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Research in to the integration of STI prevention and management intoreproductive health servicesin Africa Dr. Ian Askew Frontiers in Reproductive Health Population Council Nairobi, Kenya
Why STI prevention and management? • STIs are a major public health problem in the region • RTIs and HIV infection have adverse, often serious consequences on pregnancy, infant’s and women’s health • STIs are a proven co-factor for HIV transmission • Some RTIs may also be co-factors (e.g. BV) • Early detection and treatment of STIs demonstrated to be effective HIV reduction strategy
The problem • RTIs and HIV infection are actually common among ‘low-risk’ women • Untreated women and their partners continue to serve as a reservoir for infection in the community • Women with symptoms have problems accessing care from STI clinics • Diagnostic facilities are lacking at most MCH/FP health facilities in the region
Why integrate STI services with ANC/FP services? • Existing STI services not easily accessible for women • The vast majority of pregnant women attend ANC clinics women using FP visit clinics • Anticipated efficiencies because of existing staff skills and service procedures
Knowledge gaps • Lack of clear and common definition of integration • Inadequate knowledge, skills and experience with providing services using an integrated approach • Lack of information on the effectiveness and cost of integration strategies
Research activitiesto address gaps • Situation Analysis studies of clinic-based services in Ghana, Kenya, Zambia, Botswana, and Zimbabwe • Case studies of programs in Mombasa and Nakuru, Kenya and Busoga district, Uganda • Intervention studies to improve STI detection and management in Nakuru, Kenya and Zimbabwe
Findings with policy and program implications • Programs were providing “integrated services” without national policies, service provider guidelines and standards to support them • Basic physical infrastructure, supplies and medications had not been reviewed to correspond with service needs • Service providers and communities had not been involved in the design and introduction of the changes leading to poor commitment by providers and utilization by users • Integration was taking place at the health facilities but not at the program or donor levels
What types of “integration” have been tried? • Most emphasis on case management of symptomatic clients using syndromic approach • Some efforts to detect cases among asymptomatic clients (e.g. risk assessment, examination) • Some efforts at promoting prevention (e.g. education on STIs, promotion of safer sex, including condom use) • Antenatal syphilis screening in some sites • Early introduction of HIV VCT and PMTCT in antenatal clients
Case management of symptomatic women • Improve health-seeking behavior of symptomatic women • Education on symptoms • Awareness of need to seek treatment at clinic facilities • Effective diagnosis of symptomatic women • Laboratory (very rare) • Clinical assessments (encouraged where pelvic exams undertaken) • Syndromic (promoted as standard) • Appropriate treatment of RTIs / STIs • Appropriate partner management for RTIs / STIs
Detection and management among asymptomatic women • Case finding through risk assessment and/or clinical assessment, with syndromic management if suspected • Mass or targeted laboratory screening (mainly ANC clients) • Mass or targeted presumptive treatment (not in ANC/FP clinic settings)
Syndromes among women • Vaginal discharge • Genital ulcers • Pelvic inflammation
Assumptions in syndromiccase management • Clients with RTIs have symptoms and signs • Clients with symptoms are aware of and worried about them • Clients visit and report symptoms to health providers • Health providers listen to clients symptoms, assess and correctly interpret the information obtained
Assumptions in syndromic case management (cont.) • The techniques used to interpret the information obtained from clients are reliable • Clients identified to have STIs are started on proper treatment • Clients started on treatment will comply fully • The treatment is effective for all common causes of the syndrome being treated
But….. syndromic management of vaginal discharge is ineffective Why?
