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RHO archives : Topics : Reproductive Tract Infections

Key Issues

This section provides brief summaries of some major research areas related to prevention and control of reproductive tract infections (RTIs), particularly in low-resource settings. More detailed discussions of specific key issues are included in the Annotated Bibliography.

Be sure to use the Glossary if you are unfamiliar with any of the terms on this page.

Assessing syndromic management

The lack of accurate, affordable diagnostic tests hinders effective STI control in low-resource settings. In the absence of appropriate tests, WHO and other health agencies have promoted the use of syndromic STI management in low-resource settings (Vuylsteke et al. 1996; Hoffman et al. 1997). Syndromic management relies on the recognition of clinical signs and symptoms for diagnosis (WHO 1995). It is relatively simple, allows diagnosis and treatment in one visit, and requires minimal provider training. Primary health care workers can be trained and supported to consistently and accurately apply up-to-date syndromic STI management guidelines that are appropriate to the local setting (Bosu 1999; Steen et al. 1998; Hawkes et al. 1999). The syndromic approach is effective and has had a great impact on management of STIs (Vuylsteke 2004). However, the algorithms for syndromic treatment need to be evaluated periodically and adapted to changing local conditions, and health care workers need ongoing supervision and training to ensure adherence to the algorithms (Pépin et al. 2004; Uusküla et al. 2004; Nagot et al., 2004; Boonstra et al. 2003; Vuylsteke et al. 2003).

Syndromic management is not always appropriate. While it is often effective for men, it may be less effective for women. Protocols based on symptoms cannot identify and treat asymptomatic cases, and the majority of STIs in women are asymptomatic. Even symptomatic women do not always recognize and report their symptoms to providers (Voeten et al. 2004; Msuya et al. 2002). Syndromic management of vaginal discharge presents special challenges: it is difficult to distinguish between the conditions most often associated with vaginal discharge (bacterial vaginosis, trichomoniasis, candidiasis) and more serious cervical infections due to gonococcal and chlamydial infections (George et al. 2004; Vishwanath et al. 2000; Pettifor et al. 2000; Passey et al. 1998). However, a study of pregnant women in Jamaica found that syndromic management of vaginitis could help identify women infected with bacterial vaginosis and candidiasis (Kamara et al. 2000). It is likely that a proportion of infections are not being detected using syndromic protocols owing to the high prevalence of multiple syndromes and mixed infections, both symptomatic and asymptomatic (Desai et al. 2003; Mathews et al. 1998; Kaufman et al. 1999). The cost-effectiveness of different protocols, for diagnosing and treating STIs, depends on the local situation (Sahin-Hodoglugil et al. 2003).

In populations with high HIV prevalence, syndromic management of STIs probably would not reduce the incidence of HIV infection (Grosskurth et al. 2000; Gray et al. 1999; Hudson 1999), but improved syndromic management can contribute to lowering the burden of bacterial STIs (White et al. 2004; Korenromp et al. 2002). HIV co-infection does not appear to affect the response of non-ulcerative STIs to syndromic management (Moodley et al. 2003), but syndromic treatment has been shown to fail among HIV-positive women with genital ulcer disease caused by herpes (Wolday et al. 2004). A study in rural South Africa found that despite good staff knowledge and availability of most key resources such as drugs and condoms, STI syndromic management is poor (Harrison et al. 1998).

In many areas, treatment with commonly used drugs such as penicillins and tetracyclines is not effective due to the rapid increase in antimicrobial resistance during the last decade (Ieven et al. 2003; Llanes et al. 2003). Resistance to ciprofloxacin, one of the newer antibiotics used to treat gonorrhea, has also been documented in Asia (Trees et al. 2002). There are other effective antibiotics , but they are very expensive. As a result, the choice of a drug for treatment often involves a trade-off between effectiveness and cost (Vuylsteke and Laga 1999). However, single dose treatments for STIs are available and affordable in many developing countries (Romoren et al. 2004; Pépin and Mabey, 2003). For STI control programs to be effective, it is important to assess periodically the antimicrobial susceptibility of specific strains of STIs, as well as the quality and availability of antimicrobial products (Cheluget et al. 2004; Prazuck et al. 2002).

