STI/Condom Week: Why South Africa is lagging behind in fighting new infections

If left untreated, chlamydia and gonorrhoea can damage reproductive organs and result in long-term complications such as infertility. Picture: Jannes Jacobs /Unsplash

If left untreated, chlamydia and gonorrhoea can damage reproductive organs and result in long-term complications such as infertility. Picture: Jannes Jacobs /Unsplash

Published Feb 8, 2024


As South Africa observes STI/Condom and Pregnancy Awareness Week, from February 10 - 16, the nation engages in a vital conversation about sexual health. South Africa, with 7.5 million of its population living with HIV, has made significant strides in combating the virus.

Since 2010, new infections and deaths from HIV have plummeted by 50% and 73%, respectively.

Data from the end of 2021 indicates that an impressive 94% of people living with HIV are aware of their status, and 74% of them have begun antiretroviral treatment, with most achieving viral suppression.

Yet, amid the progress, challenges persist, particularly for children with HIV, where only 52% are on ART and their rates of viral suppression trail behind that of adults. Enhanced efforts to prevent mother-to-child transmission are clearly needed.

The South African Medical Journal offers stark numbers: sexually transmitted infections (STIs) are responsible for substantial economic impact in developing nations, with an estimated 17% of health-related financial loss.

Findings suggest the prevalence rates of Chlamydia trachomatis are at 14.7% among men and 6.0% for women, Neisseria gonorrhoeae at 6.6% for men and 3.5% for women, with syphilis rates at 0.5% for men and 0.97% for women in South Africa.

According to global estimates, about a million STI cases are recorded daily, ranging from gonorrhoea and chlamydia to syphilis. Despite improvements in screening, the infection rate for diseases like chlamydia has not witnessed a decrease over the past decade.

STIs predominantly spread through sexual contact, including vaginal, anal and oral routes. However, they can also be transmitted non-sexually, from mother to child, during pregnancy or childbirth.

STIs predominantly spread through sexual contact, including vaginal anal, and oral routes. Picture: Reproductive Health Supplies Coalition /Unsplash

Untreated STIs can cause severe health consequences, such as genital ulceration, infertility, and pelvic inflammatory disease in adults. In infants, they can lead to blindness or severe neurological issues.

In South Africa, the interplay between STIs and HIV is particularly critical. In 2017, South Africa reported around 7.9 million individuals living with HIV.

Considering the heightened risk of HIV transmission involving STI-infected individuals, tackling the incidence of STIs is a key front in the broader campaign against HIV.

Several studies in developing countries have shown that treating STIs among HIV-infected patients significantly reduces the risk of transmission by reducing levels of HIV in genital secretions.

STIs can have devastating effects on sexual, reproductive and general health. They can also lead to several complications. If left untreated, chlamydia and gonorrhoea can damage reproductive organs and result in long-term complications such as infertility.

People can even die if certain STIs such as syphilis are left untreated, or if they have complications such as pelvic inflammatory disease in the case of chlamydia.

To make matters worse, STIs increase the risk of HIV infection and transmission.

According to a report from the 2022 Antenatal HIV Sentinel Survey, in 2017, South Africa saw approximately 2.3 million new gonorrhoea infections and 1.9 million new chlamydia cases among women aged 15 to 49.

Men in the same age bracket were not spared, with an estimated 2.2 million and 3.9 million new infections of gonorrhoea and chlamydia, respectively, alongside 47 500 new syphilis cases.

The infections also significantly increase an individual's vulnerability to HIV because STIs cause a concentration of immune cells that are easily targeted by HIV that is ready to replicate.

Alarmingly, many individuals remain untreated due to a lack of symptoms, as pointed out by a PLoS ONE journal study. In 2017, South Africa, a country grappling with a staggering 7.9 million people living with HIV, recorded 23 175 new syphilis cases in women and double that in men.

The impact of the infections extends to newborn health, with the National Institute for Communicable Diseases reporting 794 clinical notifications of congenital syphilis between July 2017 and December 2020.

The condition, caused by the transmission of syphilis from mother to child during pregnancy, can result in severe birth outcomes, including neonatal death and preterm birth.

Syphilis, a complex and staged disease, remains difficult to diagnose. Its initial symptoms, like a painless sore known as a chancre, can go unnoticed.

Rashes on hands sores on feet in men, and flu-like symptoms in women are common, but the subtle nature of the signs contributes to undiagnosed cases.

Adding to the concern, a PLOS ONE study in 2018 estimated around two million people annually contract gonorrhoea in South Africa, probably an understatement considering many women do not exhibit symptoms.

The World Health Organization (WHO) estimates that, globally, there are 87 million cases of gonorrhoea annually, with the African region having the highest burden.

The bacteria Neisseria gonorrhoeae, responsible for gonorrhoea, is a major contributor to Male Urethritis Syndrome (MUS) in South Africa. This results in symptoms such as genital discharge among men seeking care at primary health-care clinics.

When men are infected, they may experience symptoms like discharge from the penis and a burning sensation during urination. If left untreated, it could lead to painful swelling of the testes and potential infertility.

The situation is equally concerning for women, with symptoms ranging from vaginal discharge to lower abdominal pain and gynaecological complications, including the risk of infertility and tubal pregnancy if left unaddressed.

However, it is important to note that many women may not display any symptoms, or only experience mild ones, making the infection difficult to detect.

Research into why South Africa may be lagging behind in reducing new infections of STIs often points to a combination of health system challenges, socio-economic factors, cultural barriers and behavioural components.

Health system constraints

The South African health system is often overburdened by high patient loads, especially in public health-care facilities. There are also shortages of health-care professionals and a limited number of clinics in rural areas, which reduce accessibility to STI testing and treatment services.

Socio-economic factors

Poverty, inequality and unemployment can contribute to increased vulnerability to STIs due to factors such as transactional sex, limited access to health-care and lower levels of education which affect sexual health knowledge.

Cultural barriers

In some communities, cultural norms and stigma around sexual health prevent open discussions about STIs. The stigma can delay individuals from seeking diagnosis and treatment due to fear of judgement or discrimination.

Education and Awareness

A lack of comprehensive sexual education in schools and communities can lead to misconceptions about STI prevention and transmission. Without proper knowledge, individuals may engage in riskier sexual behaviours.

Behavioural factors

Risky behaviours, such as having multiple sexual partners and engaging in unprotected sex, are prevalent in some populations and contribute to the spread of STIs.

Resistance to treatment

The rise of antibiotic-resistant strains of bacteria that cause STIs, such as gonorrhoea, has made treatment more difficult and has the potential to increase the rate of infections.