For women, sexual intercourse can lead to two major health consequences: pregnancy and
sexually transmitted disease (STD). Because the two are so closely entwined, many clinic
managers are encouraging staff to view family planning and STD services as two essential
components of reproductive health programs -- not as separate services with different
goals.
Many family planning programs now offer a variety of STD prevention activities,
including education about STD signs and symptoms; education about the effects of
contraceptive choice on STD risks; counseling to help women improve communication skills
so they are able to talk with their partners about sex; and education for couples on the
relationship between sexual behaviors and STD risks.
In addition, family planning clinics are training staff to understand the social,
economic and cultural factors that affect women's reproductive decision-making.
"The reality is that AIDS is a threat to family life," says Dr. Sunanda Ray,
a former research fellow at the University of Zimbabwe medical school. "It is
responsible to plan families. It is responsible to protect families, and protection
includes protection against all forms of disease. It is important to include both family
planning and disease protection in a reproductive health package."
Educating women about their risks, ways to protect themselves and how to voice their
needs and concerns is an important strategy in the effort to curtail STD and HIV
infections, as well as prevent pregnancy. Since much of this information also helps women
to control their fertility, experts say the link between family planning and STD services
is a logical one.
"These are all connected together," says Dr. Florence Tadiar of the Women's
Health Care Foundation (WHCF) in the Philippines, where STD services and family planning
were offered when WHCF clinics first opened their doors in the 1980s. "You have to
look at the whole woman -- teaching her things that would protect her health, her
children's health, the health of her husband."
Worldwide, numerous health-care programs are working to integrate family planning and
STD services, with the aim of educating women, empowering them to communicate with
partners, and helping them improve their reproductive health. Three programs in Asia,
Latin America and Africa illustrate the integration already occurring.
Responding to needs
In Nepal, the Chitwan Static Clinic has offered family planning and maternal-child
health services for 12 years. In February 1996, the clinic began to offer STD services, in
part because health-care staff noticed an increasing number of female family planning
clients with reproductive tract infections.
In an innovative program, the Nepal clinic offers diagnosis and treatment of STDs using
the syndromic approach, plus education about STD prevention through a community outreach
program. During its first 10 months, the clinic treated 416 women and 95 men for STDs, and
provided education programs to many others. Administered by the Family Planning
Association of Nepal (FPAN), the Chitwan clinic's STD services are supported by FHI's AIDS
Control and Prevention (AIDSCAP) Project.
"The integration of family planning and STD services provides an opportunity or
entrance point for women to seek services for health issues considered sensitive by young
Nepali women," write Joy Pollock and Asha Basnyat of AIDSCAP's Nepal office.
"Before the start-up of these services, women were unwilling to go to the public
hospitals or health centers for STD care due to issues of confidentiality and ignorance
[not recognizing symptoms]. Services from private providers can be very expensive."
The clinic reports that demand for these services has increased dramatically, primarily
due to word of mouth, drawing women from distant villages.
While no formal evaluation has been done, AIDSCAP and FPAN staff believe the program is
helping empower women by providing knowledge about reproductive health. When women attend
education sessions on STDs, "it is as if someone is telling them that these are
symptoms that do not have to be borne as the fate of women but actually can be
relieved," says Kari Hartwig of the AIDSCAP Asia regional office in Bangkok.
With the introduction of STD services, the Chitwan clinic added Sunday hours and
extended its weekday schedule. Clinic staff believe extended hours may encourage women in
high-risk groups, such as commercial sex workers, to come for STD services when there are
few family planning clients. The program has been so successful that FPAN is opening two
new STD and family planning offices.
Education about STD prevention, including behavioral change and communication between
couples, is integrated with other components of family planning. For example,
"Depo-Provera Day" traditionally was set aside for couples to come to the clinic
to learn about this injectable hormonal contraceptive and for women to receive the method
if they wanted it. Usually there is standing-room only in the clinic. "This is a
great opportunity to show a videodrama about HIV/AIDS to a husband waiting for his
wife," reports Dr. Bijaya Neupane, clinic director.
In addition to clinic services, the FPAN clinic has a peer education program to counsel
women in their homes about STD risks and symptoms and to provide condoms. Working with the
General Welfare Pratisthan's outreach education staff, FPAN has trained female peer
educators to refer women who may need medical treatment to the Chitwan clinic. In
September 1996, 35 of the 68 people treated for STD symptoms were referred by community
workers.
Prior to the addition of STD services, the FPAN clinic offered male condoms as a
contraceptive method. "The program focus was on family planning in the traditional
sense. Condoms were promoted for limiting family size, not for disease prevention,"
says a report from Dr. Bijaya Neupane. Today, FPAN provides counseling to clients and
their partners on condom use as a means of preventing STDs and AIDS, as well as unplanned
pregnancy.
