CHAPTER TWO
2.4 Adolescence
2.4.5 The burden of sexually transmitted infections (STIs), including HIV, among adolescents
95 and HIV education information contained in pamphlets, posters etc.; thus they know little about these issues and become vulnerable (Medel-Anonuevo & Cheick, 2007).
Lastly, Groce (1999) reported that PWD are three times more likely to be sexually abused than their peers without disability. The myth that PWD are not sexually active, and hence likely to be virgins, has increased the incidence of rape among females with disability in societies where it is believed that a man can be cured of HIV infection by having sex with a virgin (Groce & Trasi, 2004; Nganzi & Matonhodze, 2004). Therefore, adolescents with disability (especially girls) are likely to have been sexually abused and to be sexually experienced at an early age. In addition, their disability places them at a greater risk of sexual abuse than their able-bodied peers due to their physical weakness and hence ability to defend themselves and inability to assess or report violent situations exacerbates their plight (Rousso, 2003).
Therefore, sexuality of PWD deserves urgent policy attention, particularly in developing countries. This group of individuals‘ rights have to be addressed if the Millennium Development Goal six is to be achieved (P. Thomas, 2005). The fact that an estimated 10.0% of every population is disabled makes PWD an important component of any development initiatives. To ensure that policies effectively address the needs of PWD, more information is needed about the dynamics of their sexual behaviours, across countries and cultures. This will guide the development of tailored intervention programmes that meet their specific needs.
2.4.5 The burden of sexually transmitted infections (STIs), including HIV, among
96 who, often, are not empowered to negotiate safe sex. In addition, sexually active girls may be at greater risk of contracting STIs than boys for biological reasons.
Moreover, WHO (1995) reported that two thirds of the global annual estimate of 333 million curable STIs arise from developing countries. Most of these infections are believed to be concentrated in young people below the age of 25, with the largest rate occurring among the age group of 20-24, followed by the age group of 15-19 (Cates & McPheeters, 1997). While this might present a true picture of STIs in adolescents, Dehne and Riedner (2005) note that the estimates were based on a small number of surveys, and valid incidence and prevalence data for sexually active, unmarried adolescents from developing countries are still rare. Most of the available data on STIs prevalence are from Africa; little is known about the situation in Asia and Latin America, and virtually nothing about Eastern Europe (Dehne & Riedner, 2005).
Overall, girls seem to be more affected than boys, and adolescents in regular sexual partnerships and those in high-risk groups (sex workers and detainees) are more vulnerable than the general population of sexually active adolescents (de Schampheleire, 1997). It is assumed that STIs may be more prevalent among adolescents in Africa and the Caribbean than in other groups as a result of higher numbers of sexually active people, but direct evidence of regional differences is scarce (Dehne & Riedner, 2005). They also suggest that STIs are common among sexually abused women and children, but there is no data on men.
In addition, Cates and McPheeters (1997) affirm that the most commonly reported STIs in adolescents are Chlamydia and gonorrhoea. In Nigeria and elsewhere, female adolescents accounted for the highest level of Chlamydia infection (detected by specimen culture) among all age groups, and prevalence was higher among younger adolescents than older ones (Behets et al., 1995; Brabin et al., 1995). Prevalence levels ranged from less than 10.0% among sexually active girls in rural areas of Uganda and Nigeria, to 10.0-20.0% among those in regular relationships (pregnant girls and those attending family planning clinics) and more than 40.0% among sex workers in Senegal. Females are particularly vulnerable to STIs/HIV, biologically, economically and socio-culturally, particularly in Africa. Although there is limited data on gonorrhoea prevalence, the rate documented in existing data was lower than for Chlamydia, and usually well
97 below 10.0%, excluding high schools in the USA and adolescent patients in Namibia (Brabin et al., 1995; Burstein et al., 1998; Osotimehin, Dare, & Ojengbede, 1994).
Furthermore, an estimated 11.8 million of about 1 billion young people in the world were said to infected with HIV/AIDS as at the end of 2001 (UNICEF/UNAIDS/WHO, 2002). Sub-Saharan Africa bears the greatest burden of HIV infections among young people globally. About 73.0%
of all young people (15-24 years) infected with HIV are living in sub-Saharan Africa (UNICEF/UNAIDS/WHO, 2002). South Asia, East Asia and the Pacific, and Latin America and the Caribbean accounted for 9.0%, 6.0% and 5.0% respectively in terms of the percentage of young people infected with HIV. Countries of the Central and Eastern Europe, Commonwealth of Independent States and the Baltic States (4.0%), industrialised countries (2.0%), and the Middle East and North Africa (1.0%) had the lowest HIV prevalence in young people.
