Introduction
Recent progress in the development of sexual health technologies should
benefit men and women in developing countries. Chlamydia screening, HPV
screening and vaccination, trials of HSV-1 vaccine, and improved diagnostic
testing for sexually transmitted infections (STIs) have the potential to
reduce the burden of sexually transmitted infections. Chlamydia screening
has already been implemented in many European countries but is too expensive
for developing countries where the prevalence of chlamydia and its
complications is much greater. The ethical issues of implementing HPV
vaccination are being discussed as the vaccine becomes available in rich
countries. The cost of HIV testing was once prohibitive for many developing
countries, but the importance of this intervention in managing the HIV
pandemic led to improvements in quality of testing and dramatic reductions
in costs. Lessons from the HIV epidemic must be learnt for future
introduction of new technologies in resource poor conditions. In particular,
the social context of the communities meant to benefit must be assessed and
considered. The development and fast track licensing of one of two new
vaccines which have been demonstrated in trials to be highly effective in
preventing infection in women with the main types of Human Papilloma Virus (HPV)
has initiated discussion on the potential effectiveness of this vaccine in
low income countries. Cost, delivery, and access must all be considered if a
new technology is to be introduced, but partial or incomplete understanding
of the social and cultural context aggravates the difficulties. (1)
Burden of Infections
STIs cause a major burden of illness in low income countries, both because
of their serious sequelae, and in some cases as facilitators of HIV
infection (2) Data is sketchy, but the recently available information comes
from a WHO 2001 report, which estimates 340 million new cases of the main
bacterial STIs worldwide. Predominant amongst infections are Chlamydia,
trichomoniasis, gonorrhoea and syphilis, although over diagnosis through
syndromic management is an issue. From an adult population (15-49 years) of
269 million in sub-Saharan Africa, WHO estimated a prevalence of 32 million
infected people, and an incidence of 69 million new infections in 1999. With
a rate of 119/1000 adults infected, sub-Saharan Africa had the highest
infection rate in the world. In all cases of bacterial infections, women had
higher numbers than men, and numbers had increased since the previous
estimates of 1995 (3). The indicative picture is that the rate of sexually
transmitted bacterial infections is slowing whilst that of viral infections
is increasing. Bacterial infections – shorter duration, highly infectious –
spread most efficiently amongst groups of people with multiple partners of
short duration, whereas viral infections rely on multiple partnerships over
longer time periods. Therefore people in long term relationships where
multiple partners for one, other or both people are culturally accepted are
at increased risk of infection.
Women, often asymptomatic, tend to be diagnosed less frequently and later in
infection progression than men, with consequent risk of complications
Pregnancy is one of the main opportunities health services in many low
resource settings have to screen women for infections and for changes in
cervical cytology. Having a sexually transmitted infection during pregnancy
can lead to more expensive treatment, and complicated outcomes affecting the
health of the infant and increased risk of still birth.
Cancer of the uterine cervix is the leading female cancer in Sub-Saharan
Africa and the burden of the infections (80%) falls on low income countries
(4). An estimated 234,000 deaths occur world wide from cervical cancer, 75%
of them in developing countries. Africa has disproportionately higher
mortality from this infection than the rest of the world (5). This is
related to the absence of planned programme screening, and limited
opportunistic screening, in most Sub-Saharan countries. The estimated crude
incidence of cervical cancer in Kenya is 37 – 47/100,000 (6)1. Over one
hundred genotypes of HPV have been identified, divided into low and high
oncogenic risk in relation to cervical cancer. The HPV vaccine, currently
licensed for women aged 9 – 26, targets genotypes 6, 11, 16 & 18, being
those most closely associated with genital warts and cervical cancer. Types
16 and 18 are the most common in all regions, and account for about 65% of
cancers in Africa (7). De Vuyst et al (4), found during their study in
Nairobi that other genotypes were more frequent, indicating that the
distribution of HPV genotypes can be varied in different populations, with
implications for more targeted vaccine development.
Whilst there is growing awareness of the relationship between HPV and
cervical cancer, it is still misunderstood in many regions, including
amongst health professionals. Moreover, in countries where resources for
health are stretched, prevention, detection and treatment of STIs takes a
back seat in relation to the big three of HIV, TB and malaria, and the
ongoing and recurrent basic health problems resulting from poor nutrition,
sanitation and lack of basic resources - helminth infections, bacterial
infections such as leprosy, and protozoan infections. (8). HPV vaccine
requires the introduction of a screening programme, to monitor older cohorts
of women and screen vaccinated women at older ages. There is a question
about the cost-effectiveness of introducing the vaccine versus a screen and
treat programme using lower cost but possibly not as effective methods.
Cervical cytology screening programmes are undermined by paucity of
pathology and gynaecology back-up services. Vaccination as a method of
prevention provides more opportunity to tackle the high risk of cervical
cancer, but will mainly benefit younger age cohorts.
