Sexually transmitted diseases, once called venereal diseases, are among the most common infectious diseases worldwide. This list of diseases now include not only the historic venereal diseases, such as syphilis, gonorrhea and chancroid, but also more than 20 other diseases, syndromes or complications for which sexual transmission is of epidemiological importance. The incidence of STDs and their sequel have increased dramatically over the past two decades all over the world. The WHO estimated that each year some 333 million people worldwide become infected with STDs. STDs affect men and women of all backgrounds and economic levels. They are most prevalent among teenagers and young adults. Nearly two-third of all STDs occurs in people younger than 25 years of age. Estimates on the magnitude of the STD problem are based mainly on clinical data or special national surveys.

Until now there has been little information on the prevalence and pattern of the principal STDs in Armenia. The Ministry of Health collected clinical-based data for a few STDs, mainly Gonorrhea and Syphilis. According to the official estimate in Armenia, in 1992, there were 12.0 cases of Gonorrhea and 7.1 cases of Syphilis reported per 100,000 population. These rates increased up to 30.7 cases of Gonorrhea and 17.4 cases of Syphilis per 100,000 population, in 1996. However, underreporting of STDs is widespread in Armenia. Data on reported STDs are affected by differences in the completeness in reporting between the public and private health care sectors. Some reasons for underreporting are the social mores and the social stigma of seeking care at a venereal disease clinic.

In this questionnaire-based study we analyzed the history of diseases, disorders, clinical signs and symptoms suggestive of the previous or current STDs during the life span of respondents. As much as possible the interviewers tried to obtain the confidence of interviewees, however, responses are dependent upon the personal biases of individuals who participated in this survey.

According to the information obtained (Figure 1.8.1), the most frequently reported STDs in Armenia are Trichomoniasis and Gonorrhea. This survey shows that the frequencies of both Gonorrhea and Trichomoniasis cases are higher than might be expected. About 10 out of 100 Armenian men below 45 years of age ever have been infected with Trichomoniasis (10%), and 8 out of 100 men ever have had Gonorrhea (8%). Gonorrhea affects human fertility primarily through infections of the upper genital tract of both women and men. Obstructions of the epididymis or vas deferens associated with Gonococcal infection are causally related to subsequent infertility in the male partners.

Chlamydial infections of the sex organs are more common than gonorrhea and are a major public health problem today worldwide. Chlamydia Trachomatis causes about 50% of certain male uro-genital infections, including non-gonococcal urethritis and epididymitis. Up to 70% of patients with the infection may have no symptoms. Untreated disease can cause subsequent infertility. In the United States it is the most frequently occurring bacterial cause of STDs. In Armenia, Chlamydial infections, and their consequences are not well known and reportable, yet. It was diagnosed only in about 2% out of 1400 respondents of this survey.

Syphilis is highly prevalent in developing countries. In the developed countries the rates have declined but in the recent years increased dramatically. This survey found that proportion of Armenian men below 45 years of age, who have been ever infected with Syphilis was 4 per 1000 (0.4%).

In this study we analyzed not only the history of specific STDs, but also the variety of clinical signs and symptoms for which sexual transmission is of epidemiological importance. This survey found that more than 14% of men from the total survey sample ever have had discharge from the urethra, about 11% of men ever have had irritation or pruritis of the genitals, and 11% have had history of pain or burning while passing urine (Figure 1.8.2). Their admitted uro-genital symptoms indicate that the actual rates of the specific STDs might be higher than reported and underscore the importance of health education for men and their physicians.

About 0.7% of men (7 out of 1000) ever have had painful sores or vesicles on or around the sex organs. The intact vesicle is the strongest clinical indication of Genital Herpes, which prevalence has increased in recent years in the United States. Another sign of Genital Herpes is multiple genital ulcers, which occur when the vesicles rupture. This symptom was described by 0.4% of respondents. The Genital Warts or Condylomas, which are caused by the Human Papillomavirus, were reported by 0.5% of respondents (5 out of 1,000).

Figure 1.8.3 demonstrates the percentage distribution of men according to the history of genito-urinary diseases and disorders. The history of Cystitis was mentioned by 5% of respondents, Prostatitis - by 4% and Urethritis- by another 4%. Among other genito-urinary diseases and disorders were mentioned Phimosis/ Paraphimosis (2.5%), Urethral stricture (1.5%), Hydrocele (0.8%), Inguinal Lymphadenopathy (0.5%), and Epididimitis (0.1%). STDs cause many of these diseases and disorders. The usual cause of Epididimitis is infection spreading down the vas deferens from the bladder or urethra. The inflammation may spread also to the testicle affecting sperm production and leading to infertility.

