Sexually transmitted

infections (STIs)
22 August 2022
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Key facts
 More than 1 million sexually transmitted infections (STIs) are acquired
every day worldwide, the majority of which are asymptomatic.
 Each year there are an estimated 374 million new infections with 1 of 4
curable STIs: chlamydia, gonorrhea, syphilis, and trichomoniasis.
 More than 500 million people 15–49 years are estimated to have a genital
infection with herpes simplex virus (HSV or herpes) (1).
 Human papillomavirus (HPV) infection is associated with over 311 000
cervical cancer deaths each year (2).
 Almost 1 million pregnant women were estimated to be infected with
syphilis in 2016, resulting in over 350 000 adverse birth outcomes (3).
 STIs have a direct impact on sexual and reproductive health through
stigmatization, infertility, cancers, and pregnancy complications and can
increase the risk of HIV.
 Drug resistance is a major threat to reducing the burden of STIs
worldwide.

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, gonorrhea, 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 meningitides, 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), gonorrhea
(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, gonorrhea, 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 gonorrhea 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
programs 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 prevents meningitis (MenB) and provides some
cross-protection against gonorrhea. More research into vaccines for chlamydia,
gonorrhea, 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 gonorrhea. 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, gonorrhea, and syphilis) and one parasitic STI
(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 fight the virus and slow damage to the liver.

AMR of STIs – in particular gonorrhea – 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 enhance syndromic management by gradually incorporating laboratory
testing to support the 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 as
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

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

Information, education, and counseling 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 gonorrhea; and
 leads the setting of the global research agenda on STIs, including the
development of diagnostic tests, vaccines, and additional drugs for gonorrhea
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 the accessibility of people-centered quality STI care;
 facilitate adoption of point-of-care tests;
 enhance and scale-up health interventions for impacts, such as hepatitis B and
HPV vaccination, and syphilis screening in priority populations;
 strengthen capacity to monitor STIs trends; and
 monitor and respond to AMR in gonorrhea.

References

1. James C, Harfouche M, Welton NJ, et al. Herpes simplex virus: global infection
prevalence and incidence estimates, 2016. Bull World Health Organ.
2020;98(5):315-329.
2. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer
statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for
36 cancers in 185 countries. CA Cancer J Clin. 2018 Nov;68(6):394-424. Epub
2018 Sep 12. Erratum in: CA Cancer J Clin. 2020 Jul;70(4):313.
3. Unemo M, Lahra MM, Escher M, Eremin S, Cole MJ, Galarza P, Ndowa F,
Martin I, Dillon JR, Galas M, Ramon-Pardo P, Weinstock H, Wi T. WHO global
antimicrobial resistance surveillance (GASP/GLASS) for Neisseria gonorrhoeae
2017-2018: a retrospective observational study. Lancet Microbe 2021; 2: e627–
36

Comprehensive Sexuality Education

 Committee opinion
 Number 678
 November 2016

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Number 678 (Reaffirmed 2020)
Committee on Adolescent Health Care
This Committee Opinion was developed by the American College of
Obstetricians and Gynecologists Committee on Adolescent Health Care in
collaboration with committee member Joanna H. Stacey, MD.
This document reflects emerging clinical and scientific advances as of the
date issued and is subject to change. The information should not be
construed as dictating an exclusive course of treatment or procedure to
be followed.

ABSTRACT: Current sex education programs vary widely in the accuracy

of content, emphasis, and effectiveness. Data have shown that not all
programs are equally effective for all ages, races and ethnicities,
socioeconomic groups, and geographic areas. Studies have demonstrated
that comprehensive sex education programs reduce the rates of sexual
activity, sexual risk behaviors (eg, number of partners and unprotected
intercourse), sexually transmitted infections, and adolescent pregnancy.
One key component of an effective program is encouraging community-
centered efforts. In addition to counseling and service provision to
individual adolescent patients, obstetrician-gynecologists can serve
parents and communities by supporting and assisting with sexuality
education. Because of their knowledge, experience, and awareness of a
community’s unique challenges, obstetrician-gynecologists can be an
important resource for sex education programs.

Recommendations and Conclusions

The American College of Obstetricians and Gynecologists (the College)
makes the following recommendations and conclusions:

 Comprehensive sexuality education should be medically accurate,

evidence-based, and age-appropriate, and should include the
benefits of delaying sexual intercourse, while also providing
 information about normal reproductive development, contraception
(including long-acting reversible contraception methods) to prevent
unintended pregnancies, as well as barrier protection to prevent
sexually transmitted infections (STIs).
 Comprehensive sex education should begin in early childhood and
continue through a person’s lifespan.
 Programs should not only focus on reproductive development
(including abnormalities in development, such as primary ovarian
insufficiency and müllerian anomalies), prevention of STIs, and
unintended pregnancy, but also teach about forms of sexual
expression, healthy sexual and nonsexual relationships, gender
identity and sexual orientation and questioning, communication,
recognizing and preventing sexual violence, consent, and decision
making.
 Obstetrician–gynecologists can serve parents and communities by
supporting and assisting sexuality education, developing evidence-
based curricula that focus on clear health goals (eg, the prevention
of pregnancy and STIs, including human immunodeficiency virus
[HIV]), and providing health care that focuses on optimizing sexual
and reproductive health and development.
 Obstetrician–gynecologists have the unique opportunity to act “bi-
generationally” by asking their patients about their adolescents’
reproductive development and sexual education, human
papillomavirus vaccination status, and contraceptive needs.

