Screening for sexual transmitted infections in high school students in the Kurdistan Region of Iraq: an epidemiological investigation

Screening for sexual transmitted infections in high school students in the Kurdistan Region of Iraq: an epidemiological investigation | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 4 September 2025 V1 Latest version Share on Screening for sexual transmitted infections in high school students in the Kurdistan Region of Iraq: an epidemiological investigation Author : W Authors Info & Affiliations https://doi.org/10.22541/au.175699090.07369485/v1 290 views 318 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Introduction: Sexually transmitted infections (STIs) are a serious, chronic global public health issue, with substantial health, social, and economic implications. We assessed the prevalence of STIs among high school students in Duhok City in the Kurdistan Region of Iraq in 2025. Methods: This cross-sectional study involved 18 high school students in Duhok City, Kurdistan Region of Iraq, as part of an STI screening program by the Preventive Health Department. Results: The mean age was 16.31 years (range: 15–19), with females (57.2%) slightly outnumbering males (42.8%). Most students were in 10th grade (55.2%), and nearly all were Kurdish (98.7%) and Muslim (91.4%). Regarding risk behaviors, most had not undergone surgery (86.5%) or dental procedures (95.6%), and none reported sharing needles or personal items. Small proportions had blood transfusions (0.9%), tattoos (1.0%), or piercings (0.5%). Illicit drug use was rare (0.2%). Hepatitis B vaccination coverage was low (5.9%), with 81.6% unvaccinated. Laboratory results showed a 0.7% prevalence of HBV, while HCV and HIV were undetected. Only one case of syphilis was identified (0.2%). Conclusions: The findings reveal that high school students in the Kurdistan Region of Iraq have an overall low prevalence of STIs, with only a few cases of HBV and syphilis detected and no cases of HIV or HBC with limited engagement in high-risk behaviors. A key concern is the very low coverage of HBV vaccination. Introduction Sexually transmitted infections (STIs) represent a profound and persistent global public health challenge, impacting millions worldwide with significant health, social, and economic consequences. 12, The World Health Organization (WHO) estimates that over one million individuals acquire an STI daily, contributing to an annual incidence of approximately 333 million new cases of curable STIs. 23, A particularly alarming statistic highlights that one in every 20 teenagers is believed to contract a curable STI each year, even excluding widespread viral infections like Human Immunodeficiency Virus (HIV). 3 Adolescents and young adults, typically defined as those aged 10 to 24 years, are disproportionately affected by the global burden of STIs. This age group makes up as much as 60% of all new infections around the world, and with half of all STI annual cases in the United States occurring among youth aged 15-24. 4 Their heightened vulnerability is a result of a complex interplay of biological, behavioral, and societal factors. 5 Biologically, young women, for instance, face increased susceptibility to infections such as Chlamydia trachomatis due to factors like cervical ectopy, which is commonly present in sexually active adolescents. 5 Adolescence is a crucial period marked by rapid biopsychosocial development, an increased exploration of sexuality, and a growing influence of peer groups, often leading to engagement in risky sexual behaviors including unprotected intercourse and having multiple sexual partners. 6 Several key factors contribute to the high prevalence of STIs among adolescents. Inadequate knowledge regarding the causes, symptoms, and prevention methods of STIs is a significant barrier to effective control. 47, Studies consistently demonstrate that while awareness of HIV/AIDS might be relatively high, knowledge about other common STIs, their transmission routes, and potential complications remains poor. 78, There is a gap in knowledge but the limited presence of comprehensive sex education in school and existing social taboos related to discussions of sexual health only increase this problem. 8 As a result, adolescents often defer or seek treatment late, sometimes because they do not recognize symptoms, the potential stigmatization, or fear and judgement with regards to professional health care. 35, The inconsistent use of condoms in adolescents, often attributed to inconvenience or a perceived reduction in sexual pleasure, further increases transmission risk. 9 Comprehensive epidemiological data, particularly about STIs, is limited and often poor in Iraq, especially when we refer to Kurdistan Region of Iraq (KRI). Current data frequently depends on the syndromic approach or focuses primarily on HIV/AIDS and does not represent a complete spectrum of infections. 