromic management – often relies on clinical algorithms and allows health workers to
diagnose a specific infection based on observed syndromes (e.g., vaginal/urethral discharge, anogenital ulcers,
etc). Syndromic management is simple, assures rapid, same-day treatment, and avoids expensive or unavailable diagnostic
tests for patients with symptoms. However, this approach results in overtreatment and missed treatment as the majority of
STIs are asymptomatic. Thus, WHO recommends countries to enhance syndromic management by gradually incorporating
laboratory testing to support diagnosis. In settings where quality assured molecular assays are available, it is recommended
to treat STIs based on laboratory tests. Moreover, STI screening strategies are essential for those at higher risk of infection,
such sex workers, men who have sex with men, adolescents in some settings and pregnant women.

To interrupt transmission and prevent re-infection, treating sexual partners is an important component of STI case
management.

Controlling the spread

Behaviour change is complex

Despite considerable efforts to identify simple interventions that can reduce risky sexual behaviour, behaviour
change remains a complex challenge.

Information, education and counselling can improve people’s ability to recognize the symptoms of STIs and
increase the likelihood that they will seek care and encourage a sexual partner to do so. Unfortunately, lack of public
awareness, lack of training among health workers, and long-standing, widespread stigma around STIs remain barriers to
greater and more effective use of these interventions.

Health services for screening and treatment of STIs remain weak

People seeking screening and treatment for STIs face numerous problems. These include limited resources,
stigmatization, poor quality of services and often out-of-pocket expenses.

Some populations with the highest rates of STIs – such as sex workers, men who have sex with men, people who
inject drugs, prison inmates, mobile populations and adolescents in high burden countries for HIV – often do not have
access to adequate and friendly health services.

In many settings, STI services are often neglected and underfunded. These problems lead to difficulties in providing
testing for asymptomatic infections, insufficient number of trained personnel, limited laboratory capacity and inadequate
supplies of appropriate medicines.

WHO response

Our work is currently guided by the Global health sector strategy on HIV, Hepatitis and Sexually Transmitted
Infections, 2022–2030. Within this framework, WHO:
  develops global targets, norms and standards for STI prevention, testing and treatment;
 supports the estimation and economic burden of STIs and the strengthening of STI surveillance;
 globally monitors AMR to gonorrhoea; and
 leads the setting of the global research agenda on STIs, including the development of diagnostic tests, vaccines
and additional drugs for gonorrhoea and syphilis.

As part of its mission, WHO supports countries to:

 develop national strategic plans and guidelines;

 create an encouraging environment allowing individuals to discuss STIs, adopt safer sexual practices, and seek
treatment;
 scale-up primary prevention (condom availability and use, etc.);
 increase integration of STI services within primary healthcare services;
 increase accessibility of people-centred quality STI care;
 facilitate adoption of point-of-care tests;
 enhance and scale-up health intervention for impact, such as hepatitis B and HPV vaccination, syphilis screening in
priority populations;
 strengthen capacity to monitoring STIs trends; and
 monitor and respond to AMR in gonorrhoea.

An Open Discussion About STI & STD Awareness

BY THE FAMILY HEALTH CLINIC TEAM

April is national Sexually Transmitted Infection (STI) Month, so we decided to talk with one of our community
partners, the White County Health Department, about STIs and local STI services. If you are sexually active or know
someone in your life that is sexually active, this is important information that you should read!

Check out our conversation below!

What is an STI? And how is different from an STD?

STDs are infections that are passed from one person to another during vaginal, anal, and oral sex. They’re really common,
and lots of people who have them don’t have any symptoms. STDs can be dangerous, but the good news is that getting tested is no
big deal, and most STDs are easy to treat. STD stands for sexually transmitted disease—but you probably knew that part already.
“STD” is the most commonly used term for the collection of medical infections that are transmitted through sexual contact.

