SEXUALLY TRANSMITTED INFECTIONS IN SOUTH EAST ASIA

Sexually Transmitted Infections (STIs) are important health problems

Worldwide, nearly one million curable STIs occur each day, half of them in Asia. Where they are common, STIs are major causes of infertility, ectopic pregnancy, congenital infections and HIV/AIDS. Millions more incurable STIs add to the heavy burden of morbidity and mortality for women, men and children.

In addition, several STIs are potent cofactors that amplify transmission and facilitate spread of HIV epidemics. STIs are also sensitive markers of high-risk sexual activity that can indicate where HIV may be spreading.

STI surveillance is incomplete in most countries. In some areas with active prevention programmes, STI patterns are reportedly changing from high rates of curable and ulcerative STIs to lower overall rates with higher proportion of viral STIs. However, both intervention coverage and surveillance remain patchy; continued high transmission in underserved areas may go undetected and sustain high prevalence rates.

STIs in South-East Asia

Although STI rates are generally high in the Region, patterns are variable. Some countries have very high prevalence of curable STIs while others have low rates more typical of developed countries. Some countries have high rates of ulcerative STIs while others have few ulcers but high prevalence of gonorrhoea and chlamydia. While all countries can benefit from strengthening their STI control efforts, different epidemiological patterns call for different approaches.

Poor STI control has also facilitated HIV transmission in the region. Beginning in the 1980s, HIV took off quickly in several Asian countries under conditions of poverty, injecting drug use, commercial sex and population mobility. High rates of partner change with low condom use in such situations overwhelmed existing STI control efforts. STI patterns at the time were characterized by high rates of bacterial and ulcerative infections. High HIV incidence among sex workers and their clients rose quickly and clients spread infection to their lower risk partners.

1. Sex workers: The highest STI prevalence rates in the Region continue to be seen among sex workers. Prevalence of 20-50% for gonorrhoea and chlamydia and 10-20% for syphilis are common.
2. High-risk men: Males, particularly those who travel frequently or are separated from families for long periods, may serve as efficient bridging populations for STI transmission to the general population.
3. Pregnant women: High STI rates can be found in lower-risk populations if transmission among high-risk and bridging populations is not interrupted. Antenatal syphilis data can be a good marker of STI transmission in the general population.

Regional experience

In South-East Asia region, experience supports the combination of approaches outlined in WHO’s global strategy. Improved outcomes have been seen as a result of improving STI services, reaching the highest-risk populations and basing programmes on reliable data.

The 100% Condom Use Programme (CUP) in Thailand has enabled sex workers to demand condom use and access STI care. It has also had large-scale public heath impact. Rates of curable STIs fell by over 95% during the 1990s. By 2002, an estimated 5.7 million HIV infections had been averted; this includes sex workers and their clients but also - taking into account averted secondary infections - far larger numbers of people at lower-risk. Similar results are being reported to a varying degree where this approach is being adapted in Myanmar and other Asian countries.

The benefits of better STI control are within the reach of all countries in the South-East Asia region. The Regional Strategy builds on successful regional experience and global evidence to promote replicable interventions and feasible targets for STI control in South-East Asia.

Some successful initiatives of the region are:

Sex worker involvement

1. Sonagachi: STI/HIV services are one part of a broader effort to improve conditions for members of the community (community-led structural interventions). Sex workers participate actively in all aspects of community interventions and clinic-based services. HIV prevalence remains low in Kolkata compared to other Indian cities. Over 60,000 sex workers participate throughout the state of West Bengal, savings and credit schemes have reduced dependency on sex work, and self-regulatory boards effectively address a range of abuses from trafficking to child prostitution.
2. Avahan India AIDS Initiative: In order to scale up effective interventions for sex workers and other high-risk populations in India’s 6 highest HIV prevalence states, Avahan supports NGOs to organize outreach, community mobilization and dedicated clinics for sex workers. These clinics provide STI services including syndromic case management, regular checkups and treatment of asymptomatic infections. Condoms are promoted and distributed by outreach and clinic teams. Local advocacy work is carried out with police and others to promote enabling conditions for prevention work. Sex worker involvement is promoted in intervention activites from community outreach to provision of clinical services.

100% Condom use in commercial sex

1. Thailand 100% CUP: Implemented through a network of public health STI clinics, the 100% CUP achieved early success by saturating coverage of direct (brothel-based) sex establishments where condom use was mandated. The responsibility for enforcing condom use was on the establishment, which could be closed if non-compliant (although this was rarely done). One of the most important activities was local advocacy with police and other gatekeepers. As sex work changed to less direct forms (massage, karaoke and bar-based), interventions were adapted to include more outreach and increase involvement of sex workers. The Thai response highlights the importance of political commitment and public
   investment, a rapid response based on reliable epidemiological information, and multi-sectoral collaboration.
2. Myanmar 100% targeted condom promotion: Adapted from 100% CUP experience in Thailand and Cambodia, the 100% TCP in Myanmar attempts to reach sex workers and their clients through peer outreach, establishment visits and STI clinics. A clear plan of startup activities – formation of condom core groups, training of peers and clinical staff, etc – is rolled out in new sites. In 5 years, 100% TCP has been scaled up to cover 154 out of 350 townships in the country