8 The KRI generally claims to have low HIV prevalence, often because cultural and religious norms prevent premarital sexual activity and encourage marital fidelity and the practice of male circumcision 10 , however, other conditions may encourage conditions conducive to STIs. Ongoing political instability, displacement, poverty, unemployment, and fractured community organization continue, and these characteristics create a situation where STIs may have an easier opportunity to spread and be significantly underreported. 8 More research specific to the region highlights not enough information on the rates of genital warts in Iraqi Kurdistan - for instance, a study in Erbil City referencing the incidence quantity as low that may be influenced there too, by particular cultural inhibitions and male circumcision. 1112, Moreover, knowledge gaps extend far beyond just the general populace; for example, secondary school teachers in Baghdad demonstrated very little knowledge of Human Papillomavirus (HPV) infection and HPV’s link to cervical cancer. Furthermore, many teachers did not have knowledge of STIs being a cause of cervical cancer. 13 This highlights a broader educational deficit requiring urgent attention through targeted health campaigns to prevent a projected increase in cervical cancer cases. 13 Given the global burden of STIs, the established vulnerability of adolescents, the identified risk factors, and the acute scarcity of comprehensive, current epidemiological data specifically pertaining to high school students in Duhok City within the Kurdistan Region of Iraq, this study addresses a critical information gap. Understanding the prevalence and associated factors of STIs in this particular, often underserved, demographic is fundamental for developing evidence-based, culturally sensitive, and effective public health strategies. Without such foundational data, efforts towards effective prevention, early detection, and timely treatment programs for young people in the region cannot be adequately designed or implemented. The aim of this study was to determine the prevalence of STIs and infections in a sample of high school students in Duhok City in Kurdistan Region of Iraq. Materials and methods Study design and sampling This cross-sectional study included blood samples from 18 high school students in Duhok City, located in the Duhok Governorate of the Kurdistan Region of Iraq. The study aimed to involve both male and female students. Conducted by the Preventive Health Department of the Duhok General Directorate of Health, the research was part of a screening program for sexually transmitted infections (STIs) among students. A team of technicians, along with one researcher, visited the selected schools. Blood samples were collected only after obtaining permission from school administrators. The samples were placed in proper containers and transported to the Central Laboratory in Duhok City for analysis. All male and female students across various age groups and socio-demographic backgrounds were eligible to participate in the study. The only exclusion criterion was unavailability during the data collection period. Settings This study was conducted among 591 high school students in Duhok City, within the Duhok Governorate of the Kurdistan Region of Iraq. In this region, high schools provide education for students in grades 7 through 12. To identify eligible schools, a complete list was obtained from the Duhok Governorate’s Directorate of Education. Out of a total of 152 high schools—where secondary schools have been integrated into high schools for the past decade—we aimed to include approximately 10% of schools to achieve a representative sample size suitable for the large student population. Students were selected from each chosen school using proportional allocation and systematic random sampling to ensure fair representation across schools. To enhance representativeness, the selected schools were increased to confirm coverage of areas with diverse socio-demographic characteristics, including variations in economic status. Data collection was carried out between February and March 2025. The data for this study was collected by the Directorate of Preventive Health Affairs in the Duhok province and is under the General Directorate of Health. The Directorate of Preventive Health Affairs is responsible for determining health policies and considering preventive health services and general administration of primary health care delivery systems. The Communicable Disease Department is responsible for the control and prevention of communicable infectious diseases, and the Sexually Transmitted Diseases (STDs) Unit operates within the CDD for screening, monitoring, and management of, HIV, hepatitis B (HBV), hepatitis C, (HCV) and syphilis especially among high-risk groups. Data