World AIDS Day falls on 1 December each year. To increase awareness and reduce the stigma associated with this illness we spoke to Consultant Venereologist and National STD AIDS Control Programme (NSACP) Elimination of Mother to Child Transmission (EMTCT) of HIV and Syphilis Programme Co-ordinator – HIV Care Services Dr. Lilani Rajapaksa.
What are STIs and how does one contract such infections?
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Consultant Venereologist and National STD AIDS Control Programme Elimination of Mother to Child Transmission (EMTCT) of HIV and Syphilis Programme Co-ordinator – HIV Care Services Dr. Lilani Rajapaksa[/caption]
The name itself implies that sexually transmitted infections (STIs) are mainly transmitted through unprotected sexual exposures. A person can get an STI through penetrative sexual contact with a person having an STI. The sexual contact may be between a male and a female (heterosexual) or a male and a male (homosexual, men having sex with men). The type of penetrative sexual exposures can be oral, vaginal, or anal. If the person has not used a condom for penetrative sexual contact, it is an unprotected sexual act exposing them to STI and HIV.
There are many types of STIs, and of them, the common infections seen in Sri Lanka are genital herpes, genital warts, syphilis, gonorrhea, chlamydia, and HIV infections.
What is its true burden in Sri Lanka?
The true burden cannot be identified as many people infected with STI/HIV do not seek services. This may be due to multiple reasons such as not having symptoms, not perceiving the risk, not knowing where services are available, or reluctance to seek services due to stigma.
Available statistics are from the reported numbers from government STD clinics. According to the 2020 annual report from the National STD AIDS Control Programme, close to 83,000 visits have been made to STD clinics island-wide. These numbers just show the tip of the iceberg, and it is clear the actual burden is much more than this.
When should one suspect the possibility of an STI?
Usually, the diagnosis is based on the symptoms and signs. However, in STIs, a significant number of infected people can remain asymptomatic. More females are asymptomatic than males. They may not have any symptoms or signs to indicate the presence of STI.
What are the common symptoms observed in STIs?
A person who had a risky sexual exposure should seek services early if they experience the following symptoms:
Sri Lanka remains a country with a low prevalence of HIV, 35 years after identifying the first Sri Lankan with HIV in 1987. When many countries in the region experience worse epidemics, Sri Lanka was able to maintain a low prevalence of HIV due to the implementation of suitable strategies by many stakeholders under the leadership of the National STD AIDS Control Programme. These stakeholders include health and non-health sectors of the government, as well as the private sector, NGOs, organisations of key populations, and people living with HIV (PLHIV).
The main modes of transmission of HIV are through unprotected sexual exposures, blood-to-blood contact, and contact with body fluids of infected persons. In Sri Lanka, more than 95% of diagnosed adults living with HIV were infected through unprotected sexual contact. In 2019, the World Health Organisation (WHO) certified Sri Lanka as a country that had eliminated mother-to-child transmission of HIV. Transmission risk through blood has been minimised by the policies implemented by the National Blood Transfusion Services, thus further reducing the transmission risk.
According to the integrated biological and behavioural surveillance conducted in 2018, the risk behaviours are common among important key population groups such as female sex workers, men having sex with men, and beach boys. There is evidence that youth are engaging in unprotected sexual exposures, leading to increased HIV and STI in the community. Risk for HIV and STIs are increasing in society while the level of knowledge on infections or services is far from satisfactory.
Mitigation strategies currently in-place
Control of STI and HIV can be done through two strategies. It is important to maintain an uninfected status, for those not already infected, through prevention programmes for negatives. Identifying infected people early and starting treatment to reduce further transmission is another important strategy.
As a country with low prevalence, the main emphasis is placed on key populations such as female sex workers and men having sex with men to reduce the risk of transmission. NSACP works closely with NGOs and organisations of key populations to reach them through peers to give information and to provide services. The Global Fund has been supporting these prevention programmes in the community since 2012.
HIV prevention through positives
Currently available antiretroviral treatment is highly effective, and there is a marked reduction of illnesses and deaths of PLHIV on treatment. If a person takes treatment properly within six months, the HIV viral load reduces to undetectable levels. This does not mean that the virus is eliminated. A small amount of virus remains in the body which is not detectable. However, as the viral load is low the risk of transmission is minimal. Further, the persons’ immunity increases with treatment, allowing them to live a normal life with increased life expectancy.
All PLHIV are started on antiretroviral treatment and closely followed up. Antiretroviral treatment has markedly increased life expectancy. Persons living with HIV who are on treatment are doing well, being actively engaged in employment and social activities.
