This study aimed at assessing the nationwide population-based epidemiology of STIs among general population patients screened at different health facilities in Rwanda from 2014 to 2020. The total number of patients screened and the number of cases of documented STIs among screened patients increased over the period, however, the percentage of people screened among those who visited the health facilities from 2016 to 2020 decreased. This study showed the highest prevalence of STIs was in Kigali City and Eastern Province. Although the majority of patients are screened, diagnosed, and treated at health center level, the highest prevalence of STIs was seen in private clinics. This study also showed that some districts from Kigali City and majority of districts, which are closer to the borders with other countries especially in Eastern Provinces, were more likely to have higher STI prevalence over the period. The most prevalent STI syndrome reported during the study period was vaginal discharge.
Considering the number of patients screened, and those diagnosed and treated for STIs during the study period (from 2014 to 2020), the number of patients screened in 2014–2015 are two times higher than those screened one previous years (2013–2014). They are 10 times higher than that of the period of 2010–2011 for the patients screened while the number of STIs diagnosed and treated increased from 2 to 5 times when compared to the period of 2010–2011 and 2013–2014 [27]. Data from 2010–2011 were reported before implementation of different strategies for prevention and Control of STIs adopted by Rwanda Ministry of Health. Before 2013–2014, methodology for screening of STIs, and strategies for STIs reporting changed and were different from that is being used from 2013–2014 where only people with complains related to STIs were considered for STIs screening and majority of data were not reported.
This increasing coverage of screened, diagnosed and treated patients for STIs in Rwanda is probably the results of increased training of health care providers from all health facility level, provided as implementation of Rwanda HIV National Strategic Plan 2013–2018 established strategies aimed at increasing systematic STI screening and treatment in all patients who consult health facilities [28]. Other potential contributors to this success include the establishment of a unit in charge of STIs in the Rwanda Biomedical Centre, and enhanced monitoring and evaluation for STIs and HIV. However, according to available data in the MOH, the percentage of people screened for STIs by total population who visited the health facilities decreased over the years from 36.57% in 2016–2017 to 25.78% in 2019–2020 [26]. There is a need of further strengthening the STI program by training of more health care providers especially at health center level where most STIs cases are diagnosed and treated. Strengthening monitoring and evaluation is also needed for increasing the rate of syndromic screening for health facility attendees.
In this study, the overall prevalence of STIs among patients screened for STIs was 2.6% in 2014–2015, 2.4% in 2015–2016, 2016–2017, and in 2017–2018, 3.0% in 2018–2019 and 4.1% in 2019–2020. The highest prevalence in 2019–2020 could be due to the impact of the COVID-19 pandemic [29] where on one way the number of patients screened was reduced while the number of patients diagnosed and treated for STIs increased because majority of cases who consulted were likely presenting with acute STI symptoms while for another way health care providers did not perform STIs screening for a big number of population who visited the HFs. Individuals with more pronounced symptoms and presentations may have been more likely to visit a healthcare facility compared to previous years.
The most common STI syndrome in this study was vaginal discharge syndrome. Predominance of abnormal vaginal discharge was reported also in a cross-sectional study conducted among HIV-negative sex workers in Rwanda [12]. RDHS 2020 has reported a prevalence of 4.4% of STIs among women with the predominance of abnormal genital discharge and genital ulcer (13.3%)[14]. The predominance of vaginal discharge as an STI syndrome was also reported in the study exploring the prevalence of STIs using a syndromic approach in India that has found the predominance of vaginal discharge syndrome with 51.7% [30]. In addition to reduced rate of syndromic screening for health facility attendees, the majority of STIs are still likely to be missed due to their asymptomatic nature, given the increasing body of evidence demonstrating the limitations of syndromic screening and management. The government should look how to establish targeted point-of –care testing but in the meantime, the rate of people screened for STIs could be increased.