collection was focused on assessing the possibility of infectious diseases, HIV, HCV, HBV, and syphilis among high school students. This study is a part of broader public health initiatives with the focus of disease prevention and control at the school level. Also as part of a screening program for students. Infectious disease screening is a principal function of the Communicable Diseases Department (CDD), as they routinely screen populations in high-risk and institutional settings such as prisons, among travelers, and at military bases. Measurements Blood specimens from 591 students were collected by trained technicians and sent to the Central Laboratory in Duhok City for assessments. The screening was for the most prevalent STIs, including hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), and syphilis. In addition to the biological samples taken, two researchers collected general and medical information from the participants using a pre-designed questionnaire. The questionnaire included information regarding socio-demographic characteristics, the medical history of the individual prior to the study, previous laboratory confirmation of STIs, and potential reason for the transmission of STIs (risk factors). Testing for the STIs was performed using the following laboratory procedures: Biological Sampling and Analysis Blood specimens were obtained by trained technicians before being sent to the Central Laboratory in Duhok City for their analysis. The serological tests allowed us to screen for the following ST): • Hepatitis B (HBV): Detection of hepatitis B surface antigen (HBsAg) was performed using enzyme-linked immunosorbent assay (ELISA). • Hepatitis C (HCV): Presence of anti-HCV antibodies was determined using ELISA. • Syphilis: Screening was conducted using the Venereal Disease Research Laboratory (VDRL) test to detect antibodies against Treponema pallidum . • HIV: Initial screening was carried out using ELISA to identify HIV antibodies. All positive results were confirmed following the standard diagnostic protocols recommended by the health authorities. Statistical analyses General and medical characteristics of the study participants were summarized using mean (standard deviation) for continuous variables and frequency (percentage) for categorical variables. The normality assumption for age was assessed using a Q-Q plot and histogram visualization, which indicated that the distribution of age was approximately normal. The prevalence of STIs, as well as associated risk factors and previous STI diagnoses, were calculated and presented as frequencies and percentages. All statistical analyses were conducted using JMP® software, Version 18.0 (SAS Institute Inc., Cary, NC; 1989–2023). Ethical approval Ethical approval for the study was granted by the local health ethics committee of the Duhok Directorate General of Health in Duhok City, Kurdistan Region of Iraq. The study protocol was officially registered under number 08012025-1-50 on January 8, 2025. Written permission was also obtained from the relevant school administrations prior to data collection. Participation was voluntary, and individuals had the right to refuse to answer any general or medical questions. Written informed consent was obtained from all participants. Blood sample collection was performed by trained personnel following strict health and safety protocols. The study adhered to all ethical guidelines in accordance with the principles of the Declaration of Helsinki. Results The results presented in the tables describe the general characteristics, risk-related behaviors, and prevalence of sexually transmitted infections (STIs) among high school students in the Kurdistan Region of Iraq (Duhok Governorate). The first table outlines the sociodemographic profile of 591 students. Their mean age was 16.31 years, with students falling between 15 and 19 years. Females constituted a slightly larger proportion (57.2%) compared to males (42.8%). The distribution across education levels showed the highest proportion in 10th grade (55.2%), followed by 11th grade (23.9%) and 12th grade (21.0%). Nearly all students were Kurdish (98.7%) and predominantly Muslim (91.4%), while smaller proportions identified as Yazidis (8.3%) and Christians (0.3%; Table 1). Table 1: General characteristics of the high school students in the Kurdistan Region of Iraq in 2024 (Duhok Governorate) General characteristics (n=591) All patients No. % Age (15-19 years) Std Err Mean: 0.04 Mean: 16.31 SD: 0.86 Gender Male Female 253 338 42.81 57.19 Education level 10th 11th 12th 326 141 124 55.16 23.86 20.98 Ethnicity Kurd Arab 583 8 98.65 1.35 Religion Muslim Yazidis Christian 540 49 2 91.37 8.29 0.34 The second table focuses on risk-related behaviors and exposures linked to STI transmission. A majority of students reported never undergoing surgical operations (86.5%) or dental