The median number of sexual partners also varied considerably across the three sub-groups. The median number of sex partners over the last year and during last three months was the same for heterosexual women, at 1.0, with a range of (0–1) during the last three months and (1–2) during the last year. The median number of sexual partners for heterosexual men was 2.0 (1–4) in the last year and 1.0 (1–2) in the last three months. Among MSM, the median number of sex partners during the last year was 50.0 (4–1500) and during the last three months 30.0 (1–300). One MSM reported that he had too many partners to recall during those time periods. During the course of the interviews, it became clear that several MSM interviewed exchanged sex for money on a regular basis, which in turn influenced the high numbers of sexual partners reported by those participants.
STI-related knowledge, fears and perceived stigma prior to care-seeking
All participants delayed seeking care for at least one week after the onset of symptoms. However, there were many participants who waited much longer, such as a few months in several cases to over a year among a few cases, before seeking clinical care for their symptoms. For most participants, the main reason they sought care at an STI clinic was the existence of prolonged, "visible", "scary" and often painful symptoms including discomfort during intercourse, frequent urination, bleeding, abdominal pain, and warts or wounds around their genital organs. In interpreting the significance of these signs and cues, participants experienced considerable uncertainty. In the absence of information surrounding these symptoms, they often did not readily recognize them as being STI-related and assumed that they would resolve themselves with time as narrated below.
"I was sick before...but I didn't know what I had... I got this [the STI] 3 years ago and I didn't know exactly what was it. Anyway, the wounds eventually went away over time...but I got concerned when I saw the same wounds come back again. Then I got really worried and came here to see a doctor" [Heterosexual male, 19 years old, with syphilis]
"I came here [to the STI clinic] with fear, because it had been more than two months that each time I had sex I bled. At first I thought it was my period, but now I know it isn't..." [Heterosexual female, 42 years old, with HPV]
However, there were important indications in the data that awareness and information regarding STI-related symptoms may differ across the different study sub-groups. For example, more heterosexual males and in particular the MSM interviewed, as compared to female participants, had a stronger sense that they were dealing with an STI before coming to the clinic.
Respondent: I saw some small warts and looked for care right away.
Interviewer: And did you know what it was, even before your exams?
Respondent: Definitely, I knew when I saw it. This is the kind of disease you see the symptoms right away, just like a scratch, you can see it right away. [Heterosexual male, 19 years old, with HPV]
"It seems like a small wart (...) I was reading about it, it can be Condyloma Acuminatum or it can be Hemorroids." [MSM, 19 years old, with HPV]
The MSM interviewed in the study seemed to have a more defined social network of friends and/or sexual partners within which health-related information tended to flow. While this type of network facilitated access to information about issues such as STIs, the information received did not always encourage care seeking. For example:
"I feel a sort of pain... I mean, just after having sex, when I get relaxed... I feel a sort of pain and no one can touch it [his penis]. If you touch it, it really hurts, I just can't... But I've talked to my friends, and they told me that this is quite normal" [MSM, 31 years old, with gonorrhea]
Several of the study participants that suspected they had an STI prior to clinical diagnosis reported trying to alleviate their symptoms through self-medication. They reported being able to purchase medicines to treat STIs without going to the doctor by going to pharmacists that did not require prescriptions. A few participants discussed procuring alternative medicines from traditional healers. While many attempts at self-treatment were uncovered in the interviews, none of the study participants reported having gone to another clinical center or STI-related provider prior to accessing care for their current symptoms at the center where they were recruited.
The excerpts below are examples of common strategies employed by participants to self-treat and the clinical implications of such unsuccessful efforts.
"I took an antibiotic on my own, just to see if it would disappear [some warts]. I was already using it for my pimples, then I decided to take a bigger dose of it" [MSM, 19 years old, with HPV]
"Well... Sometimes some small warts popped up on my behind... Yeah, and I bought a salve, used it, and it just disappeared. It stopped. But it's now there are some others which keep appearing." [MSM, 19 years old, with HPV]
Again, many of the MSM participants reported receiving advice from friends regarding how to best deal with the STI-related symptoms they were experiencing.
"Once I had a kind of anal secretion (...) But I took tetracycline on my own...Tetracycline is an antibiotic that a friend of mine told me to use, and it cured everything." [MSM, 23, with syphilis]
For some, particularly female participants, self-medication seemed to be linked to perceived STI-related stigma and a behavioral strategy to avoid having to face this fear vis-à-vis the clinical care consultation with a physician.
