11

Sexually Transmitted Diseases and HIV Infection

In Sub-Saharan Africa, sexually transmitted diseases (STDs) are among the most common reasons that adults, as a group, seek health care (Hira et al., 1992b; Meheus et al., 1990; Zimbabwe, 1989). Yet this statistic refers primarily to males. Most women with STDs will not seek medical care at all, or will only present late for treatment, when complications have already developed, complications that have devastating physical, psychological, and social consequences, particularly for women and their children (Carty et al., 1972; Latif, 1981). These consequences for individuals, in turn, have serious repercussions for the societies of which they are part.

Human immunodeficiency virus (HIV) infection is considered by many to be the most serious STD because of its multiple debilitating manifestations, its high fatality rate, and the severe stigma and discrimination that surround it in communities around the globe. In Sub-Saharan Africa, where the infection is acquired sexually in most cases, HIV seriously affects, and will spread among, the very same women and men who already have very high rates of other STDs.

Table 11-1 depicts the gender-related burden of HIV infection and the STDs reviewed in this chapter. As the table indicates, both are of unique significance to female health because of their capacity for transmission from mother to offspring during pregnancy and birth and, in the case of HIV infection, through breast milk. In contrast to HIV infection, which in Sub-Saharan Africa is a disease of both women and men, the other STDs disproportionately affect women, who bear 80 percent of the disability-adjusted life years (DALYs) lost to these diseases (World Bank, 1993). In addition, compared with HIV infection, which has stimulated extensive research, including research related to the women of Sub-Saharan Africa (de Bruyn, 1992; Mane et al., 1994; Mann et al., 1992; Orubuloye et al., 1993; Temmerman et al., 1994; Ulin, 1992; WHO, 1993, 1994), relatively little attention has been paid to the other STDs. We therefore choose to consider HIV and other STDs together, and to place greater emphasis on non-HIV STDs.

This chapter first provides a conceptual framework for thinking about STDs and HIV infection. It then highlights the gender differences that make all STDs a critical women's health concern and examines special issues that are unique to the different stages of women's lives. Next, the chapter describes the magnitude of the problem in Sub-Saharan Africa, analyzing existing data, explores the geographic distribution and clustering of five common STDs, including HIV infection. The chapter proceeds to an examination of societal factors that may influence STD and HIV prevalence, and closes with a discussion of implications for research, policy, and programs.



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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa 11 Sexually Transmitted Diseases and HIV Infection In Sub-Saharan Africa, sexually transmitted diseases (STDs) are among the most common reasons that adults, as a group, seek health care (Hira et al., 1992b; Meheus et al., 1990; Zimbabwe, 1989). Yet this statistic refers primarily to males. Most women with STDs will not seek medical care at all, or will only present late for treatment, when complications have already developed, complications that have devastating physical, psychological, and social consequences, particularly for women and their children (Carty et al., 1972; Latif, 1981). These consequences for individuals, in turn, have serious repercussions for the societies of which they are part. Human immunodeficiency virus (HIV) infection is considered by many to be the most serious STD because of its multiple debilitating manifestations, its high fatality rate, and the severe stigma and discrimination that surround it in communities around the globe. In Sub-Saharan Africa, where the infection is acquired sexually in most cases, HIV seriously affects, and will spread among, the very same women and men who already have very high rates of other STDs. Table 11-1 depicts the gender-related burden of HIV infection and the STDs reviewed in this chapter. As the table indicates, both are of unique significance to female health because of their capacity for transmission from mother to offspring during pregnancy and birth and, in the case of HIV infection, through breast milk. In contrast to HIV infection, which in Sub-Saharan Africa is a disease of both women and men, the other STDs disproportionately affect women, who bear 80 percent of the disability-adjusted life years (DALYs) lost to these diseases (World Bank, 1993). In addition, compared with HIV infection, which has stimulated extensive research, including research related to the women of Sub-Saharan Africa (de Bruyn, 1992; Mane et al., 1994; Mann et al., 1992; Orubuloye et al., 1993; Temmerman et al., 1994; Ulin, 1992; WHO, 1993, 1994), relatively little attention has been paid to the other STDs. We therefore choose to consider HIV and other STDs together, and to place greater emphasis on non-HIV STDs. This chapter first provides a conceptual framework for thinking about STDs and HIV infection. It then highlights the gender differences that make all STDs a critical women's health concern and examines special issues that are unique to the different stages of women's lives. Next, the chapter describes the magnitude of the problem in Sub-Saharan Africa, analyzing existing data, explores the geographic distribution and clustering of five common STDs, including HIV infection. The chapter proceeds to an examination of societal factors that may influence STD and HIV prevalence, and closes with a discussion of implications for research, policy, and programs.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 11-1 HIV Infection and Other Sexually Transmitted Diseases in Sub-Saharan Africa: Gender-Related Burden Disorder Exclusive to Females Greater for Females than for Males Burden for Females and Males Comparable, but of Particular Significance for Females HIV infection Xa     Other STDs   Xa   NOTE: Significance is defined here as having impact on health that, for any reason—biological, reproductive, sociocultural, or economic —is different in its implications for females than for males. a Both HIV infection and other STDs have the capacity to be passed on from an infected mother to her offspring through congenital, perinatal, or neonatal transmission. OVERVIEW STDs, Including HIV Infection, and their Complications One of the simplest and most useful ways to classify STDs is based on their two most common syndromes: genital discharge and genital lesions. STDs such as gonorrhea, chlamydia, and trichomoniasis cause genital discharge. Others cause genital lesions that can be further categorized as ulcerative diseases such as syphilis, chancroid, and genital herpes, or as nonulcerative diseases such as genital warts. In addition, a few STDs, such as human immunodeficiency virus (HIV) infection, do not fit this syndromic classification. The final stage of HIV infection, acquired immunodeficiency syndrome (AIDS), develops after a variable period of time, with onset generally following initial infection within approximately 10 years, during which it remains largely asymptomatic. The symptomatic stages of AIDS are characterized by the onset of opportunistic infections or cancers, some of which, such as cervical cancer, affect the genital tract. This chapter refers to studies from Africa whenever they are available. When African data do not exist, or when comparison is appropriate, data are presented from other countries, particularly Sweden, which has accumulated a substantial and unique body of data on STDs in women. Complications of STDs Untreated or inappropriately treated, STDs may lead to severe complications, which account for most of their morbidity. Such complications occur most frequently in populations that lack ready access to effective treatment. Furthermore, both the anatomy of the female genital tract —prone to ascending infections—and reproductive events and related medical procedures—childbirth, stillbirth, abortion, uterine curettage, and intrauterine device insertion—are additional risk factors for STD complications particular to women (Meheus et al., 1990). The main STD complications include pelvic inflammatory disease (PID) and its sequelae, and the most important of these are impaired fertility and adverse pregnancy outcomes, enhanced HIV transmission, and cervical cancer. The clinical manifestations associated with HIV infection depend on several factors, including the pathogens to which an individual has been exposed; the susceptibility of the host; possibly, the strain of HIV; and access to medical care. Most studies have not highlighted significant gender differences in disease progression. In the United States, however, one study indicated that, compared with men, HIV-infected women were at increased risk of death, which may reflect differential access to health care or different socioeconomic status and social support for women compared with men (Melnick et al., 1994). In Africa, little information is available on the natural history of HIV infection, particularly among women. The clinical picture of HIV infection in Sub-Saharan Africa

