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Global sexual health education: STIF in Zambia
  1. Jaime H Vera1,2,
  2. Owen Ngalamika3,
  3. Ashini Fox4,
  4. Emma Collins2,
  5. Matthew Grundy-Bowers5
  1. 1 Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
  2. 2 Department of Sexual Health, Brighton and Sussex University Hospitals NHS Trust, Brighton, Brighton and Hove, UK
  3. 3 Department of Dermatology, Lusaka University Teaching Hospital, Lusaka, Zambia
  4. 4 Department of Medicine Building, Nottingham University Hospitals NHS Trust, Nottingham, Nottingham, UK
  5. 5 Department of Sexual Health and HIV, Imperial College Hospital NHS trust, St Mary’s Hospital, London, UK
  1. Correspondence to Dr Jaime H Vera, Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton BN2 4AT, UK; j.vera{at}

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The STI Foundation (STIF) course is a recognised programme that has been providing comprehensive training in sexual health in the UK since it was launched in 2002 by BASHH. STIF courses have also been successfully ran outside the UK in several European countries (Greece, Malta and Ireland) and the Caribbean (Trinidad, Tobago and Barbados), corroborating the international relevance of the programme.1 In July 2017, for the first time, the STIF course was delivered in the African Continent in Lusaka, Zambia. But why Zambia? STIs including HIV remain a major public health problem in Sub-Saharan Africa. Zambia has been significantly affected by the STIs and HIV epidemics, with an estimated 1 million people living with HIV, half of them women (prevalence of 12.5%), and a high prevalence of curable STIs in adults aged 15–49.2 The WHO recommends the use of syndromic management of STIs in resource-poor settings, which is based on groups of consistent symptoms and easily recognisable clinical findings to arrive at a diagnosis. The problem with this approach is that it relies on well-trained staff who can confidently recognise symptoms and signs of STIs, deal with issues of confidentiality, partner notification and treatment of complex clinical presentations. Following a needs assessment visit to Lusaka, we found consistently that staff managing STIs at the University Teaching Hospital in Lusaka had never been trained in sexual health. With support from a British Medical Association grant, The Brighton Lusaka Link charity, BASHH and the Zambian Medical Association, we decided to run the first STIF Theory Course (STIF Core and STIF Plus) in Lusaka, followed by a 1-day BASSH microscopy course. Because the STIF Core, STIF Plus and BASHH microscopy courses are prescriptive in content and delivery and have been developed for a UK audience, with the help of local collaborators, we obtained permission from BASHH to adapt the courses to the Zambian setting, developing content that reflected local needs, while retaining the key elements that made them a STIF product. Adaptions undertaken by the team reflected local prevalence of STIs and HIV (where these were known), local access to investigations and treatments, the law surrounding sex, sexuality and sexual assault and cultural norms. We also modified the delegate manual, course questionnaires and the list of e-learning sessions.

Twenty-five delegates completed the STIF theory course and 11 selected delegates completed the microscopy course for a total of 3 days of training. Delegates’ roles included doctors (specialists and non-specialists), nurses, clinical officers and biomedical scientists. The adapted course format took the same approach employed for the standard STIF course with preparatory e-learning, lectures, workshops and small group discussions. The team had hoped to undertake ‘real-time’ microscopy but this was not possible due to the number of delegates and resourcing of the laboratory. Instead, a presentation that included high-quality microscopy images, in addition to the BASHH microscopy course manual, and group discussion complemented the session. The feedback was positive with delegates rating each of the sessions good to excellent. More importantly, delegates felt that the format of the course facilitated open and honest discussions about sensitive topics such as sexual history taking and sex between men. There was a significant improvement in knowledge as demonstrated by the comparison between precourse and postcourse questionnaires scores for both STIF theory (P<0.005) and microscopy courses (P<0.001). We have several challenges. First, although the working language in Zambia is English, we had to be careful to avoid the use of idioms and colloquialisms that the delegates may not be familiar with and to be aware about the barriers in terms of culture and language, for example, something said in English might be inappropriate in a local Zambian language when interpreted during a sexual history taking. Second, we needed to be sensitive to the legal and cultural milieu in which the delegates practise medicine in Zambia, when discussing subjects such as domestic and sexual violence, and homosexuality. Third, most of the copyrighted images available from the course are of Caucasian doctors or patients which are not ideal when the target audience is black African. Finally, the e-learning modules were not found to be useful in this setting with only three delegates completing the modules before the course, which they found not relevant and time consuming.

Despite the challenges, it was a privilege to deliver the STIF programme in a setting that urgently needs training in sexual health. However, the biggest challenge will be to ensure sustainability, and to address with the help of BASHH, we plan to use the STIF competency framework to develop a local competency programme to train the trainers, so local doctors will have the knowledge and capacity to train other healthcare staff involved with sexual health in Zambia.



  • Handling editor Jackie A Cassell

  • Contributors All authors contributed equally to this report.

  • Funding This work was funded by grants from the British Medical Association and the Brighton Lusaka Link Charity.

  • Competing interests None declared.

  • Ethics approval Not applicable

  • Provenance and peer review Not commissioned; internally peer reviewed.