Discussion and Conclusions

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The workshop was divided into two working groups. The following is a summary of the discussion.

Group 1—Strategies for Successful Integration of STD Management into Family Planning Services

Tasks:

• Review specific issues for integration of STD management into FP services
• Identify major constraints
• Propose specific activities and solutions to successfully integrate STD management into FP services in low-resource settings

Summary of Group 1 Discussion

• Assess the burden of STDs/HIV as a reproductive health problem by
  • Determining their relative importance in comparison to other preventable morbidity
  • Finding out who is at risk
  • Determining if interventions will make any difference
• Define the objective of integration
  • Expanding women’s reproductive health care
  • Increasing client satisfaction
  • Improving FP and STD services
  • Reducing costs
  • Providing one-stop services
• Ensure consensus and collaboration on integration of STDs among the following types of programs
  • STD control programs
  • FP programs
  • MCH programs
  • Primary health care programs
  • AIDS/HIV programs
• Ensure commitment to integrated activities in the following areas
  • Personnel
  • Infrastructure
  • Financing
  • Policy
• Understand the constraints to integration, which include
  • Increased workload
  • Unavailability of funds
  • Lack of supplies and drugs
  • Stigma of STDs
  • Failure to reach core transmitters
  • Failure to reach VS clients
  • Expensive tests
• Determine the level at which integration will take place by developing criteria for
  • Appropriate level of care
  • Sites offering integrated services
  • Sites offering training in STDs/FP
• Develop appropriate training strategies for
  • Preservice personnel
  • Inservice personnel
  • Teams at service and referral sites
• Determine priority areas for training, including training in
  • Risk assessment, involving history taking and the use of checklists
  • STD management, including information about diseases of local relevance and treatment modalities appropriate for the country
  • Interpersonal communication, including training to ask culturally sensitive questions
  • Sexuality issues
  • Supervisory skills
  • Evaluation and followup

Group 2—Strategies for Supporting STD Treatment

Tasks:

• Review specific issues related to treatment and management of STDs
• Identify major constraints
• Propose specific activities and solutions to successfully treat and manage STDs

Summary of Group 2 Discussion

• Develop effective protocols for diagnosis and treatment by
  • Defining the burden of STDs
  • Conducting research, carrying out ongoing surveillance, setting up record keeping systems
  • Integrating risk assessment, syndromic and etiologic data
  • Devising simple diagnostic and therapeutic algorithms
  • Developing treatment protocols that involve the use of available and affordable therapies and drugs that are on national lists
  • Monitoring successful treatment
  • Including condoms and other barrier methods as part of treatment
• Strengthen and expand existing services by
  • Avoiding duplication of services
  • Reaching out to core STD groups (e.g., adolescents, men)
  • Developing treatment protocols
  • Devising strategies to ensure that treatment is successfully completed
  • Including counseling and partner treatment as part of services
  • Implementing training programs in preservice and inservice settings
• Organize and offer effective training programs by
  • Evaluating existing resources and guidelines
  • Assessing training needs
  • Considering political, social and cultural issues relevant to human sexuality and STDs
  • Applying local guidelines in devising training programs
  • Defining responsibilities and functions of different levels of personnel
  • Developing problem-solving, competency-based curricula for each level of personnel
  • Developing appropriate, effective training materials
  • Evaluating the curricula and training programs, including assessment of competency and overall effect of the program
• Initiate outreach activities, including
  • Increasing efforts to reach men, in particular those whose female partners have STDs and/or high-risk behavior
  • Targeting adolescents by integrating sexuality and health education into the school system
  • Determining factors that will attract clients to seek care early
  • Assuring privacy in clinics
  • Encouraging clients to come to clinics with their partners
  • Extending clinic hours of operation
  • Revitalizing syphilis screening in pregnancy
  • Promoting diagnosis and treatment of ophthalmia neonatorum
  • Introducing screening of potential IUD users
  • Promoting condoms and other barrier methods

Conclusions

Consensus was obtained on the following strategy for integration of STD/HIV services into family planning settings:

1. Determine national policy as it pertains to:

• National STD control programs
• National HIV and AIDS control programs
• National FP programs
• Commitment to integration activities

2. Review published or unpublished data, or conduct rapid surveys, to determine:

• Prevalence of STDs
• Prevalence of HIV/AIDS
• Local risk factors
• Data on antibiotic sensitivity, and availability

3. Develop guidelines for STD integration into FP programs that consider:

• Levels of integration
• Who will provide services
• Who will provide the additional funding
• How the integrated program will link with national STD/HIV control and other health programs

4. Promote primary prevention activities by:

• Disseminating STD/HIV information to FP workers
• Helping individual clients to determine their own risk status
• Helping individual clients to recognize and determine their partners’ risk status
• Counseling clients on safe sex practices
• Aggressively promoting condoms
• Aggressively promoting female controlled barrier methods

5. Promote case finding and treatment activities, particularly in those countries where a national STD integration policy exists, prevalence data are available and routine therapies are available on the country's essential drugs lists. The level of care available will dictate which of the following are the appropriate case finding and treatment levels:

• Syndromic diagnosis
• Clinical diagnosis
• On site etiologic diagnosis

6. Develop training programs and packages and conduct competency-based training in:

• Risk assessment, particularly in enabling health workers to talk about sexuality-related issues
• Training in the appropriate and correct use of barrier methods
• Syndromic diagnosis and treatment
• Clinical diagnosis and treatment
• Competency based low technology on site etiologic diagnosis and treatment
• Counseling in risk reduction and safe sex practices, including skills in negotiating for partner treatment and followup

7. Develop a central reference facility for:

• Preparing appropriate risk assessment tools that are relevant to FP clients
• Developing diagnostic algorithms
• Conducting “gold standard” diagnostics
• Carrying out periodic STD/HIV prevalence studies of FP clients
• Preparing treatment protocols based on assessment of antibiotic sensitivity and availability
• Determining country specific objective, and guiding policy change

8. Support the development and testing of low cost diagnostic tests that are applicable in low technology situations and that can give immediate result for:

• Chlamydia
• Gonorrhea
• Syphilis

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