procedures (95.6%). Importantly, none of the participants reported sharing needles or personal items such as razors or toothbrushes, eliminating some common transmission routes. However, a small proportion had undergone blood transfusions (0.9%), tattoos (1.0%), and body piercings (0.5%). Very few students admitted to illicit drug use (0.2%), though some declined to answer. Vaccination coverage for hepatitis B was low; only 5.9% had received the vaccine, while the majority (81.6%) had not, and 12.5% were unsure. Among vaccinated students, most received three doses, but a notable proportion were uncertain about the exact number (Table 2). Table 2: STI-related information on high school students in the Kurdistan Region of Iraq in 2025 STI-related information (n=591) Frequency distribution No. % Have you ever been tested or diagnosed with one or more of the following diseases? No Yes 583 8 98.65 1.35 Have you ever had any surgical operation? No Yes 511 80 86.46 13.54 Have you ever had any dental procedure? No Yes 565 26 95.60 4.40 Have you ever shared any needle, syringe or other injection equipment with the others? No 591 100 Have you ever had any blood or blood product transfusion? No Yes 586 5 99.15 0.85 Do you have any tattoos? Declined No Yes 2 583 6 0.34 98.65 1.02 if yes, were tattoos done in a professional setting Bladder Surgery No Yes 1 2 3 16.67 33.33 50.00 Do you have any body piercing? Declined No Yes 3 585 3 0.51 98.98 0.51 if yes, was piercing done in a professional setting? No Yes 3 1 75.00 25.00 Have you ever had unprotected sex (without condom) outside marriage or prior to marriage? Declined No 1 590 0.17 99.83 Are you administering illicit injection drugs? Declined No Yes 3 587 1 0.51 99.32 0.17 Have you ever shared any personal item (toothbrush & razor) with the others? No 591 100 Have ever been vaccinated against hepatitis B vaccine? Do not know No Yes 74 482 35 12.52 81.56 5.92 If yes, how many doses of hepatitis B vaccine have you received? Do not know More than three No One Three Two 9 3 1 2 14 7 25.00 8.33 2.78 5.56 38.89 19.44 The third table shows the laboratory results of STI prevalence. Hepatitis B virus (HBV) was detected in 0.7% of students, while hepatitis C virus (HCV) and human immunodeficiency virus (HIV) were absent in all cases. Syphilis was found in just one student (0.2%; Table 3). Table 3: Prevalence of STI in high school students in the Kurdistan Region of Iraq (Duhok Governorate) STIs (n=591) Prevalence of STIs No. (%). Negative Positive HBV 587 (99.32 4 (0.68 HCV 591 (100) 0 (0.0) HIV 591 (100) 0 (0.0) Syphilis (VDRL) 590 (99.83) 1 (0.17) Discussion This study addresses a critical gap in regional health data, as comprehensive information on STI prevalence and associated factors among adolescents in this specific demographic is notably scarce. 35, Adolescents and young adults (typically 10-24 years) are globally recognized as a particularly vulnerable group for STIs, accounting for a significant proportion of new infections worldwide due to a complex interplay of biological, behavioral, and societal factors. 45, Understanding the local context, including sociodemographic characteristics, risk behaviors, and actual prevalence, is therefore crucial for developing targeted and effective public health interventions. The sociodemographic profile of the 591 students included in this study revealed a mean age of 16.31 years, with participants ranging from 15 to 19 years, a period marked by significant biopsychosocial development and increasing exploration of sexuality. 5 Females constituted a slight majority (57.2%), which is consistent with the gender distribution in similar school-based studies in other regions. 61415, The student body was overwhelmingly Kurdish (98.7%) and predominantly Muslim (91.4%), reflecting the cultural and religious landscape of the KRI. This ethno-religious context is important, as strong cultural and religious norms in the region often discourage premarital sex and promote marital faithfulness, which can influence sexual behaviors and the reported incidence of STIs. 1216, A detailed examination of risk-related behaviors and exposures showed remarkably low rates for several common STI transmission routes. None of the students reported sharing needles or personal items such as razors or toothbrushes, which are known vectors for blood-borne infections. Similarly, very few students had a history of blood transfusions (0.9%), tattoos (1.0%), body piercings (0.5%), or illicit drug use (0.2%). The absence of reported needle sharing and extremely low rates of other direct contact/blood-borne risk factors are encouraging and likely contribute to the low prevalence of certain STIs observed. However, it is important to acknowledge that self-reported data on sensitive topics, particularly in conservative societies like the KRI, may be subject to social desirability bias and underreporting. 