Sexuality, Sexual Practice, Sexual Infections
In any culture acknowledgement of sexuality across generations can be
difficult. Some sexual health technologies coming on stream (HPV, HIV) might
require parents to think in more concrete terms about the sexuality of their
adolescent female children, an area which might normally only receive tacit
acknowledgement. Zimet et al (9), argue that people in the USA, UK and
Mexico find this vaccine acceptable, although the complex sets of beliefs
inherent in any discussion of sexuality will arise in any social setting. A
brief review of the literature on sexuality and sexual practice in rural and
urban Kenya highlights a sexual economy partially in transition,
accommodating new and older ideas, as well as the difficulties that arise
with regard to behaviour change in sexual health and sexual infections.
Adolescent sexual activity in urban Kenya has been described as expected,
mundane and following a normative script for both men and women (10). A mix
of older and ‘modern’ beliefs combine to provide a set of gender norms,
including forced sex in many cases and some involvement of the family in
establishing or approving the relationship. Young girls and women in many
poor areas accept gifts to ‘play sex’ – often financial. This has been
interpreted as building on older traditions of bridewealth. Whilst varying
cultural groups may have different ideas about appropriate sexual practice,
and despite what may really be happening in a young person’s life with or
without their parents knowledge and/or consent, sex outside of marriage or
at an early age is also described as “bad manners” and parents claim that
they don’t know how to influence their children’s behaviour. Alternatively,
parents know that the only way they will able to pay for basic necessities –
whether for themselves or for the family – is by overlooking the fact that
their children are selling sex.
Sexual activity starts at a young age for many women with men 5-10 years
older. Early sex is associated with later health problems, including
infertility. A survey in Kenya with over 8000 girls and boys aged 11 - 16
found 53% to be sexually active, the median age of first intercourse being
12 years old(10). Young women living in urban deprived areas of Nairobi tend
to initiate sex on average two years earlier than women in more economically
stable environments. They typically have significantly more sexual partners
over time. This is related to the insecure environments they grow up in or
move into, and/or their lack of education, and often the need to earn money
through commercial or transactional sex (11).
With regard to safe-sex practice, focus groups held with 94 school-age rural
Akamba girls discussed how these girls managed STIs and unwanted pregnancy
(12). Despite a high level of knowledge of HIV and other STIs, there was a
persisting belief in their own invulnerability amongst the girls. The vast
majority of the girls knew about condoms, but the prevailing belief was that
good girls could not introduce them to a sexual relationship (in addition to
their not being available in a rural location). There was also a great deal
of knowledge of traditional means of preventing infection and procuring
abortion, and these were frequently relied upon.
The little research available on effective STI interventions with
heterosexual men (13) outlines their vulnerability to infection because of
similar predominant discourses. The need to demon-strate virility and
potency justify multiple sexual partners and the difficulties of
accommodating preventive action (condom use). Equally sparse is evaluation
of men’s involvement in health promotion about women’s reproductive health
(14). The benefits of men’s involvement in discussion and decision making
about new technologies is important to gauge, and therefore this sort of
information is crucial.
Indicative of a transitional sexual economy, Spronk (15) describes how some
urban profe-ssional women in Nairobi are challenging the dominant discourses
of female chastity, modesty in appearance and women’s value being held in
their reproductive function, by occupying spaces and activities previously
understood as reserved for men. However, ‘playing hard to get’, which is
used by these women as a screening tool to reveal men’s’ “intentions”,
echoes the actions of younger women in poorer areas who hold out for a
higher priced ‘gift’ before agreeing to have sex.
Cultural beliefs about sexuality and the difficulty of behaviour change in
sexual practice in all settings have emerged as key influences on rights to
sexual health during the last few years of research on HIV/AIDS. As Crichton
et al (16) argue, in Africa, sexual rights are often mediated by claimed
cultural norms. Difficulties of access to quality, preventive health
services compounds sexual health problems.
Accessing sexual health care, and preventive health care
Access to sexual health services is vital to good sexual health. Nairobi is
typical of many large and growing cities in the South. Urban slums like
Kibera and others present people with problems everyday in accessing the
basic resources for a dignified life, including clean water and
sanitation. Health care is often a luxury, preventive healthcare even more
so.
Sexual health services are provided by a range of providers, including
government, private-for-profit, NGO and faith-based health centres and
dispensaries. Government clinics and many NGO-run clinics provide
consultations and some drugs at low cost or free. However, there are
problems with long queues or lack of drug supplies for these subsidized
services. There are many informal settlements in Nairobi, and they vary in
size, the number of international and local NGOs working there, the number
of services and geographical location. Some are better served by health
services or closer to hospitals than others. An alternative is to travel out
of the slums to hospitals, although cost of travel is a barrier, as well as
costs of services. The preferred method of contraception is often injected,
because this is discrete, and relatively easy to manage.
