Download Handout on lesson 10 - The World Starts With Me | Ethiopia

Background Information to Lesson 10
Protect yourself: STIs and HIV/AIDS
1. Introduction
The majority of young people worldwide are sexually experienced by the age of twenty1.
Many youngsters abstain from sex or sexual intercourse, but a great part of them cannot or
do not want to wait until marriage before they engage in sexual activity. If both partners feel
ready for sex and practise it in a healthy, safe and consensual way, sex can be a satisfactory
and pleasant part of a relationship. Unfortunately, sex can have negative consequences if it
is unprotected, coerced or forced. Unsafe sex can result in unintended pregnancies (see the
Background Information to Lesson ---------) or it can cause the transmission of Sexually
Transmitted Infections (STI), including HIV/AIDS. Practicing safe and protected sex can
prevent both pregnancy and STIs. To decide on these measures, young people need
adequate information and skills to choose one of the ABC methods (Abstinence, Be faithful
and use Condoms) that suit their lifestyles.
The WHO estimated that, worldwide, nearly 340 million new cases of sexually transmitted
infections occur each year, of which one-third in people under 252. Worldwide, one in twenty
adolescents contract a sexually transmitted infection each year, and half of all new HIV
infections each year occur among young people3. While most STIs are treatable, many are
undiagnosed and go untreated due to fear of stigmatisation or lack of accessible services
(youth friendly services) for young people. Untreated STIs can have severe consequences.
They are an important cause of infertility.4 In addition, STIs that go untreated can increase
the risk of HIV infection and transmission by up to ten times.5 The largest of the new cases of
HIV infection each day, worldwide, are sexually transmitted.6
2. STIs in Ethiopia
Sexually Transmitted Infections
Sexually transmitted infections (STIs) remain a major public health problem in Ethiopia.
Stigma is associated with sexually transmitted infections, which discourages clients from
seeking timely and appropriate care.
Available data7 show that even though rates of STIs remain much higher in high risk groups
such as commercial sex workers and urban populations the infections are also quite
prevalent among women in what would be seen as low risk groups including antenatal and
women seeking family planning services
In such Family planning clinics, rates for gonorrhoea, Chlamydia and syphilis were recorded
high. With continued unprotected sexual relations among young people, the risk and the
spread of STIs remains potentially high.
3. What are STIs and how are they transmitted?
Sexually Transmitted Infections (STIs) are infections that can be passed on from one person
to another by way of sexual contact. Previously, they were also called venereal diseases
(VD) or sexually transmitted diseases (STDs). STIs can be caused by parasites, bacteria,
fungal infections and viruses. Most STIs can be cured if diagnosed and treated in time, with
the exception of viral infections. Viral infections may not be lethal – only HIV/AIDS, Hepatitis
B and C may be lethal if untreated – but the virus causing the disease will stay present in the
body, causing the symptoms of the infection to return. This means that treatment of
symptoms of viral STIs is possible, but there is no cure yet. Hepatitis B and C, for that matter,
do not always develop into chronic diseases, and a percentage of patients clear the virus
spontaneously or after treatment.
The most common STIs caused by parasites are public lice, scabies and trichomonas. The
most common bacterial STIs are Chlamydia, gonorrhoea and syphilis. Hepatitis, herpes and
warts (papiloma virus) are the most common viral STIs, and HIV is the best known viral STI.
HIV will be dealt with separately in this Background Information section and is also discussed
in the Background Information to Lesson -------, because of its high prevalence among young
people and its more severe consequences.
Candidacies, a fungal infection, is a very common and quite harmless vaginal infection. It can
be compared with the common cold: if a person’s resistance is low, such an infection can
occur. Candidacies, therefore, is not necessarily a sexually transmitted infection though its
similar symptoms can easily be confused with those of STIs. It is estimated that 75% of
women has the symptoms of candidacies at least once in their lives8.
Types and symptoms of STIs: You cannot tell from the outside whether someone has an
STI or HIV. STIs often do not present symptoms. Someone may be infected without having
symptoms for months or years; or the symptoms can be very mild and disappear by
themselves after a few days. This does not mean STIs need not be treated. In general, if
there are any symptoms, they include: unusual smelly or coloured vaginal fluid; pus coming
from the penis or, in the case of anal sex, from the anus; or sores, itching, blisters or warts in
the genital area or anus9. The infected person can also experience pain when urinating or
during sexual activities.
If untreated, more serious STIs can result in infections in the abdomen, causing abdominal
pain and possibly fever. Chlamydia often does not show any symptoms at all but can
damage the tubes and cause infertility. Not all symptoms will occur in the genital or anal
area: warts and blisters sometimes occur in other parts of the body. Symptoms of
candidacies, not necessarily sexually transmitted, may be similar to other STIs: itching and
burning. If someone suspects he/she may have contracted an STI or if there are symptoms,
it is important to seek medical advice at a clinic immediately. More information about each
particular STI can be found in Annex 1.
HIV/AIDS: HIV is an STI. HIV stands for Human Immunodeficiency Virus and is the cause of
AIDS. The virus damages the cells of the immune system of the person it lives in. The
immune system is a group of cells and organs that protect the body by fighting viruses and
infections. The body's immune system usually finds and kills viruses quickly. The HIV virus,
however, attacks the immune system itself, limiting the body’s capacity to fight infections.
