Sexually Transmitted Diseases Hamper Development Efforts

Improving the health conditions of individuals and families in the developing world has long been a priority for American humanitarian aid.

As a result of 30 years of U.S. assistance, maternal and infant death rates have dropped in many regions, significantly more couples are using contraceptives to plan their families and more children are living past their fifth birthday.

Nevertheless, despite the tremendous progress brought about by investments in maternity care, family planning, child immunization and better nutrition, one crucial element of maternal and child health has been sorely neglected: the prevention and treatment of sexually transmitted diseases (STDs). Historically, STDs have also been overlooked in the global fight against infectious diseases; as a result, they continue to drain the lives of young and old throughout the developing world.

The vast majority of STDs are spread through sexual intercourse—which is perhaps the most important reason for the lack of public discourse on their impact—and women of childbearing age (15-44) are disproportionately affected. In addition, each year, millions of infants begin their lives disadvantaged by an STD they contracted from their mother; STD infections in newborns compromise their health, both immediately and in the coming years.

STDs are a serious problem not only because they are widespread, but also because they may have delayed, long-term consequences, including poor maternal health, ectopic pregnancy, infant illness and death, cervical cancer, infertility and increased susceptibility to HIV. Millions of men and women suffering these and other effects of STDs are hindered in their ability to provide for their families and contribute to their society. For countries struggling to develop economically, the health and economic costs are immense.

The toll of STDs also hampers U.S. international aid. American assistance aimed at improving educational, health and economic conditions overseas becomes less effective, and therefore more costly, when a substantial proportion of recipients are suffering from STDs. Thus, although this is not always well understood by policymakers and the public, the United States has a considerable stake in combating the burgeoning STD epidemic in developing countries. This Issues in Brief examines the incidence and consequences of STDs in developing countries, and describes why a strengthened U.S. commitment to the prevention and treatment of these diseases is needed.

STDs Are Widespread

Worldwide, more than 400 million adults become infected with an STD every year. Four STDs that are spread primarily through heterosexual contact are completely curable—trichomoniasis, chlamydia, syphilis and gonorrhea. These account for 333 million STD infections, or about 80% of the worldwide total (Chart A). Some 9% of all persons aged 15-44 in North America contract one of these STDs annually, but the rate rises to 25% in Sub-Saharan Africa. Tricho-moniasis alone has been detected in more than 40% of women attending prenatal clinics in Uganda and Botswana.

Every day, about 16,000 people (or nearly six million people each year) become infected with HIV, a startling number, given the short period of time since the virus emerged. Some nations have been hit harder than others. Among developing nations, for example, the United Nations estimates that more than 20 million people in Sub-Saharan Africa are HIV-positive, and most are unaware of their infection. While fewer than 1% of India‚—�´s adults have the virus, India has the largest number of HIV-infected people in the world: 3-5 million, 89% of whom are younger than 45.

Globally, women and children represent a large proportion of those infected with HIV: In 1997, an estimated 36% of new HIV infections occurred among women; 10% were among children younger than 15. In Latin America, HIV infections among women and teenagers, who contract the disease primarily through heterosexual intercourse, have been increasing sharply. Throughout Africa, heterosexual intercourse was responsible for an estimated 85% of new HIV infections in 1997.

Because STDs strike relatively young persons and treatment often is not sought or is inaccessible, delayed or inadequate, the impact of these infections on individuals‚—�´ health is high. The impact on society also is substantial, since STDs affect primarily men and women who are forming families and contributing to the work force. The World Bank and the World Health Organization have led efforts to develop measures to quantify the burden of disease. One of the best-known measures is the number of healthy years of life lost as a result of illness or premature death.

Each year, STDs, including HIV, account for 6% of healthy years of life lost among women aged 15-44 worldwide. The annual occurrence of four STDs—syphilis, gonorrhea, chlamydia and HIV—along with pelvic inflammatory disease (PID), a result of some STDs that often leads to sterility among women, accounts for the loss of more than 51 million years of healthy life among men, women and children worldwide (Chart B). Women lose a disproportionate share of healthy years of life to STDs, largely because of PID.