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 11-2 Sexually Transmitted Diseases in Women     Potential Complications Syndrome Etiology Infertility/Ectopic Pregnancya Adverse Pregnancy Outcomea Cervical Cancera Enhanced HIVa Transmission Discharge Chlamydia X X   X   Gonorrhea X X   X   Trichomonas   X   X Lesions           Genital ulcers             Syphilis   X   X   Chancroid       X   Herpes   X   X Other             HPV infection and genital warts   X X   a Potentially fatal. appears to be dominated by dermatological and gastrointestinal manifestations and by tuberculosis (De Cock et al., 1993; Kreiss and Castro, 1990). A recent study strongly suggests that a sexually transmitted herpes virus causes Kaposi's sarcoma, one of the clinical manifestation of AIDS (Chang, 1994). In Africa, while this cancer has always been endemic, predominantly affecting men, with the spread of HIV its incidence has risen notably, and it is affecting an increasing number of women. In Zambia, the proportion of women among persons with Kaposi's sarcoma increased from 9 percent in 1983 to 30 percent in 1990–1992 (Ebrahim et al., 1993). The onset of AIDS may be delayed by antiretroviral drugs. Because of their high cost, however, it is unlikely that these drugs will become widely available in the near future in Sub-Saharan Africa. Most important, several AIDS-indicative diseases may be prevented. Indeed, some opportunistic infections can be prevented by the use of chemoprophylaxis, and invasive cervical cancer can be prevented by proper recognition and treatment of cervical dysplasia or early cervical cancer. The syndromic classification of STDs described above also suggests the kinds of complications that may occur. For example, fertility impairment is primarily associated with the genital discharge syndromes, and both genital discharges and genital ulcers may be prodromal to poor pregnancy outcomes and enhanced risk of sexual HIV transmission (Table 11-2). In men, STD complications do not have the frequency, severity, or consequences they have in women. They result mainly from urethral infections, and include urethral strictures and epididymitis, an inflammation of the excretory duct of the testicle and the leading cause of male infertility in parts of Sub-Saharan Africa (Berger, 1990). Pelvic Inflammatory Disease and Its Sequelae In women, pathogens that cause genital discharge, such as gonococci and chlamydiae, tend to rise into the upper genital tract and cause pelvic inflammatory disease. As many as 10 to 20 percent of women with untreated gonorrhea or chlamydia develop PID (Hook and Handsfield, 1990; Weström and Mårdh, 1984), the most common of the complications of sexually transmitted diseases. Although the acute clinical manifestations of pelvic inflammatory disease may be quite severe, their public health significance resides primarily in their long-term sequelae. The partial or total occlusion of the fallopian tubes that can ensue from ID produces harsh and irreversible sequelae: infertility, ectopic pregnancy, chronic pelvic pain, and recurrent infection. Both gonococcal and chlamydial PID may be associated with those sequelae, but manifest differently. PIDs of chlamydial origin generally produce less severe symptoms than those of gonococcal cause, and they appear to produce more tubal damage and correspondingly higher rates of infertility

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa and ectopic pregnancy. In part, this may be caused by the more indolent character of chlamydia, which makes women with chlamydial PID less likely to seek timely treatment than women with gonococcal PID (Hillis et al., 1993). Rates of infertility consequent to a pelvic inflammatory disease are high, even in developed countries. In a landmark study of Swedish women treated for one episode of PID, 11.4 percent became involuntarily infertile, with the risk of infertility roughly doubling with each subsequent episode; 23.1 percent of women became infertile after two episodes of PID; and 54.3 percent became infertile after three or more episodes (Weström and Mårdh, 1990). In the absence of timely, effective treatment, which is the normative circumstance in Sub-Saharan Africa, this risk becomes even greater: according to data from the preantibiotic era, 45–75 percent of women who had suffered from PID became infertile (Weström and Mårdh, 1990). Delay in PID treatment is a critical risk factor for impaired fertility; women who wait to seek health care for more than two days after onset of symptoms have a threefold increase in risk of infertility or ectopic pregnancy compared with those who seek care promptly. This risk is highest for women with chlamydial infection: 17.8 percent of those who delayed seeking health care developed impaired fertility; none of those who sought prompt treatment became so afflicted (Hillis et al., 1993). Ectopic pregnancy is caused by partial occlusion of the fallopian tubes, in which the damaged tube hampers the passage of the fertilized ovum into the uterus. Absent emergency care, it is frequently fatal. In Sweden, women with a history of any pelvic infection have a risk of ectopic pregnancy 6 to 10 times greater than women with no such history, and the first conception following an infection leads to ectopic pregnancy in almost 10 percent of women (Weström et al., 1992). In Africa, studies from Zimbabwe and Gabon implicate both gonorrhea and chlamydia in the development of ectopic pregnancy (De Muylder et al., 1990; Ville et al., 1991), although the Gabon study shows a stronger association between chlamydia and ectopic pregnancy, which is consistent with the pattern of association suggested by the Swedish data. While chronic pelvic pain has neither the emotional significance of infertility nor the fatal character of ectopic pregnancy, it is the most disabling of all PID sequelae, often so insidious and severe that it interferes with daily activities. It affects 15 to 18 percent of all women who have had a pelvic inflammatory disease and is often associated with infertility (Weström, 1980). In industrialized countries, up to one-third of women who have had a single episode of PID develop recurrent infections because of inadequate treatment, increased vulnerability of damaged tubes, repeated exposure to sex partners who remain untreated, or unaltered risky behaviors (Weström and Mårdh, 1990). This risk, as is the case for all the other sequelae of PID, may be much greater in Sub-Saharan Africa simply because of the pervasive lack of access to effective care. Adverse Pregnancy Outcomes Adverse pregnancy outcomes, which include congenital or perinatal infection, low birthweight, and fetal death, are a major public health problem in Sub-Saharan Africa, and linked to both genital discharge syndromes and genital ulcer diseases. When STDs occur during pregnancy, a mother may pass the infection to her child, either during pregnancy or at the time of delivery Thus, not only the pregnant woman herself but her entire family is affected, so that she becomes the unwitting, critical link between horizontal and vertical transmission. Congenital infections occur during pregnancy; perinatal infections occur around the time of birth. Either may result in transient illness, permanent disability, or neonatal death. In Sub-Saharan Africa, the most common and best-documented congenital or perinatal infections caused by STDs include ophthalmia neonatorum, congenital syphilis, and congenital HIV infection. Ophthalmia neonatorum, an eye infection that develops within the first month of life, is one of the most common infections of newborns related to maternal STDs, and may be caused by gonorrhea, chlamydia, or both. Easily preventable by instillation of medication in the eye at birth, untreated it may result in blindness. In a Nairobi hospital where ocular prophylaxis at birth had been discontinued, ophthalmia neonatorum occurred in 42 percent of infants whose mothers were infected with gonorrhea, and in 31 percent of infants whose mothers had chlamydia (Laga et al., 1986). Congenital syphilis is a very serious condition, often debilitating when it is not fatal. Approximately one-third of women with syphilis are delivered of live infants with syphilis, who then go on to suffer the ravages of that disease; untreated, the disease can proceed to fatality (Schultz et al., 1990). HIV-infected babies have an even

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa worse prognosis, since no good therapeutic options are yet available. In a Rwanda study, 38 percent of HIV-infected infants had died by the age of 6 months (Lepage and Van de Perre, 1988a,b). HIV-infected mothers have a risk of transmitting HIV to their babies ranging from 13 to 45 percent, with a tendency toward higher rates in Africa (Blanche et al., 1989; Hira et al., 1989; Lallemant et al., 1994; Lepage et al., 1993; Newell, 1992; Ryder et al., 1989; St. Louis et al., 1993; Tovo et al., 1988). One reason that has been postulated for the difference in transmission rates between countries is that, compared with those from industrialized countries, African HIV-infected women are generally in poor health because of poor nutritional status and frequent infections, and thus are at greater risk of transmutting HIV to their infants (Lepage et al., 1993). HIV may be transmitted during pregnancy, during birth, or through breast milk, but the relative contribution of these different modes of transmission to infection is still unclear in most African countries. A collaborative French-American study showed that the uptake of zidovudine by HIV-infected pregnant women reduces the risk of mother-to-child transmission by approximately one-third (Connor et al., 1994). The complexity of the regimen used in this study and the cost of the drug, however, make it unlikely that this kind of therapy will become available to most of the HIV-infected women of Sub-Saharan Africa in the near future. Low birthweight, defined as live birth below 2,500 grams, occurs because of intrauterine growth retardation, premature delivery, or both. Many factors, both infectious and noninfectious—such as diet, smoking, and hypertension—may cause low birthweight. The relative contribution of each of these factors remains to be determined, and undoubtedly varies substantially according to their local prevalence. In developing countries, up to 30 percent of infants are below 2,500 grams at birth, compared with only 2 to 10 percent of infants in industrialized countries (Barnes, 1979). Because 70 percent of mortality and morbidity during the first month of life occurs among low birthweight babies (Barnes, 1979), STDs would appear to be an important factor in child survival. Syphilis and genital herpes appear to be associated with both intrauterine growth retardation and premature delivery, while gonorrhea, chlamydia, and trichomoniasis induce premature delivery without affecting intrauterine growth (Brunham et al., 1990a; Cotch, 1990). In a study in Nairobi, Elliot and colleagues suggested that treatment of maternal gonorrhea may reduce prematurity rates by 14 percent (Elliot et al., 1990). Studies from Kenya, Rwanda, Zaire, and Zambia have identified a significant association between HIV infection and low birthweight (Braddick et al., 1990; Bulterys et al., 1991; Hira et al., 1989; Ryder et al., 1989; Temmerman et al., 1992b), which appears to derive from intrauterine growth retardation. Fetal death, occurring either before 20 weeks of gestation (spontaneous abortion), or at or after 20 weeks of gestation (stillbirth), also appears to be associated with several types of sexually transmitted infections. Studies from industrialized countries suggest that spontaneous abortion is more frequently associated with gonorrhea or genital herpes, with stillbirth more often linked with chlamydia or syphilis (Brunham et al., 1990a; Cooper-Poole, 1986; Mtimavalye and Belsey, 1987). Schulz and his colleagues have estimated that at least 50 percent of women with untreated syphilis may lose the fetus they are carrying (Schulz et al., 1990). In Zambia, pregnant women with untreated syphilis had a risk of bearing a stillborn child 28 times higher than pregnant women without syphilis (Watts et al., 1984). In another Zambian study, 42 percent of stillbirths were attributed to syphilis (Ratnam et al., 1982), and in Ethiopia, data suggest that 5 percent of all pregnancies are lost to that disease (Bishaw et al., 1983). Enhanced HIV Tranmission The relationships between HIV infection and other STDs are complex, intriguing, and in large measure speculative. STDs may enhance HIV transmission either by increasing the infectivity of HIV-infected persons or by increasing the susceptibility to HIV infection of non-HIV-infected persons. Several studies, mostly from Africa, indicate that both genital ulcers and genital discharge syndromes enhance the risk of HIV transmission (Cameron et al., 1989; Laga, 1990; Laga et al., 1990; Plummer et al., 1991; Wasserheit, 1992). HIV also may alter the natural course of other STDs, including their response to treatment. In Zimbabwe and Kenya, HIV-infected persons have an increased risk of treatment failure for chancroid (Latif, 1989; MacDonald et al., 1989). All of these interactions are worrisome. If co-infection with HIV prolongs or increases the infectivity of individuals with genital ulcers, and if genital ulcers facilitate transmission of HIV infection, then at the community level the two infections have the potential to greatly amplify each other (Wasserheit, 1992). Cervical Cancer Cervical cancer is a major public health problem throughout the world, and it is the most