The body becomes increasingly vulnerable, not just to the HIV virus, but also to other
viruses. Over time, an infected person becomes ill more frequently and more severely. At
that point, a person has developed AIDS, the Acquired Immune Deficiency Syndrome10.
The difference between HIV and AIDS: HIV is the virus that causes AIDS. Some first
symptoms of an HIV infection may be noted, such as a flu-like illness. These symptoms may
disappear without the HIV-infected person noticing them.
AIDS, on the other hand, is the name of the syndrome that arises once the symptoms of one
or more diseases are becoming manifest. A simple boil or wart may spread all over the body.
The mouth may be infected with thrush (a thick white coating). People may develop severe
shingles (painful blisters in a band of red skin), or herpes. They may feel very tired all the
time, run high temperatures, have drenching night sweats, lose more than 10% of their body
weight and have diarrhoea for more than a month. When no other cause is found, a blood
test will usually indicate infection with HIV. People with AIDS may also suffer from infection of
the lungs, Tuberculosis, infections of the nervous system, skin cancer, et cetera. At this
stage, AIDS has fully developed as a syndrome.
Window period: Someone who has been infected with HIV may still be a healthy-looking
person. People who have been infected are called HIV positive, meaning that antibodies
against HIV can be found in their blood, while HIV virus has not yet attacked most white
blood cells and they may feel healthy. After HIV infection has taken place, people start
producing antibodies against the HIV virus, mostly within about twelve weeks. As an HIV test
is unable to detect the HIV viruses themselves but only the antibodies against the HIV virus,
an HIV test can only show a reliable result after these twelve weeks. The process of the
blood test changing from negative to positive is called ‘sero-conversion’. The time between
infection (when the virus is present in the blood) and sero-conversion (when anti-bodies
against the virus can be demonstrated in the blood) is called the ‘window period’. In this
window period, when an HIV test will still be negative, there are a lot of HIV viruses in the
blood, and this person is highly infectious.
After a certain time, all HIV-infected people will develop AIDS. However, the time between
HIV infection and the onset of AIDS varies. Some HIV-positive people may live a long time
after they get infected, even up to 15 years or more, without getting any symptoms of AIDS,
whereas other people may show symptoms within some months or years. There is no
answer to the question how long someone with HIV can continue to live. The number of
years an infected person will survive, depends on many factors. For example, it depends on
the immune system itself, his or her diet, the number of viruses in the body, whether other
diseases are treated fully and immediately whenever they occur and whether he or she takes
specific drugs for HIV.
Ways of STI transmission: STIs are transmitted in various ways. All STIs can be
transmitted through unprotected sexual contact, particularly sexual intercourse. Unprotected
sex is called unsafe sex, that is, sex without proper use of a condom. Parasites can also be
transmitted by sleeping in infected bedclothes, sharing clothes with someone who is infected
or by intimate contact. Genital warts and herpes can be transmitted by sexual intercourse
and by intimate bodily contact without having sexual intercourse. HIV and hepatitis can be
transmitted sexually but also through blood contact, for example, when intravenous drug
users share contaminated needles. In addition, HIV can be transmitted from mothers to their
babies through pregnancy, labour, delivery or breastfeeding.11
Transmission of all STIs can be prevented by abstaining from sexual, vaginal and anal
intercourse and/or by using a condom during all sexual intercourse. There is a risk of
contracting STIs via oral sex, but this is quite low, and is even lower for HIV transmission
(see below: prevention of STIs).
Transmission of HIV: HIV is present in all bodily fluids. However, the concentration of HIV
viruses in saliva, tears and sweat is too low to cause infection in a partner. Vaginal fluid is
particularly infectious if menstruation blood is present. HIV is only transmitted through bloodblood contact and sperm-blood contact: HIV in infected people’s blood or sperm may enter
the blood stream of their sexual partner through small bruises and scratches in and around
the private parts. This is why STIs (which often show wounds on private parts) and rape
(which is often accompanied by force and violence and usually involves unprotected
intercourse) increase the risk of HIV infection.
If people share shaving blades or needles for drug injection with an HIV-infected person, this
may involve blood-blood contact and HIV transmission. Traditional customs such as
circumcision or body tattooing with non-sterilized blades or knives can spread HIV as well.
Wife inheritance and wife sharing can contribute to the spread of HIV if unsafe sex is
practised. Risky traditional customs, therefore, should be avoided to stop the spread of HIV.
4. Misconceptions about STIs and HIV
There are a lot of misconceptions about STIs and the spread of HIV. However, it is important
for people to know the facts and the truth about STI infection, including HIV, to protect them
selves and other people from getting infected. Below, we address some common
misconceptions.
Misconception: If the male withdraws his penis before ejaculating, STIs and HIV cannot be
transmitted.
Truth: many viruses and bacteria can be present in vaginal fluids; HIV may be present in the
woman’s menstrual blood or the man’s pre-cum fluids. STIs can be transmitted easily.
HIV/AIDS can also be transmitted if one of the lovers has sores or small cuts in or on his or
her sexual organs (usually caused by an STI). Withdrawing the penis from the vagina or
anus before ejaculation, therefore, is not a way of preventing the transmission of STIs and
HIV.
Misconception: oral sex is safe sex.
