Sexually transmitted infections based on syndromic approach and risk behavior factors in Ethiopia

Introduction: Sexually transmitted infections constitute a major public health problem worldwide. They are important because of their magnitude, potential complications, and interactions with HIV/AIDS. Due to this fact, the National HIV/AIDS Policy of Ethiopia identified STI prevention and control as one of the strategies to prevent and control HIV/AIDS. In order to fill the critical information gap on STI, Ethiopian Public Health Institute (EPHI) has established a national STI surveillance system in selected sentinel health facilities, since 2011. Objective: To determine the proportion of respondent with sexually transmitted infections syndroms. Method: From July 2014 to June 2015, a cross sectional study was carried out in 20 sentinel health facilities to determine the proportion of respondent with Urethral discharge, Vaginal discharge, Lower abdominal pain, Inguinal Bubo, Scrotal swelling, Genital ulcer disease and their HIV status. Result: Nearly 67% of the participants were in the age group 20-34yrs and 68% of them were females. From 1421 participants, 441 male and 968 female; 1333(93.8%) were diagnosed with one symptom and 88 (6.2%) with two symptoms; vaginal discharge constitutes the highest proportion (52.2%) followed by urethral discharge (25.3%), lower abdominal pain (13.3%), non-vesicular GUD (4.6%) and vesicular GUD (2.7%). The participant’s sexual history for the past three months was assessed and 17.4% of them had sexual contact with a non-regular partner and of them 55.8% have not used condom during the last contact. In addition, HIV status was reported by 1118 (78.7%). Conclusion: Our findings indicated that, the major symptoms are vaginal and urethral discharge, a considerable proportion of patients had sexual encounter with a non-regular partner in the last three months period and of them more than half have not used condom during the last sexual contact. Moreover, a larger proportion of HIV positive STI patients used to know their status before the study. Therefore, expansion of STI preventive services including health education on the transmission and possible complications of untreated STI is crucial.


Introduction
Sexually transmitted infections (STIs) constitute a major public health problem worldwide especially in developing countries. An estimated 357 million new cases of curable sexually transmitted infections, mainly due to Treponema palladium (syphilis), Neisseria gonorrhea, Chlamydia trachomatis, and Trichomonas vaginalis, occur every year throughout the world in men and women aged 15-49 years. Moreover, the impact of these diseases is magnified by their potential to facilitate the spread of human immunodeficiency virus (HIV) (WHO 2012). Cognizant of these facts, the National HIV/AIDS Policy of Ethiopia identifies STI prevention and control as one of the strategies to prevent and control HIV/AIDS (FDRE 1998). However, nationally there is still considerable underreporting of STI cases. Underreporting has been due to excessively long list of reportable diseases; concerns about confidentiality; provision of treatment by the informal sector; the asymptomatic nature of some STIs and the fact that there is no strong Syndromic Case Management Program in all the regions of the country, even though Ethiopia has adopted the syndromic approach to manage STI cases (FDRE 1998).
In Ethiopia, any patient who presents with STI case in health facilities is treated by syndromic approach. The main reason for the development of STI syndromic approach is not only lack of skilled health professionals' rather inadequate access to laboratory for etiological diagnosis; it is only syphilis testing which is being conducted by laboratory investigation. The syndromic approach has its guideline and every health professional takes training on how to manage STI cases (FMOH 2015). Nevertheless, much remains to be done in strengthening the STI prevention and control program in the country. One of the most outstanding problems is lack of information on the status and trends of STIs in the country. Therefore, this study was aimed to estimate the magnitude of the priority reportable STI syndromes and generate additional information on

Materials and Methods
Study Design: Across sectional study was carried out from July 2014 to June 2015 in 20 sentinel health facilities to determine the proportion of respondents with Urethral discharge, Vaginal discharge, Lower abdominal pain, Inguinal Bubo, Scrotal swelling, Genital ulcer disease and their HIV status. The study sites were selected from health centres and hospitals across the country. Any client, who is newly diagnosed and/or treated as a case of STI in the general outpatient department (OPD), in the STI unit, antiretroviral treatment (ART) room, and in the youth friendly service unit was included in the sampling.
The questionnaire was adopted from WHO recommendation for STI studies (WOH 1999). The health professionals (medical doctor/Nurse/Health officer) collected the data and filled the required information on the data collecting form for every consecutive STI patient with new symptom. Data was entered using CSPRO software and the analysis and tabulation of data was made using SPSS version 20. Trainings were given on data collection, handling, and reporting for regional coordinators and site level staffs using standardized-training manuals. Every month, the collected data was submitted to the investigator through the assigned coordinators. The diagnosis of STIs relied on proper history taking and physical examination. For each syndrome, a clinical flow chart is developed for STI case management. A flow chart (algorithm) is a decision and action tree, which is like a map that guides the health worker to go through a series of decisions and actions (FMOH 2015).

Results
Socio-demographic characteristics of the respondents: A total of 1421(441 male and 968 female) individuals from 20 health facilities had participated in the study. Around 62.8% of the study participants were in the age group of 20-34 years with a mean age of 26 years and 68.2% were females. Nearly 66.6% of the clients had educational status of 8 th grade or less, only a small proportion (7.2%) attended above 12 th grade. About 51.3% of the respondents were married and15.4% of participants were daily laborers ( Table 1).