To improve the effectiveness of syndromic management, a risk-assessment component sometimes is added (see "The Usefulness of Risk Assessment" below). Syndromic management also requires treating two or more infections, even though only one, or none, may be present. One study in Malawi, however, found that use of the syndromic approach resulted in more effective treatment of STIs at no additional cost (Daly et al. 1998). In settings where laboratory support is not available, syndromic management is preferable to a clinical approach (i.e., provider judgment) for the management of STI-related syndromes, and can result in more cases receiving effective treatment (Behets et al. 1999; Bogaerts et al. 1995; Moherdaui et al. 1998). Even if laboratory tests are available, the failure of clients to return for results and treatment can make such tests less sensitive for diagnosing cervical infections than syndromic diagnoses (Mukenge-Tshibaka et al. 2002). A study in China found that the quality of laboratory tests for STIs was low, and syndromic management should be considered in areas with inadequate laboratory and physician resources (Liu et al., 2003).

A study evaluating STI syndrome packets containing recommended drugs for each syndrome, condoms, a partner notification card, and a patient information leaflet found that these packets have the potential to improve STI syndromic management (Wilkinson et al. 1999). Similarly, in Uganda social marketing of pre-packaged treatment for men with urethral discharge improved cure rates, compliance, condom usage, and appropriate referral of partners (Jacobs et al. 2003).

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The usefulness of risk assessment

Risk assessment uses socioeconomic, demographic, clinical, and behavioral indicators to predict which clients are at risk of RTI/STI infection and thus in need of testing and treatment. For example, in World Health Organization (WHO) protocols symptomatic women are classified as high risk if they are under 21, single, have more than one sexual partner, or have a new sexual partner. This approach has been proposed as a way to increase the effectiveness of syndromic management. It can also be used alone or in combination with clinical examination (where laboratory diagnosis is not feasible) to screen all clients in a family planning clinic as a way to allocate STI laboratory services or to guide contraceptive method choice.

In high-risk populations, however, most clients will be "positive" according to risk assessment; this can result in the unnecessary treatment of many women. Studies show that the benefit of risk assessment is also limited in low-risk populations (such as family planning and antenatal clinic attendees) (Teles et al. 1997; Vuylsteke et al. 1993; Welsh et al. 1997). Studies of low-risk groups can show high rates of STI infection, especially HIV, indicating that routine screening may be useful for identifying and treating those infected (Claeys et al. 2002; Mbizvo et al.,2001). A cost-effectiveness model of alternative approaches to screening and treatment of sex workers in Madagascar found that a combination of syndromic management and risk assessment would be cost-effective (Homan et al. 2002). Risk assessment tools may be more effective when they are adapted to local conditions (Cates 1997; Bourgeois et al. 1998, Welsh et al. 1997). Efforts to educate the general population, as well as those thought to be at increased risk, about STIs could lead to improved self-risk assessment (Aral 2001). A study in Mexico found that providing women in family planning clinics with information about the infection protection of various contraceptive methods improved their ability to evaluate their own risk of infection and select an appropriate contraceptive method (Coggins and Heimburger 2002). Risk assessment surveys can indicate levels and types of risks prevalent within groups, and can be used to develop targeted interventions to reduce STI transmission (Lau et al. 2003).

A review of several studies of screening and syndromic approaches to identify gonorrhea and chlamydial infections in women found that risk factors, algorithms, and risk scoring were ineffective methods for identifying infections in both low- and high-prevalence samples (Sloan, et al. 2000). Although it is widely accepted that screening and treating pregnant women for syphilis is cost-effective (Terris-Prestholt et al. 2003; Maggwa et al. 2001), many low-resource countries do not routinely test women during antenatal visits because of logistical, financial, and operational constraints (Sullivan et al. 2004; Temmerman et al. 2000). A study of herpes simplex 2 infection among women in a polygynous population indicates high transmission rates within marriage, where the opportunity for personal protection is limited (Halton et al. 2003). This highlights the need to identify an individual’s social network and history of exposure in determining personal risk and the spread of STIs (Aral 2002).

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Simple diagnostic tests

Diagnostic tests are the most clinically accurate way to identify and confirm specific STI pathogens. Laboratory tests and microscopy can strengthen both clinical diagnosis and syndromic algorithms to improve the diagnosis, treatment, and surveillance of STIs (Myziuk et al. 2001). (For more information about diagnostics research, see the Sexually Transmitted Diseases Diagnostics Initiative (SDI), available at www.who.int/std_diagnostics/, and the Rapid Diagnostic Tests website at www.rapid-diagnostics.org). However, many currently available laboratory tests, such as cultures, require a well-equipped laboratory, highly trained staff, and several days for processing. A good-quality microscope permits immediate analysis of wet mounts and stained specimens, and can be an effective tool in diagnosing gonorrhea, trichomoniasis, and vaginitis, but requires investment in equipment, supplies, maintenance, and personnel training. A study in Peru found microscopy, whiff testing, and pH testing to be useful in the diagnosis of vaginal infections (Thompson et al. 2000).