To meet the anticipated demand created by the new STD services, FPAN hired additional
staff, including a nurse, a health aide and a health educator. The clinic also trained
existing staff, including family planning nurses, counselors, lab technicians, health
aides and field supervisors, to serve on its STD services team. The same staff who educate
clients about STDs also train staff on the importance of disease prevention to the health
of the family. Experts recommend that managers involve staff when planning new services
and offer continual follow-up training.
One of the problems FPAN has encountered is that poor women have not been able to
afford drugs needed for STD treatment. While the clinic can provide large numbers of free
condoms for STD prevention, it cannot afford to supply free drugs for treatment. Staff are
hoping to identify additional sources locally to buy drugs for these clients.
Provider attitudes
In the Latin American countries of Brazil, Honduras and Jamaica, International Planned
Parenthood Federation's (IPPF) Western Hemisphere Region is conducting a pilot project to
integrate family planning and STD services at local affiliate clinics. The project, funded
by the U.S. Agency for International Development (USAID), trains providers to view STD
services as an essential component in addressing reproductive health needs, not as an
optional service added to family planning programs.
Traditionally, family planning counseling has focused on provision of contraceptive
methods, with the aim of helping women prevent unplanned pregnancy. The increasing
incidence of AIDS, coupled with demand from clients for more information, is motivating
family planning providers to broaden their discussions with clients to include sexual
behavior and gender roles, says Julie Becker of IPPF.
"Every day, I am with a person who, if [she] does not have AIDS, or her husband
does not have AIDS, she has some cousin, uncle or brother with AIDS or HIV," says a
counselor at the Asociación Hondureña de Planificación de la Familia (ASHONPLAFA)
clinic in Honduras. "I have had to see so many cases that it is no longer
strange."1
IPPF's program trains providers to change the starting point of counseling sessions --
from a discussion of contraceptive devices to a discussion of the client's sex life. For
example, providers may ask: Who is your sexual partner? Do you think your partner has
other partners? How do you feel about his or her other relationships? Are you satisfied
with your sex life? Do you feel pleasure when you have sex? These questions can open up
discussion about the client's concerns about STDs and unplanned pregnancy, as well as
fertility goals -- important factors in choosing a method, says Becker.
"Previously, we used to talk about methods, and we would arrive at an agreement
with a client," says a counselor at the ASHONPLAFA clinic. "But now we go much
deeper. We ask if she has an infection ... we look for risk factors ... we can talk about
other things, such as sexual relations."2
Training staff was an important first step in integrating family planning and STD
services. In all three countries, a variety of staff members -- including counselors,
educators, physicians, nurses, administrators, support staff, drivers, and cleaning staff
-- attended two- to three-day sessions on HIV and STDs, sexuality, education and
counseling skills. Additional training allowed staff to discuss broader issues of
reproductive health, gender and power, and communication about sexual issues.
Sessions also included training on correct condom use, and staff discussed biases
against condoms, which in typical use are less effective as contraception. Prior to the
training sessions, providers tended to recommend condoms as a backup method, or a method
of last choice when other methods were not available. Afterward, staff were able to
provide instructions on condom use and promote the dual benefits of condoms as a method to
prevent both pregnancy and STDs. Some staff said they themselves began using condoms.
After training, client condom use increased significantly. In Jamaica, 245,000 condoms
were distributed at clinics in 1994, compared with 60,000 in 1992. In Brazil, 36 percent
of all new family planning acceptors asked for condoms.3 In
addition, an FHI study in Jamaica shows that many women are asking for condoms in addition
to another contraceptive method, indicating that dual method use has become more
acceptable.4
A central theme in all training sessions has been that integration of services can
improve the overall quality of and sensitivity to women's and men's health. A physician at
the Sociedade Civil Bem-estar
Familiar no Brasil (BEMFAM) said, "Someone can be a good professional, knowing how
to insert an IUD correctly, knowing exactly which medication should be given for
gonorrhea, but his [approach] needs to involve viewing a person as a whole, tending to a
client from a holistic perspective of overall health and well-being."5
In working with clients, one of the goals of the IPPF pilot program is to help women
learn how to communicate about sexual issues. For many women, talking with a partner about
sex is taboo, making condom negotiation impossible. Often women lack power within a
relationship, and refusing to have sex can carry consequences of physical violence and
abandonment.