Overall, more young women (7.3 million) than young men (4.5 million) are HIV-infected. In all the other regions of the world, more young men than women are infected with the virus, except in sub-Saharan Africa and South Asia (the two regions with the largest burdens), where two thirds of HIV-infected young people are women and girls. It was also estimated that more than two thirds of the new infections among the 15-19 year age group in sub-Saharan Africa are girls (UNICEF/UNAIDS/WHO, 2002).
Factors contributing to the spread of STIs, including HIV, among adolescents include their sexual behaviours (which are influenced by both individual and environmental factors, as discussed earlier); treatment-seeking behaviours; and unsuccessful preventative strategies.
Adolescents‘ treatment-seeking behaviour is influenced by the following factors:
Asymptomatic nature of STIs and HIV: Most STIs in girls and many in boys remain asymptomatic until serious consequences emerge (Dehne & Riedner, 2005). More than two thirds of non-ulcerative STIs present with non-specific symptoms which sometimes are considered ‗normal‘ by young people.
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Lack of adolescent-friendly services: Many adolescents do not seek treatment for symptoms of STIs at clinics because of health workers‘ disapproval of their sexual behaviour (Brabin, 2004; Temin et al., 1999).
Lack of confidentiality: Adolescents are often scared to attend clinics because they do not want their parents and/or classmates to be aware of their health concerns (T.L. Cheng, Savageau, Sattler, & DeWitt, 1993; Temin et al., 1999), and this applies to the use of both school health clinics as well as public health services (Ferguson, 1998).
Financial constraints: Many adolescents may want to use the services of private practitioners but often cannot afford them (Brabin, 2004; Temin et al., 1999). In a study by Brabin et al. (1995), only 2.8% of symptomatic girls sought any form of treatment, and this varies according to age. Older girls sought treatment more often than younger girls. The kind of treatment sought was often provided by patent medicine dealers (Brabin et al., 1995) or traditional healers, as reported in Nigeria (Temin et al., 1999), because such persons were able to offer them cheap and anonymous services. However, Brabin (2004) argues that such treatments may not be appropriate for their health problem, and may deter them from receiving much-needed preventative education.
Ignorance: One of the greatest problems faced by adolescent girls is ignorance of symptoms of STIs (Brabin et al., 1995). Adolescents generally lack access to adequate and accurate information about STIs and HIV (Dehne & Riedner, 2005). Even when symptoms persist and they are sure they need medical help, they delay seeking treatment due to embarrassment and guilt.
Concerns about pregnancy: Pregnant adolescents in developing countries often miss out on routine syphilis screening because they do not attend (or attend only late in pregnancy) antenatal clinics (Brabin, 2004). This often happens because they are trying to hide their pregnancies from parents or other adults around them who may disapprove of their sexual behaviour. Some do not report for antenatal care because they cannot afford.
Self-medication: Many adolescents in countries where prescription drugs can be obtained over-the-counter would rather self-medicate than seek proper medical attention. This may be attributed to financial constraints, unfriendly health workers and embarrassment and guilt. A study in Nigeria revealed that adolescents self-medicate with antibiotics such as
99 tetracycline and chloramphenicol to treat STIs (Temin et al., 1999). In addition, they use herbs and roots, Krest Bitter lemon soda, kola and combinations of salt, potash, gin, lime and pepper fruit to treat STIs. All of these have no proven efficacy in treating their ailments, and they can build antibiotic resistance and incur side-effects from using such products.
Unsuccessful preventative strategies have also been implicated in the spread of STIs among adolescents. Studies have shown that inadequate and inaccurate information about STIs is common in adolescents and that, even when the adolescent is knowledgeable, it does not always translate into the adoption of healthy behaviours (Lema, 1990; Odujinrin & Akinkuade, 1991).
Brabin (2004) points out that lack of access to condoms and inconsistent condom use exposes sexually active adolescent to STIs, including HIV.
It has been established from the aforementioned that adolescents do engage in risky sexual behaviours that put them at risk of contracting STIs, including HIV. Looking at the interconnectedness of STIs and HIV, one should not be surprised by the high prevalence of HIV infection in this group. An adolescent who has contracted a STI and does not seek treatment early enough is therefore at a greater risk of HIV infection.