In many resource-limited settings, microscopy, serology, and culture analysis often are not available. Even when laboratory tests are obtainable, their quality and accuracy may be inadequate (Behets et al. 2002; Blankhart et al. 1999; FHI 1999). Without accurate confirmatory tests, providers rely on clinical findings and syndromic diagnoses, which can lead to both over-treatment (in the absence of disease) and under-treatment (missed infection) (PATH 1997). Diagnosis of cervical infection through syndromic management and risk assessment is especially inaccurate (Iskandar et al. 2000). Due to the limitations of these methods, especially for diagnosing vaginal discharge, there is need for simple diagnostic tests appropriate for use in resource-limited settings (Tam 1999). Such tests should meet the following criteria:

  • Affordable and cost-effective.
  • Simple: requires minimal training and little or no equipment.
  • Rapid: results available before patient leaves clinic, preferably within 10 to 15 minutes.
  • Convenient: specimens should be simple to collect, socioculturally acceptable, and need minimal preparation.
  • Stable: for use in the field, assay reagents should have a long shelf-life (1 to 2 years) at ambient temperature (at or above 30 degrees Celsius).
  • Accurate: appropriately sensitive and specific, differentiates past from present infection.

Due to recent technological advances, there are now a number of rapid point-of-care tests on the market for syphilis, chlamydia, and gonorrhea (CDC 2002; WHO/WPRO 1999). However, few have been independently evaluated or assessed to determine if they perform well enough to meet the needs of providers and clients in low-income countries—let alone meet the criteria listed above. Point-of-care tests with moderate sensitivity may be useful in situations where many women do not return for treatment, and where any delay in treatment would result in significant transmission of STIs (Vickerman et al. 2003). Global STI experts agree that rapid point-of-care tests for gonorrhea and chlamydia should be the highest priority to enable screening of asymptomatic patients and reduce overtreatment of women with vaginal discharge (Mabey et al. 2001). There is also need for a rapid test for syphilis that uses whole blood and can distinguish between current and past infection. An assessment of the rapid plasma reagin (RPR) test and a new rapid syphilis test (RST) in The Gambia found the RST easier to use in difficult field conditions, but neither test predicted well the presence of active syphilis in rural women (West et al. 2002). A new rapid test for bacterial vaginosis compared favorably with clinical diagnosis, and has the advantages of being rapid, less subjective, and easy to use (West et al. 2003). Its current high cost limits its use in resource-poor settings.

Recent advances in genome sequencing and microarray technology, along with pledges of donor support, improve the likelihood that such rapid diagnostic tests will become available in the next few years. Recent analyses of nucleic acid amplification diagnostic tests for trichomoniasis and chlamydia found that polymerase chain reaction (PCR) tests look promising (Mgone et al. 2002; Tanaka et al. 2000; Wilcox et al. 2000; Patel et al. 2000), as do new techniques for sample collection that are more acceptable to women (for example, tampons, self-collected vaginal swabs) (Sturm et al. 2004; Knox et al. 2002; Tabrizi et al. 1997; Rompalo et al. 2001; Smith et al. 2001; Garrow et al. 2002). Amplification tests using urine specimens offer non-invasive, highly sensitive and specific ways to diagnose chlamydia and gonorrhea, yet cost and availability limit their widespread use (Blake and Woods 2002; Macmillan et al. 2003). Research is underway by several groups to develop immunochromatographic (IC) strip tests for hepatitis B, gonorrhea, chlamydia, and syphilis, which are simple, rapid, and cost-effective. IC tests are commercially available for hepatitis B and syphilis (for more information, see the PATH website).

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Best approaches to partner notification

Partner notification (also referred to as contact tracing) is an attempt to prevent reinfection of the index patient, treat infected partners, and reduce the burden of infection on the community. It is an important component of any STI program, but it also is one of the most difficult. The stigma associated with having an STI can lead to delays in seeking treatment and failure to notify sexual partners (Liu et al. 2002). Either the client or the provider (or both) can contact the partner (Fenton et al. 1998), but few developing country programs have the resources to carry out provider referral activities. The willingness and ability of health care providers to initiate partner notification is paramount to the success of this approach (Seubert et al. 1999). A study in Kenya found that the majority of providers promoted contact treatment, but few clients were given contact cards to facilitate partner referral (OHara et al. 2001). In South Africa, use of a video to educate clients in a public health clinic waiting area about the importance of partner notification could be cost-effective and acceptable (Mathews et al. 2002).