"A lot of the same issues in communication and negotiation are the same for HIV
prevention and pregnancy prevention," says Becker. "The behavioral change we are
looking for with women is for them to be able to communicate and negotiate, not just about
HIV, but pregnancy. We are helping empower women to bring up the subject of sex with their
partner. You cannot disentangle the way a woman feels about her sex life with her ability
to talk about her sex life. If she cannot talk to her partner, she is never going to get
him to use a condom."
In Brazil, more than 3,000 women have participated in group discussions that allowed
them to share concerns with other women about sexual issues, such as STD history, risk and
condom use, and to "practice" conversations with their partners. "The
sharing of life stories allows women to recognize that they are not alone in their
feelings," says Rita Badiani of BEMFAM. "The group setting permits women to
express themselves and practice more assertive behavior in a non-threatening environment,
helping them to overcome feelings of intimidation in communicating with their partners
about sexuality and preventive practices."6
BEMFAM staff say these sessions had positive results. One participant, who wanted to
become less financially dependent on her partner, found a job. Another woman, who
participated three times in group discussions, said her husband now uses condoms.
"Now I feel more secure," she said, "and indeed feel pleasure."7
Similar discussion sessions were held in Honduras, and a focus group of community
members in Jamaica has recommended assistance in building communication skills between the
sexes.
Community dialogues
In the West African country of Nigeria, another type of group discussion is being used
as a strategy to reduce the incidence of AIDS, STDs and unplanned pregnancies. Community
dialogues -- a series of eight focus group discussions -- have been held with workers,
market women and young people to explore their perceptions of how men and women
communicate about a variety of topics. The dialogues, sponsored by AIDSCAP's Women's
Initiative, will be used to develop programs to improve communications between couples
about reproductive health.
"The goal is to increase the level of communications between the sexes at home, in
the workplace and at the community level," says Dr. Eka Esu Williams, resident
advisor for AIDSCAP in Nigeria and president of the Society for Women Against AIDS in
Africa. "The approach is to understand what the parameters for a dialogue should be,
how should a dialogue take place, when it should happen. Then, we will think how all this
can be applied to AIDS and STDs services."
In analyzing dialogue results, AIDSCAP staff concluded there is a need for
communication between men and women to be less formal and to introduce the topic of AIDS
in an indirect, non-threatening way. "We need to talk about why this [disease]
affects all of us," says Dr. Williams. "People will say, 'Oh, that has to do
with prostitutes. It has nothing to do with us.' We need to talk about why men and women
see things differently, why they respond differently, and how we can reduce those lines of
division so that people are at the same starting point."
In helping women and men discuss AIDS, programs may be able to use messages similar to
those used to promote family planning, Dr. Williams says. Often, proponents of family
planning have encouraged couples to have only as many children as they can care for
financially. AIDS prevention messages might also address the importance of disease
prevention as a means of ensuring the family's future, Dr. Williams says. "We have to
explain AIDS in terms of what will happen to children. We have to present it in terms of
what happens to the family rather than what happens to the individual."
To link AIDS prevention with pregnancy prevention, AIDSCAP's Nigeria office is
conducting training for AIDS workers that incorporates information on family planning. In
addition, peer education programs for young people have been expanded to include
discussions of abortion and pregnancy, as well as AIDS. Dr. Williams says combining family
planning and STD services and expertise may be a more efficient, effective way to deliver
reproductive health services.
As in Brazil, discussion groups have proven to be an effective means of encouraging
women to express concerns about reproductive health -- and a way of involving men, says
Dr. Williams. In same-sex discussion groups, "women develop solidarity," she
says, and gain confidence in speaking about sexual issues. Often, when discussion groups
are held for women, men will express an interest in attending, too. Group discussions can
be less threatening than one-on-one communications between husband and wife, Dr. Williams
says. Because not all women can easily talk to their partner about STDs and AIDs, AIDSCAP
has trained women leaders to talk to groups of men about AIDS prevention.
-- Barbara Barnett
References
- Becker J, Ureno M, Mora C. How Integration of HIV
Prevention Has Helped Family Planning: Sexuality, The Essential Link. XIth International
Conference on AIDS, Vancover, July 1996.
- Becker, Ureno, Mora.
- Becker J. Integration of HIV/STD prevention and family
planning: Lessons learned by IPPF/WHR and the family planning associations in Honduras,
Brazil and Jamaica. Presentation to USAID, Washington, September 12, 1996.
- Behets F, Ward E, Fox L, et al. Sexually transmitted
diseases in women attending Jamaican family planning clinics and the lack of appropriate
detection tools. Unpublished.
- Becker, Ureno, Mora.
- Becker J, Ureno M. Integration of HIV/STD Prevention
in Family Planning Programs and Services: The HIV/STD Add-on to the Transition Project.
Nd.
- Becker, Ureno. Nd.
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