Comprehensive sexuality education should be medically accurate,

evidence-based, and age-appropriate, and should include the benefits of
delaying sexual intercourse, while also providing information about
normal reproductive development, contraception (including long-acting
reversible contraception methods) to prevent unintended pregnancies, as
well as barrier protection to prevent STIs Box 1. Comprehensive sex
education should begin in early childhood and continue through a person’s
lifespan. Programs should not only focus on reproductive development
(including abnormalities in development, such as primary ovarian
insufficiency and müllerian anomalies), prevention of STIs, and unintended
pregnancy, but also teach about forms of sexual expression, healthy
sexual and nonsexual relationships, gender identity and sexual orientation
and questioning, communication, recognizing and preventing sexual
violence, consent, and decision making. They also should include state-
specific legal ramifications of sexual behavior and the growing risks of
sharing information online 1. Additionally, programs should cover the
variations in sexual expression, including vaginal intercourse, oral sex,
anal sex, mutual masturbation, as well as texting and virtual sex 2. The
American Academy of Pediatrics provides an overview of the published
research on evidence-based sexual and reproductive health education 3.
Box 1.
What Constitutes Comprehensive Sexuality
Education
The following are components of comprehensive sex education:

 Comprehensive sexuality education should be medically accurate,

evidence-based, and age-appropriate, and should include the
benefits of delaying sexual intercourse, while also providing
information about normal reproductive development, contraception
(including long-acting reversible contraception methods) to prevent
unintended pregnancies, as well as barrier protection to prevent
sexually transmitted infections.
o Emphasis on human rights values of all individuals, including
gender equality, gender identity, and sexual diversity, and
differences in sexual development.
o Encourage consideration of implants and intrauterine devices
for all appropriate candidates.
o Include information on consent and decision-making, intimate
partner violence, and healthy relationships.
o Participatory and culturally sensitive teaching approaches that
are appropriate to the student’s age as well as identification
with distinct subpopulations, including adolescents with
intellectual and physical disabilities, sexual minorities, and
variations in sexual development.
o Knowledgeable about and inclusive of state-specific
consequences of sexual activity during adolescence, including
online and social media activity.
o Discussion of the benefits and pitfalls of online information
(eg, gross misinformation on sexuality in cyberspace).

Current Quality of Sexuality Education

Current sex education programs vary widely in the accuracy of content,
emphasis, and effectiveness. Evaluations of biological outcomes of sex
education programs, such as pregnancy rates and STIs, are expensive and
complex, and they can be unreliable, often relying on self-reported
behaviors to measure effectiveness. Between 1996 and 2010, there was a
strong emphasis in sexuality education on abstinence until marriage
because of federal and state funding bans on comprehensive information
about contraception. Several states have responded to parents’ and
communities’ calls to provide education on not only abstinence, but on
contraception, STIs (including human immunodeficiency virus [HIV]), and
the proper use of condoms 4.
State definitions of “medically accurate” vary widely, and most states
require school districts to allow parental involvement in sex education
programs 5. Many states have requirements regarding topics that must be
included in sex education programs. Although most federal funding goes
to comprehensive sexual education programs, Title V Abstinence
Education Grant funding is available to states that choose to provide
activities meeting abstinence-only specifications, which can be found
at www.ssa.gov/OP_Home/ssact/title05/0510.htm and www.siecus.org/ind
ex.cfm?fuseaction=Page.ViewPage&PageID=1158. Up-to-date state-level
policy information can be found at the Guttmacher Institute’s State
Center at www.guttmacher.org/state-policy/explore/sex-and-HIV-
education.

