Population Action International

2 - Unsafe sex destroys lives and decimates societies.

Among common causes of disease and death of people in low-income countries, unsafe sex was found to be the second greatest risk factor for health loss and the fifth greatest risk factor for death. The burden of unsafe sex is highest in sub-Saharan Africa, followed by South Asia.1 Consequences of unprotected sex include transmission of HIV and other sexually transmitted infections (STIs), complications from pregnancy, childbirth and abortion. In 2005, over 4 million people became newly infected with HIV, mostly through sexual transmission, and 340 million new cases of common, curable STIs occur annually (See box on STIs).2 3 The majority of HIV/AIDS epidemics in the world are fueled by unprotected sex.

Unprotected sex is the primary mode of HIV transmission for women. Worldwide, almost half of the people living with HIV or AIDS are women, and in sub-Saharan Africa—where heterosexual transmission is highest—60 percent of those living with HIV or AIDS are women. Although marriage is often perceived as a protective factor, it is not. Even in countries that have seen declines in HIV prevalence, the majority of new infections are now among monogamous married women. In Cambodia, for example, husband-to-wife-transmission is the main route of HIV transmission, causing two-fifths of new infections.4

Condom use remains uncommon among married couples and regular partners. Non-commercial, non-marital, longer-term sexual relationships that involve a certain level of affection and trust are on the rise in many countries.5 Condoms, which remain associated with infidelity and casual or commercial sex, are less likely to be used in these relationships. According to the 2000-01 Uganda Demographic and Health Survey (DHS), only 4 percent of men and 3 percent of women reported using condoms during their last sex act with their spouse or cohabitating partner.6 Male and female condoms must be accessible to those who need them—as methods of contraception and HIV/STI prevention. The female condom expands the limited range of available barrier methods. As always, information about condoms should be age-appropriate, medically accurate and part of a comprehensive approach that empowers individuals to make informed decisions.

People with concurrent sexual partners are significantly more likely to contract HIV than those who practice serial monogamy. During the first weeks of HIV infection, HIV transmissibility is very high. Therefore, concurrent sexual partnerships accelerate the spread of HIV through sexual networks during this acute phase. On the other hand, partner reduction and serial monogamy reduce the chances of spreading the infection. Messages encouraging faithfulness are essential and should be part of a comprehensive, balanced and sustained HIV-prevention effort. The promotion and funding of abstinence and fidelity above and apart from other prevention strategies, such as U.S. policy currently does, dangerously ignores the reality of women's lives and increases their risk of contracting HIV.

When only one partner adheres to monogamy, the result can be tragic, particularly for married women. Preventing infections among monogamous women requires longer-term strategies to address the roots of gender inequity. Cultures are not static, and there are opportunities to challenge deep-rooted notions of masculinity among young boys. For example, exposure to formal learning in a school setting provides an opportunity to challenge traditional gender roles, for both girls and boys. Additionally, special interventions are needed to reach out-of-school youth.

STIs

Data on the global prevalence of sexually transmitted infections (STIs) are limited because STI surveillance has been largely neglected and underfunded. However, the best available estimates indicate that more than 340 million new cases of the common bacterial and protozoal STIs (i.e. syphilis, gonorrhea, chlamydial genital infections and trichomoniasis) occur every year throughout the world in men and women aged 15 to 49.7

The largest number of new infections occurs in South and Southeast Asia. However, the highest rate of new infections occurs in sub-Saharan Africa, followed by Latin America and the Caribbean.8 Prevalence and incidence of STIs varies within countries and between countries in the same region, as well as between rural and urban populations and even in similar population groups.9 In general, STI prevalence tends to be higher among urban residents, unmarried individuals and young adults.10 It is estimated that at least a third of the 340 million new annual STI cases are among people under age 25.

The most serious consequences of untreated STIs tend to affect women and newborns. In developing countries, STIs and their complications are among the top five disease categories for which adults seek health care. STIs (excluding HIV) are second only to maternal factors as causes of disease, death and healthy life lost among women of reproductive age.11

In adults, STIs can lead to pelvic inflammatory disease and potentially fatal ectopic pregnancy or chronic illness. STIs are also the leading preventable cause of infertility, which affects more than 180 million couples in developing countries.12 While infertility affects both men and women, women typically suffer the greater social consequences from their partners and their communities. Untreated STIs can also increase the risk of both acquisition and transmission of HIV. Improvement in the management of STIs can reduce the incidence of HIV infection in the general population.13 In unborn and newborn children, STIs can cause stillbirths, low birth weight and pneumonia.

Despite the widespread prevalence and serious consequences, STIs receive little political or financial support. For example, in sub-Saharan Africa, it is estimated that 1,640,000 pregnant women have undiagnosed syphilis every year.14 Untreated syphilis results in a stillbirth rate of 25 percent and a perinatal mortality of about 20 percent. Although screening and treatment programs for syphilis have roughly the same potential to prevent fetal deaths as PMTCT programs (an estimated half a million fetal deaths averted per year) syphilis receives far less attention and funding.15 16

 

Notes

  1. Lopez AD, CD Mathers, M Ezzaati, DT Jamison, and CJL Murray. 2006. “Global and regional burden of disease and risk factors, 2001: Systematic analysis of population health data.” The Lancet 367: 1747-57.
  2. UNAIDS. 2006. 2006 Report on the Global AIDS Epidemic. Geneva: UNAIDS.   
  3. WHO. 2001. Global Prevalence and Incidence of Selected Curable Sexually Transmitted Infections Overview and Estimates. Geneva: WHO.

     

  4. Ek, V. 2004. Gender and HIV/AIDS Policy in Cambodia. Poster presented at the International AIDS Conference, Bangkok. Abstract No. ThPeC75674.
  5. Population Services International (PSI). 2002. Sweetheart relationships in Cambodia: Love, sex and condoms in time of HIV. Washington, DC: PSI.
  6. Measure DHS STATCompiler. Available from http://www.statcompiler.com/statcompiler/index.cfm; accessed on August 27, 2007.

     

  7. WHO. 2001. Global Prevalence and Incidence of Selected Curable Sexually Transmitted Infections Overview and Estimates. Geneva: WHO.  
  8. Ibid.
  9. Ibid.

  10. Ibid.

  11. The World Bank. 1993. World Development Report: Investing in Health. Washington DC: The World Bank. 
  12. Rustein SO and Shah IH. 2004. “Infecundity, infertility, and childlessness in developing countries.” DHS Comparative Reports No.9. Calverton, MD: ORC Macro and Geneva: WHO.
  13. Gilson L., et. al. 1997. “Cost-effectiveness of improved treatment services for sexually transmitted diseases in preventing HIV-1 infection in Mwanza Region, Tanzania.” The Lancet 350: 1805-09.
  14. UNAIDS. 2005. AIDS Epidemic Update 2005. Geneva: UNAIDS.  
  15. Schmid G. 2004. “Economic and programmatic aspects of congenital syphillis prevention.” Bulletin of the World Health Organization 82: 1-8. 
  16. Glasier, Anna, et. al. 2006. “Sexual and reproductive health: a matter of life and death.” The Lancet 368: 1595-1607.