• Some use emergency contraception as a regular method 
• Infections only contracted via sex workers or relations with the opposite sex
• Some use condoms only during vaginal or anal sex not oral sex 

Sexual health and Human Immunodeficiency Virus (HIV) medicine plays an important role in Sri Lanka, not only in preventing and treating HIV and sexually transmitted diseases (STDs) and infections (STIs), but also in addressing sexual health problems that people may find difficult to discuss due to social and cultural sensitivities.

The Daily Morning spoke to Consultant Venereologist at the National STD,  Acquired Immunodeficiency Syndrome (AIDS) Control Programme (NSACP), Dr Prageeth S Premadasa about the growing need for sexual health services and the social stigma that can prevent people from openly discussing sexual matters, even with healthcare professionals.

Following are excerpts of the interview:

What is the current status of sexual education in schools and the parents role in the same?

It was actually introduced a few years ago before sexual education was incorporated into the school curriculum. However, it was not done on a regular basis, and teachers also had a lot of difficulty explaining these issues to children.

Some parents do get involved. I have also worked in rural areas, and many parents don’t provide any sexual education for their children. It depends on the family. Some educated parents do discuss these issues with their children, but, in rural areas, children don’t receive this kind of education at home.

What is the current status of STDs/STIs and HIV?

If we look at HIV, we still have a low prevalence as far as the epidemic is concerned. It is less than 0.1 per cent of the population. However, over the last few years, the trend has been that the number of patients diagnosed each year is increasing. So, we are seeing an upward trend in HIV cases.

With regard to other STIs, we are also seeing an upward trend. As a country, we still remain a low-prevalence country, the direction that we are heading in is not good. If this trend continues, we could face a major public health problem in the future.

Is this because more testing is being done, or is it because of social media and its influence?

Testing has actually increased. As the NSACP, we have scaled up testing and launched several projects to improve testing among high-risk groups and the general public. So, this may be contributing to the increase in reported cases.

However, the positive cases and patients who come to our clinics tell us that high-risk sexual behaviour continues. It may be due to the influence of social media, but, we don’t know for sure. This needs to be researched.

Drug use has contributed to this. Earlier, we mainly had heroin, but now, there are many other drugs, including party drugs and those used for chem.-sex. These can impair people's judgement. Even when people know about the diseases and the risks, they may not know what they are doing or remember what happened afterwards when they are under the influence of drugs. I say this based on the experiences of our patients, who sometimes tell us that they knew about the risks but that they cannot remember what happened during a particular incident.

Awareness is key. It is difficult for a Programme like the NSACP to go into communities, identify people at risk and test them. We need to raise awareness so that those at risk come forward for testing. Only through testing can we know whether someone has an infection.

This is especially important with HIV. The more people who get tested, the more infections that we can detect, which benefits both the individual and the community.

For the patient, we now have effective drugs that can control the Virus and allow them to live a normal life. They can marry and have children, and their lifespan is not affected. When treatment reduces their Viral load to an undetectable level, they cannot transmit the Virus to others. This is what we call ‘positive prevention’.

So, we need to raise awareness, encourage testing and ensure that those who test positive are started on treatment.

What is the possibility of an HIV vaccine being introduced to Sri Lanka?

Research is being carried out worldwide, but, a vaccine is still not on the horizon. We cannot expect an HIV vaccine in the near future.

However, there are newer developments. In the coming years, Sri Lanka will probably also have injectable drugs for HIV. This could help overcome some of the difficulties with the daily treatment that patients currently have to take. Some of these drugs only need to be given every six months. It is almost like a vaccine, although technically it is not a vaccine. It is a long-acting drug that can reduce the number of visits that patients have to make to a clinic and also improve treatment compliance.

Are the patients who come to the clinics mainly younger people, older people, or is it a mix?

It is a mix. We cannot say that one particular age group comes to the clinics. We see schoolchildren and people of school-going age, as well as older people.

However, if we look at the national figures for HIV infections, the majority of patients are between 25 and 40 years of age. They account for around 50 per cent of the patients.

What is the impact of social media on children sexually, and how much should it be controlled?

Social media has created many opportunities for high-risk individuals to connect with each other. For example, people are finding partners through social media, and this is happening quite often.

When it comes to children, we need to learn from what other countries are doing. Some countries have already banned or limited social media use among minors. Sri Lanka could also introduce some form of restriction rather than allowing children unlimited access.

In the United Kingdom, there are restrictions on children's social media use during certain hours, particularly at night. Something similar could help reduce children's exposure to unnecessary or harmful content.

At the same time, social media has many positive uses, particularly for education. Completely banning it could create problems, as many online classes and educational activities are now conducted through these platforms.

So, rather than a complete ban, some form of restriction, as introduced in other countries, would be a better approach. We could even try it as a pilot project and see how it works.

hat are the common myths one comes across regarding STDs/STIs and HIV?

When it comes to sexual health, there are a lot of myths because people don’t have proper channels to get the correct information. They often get information from other sources, which may not be accurate. That is why these myths continue.

First of all, when we talk about STIs, a lot of people think that because they are not openly discussed, the prevalence of STIs is low. But, that is not the case. As people who handle the National statistics, we know how many patients we see with STIs.

There are also myths about how STIs, including HIV, are transmitted. A lot of people think that STIs are only contracted through sex with sex workers or through sexual relationships with the opposite sex. But that is not the case. If we analyse the HIV statistics, more than 50% of the infections have occurred through sexual activity between men.