Symbiotic STDs

A mutually reinforcing link exists between HIV and other, more common STDs. One of the principal reasons HIV prevalence is so high in developing countries is that STD levels were high before the epidemic. The susceptibility of people to HIV infection is 2-9 times as high if they already have certain infections, particularly syphilis and chancroid. Similarly, HIV facilitates the transmission, hampers the diagnosis and accelerates the progression of other STDs. For example, human papilloma virus—which is closely associated with cervical cancer—progresses at a much faster rate in HIV-infected women than in others.

Early and effective treatment of STDs, especially those that result in genital ulcers, can reduce the incidence of HIV infection. In one Tanzanian community, a program that allowed for the diagnosis and treatment of STDs without using expensive laboratory tests reduced HIV incidence by about 40%.

Groups at Greatest Risk

Women. A variety of biological and social factors make women more susceptible to STDs than men. Women are physiologically more vulnerable than are men to contracting STDs when they have unprotected sex (i.e., without using a condom) with an infected partner. Additionally, STDs in women are more likely to be asymptomatic; if women are unaware of their infection, they will not seek timely care and hence may experience serious complications. Further, the use of traditional vaginal medications and douching may increase a woman‚—�´s risk of acquiring an STD. With the exception of HIV, STDs may have more life-threatening consequences for women (PID, ectopic pregnancy and cervical cancer, for example) than for men.

Married and monogamous women are often at higher risk of contracting STDs than might be expected, because of the high-risk behaviors that are relatively common among men in many countries: intercourse with multiple partners and with commercial sex workers. Moreover, in some countries, women‚—�´s low social and educational status conspire to deny the majority of them the power and knowledge to protect themselves against STDs. In many cultures, few women are able to negotiate the conditions of their sexual lives or the effective use of protective measures with a partner. In fact, many women consider STD-related symptoms such as abdominal pain or vaginal discharge a normal condition, not realizing that their suffering is caused by a contagious disease and can be treated.

Infants of Infected Mothers. Infants born to women with an active STD are highly likely to be infected before, during or after delivery. Globally, the probability that the mother‚—�´s HIV infection will be transmitted to the infant at birth ranges from about 20% to 40%; this mode of transmission accounts for 5-10% of all HIV infections worldwide. The consequences of STD infection are serious for the newborn: stillbirth or prematurity, permanent damage to vital organs and possibly death.

Should an infant manage to escape STD infection at birth, he or she is likely to feel the impact of the disease in other ways. By the end of 1997, more than eight million children had lost their mother or both parents as a result of AIDS before they had reached the age of 15. Further, untreated STDs can severely impair parents‚—�´ ability to work outside the home and provide for their family adequately, increasing the risks to their children's health and well-being.

Teenagers. Sexually active teenagers, especially males, tend to engage in riskier behavior than adults: They have more partners, have more high-risk partners and often do not use condoms. Consequently, sexually active teenagers, along with adults younger than 25, generally have the highest STD rates of any age-group. Married adolescent women who themselves may be monogamous are at risk of acquiring STDs if their husbands have sexual encounters outside the marriage.

Additionally, biological and social factors heighten the risk for young girls and teenage women. Young women contract STDs more easily than adults because they have fewer protective antibodies and the immaturity of their cervix facilitates the transmission of an infection. In some societies, sexual coercion has emerged as a major risk factor for young girls; many are forced to have sex or are given gifts or money in exchange for sex, precisely because they are seen as being disease-free.

Youth who are infected with an incurable STD—genital warts, herpes or HIV—bear the debilitating effects of the disease for the rest of their lives. Many become infertile and are unable to have families of their own.

What Is Needed?

STD prevention efforts are critical and should be of highest priority for policymakers, a 1997 World Bank report declared. The sooner developing countries act to contain the spread of STDs, especially HIV, the more manageable and less severe the problem will be in future years. In particular, the Bank concluded, reaching groups most prone to spread STDs (such as sex workers, their customers and youth) with prevention programs will have the largest impact in reducing infection rates throughout a population.