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa common cancer in Africa (Parkin et al., 1988; see also Chapter 7). It is strongly associated with several types of human papillomavirus (HPV), the etiologic agent of genital warts (WHO, 1987) and increasingly recognized as important human carcinogens. HIV-infected women are at increased risk for cervical dysplasia, a precursor lesion for cervical cancer (Laga et al., 1992; Schafer et al., 1991; Wright et al., 1994a). Furthermore, HIV infection may adversely alter the course and treatment of cervical dysplasia and cancer (Frutcher et al., 1992; Klein et al., 1992; Maiman et al., 1990; Rellihan et al., 1990; Schwartz et al., 1991; Wright et al., 1994b). Compared with women of unknown HIV serostatus, HIV-infected women have a ninefold greater risk of recurrent or persistent cervical intraepithelial neoplasia following loop electrosurgical excision (Wright et al., 1994b). If detected and treated early, cervical cancer is almost always curable; in the absence of early treatment, it is almost always fatal. In Sub-Saharan Africa, many women die from cervical cancer because their disease is only diagnosed at an advanced, incurable stage. Gender Differentials in STDs and HIV Infection Gender is linked to biological and behavioral factors that contribute to crucial differences in the acquisition, course, and consequences of STDs. Compared with men, women are less likely to have control over the circumstances of their sexual activity. If they have sex with an infected partner, they are more likely to acquire an STD, including HIV infection; if they have an STD or HIV infection, they are less likely to seek health care; if they seek health care, they are less likely to be treated effectively, are more likely to develop complications, and, finally, frequently pay a heavier social toll for STDs, including HIV and their sequelae. These individual factors operate against a backdrop of such societal features as the low-status of women and the high ratios of males to females in urban areas. These societal factors clearly influence sexual behavior and are discussed in greater detail below. Control Over the Circumstances of Sexual Intercourse Gender typically influences economic and social status and, in most societies, women's roles are defined primarily by their sexual and reproductive relationships with men, relationships that place severe limitations on the extent of women's control of their own sexuality (Aral, 1990). Compared with men, in most societies women also have fewer options about when, where, how, and with whom they will have sex. Acquisition of STDs and HIV Infection and Development of Complications Gender affects the efficiency of transmission of some STDs. Transmission of STD pathogens that produce discharge or are present in genital secretions—such as gonococci, chlamydiae, trichomonads, and HIV—appears to be more efficient from male to female than vice versa, at least partly because of the prolonged exposure to organisms when infected ejaculate is retained in the vagina. In contrast, the transmission of syphilis, chancroid, and genital herpes, all of which cause genital ulcers, differs little by gender. This may be because transmission of these STDs depends on small breaks in the genital skin that probably occur in both sexes during vigorous coitus. Sexual behaviors may also synergize with biological factors to promote STD transmission. For example, the practice of ''dry sex" (use of intravaginal desiccants to increase friction during coitus) in some parts of Sub-Saharan Africa—such as Malawi, Zaire, and Zambia (Brown et al., 1992; Dallabetta et al., 1990; Nyirenda, 1992)—frequently causes breaks in the vaginal surface (Brown et al., 1992), which may enhance the risk of acquiring HIV infection and other STDs. Finally, unavailability of female-controlled barrier methods of birth control restricts women's ability to protect themselves against all STDs, including HIV infection. Health-Seeking Behavior Another gender-related consequence of STDs is the exacerbation of their sequelae brought about by differences in health-seeking behavior. Although in some industrialized countries women are more likely than men to

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa seek health care and subsequently receive appropriate treatment, this is rarely the case in Sub-Saharan Africa (Ehrhardt and Wasserheit, 1991). First, women may not suspect that they have an STD. Indeed, women with STDs are more frequently asymptomatic than men: 50 to 80 percent of women infected with gonorrhea are asymptomatic (Jones and Wasserheit, 1991), compared with 20 to 40 percent of men (Rothenberg and Potterat, 1990). In addition, when STD symptoms are present in women, they are often subtle, and may resemble changes that normally occur during the menstrual cycle, such as increased vaginal discharge, lower abdominal pain, and vaginal bleeding. Finally, cultural factors may influence the way women perceive the significance of their symptoms. For example, in regions where women are circumcised, practice "dry sex," or where STDs are widespread, pain during coitus, irregular vaginal bleeding, or pelvic pain may be considered the norm. Another major reason for gender differentials in seeking care for STDs is the female-specific, stigmatizing character of STDs, including HIV infection. Women face very strong sociocultural barriers to STD care, which are frequently fueled by the judgmental attitudes of health care providers. Finally, financial barriers for accessing care for HIV and other STDs may be stronger for women than for men, because women are frequently either of lower socioeconomic status than men or do not have independent financial resources. Detection and Treatment of STDs Even if they do seek health care for STDs, women are less likely than men to receive correct diagnosis and adequate treatment, for several reasons. First, most health care providers have limited expertise in STD management in women; they also share a common misconception that STDs affect only promiscuous women and prostitutes. Second, as discussed earlier, because STD signs and symptoms in women are often subtle and nonspecific, clinical diagnosis is not reliable. Third, in many Sub-Saharan African settings, laboratory tests are not available, even though it is women who would benefit most from laboratory tests because of the poor predictive value of female STD syndromes, particularly for vaginal discharge. Finally, the increased antimicrobial resistance of many pathogens to older antibiotics such as penicillin requires that new, more expensive drugs be used. Once again, women may be disproportionately affected: most sexually active women in Sub-Saharan Africa are either pregnant or breastfeeding at any given time, yet antibiotics that are effective and safe under those conditions may be neither available nor affordable. The Social Implications of STDs and HIV Infection Both STDs and their complications have far greater social significance for women than they do for men. Uncomplicated STDs typically cause personal embarrassment and domestic conflicts, but whoever is responsible for bringing a given infection into the relationship, it is the woman who is typically blamed and who endures the most serious consequences; these may include violence, divorce, and social ostracism. The complications of STDs, especially impaired fertility, are even more devastating. Although male infertility scientifically explains about one-third of all infertility, women are customarily blamed when a couple cannot have children. In parts of Africa, it is not uncommon for the female of an infertile couple to look for another male to make her pregnant (Rob et al., 1987), out of fear of being rejected by her husband and in-laws and becoming a social outcast. As a result, many infertile men may never become aware of their infertility. For women, childlessness, whether through infertility or poor pregnancy outcome, can be a major tragedy. Not only does it cause personal pain for the women themselves, but it becomes a paramount infirmity in a society that values women primarily for their ability to produce healthy offspring. Infertile women may be divorced by the same husbands who infected them with the STD that produced the infertility. The same is true of HIV-infected women, who are at risk of abandonment by the very men who transmitted the infection (de Bruyn, 1992). Ostracized by society, divorced women have few survival options other than prostitution, which increases STD transmission and the risk of infertility in the larger community, creating a vicious cycle of disease; misery; and, increasingly, death. In this way, STDs and their complications affect individuals, communities, and, eventually, whole societies. In some areas, notably the so-called "infertility belt," which extends from Gabon in the west of Africa to southwestern Sudan in the east, STDs have had a dramatic impact on fertility rates. Brunham estimates in a mathematical