The role of creating awareness, especially among youth
Unprotected sexual exposures lead to STIs and HIV. Therefore, it is important to provide information on sexual health including services for prevention and care of STI and HIV. The topic of sexual health is taboo and the opportunities to get the correct information is limited.
Liberal attitudes towards sex among youth expose them to higher risk. When they are not well informed about the risks, they realise the gravity of risk behaviour only after the risk behaviour. Then it is too late. When a person gets infected with HIV, that cannot be reversed. Every step must be taken before that to avoid the risk of contracting HIV. All unprotected penetrative sex acts (anal, vaginal, and oral) expose a person to HIV. Anal sex carries the highest risk of HIV transmission, followed by vaginal and oral sexual encounters. Knowledge of condoms as a safer sex practice needs to be promoted. It is important to fund the implementation of the national HIV communication strategy which was published in 2017.
What are the challenges and how do we overcome them?
Among the estimated 3,500 people living with HIV, close to 2,000 are currently on antiretroviral treatment. Most people are not aware of the infection and do not come forward for testing. Every person who had unsafe sexual exposure should get themselves tested for HIV. HIV tests are available from district STD clinics, main hospital OPD, or in the private sector. Further information can be obtained through the website “National STD AIDS Control Programme”.
Take home message
Sri Lanka remains a country with a low prevalence of HIV due to the dedicated efforts of many stakeholders led by NSACP over the last 35 years. Having a low prevalence for a long period can lead to complacency, which can lead to risks such as lowered funding and reduced resources. Sri Lanka is facing this risk amid the Covid-19 pandemic, stated Dr. Rajapaksa.
It is important to understand the seriousness of the HIV pandemic which contributed to 76 million infections with 36 million deaths globally over the last 40 years, and take necessary measures to maintain the low prevalence of HIV.
Consultant Venereologist and National STD AIDS Control Programme Elimination of Mother to Child Transmission (EMTCT) of HIV and Syphilis Programme Co-ordinator – HIV Care Services Dr. Lilani Rajapaksa[/caption]
The name itself implies that sexually transmitted infections (STIs) are mainly transmitted through unprotected sexual exposures. A person can get an STI through penetrative sexual contact with a person having an STI. The sexual contact may be between a male and a female (heterosexual) or a male and a male (homosexual, men having sex with men). The type of penetrative sexual exposures can be oral, vaginal, or anal. If the person has not used a condom for penetrative sexual contact, it is an unprotected sexual act exposing them to STI and HIV.
There are many types of STIs, and of them, the common infections seen in Sri Lanka are genital herpes, genital warts, syphilis, gonorrhea, chlamydia, and HIV infections.
What is its true burden in Sri Lanka?
The true burden cannot be identified as many people infected with STI/HIV do not seek services. This may be due to multiple reasons such as not having symptoms, not perceiving the risk, not knowing where services are available, or reluctance to seek services due to stigma.
Available statistics are from the reported numbers from government STD clinics. According to the 2020 annual report from the National STD AIDS Control Programme, close to 83,000 visits have been made to STD clinics island-wide. These numbers just show the tip of the iceberg, and it is clear the actual burden is much more than this.
When should one suspect the possibility of an STI?
Usually, the diagnosis is based on the symptoms and signs. However, in STIs, a significant number of infected people can remain asymptomatic. More females are asymptomatic than males. They may not have any symptoms or signs to indicate the presence of STI.
What are the common symptoms observed in STIs?
A person who had a risky sexual exposure should seek services early if they experience the following symptoms:
- Genital ulcers
- Urethral discharge in males
- Scrotal pain or swelling
- Genital warts
- Vaginal discharge
- Lower abdominal pain in females
- The infected person may not be aware of the infection and can infect future partners
- Some STIs can be fully cured. But some viral STIs such as genital herpes or genital warts cannot be fully cured and need to be controlled for long periods. These can lead to physical as well as psychological distress to those infected
- STIs, if not managed early, can cause serious complications. The complications can involve the nervous system in syphilis, cause cervical cancers in genital warts, and infection in the reproductive system can lead to chronic conditions such as pelvic inflammatory disease
- Sri Lanka has a well-developed STD clinic system with 41 district STD clinics and several branch clinics based in major hospitals throughout the country. Comprehensive care services are offered free of charge to all who seek services at the STD clinics in a non-judgmental environment where seeking services are encouraged by having open clinics. Any person who is symptomatic or asymptomatic who needs a checkup can attend an STD clinic during working hours. Patients do not need referral letters etc. to receive services. The staff is appropriately trained, and 100% maintenance of confidentiality is assured
- Consider STD clinics as “Centres for Sexual Health”. Most of these clinics are equipped with the necessary facilities to provide the best services to needy people. However, the number receiving services at these clinics is much less than the number who really need services. A barrier has been created by identifying STD clinics as a place that serves people with unacceptable behaviour. This stigma attached to STD clinics prevents needy people from accessing available sexual health and STI services
Sri Lanka remains a country with a low prevalence of HIV, 35 years after identifying the first Sri Lankan with HIV in 1987. When many countries in the region experience worse epidemics, Sri Lanka was able to maintain a low prevalence of HIV due to the implementation of suitable strategies by many stakeholders under the leadership of the National STD AIDS Control Programme. These stakeholders include health and non-health sectors of the government, as well as the private sector, NGOs, organisations of key populations, and people living with HIV (PLHIV).