Truth: STIs can be transmitted during oral sex. However, the risk of HIV transmission is low.
For HIV transmission to take place, there needs to be blood-blood or blood-sperm contact.
Oral HIV infection can only take place, therefore, if partners have cuts or wounds in their
mouths or if infected sperm or vaginal fluid with menstrual blood comes into contact with cuts
or wounds in the mouths or genitals of their sexual partners. If people are really concerned
about STI and HIV transmission during oral sex, they can decide to use a condom when they
have oral sex. In any case, sperm or vaginal fluid during menstruation should be prevented
from entering the mouth.
Misconception: kissing can transmit STIs, including HIV.
Truth: Kissing will not cause an infection, neither with STIs nor with HIV. In case of deep
kissing or French kissing, the probability of getting an STI or HIV is very small. Exchanging
saliva during kissing alone does not cause STI or HIV infection. Transmission is possible,
however, if both partners have small wounds or cuts in their mouths, which would involve
blood-blood contact.
Misconception: safe sex means using any method of contraception, for example,
contraceptive pills.
Truth: Contraceptive pills prevent pregnancy but do not protect against STIs and HIV
infection. Only condoms protect people against both pregnancy and STIs, including HIV.
Misconception: Having sex with a virgin cures HIV infection or AIDS.
Truth: HIV and AIDS cannot be cured. HIV infection is caused by having unprotected sexual
intercourse with anyone who is already carrying HIV, as sexual intercourse involves
exchanging risky body fluids such as seminal fluid and vaginal fluid that may contain
menstrual blood. Having unprotected sex with a virgin puts this girl at risk of HIV infection,
especially when very young girls are involved and if they are forced into having sex.
Misconception: Being married protects against STIs or HIV.
Truth: One of the partners may have been infected before or outside marriage and can
transmit this infection to their spouse. Only a test for STIs and HIV can tell whether either
one of the partners has been infected or not. Marriage will only protect against STIs and HIV
when both partners have been tested negative and are completely faithful to one another.
4. High-risk situations and behaviours
STI and HIV transmission may happen to anyone who practises unsafe sex, that is, sexual
intercourse without using a condom. There are several situations and behaviours that
increase the risk of STI or HIV transmission through unprotected sexual intercourse. These
include:12
- Unprotected sexual intercourse due to lack of adequate knowledge about STIs and HIV;
or misconceptions, for example, the mistaken idea that sexual intercourse can cure an
STI; or the idea that the STI has been cured when the symptoms disappear.
- Unprotected sexual intercourse due to lack of negotiation skills. In a social sense, young
girls are more vulnerable to STI transmission because they often lack skills in negotiating
safe sex. In a biological sense, young girls are more vulnerable to infections with STIs or
HIV than boys and adult women because the mucous cells of the vagina and cervix are
not yet fully developed and thinner, providing a less effective barrier to viruses.
- Unprotected sexual intercourse because young men and women may find it difficult to
use condoms. They may feel too embarrassed to purchase or ask for condoms, to have
condoms with them, to talk about condom use before having sexual intercourse and to
use condoms correctly and consistently. This may be more difficult for girls than for boys.
However, having condoms available whenever they have sexual intercourse is a
responsibility for both girls and boys.
- Unprotected sexual intercourse after discontinued treatment of STIs. People often stop
the treatment of a disease as soon as the symptoms disappear, before confirming that
the STI has actually been cured. If they then have unprotected sex, they may transmit the
STI while also being more vulnerable to HIV infection. If they discontinue treatment too
early, they may also build up resistance towards the antibiotics that can treat and cure
STIs, which means that STIs will be more difficult to cure in future.
- Pressure from peers to engage in unsafe sexual conduct. Young boys often boast about
their sexual experiences and pressurize other boys into doing the same.
- Drug abuse increases vulnerability to HIV infection in two ways: it increases false feelings
of being in control, which may lead people to take risks such as unsafe sex. Sharing nonsterilized injecting equipment with an infected person may lead to direct transmission of
the HIV virus.
5. Treatment of STIs
If people think they may have an STI, they should seek help at a health clinic or Voluntary
Counselling and Testing (VCT) centre immediately. When diagnosed and treated in time, all
bacterial STIs can be cured with antibiotics. It is important to finish the treatment completely,
even if the symptoms disappear before the end of the treatment. Although viral STIs cannot
be cured, symptoms of viral STIs can be treated with prescribed medicines, which prevents
further STI transmission. Pubic lice and scabies can be treated with special shampoos or
creams.
When people have been infected with an STI, they should take care to prevent transmission
and avoid having sexual intercourse during treatment. If they cannot avoid having sex, they
should not have sexual intercourse or use a condom correctly and consistently. Risk
situations (see above) should be avoided as well. Without treatment, some STIs can cause
severe trauma. For example, chlamydia and syphilis can cause infertility in both women and
men. Infection with the human papilloma virus, a common STI among adolescent women in
some areas, is associated with increased risks of cervical cancer.
Like all viral STIs, HIV cannot be cured. Anti-retroviral (ARV) treatment can be used to stop
the process of viruses attacking white blood cells. These medicines are getting less
expensive and are also becoming more available in developing countries. They must be
taken every day for the rest of the lifetime. At the international level, there is a struggle to
make these medicines available and accessible on a wider scale because all people
worldwide have the right to access to medication.