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa model that a 20 percent gonorrhea prevalence in sexually active adults may produce up to a 50 percent reduction in net population growth, an estimate consistent with fertility levels actually observed in some parts of Uganda (Brunham et al., 1991). The consequences of HIV infection are even more striking. In another mathematical model, Anderson predicts that in some Sub-Saharan African countries, HIV infection may reverse demographic growth from positive to negative over a few decades (Anderson et al., 1988). Yet another dramatic—and paradoxical—effect of STDs on society is their potential for jeopardizing family planning programs. STDs may decrease acceptance and continuation of contraceptive methods in two ways: directly, by creating the perception of a contraceptive side effect, and indirectly, by creating a fear of fertility impairment in the face of complications of STDs. Numerous studies in Bangladesh have found that the most common reason given for discontinuing a contraceptive method is the perception of a method-associated side effect (Akbar et al., 1981; Bhatia, 1982; Jain and Sivin, 1977; Rob et al., 1987). Similar findings have turned up all over the globe and can be extrapolated comfortably to other settings. Absent accurate diagnosis and effective education and therapy, it is far easier for a woman to blame a vaginal discharge on her current contraceptive method than to confront the possibility of having been infected by her husband—who is then, by definition, unfaithful. The net result is that the woman stops using her contraceptive method in the mistaken belief that if caused the unrelated infection (Wasserheit, 1989). The indirect impact of STDs on family planning is equally important. Several authors have postulated that high levels of infertility or frequent adverse pregnancy outcomes might result in a compensatory decrease in acceptance of family planning methods (O'Reilly, 1986; Rosenberg et al., 1986). In societies that value children highly, couples are unlikely to undertake voluntary fertility regulation unless they are confident that they will be able to raise as many healthy children as they desire (Wasserheit, 1989). STDs and HIV Infection Throughout the Female Life Span The relative contribution of different risk factors for STDs, including HIV infection, varies with age. Increased vulnerability to STDs may be the result of biological or behavioral factors, and these may go in the same or in the opposite direction. In adolescence, for example, biological and behavioral factors act concurrently to increase dramatically the risk of HIV infection and other STDs and their complications. In later years, however, these factors may have different weights. In the adult, biological factors tend to decrease in importance and to be outweighed by behavioral factors. In the elderly, while physiological changes may facilitate the transmission of HIV and other STDs, behavioral factors tend to be protective (Ehrhardt and Wasserheit, 1991). The striking changes that occur in cellular morphology in the vagina and cervix over the female life span have a direct effect on susceptibility to STDs and on the spectrum of infections found at each stage. During the first few weeks of life, the vagina and cervix of the newborn are lined by squamous epithelial thick cells that are relatively resistant to infection. From one month until menarche, changes in this lining increase susceptibility to STDs, especially to chlamydia and gonorrhea. Then, beginning at puberty, under hormonal influence, the cervico-vagina vault will again be covered by a thicker layer of squamous cells that are more resistant to some infections. The junction between squamous cells and the columnal cells that are the site of attachment for chlamydial and gonococcal infection is called the zone of ectopy. In the adolescent, the zone of ectopy is found on the surface of the cervix, where it is particularly susceptible to chlamydia, gonorrhea, and HIV. In young adulthood, the zone will usually migrate from the surface of the cervix to a less-exposed position in the cervical canal, reducing susceptibility to those infections (Cohen et al., 1985). Sexuality and sexual behavior are forbidden subjects in many societies. As a result, real data on these topics are quite limited, particularly in developing countries. Most of our knowledge about sexual behavior comes from studies in industrialized countries, and it may not be applicable to Sub-Saharan Africa. In addition, sexual behavior in Sub-Saharan Africa is likely to vary a great deal across its many cultures and countries. At the same time, biological factors are more likely to be similar across cultures. This section enlarges upon the key biological and behavioral risk factors that are unique to each stage of the female life span.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Infancy, Childhood, and Adolescence Infancy During infancy, STDs, including HIV infection, are rarely transmitted sexually unless sexual abuse has occurred. Instead, they result from intrauterine or perinatal transmission of maternal infections. Behavioral risk factors for congenital infections therefore concern the infant's mother. The consequences of congenital and perinatal infections associated with STDs and HIV infection include, at the extreme, blindness and other physical disabilities, mental retardation, and death. All the morbidities may have continuous, severe consequences throughout childhood, adulthood, and senescence. In addition, congenital infections affect not only the baby, but also its mother, who has to care for the sick or disabled child, perhaps for her remaining lifetime. Also, the children born to HIV-infected mothers, whether infected themselves or not, will, if they outlive their parents, become orphans, representing an extra burden for the older members of the community, often the grandmothers. Childhood STDs and HIV infection during childhood are relatively rare, and result almost entirely from sexual abuse. Sexual activities during childhood are exploratory and sporadic; while such sexual play between children of the same age is normative, sexual behavior between adults and children is not. Sexual abuse of children by strangers or by family members has received very little attention in Sub-Saharan Africa, and may well merit more. There are no studies of the region that would permit evaluation of the extent of emotional injury and long-term impact on the subsequent psychosexual development of sexually abused children or the magnitude of the problem. Studies from industrialized countries indicate that the extent of trauma varies and that the effects are nonspecific and may influence later sexual, emotional, or substance abuse behavior (Browne and Finkelhor, 1986). Sexual abuse of children may be more likely than rape of adult women to result in STD and HIV transmission because penetration is more likely to be traumatic in children. Adolescence This is the period when behavioral and biological factors combine to maximize the risk for STDs and HIV infection. As noted, during puberty and adolescence, several physiological changes occur in the female genital tract that result in a particularly high-risk. In addition, adolescence is a period of life in which many women have their first sexual encounter, and it is the time when sexual behavior patterns become established. Furthermore, when the initial sexual encounter is traumatic, it may be a high-risk event for male-to-female HIV transmission (Bouvet et al., 1989). Age at sexual debut (time of first sexual intercourse) and sexual activities during adolescence follow secular trends and also vary greatly according to culture. Studies indicate that an earlier age of sexual debut is associated with higher total numbers of sex partners over a lifetime. In Ethiopia, where child marriage is practiced, half of 2,111 women surveyed had experienced their first sexual intercourse before the menarche (Duncan et al., 1990). That same early sexual activity was associated with an increased prevalence of STDs, PID, and cervical cancer later in life. The study also indicates that the younger the age at first marriage or first coitus, the shorter the duration of the marriage and the greater the likelihood of divorce (Duncan et al., 1990). The extent of sexual assault in Sub-Saharan Africa is unknown. As in other parts of the world, rapes are rarely reported (see also Chapters 2 and 8). Instead, the incident is often settled between the families involved through compensation, in cash or goods, by the perpetrator to the family of the woman raped. There is evidence that rape is a serious problem in parts of Sub-Saharan Africa. In Kenya, when 71 teenage girls were raped during one night in the dormitory of a boarding school, a Kenyan newspaper described the incident as a common occurrence, and as sanctioned by the principal and his staff (Heise et al., 1994). There is a good chance that sexual abuse is a menace for African women throughout their lives. In South Africa, as one example, the incidence of rape appears to exceed rates in the United States, with an annual incidence of 34 rapes per 1,000 women, compared with 18 per 1,000 women in the United States (Heise et al., 1994). Finally, the limited health knowledge and constrained health-seeking behavior of adolescents compound the impact of physiological factors on STD and HIV infection morbidity. Many adolescents are unable to recognize or to understand the significance of STD or HIV symptoms and have little or no independent access to health care, or are afraid to utilize existing services.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Adulthood In adulthood, behavioral factors dominate the risk for STDs and HIV infection and are characteristically tied to the sex partner's sexual behavior. The physiological changes that affect the risk for STDs, including HIV infection, during the adult reproductive years are related primarily to the menstrual cycle, pregnancy, and contraceptive use. The menstrual cycle seems to play a key role in the risk of PID. Symptomatic gonococcal and chlamydial PID appear to occur more frequently during the first week of the menstrual cycle, probably because of the retrograde flow of menstrual blood from the uterus into the fallopian tubes. During pregnancy, although the lower genital tract, particularly the cervix, may be more susceptible to infections, the upper genital tract appears to be protected from infections by gestational anatomical changes. Sex during menses has been hypothesized, although not shown, to be a risk factor for female-to-male transmission (De Vincenzi, 1994). Although there is no evidence thus far to suggest that pregnancy aggravates the course of HIV infection, several studies have documented the occurrence of serious HIV-related infections during pregnancy (Selwyn and Antoniello, 1993). Contraceptives may play a prominent part in altering the risk of HIV and other STDs during the reproductive years, and even beyond. Barrier contraceptive methods such as condoms and diaphragms serve as a mechanical barrier to pathogens. Oral contraceptive pills seem to increase risk of cervical chlamydial infection, but appear to decrease the frequency and severity of PID. Users of intrauterine devices have increased risk of developing PID, particularly during the first four months following insertion, and this risk varies by geographic area; Africa has the highest rates of all the world's regions (Farley et al., 1992). Behavioral risk factors for STDs include sexual and health-seeking behavior. Because men tend to have more partners and engage in riskier sexual behavior than women, women's risk for STDs, including HIV infection, is more closely related to their husbands' sexual behavior than their own. Nonsexual transmission of STD pathogens present in the blood—such as HIV, treponemes (which cause syphilis), and hepatitis B virus—may be a concern for health workers, particularly for midwives and traditional birth attendants, who are usually women and who frequently come into contact with abundant quantities of blood. The lifelong impacts of STDs and their long-term sequelae are tremendous, and were described earlier. Obviously, the earlier in life those sequelae occur, the longer women have to bear their consequences. In addition, women may be more susceptible to such consequences, notably the psychological and social repercussions, in part because they are affected by HIV and other STDs at an earlier age than men. Maturity and Senescence As people become older, their sexual activity often decreases as a result of physiologic changes and societal influences. During senescence, increased biological risk for STDs compensates for decreased behavioral risk. The physiologic changes that occur in women include atrophic changes in the vagina, with thinning of the epithelium, reduced lubrication, and narrowing and shortening of the vaginal canal. A vagina that is dry can be injured more easily by penile penetration (Holmes, 1990; Mooradian and Greiff, 1990), placing a woman at greater risk for transmission of HIV infection and other STDs from an infectected partner. Sexual behavior at older ages is determined by sexual interest, which is influenced, in turn, by the hormonal environment and sociocultural factors. The level of sexual activity among older people, particularly women, varies greatly across cultures. While sexual activity is socially acceptable or desirable for older men, it may not be so for older women. In Sub-Saharan Africa, for example, the limited available evidence suggests that many women cease to be sexually active at menopause. A different, yet major aspect of the burden of the HIV epidemic on women, including older women, is the care of the sick. Indeed, it is women who—as health care workers, community members, or family members—provide most of the care for people with chronic illnesses, including HIV infection and AIDS (Richardson, 1989).