Men and women are influenced by different factors in referring their partners for treatment (Nuwaha, Faxelid, et al. 2001). Some studies suggest that women being treated for STIs are more likely to refer their partners than are men (Steen 1996; van de Laar et al. 1997), and that concern for the unborn child may contribute to the success of referral in an antenatal setting (Desormeaux et al. 1996). Men and women are more likely to refer steady partners than casual partners (Koumans et al. 1999; van de Laar et al. 1997). Providing patients with medication to give to their partners can be effective, and offers an alternative to patient referral (Schillinger et al. 2002; Nuwaha et al. 2001). A 2001 WHO Reproductive Health Library review of 11 randomized controlled studies on strategies for partner notification for STIs found some evidence that provider referral, or the choice of provider or patient referral results in more clients presenting for medical treatment than patient referral alone (Mathews et al. 2002). Counseling STI patients on their diagnosis, the mode of transmission and the need to treat all partners is an important part of partner notification (Wakasiaka et al., 2003). Recent studies suggest that analysis of social networks, and not just partner notification, can help identify geographic clusters of individuals important to the transmission of STIs (Rothenberg 2002).

In establishing a referral system, each program must consider its patient population, the syndromes and diseases identified in the patients, the overall STI prevalence in the community, and the availability of laboratory diagnosis (Toomey et al. 1996). Given the lack of specificity of STI diagnoses in many resource-poor settings, partner notification may not be effective or even warranted in many cases (Hawkes and Mabey 2003). Consideration also should be given to the risks women face, including domestic violence, if partner notification is not performed with care.

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Men and reproductive tract infections

Reproductive tract infections in men are usually symptomatic, making them easier to identify and treat than those in women. Men and women can be infected with the same bacteria or virus, but the signs and symptoms of infection differ. Although the consequences of RTIs are often more serious for women, men also can suffer long-term effects. RTIs in men begin in the lower reproductive tract. If untreated, they can move to the upper reproductive tract, and occasionally lead to infertility. WHO estimates that 8 to 22 percent of infertility worldwide is due to male causes. A meta-analysis showed an elevated risk of prostate cancer among men with a history of STIs (Dennis and Dawson 2002).

Early signs of infection in men are from urethritis, an inflammation of the urethra that causes pain and burning on urination. It is often accompanied by discharge. One cause of urethral discharge is gonorrhea infection. However, non-gonoccocal urethritis (NGU) has many causes, including mycoplasma genitalium, chlamydia, trichomonas, and ureaplasma urealyticum (Pépin et al. 2001; Hobbs et al. 1999; Morency et al. 2001). Men who are infected with STIs can be highly infectious to their wives, whether or not they show symptoms of infection (Klouman et al. 2002; Alary et al. 2003).

Another common symptom of RTIs in men is genital ulcers. These can be caused by several infections, including chancroid, syphilis, herpes, and donovanosis (Ahmed et al. 2003; Steen 2001; OFarrell 2001). Because of the multiple causes of genital ulcers in men, they are usually managed using the syndromic approach. This involves treating for syphilis and chancroid, and for donovanosis in endemic regions. It is important that the algorithms for treating genital ulcers be developed according to local conditions (Lewis 2003; Sanchez et al. 2002). In some populations, there may also be a need to treat for gonococcal urethritis and NGU in men presenting with genital ulcer disease (Ballard et al. 2002). A study in China found that syndromic management of genital ulcers is effective and low-cost (Liu et al. 2003). STIs that cause ulcers significantly increase the risk of sexual transmission of HIV. However, other RTIs that cause inflammation can also increase the risk of HIV transmission (Population Council 2001).

Certain groups of men are often considered "high risk" because of the high-risk sexual behaviors they practice. For example, studies confirm the high prevalence of STIs and limited condom use among truck drivers (Gibney et al. 2002; Manjunath et al. 2002). Despite practicing high-risk behaviors (extramarital sex, limited condom use), men often perceive themselves to be at low risk for STIs and HIV. This, in turn, puts their partners at increased risk for STIs, often without their knowledge (Pulerwitz et al. 2001).

Men often seek treatment for STIs at special STI clinics or from pharmacies, and these service-delivery points can be important sources of information about the causes, prevention, and treatment of RTIs. They can also serve as an entry point to inform men about other reproductive health services, including family planning. For more information about private-sector services, please see Involving the private and public sectors in STI control, below. Most young men know little about STIs or how to prevent them. Educating young men about the signs, symptoms, and health risks associated with STIs is crucial in the effort to reduce these infections (Drennan 1998). For more information, please see RHO's Adolescent Reproductive Health and Men and Reproductive Health sections.

