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Seeking ways to include
men and adolescents in family planning and maternal health programs are
among recent ideas for how the programs can help prevent the spread of
sexually transmitted infections (STIs), including HIV.
Historically, adding STI services to family planning and maternal and
child health-care programs has focused primarily on education and
treatment for the traditional family planning client, typically a woman
who has one partner and is seeking pregnancy prevention. Currently, in
addition to finding new ways to reach men and adolescents, some family
planning agencies are promoting condom use for dual protection against
pregnancy and disease; are encouraging community policies that promote
condoms; and are adding counseling about gender relations, which can help
women convince their partners to use condoms.
"So much of the literature on integration has focused solely on
the detection and management of STIs within female family planning clients
through syndromic management that the bigger picture of what integration
could and does include tends to get lost," says Dr. Ian Askew of the
Population Council in Kenya, who has written extensively about integrating
services. Syndromic management refers to diagnosis and treatment based on
a client's signs and symptoms, rather than on laboratory tests, which are
prohibitively expensive in some settings. Syndromic management tends to be
ineffective since women can often be infected without showing symptoms.
In general, the broader approach to integrating services emphasizes
prevention of HIV and other STIs over diagnosis and treatment. Besides
helping traditional clients prevent infection, family planning programs
focus on individuals at greater risk of an STI, especially youth and men.
Efforts to reach high-risk people include social marketing programs,
public education and communication efforts, and advocacy for policy
changes.1
Efforts to integrate family planning and STI services increased
following the 1994 International Conference on Population and Development
in Cairo, which encouraged the concept. In some countries, especially in
sub-Saharan Africa, integrating STI management into primary health-care
services has been a national policy. Since 1996, for example, Kenya has
trained nurses in STI management, improved its system for distribution of
STI treatment drugs and revised national family planning guidelines to
include STI management. One in every 10 adults in Kenya is infected with
HIV.2
However, integrating STI and family planning services is difficult to
achieve. In Kenya, a recent national survey shows only one in five family
planning providers discussed STI risk factors during counseling and only
one in 10 promoted the use of condoms for STI protection.3
Preventive activities
A review of integration models from around the world concluded that
behavioral change messages directed at women have potential but their
impact is low, particularly if the women are married and have only one
sexual partner. STI prevention messages could be more productive if
directed towards their male partners, the review concludes. "Behavior
change promotion in family planning settings appears to have significant
potential only if it succeeds either in empowering women to negotiate safe
sex with their partners or in reaching out to other segments of the
population, including young and unmarried women, sex workers and
men," the study found. Expanding counseling programs to these broader
audiences will take time, however.
In the meantime, the most feasible and immediate step toward STI
prevention through family planning programs is emphasizing the dual
protection offered by condoms, according to the study.4
Some integration efforts are experimenting with ways to reach men and
youth. In a project among the national affiliates of the International
Planned Parenthood Federation (IPPF) in Brazil, Honduras and Jamaica, STI
prevention campaigns focus on men in factories and community settings, as
well as on adolescents in school and non-school settings. Staff training
includes ways of empowering women clients to negotiate condom use.5
IPPF programs in Brazil and Honduras have begun condom social marketing
campaigns. Condoms now account for more than half of the couple-years of
protection from all contraceptive use in the Brazil program.6
Policy planners from several African nations have used the Brazil and
Jamaica programs as models for changes in their family planning programs,
specifically incorporating "gender-sensitive programs focusing on the
youth," says Antero Veiga of the IPPF Africa office.
An analysis of integration efforts in Ghana, Kenya, South Africa and
Zambia, looking at 20 health facilities in each country, found "a
critical need to reexamine the continuing focus on family planning
service," particularly clinical services. There remains
"continued relative inattention to large population groups such as
men and sexually active unmarried women" who rarely use family
planning or maternal and child health services.
Providing STI services to women receiving antenatal services was
described in the study as an important element. Antenatal services reach
four of every five women at some point during each pregnancy in three of
the four countries studied.7A simple screening test can help
diagnose and treat pregnant women who may have syphilis, for example. The
test can be performed while the woman waits for the result, and treatment
with penicillin can begin immediately. Untreated syphilis in pregnant
women can cause spontaneous abortion, stillbirth, premature birth and
infection in the infant. Transmission to the fetus occurs at least 20
percent of the time.