People who are infected with STIs or HIV should always tell their sexual partners if they have
practised unprotected sexual intercourse. Their partners must be tested for STIs as well.
Health centres and clinics provide counselling and help to inform partners about STIs or HIV
infection. HIV-positive people often do not tell their former and current sex partners: they may
feel shameful about their condition, be afraid they will be discriminated against, or fear they
will lose their job or their partner and children. They must take the responsibility to practise
safe sex only and consistently. They could ask the health centre to help them deal with the
infection and the possible disclosure of their HIV status.
6. Prevention and Control of STIs and HIV
Primary prevention
 abstention from sexual activity altogether
 delaying the age of sexual debut
 life-long mutual monogamy
 engaging only in non-penetrative sex acts
 engaging in penetrative sex acts only if condoms (male or female) are
used
Secondary prevention

Promoting STI care-seeking behaviour, through:





public education campaigns
providing non-stigmatizing and non-discriminatory health facilities
providing quality STI care
ensuring a continuous supply of highly effective drugs
ensuring a continuous supply of condoms
Although most STIs can be cured, it is better to prevent them. Certain behaviours help to
protect yourself against STIs and against HIV/AIDS.13
The Background Information to Lesson -------- explained that responsible sex is consensual,
healthy and safe. Besides sexual intercourse, there are many safe alternative ways of being
intimate and having sexual relations. When it comes to sexual intercourse, it is important that
adolescents should know how to act responsibly and practise safe sex. Safe sex includes
sexual acts with and without penetration and is always based on respect, lack of coercion
and mutual consent.
Safe sex is the only way to prevent STIs and HIV. It means avoiding risk situations and using
an appropriate method of protection. One way of approaching this is the ABC approach.
A stands for: Abstain from all sexual activities or from vaginal or anal penetration. This
means that young people can choose to abstain from all sexual acts or opt only for those
sexual practices that are safe, while not having sexual intercourse. B stands for Being faithful
to your partner. The message of being faithful includes having sexual intercourse in a longterm relationship with a single partner. Being faithful, however, only works when both
partners can fully trust each other. Still, it is advisable for both partners to be tested before
their first unprotected sexual intercourse. Most relations between young people do not have
a long time span, and they engage in a series of successive relationships with one partner
(serial monogamy). Therefore, they should practise safe sex with their new partner until a
test has proven both of them to be free of STIs or HIV.14 If they have sexual intercourse with
anybody else outside the relationship, they should always use a condom.
C stands for Condomise: using a condom correctly and consistently for every penetrative
sexual activity.
Each of the ABC methods can be an effective prevention method. However, as soon as
people become sexually active, they should know their options for practising safe sex.
Adolescents, like adults, should be able to make a well-informed choice about which of the
ABC methods is most appropriate for them. Adolescents have the right to choose the most
effective method of protecting themselves from unintended pregnancy, STIs and HIV
infection that suits their lifestyle.
For young people who are not yet sexually active, abstaining from sex and delaying their first
sexual experience is an important option. This option is particularly important for girls, as
they face some of the greatest sexual health risks, such as forced to sex or being abused.
Especially girls, therefore, need to develop their refusal and negotiation skills and be taught
how to anticipate and avoid risky situations.
Methods A and C will protect people against both STIs and HIV and unintended pregnancy,
provided these methods are used consistently. If they choose method B – Be faithful – both
partners should have an STI/HIV test taken before they have unprotected sexual intercourse;
after they have taken this test, they need to be strictly faithful and have only one sexual
partner. In every new relationship, partners need to communicate on which method of
protection is most suits their particular relationship and decide together.
Condom use
A condom is a barrier method that will prevent any body fluid passing from one body to
another, provided it is used correctly and consistently. Condoms for men are widely
available: at health clinics, pharmacies, drug stores and supermarkets. Condoms for women
(female condoms) are not as freely available in Ethiopia as the male condom.
Advantages of condoms are:
 They are usually widely available.
 They require no prescription.
 They protect against both unintended pregnancy and STIs/HIV.
Disadvantages may be:
 Myths and misconceptions (see before and below).
 The cost of condoms may be a problem, especially for young people.
 It may be difficult for young people to purchase, carry and store condoms
and use them correctly.
 may be difficult to communication on and negotiate the use of condoms.
Myths and excuses for not using a condom15
There are many misconceptions and myths about condoms. People often try to find excuses
for not using them. However, the truth is that condoms are a safe and reliable method in
preventing both STIs and unintended pregnancies, if they are used correctly and
consistently.
Myth: The HIV virus can pass through tiny holes in a condom.
Fact: Nothing passes through a condom, unless the condom is damaged.
Myth: If a condom slips off during sexual intercourse, it might get lost inside the woman’s
body.
Fact: The condom should be rolled down to the base of the erect penis. If the condom is put
on properly, it will not slip off. The condom can never get lost inside the woman’s body
because the cervix, which is the entrance to the uterus, cannot accommodate the condom. If
it accidentally comes off, it should be carefully pulled out with the finger, taking care not to
spill any semen that may cause pregnancy or STI.
Myth: My penis is too big: there are no condoms that are big enough.
Fact: Condoms come in one size, and they always fit!
Myth: You do not feel anything if you use a condom. It is like taking a shower with a raincoat
on. It is not real 'skin-to-skin' sex.