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa MAGNITUDE OF THE PROBLEM Morbidity This section provides general information on the extent of the problem of sexually transmitted diseases, including HIV infection, in Sub-Saharan Africa and estimates the prevalence of five common STDs across the countries of the region. There are noteworthy differences in the magnitude of the STD burden between the industrialized and the developing countries. First, sexually transmitted diseases including HIV infection are much more prevalent in most developing countries, particularly in Sub-Saharan Africa, than in the majority of industrialized countries. Second, developing countries, again particularly those in Sub-Saharan Africa, have a higher incidence of complications of STDs than industrialized countries experience, and these complications are often more severe. Third, different kinds of STDs predominate in developing and industrialized countries. For example, the proportion of STDs characterized by genital ulcers is greater in developing countries than in industrialized countries; in Sub-Saharan Africa, chancroid and syphilis account for the majority of genital ulcers, while in industrialized countries, herpes is the main cause of those lesions (Meheus et al., 1990). Finally, while in industrialized countries HIV infection is often transmitted through homosexual contact and injecting drug use, and affects predominantly males, in Sub-Saharan Africa, HIV infection is almost exclusively transmitted heterosexually and affects both women and men equally, except for substantial mother-to-child transmission. The following statistics highlight the severity of the problem in Sub-Saharan Africa. STDs are among the top five reasons for clinic attendance in many Sub-Saharan African countries (Meheus, 1990). For example, STDs account for 13 percent of adult outpatient visits in Zimbabwe (Zimbabwe, 1989), and for 5 to 10 percent of outpatient visits in Zambia (Hira et al., 1992b). In some countries, PID is the most common diagnosis among women attending STD clinics. In Zimbabwe, 47 percent of women attending an STD clinic had a pelvic inflammatory disease (Latif, 1981), and in Ethiopia at least 39 percent of gynecological outpatients had signs or symptoms suggestive of PID (Perine et al., 1980). Even though many women with PID are never diagnosed and the majority are not hospitalized (Carty et al., 1972), it is one of the leading causes of gynecological admission (Brown and Cruickshank, 1976; De Muylder, 1989; Perine et al., 1980; Ratnam et al., 1980b; Zacarias and Aral, 1985). In many countries of Sub-Saharan Africa, where the prevalence of syphilis among pregnant women is at least 10 percent, Schulz and colleagues estimate that 5 to 8 percent of all pregnancies that last beyond 12 weeks will fail to produce a healthy infant because of congenital syphilis, or syphilis-related fetal death or infant death (Schulz et al., 1987). In some Sub-Saharan African countries—for example, Cameroon, Ethiopia, and Kenya—as many as 4 to 6 percent of newborn babies develop gonococcal ophthalmia, a condition that, untreated, leads to blindness (Galega et al., 1984; Lepage and Van de Perre, 1988a; Muhe and Tafari, 1986). In Sub-Saharan Africa, HIV infection has not only reached high levels of prevalence—overall, affecting one in 40 adults, and in certain cities as many as 30 percent of pregnant women (see Appendix, Table 11-8)—but is also rapidly spreading, particularly in urban areas and among selected subgroups, such as prostitutes (Nkowame, 1991). In several African cities, AIDS is the leading cause of death among young women and men. Prevalence Estimates of the prevalence of HIV infection and other STDs among women in Sub-Saharan Africa must be made cautiously. Although more information on STDs is available in Sub-Saharan Africa than in other parts of the developing world, the quantity, quality, and heterogeneity of data across countries and populations limit the ability to precisely define the extent of STD morbidity in the region. There is virtually no surveillance system in Sub-Saharan