Pattern of reported STI syndromes:
A total of 1509 (452 from male and 1057 from female) STI syndromes were identified; majority 1333/1421(93.8%) of them only had one syndrome while 88/1421(6.2%) were diagnosed with two syndromes. Regarding the proportion of all syndromes, vaginal discharge consists the highest proportion (52.2%) followed by urethral discharge (25.3%). Analysis of the STI cases with agedisaggregation showed that 42.3% fall under 24-34 years age group (Table 2).    Furthermore, higher HIV prevalence was observed among patients with vesicular GUD (32%) and ING (28%) syndrome. HIV prevalence also showed the same demographic pattern with other STIs, majority of HIV positive study participants (53%) lay between the age group of 24-34 (Table 4).

STI patients with pregnancy status:
Out of 946 female participants whose pregnancy status was checked, 64 (6.8%) were at some stage of pregnancy (Table 3). The pregnancy status was reported by the clients and supported with physical examination and laboratory diagnosis.

Discussion
The study has shown that 67% of the participants were in the age group 20-34years and 68%of them were females. Regarding the syndromes, vaginal discharge constitutes the highest proportion (52.2%) followed by urethral discharge (25.3%). In addition, 181 (16.2%) of Ethiop. j. public health nutr.
the participants were HIV positive (8.4% among males and 19.7% among females).
Reported STIs represents only the "tip of the iceberg", because most infections typically more than half of any specific diagnosis regardless of bacterial or viral etiology, are entirely asymptomatic or unrecognized, this is especially true for women (Adler 1996;Bolan et al. 1991). This showed that the actual situation in the study area could even be worse as only symptomatic cases came to the clinic. There could also be unreported symptomatic cases due to stigma and discrimination, fear of potential conflict with sexual partner especially in the married group, selfprescription of medicines from pharmacies, preference to traditional healers, and because of the general poor health seeking behaviour of the community (Beyene et al. 2013).
In 2015, WHO reported a global estimate of 357 million new cases especially by four curable STIs (syphilis, gonorrhoea, Chlamydia and trichomoniasis) in adults aged 15 -49 years (WHO factsheet 2015). In addition, younger age group (15-24years), even though they represent only 25% of sexually active population, they consists almost 50% of the new acquired STIs (Da Ros and Schmitt 2008). This study also showed that young people in the age group of 20-34years are the most affected with a larger proportion of females. The result is in agreement with the report by Klouman et al. in Tanzania and Getu Kassa et al. in Southern nation, nationality and people region (SNNPR) (Kassa and Anteneh 2013). Men and women have different susceptibility to STI due to biological vulnerability; one of the reasons for the difference is the contact period with pathogens after sexual exposure, it is more extended among women than men are. That is, if the male partner has an STI, the infected semen remains in the vagina following intercourse; in contrast, if the female partner is infected, the male's exposure to the pathogens is limited to the duration of coitus (Koray et al. 1995). The cervix may also be more susceptible to infection than the male's urethra. Furthermore, STIs are asymptomatic in women than in men (Koray et al. 1995). The most frequent STI syndromes reported for women were vaginal discharge and urethral discharge for men; this is consistent with the study done by (Kassa and Anteneh 2013), in SNNPR and Beyene et al in Gondor town, they reported 55.7% and 38.38% vaginal discharge and 25.8% and 13.58% urethral discharge, respectively.
The Proportion of study participants with vesicular and non-vesicular ulcer disease were 7.4%, which is almost similar with the study done in SNNPR (6%) (Kassa and Anteneh 2013). Genital ulcer diseases serve as a proxy for important curable bacterial STIs, such as syphilis and chancroid, as well as for incurable viral STIs such as herpes simplex virus (WHO 2003;WHO 2012;WHO 2015). Where most genital ulcer cases are due to curable bacterial STI, strengthening management of STIs should lead to a decline in rates of genital ulcer cases. The proportion of study participants with uretheral discharge was 25%. It indicates the need for careful assessment of STI control efforts in the country and also shows the strength of STI control programs, in countries without strong STI laboratory capacity (WHO 2012). Different behavioral risk factors have been frequently associated with sexually transmitted infections (WHO 2003). This study also showed that 17.4% of patients had sexual contact with a non-regular partner in the last three months period and around 55.8% of them have not used condom during the last sexual contact with a non-regular partners. In addition, 14.3% of the patients had two or more sexual partners in the last three months, which calls for a need to strengthen our effort in health education activities. Health care providers and community health workers should focus on behavioral change intervention such as safer sexual practices and condom use (Philippe and Duncan 2001

Conclusions and Recommendations
This study indicated that a considerable proportion of patients had sexual contact with non-regular partner in the last three months period and more than half of them have not used condom during the last sexual contact. Moreover, a larger proportion of HIV positive STI patients used to know their status before the study. Therefore, expansion of STI preventive services including activities on appropriate health care seeking behavior, information education and communication should also be strengthened.

Limitation:
This study was conducted in twenty selected health facilities across the country, which does not assume neither regional nor national representativeness; therefore, care should be taken not to generalize these study findings to respective regional or national program performance.