Fact: A condom is very thin and hardly interferes with sensitivity in the penis or vagina at all.
Besides, ‘real’ sex is responsible sex. This means that you care for your partner and yourself
and make sure neither of you needs to worry about STI/HIV infection or pregnancy. Real sex
is safe sex.
Myth: We do not need to use a condom: it is her/his first time.
Fact: Some STIs, such as hepatitis and HIV, can also be transmitted in ways other than
sexual intercourse. People may be infected without being aware of it and transmit STIs
without sexual intercourse. If people or their partners have never been tested, they should
either use a condom during each act of sexual intercourse until their health status has been
confirmed or abstain from sexual intercourse.
Myth: People who use condoms have multiple partners, are always looking for sex or have
an STI.
Fact: There are different reasons for using condoms, for example, to avoid unintended
pregnancy. People who use condoms practise safe and responsible sex: a condom is a sign
of care, not of promiscuity. It is wise always to use a condom in sexual intercourse until both
partners have been tested for STIs and HIV and declared healthy, even in a monogamous
relation.
How to buy, carry and use a condom
Condoms can be obtained at health centres clinics and VCT centres, pharmacies,
drugstores, shops or supermarkets or from peer educators. It may be difficult for young
people to purchase condoms, for various reasons, such as:
 Lack of financial resources.
 Peer pressure: when it may seem common not to use a condom.
 Social pressure in the community or family: when it is not accepted to
practise sex, particularly sexual intercourse, before marriage, and
adolescents are expected to retain virginity.
 Feelings of shyness and shame about going to a shop or a health centre
to purchase condoms.
 Staff at the shop protect themselves, health centre or pharmacy may
perceive them as too young to have sexual intercourse and refuse to give
them information or sell condoms to them.
It is important, therefore, that adolescents are convinced of the risks of unsafe sex; that they
develop positive attitudes towards condom use; and that knowledge of their entitlements
dominates feelings of embarrassment or shame. If adolescents have decided to be sexually
active, they have a right to healthy sexual behaviour, and, therefore, they should be able to
buy, carry and use condoms and talk about them. Staff at a clinic, pharmacy or shop does
not have the right to deny young people their right to purchase condoms and.
Use of condoms
Condoms are sensitive objects that can tear or break if not handled properly. Prevent the
package from being punctured by any sharp objects. Store condoms in a cool dry place.
Never use a condom when its package is torn or damaged or when it is past its expiry date.
Condoms are meant to be used only once. Both men and women need to know how to use a
condom. In the Annex to the Background Information on pregnancy (Lesson ----), you can
find instructions on how to use male and female condoms.
Communicating safe sex with a partner
In any kind of relationship, communication is important. Where sexuality, sex and sexual
intercourse are concerned, clear and open communication is especially important. Both
partners should be clear about what they want and how far they want to go. If they decide to
have sexual intercourse, they need to discuss which method of protection against unintended
pregnancy and STIs they will use.
It may be difficult to refuse unsafe sex or negotiate safe sex, especially for girls and even
more so if one partner is much older than the other. Some obstacles to communicating about
sexuality and sex have been described in the Background Information on sexuality and love
(Lesson -------). These also apply to communication about safe sex. Communication may be
especially difficult for girls, as traditional gender roles may inhibit them from taking the
initiative to talk about sex. They are generally also in a weaker position to negotiate safe sex,
as traditional social norms may expect them to be submissive to the male. Therefore, it is
important to empower girls by developing their refusal and negotiation skills and to teach
boys to respect the entitlements and decisions of girls and women.
Communication and negotiation on safe sex should be based on entitlements and mutual
respect. Both partners have the right to take individual decisions about their own sexual
activities as long as they do not force their partner into something against their will. They
should be equal partners in communicating about and negotiating safe sex. Because girls
and young women are more vulnerable to STI transmission than boys, it is even more
important for them to know their entitlements and have the skills to stand up for their
entitlements. This often comes down to their having refusal skills in negotiating safe sex. But
whatever happens, the main message is: there will be no sex unless it is consensual and
safe.
7. Communication and support
Looking for support
If people have been infected or suspect they have been infected with an STI or HIV, it is
important they have someone to talk to. Because of the stigmas attached to STIs and HIV,
young people may feel inhibited to talk about such infections at all. Yet they should at least
talk about STIs with their partners. They also need to seek medical help. Having a person
they can trust will help adolescents to overcome barriers and seek help. They may seek help
from a mentor, counsellor or confidential adviser at school, in their family or among their
friends before going to a health centres, clinic or VCT centre for medical advice. People who
suspect they may have been infected with STIs or HIV should always be referred to a health
clinic or VCT centre. These are the only places where they can be properly tested,
diagnosed and treated. Health centres, clinics and VCT centres can also provide information
about STIs, HIV, pregnancy, prevention, safe sex and negotiation and may help them to talk
to their partner.
Communication with health service providers
Young people often encounter problems when they seek care at hospitals or health centres.
These may include consultation or prescription expenses, lack of confidentiality and negative
judgments and attitudes from health care providers.16 However, it is crucial to encourage
young people to seek information about prevention and to timely medical help if they worry
about a suspected STI or pregnancy.