But that’s just the thing. People who become infected, don’t always experience any symptoms or have their infection develop
into a disease. That’s where the more modern term “STI” comes from. STI stands for sexually transmitted infection, and many people,
mostly the medical community, have begun transitioning from “STD” to “STI” in an effort to clarify that not all sexually transmitted
infections turn into a disease.

For instance, the vast majority of women who contract HPV (human papilloma virus) will not develop the resulting
disease cervical cancer. In fact, most cases of infection will clear up within two years. Additionally, people who use this term
believe that it also eliminates some of the shame that’s been associated with the acronym “STD.” So, the long and short of it
is this: STD and STI both essentially stand for the same thing. The distinction is that an STI doesn’t always mean you have
an STD.
How can STIs impact peoples lives?

While sexually transmitted diseases (STDs) affect individuals of all ages, STDs take a particularly heavy toll on
young people. CDC estimates that youth ages 15-24 make up just over one quarter of the sexually active population, but
account for half of -the 20 million new sexually transmitted infections that occur in the United States each year.

If you could have people remember one thing about STIs, what is it?

An ounce of Prevention is worth a pound of cure! Abstinence is best or limiting the number of sexual partners is a
great way to avoid STD’s. Making it a policy to always have protected sex. Correctly using male condoms and other
barriers like female condoms and dental dams, every time, can reduce (though not eliminate) the risk of sexually transmitted
diseases (STDs), including human immunodeficiency virus (HIV) and viral hepatitis. They can also provide protection
against other diseases that may be transmitted through sex like Zika and Ebola. Using male and female condoms correctly,
every time, can also help prevent pregnancy. However, remember that STD’s can be passed with oral sex as well.

If you test positive for any STI, you should inform all recent sexual partners (past 60 days) so they can get tested and
treated too. This is the right thing to do!

How would you encourage someone to get tested for STIs?

Testing is easy and will be done by professionals. No one should fear any judgement.

What are some of the STI health services the White County Health Department provides for the county?

Vaccines and some testing are both offered.

Vaccines are safe, effective, and recommended ways to prevent hepatitis B and HPV. HPV vaccines for males and females
can protect against some of the most common types of HPV. It is best to get all three doses (shots) before becoming
sexually active. However, HPV vaccines are recommended for all teen girls and women through age 26 and all teen boys
and men through age 21, who did not get all three doses of the vaccine when they were younger.

You should also get vaccinated for hepatitis B if you were not vaccinated when you were younger. The HPV vaccine is a
strong weapon in cancer prevention. Quadrivalent HPV vaccine prevents infection with the HPV types that cause many
anal, penile, and oropharyngeal cancers, as well as genital warts, in men. Each year in the United States, about 7000
cancers in men are caused by these HPV types. Clinical trials have shown the quadrivalent HPV vaccine to be very
effective in preventing anal pre-cancers and genital warts. The vaccine will likely prevent HPV-associated penile cancers, as
well as oropharyngeal cancers, but no studies have yet demonstrated efficacy against these outcomes.

Call to make an appointment. 574-583-8254.

Confidential testing is offered locally every other Thursday by a partnership with Aspire. No appointment is necessary. They
can screen for Hepatitis C and HIV. This testing is free of charge! Please call to see which Thursday they are at the
Monticello location. 574-583-8254.

All other STD’s are screened at the Tippecanoe County Health Department. However, they do require an appointment.
Please call to make that appointment at 765-423-9221.

Sexually Transmitted Disease (STD) Testing By Appointment Only!

Call for hours and to schedule an appointment today: 765-423-9221
  General STD Testing: 20 – 30 minutes
 If rapid HIV test is needed, 45 – 60 minutes
 Testing is $20 (Treatment, if needed, is included)
 Questions, Comments, or Concerns? (765) 423-9221 Ext. 1
 Address: 20 N. Third Street Lafayette, IN 47901

What are other STI-related health services that people can turn to if they need help?

Treatment is readily available. Testing, however, is the first step. Once you are tested you will be given information
about treatment if necessary.