In a number of countries, national prevention campaigns, using a variety of messages targeted for specific audiences, have proven effective in helping people adopt healthier behaviors. Messages that should be promoted widely among the general public include the importance of reducing the number of sexual partners, the effectiveness of condoms in protecting against infection and the benefit of dual method use, or simultaneously using a condom to prevent STD transmission and another contraceptive method to prevent unintended pregnancy.

How and in what clinical settings STD-related counseling and medical services might best be offered are less clear. These questions have long bedeviled health advocates and policymakers. In the United States, for a variety of reasons, largely separate networks of family planning clinics and STD clinics have evolved. Recently, this two-track system has come under criticism; opponents urge that whenever possible, STD prevention, screening and treatment services be fully integrated within family planning and primary care settings, which are considered conducive to providing counseling and services to help individuals meet their pregnancy and STD prevention needs. In developing countries, where the existing formal health system may provide inadequate or no STD services, there is an opportunity to think through these infrastructure issues from the beginning, with an eye toward developing a more integrated, comprehensive approach to STD care.

The Global Response

The extent of STDs and their impact on families and society first received formal recognition from the world community at the 1994 United Nations-sponsored International Conference on Population and Development, held in Cairo. At this historic gathering, policymakers pledged to focus on individuals‚—�´ reproductive and sexual health needs. Such a focus, they agreed, would enable women, men and young people to lead healthier and more productive lives, and would, in turn, promote sustainable development and lower population growth rates.

The key question facing policymakers is how—and, to some extent, whether—they can fulfill their financial commitments to ensure that individuals most in need will have access to a full range of reproductive health care services. In addition to family planning, these include STD screening and treatment, maternity and postpartum care, safe abortion (where the procedure is legal) and routine gynecologic care. At the Cairo conference, both donor and developing country governments pledged new funds to fight STDs, yet that promise has gone largely unrealized, in part because U.S. political and financial leadership in the reproductive health field has faltered in recent years.

The U.S. Challenge

Beginning in 1995, the long-simmering legislative feud over domestic abortion policies spilled over to the international arena, wreaking havoc with U.S. family planning and reproductive health care efforts overseas. Over the past three years, Congress has imposed deep funding cuts on the U.S. Agency for International Development‚—�´s population assistance program, effectively scuttling its expansion into the provision of more comprehensive STD services. Continued funding at these depressed levels means that, in developing countries, far fewer resources will be available for STD care in family planning settings and that the burden of STDs will continue to fall on the primary caregivers and household managers—women.

Clearly, there is a compelling need for STD services. For decades, U.S. lawmakers have acknowledged the fundamental role of disease prevention and treatment in social and economic development, which remains a cornerstone of American foreign assistance. To the detriment of millions, however, the long-term impact of STDs has gone unnoticed.

Fortunately, times are changing. The global consensus that emerged in Cairo recognizes the toll of STDs on individuals and society overall, but the funding to carry out this new public health mandate is crucial. The United States was instrumental in shaping this enlightened worldview and should endeavor to follow through on its political and financial commitments to STD prevention and treatment. The quality of life for individuals and families worldwide will be greatly enhanced.

Sources of Data

Eng TR and Butler WT, eds., The Hidden Epidemic: Confronting Sexually Transmitted Diseases, Washington DC: National Academy Press, 1997.

Tsui AO, Wasserheit JN and Haaga JG, eds., Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions, Washington, DC: National Academy Press, 1997.

United Nations Joint Programme on HIV/AIDS and World Health Organization, Report on the global HIV/AIDS epidemic, June 1998, "http://www.unaids.org/highband/document/epidemio/june98/global_report/index.html, accessed July 2, 1998.

World Bank, Confronting AIDS: Public Priorities in a Global Epidemic, New York: Oxford University Press, 1997.

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