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Wasserheit, J. N. 1992. Epidemiological synergy: interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sex. Trans. Dis. 19:61–77. Wasserheit, J. N., and K. K. Holmes. 1990. Reproductive tract infections: Challenge for international health policy, programs, and research. Pp. 7–33 in Reproductive Tract Infections: Global Impact and Priorities for Women's Reproductive Health, A. Germaine, K. K. Holmes, P. Piot, and J. Wasserheit, eds. New York: Plenum. Watson, P. 1985. The use of screening tests for sexually transmitted diseases in a Third World community—a feasibility study in Malawi. Eur. J. Sex. Trans. Dis. 2:63–65. Watts, T., S. Larsen, and S. Brown. 1984. A case-control study of stillbirths at a teaching hospital in Zambia, 1979–80: Serological investigations for selected infectious agents Bull. WHO 62:803–808. Weissenberger, R., A. Robertson, S. Holland, et al. 1977. The incidence of gonorrhea in urban Rhodesian black women. S. Fr. Med. J. 52(28):1119–20. Welcomed, N., A. Mahaffey, and J. Van de Ended. 1986. Prevalence of Neisseria gonorrhea infection in patients attending an antenuptial clinic. S. Fr. Med. J. 69(1):32–34. Weasels, P. H., G. J. Viljoen, N. F. Marais, J. A. de Beer, M. Smith, and A. Gericke. 1991. The prevalence, risks, and management of Chlamydia trachomatis infections in fertile and infertile patients from the high socioeconomic bracket of the South African population. Fertil. Steril. 56(3):485–488. Weström, L. 1980. Incidence, prevalence and trends of acute pelvic inflammatory disease and its consequences in industrialized countries. Am. J. Obstet. Gynecol. 138:880–892. Weström, L., and P. A. Mårdh. 1984. Salpingitis. Pp. 615–632 in Sexually Transmitted Diseases, K. K. Holmes, P. A. Mårdh, P. F. Sparling, et al., eds. New York: McGraw-Hill. Weström, L., and P. A. Mårdh. 1990. Acute pelvic inflammatory disease (PID). Pp. 593–613 in Sexually Transmitted Diseases, K. K. Holmes, P. A. Mårdh, P. F. Sparling, et al., eds. New York: McGraw-Hill. Weström, L., R. Joesoef, G. Reynolds, A. Hagdu, and S. Thompson. 1992. Pelvic inflammatory disease and fertility: A cohort of 1844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results. Sex. Trans. Dis. July–August:185–192. Whiteside, A. 1991. HIV infection and AIDS in Zimbabwe: An assessment. Southern Africa Foundation for Economic Research. Economic Research Unit, University of Natal. Whiteside, A. 1992. An evaluation of the likely impact of AIDS on the Mananga medical service subscribing companies. Draft report: 1–12. Photocopy. Widy-Wirski, R., and J. D'Costa. 1980. Maladies transmises par voie sexuelle dans une population rurale en Centrafrique. Pp. 651–656 in Rapport Final, 13e Confírence Technique. Yaounde, Cameroon: OCEAC. World Bank. 1992. World development indicators. Pp. 209–308 in World Development Report 1992: Development and Environment. New York: Oxford University Press. World Bank. 1993. World Development Report 1993: Investing in Health. New York: Oxford University Press. WHO (World Health Organization). 1987. Genital human papillomavirus infections and cancer: Memorandum from a WHO meeting Bull. WHO 65(6):817–827. WHO (World Health Organization). 1993. Report of a Consultation on Women and HIV/AIDS. WHO/GPA/DIR/94.1. Geneva. WHO (World Health Organization). 1994. Women and AIDS: Agenda for Action. WHO/GPA/DIR/94.4. Geneva. Wright, T. C., T. V. Ellerbrock, M. A. Chiasson, N. Van Devanter, and S. Xiao-Wei. 1994a. Cervical intraepithelial neoplasia in women infected with human immunodeficiency virus: prevalence, risk factors, and validity of Papanicolaou smears Obstet Gynecol. 84:591–597. Wright, T. C., J. Koulos, F. Schnoll, J. Swanbeck, T. V. Ellerbrock, M. A. Chiasson, and R. M. Richart. 1994b. Cervical intraepithelial neoplasia in women infected with the human immunodeficiency virus: outcome after loop electrosurgical excision Gyn. Oncol. 55:253–258. Yorke, J. A., H. W., Hethcote, and A. Nold. 1978. Dynamics and control of the transmission of gonorrhea. Sex. Trans. Dis. 5:51–56. Yvert, F., J. Riou, E. Frost, and B. Ivanoff. 1984. Les infections gonococciques au Gabon (Haut-Ogooué). Pathol. Biol. 32(2):80–84. Zacarias, F. R., and S. O. Aral. 1985. STD control in less developed countries: The time is now. Intl. J. Epidmiol. 14:505–509. Zekeng, L., P. Barth, R. Salla, L. Kaptue, B. Schmidt-Ehry, and T. Rehle. 1990. Seroepidemiological study of sexually transmitted agents (HIV, hepatitis B virus, T. pallidum) among sentinel populations in the northwest and southwest provinces, Cameroon. Int. Conf. AIDS 6(2):230 (abstract FC 598). Zekeng, L., R. Salla, L. Kaptue, et al., 1992. HIV-2 infection in Cameroon: No evidence of indigenous cases. J. AIDS 5(3):319–320. Zimbabwe, Central Statistical Office, Ministry of Health. 1989. Annual Report. Harare.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa APPENDIX TABLE 11-6 Genital Discharge Syndrome Country Year Population N Ref. GC CT TV Low-risk population               Cameroon 1977 PP 296 87 14       1980 AN (asymptomatic) 110 180 14   15   1980 FP (asymptomatic) 53 180 2   8   1980 PP (asymptomatic) 296 180 10       1986a AN   234   9   Central African Republic 1980 AN   268 10     Ethiopia 1973–75 PP (asymptomatic) 200 209 9     Gabon 1981 AN 530 270 6       1988 PP (asymptomatic) 598 137   10     1987–89 AN 2,305 82   19   Gambia, The 1982 AN 87 145 7 7     1982 AN (asymptomatic) 100 144 7 7 32 Ghana 1983 AN   213 3       1988a AN (asymptomatic) 110 74   4   Kenya 1973 FP 200 111 18   26   1981 AN 54 188 0 6     1981 FP 57 188 17 4     1984 PP 728 131 7 23     1984 PP 845 212 7 21     1985 PP 175 99 4 17     1985–86 PP 2,732 127 6 9     1985–87 Trachoma area 168 35   4     1988–89 AN 549 161 3   2   1990 AN 269 242 7       1990 FP   80   6 11   1992 AN 5,674 178 10     Malawi 1973 AN 100 162     19   1990 AN 6,483 57 5 3 32 Nigeria 1971 AN 208 203 3   21   1971–75 Gyn (IUD users) 282 256 5   27   1971–75 Asymptomatic housewife 130 256 5   15   1983–85 FP 500 196 4       1988 AN 80 253   11     1988 Infertile 20 253   15     1989a FP 150 189 0–8   0–8   1989a No FP 50 189 6   4   1989a AN 46 6   6     1991a AN (rural) 250 195     25   1991a AN (urban) 250 195     38 Rwanda 1987 AN + FP 199 236 5       1987 AN + FP 198 236   16   Senegal 1983 AN   213 19       1987 AN 236 176 2       1990   511 93     30 Senegal 1987 AN 200 68 2 7     1989–92 AN 781 227 1 8 16 Somalia 1987 All village 200 115 0 18   South Africa 1980a AN 105 110 10   23   1980a AN 80 110 90       1981 AN (asymptomatic) 1,200 260 11       1983 AN   213 10       1986 AN 88 12   13  

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Country Year Population N Ref. GC CT TV Low-risk population               South Africa 1986a AN 231 14   1     1986a FP 62 14   16     1987 AN 193 193 6 11 49   1991a AN (white, high SES) 41 261   7     1992a AN (asymptomatic) 170 72 4 5     1992a AN 206 249 7 11   Swaziland 1973 OPD (all women) 179 39     29   1973 AN 215 39     50   1978 AN 51 167 4   23   1978 FP 52 167 2   15 Tanzania 1978 FP (asymptomatic) 341 147 8       1983 AN   213 8       1986a AN   69 6       1991–92 AN 2,009 237 5   14 Uganda 1971–72 Community (Ankole) 168 9 2       1971–72 Community (Teso) 295 9 22       1980 Low fertil. district 336 10 18       1980 High fertil. district 246 10 2       1992a AN 450 101 1 7 43 Zaire 1985 AN 208 64 2   4   1988 AN 101 17   9     1990 AN 701 142 2 6 17   1991 AN 1,875 174 1 5 16 Zambia 1977a AN 218 102     39   1979 AN (asymptomatic) 161 216 11     Zimbabwe 1976 AN 50 259 2       1976 FP 100 259 12       1983 AN 199 154     31   1986–87 PP (asymptomatic) 111 155 5 6 14 High-risk population               Cameroon 1980 AN (symptomatic) 610 180 15   21   1980 FP (symptomatic) 81 180 21   7   1980 PP (symptomatic) 42 180 21   2 Côte d'Ivoire 1986a Symptoms   73 10     Ethiopia 1973–75 PP (puerperal sepsis) 67 209 28       1973–75 PID (outpatient) 100 209 19       1973–75 PID (hospital) 46 209 15     Gabon 1980–82 Symptomatic (vaginal D/C) 261 270 15   23   1988a Symptomatic (vaginal D/C) 252 137   18     1988a Symptomatic (LAP) 265 137   14   Gambia, The 1982 Gyn (symptomatic) 23 145   14   Ghana 1985 Gyn 162 20 3 5     1985 Gyn (LAP) 40 20 0 10     1985 PP (hospitalized) 148 20 3       1985 PP (hospitalized) 39 20   8   Kenya 1981 STD (symptomatic) 58 188 23 7     1982 STD (vaginal D/C) 122 171 26   34   1982 STD (vaginal D/C) 58 171   7     1985 PP (preterm) 166 99 11 13     1992 STD   80   4 11   1992 STD+FP 212 80     11