16-18 Students may be reluctant to disclose behaviors perceived as socially unacceptable, which could lead to an underestimation of actual risk. Despite the low reported risk behaviors, a concerning finding was the low hepatitis B vaccination coverage, with only 5.9% of students having received the vaccine, while 81.6% had not, and 12.5% were unsure. This widespread lack of vaccination leaves a large proportion of the student population vulnerable to HBV infection, which can be transmitted sexually as well as through blood-to-blood contact. Even among those vaccinated, a notable proportion were uncertain about the exact number of doses received, highlighting a potential gap in health literacy or record-keeping. This suggests a need for enhanced awareness campaigns on the importance of HBV vaccination, especially as a preventive measure against a sexually transmissible disease, irrespective of other reported risk behaviors. The laboratory results of STI prevalence revealed a very low burden among the high school students in Duhok City. Human Immunodeficiency Virus (HIV) and HCV were entirely absent in all tested cases. This finding for HIV is consistent with previous reports indicating a generally low prevalence of HIV in Iraq and the KRI, often attributed to strong cultural and religious norms. 19 However, low reported prevalence can also reflect under-reporting or limited testing, especially given existing challenges such as geopolitical instability and disrupted community structures that might create environments for STIs to spread under the radar. 8 Hepatitis B Virus was detected in a small proportion of students (0.7%), and syphilis was found in just one student (0.2%). These figures are remarkably low, especially when compared to prevalence rates reported in other developing countries or even among specific vulnerable groups within the KRI. For instance, a study among inmates in Duhok City, while primarily male and older, found a syphilis prevalence of 0.59%. 18 Other Iraqi studies among blood donors have reported syphilis prevalence rates ranging from 0.21% to 0.36%. 20 The low HBV prevalence in this study, despite the very low vaccination rate, suggests that while the students may be biologically susceptible, their actual exposure to the virus might be limited by other factors, possibly including conservative sexual practices not fully captured in the questionnaire. The detection of syphilis in a single student, while a very low percentage, underscores that even in low-prevalence settings, these infections can occur. The worst effects of syphilis, such as congenital syphilis or tertiary syphilis in older adults, are not typically seen in adolescence. 3 Comparing these results with studies from other regions highlights the unique context of Duhok. For example, self-reported STI prevalence among sexually active university students in Northeast Ethiopia was 21.5%. 21 In Serbia, approximately 18.0% of high school students reported STI symptoms. 17 Even in Nigeria, some studies reported candidiasis prevalence around 10.9% and gonorrhea at 0.6% among adolescents. 6 Globally, significant proportions of adolescents and young people are affected by chlamydia and gonorrhea, with prevalence rates in some studies reaching over 10%. 3 The current study’s findings of zero prevalence for HIV/HCV and extremely low rates for HBV/syphilis are markedly lower than many international reports, suggesting that the specific sociocultural context and potentially lower rates of risky sexual behaviors among high school students in Duhok play a protective role. Local studies in Erbil City on genital warts also indicated a low incidence, possibly due to cultural inhibitions and male circumcision, further supporting a generally low STI prevalence in the KRI that might be influenced by social factors. 12 The low prevalence of STIs in this study population, while positive, should be interpreted cautiously and does not negate the importance of sexual health education and comprehensive prevention strategies. Global data consistently show that many adolescents and young adults possess inadequate and inaccurate knowledge about STIs, their symptoms, and transmission routes. 71422, For instance, a study in Baghdad University found that 78% of participants had low knowledge of STIs, with non-medical students showing higher deficiencies. Secondary school teachers in Baghdad also demonstrated poor understanding of HPV and its link to cervical cancer, often failing to recognize STIs as a causative factor. 13 Misconceptions about STI transmission, such as contracting them from toilets or sharing clothes, are also common among high school students in various countries. 