STDs Workshop Proceedings |
Workshop Summary
Printer-friendly version (26k, Adobe® Acrobat®)
From 19 to 21 April 1995 JHPIEGO, a Johns Hopkins University program for international education in reproductive health, sponsored a workshop designed to explore options for introducing management of sexually transmitted diseases (STDs) into family planning programs. Specific objectives of the workshop were to:
- Review existing knowledge on the screening, diagnosis and treatment, and prevention of STDs and human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) infection
- Assess different country situations and strategies for managing STDs and HIV/AIDS in the family planning setting
- Review training and program strategies to integrate the management of STDs and HIV/AIDS into family planning programs
- Develop a common training and program strategy to promote the management of STDs and HIV/AIDS in family planning programs
These proceedings are based on selected presentations given at the workshop and on the recommendations of two working groups. A list of participants the workshop program are included.
In the first paper, Dr. Mati discussed the need to reorient STD and HIV/AIDS campaigns to low-risk groups. Because of the limited diagnostic facilities available in much of sub-Saharan Africa, the syndromic approach to diagnosis, although flawed, is the most practical one for many areas. Dr. Mati also discussed the association between STDs and the risk of HIV.
In the second paper, Dr. Seth Pincus reviewed the epidemiology of HIV. He compared the regional patterns of the epidemic and discussed modes of transmission. Dr. Pincus emphasized that education about high-risk behaviors is the only means of preventing the spread of HIV and that improved strategies for changing high-risk sexual behaviors are a priority.
Dr. Temmerman’s paper detailed the devastating impact that STDs have on the health of women. Like Dr. Mati, she encouraged use of diagnostic algorithms in countries with limited resources. In addition, she noted that hierarchical scoring systems (risk assessment) can play an important role in improving the diagnosis of STDs in developing countries.
In the following paper, Dr. Sanghvi focused on the role of contraception in the context of increasing prevalence of STDs and HIV/AIDS. He discussed the importance of barrier methods in reducing transmission of STDs and HIV and reviewed the sometimes conflicting evidence on the effect of hormonal methods on STDs and HIV/AIDS. Dr. Pincus then described the difficulty in diagnosing STDs. He also pointed out that use of current assay techniques may not be feasible in low resource settings; however, some less sensitive newer tests may be useful in devising diagnostic algorithms that are more suited to the developing country situation.
The next group of papers explored the status of STDs in five countries. Dr. Bomfim Hyppólito discussed the situation in Ceará, Brazil. She pointed out that screening and diagnosis for STDs are not done routinely. STDs are still not a high priority in Brazil because there are so many other diseases more prevalent. Jean-Robert Brutus then described the situation in Haiti where there is a high prevalence of STDs and HIV/AIDS and lack of programs to manage them. He suggested using the syndromic approach (algorithms) for all symptomatic patients and stressed the importance of IEC campaigns to help change behavior. Dr. Saiffudin examined the situation in Indonesia where STDs are a serious problem. The main target of programs in Indonesia thus far has been commercial sex workers, but a number of new government-sponsored activities are getting underway. Of special note is that STD management is beginning to be linked to the family welfare movement.
In the Philippines, relevant data on STDs are largely lacking. Dr. Palaypay also described both a government initiative and a joint government-private sector program that show promise. Like a number of presenters at the workshop, Dr. Limpaphayom, in her report on Thailand, discussed the interaction between STDs and HIV. In Thailand, STDs increased rapidly in the early 1980s, but a mass media campaign led to a dramatic decline by 1992. The decrease in the number of people newly infected with STDs in Thailand was due to a combination of case finding, case management activities, contract tracing, counseling, promotion of condom use and surveillance of commercial sex workers.
Drs. Schmeding and Gaffikin then described the progress in integrating GTI services into family planning programs in Zimbabwe. They also provided data on the impact of a combined IUD/GTI training program.
They concluded their presentation with a discussion of key factors that are required for achieving successful integration of STDs and family planning services. In the last two papers, Dr. Anderson first presented an overview of STD management. She discussed the goals of STD management, benefits and limitations of etiologic and syndromic diagnosis and the types of data needed to develop management strategies. In her second paper, she also explored barriers that are often encountered in managing STDs as well as strategies that work to improve their management.
After the formal presentations were completed, the participants divided into two working groups to discuss strategies for:
- integrating STD management into family planning services, or
- supporting STD treatment in the family planning setting.
