Hidden Disease: Female Genital Schistosomiasis Remains Unknown in Southern Chad Despite HIV Risk

In the rural communities of southern Chad, nearly everyone knows that schistosomiasis exists. The parasitic disease, spread through freshwater snails, is a familiar presence along the rivers and lakes where villagers bathe, fish, and collect water. Yet when researchers asked residents and health workers about female genital schistosomiasis, a manifestation of the same infection that can scar the reproductive tract and raise the risk of HIV acquisition, only a tiny fraction had ever heard of it. A new mixed-methods study published in PLOS Neglected Tropical Diseases documents this striking knowledge gap and its consequences for women’s health in one of the disease’s endemic strongholds.

The research, led by Melissa N. Asongha and colleagues, was conducted in communities within the Guelo district of southern Chad between June and July 2025. The team employed a cross-sectional design that combined quantitative and qualitative approaches. Structured questionnaires captured numerical data on awareness and perceptions, while eleven focus group discussions and fifteen key informant interviews provided deeper insight into how community members and healthcare professionals understand, explain, and respond to the genital form of the disease. Quantitative responses were analyzed with statistical tools, and the qualitative transcripts were coded using NVIVO software and organized into thematic categories.

The headline finding is a disparity so large it borders on the surreal. Among 548 respondents, 93.8 percent demonstrated sufficient knowledge about the urinary form of schistosomiasis, the classic presentation involving blood in the urine that has long been the focus of control campaigns. By contrast, just 3.1 percent, only 17 people out of 548, had any meaningful knowledge of female genital schistosomiasis. The confidence intervals tell the same story: 91.5 to 96.2 percent for urinary knowledge versus a mere 2.3 to 4.9 percent for FGS. In practical terms, the disease that disproportionately burdens women is almost entirely invisible to the very communities it affects.

Female genital schistosomiasis arises when eggs of the parasite Schistosoma haematobium, which normally lodge in the walls of the bladder and genital blood vessels, trigger chronic inflammation in the cervix, vagina, and vulva. The resulting lesions can cause bleeding, pain, and abnormal discharge, and they create entry points through which HIV can pass during sexual contact. Epidemiologists have long noted that the geographic distribution of S. haematobium overlaps substantially with regions of high HIV prevalence across sub-Saharan Africa, and the World Health Organization has recognized FGS as a neglected condition that may contribute substantially to HIV transmission. Yet as the Chad study makes clear, recognition at the community and clinic level has not followed the science.

The statistical analysis went beyond simple awareness counts. The researchers identified moderate awareness of urinary schistosomiasis, reported by 63.2 percent of those knowledgeable about the urinary form, as a predictor of general schistosomiasis understanding, while the low 17.7 percent awareness level among the small FGS-informed subgroup underscored how shallow even that limited knowledge runs. Critically, the study documented a widespread perception that FGS is neither a risk factor for HIV nor for cervical cancer. This misperception matters enormously, because women who do not know that a parasitic infection can interact with viral oncogenesis and HIV acquisition have no reason to seek screening, disclose symptoms, or demand targeted care.

Perhaps most troubling were the beliefs uncovered in the qualitative interviews. Both informed community members and healthcare professionals shared the conviction that FGS is sexually transmitted and is typically treated with antibiotics or antifungal medications. This is medically incorrect: FGS is caused by parasitic worms acquired through freshwater contact, not through sexual intercourse, and the appropriate treatment is the antiparasitic drug praziquantel. The misconception that the condition is a sexually transmitted infection carries a heavy social cost. The study found that this belief was significantly associated, with a chi-square statistic of 13.7 and a p-value of 0.002, with negative consequences for hospital treatment-seeking behavior driven by fear of identity-related stigma, particularly among women suffering recurrent genital symptoms.

The stigma mechanism deserves close attention. In communities where genital symptoms are read as evidence of sexual behavior, a woman experiencing the bleeding and discharge characteristic of FGS may avoid clinics altogether rather than risk being labeled. Delayed or absent care means the lesions persist, the parasite burden may continue, and any elevated HIV susceptibility remains unaddressed. The researchers’ finding that misattribution of the disease to sexual transmission actively suppresses care-seeking transforms what might seem like an educational shortfall into a measurable clinical harm. Knowledge gaps, in other words, are not benign; they funnel women away from the health system at precisely the moments when intervention matters most.

The implications for health policy in Chad and comparable settings are direct. The authors argue for integrating FGS education and awareness initiatives into existing praziquantel delivery campaigns, which already reach endemic communities through mass drug administration programs. Because those campaigns are built around the urinary presentation of the disease, they represent a ready-made platform for teaching communities that the same parasite can affect the female reproductive tract. The study also calls for embedding FGS information within sexual and reproductive health services at primary care facilities in rural Chad, ensuring that women who present with genital symptoms are asked about freshwater exposure rather than being treated presumptively for sexually transmitted infections.

Training the health workforce emerges as a second pillar of the recommended response. If healthcare professionals themselves believe FGS is sexually transmitted and treat it with antibiotics or antifungals, the clinic becomes a site where misinformation is reinforced rather than corrected. The researchers emphasize the urgency of comprehensive training for local healthcare workers on the diagnosis and clinical management of FGS, including recognition of its characteristic lesions and appropriate prescription of praziquantel. Complementing this clinical capacity, the study underscores the need to improve water, sanitation, and hygiene services so that residents have safe alternatives to contact with the freshwater bodies where the parasite’s snail hosts live, reducing transmission at its source.

The Chad findings arrive amid growing international momentum to confront FGS. The WHO has issued programmatic guidance encouraging countries to integrate FGS assessment and care into sexual and reproductive health services, and pilot programs in several African countries have begun training nurses to recognize the condition during routine pelvic examinations. What the Guelo district study adds is a rigorous baseline demonstrating how far awareness lags behind the science in an endemic setting, and a quantified link between misconception and care avoidance. For the women of southern Chad, the distance between a 93.8 percent familiarity with blood in the urine and a 3.1 percent familiarity with genital schistosomiasis is not an abstract statistic. It is the gap between a disease people know to fear and a condition that silently shapes their risk of HIV, their experience of pain, and their willingness to walk through a clinic door. Closing that gap, the authors conclude, requires education, clinical training, and clean water delivered together, not one at a time.

Subject of Research: Awareness gaps and health consequences of female genital schistosomiasis in southern Chad

Article Title: “We don’t know schistosomiasis can affect the female reproductive system and increase the risk of HIV” : A mixed-methods analysis reveals gaps in risk factor determinants and health consequences of female genital schistosomiasis in Southern Chad

Article References: Asongha, M. N., Ngakia, T. N., Akawung, P., Lokissidingao, C., Nnamdi, D.-B., Zephanias, B. O., Blondeau, F., Djelamde, A., Lewis, D. A., Betehndoh, E., & Nkemngo, F. N. (2026). “We don’t know schistosomiasis can affect the female reproductive system and increase the risk of HIV”: A mixed-methods analysis reveals gaps in risk factor determinants and health consequences of female genital schistosomiasis in Southern Chad. PLOS Neglected Tropical Diseases, 20(10), e0014791. https://doi.org/10.1371/journal.pntd.0014791

Image Credits: AI Generated

DOI: 10.1371/journal.pntd.0014791

Keywords: female genital schistosomiasis, Schistosoma haematobium, Chad, HIV risk, neglected tropical diseases, praziquantel, stigma, healthcare workers, water sanitation hygiene, mixed-methods research, women's health, cervical cancer