The Washroom Conversation -Facts and Preventive Measures on Antimicrobial Resistant Sexually Transmitted Infections (STIs) among Women

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By Wambui Ngugi

For correspondence: lilacbriton12@gmail.com

Female washrooms are like magazines. All sorts of conversations happen there. From mundane conversations such as how the morning coffee tasted different to the extremes of how sexually satisfying the previous night was.

On one recent in-between-class rush to the washroom, I overheard an interesting conversation. One feminine low-toned voice explained how she was taking a second, different set of medicine, because what she had picked from her one-night stand “just a rebound guy” wasn’t going away. Sounding disgusted and desperate, she further defined her vaginal discharge as so smelly that she had to find a stronger deodorant.  “…the itch is like the cherry on it all. A reminder of my sins, a punishment to my sodden soul. Now it even feels like it’s crawling into my rectum, especially when the classes get boring.”

I felt for her. No woman should have to feel like this.

Her friend chipped in sympathetically, advising her “start douching your vagina and rectum with lemon water and garlic to help with the smell.” I wanted to scream. Douch! Who uses such ‘grandma’ methods, especially when this sounded to me like an antimicrobial-resistant sexually transmitted infection (STI)?

STIs are infections spread through sexual contact: oral, vaginal, or anal (WHO, Sexually Transmitted Infections 2020). While both men and women are affected by STIs, a woman with the infection can pass it on to her fetus during pregnancy or the birthing process. The WHO estimates that more than 1 million STIs are acquired every day (, WHO 2021).

Antimicrobial resistance is when microscopic, disease-causing organisms—like those that cause STIs—no longer respond to the medicines designed to stop them. When STIs are antimicrobial resistant, they become difficult to cure. The WHO has referred to gonorrhoea, syphilis, chlamydia, and trichomoniasis as curable STIs, meaning that with proper treatment they are eliminated from the body (WHO, Sexually Transmitted Infections 2020). Over time though, the world of medicine has watched these infections evolve through various treatments. For example, gonorrhoea has slowly developed resistance to treatment by fluoroquinolone antibiotics, and presently, there is an emerging resistance to cephalosporin drugs, which are the currently recommended antibiotic treatment (CDC 2022). Resistance is also happening with the other STIs, not just gonorrhoea.

STIs can be asymptomatic or symptomatic (WHO, Sexually Transmitted Infections 2020). Symptomatology largely presents as vaginal discharge, genital ulcers, lower abdominal pain, and neonatal conjunctivitis (WHO, Sexually Transmitted Infections 2020). The listed symptoms are not exhaustive, as the different infections could have further manifestations depending on the type sex of sexual activity (e.g., oral ulceration after oral sex).

 In women, long term complications of STIs include pelvic inflammation, chronic pelvic pain, ectopic pregnancies, infertility, and enhanced HIV transmission (especially the ulcerative ones) (Francis 2020). In addition, when there is vertical transmission from mother to child, complications may include stillbirth, neonatal infection (e.g., neonatal conjunctivitis leading to infant blindness), and newborn deaths, among others (World Bank Organisation 2007). Syphilis alone is estimated to cause up to 1,500,000 perinatal deaths each year (World Bank Organisation 2007).

Furthermore, some STIs, such as syphilis, have been known to continue breaking down other organs like the heart, brain, lung, and kidneys, and this can lead to disability and death. (Quinn 2018). In developing countries, STIs are the second leading cause of disability-adjusted life years lost to women, after maternal deaths (World Bank Organisation 2007). The World Bank estimates that the second leading cause of healthy life lost among women between the ages of 16 and 44 in the developing world is STIs, HIV excluded! Can you imagine how many more deaths would occur in the face of incurable STIs?

Seeing that sexual behaviours are the greatest causative link, I would happily go ahead and advise every woman to abstain from sex. Abstinence has been known to be the only sure way to prevent the spread of STIs. However, as it is natural to become sexually involved, this isn’t enough (Quinn 2018).

Other specific sexual behavioural changes, including increased monogamy, reduced number of partners, avoidance of sex workers, and increased condom use, have in the past shown effectiveness in STI prevention (DT, JG and AR 2006). Researchers have also shown that targeted education to travellers on STIs decreased their likelihood of having unprotected casual sex during their international visits (tien, Punjabi and Holubar 2020).

In the past, however, sustainment of preventive behaviours in the long term has resulted in prevention fatigue (tien, Punjabi and Holubar 2020). Thus, it is fair enough to point out that we will slip up and probably have that casual, condomless sex at some point. Sometimes, it may be our trusted partner who will bring the sexually transmitted microbe to us. Therefore, it is wise for us to practice healthy health-seeking behaviours.