A framework for evaluating RTI management strategies Step 1 Clients with any RTI Step 2 Clients with any RTI symptom or sign No Step 3 Clients reporting symptoms No Step 4 Providers’ correctly interpret Reported symptoms Step 5 Correct Medications, Counseling & condom promotion No Yes Step 6 Partner notification and treatment No Yes Yes No Yes No Yes Yes
Symptoms / signs not always indicative of an RTI • Using syndromic management can lead to wrong diagnosis, over-treatment and possible wrongful partner notification
Clients under-report symptoms • Half of clients found to have clinical signs of an RTI did not report a symptom, and so clinical assessment is essential
Staff do not always follow protocols • Over one third of clients having a symptom and/or sign are not managed syndromically
And let us not forget……. • Many women with an RTI do not have symptoms, and so can only be detected through mass screening or presumptive treatment
And that….. • Most women with an RTI have a non-sexually transmitted infection, and so partner notification needs to be handled with extreme caution
What more can be done? • Maintain syndromic management approach and treat for vaginitis • With emphasis on education for better symptom recognition • Mandate clinic assessment and risk assessment • Use of checklist to strengthen provider performance • Do nothing for women with vaginal discharge • Promote trials of rapid low-cost tests
Improve health-seeking behaviour of symptomatic women • Encouraging symptom recognition and reporting could increasescreening and treatment
Improve health-seeking behaviour of symptomatic women • In Uganda, over half of women with a discharge did not seek any treatment • Of those seeking treatment, only 56 percent used the formal sector • Of those using the formal sector, there was a delay of three weeks between symptom onset and clinic attendance
Consider cost-effectiveness of better case finding methods • Laboratory confirmation of symptomatic women • Mass screening for vaginitis • Mass screening for cervicitis • Presumptive treatment for cervicitis or vaginitis • Undertake cost modelling to compare alternatives prior to testing new services
Greater emphasis onprevention • More education on STIs and on safer sexual behaviours • Condom promotion for dual protection • Reach men and adolescents through antenatal services, community-based services and making clinics youth-friendly
Raise awareness of STIs • STIs were discussed with less than one quarter of family planning clients
Promote safer sexual behaviours • Sexual relations were discussed with less than one third of new family planning clients
Condom promotion • Condoms discussed with about half of new FP clients, but are promoted for family planning rather than STI protection
What more can be done? • Reinforce case finding and syndromic management of genital ulcers and pelvic inflammation • BUT….more evidence needed for effectiveness and costs
What more can be done? • Partner notification essential for women with STIs, but crucial that exact type of infection is confirmed • Staff promote notification and give neutral contact cards • BUT….more evidence needed for culturally appropriate approaches
What more can be done? • Encourage partner attendance during antenatal care visits • Educational opportunity • Screening and treatment of male syndromes • Make standards / guidelines and clinics youth-friendly • BUT….more evidence needed on how to do this and to with what effect
What more can be done? • Greater emphasis on reaching men through community-based health programmes: • verbal screening for STI symptoms • Refer for treatment by syndromic management at nearest clinic • BUT….more evidence needed of how to do this and with what effect
Antenatal syphilis screening - an integration success story in Nairobi, Kenya?
Original model • Women had blood taken during first visit • Blood sent for testing to central laboratory using VDRL and TPHA tests • Results sent back to clinic after 2-4 weeks • Women testing positive referred to the STD clinic for treatment
Decentralized model(1992, 9 clinics) • On-site testing of women by clinic staff • Use of the RPR test • Treatment of women on-site by clinic staff • Active promotion of partner notification and treatment
Review of new strategy (1993) • Virtually all (99.9%) clients screened (blood taken and tested) • 6.5% (2.7-9%) tested positive • 87% of the positives received treatment (74.6-100%) • Same day treatment • 48% of partners also treated at the same clinic as the client (37.3-72.9%)
Approaches in standard clinics • Some women referred to the nearest pilot clinic for testing • If positive she is either: • treated at the pilot clinic and takes a letter to the referring clinic indicating treatment • she takes her result back to the referring clinic and gets treated there • Some women have specimen sent from referring clinic to pilot clinic for testing and are referred for treatment at referring clinic • Clients in all clinics are counseled and given a slip for inviting partners to come for treatment
In pilot clinics… • 85% pregnant women screened • 95% of positives treated • 70% of partners treated • Syphilis prevalence declining from 7.3% to 3.2% (1995-1999) • Incremental cost per ANC client = $1.00 ($6.60$7.60)
Making decisions about integration • Public good versus individual health • Effectiveness and cost-effectiveness • of alternative strategies • of doing or not doing integration • Evidence-based decision-making - do we know what does and does not work?