71423, Given the low HBV vaccination rates and the general findings of knowledge gaps in similar Iraqi populations, it is plausible that students in Duhok City may also have limited knowledge about STIs beyond common understanding of HIV/AIDS. This educational gap is exacerbated by the absence of comprehensive sex education in many secondary school curricula and prevailing societal taboos around discussions of sexual health, which hinder effective prevention efforts. 622, Such knowledge deficits can lead to a delay in seeking treatment, which is often driven by an inability to recognize symptoms, fear of judgment, and concerns over confidentiality and stigma. 3617, Even when individuals are aware of STIs, their perception of management options can be poor, with some believing in non-empirical methods like divine intervention or local concoctions. 6 The lack of youth-friendly clinics further complicates access to appropriate care. 14 The study’s findings, especially the low prevalence in the context of potentially unmeasured sexual activity and documented knowledge gaps, highlight several implications. First, while direct high-risk sexual behaviors appear low or are underreported, the low HBV vaccination rate presents a preventable risk that needs to be addressed through targeted public health campaigns. Second, the absence of reported cases for HIV and HCV is encouraging but necessitates continued surveillance and perhaps expanded screening if sexual activity patterns change in the future. Third, the study underscores the urgent need for culturally sensitive and comprehensive sexual health education within school curricula in Duhok City and the KRI. This education should go beyond basic awareness of HIV, encompassing a broader range of STIs, their symptoms, transmission routes (including non-sexual ones for HBV), prevention methods (including vaccination), and the importance of timely, evidence-based medical care. 142324, Such programs, ideally delivered by health experts, can help address misconceptions, foster positive attitudes towards sexual health, and reduce stigma associated with STIs. 122, Finally, future research in the KRI should consider employing methodologies that can more effectively capture sensitive behavioral data while respecting cultural norms, possibly through qualitative approaches or anonymous surveys with advanced confidentiality measures. This would provide a more nuanced understanding of underlying sexual behaviors and associated risk factors among adolescents, which are difficult to assess directly in such studies. 16 Conclusion In conclusion, the findings reveal that high school students in the Kurdistan Region of Iraq have an overall low prevalence of STIs, with only a few cases of hepatitis B and syphilis detected and no cases of HIV or hepatitis C. Most students reported limited engagement in high-risk behaviors such as drug use, unprotected sex, or needle sharing, although small numbers had tattoos, piercings, or blood transfusions that could pose some risk. A key concern is the very low coverage of hepatitis B vaccination, with the majority of students unvaccinated or uncertain of their status. While the results suggest that STIs are not yet a major public health problem in this group, strengthening awareness programs, promoting safe practices, and improving vaccination uptake are important measures to sustain protection and reduce potential risks in the future. Reference List 1. Talib RM, Nasir NA. Knowledge and Attitudes towards Sexually Transmitted Infections among Medical Groups and Non-Medical Colleges at Baghdad University 2024. 2025. 2. world Health Organization. Sexually transmitted infections (STIs). 2025. 3. Dehne KL, Riedner G. Sexually transmitted infections among adolescents. The need for adequate health services. 2005. 4. Jefferson IS, Robinson SK, Tung-Hahn E, et al. Assessing and improving the knowledge of sexually transmitted infections among high school adolescents. Dermatology research and practice. 2021;2021(1):6696316. 5. Brabin L. Sexually transmitted infections: issues in adolescent health and development. 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Sexually transmitted diseases: knowledge and sexual behavior of adolescents. Texto & Contexto-Enfermagem. 2017;26:e5100015. Information & Authors Information Version history V1 Version 1 04 September 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords hepatitis b virus hepatitis c virus human immunodeficiency virus virus classification Authors Affiliations W View all articles by this author Funding Information National Science Foundation Metrics & Citations Metrics Article Usage 290 views 318 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation W. Screening for sexual transmitted infections in high school students in the Kurdistan Region of Iraq: an epidemiological investigation. Authorea . 04 September 2025. DOI: https://doi.org/10.22541/au.175699090.07369485/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. 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