Whatever may be the case, young people should know their entitlements and learn to stand
up for them. These entitlements include:
 the right to information about STIs/HIV and prevention;
 the right to make their own decisions about their sexuality;
 the right to respect;
 the right to confidentiality in health services;
 the right to protection and being free of discrimination.
8. Addressing this lesson in the classroom
Sexuality and STIs/HIV are difficult but essential themes to address in the classroom. The
following points are important in addressing STIs and HIV/AIDS in the classroom:
- Be alert to giving balanced information about sexuality, sex and sexual intercourse and
the ABC methods. As this lesson includes a lot of negative information on sexuality, such
as the risks and possibly serious consequences of unsafe sex, it is very important to
stress that sexuality is a positive thing in life and that transmission of STIs and HIV can
easily be prevented with one of the ABC options.
- Young people often have unrealistic risk perceptions. For example, they may think they
are invulnerable, they are not at risk because they never associated with sex workers,
they live in a low epidemic area, etc. They may think they are monogamous in each one
of a series of relationships and incorrectly believe they do not have multiple partners.
However, serial monogamy is a way of having multiple partners. The purpose of this
lesson is to change such unrealistic perceptions into realistic ones.
- If you address the ABC methods, it is important to give students possibilities for exploring
and weighing the advantages and disadvantages of each method for themselves. This is
good preparation for deciding which method will suit their lifestyle, whenever they will
take this decision.
- Sometimes it is easier to practise negotiation skills in small peer groups: the classroom
may provide a safe environment for young people to start talking about safe sex and
exercise communication and negotiation skills in a controlled situation. Girls may feel
empowered by the fact they are not alone or by the teacher being assertive and
supportive. Boys may need encouragement to listen to the girls’ needs and entitlements
and respect them.
- In a negotiation process, it is important for both parties to learn to listen to each other’s
arguments properly and to stress that the best thing for the negotiation is to end up in a
consensual and safe compromise. Be alert to students with a gender bias. Make sure
they respect each other’s entitlements. Also be aware that, as a teacher, you are a role
model to many students. It might be helpful to make students aware of their own genderrelated ideas on entitlements, relations, roles and negotiation positions. It is crucial to
enable students to make their own decisions without influencing them.
- In a Right-based approach, young people, girls in particular, need to learn about their
entitlements and stand up for them. Negotiating their own decisions in a relationship and
with family or health care providers is an important life skill. It is crucial to discuss, teach
and exercise such skills in the classroom.
- A supportive environment at school is helpful. See also the Background Information to
Lesson ------, Sexuality and love.
- For students with personal questions, it may be helpful to offer opportunities for them to
seek information confidentially, to refer them to confidential advisers in the school and to
have a list of health services that are accessible to young people.
Annex I
Overview of STIs (including HIV)
Organism
Viral infections
Human Immunodeficiency Virus
(HIV)
Symptoms
An HIV positive person may
not
be
showing
any
symptoms until the virus
has damaged the immune
system.
Signs and symptoms of
AIDS can be general
diseases, like continuing
diarrhoea, coughing, fever.
Often HIV positive people
will develop TB.
Hepatitis B
Herpes Genitalis
(Herpes Simplex Virus
(HSV))
Genital Warts
(Human
papilloma
virus (HPVs).
Muscle
aches,
fever,
tiredness, loss of appetite,
headache and dizziness.
When the disease worsens,
one can have dark urine,
loose and light-collared
stools, yellow eyes and
skin, and tenderness in the
liver area (just below the
ribs on the right side).
Transmission ways/
prevention
Treatment,
consequences
untreated
Ways of transmission
Unprotected anal and vaginal
intercourse — oral sex has a low
risk.
Mother to child: during pregnancy,
labour and delivery; through breastfeeding.
Sharing contaminated needles for
injecting
intravenous
drugs;
accidental pricks with contaminated
needles in the course of health
care; transfusion of contaminated
blood products
No cure
Treatment
with
medicines
which stop the process of
getting AIDS is possible, but in
Uganda these medicines are
not
(yet)
available
and
accessible for most people
with HIV
Causes
AIDS
(Acquired
Immune
Deficiency
Syndrome), in which the
weakened immune system of
the body has lost its capacity
to fight off infections from other
diseases, cancers, et cetera.
Ultimately a person who has
been infected with HIV will die.
Ways of prevention
Abstain from sexual (vaginal and
anal) intercourse; Be faithful when
both partners are confirmed by a
test to be healthy; stay strictly
faithful throughout the relationship;
Using condoms correctly and
consistently.
No
sharing
of
non-sterilized
needles, razor blades or cutting
objects.
Medication during pregnancy and
around delivery as well as
abstinence from breast feeding can
prevent
mother
to
child
transmission
Ways of transmission
Hepatitis is highly contagious; a
needle prick with infected blood can
cause the disease.
Unprotected sex (vaginal, anal, oral
sex).
Ways of prevention
See HIV
if
When (opportunistic) infections
occur, treat accordingly.
No cure exists; antibiotics do
not
help
against
viral
infections.
It can lead to liver failure and
liver cancer, in which case
hepatitis can be fatal.
There is a vaccine against
hepatitis. A drug is available
for chronic Hepatitis B to
recover the liver.
At first tingling or itching
around the genitals. Small
blisters may form in the
area and then pop open.
When this happens, one
might
feel
burning,
especially when urinating.
