The Importance of New Campaigns for the Preventions of Sexually Transmitted Diseases

Sexually transmitted diseases are an increasing public health problem, mostly affecting young adults and adolescents.

The prevalence of these infections is still high in the developing countries, but has also increased in the European countries, being estimated that there are at least 340 million new cases per year of only four of these infections: syphilis, gonorrhoea, Chlamydia and trichomoniasis.

Fig_ 1 – Intercellular diplococci in neutrophiles in exuded urethral from a patient with gonorrhoeia (adapted from www.cdc.gov/)

In the pandemic caused by HIV these infections are co-factors in acquisition of the disease, also increasing the risk of HIV transmission between two and five times.

The World Health Organization includes unprotected sexual relations among the five most relevant risk factors for the lowering of life expectancy of the population, with side effects such as infertility or inflammatory pelvic disease. The female sex is disproportionately affected by often asymptomatic sexually transmitted diseases, and it is in the pregnant woman that one can see the most serious consequences, such as materno-foetal morbility or even foetal mortality in syphilis.

In Western Europe, after the decrease in the prevalence of these infections at the end of the nineteen eighties, linked to the emergence of the infection by the HIV virus and the campaigns for prevention and the promoting of the use of condoms that followed this, there was a reappearance of the prevalence in the nineties. In current public health campaigns these infections are often overlooked or dealt with only in the prevention of HIV infection.

Portugal is the Western European country with the highest prevalence of HIV infection. In studies by the National Commission for the Fight against AIDS, the Portuguese state that it is infrequent for them to use condoms with new partners and that they are unaware of other sexually transmitted diseases. In studies by the World Health Organization the Portuguese adolescents had the lowest percentage of use of condoms in Europe, and this is even lower in adolescents with no schooling.

The Portuguese system of notification of these diseases is clinical, yet with under-notification being predominant as well as a lack of active search for treatment of partners. These deficiencies compromise the gathering of information that might allow an interpretation of epidemiological tendencies and thus orientate medical testings and campaigns for specific groups, increasing their cost-benefit ratio.

Studies on sexually transmitted diseases are rare in Portugal, and in adolescence they are mainly carried out within the field of social sciences and only include HIV infection.

In an epidemiological and laboratory study on sexually transmitted diseases in adolescents, included in a PhD programme at the Institute of Hygiene and Tropical Medicine, 403 adolescent females were included, both pregnant and not, accompanied at the Alfredo da Costa Maternity Hospital and Santa Maria Hospital during the years 2005 to 2007.

These adolescents had a prevalence of 10% of infections by Chlamydia trachomatis, and 4% of Neisseria gonorrhoeae, with no diagnosis of syphilis or HIV infection.

Fig_ 2 – Distribution of answers referring to the use of condoms

The consistent use of condoms by their partners was stated in only 8% of the population studied, in contrast with the use of hormonal contraceptives in 35% of the adolescents (in the pregnant adolescents this use was relative to the time of being diagnosed as pregnant, with 26% of the pregnant adolescents stating that they had become pregnant while taking hormonal contraceptives). Only 41% of the adolescents went to school and 48% were unemployed.

Several authors defend that in developed countries the main difficulty for adolescents is not a lack of or difficulty in getting condoms, but inconsistence in their use, as well as their being replaced by oral contraceptives as the relationship lasts longer. Adolescents often confuse their contraceptive effect with protection against HIV infection and other sexually transmitted diseases.

In our study, like other Portuguese series, there was a reduced use of condoms and high school dropout rate. The high percentage of infection by Chlamydia trachomatis observed in this population group is thus a reason for concern due to the effects this infection is causing on the female sex, interfering with their future sex life and reproductive function.

It is important to make the health professionals involved in adolescents’ health care aware of the need to promote the use of condoms, because in the population studied, and like national data, their was a high prescribing of the pill and a reduced use of condoms. Adolescents are also the group in Portugal that most uses the “morning after pill”.

Promotion of the use of condoms, with or without hormonal contraceptives, is necessary in adolescents, given that the use of condoms at younger ages is linked to a greater percentage of use at older ages and a lower percentage of sexually transmitted diseases later on. Training actions in schools about these infections and the use of condoms, adapted to the adolescent population, have shown a later reduction, both in risk sexual behaviour and in the incidence of these infections in adolescents.

Sex education in adolescence, attributed under Portuguese law essentially to schools, does not cover adolescents who leave school, and Portugal has the second highest school dropout rate in the European Union.

This low school attendance and high dropout rate compromise the efficiency of testing and prevention programmes to prevent sexually transmitted diseases when they are based only in schools. It is thus necessary to go back to promoting the use of condoms in campaigns that are not limited to schools and to inform adolescents about sexually transmitted diseases.
João Borges da Costa
Lisbon Dermatological University Clinic, Santa Maria Hospital
Sexually Transmittable Diseases Unit of the Institute of Hygiene and Tropical Medicine, Lisbon
joaobc77@hotmail.com

Bibliography:

Anderson JE, Santelli JS, Gilbert BC. Adolescent dual use of condoms and hormonal contraception: trends and correlates 1991-2001. Sex Transm Dis 2003, 30(9): 719-22.

Currie C, Roberts C, Morgan A et al. Young people’s health in context. Health behaviour in School-aged Children (HBSC) study: international report from the 2001/2002 survey 2004, 153- 60.

Fleming DT, Wasserheit J. A comprehensive review of the influence of traditional STD on HIV transmission and implications for HIV prevention. Sex Transm Infect 1999, 75: 3-17.

Gaydos CA, Hsieh YH, Galbraith JS et al. Focus-on-Teens, sexual risk-reduction intervention for high-school adolescents: impact on knowledge, change of risk-behaviours, and prevalence of sexually transmitted diseases. Int J STD AIDS 2008, 19(10): 704-10.

Low N, Broutet N, Adu-Sarkodie Y et al. Global control of sexually transmitted infections. Lancet 2006, 368: 2001-16.