Recommendations for Contraceptive Use
RH TOC		STD Risk Assessment

Sexually Transmitted Disease (STD) risk assessment in the context of family planning (FP) is under study. STD risk assessment should have a variety of benefits in reproductive health (RH) and improve overall quality of care. A risk assessment will potentially help determine what type of RH services should be offered to a client, for example:

a) what contraceptive options are best suited to the client's needs, including dual method use,

b) what risk reduction counseling is needed,

c) whether testing and/or treatment/referral for STDs is needed, and

d) in the case of maternal and newborn care, what diagnostic and/or treatment options are needed to decrease maternal and neonatal morbidity and mortality.

Thus, appropriate STD risk assessment tools are under study for both effective STD management and appropriate FP counseling to form a unified pathway for integrated RH health services.

Uses of STD Risk Assessment in Reproductive Health

• For all family planning clients:

STD risk assessment can be a tool to aid in counseling regarding appropriate contraceptive options. For example, clients determined to be at increased risk of current or future STDs would be poor candidates for intrauterine devices (IUDs), but may be good candidates for barrier methods.

• For symptomatic clients:

For clients with symptoms and signs of an STD, syndromic management (i.e., management based on symptoms and signs as opposed to detection of specific organisms) is a programmatic option in settings where laboratory diagnosis is not feasible. Where STD treatment services are offered, clients should be treated with antibiotic regimens appropriate to cure the range of organisms typically causing the particular syndrome. Syndromic management of urethral discharge in men, and of genital ulcers in men and women, has been shown to have a high positive predictive value. In cases of vaginal discharge, where syndromic management is problematic, STD risk assessment may help predict more specific treatment, i.e., treatment for vaginitis alone or treatment for both vaginitis and cervicitis.

• For asymptomatic clients:

STD risk assessment might help to identify those clients who are at greater risk of being infected and therefore good candidates for further clinical examination or laboratory evaluation, or alternatively for treatment of presumptive infections. Unfortunately, studies have shown that results of STD risk assessment in asymptomatic women do not correlate well with actual presence of infection, however, in some settings it may still be a useful approach to determine who should undergo further evaluation.

Risk Factors to be Assessed

Several recent investigations^1-3 have found that certain demographic, behavioral and non-laboratory clinical factors (e.g., self reported vaginal discharge or lower abdominal pain) werecorrelated with the presence of various STDs in the study populations. These factors were (or could be) used to assess the likelihood that persons coming for RH services are either currently infected or at high risk of future infection with STDs.

Helping Clients Receive an Accurate STD Risk Assessment:

The studies mentioned above also have shown that the risk factors vary from one setting to another. Thus, a characteristic which indicates increased STD risk in one country/population may not be indicative of elevated risk in a different country/population. To increase the utility and predictive value of STD risk assessment, programs should try to establish what demographic characteristics, behavioral risk factors, and clinical symptoms and signs are associated with the various STDs seen in their local setting. When doing so is not possible, creating a risk assessment tool based on some of the characteristics which have been demonstrated to be risk factors for STD infection in other settings may be a useful alternative. The utility of using STD risk assessment without clinical validation must be judged in the context of the current services available and the scope of the STD problem.

Because of the sensitive nature of sexuality and STDs in many cultures, clients may be hesitant to respond truthfully during an STD risk assessment. Thus, the provider should ask questions in a non-judgmental manner and assure the client that the discussion is strictly confidential.

Self-assessment methods, where the client determines his or her own level of risk based on information given by the provider but does not indicate which specific risk factors apply, might be useful in such settings. Research into the utility of self-assessment for STD risk is ongoing.

Citations:

1. Behets FM, Liomba G, Lule G, Dallabetta G, Hoffman IF, Hamilton HA, et al. Sexually transmitted diseases and human immunodeficiency virus control in Malawi: a field study of genital ulcer disease. Journal of Infectious Diseases 1995;171(2):451-5.
2. Vuylsteke B, Laga M, Alary M, Gerniers MM, Lebughe J, Nzila N, et al. Clinical algorithms for the screening of women for gonococcal and chlamydial infection: evaluation of pregnant women and prostitutes in Zaire. Clinical Infectious Diseases 1993;17(1):82-8.
3. Behets FM, Williams Y, Brathwaite A, Hylton-Kong T, Hoffman I, Dallabetta G, et al. Management of vaginal discharge in women treated at a Jamaican sexually transmitted disease clinic: use of diagnostic algorithms versus laboratory testing. Clinical Infectious Diseases 1995;21(6):1450-5.

Subsequent pages demonstrate a list of risk factors which have been associated with an increased risk of STDs. These risk factors are not meant to be universally applicable; the development of a local STD risk assessment, based on the local situation, would be useful and merits consideration.

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Any part of Recommendations for Updating Selected Practices in Contraceptive Use may be reproduced or adapted to meet local needs without prior permission from the TG/CWG Secretariat, provided the TG/CWG is acknowledged and the material is made available free of charge or at cost.