For example, as women, we need to avoid self-medication for STIs, especially with antibiotics. The best route is to see a doctor and have proper check-ups and tests done. Where a diagnosis has been made, it is best to take medicine as prescribed and to the fullness of the dose. If symptoms persist, have another check-up at the hospital to help ascertain what is going on. The rapid detection of an antimicrobial-resistant STI can help with its effective treatment and help control its spread.

Another target in reducing the spread of antimicrobial-resistant STIs is core groups. Core groups are individuals with many sexual partners, who themselves may also have other partners. Examples of core groups include sex workers, drug users, and bar girls. Treatment of an STI in a core group has been found to be preventive for several other people. The treatment programs targeting core groups further help minimize the prevalence of dissemination by the bridge populations— individuals with sexual links between members of high-prevalence (e.g., core groups) and low-prevalence subpopulations (Huang, et al. 2011).

One example of  core group-targeted management is the Nairobi-based sexual workers outreach program (SWOP). SWOP is the leading sex workers’ health agency in Kenya that promotes the health, safety, and well-being of sex workers and affirms their occupational and human rights. The program also carries out community education that is targeted at women and adolescents, thus helping raise awareness in the community (SWOP-Kenya 2014). As women, when we are aware of such programs at our disposal and we take advantage of them, we benefit greatly.

In addition, reducing the stigma around STIs would help us get to the talk about antimicrobial-resistant STIs and enable people to seek better treatment. Empowered with the knowledge of what STIs are and what antimicrobial resistance is, we can walk away from the trap of myths such as what I heard in that washroom conversation (“putting garlic in the vagina would help cure the STI”).

A sharp knock on the bathroom door was just the right reminder that there was an ongoing class that I was missing.

References

, WHO. 2021. Antimicrobial Resistance. 11 01. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance.

Brownne, Annie J, and Emmanuelle A. P. Kumaran, Puja Rao, Joshua Longbottom, Eli Harriss, Catrin E. Moore, Susanna Dunachie, Buddha Basnyat, Stephen Baker, Alan D. Lopez, Nicholas P. J. Day, Simon I. Hay & Christiane Dolecek Bahar H. Kashef Hamadani. 2020. “Drug-resistant enteric fever worldwide, 1990 to 2018: a systematic review and meta-analysis.” BMC MEDICINE. JANUARY 3. Accessed April 1, 2022. https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-019-1443-1.

CDC. 2022. Antibiotic-resistant Gonorrhoea. January 13. Accessed April 22, 2022. https://www.cdc.gov/std/gonorrhea/arg/default.htm.

Cristaudo, Antonio, and Massiamo Giuliani. 2020. Sexually Transmitted Infections Advances in Understanding and Management. Rome: Springer Nature Switzerland.

DT, Jameson, Benman JG, and Measham AR. 2006. disease control priorities in developing countries. new york oxford university press.

Francis, Suzanna. 2020. “STI control in low and middle-income countries.” Role of syndromic management in AMR. LONDON: London School of Hygiene and Tropical Medicine, JANUARY 9.

Huang, ZJ, W Wang, M C Martin, E.J. Nehl, B.D. Smith, and F.Y. Wong. 2011. “Bridge population”: sex workers or their clients ?- STI prevalence and risk behaviours of clients of female sex workers in China.” AIDS Care 45-53.

Peter R., Paul Zeitz. 2001. 1) Family health international. strategies for expanded and comprehensive response (ECR) to a National HIV/AIDS epidemic. Module 7-managing the supply of drugs and commodities. Arlington: Family Health International.

Quinn, Paul. 2018. Sexually Transmitted Diseases; Your Questions Answered. california: ABC-CLIO,LLC.

SWOP-Kenya. 2014. Who we are. Accessed April 22, 2022. https://www.swop-kenya.org/services/.

tien, Vivian, Chitra Punjabi, and Marisa K Holubar. 2020. “Antimicrobial Resistance in sexually transmitted infections.” journal of travel medicine 2.

WHO. 2020. Sexually Transmitted Infections. March 25. Accessed April 22, 2022. https://www.who.int/news-room/fact-sheets/detail/oral-health.

World Bank Organisation. 2007. Sexually Transmitted infections in Developing Countries. December. Accessed April 22, 2022. https://web.worldbank.org/archive/website01213/external.html?link=http://go.worldbank.org/4LJ1038UG0.

About the Author: Wambui Ngugi is a medical student at Kenya Methodist University. She is interested in seeing the science behind every story and is geared up to fight Antimicrobial Resistance.

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