The sores then turn to
scabs. During the first
outbreak,
An
infected
person might have swollen
glands, fever and body
aches.
Symptoms may not always
be obvious.
Ways of transmission:
Touching the infected area, sexual
intimacy — including kissing;
vaginal, anal, and oral intercourse
Warts appear on and
around the genitals, in the
urethra, in the anus and,
Transmission:
Prevention:
Refraining from sexual intimacy
from the time when infected people
know the blisters are going to recur
until seven days after the scabs
have completely fallen off the
healed sores.
There is no cure.
Increases risk of HIV infection
through genital lesions.
Symptoms can be relieved with
medication; however outbreaks
may occur during the rest of
the life of an infected person.
Condoms reduce the risk of
transmitting the virus between
outbreaks, but, during outbreaks,
the virus may ‘shed’ beyond the
area protected by condoms.
Vaginal and anal intercourse and
oral sex.
There is no cure.
Untreated genital warts can
grow to block the openings of
Organism
Symptoms
rarely, in the throat.
Transmission ways/
prevention
Treatment,
consequences
untreated
Very rarely: to the foetus during
childbirth.
the vagina, anus or throat
and
become
quite
uncomfortable.
There is a link between some
types of HPV and cancer of
the cervix.
Prevention:
Condoms reduce the risk of
genital warts and cervical cancer.
However, the virus may ‘shed’
beyond the area protected by
condoms.
Bacterial infections
Early signs include a Transmission:
Syphilis
chancre (a painless, red Mostly by sexual intercourse
(Treponema
sore). The sore may appear (vaginal or anal).
in places that were touched From infected mother to child
Pallideem)
Gonorrhoea
(Neisseria gonorrhoea)
Chlamydia
(Chlamydia
trachomatis)
during
sex,
including
genitals, anus, tongue and
throat.
Swelling of the glands near
the chancre.
A few months later, a fever,
sore throat, and headache
can occur together with not
feeling hungry or joint pain.
A scaly rash may appear
on the palms of the hands
and the soles of the feet.
After these symptoms pass,
you may not have any
symptoms for a number of
years.
during pregnancy.
Eighty per cent of women
and 10 per cent of men
with gonorrhoea show no
symptoms.
For women: within 10
days,
frequent,
often
burning,
urination;
menstrual
irregularities,
pelvic or lower abdominal
pain; pain during sex or
pelvic examination; a
yellowish or yellow-green
discharge
from
the
vagina;
swelling
or
tenderness of the vulva;
and even arthritic pain.
For men: within 1 to 14
days, a pus-like discharge
from the urethra or pain
during urination.
Transmission:
Usually no symptoms or
only vague ones, and only
after 7-21 days after
infection.
Women: itching around the
vagina, a yellow, odourless
discharge from the vagina,
pain during sex and
needing to urinate often or
pain
when
urinating;
bleeding between periods
or dull pain in the pelvic
area.
Men: pain or burning when
Transmission:
Prevention:
Using condoms
intercourse.
Vaginal,
anal
intercourse.
during
sexual
and
oral
Prevention:
Condom use during vaginal, anal
and oral intercourse.
Through
vaginal
and
anal
intercourse and oral sex.
Mother-to-child transmission during
delivery.
Prevention:
Condom use during vaginal, oral
and anal intercourse.
if
Increases risk of HIV infection
through genital lesions.
Symptoms can be relieved with
medication;
however,
outbreaks may occur during
the infected person’s lifetime.
Treatment
Antibiotics. Always finish the
complete course of antibiotics!
Increases risk of HIV infection
through lesions in the skin.
Untreated syphilis can be
transmitted during the first
years of infection.
Treatment
Antibiotics. Always finish the
complete course of antibiotics!
Increases risk of HIV infection
through genital lesions.
Treatment:
Antibiotics. Always finish the
complete course of antibiotics!
Increases risk of HIV infection
through genital lesions.
Pelvic abscesses, infertility and
pelvic pain.
Mother-to-child- transmission
during
delivery,
causing
pneumonia.
Organism
Chancroid
Symptoms
urinating and a watery,
milky-coloured
discharge
from the penis.
Ulcers or sores at the
genitals, after 10 days after
exposure. Later pus-filled,
open sores with ragged
edges.
Painful
lymph
glands in the groin.
In women often no visible
symptoms.
Transmission ways/
prevention
Treatment,
consequences
untreated
Transmission:
Treatment:
Antibiotics. Always finish the
complete course of antibiotics!
Sexual transmission through skinto-skin contact with an open sore.
Non-sexual transmission when
contact is made with the pus-like
fluid from the ulcer.
if
Increases risk of HIV infection
through genital lesions.
Prevention:
Condom use during vaginal, anal
and oral intercourse.
Parasite infections
Scabies
Scabies
Pubic lice
Trichomonas
are very small
parasites, smaller than lice
and almost invisible. They
can be found all over the
body, but especially around
the genitals, between the
fingers and in the armpits.
The main symptom is
severe itching.
These are small grey
parasites, a little smaller
than a flea, which live in
pubic
hair,
armpits,
eyebrows and scalp. They
produce small white eggs
that cling to the hair, also
noticeable.
They
suck
blood and cause small
itching sores.
In women: inflammation of
the vagina.