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Country Year Population N Ref. GC CT TV High-risk population               Malawi 1992 STD 505 58 15   26   1992 STD 175 58   5     1990 STD 255 57 25   36 Nigeria 1971–75 Gyn (symptomatic) 228 256 17   19   1977–81 STD 435 19 13   11   1988a Gyn 120 114 15     Senegal 1990 Gyn 250 68 4 8     1989–92 Gyn 795 227 2 8 16 South Africa 1980 STD 135 19 13       1980a AN (symptomatic) 127 110 9   31   1980a Gyn 100 252 11       1986a STD 135 14   13   Sudan 1976 Gyn (symptomatic) 147 224 1   12   1977 STD (symptomatic) 613 199 7   20   1976–78 STD (vaginal D/C) 132 200 4       1976–78 STD (vaginal D/C) 144 200         1976–78 STD (vaginal D/C) 114 200     20   1985a STD 404 201 8       1985a STD 613 199     20 Zambia 1977a Gyn 518 102     31   1979 STD (nonpregnant) 1,000 216 19       1979 STD (pregnant) 170 216 23       1979 PID (hospitalized) 100 216 46     Zimbabwe 1976 Gyn 118 259 11       1979–80 STD 234 200 23       1982 STD (pregnant) 160 133 26   38   1983 STD 156 154     37   1986–87 PP (puerperal sepsis) 95 155 19 16 12   1990a STD 100 153 19 8 32                 Very-high-risk population               Burkina Faso 1990 CSW 127 59 20   17 Cameroon 1991a CSW 168 122   39   Côte d'Ivoire 1988a CSW   228   65   Ethiopia 1991a CSW 282 90 30   24   1992 CSW 46 28 30 6   Kenya 1981 CSW (upper SES)   60 16       1981 CSW (middle SES)   60 28       1981 CSW (lower SES)   60 46     Madagascar 1987 CSW 298 175     39   1987 CSW 40 175   18   Malawi 1990 CSW (STD) 274 57 29   27 Senegal 1989–92 CSW 397 227 13 17 18   1989–92 CSW 653 70 16 14 24 Somalia 1990a CSW 89 38 11     Tanzania 1991a CSW 106 185 51       1991a CSW 47 185   25     1992a CSW 70 156       Zaire 1989a CSW 801 130 23 14 22 NOTE: GC, gonorrhea; CT, chlamydia; TV, trichomoniasis; AN, antenatal; PP, postpartum; FP, family planning; LAP, lower abdominal pain; D/C, discharge; CSW, commercial sex worker; SES, socioeconomic status. a No study date.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 11-7 Syphilis Country Year Population N Ref. Non-T Trep Non-T + Trep GUD Low-risk population                 Botswana 1985–87 AN 113 238     17 3 Burkina Faso 1973a Village (Karba) 208 217 18         1973a Village (Dedougo) 239 217 32         1973a Village (Moko) 133 217 8       Cameroon 1989–90 AN 544 184   16       1990a AN 608 272   24       1990a AN 900 121     10   Central African Republic 1980 AN   268     10   Ethiopia 1974–75 AN 2,717 208 18   17     1977a AN 337 86 13 11 11     1990a AN 1,719 240     7     1992a AN 100 83     9   Gabon 1983 AN 527 165     12     1984 AN 715 165     13     1985 AN 623 165     14     1986 Urban 211 77     15     1987 Semi-rural 277 77     9   Gambia, The 1986a AN (rural) 100 143 15 11       1986a AN 238 143 26   13     1982 AN (urban) 100 144 9 1 1   Kenya 1984 PP 1,013 131   11 4     1985 PP 133 99     5     1988–89 AN 549 161     4     1989–91 AN 4,883 91     4     1992a AN 5,674 178     3   Malawi 1985a AN 182 257 18   14     1990 AN 6,483 57 13     7 Mozambique 1985 AN 10 districts 1,468 140 8   6   Nigeria 1971 AN 208 203     0     1979–84 AN 29,083 92 3   0.4     1986a AN   81     2     1989a FP 150 189   15       1989a Controls (non-FP) 50 189   12     Rwanda 1972 AN 862 166 3         1972 Students 153 166 1         1980 AN 2,321 62 4         1987a Asympt. blood donor 33 248   15 6     1989a AN   54 4 4     Senegal 1989–92 AN 781 227     6     1990 AN 511 93     8   Somalia 1985–86 AN 67 117 3 3 3     1987 Village 200 115   23 16   South Africa 1981 AN 1,200 260     21     1985–86 AN 9,071 250 3         1987 AN 193 193     12     1992a AN (asymptomatic) 170 72     8   South Africa 1992a AN (unbooked) 114 172     31   Swaziland 1978 FP 52 167 6     6   1978 AN 51 167 14     2   1981a AN 90 247 10 33       1986 PP (asymptomatic) 283 96     13   Tanzania 1983–84 AN 5,430 51 19   16     1991–92 AN 2,009 237     3     1992a Community 115 136     16  

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Country Year Population N Ref. Non-T Trep Non-T +Trep GUD Low-risk population                 Uganda 1986 Outpatients 24 112 0 8 0     1986 AN 1,011 43   26       1992a AN 405 190     10   Zaire 1988 PP 314 198     2     1990 AN 701 142     1     1991 AN 1,857 174   2 1 2 Zambia 1979–80 PP (asympt. live birth) 261 258   29 4     1980a AN 163 215     18     1981 PP 464 104     7     1982a AN 202 214 14 13 13     1984a AN   101 13         1985–86 AN 5,007 103     8   Zimbabwe 1985–87 PP (asymptomatic) 104 67   19 9   High-risk population                 Botswana 1985–87 AN 175 238   25 16   Central African Republic 1988a Hosp. 30 18     20   Kenya 1985 PP (pretiorum) 157 79     6   Malawi 1992a STD 505 58     25   Nigeria 1977–81 STD 435 19     4   Senegal 1989–92 Gyn 796 227     14   Sudan 1976–78 STD (vaginal D/C) 152 200 8   0   Zambia 1979–80 PP (stillbirth) 262 258   54 29   Zimbabwe 1982 STD (pregnant) 160 133     4     1990 STD 100 153 44   33   Very-high-risk population                 Burkina Faso 1990 CSW 127 59 22       Ethiopia 1991a CSW 203 90     37   Gambia, The 1986a CSW 31 143 74 71     Kenya 1981 CSW (upper SES) 71 60     37 2   1981 CSW (middle SES) 51 60     31 6   1981 CSW (lower SES) 71 60     53 6   1985 CSW (low SES) 64 126     55 42   1989a CSW 366 161     22   Madagascar 1987 CSW 298 175 25       Malawi 1990 CSW (STD) 274 57 21       Rwanda 1973 CSW 43 166 30         1987a CSW 33 248 58 82     Senegal 1989–92 CSW 653 70 6 31       1989–92 CSW 397 227     40   Somalia 1985–86 CSW 85 117     45     1989 CSW 57 232     51     1990 CSW 155 2 69   47     1990a CSW 89 38   28     Sudan 1987 CSW 202 163     29   Tanzania 1992a CSW 70 156 18     16   1991a CSW 106 185 27 74     Uganda 1986 Bar girls 36 112   46 6   Zaire 1989a CSW 801 150   28 16 7   1990a CSW 1,233 125   28 16 7 NOTE: Non-T, non-treponemal test; Trep, treponemal test; Non-T+Trep, positive non-treponemal test confirmed by treponemal test in most cases; GUD, genital ulcer disease; D/C, discharge; AN, antenatal; PP, postpartum; FP, family planning; CSW, commercial sex worker; SES, socioeconomic status. a No study date.

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa TABLE 11-8 HIV-1 Infection Country Year Population N Ref. HIV-1 Low-risk population           Angola 1986 AN (Luanda) 357 25 0.3 Botswana 1985–87 AN (Maun) 113 121 0 Cameroon 1987–90 AN (4 cities/towns) 2,417 273 0.9 Côte d'Ivoire 1992 AN (Abdidjan) 12,750 239 9.5   1992 15–49 (Abidjan) 10,136 1 9.4   1991 15–49 (Abidjan) 3,833 1 8.7   1987 AN 246 204 3.6 Ethiopia 1991 AN (Diredawa) 360 179 6.9   1991 AN (Metu) 322 179 2.8 Gambia, The 1990 AN (Banjul) 1,057 149 0.3   1989 Vil (Gunjur) 98 65 0   1988 Vil (Essau) 96 65 0   1988 Vil (Kankunku) 103 65 0   1988 Vil (Badjakunda) 105 65 0   1988 Vil (Brikama) 109 65 0   1989 Vil (Sibanor) 108 65 0   1989 Vil (Diabugu) 97 65 0   1989 Vil (Farafeni) 99 65 0   1988 Vil (Gambisara) 98 65 0 Guinea Bissau 1989–90 AN (Bissau) 272 181 0 Kenya 1991 AN (national) 4,599 159 10.1   1990 AN (national) 7,232 159 6.6 Malawi 1990a AN 1,482 47 21.6   1988 AN 247 48 19.0 Niger 1987–88 AN (Niamey) 1,477 205 0.1 Nigeria 1988–90 AN (Lagos) 500 5 1.0 Rwanda 1992 AN (Kigali) 128 84 31.3   1989 AN (urban) 164 37 20.1   1989–91 AN (Butare) 5,288 46 9.8   1989 AN (rural) 193 37 4.2 Senegal 1990 AN (Dakar Reg) 182 157 1.2   1990 AN (Kaolak Reg) 496 157 0.4   1991 AN (Dakar Reg) 299 157 0.3   1992 AN (remote areas) 781 227 0.3   1990 AN (Ziguinchor) 825 157 0.2   1992 AN (various areas) 2,120 88 0.2   1991–92 AN (Dakar) 4,698 183 0.2   1991 AN (Kaolak Reg) 240 157 0   1991 AN (Ziguinchor) 715 157 0   1990 AN (St Louis) 603 157 0   1991 AN (St Louis) 418 157 0 South Africa 1991 AN (national) 17,155 157 0   1991 AN (national) 1,576 157 0.6 Swaziland 1990 AN   266 2.3 Tanzania 1991 All 15–54 (Arusha) 148 197 12.8   1991–92 FP (Dar es Salaam) 2,009 237 12.5   1992 AN (Mwanza region)   24 11.6 Tanzania 1991–92 FP (Dar es Salaam) 2,285 120 11.5   1992 Rural (10–19) Kagera 717 16 3.2   1992 All (Mwanza town) 590 156 1.9   1987 AN (Moshi town) 180 187 1.1 Uganda 1992 AN (Aber) 239 11 17.2   1990–91 AN (Hoima) 346 3 13.0   1989 AN (Jinja)   11 24.9