The Role of the Obstetrician–Gynecologist

In addition to counseling and service provision to adolescent patients,
obstetrician-gynecologists can serve parents and communities by
supporting and assisting sexuality education by developing evidence-
based curricula that focus on clear health goals (eg, the prevention of
pregnancy and STIs, including HIV) and providing health care that focuses
on optimizing sexual and reproductive health and development, including,
for example, education about and administration of the human
papillomavirus vaccine 6. Because of their knowledge, experience, and
awareness of a community’s unique challenges, obstetrician-
gynecologists can be an important resource for sexuality education
programs 7. Additionally, obstetrician-gynecologists can encourage
patients to engage in positive behaviors to achieve their health goals and
discourage unhealthy relationships and behaviors that put patients at high
risk of pregnancy and STIs. Clinicians also can evaluate adolescents’ level
of engagement in risky behaviors, including those occurring online, and
educate patients and guardians of the risks of social media and the
Internet; and provide support to the parents and guardians of adolescents
by encouraging them to be actively involved in their children’s sexuality
education. Obstetrician–gynecologists have the unique opportunity to act
“bi-generationally” by asking their patients about their adolescents’
reproductive development and sexual education, human papillomavirus
vaccination status, and contraceptive needs. Although obstetrician-
gynecologists are well-suited to provide sexuality education, some may
encounter obstacles; local laws have been proposed to restrict family
planning providers from giving sexual health information to adolescents
outside of a medical setting (a physician’s office or community health
clinic) 8.
When a responsible adult communicates about sexual topics with
adolescents, there is evidence of delayed sexual initiation and increased
birth control and condom use 9. Although many parents talk with their
adolescents about the risks and responsibilities of sexual activity, one-
third to one-half of females aged 15–19 years report never having talked
with a parent about contraception, STIs, or “how to say no to sex” 9.
Community and school-based programs also are an important facet of sex
education.

Effective Programs
Data have shown that not all programs are equally effective for all ages,
races and ethnicities, socioeconomic groups, and geographic areas; there
is no “one size fits all” program. However, one key component of an
effective program is to encourage community-centered efforts. Innovative,
multicomponent, community-wide initiatives that use evidence-based
adolescent pregnancy prevention interventions and reproductive health
services (including inclusion of moderately or highly effective
contraceptive methods, such as long-acting reversible contraception)
have dramatically reduced pregnancy rates among African American and
Hispanic individuals aged 15–19 years old 10. Although formal sex
education varies in content across schools, studies have demonstrated
that comprehensive sex education programs reduce the rates of sexual
activity, sexual risk behaviors (eg, number of partners and unprotected
intercourse), STIs, and adolescent pregnancy 11. However, despite
concerns raised by some involved in health education, a study of four
select abstinence-only education programs reported no increase in the
risk of adolescent pregnancy, STIs, or the rates of adolescent sexual
activity compared with students in a control group 12.

Reaching Special Populations

Adolescents with physical and cognitive disabilities often are considered
to be asexual and, thus, have been excluded from sex education 13.
However, they have concerns regarding sexuality similar to those of their
peers without disabilities. Their knowledge of anatomy and development,
sexuality, contraception, and STIs (including HIV), should be on par with
their peers, and they should be included in sexuality programs through
their schools and communities.
Comprehensive sexuality education should not marginalize lesbian, gay,
bisexual, questioning, and transgender individuals and those that have
variations in sexual development (eg, primary ovarian insufficiency,
müllerian anomalies). Curricula that emphasize empowerment and gender
equality tend to engage learners to question prevailing norms through
critical thinking and encourage adolescents to adopt more egalitarian
attitudes and relationships, resulting in better sexual and health
outcomes 14.

Online Communication and Using Cyberspace as

a Source of Information
Adolescents may use a variety of media sources to fill in gaps in the
sexual education they receive from schools, community programs, and
parents; thus, media literacy is increasingly a key factor in children’s
sexual health. Three-quarters of adolescents use a social networking site,
more than 80% own a cell phone, and the Internet is available to almost
all adolescents at school and home 15. Comprehensive sexuality
programs should consider the benefits and pitfalls of social media.
Adolescents should be aware of their “digital footprint” and the physical
and legal dangers of their online behavior 1.
There is a growing interest among adolescents to access sexual health
information online that is written in a language they can understand, that
is in an interactive format, and that is presented in an entertaining
manner 16 17. Educational opportunities may be limited by the Internet
because popular search engines often will include inappropriate sites or
pornography as the first available choice, and some reputable sexual
education sites will have their content blocked by social networking sites
as “offensive.” Finally, adolescents are not likely to seek out and follow an
organization through a social networking site but will heed an RSS feed
(an aggregation of information, including blog entries, news headlines,
audio, and video) or text messages 18. For more information, see
Committee Opinion No. 653, Concerns Regarding Social Media and Health
Issues in Adolescents and Young Adults 1.

For More Information

The American College of Obstetricians and Gynecologists has identified
additional resources on topics related to this document that may be
helpful for ob-gyms, other healthcare providers, and patients. You may
view these resources
at www.acog.org/More-Info/ComprehensiveSexualityEducation.
These resources are for information only and are not meant to be
comprehensive. Referral to these resources does not imply the American
College of Obstetricians and Gynecologists’ endorsement of the
organization, the organization’s website, or the content of the resource.
The resources may change without notice.

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