The strategies discussed by the first group centered on:
- determining the relative importance of STDs,
- defining the objectives of integration,
- ensuring consensus and collaboration among programs,
- ensuring the commitment of required resources,
- understanding the constraints to integration,
- determining the level at which integration will take place, and
- developing appropriate content and strategies for training.
The second working group discussed strategies involving:
- effective protocols for diagnosis and treatment of STDs,
- strengthening and expanding existing services,
- organizing and offering effective training programs, and
- initiating outreach activities.
During the group response session, it was agreed that for initiatives to have a lasting impact, countries must have a national commitment to STD and HIV/AIDS management. Because isolated interventions do not have a permanent effect, there is a need for long-term planning to effectively manage these devastating problems.
The proposed STD/family planning management system that incorporates the strategies outlined by the working groups is summarized in Table 1.
Table 1. Management of STDs in Family Planning Settings
| Location of Facility | Level 1 (Dispensary or health post, community-based delivery system) | Level 2 (Health center FP clinics) | Level 3 (District hospital FP clinics) | Level 4 (Referral hospitals) |
| Screening | Risk assessment Basic checklist | Risk assessment Basic checklist | Risk assessment Score-based checklist | Development of risk assessment tools |
| Diagnosis | Syndromic Vaginal and urethral discharge, genital ulcer, bubo, scrotal swelling, lower abdominal pain | Syndromic Plus Clinical History, inspection and examination, including pelvic examination | Etiological Clinical plus simple tests, (urinalysis, pH, whiff test) and light microscopy (wet prep, Gram’s stain) | Reference Laboratory Cultures, serology, Ag-Ab tests, gold standard diagnostics, development of diagnostic algorithms |
| Treatment | Reassurance, low-cost, broad spectrum oral drugs | Reassurance, low-cost broad spectrum drugs, oral and injectable | Wider range, intermediate cost | Assessment of prevailing antibiotic sensitivity, new drugs; development of treatment protocols |
| Prevention | IEC, promotion and provision of condoms, partner management, followup, referral of treatment failures; male motivation | IEC, promotion and provision of condoms, partner management, followup, referral of treatment failures; male motivation | Same, target risk groups, (core transmitters, adolescents), referral of treatment failures | Sentinel surveillance, prevalence studies, community diagnosis, cost benefit analysis |
| Personnel | Community health workers and volunteers | Nurses, medical assistants, physicians | Nurses, medical assistants, physicians | Nurses, physicians, laboratory technicians, researchers, trainers |
| Training | Mainly preservice (will require modification of curriculum) | Mainly preservice (will require modification of curriculum) | Pre- and inservice | Inservice |
By the end of the workshop, consensus had been reached on a number of steps that need to be taken when formulating a national strategy for integrating STDs and HIV/AIDS services into family planning settings. These include:
Determine national policy as it pertains to national STD, HIV/AIDS and family planning programs.
- Review or collect data to determine prevalence of and local risk factors for STDs and availability of antibiotic treatments.
- Develop guidelines for STD integration into family planning programs that consider levels of integration, available resources and links to other health programs.
- Promote primary prevention activities, including education, counseling and promotion of barrier methods.
- Promote case finding and treatment activities appropriate to the levels of care available.
- Develop training programs and conduct competency-based training in risk assessment, use of barrier methods, diagnosis and treatment in countries where resources are limited.
- Develop one or two central reference facilities per country for the purposes of providing sentinel surveillance, refining risk assessment and diagnostic tools, conducting prevalence studies, preparing treatment protocols and recommending national policy guidelines.
- Support the development and testing of low-cost diagnostic tests for chlamydia, gonorrhea and syphilis that are appropriate in low technology situations.
In summary, although each of the papers presented during the workshop had a different focus, there were several common themes; namely:
- STDs are a serious problem in every country represented, even when their management is not yet a high priority.
- Because STDs are risk factors in the spread of HIV/AIDS, it is doubly important that successful management strategies for common STDs be developed to slow the spread of both.
- STDs and HIV/AIDS have a devastating impact on populations, particularly women.
If progress is to be made, it is imperative that better quality data on STDs be collected to determine their prevalence and also local risk factors. Methods to improve diagnosis of common STDs in developing countries are urgently needed. Until better tools for diagnosis are available, diagnostic algorithms (syndromic approach) and scoring systems (risk assessment) must be used. In addition, IEC programs and outreach activities are critical to changing high-risk sexual behavior and slowing the spread of disease.
Finally, the participants trust that the Proceedings of this workshop may contribute to the development of sustainable and effective strategies for integrating STD services in family planning settings, and that STD training programs will benefit from the information contained in these Proceedings as well.