"I felt sort of abdominal pain (...) I always used some salve, you know, vaginal salve, 'cause I know those meds. I'd rather use a vaginal salve than see a doctor...I was ashamed". [Heterosexual female, 35 years old, with HPV]
In addition to fears or embarrassment associated with the potential of having an STI, prior experiences of perceived stigma and discrimination related to other social categories also appeared within interview discussions as a barrier to care seeking, particularly among MSM as the following excerpt reveals.
Respondent: When I first saw it [a wart] I didn't pay much attention to it. I talked to a friend of mine, because he already had it, and he told me it will disappear naturally. But I got concerned, because it wasn't disappearing...
Interviewer: And why didn't you go to the clinic?
Respondent: I felt ashamed...
Respondent: Previously, I went to see a doctor near where I leave, and I told him that I wanted to run some exams, because I was feeling pretty bad... So he told me just like that: 'It must be AIDS, because every homosexual has it!' He was completely rude, he treated me like... Then I ran out the clinic, crying. I swore that I would never, ever go back again... [MSM, 19 years old, with HPV]
STI-related knowledge, fears and perceived stigma post-diagnosis
Many of the participants interviewed across all three sub-groups reported being physically examined and given a prescription, but not specifically counseled regarding the fact that they had an STI, nor the type of STI. For example:
"The doctor just told me it was a severe illness... He didn't tell me what it was, he didn't explain anything to me. He just asked me to use this salve." [Heterosexual female, 23 years old, with HPV]
"He [the physician] just told me that I had a kind of inflammation, and that he couldn't run my exams today, that first he needed to treat my inflammation. That's all." [Heterosexual female, 18 years old, with candidiasis]
Some participants left their consult without having received any information regarding how STIs were transmitted, as seen below.
Interviewer: And do you have any idea how you got this STI?
Respondent: I just don't know. I have no clue at all...
Interviewer: Didn't your doctor talk with you about your STI, or about the STI risks?
Respondent: No, not at all. [Heterosexual female, 42 years old, with HPV]
Interviewer: How do you think you got this STI?
Respondent: Well, I really don't know. He [the physician] told me that I can get it by using someone else's shorts... It could be because of that, 'cause I usually go to a friend's house, and I always use his shorts. [Heterosexual male, 22 years old, with HPV]
Interviewer: And how do you think you would end up with this STI?
Respondent: This inflammation, well I think that it's because I walk around barefoot, most of the time my stomach is wet, I am washing clothes and I get all wet and I don't warm myself up. It could be that..." [Heterosexual female, 18 years old, candidiasis]
Perceived stigma and the lack of counseling and support received not only appeared to impact the patient's knowledge and health, but also their ability to notify their partner(s) of their STI diagnosis, as suggested in the following excerpt:
Interviewer: Do you have any idea how you got this STI?
Respondent: I really don't know. This type of thing never even entered my mind before. All girls think they will never get this type of thing. People say there is a cure, but it's so embarrassing. I didn't have the courage to tell my husband about this. What would he think? He would think I was with someone else. So now I am living with a heavy conscience." [Heterosexual female, 21 years old, with HPV]
In cases where participants did report having discussed their diagnosis with their physician, the information they received or ultimately came away with did not in most cases clear up their initial confusions and sometimes provoked additional fears and perceived stigma regarding the nature and future course of their disease.
"A doc told me that syphilis is a blood disease, and if you leave it untreated, it becomes worse and worse...She talked to me very briefly about it, that when a disease becomes more and more severe it can even turn into another disease, it can cause other diseases. So, if this first disease becomes more severe, and if I do not achieve my cure, it can even turn into AIDS." [Heterosexual male, 19 years old, with syphilis]
"I could never, ever imagine this. I went to the clinic as I always do, and I got really desperate when I saw HPV in my exams. I felt really dirty, and thought that I'll have lots and lots of warts. Then I talked to my doc, and he made me even more anxious, 'cause he told me that if I do not look for treatment I could never have a child...I could never imagine that such thing will happen to someone like me." [Heterosexual female, 22 years old, with HPV]
While the MSM interviewed generally exhibited higher levels of STI-related knowledge and in many cases prior experiences with STIs, there were almost no indications that they had any dialogue or counseling with their attending physicians regarding STI prevention. Only a minority of participants reported having discussions regarding condom use or partner notification with their attending STI care provider calling into question the quality of health education efforts at these public clinics.