Syndromic management
As policy planners continue to search for ways to address the STI/HIV
epidemics, they face discouraging findings regarding how well the
syndromic management system works among family planning clients.8
Because laboratory tests for most sexually transmitted infections are
too expensive in some countries, the World Health Organization (WHO) and
others developed algorithms (a set of questions given in a flow chart)
that providers could follow to treat a syndrome of signs and symptoms.
Algorithms work well for ulcerative infections, such as syphilis and
chancroid. However, when signs and symptoms are less predictive of a
specific infection or there are no symptoms with an infection, the
algorithms have not been successful.
For example, gonorrhea and chlamydia are usually asymptomatic in women
and cannot be recognized easily using syndromic management. These two
cervical infections account for about 45 percent of the new cases of
curable STIs per year and can have severe consequences if untreated.
In an attempt to make the vaginal discharge algorithm work better,
programs have developed screening tools to help identify women who have a
greater risk for cervical infections. These "risk assessments"
involve asking other questions beyond medical signs and symptoms, such as:
Have you had sex with more than one person or with a new partner in the
last three months? In an FHI-coordinated survey of risk assessments used
among low-risk populations, scientists concluded that "unless risk
assessments can be made more accurate, they will remain promising but
ineffective in low-prevalence settings" such as family planning and
antenatal clinics.9
A recent review analyzed 29 studies that have tested the use of various
screening and syndromic management approaches to diagnose and treat women
with vaginal discharge. "This review found little difference in the
usefulness of simple screening criteria and algorithms or risk scores to
identify gonorrhea and chlamydial infection among women," reported
the authors from the Population Council. "These strategies
consistently identify many more women incorrectly than correctly as
needing treatment." Rather than spending time on ineffective care,
clinicians should spend their time on providing condoms and information,
the study concluded.10
A recent study of five health clinics in Nakuru, in northwest Kenya,
examined the validity of the syndromic management approach in use there
during the last several years. More than 900 family planning and 800
antenatal clients participated in the study, which included medical and
pelvic exams, assessment of STI symptoms and signs using the vaginal
discharge algorithm, and risk assessment tools. Most women found to have
an infection were asymptomatic. The vaginal discharge algorithm identified
only a small portion of the women who actually had a laboratory-diagnosed
infection (5 percent of the family planning clients and 16 percent of the
antenatal clients). The study concluded that the program should emphasize
preventive approaches.11
An FHI study among family planning clients in Jamaica compared several
approaches to identifying cervical infections among asymptomatic women.
The WHO vaginal discharge algorithm with risk assessments (adapted for use
in Jamaica) was the least accurate of the five approaches studied. Two
risk assessment algorithms that weighted various factors had the highest
positive predictive value but were more difficult to use. A rapid risk
analysis with a urine leukocyte esterase dipstick (LED) test was nearly as
accurate as the risk assessments and simpler to conduct. "Even
without access to urine dipsticks, simple risk questions alone may be
preferable to the WHO algorithm to identify family planning clients in
need of STI counseling, referral or presumptive treatment," explains
Alan Spruyt of FHI, who helped coordinate the study.12
Cost concerns
Other challenges in integrating family planing and STI services involve
funding systems and the limited resources available for training,
supervision, dissemination of management guidelines, and development of
useful information, education and communication materials.
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Wet sand cools reagents in Mali clinic.
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An assumption about integration of services is that it would be more
cost-effective to use existing family planning and maternal health
infrastructures to manage infections rather than using separate services.
Early research indicated that integrated services might be cost-effective.
For example, a 1996 study of clinics in Kenya found that offering services
to a symptomatic client who requested oral contraceptives during the same
visit cost about U.S. $8.60, while offering the services separately would
be more expensive, costing U.S. $12.40.13
However, as studies of the cost of integration have begun to address
how well syndromic management works, the cost-effectiveness of integrated
services seems less certain. A study in Zimbabwe concluded that screening
women for STIs at family planning clinics based on their signs and
symptoms is not cost-effective. The analysis included four diagnostic
models, ranging from a syndromic approach at U.S. $2.48 per client to
providing laboratory testing for all family planning clients at a cost of
U.S. $25.77 per client.