In this study, the prevalence of STIs is very high for patients screened at private clinics, ranging between 15.69% and 19.4% for the whole study period. The reason behind this high prevalence could be the stigma and discrimination experienced by patients suffering from these infections. It is possible that people who felt stigmatized chose to visit private clinics where they will meet fewer people instead of local or public health centers. Rwanda DHS has reported experience of stigma as 37% among men and 50% among women living with HIV or other STIs [25]. Literature revealed that in Africa STI-related stigma was significantly associated with a decreased odds of STI testing and a decreased willingness to notify partners of an STI which sometimes leads to a preference for traditional healers who are still viewed by many as having the best treatment for STIs even though the efficacy of such treatments remains unproved [31]. Therefore, there is a need to reduce the stigma related to STIs by providing integrated services, health education, wider options to STIs management, aid disclosure and partner notification practices.
Findings from this study showed that there are districts which are more affected by STIs than others. These districts are known to be home to more at risk people for STIs like female sex workers and truck drivers due to availability of means that meet their daily needs. It has been shown that sex workers and truck drivers are more engaged in high-risk sexual behaviors such as multiple sexual partnerships, and low consistent condom use which increase the risk of getting and transmit STIs [15, 32, 33]. Other reasons for this high prevalence among these districts include the high mobility from different countries including those with high prevalence of HIV and STIs, non-adherence to programs aimed at HIV/AIDs and STIs prevention like consistent condom use, and PrEP. More efforts need to be put in STIs prevention and management for most at risk populations living mainly in Kigali City and in some districts closer to borders with other countries. A recent publication on key populations in Kigali found that prevention and timely treatment in key populations including FSWs are lacking which highlight the need of establishment of HIV and STIs prevention programs like tailored and integrated HIV/STIs programs [34].
This study has several strengths including the nationwide sample size and representative of all health facilities countrywide were considered which increase the external validity as well as the estimates over time of STIs in Rwanda. The STI prevalence from this study are comparable with other studies like DHS- 2015 and DHS 2020 [14, 25]. To date in Rwanda few studies interpret district-level data, as this study did it, this is an added value to results interpretation.
However, different limitations were noted. Firstly, there are limited variables due to aggregate data, having more variables like sex and age group could explain more the cause of change or no change of STIs epidemiology in one or another region. Secondly, lack of individualized data could lead to ecological fallacy, so there a need to conduct another study with individualized data for confirming the STIs distribution according to different factors. Thirdly, on one hand most STIs were diagnosed based on syndromes, then the exact cause of the STI syndrome remains unknown. This means that people could have multiple STIs when presenting with a specific syndrome. For example, vaginal or urethral discharge could have Chlamydia and Gonorrhea and even be co-infected with syphilis, HSV, or something else at the same time. On the other hand, there is a possibility of over-diagnosis for vaginal discharge, given that bacterial vaginosis is not an STI, and is a very common cause of vaginal discharge. We cannot forget that there are several cases of asymptomatic STIs which may underestimate the number of reported STIs. Lastly, there is a problem of data accuracy due to its nature, so there is a possibility that some data were not well collected or there is under- or over-estimation of STI prevalence. These are only diagnosed cases at health facilities. People who go to seek care might not be representative of the general population. Future studies on patient-level are recommended for assessing the factors associated to STIs among Rwandan population.
To conclude, this study showed that from 2014 to 2020, in Rwanda, the number of individuals screened for STIs did not vary significantly, but the reported cases of STIs as well as its prevalence among screened patients increased. This study reports the highest prevalence of total STIs in urban area of Rwanda and in regions bordering other countries. The majority of patients are screened, diagnosed and treated at the peripheral level; however, the high prevalence of STIs was seen in the private clinics. There is a necessity to strengthen STIs prevention measures in the general population, with increased efforts to reach most at risk population. More trainings for health care workers and providing screening and testing materials and effective treatment at health centers and even in private clinics are encouraged. Results from this study will provide important knowledge about the impact of different measures taken by the Rwanda Ministry of Health and inform strategic direction and program planning.