Another common misconception is that using condoms during vaginal or anal sex is enough. People sometimes make the mistake of not using condoms during oral sex.  Oral sex can also transmit certain STIs.

There are also myths about condom use. Some people think that condoms are not pleasurable or that using them will create unnecessary problems, so they avoid using them.

Another issue is that some people don’t take STIs seriously. They think that they will not cause complications or that the infection will go away on its own. But, we have to remember that certain STIs can be lifelong. A good example is genital herpes. If someone acquires genital herpes, even through oral sex, the infection can persist for life. So, it is a serious issue.

How do you deal with such myths and misconceptions?

We continue to conduct awareness programmes because the NSACP has two arms. One is the curative arm, where we treat people at our clinics, while the other focuses on awareness in the community.

We have 40 sexual health centres island-wide, through which we conduct awareness programmes for young people, both school-going and out-of-school youth, as well as high-risk groups. We also run national social media campaigns to raise public awareness.

We have also introduced programmes such as ‘Know For Sure’, a website where people can assess their risk. They can order test kits to their homes or book an appointment at their nearest centre at a suitable time if they have concerns.

So, we have made these services more user-friendly, especially for young people, to improve their access to sexual health services.

Is this particularly for HIV or for STDs/STIs as well?

We basically provide comprehensive sexual health services. Whatever question or problem that people have regarding their sexual health, they can come and discuss it with us.

Our clinics are very friendly and are not only for STIs. If they have any kind of sexual health problem, they can come and discuss it with us. They don’t necessarily have to come for treatment. They can also come for counselling or to discuss other issues related to their sexual well-being.

Has the use of contraceptive methods declined as a result of these myths? What is the present situation?

The concept is still misunderstood by many people. For example, some use emergency contraception as a regular method. We see people taking Postinor almost every day.

Regular contraceptive methods are available and promoted through various campaigns and awareness programmes. However, myths still exist, particularly about oral contraceptives. Some people believe that they can affect their fertility, so they avoid using them and instead try natural methods, which can result in unintended pregnancies.

With unprotected sex, there is also the risk of STIs and unintended pregnancy. Some may then feel that they have no option but to seek an abortion.

However, abortion is illegal in this country except under very limited circumstances. As a result, some turn to unqualified people for abortions, putting their lives at risk.

We have seen patients who have undergone such procedures and developed serious complications. In some cases, they have even died.

What are the most prevalent STIs in Sri Lanka?

Viral STIs are quite common. This is the case in many countries because we don’t have a permanent cure for viral infections. Genital warts and genital herpes are particularly common among STIs, and they have a high prevalence.

Can you explain some of the common symptoms?

Some symptoms are limited to the genital area. People can develop ulcers or warts, or an abnormal increase in genital secretions, such as discharge from the urinary tract or anus. However, symptoms can also appear elsewhere, such as a generalised rash.

What is important is that we should never wait for symptoms to appear. If someone has had unprotected sex, they should get tested because some STIs are asymptomatic. They may not cause any symptoms but can still lead to complications and be transmitted to others.

HIV is a good example. Some people may not develop symptoms for the first two or three years.

Sex is very intimate and private, so, only the people involved may know the level of risk that they have been exposed to. That is why it is important to understand the risk and get tested rather than wait for symptoms. Some STIs, including HIV, can only be detected through testing.

What are the other sexual health issues that people come to sexual health centres with?

A: We manage all kinds of sexual health problems. We often focus on one aspect, which is STIs, including HIV, but, there are other sexual health problems as well.

There are male and female sexual dysfunctions. Some men may have difficulty engaging in sexual activity because of conditions such as erectile dysfunction or premature ejaculation. Women can also experience sexual problems, such as vaginitis and low sexual desire, which can affect their quality of life.

We need to look at these problems from that perspective, because, ultimately, what matters is a person's quality of life. For example, we know that many patients with diabetes develop erectile dysfunction as a complication of the condition. We also help them manage these problems and improve their overall health, quality of life and mental well-being.

How is the sexual health of elderly persons dealt with?

It is quite an unspoken issue. In a cultural setting like Sri Lanka, many people, including the elderly, think that there is no room for sexual activity when they reach old age. But that is not the case. They also want to have a good sexual life. Especially after their children have grown up and they reach retirement age, they may want to continue having sex.

The problem is that because of stigma, discrimination and social attitudes, they do not come forward with problems related to their sexual life. The social norm is that once people become elderly, they should engage in religious activities, look after their grandchildren and do things like that. So, they often don’t talk about these problems.

Now, with greater awareness, people are coming forward with specific concerns. The sexual life of a young man is quite different from that of an older man. When people reach that age, they also face medical conditions such as diabetes and high blood pressure and may be taking several medications. These health conditions and medicines can affect their sexual activity, so, we need to take those issues into consideration.

We are trying our best to incorporate sexual health services into general healthcare, because, ultimately, what we need is to improve a person's quality of life. Research carried out in Sri Lanka has shown that 72% of diabetic men have erectile dysfunction. But, even when they attend a Government diabetic clinic for routine visits, unless they raise the issue themselves, the doctor, even if they are a specialist, may not ask elderly patients about their sexual health.

It is time to change this and look at these problems from a different perspective, particularly when it comes to improving their quality of life. It would be better if we could address these issues as part of their routine care.

We are also conducting awareness campaigns to encourage doctors to ask about these problems. Some of the sexual health problems may be directly related to the medicines that they are taking. Unless doctors ask about them, patients may not come forward because of these cultural barriers.

The views and opinions expressed in this column are those of the interviewee, and do not necessarily reflect those of this publication