Main symptom: a yellowish,
foul-smelling,
bubbly
discharge from the vagina.
About 30% of infected
women have no symptoms
Men rarely have symptoms.
Transmission:
Close bodily contact or sharing a
bed with an infected person.
Transmission:
Sexual contact; sleeping in the bed
of an infected person or wearing
clothes from someone who is
infected.
any signs. Some women
will
experience
signs
regularly. Signs include:
itching in the genital area
and (not always) vaginal
discharge. The discharge
can be watery or thick, like
cottage
cheese.
Also
vaginal soreness, irritation
and vulvar burning.
In men, symptoms are a
transient rash, itching or a
burning sensation in the
penis. These symptoms are
self-limiting and frequently
disappear after showering.
Transmission of the infection to
other people.
Treatment:
With a specially prescribed
soap or cream.
Clothing and bedding have to
be washed and hung out in the
air.
Transmission of the infection to
other people.
Transmission:
By sexual intercourse.
Prevention:
Using condoms during vaginal, anal
or oral sex.
Fungal infections
Candidiasis
or Candida is an innocent Transmission:
fungal infection that is It has been estimated that
candidal
present in many women. approximately 75% of all women
Most women will not show will experience at least one episode
vaginitis
(Candida albicans)
Treatment:
With a specially prescribed
soap or cream.
Clothing and bedding have to
be washed and hung out in the
air.
of candidiasis during their lifetime.
Transmission from women to men
can occur by sexual intercourse.
Prevention:
Using condoms during vaginal, anal
or oral sex.
Treatment:
Antibiotics. Always finish the
complete course of antibiotics!
Increases risk of HIV infection
through genital lesions.
Transmission of the infection to
other people.
Treatment:
Vaginal tablets or creams.
1
Dr. Akinyele Dairo, Youth unmet RH/FP needs; implication for achieving health and development
goals. UNFPA 2005. Available at: http://www.fhi.org/en/Youth/YouthNet/NewsEvents/fpreposwshp.htm
2 WHO The Second Decade: Improving Adolescent Health and Development (WHO/FRH/ADH/98.18),
p. 6. Geneva: Adolescent Health and Development Programme, WHO, 1998.
3 Dehne K and Riedner G Sexually transmitted infections among adolescents. The need for adequate
health services Geneva: WHO and GTZ 2005, p. 2. Available at: http://www.who.int/reproductivehealth/publications/stis_among_adolescents/ .
4 Path Infertility: Overview and Lessons Learned Reproductive Health Outlook (RHO). Available at:
http://www.rho.org/html/infertility_overview.htm.
5 UNFPA State of World Population 2004: The Cairo Consensus at Ten: Population, Reproductive
Health and the Global Effort to En Poverty, UNFPA 2004, page 43. Available at: http://www.unfpa.org.
6 UNFPA State of World Population 2004: Op. cit., pages 7 and 63.
7 National Reproductive Health strategy 1997-2010, Ministry of Health Ethiopia
8 Adimora A, Hamilton H, Holmes K and Sparling F Sexually transmitted infections. Companion
handbook. Second edition. McGraw-Hill, 1994. See also: E Rylander E. Berglund A-L., Krassny C. and
Petrini B. Vulvovaginal candida in a young sexually active population: prevalence and association with
oro-genital sex and frequent pain at intercourse Sex Transm Infect 2004;80:54-57
Available at: http://sti.bmjjournals.com/cgi/content/abstract/80/1/54.
9 CFPC STIs (Sexually Transmitted Infections) - Common STIs and tips on prevention. The College of
Family Physicians of Cananda, 2004. Available at:
http://www.cfpc.ca/English/cfpc/programs/patient%20education/sti/default.asp?s=1.
Steyn P. Today’s Choices. A resource for Life Orientation in the FET phase. Stellenbosch University
2004.
10 For more information about HIV/AIDS see: Avert What is Aids. Available at:
http://www.avert.org/aids.htm.
11 Mother to child infection and breastfeeding is a complicated matter. More information can be found
at the WHO website: http://www.who.int/child-adolescent-health/NUTRITION/HIV_infant.htm
12 De Bruyn M. and France N. Gender Or Sex: Who cares? Skills building resource pack on gender
and reproductive health for adolescents and youth workers. Chapel Hill: Ipas 2001. Available at:
http://www.ipas.org/english/womens_entitlements_and_policies/adolescents/ .
And: Dhun Panthaki: Education in Human Sexuality. A sourcebook for educators. Mumbai: Family
Planning Association of India 1997, p 151.
13 See overview of STIs in the annex for a complete listing of ways of transmission and prevention of
STIs.
14 (Young) people often practice ‘serial monogamy’: they are monogamous within each relationship,
but they have various relationships. In order to practice safe sex, practitioners of serial monogamy
should get tested at the onset of each new relationship, before having sexual intercourse. Only when
both partners are tested negative for STIs and HIV they could have unprotected sex.
15 For more information about myths and misconceptions, see for example:
http://www.engenderhealth.org/res/onc/sti/preventing/sti6p6.html .
16 Amyunzu-Myamongo, M., Biddlecom, A., Ouedraogo, C., and Woog, V. Qualitative Evidence on
Adolescents’ Views of sexual and Reproductive Health in Sub-Saharan Africa. Alan Guttmacher
Institute 2005.