Voluntary counseling & testing services and sometimes family planning
providers are available in some of the bigger slums. Some NGOs organise ad
hoc health events or mobile units (‘health camps’) that carry out
vaccinations, along with public awareness activities. There are some
community-based organizations that provide maternity services for women,
although these may be poorly equipped and insufficient to serve the local
population. They may also be too expensive for some women.
Some health facilities also provide screening and treatment for sexually
transmitted infections. There have recently been campaigns to encourage
people to come forward for treatment at government facilities, although many
people who can afford to prefer to pay, considering that payment also buys
discretion. There is cross referral between HIV services and STI services.
Studies on understanding of cervical cancer among women in Kenya and
elsewhere in sub-Saharan Africa (6), (17), (18) look at the reality of
undertaking preventive health care in low resource settings. As well as
varying understandings of reproductive organs, etiology of infections,
causal factors, and methods of detection, there are other priorities; both
health and other that took precedence in women’s lives. Women in affluent
areas are encouraged to screen regularly but there is a low level of
awareness of the problem across the country, especially in rural areas.
Acceptability of new SRH technologies; trust in service provision
How does a new SRH technology gain and keep social and cultural
acceptance? In addition to beliefs about sexuality and sexual practice,
parents and women’s understandings of the reproductive system, and what
immunisations do are two considerations. (19). There are many reasons why a
SRH technology might not be considered necessary or acceptable. They could
include the experience of a neighbour or friend of adverse side effects, or
less immediately experiential factors such as local political and/or
religious influence, anti-vaccine lobbying, or resistance to what is
perceived as colonial legacy or foreign interference, or an interpretation
of a new techno-logy as a form of imposed and unsolicited family planning
(20). Young people themselves could be reluctant to associate themselves
with something stigmatising, because it is associated with sexually
transmitted infection (9). These responses are not irrational or due to
ignorance (21), but reflect local interpretations of new globalised
healthcare technologies (22).
Other studies of health care technologies introduced in Africa have explored
some of these issues. Bierlich (23) investigated local under-standings of
biomedicine and vaccine in Ghana and found an ambivalent attitude towards
Western medicine. This was partly because older people had experienced both
the success and failures of early vaccine initiatives, but also because of
the context within which this happened (the end of the colonial era).
Younger people were also wary, interpreting biomedicine as a powerful force
external to local culture, to be both respected and treated with caution.
Molyneux et al (24) discuss how coastal Kenyans interpret the aims and
achievements of a medical research centre, and why injections, hospitals and
clinics might be avoided when these were feared to aggravate the spirit
believed to be at root of an illness. Experiences during a tetanus campaign
in Cameron during the 1990s highlight a feminine side to the global-local
relations at play in the campaign, as the vaccine came to be interpreted as
a threat to local reproductive capacity. (25)
This important consideration of trust also relates to what people believe
about their local health services, and how this influences their access to
and take-up of services. Introducing a new SRH technology needs to take into
account and address these local issues.
Conclusions
Preventive health care is both an individual and a state responsibility. The
evidence shows people attempt to take preventive health care measures where
they can (contraception, limited use of screening where available) but there
are multiple obstacles. Sexual health and sexual infections are gendered
development issues. Failure to address the sexual health and sexual rights
of adolescent and older women in low resource settings such as Kenya
exacerbates the health inequality between industrialised countries and the
rest of the world. Middle aged and older women in sub-Saharan Africa may be
less politically visible, but they have a significant social role, being
household managers, the main providers of food, and wage earners, as well as
the mothers of young women. Having had a role in the care of grandchildren,
in many places they are more frequently primary carers of children, where a
generation of men and women have disappeared due to HIV/AIDS. The impact of
sexual infections on this important part of any community needs to be
recognised, and demand created for technologies to resolve the problems.
Beyond delivery and access, the appro-priateness of a new SRH technology
should be explored (26). This includes exploring beliefs about sexualities
and sexual practice, the reality of being able to take preventive health
behaviour, parental beliefs about children, trust in health services, and
beliefs about vaccines, biomedicines and their interaction with ideas about
fertility and reproduction. Poverty does not mean that health service
provision must always be basic, but it is worth recognising that new
technological fixes might not be enough (27). Tried and tested ‘older’
technologies, adapted to local circumstances, might provide better
solutions.
With thanks to
Joanna Crichton, Teresa Saliku and Philippe Mayaud for comments and
discussion
“The authors express their appreciation for the financial support (Grant
HD4) provided by the UK Department for International Development (DfID) for
the Realising Rights Research Programme Consortium. This document is an
output from a project funded by DfID for the benefit of developing
countries. The views expressed are not necessarily those of DfID.” (Rev Afr
Santé Reprod 2007; 11[1]: 7-13)
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