The history of Varicocele was reported by 0.5% of the survey respondents (5 out of 1000). This disorder in some cases is associated with a poor sperm count and is a cause of infertility. However, often it is asymptomatic and remains unrecognized. The reported rates of Cryptorchidism was about 0.1% (1 out of 1000). This is the condition in which testes fail to descend into the scrotum and are retained within the abdomen or inguinal canal. A surgical operation is necessary to bring the testes into the scrotum before puberty to allow subsequent normal development. It is thought that the higher temperature in the abdomen interferes with sperm production and predisposes a male to testicular carcinoma.

Prevention and control of STDs is based on four major concepts: 1) public education with emphasis on those at risk, 2) detection of infected individuals, 3) effective diagnosis and treatment, and, 4) evaluation, counseling and treatment of sex partners.

This study revealed that accessibility to sexual health counseling and clinical services for Armenian men is not sufficient. Many infected persons either did not apply for medical care or received ineffective treatment, which resulted in recurrent infection and long-term consequences for sexual and reproductive health.

Information provided in Table 1.8.1 represents the proportion of men with recurrent uro-genital diseases and symptoms, which are related to STDs. For treatable STDs, effective counseling and treatment of both partners can prevent further re-infection.

Table 1.8.2. demonstrates the proportion of men with genito-urinary diseases and disorders, according to their access to effective sexual health care. Results show that a significant proportion of men suffering from genito-urinary diseases and disorders either do not receive treatment, or it is ineffective.

Physicians and other health providers have a critical role in prevention of the spread of the STDs. When diagnosed and treated early, almost all STDs, except for HIV/AIDS and Genital Herpes, can been treated effectively. However, some microorganisms, such as certain forms of gonococci, have become resistant to the drugs used to treat them and require newer types of antibiotics. The treatment of severe or frequently recurrent genital herpes helps control the symptoms but does not eliminate the herpes virus from the body. In fact, chlamydial infections and trichomoniasis are treatable with the specific drugs, if both partners are treated simultaneously.

The data obtained from this survey indicate a lack of access by men with the history of sexually transmitted infections to qualified and effective sexual health care. Thus, for example, about 26% of men infected with the Chlamydia, 19% with the Fungal infection and 13% with the Trichomoniasis either did not get any treatment or it was not effective (Table 1.8.3).

As demonstrated above, a significant proportion of men with urethral discharge (12%), dysuria (18%), genital itching or erythema (12.5%), genital vesicles (44%), and multiple genital ulcers (17%) reported that they did not receive an adequate sexual health care. 

1.8.5.  Evaluation and Treatment of Sex Partners

One of the major concepts of prevention and control of STDs is evaluation, counseling and treatment of sex partners. In Armenia, Syphilis and Gonorrhea are reportable diseases. Reporting assists local health authorities in identifying sex partners who may be infected. However, because of the stigma associated with STDs, infected persons often seek out medical care from private practitioners and are inclined not to identify their infected sex partners. Many STDs initially cause no symptoms, particularly in women. As a result of not reporting, asymptomatic cases in sex partners often remain unknown and untreated, with all the possible public health consequences. STDs can be passed also from a mother to her baby before or during birth. Some of these infections of the newborn can be cured easily, but others may cause a baby to be permanently disabled and even die.   

The assessment shows that sexual partners of the survey respondents that were infected with STDs have been treated only in about 26% of Gonorrhea cases, 42% of cases of Chlamydial infection and 36% of cases of Trichomoniasis (Table 1.8.4).

Many of these men even did not realized that their partners also were infected with the organism causing STDs. Only 165 (12%) men reported that their sex partners had STDs (Figure 1.8.4), which is much less than might be expected from they’re own history.

In about 50% of mentioned STDs cases, men had no idea about the partner’s treatment, and in 5% said that sex partners remained untreated (Table 1.8.5.).

Thus, results of this study indicate that the risk of spreading STDs, including HIV/AIDS, is very high in Armenia.  The socio-economic and cultural realities of the present life in the country, together with the high migration rates, indicate an urgent need for STDs and AIDS control.