Although the syndromic approach was least expensive, it was still
unaffordable in some settings. Furthermore, it failed to detect infections
in three of every four women who were infected, and more than half of
those who were treated had no infection (as confirmed by laboratory
tests).14
"We found that family planning providers have the technical skills
to do sexually transmitted infections management, and thus adding this
service is feasible," says Rick Homan of FHI, who helped conduct the
study. "However, being feasible does not guarantee that the service
is either cost-effective or affordable. In our study, the syndromic
management guidelines were not effective in terms of the number of people
treated correctly (infected or uninfected). In addition, it is not
affordable for the health ministry to consider any of the diagnostic
models for screening family planning clients." In the absence of
cost-effective approaches to the diagnosis and management of STIs, the
report recommended that family planning programs in the region put more
emphasis on preventive strategies.
-- William R. Finger
References
- Shelton JD. Prevention first: a three-pronged
strategy to integrate family planning program efforts against HIV and
sexually transmitted infections. Int Fam Plann Perspect
1999;25(3):147-52.
- Askew I, Fassihian G, Maggwa N. Integrating STI and
HIV/AIDS services at MCH/family planning clinics. In Miller K, Miller
R, Askew I, et al, eds. Clinic-based Family Planning and
Reproductive Health Services in Africa: Findings from Situation
Analysis Studies. (New York: Population Council, 1998)199-216.
- National Council for Population and Development,
Ministry of Health, ORC Macro. Kenya Service Provision Assessment
Survey 1999. Calverton, MD: ORC Macro, 2000.
- O'Reilly KR, Dehne KL, Snow R. Should management of
sexually transmitted infections be integrated into family planning
services: evidence and challenges. Rep Health Matters
1999;7(14):49-59.
- Becker J, Letiman E. Introducing sexuality within
family planning: the experience of three HIV/STD prevention projects
from Latin America and the Caribbean. Quality/Calidad/Qualité
1997;8.
- Frautschi F. Long-term outcomes of the IPPF/WHR
transition project add-on: integration of HIV/STI prevention in family
planning. Unpublished paper. International Planned Parenthood
Federation/Western Hemisphere Region, 2000.
- Mayhew SH, Lush L, Cleland J, et al. Implementing
the integration of component services for reproductive health. Stud
Fam Plann 2000;31(2):151-62.
- Mindel A, Dallabetta G, Gerbase A, et al., eds.
Syndromic approach to STD management. Sex Trans Infec 1998;74(S):S1-178.
- Welsh M, Feldblum P, Chen S. Sexually transmitted
disease risk assessment used among low-risk populations in
East/Central Africa: a review. East Afr Med J 1997;74(12):764-71.
- Sloan NL, Winikoff B, Haberland N, et al. Screening
and syndromic approaches to identify gonorrhea and chlamydial
infection among women. Stud Fam Plann 2000;31(1):55-68.
- Solo J, Maggwa N, Wabaru JK, et al. Improving the
management of STIs and MCH/FP clients at the Nakuru Municipal Council
Health Clinics, 1999. In Frontiers in Reproductive Health:
Electronic Library 1900-1999. New York: Population Council, 2000.
- Ward E, Spruyt A, Fox L, et al. Strategies for STD
detection among family planning clients in Jamaica. Unpublished paper.
Family Health International, 2000.
- Twahir A, Maggwa BN, Askew I. Integration of STI
and HIV/AIDS Services with MCH-FP Services: A Case Study of the
Mkemani Clinic Society in Mombasa, Kenya, Operations Research and
Technical Assistance, Africa Project II. New York: Population
Council, 1996.
- Maggwa N, Askew I, Marangwanda C, et al. Demand
for and Cost-effectiveness of Integrating RTI/HIV Services with
Clinic-based Family Planning Services in Zimbabwe. New York:
Population Council, 1999.
For more information, visit Family Health International's Website at www.fhi.org
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