The main modes of transmission of HIV are through unprotected sexual exposures, blood-to-blood contact, and contact with body fluids of infected persons. In Sri Lanka, more than 95% of diagnosed adults living with HIV were infected through unprotected sexual contact. In 2019, the World Health Organisation (WHO) certified Sri Lanka as a country that had eliminated mother-to-child transmission of HIV. Transmission risk through blood has been minimised by the policies implemented by the National Blood Transfusion Services, thus further reducing the transmission risk.
According to the integrated biological and behavioural surveillance conducted in 2018, the risk behaviours are common among important key population groups such as female sex workers, men having sex with men, and beach boys. There is evidence that youth are engaging in unprotected sexual exposures, leading to increased HIV and STI in the community. Risk for HIV and STIs are increasing in society while the level of knowledge on infections or services is far from satisfactory.
Mitigation strategies currently in-place
Control of STI and HIV can be done through two strategies. It is important to maintain an uninfected status, for those not already infected, through prevention programmes for negatives. Identifying infected people early and starting treatment to reduce further transmission is another important strategy.
As a country with low prevalence, the main emphasis is placed on key populations such as female sex workers and men having sex with men to reduce the risk of transmission. NSACP works closely with NGOs and organisations of key populations to reach them through peers to give information and to provide services. The Global Fund has been supporting these prevention programmes in the community since 2012.
HIV prevention through positives
Currently available antiretroviral treatment is highly effective, and there is a marked reduction of illnesses and deaths of PLHIV on treatment. If a person takes treatment properly within six months, the HIV viral load reduces to undetectable levels. This does not mean that the virus is eliminated. A small amount of virus remains in the body which is not detectable. However, as the viral load is low the risk of transmission is minimal. Further, the persons’ immunity increases with treatment, allowing them to live a normal life with increased life expectancy.
All PLHIV are started on antiretroviral treatment and closely followed up. Antiretroviral treatment has markedly increased life expectancy. Persons living with HIV who are on treatment are doing well, being actively engaged in employment and social activities.
The role of creating awareness, especially among youth
Unprotected sexual exposures lead to STIs and HIV. Therefore, it is important to provide information on sexual health including services for prevention and care of STI and HIV. The topic of sexual health is taboo and the opportunities to get the correct information is limited.
Liberal attitudes towards sex among youth expose them to higher risk. When they are not well informed about the risks, they realise the gravity of risk behaviour only after the risk behaviour. Then it is too late. When a person gets infected with HIV, that cannot be reversed. Every step must be taken before that to avoid the risk of contracting HIV. All unprotected penetrative sex acts (anal, vaginal, and oral) expose a person to HIV. Anal sex carries the highest risk of HIV transmission, followed by vaginal and oral sexual encounters. Knowledge of condoms as a safer sex practice needs to be promoted. It is important to fund the implementation of the national HIV communication strategy which was published in 2017.
What are the challenges and how do we overcome them?
Among the estimated 3,500 people living with HIV, close to 2,000 are currently on antiretroviral treatment. Most people are not aware of the infection and do not come forward for testing. Every person who had unsafe sexual exposure should get themselves tested for HIV. HIV tests are available from district STD clinics, main hospital OPD, or in the private sector. Further information can be obtained through the website “National STD AIDS Control Programme”.
Take home message
Sri Lanka remains a country with a low prevalence of HIV due to the dedicated efforts of many stakeholders led by NSACP over the last 35 years. Having a low prevalence for a long period can lead to complacency, which can lead to risks such as lowered funding and reduced resources. Sri Lanka is facing this risk amid the Covid-19 pandemic, stated Dr. Rajapaksa.
It is important to understand the seriousness of the HIV pandemic which contributed to 76 million infections with 36 million deaths globally over the last 40 years, and take necessary measures to maintain the low prevalence of HIV.