Failure to diagnose and treat syphilis and other sexually transmitted infections (STIs) among pregnant women in Kenya means thousands of mothers risk losing their children or passing on the infections to their unborn children.
While prevention of mother-to-child HIV transmission (PMTCT) has expanded, with more than 1,000 sites offering the services across the country, STIs – which raise the risk of contracting HIV and can lead to congenital STIs, low birth weight and stillbirths – are often missed, even when women visit antenatal care centres; an estimated 92 percent of Kenyan women will seek antenatal care at least once during pregnancy. The prevalence of syphilis in the general population is 1.8 percent, but is higher among people infected with HIV.
"Not many health facilities, especially small ones like this one, have personnel who can screen for sexually transmitted diseases and so once they enrol HIV-positive mothers on prevention of mother-to-child transmission programmes, it ends there and it is believed all is well," said Ann Karanja, a clinical officer at Korogocho Health Centre, a government clinic in the Kenyan capital, Nairobi. "Many women and even men keep signs of a venereal infection secret and never report [it] to health workers - it is only realized after delivery during which it might be too late to reverse the damage already inflicted on the child, or when they have already had premature or stillbirths."
Trephine Nyambuga learned of her syphilis infection too late to save her baby. Nyambuga knew she was HIV-positive and when she fell pregnant with her sixth child, she faithfully adhered to the advice given to her for PMTCT. "When I was pregnant, I was told that if I came to the hospital as the doctor had told me, I would give birth to my child free of HIV and I was always coming for the antenatal clinic every month," she said.
However, soon after delivery, Nyambuga realized the infant was abnormally underweight and she initially worried that she may have infected her child with HIV; five months later, her baby died after being diagnosed with congenital syphilis. "I don’t know why they couldn’t get it earlier and I also didn’t know I had it [syphilis]," she said. "Now I am being treated but it is sad that I had HIV yet something treatable like syphilis killed my child. I wish they could have found it early enough and treated it."
The UN World Health Organization estimates that globally, two million pregnant women each year are infected with syphilis; 1.2 million will transmit the infection to their newborn. Globally, it is estimated that syphilis in pregnancy contributes to 650,000 foetal and neo-natal deaths each year in developing countries; 10 high-burden countries – including Kenya – account for 40 percent of pregnancies and newborns affected by syphilis.
STIs increase one's risk of HIV infection, making screening for these infections a vital part of any HIV prevention programme. HIV-positive people are often co-infected with syphilis - according to the latest Kenya AIDS Indicator Survey, an estimated 17 percent of participants infected with syphilis were also HIV-positive.
Need for training, greater awareness
According to Karanja, health-worker training is key to increasing syphilis screening. "We as health workers need training on screening of both women and men who come to our clinics for sexually transmitted infections and getting the equipment to do it and the drugs to treat them too… not many health facilities have all these," she said.
|It is sad that I had HIV but something treatable like syphilis killed my child|
Andrew Sulleh, medical superintendent of Mbagathi District Hospital in Nairobi, says raising awareness within Kenyan communities is also key to improving the detection and treatment of syphilis and other STIs. "We must train our health workers, provide the drugs, but above all, promote male involvement because treating a woman infected with syphilis without treating the husband as well means she will get re-infected, so male involvement cannot be overlooked," he said.
A 2009 report from a high-level consultative meeting on STIs and reproductive health convened by the government concluded that there had been weak policy level support for the management of STIs; the report noted, for instance, that the Kenya National AIDS Strategic Plan 2009-13 did not put sufficient emphasis on the management of STIs. It further noted that the "linkages between STI clinics and counselling and testing services remain weak".
Nicholas Muraguri, head of the National AIDS and STI Control Programme, says the government is now starting to take STIs more seriously. "Not much has been done over the years in screening women who come to antenatal clinics for sexually transmitted infections but we have started doing this now and even training health workers in parts of the country so that they are able to screen and treat these diseases. I hope we will soon have this in all health facilities with antenatal clinics so that child deaths attributable to them are reduced.
"Even as we talk about treatment, we must emphasize prevention because it is cheaper, so we are promoting prevention methods such as increased condom use, reduction of sexual partners and increased uptake of voluntary medical male circumcision," he added.