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Country Year Population N Ref. HIV-1 Low-risk population           Uganda 1992 AN (Jinja) 296 11 24.7   1991 AN (Jinja) 300 11 22.0   1990–91 AN (Jinja) 1,485 3 18.0   1990 AN (Jinja)   11 15.8   1990–91 AN (Kabale) 791 3 12.5   1990 AN (Kampala) 628 245 36.6   1991 AN (Kampala) 512 245 29.7   1992 AN (Kampala) 285 11 29.5   1992 AN (Kampala) 269 11 29.4   1989 AN (Kampala) 2,017 245 29.0   1991 AN (Kampala) 266 11 27.8   1990 AN (Kampala) 426 245 27.0   1991 AN (Kampala) 305 11 26.9   1988 AN (Kampala) 88 245 25.0   1989 AN (Kampala) 498 245 24.5   1992 AN (Kilembe) 257 11 25.3   1992 AN (Mbale) 255 11 17.3   1991 AN (Mbale) 264 11 12.1   1991 AN (Mbale)   241 12.0   1990 AN (Mbale)   11 11.0   1989 AN (Mbale)   11 9.0   1992 AN (Mbarara) 205 11 30.2   1991 AN (Mbarara) 217 11 24.4   1989 AN (Mbarara) 1,017 245 21.6   1990–91 AN (Mbarara) 1,098 3 20.6   1991 AN (Moyo)   241 12.8   1990 AN (Moyo)   241 11.0   1989 AN (Moyo)   241 3.3   1989 AN (Moyo) 615 245 3.3   1992 AN (Mutolere)   11 5.6   1991 AN (Mutolere)   11 4.1   1992 AN (Palisa) 236 11 7.6   1991 AN (Potal) 689 11 23.1   1992 AN (Tororo) 222 11 13.1   1991 AN (Tororo) 257 11 12.8   1990 AN (Tororo)   11 4.1 Zaire 1988–91 An (Kimpese) 9,129 194 3.8 Zambia 1991a AN (Solwezi—periurban)   119 30.0   1991a AN (Kabompo—rural)   119 20.0   1991a AN (Mukinge—rural)   119 16.0   1991a AN (Mwinilunga—rural)   119 9.0 Zimbabwe 1989 AN (Mash. W) 295 267 20.0   1989 AN (Mat. N) 289 267 11.1   1989 AN (Midlands) 298 267 7.7 High-risk population           Central African Republic 1989 STD (Bangui) 76 95 21.0 Gabon 1988 STD (Southeast) 734 231 3.7 Rwanda 1990 STD (Kigali)   123 75.0   1989 STD (Kigali)   123 74.0   1988 STD (Kigali)   123 70.0   1991 STD (Kigali)   123 69.0 Senegal 1992 Gyn (remote areas) 795 227 0.1

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Country Year Population N Ref. HIV-1 High-risk population           South Africa 1990a STD (Durban) 937 194 3.2   1991 STD (J'burg Black) 1,626 223 9.8 Tanzania 1991–92 STD (Mbeya) 299 226 48.8   1992 STD (urban,w/syph)   235 21.0   1992 STD (urban,w/out syph)   235 14.0   1992 STD (north,w/syph)   235 9.5   1992 STD (north,w/out syph)   235 8.9   1992 STD (rural,w/syph)   235 4.5   1992 STD (rural,w/out syph)   235 3.0 Uganda 1990a STD (Kampala) 96 98 60.5   1989–91 STD (Kampala, 20–29)   107 59.0   1989–91 STD (Kampala, 30–39)   107 55.0   1989–91 STD (Kampala, 10–19)   107 45.0   1989–91 STD (Kampala, 40–49)   107 40.0   1989–91 STD (Kampala, 50+)   107 20.0 Zimbabwe 1991 STD (Karoi) 72 152 65.3 Very-high-risk population           Burkina Faso 1990a CSW (rural) 38 88 44.7 Cameroon 1988 CSW (Younde) 168 122 7.1 Côte d'Ivoire 1987 CSW 210 204 35.3 Ethiopia 1990 Bar girls (Adis) 858 179 42.0   1989 Bar girls (Adis) 966 179 22.0   1989 CSW (Adaitu) 110 179 41.8   1988 CSW (Adaitu) 116 179 32.8   1990 CSW (Adis) 1,225 179 54.2   1989 CSW (Adis) 2,663 179 24.3   1988 CSW (Adis) 330 179 19.4   1988 CSW (Arbaminch) 255 179 8.2   1989 CSW (Asmara) 379 179 5.8   1988 CSW (Asmara) 389 179 2.3   1988 CSW (Asseb) 352 179 31.5   1988 CSW (Assela) 326 179 12.9   1988 CSW (Awasa) 260 179 15.4   1991 CSW (Baherdar) 366 179 69.4   1990 CSW (Baherdar) 362 179 55.0   1989 CSW (Baherdar) 353 179 48.2 Ethiopia 1988 CSW (Baherdar) 324 179 35.8   1988 CSW (Bobi) 213 179 12.2   1988 CSW (Dessie) 312 179 38.1   1990 CSW (Diredawa) 366 179 48.1   1989 CSW (Diredawa) 361 179 30.5   1988 CSW (Diredawa) 361 179 18.0   1988 CSW (Gewane) 119 179 30.3   1988 CSW (Gonder) 367 179 14.7   1988 CSW (Jimma) 309 179 9.7   1988 CSW (Keren) 361 179 2.5   1988 CSW (Massawa) 318 179 1.3   1988 CSW (Mekele) 363 179 24.2   1988 CSW (Meteka) 79 179 17.9   1990 CSW (Metu) 165 179 36.4   1989 CSW (Metu) 240 179 12.5   1988 CSW (Metu) 262 179 5.3   1988 CSW (Moyale) 99 179 16.2

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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa Country Year Population N Ref. HIV-1 Very-high-risk population           Ethiopia 1991 CSW (Nazareth) 328 179 65.6   1990 CSW (Nazareth) 315 179 52.4   1989 CSW (Nazareth) 354 179 31.1   1988 CSW (Nazareth) 333 179 19.5   1989 CSW (Nekemt) 294 179 31.3   1988 CSW (Nekemt) 274 179 15.3   1988 CSW (Shashemene) 325 179 19.4 Ghana 1986–87 CSW (return from Côte d'Ivoire) 151 182 49.0 Kenya 1991 CSW (Nairobi) 490 40 85.9   1991 CSW (Nairobi) 524 124 75.2   1990 CSW (Nairobi) 981 124 73.8   1989 CSW (Nairobi) 656 124 67.2 Niger 1987–89 CSW (Niamey) 610 205 4.9 Nigeria 1990 CSW (Lagos) 546 55 10.3   1988–90 CSW (Lagos) 117 5 2.6 Senegal 1985–92 CSW (Dakar) 1,364 158 4.7   1990 CSW (Dakar) 471 157 4.5   1991 CSW (Dakar) 665 157 4.4   1989–91 CSW (Dakar,Regis) 653 96 4.4   1985–92 CSW (Dakar,Regis) 2,216 158 4.3   1991 CSW (Kaolack) 113 157 11.5   1990 CSW (Kaolack) 106 157 4.7   1990 CSW (St Louis) 74 157 2.7   1991 CSW (St Louis) 69 157 0   1992 CSW (various area) 1,342 88 2.4   1991 CSW (Ziguinchor) 138 157 1.4   1990 CSW (Ziguinchor) 194 157 0.5   1992 CSW (remote) 397 227 13.8 Somalia 1990 CSW (Mogad, Merca, Ch) 303 52 3.0 Sudan 1989 CSW (Juba) 50 164 16.0 Tanzania 1987–89 CSW (Moshi—Arusha) 212 186 72.2   1987 CSW (Kili) 52 187 57.7   1992 CSW (Niwanza town) 103 156 39.8 Zaire 1988 CSW (Kin) 801 130 37.2   1988a CSW (Kin) 377 148 26.8 a No study date. NOTE: AN, antenatal; FP, family planning; Vil, village; w/syph, with syphilis; w/out syph, without syphilis; CSW, commercial sex worker.

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