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Increasing adolescent access to RTI/STI services

Adolescents seek treatment for STIs from a variety of sources, both formal and informal, public and private. However, the care they receive is often inadequate (Okonofua et al. 1999). Because adolescents rarely visit primary health care or family planning clinics, they may be excluded when RTI services are integrated into existing clinics. Reproductive health programs that seek to reach both rural and urban adolescents—who are at particular risk of RTIs, including HIV (Voeten et al. 2004; Eaton et al. 2003; Hawken et al. 2002; Taffa et al. 2002; Obasi et al. 2001; Todd et al. 2001)—must develop special programs to address their needs. This implies not only making services available, but also making them acceptable to young people (UNICEF et al. 2002; Brabin et al. 2001).

It is important to determine where adolescents want to go for information and treatment (Ndubani and Hojer 2001; Palmer 2002). Approaches that are innovative and specially designed for adolescents are most effective in bringing sexual and reproductive health services to this population (Temin et al. 1999). Primary care facilities may designate youth days at their own facilities or provide services at multipurpose youth centers. Use of peer educators can be an efficient way to provide information on prevention, and can reduce risk-taking behavior in adolescents (Speizer et al. 2001; Fetters et al. 2001; Brieger et al. 2001; Merati et al. 1997). Making use of traditional channels for sex education, such as the senga (father’s sister), offers a culturally acceptable way to educate adolescent girls (Muyinda et al. 2003). Collaborative approaches that incorporate cross-referencing between community-based services and STI clinics may improve effective management and care of adolescents seeking STI services (James et al. 1999). Because of their unique position, primary health care providers play an important role in the prevention and control of RTIs, particularly STIs, among adolescents (Lappa et al. 1998; Ikimalo et al. 1999; Blankhart et al. 1999; Obunge et al. 2001). Traditional health care providers are also an important source of reproductive health information and care for young people, but they need to be trained and better integrated into the service delivery system (Kiapi-Iwa and Hart, 2004).

Experience in communicating with youth about reproductive health gained over the years has yielded key lessons learned including the need to:

  • Build broad, high-level support for the project from the start.
  • Involve youth from the start.
  • Recognize that young people are eager for accurate information about sex.
  • Use information to link young people with services.
  • Work with boys, adults, families, schools, and communities.
  • Use a variety of communication channels.
  • Provide engaging and positive role models for youth (Pathfinder International 1997; Palmer 2002).

A review of studies with adolescents in developing countries found that effective programs provide consistent, accurate messages; provide training in life skills; offer social support; and provide access to contraceptives and appropriate health services (Speizer et al., 2003). Several studies have shown that parental support for condom use, personal risk perception, and self-efficacy are associated with higher levels of condom use (Finger and Pribila 2003; Meekers and Klein 2002). Developing young peoples social and practical skills can boost self-confidence, improve their skills in sexual negotiation, and help them resist peer pressure and sexual coercion (Nzioka, 2004; Karim et al. 2003; Taffa et al. 2002). (For more information, see RHO's Adolescent Reproductive Health section.)

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Improving client-provider interaction

Provider discomfort and unwillingness to counsel clients about sexual practices and reproductive tract infections is a barrier to integrating RTI into family planning services. In addition, poor provider attitudes toward STI patients, the perception that STI patients are stigmatized and thus receive a lower standard of care than other patients, and a lack of training and support are major constraints (Harrison et al. 1998). A study in Zambia found that the education levels of providers and clients affect the successful transfer of STI prevention information (Chikamata et al. 2002). Special training techniques often are necessary to ensure that providers can talk with clients about STIs in a helpful, nonjudgmental way (Wotton et al. 1996; Ghee et al. 1996). Experience from many countries has found that training programs are most effective when they are active and participatory; emphasize practice; and are responsive to the knowledge level, skills, values, and emotions of trainees. Improving the interaction between clients and providers improves the overall quality of reproductive health services and is key to successful integration of services (PATH/Outlook 1999; Kisubi et al. 1997).

Effective client-provider interaction assumes that clients are treated with respect, that their questions are fully answered, and that aspects of their lives that affect their health are addressed. A client-provider IEC project in Kenya found that radio drama can be an effective way to encourage Kenyan women to go to family planning service providers. High family planning use among listeners, compared with women in the general population, and clients' reports of referral sources confirm this (Kim et al. 1996). Provider skills can be improved to elicit necessary reproductive health information from clients and create a physical environment that enhances effective client-provider interaction. Experience in Bangladesh suggests that service delivery protocols can be revised so that each medical appointment is seen as an opportunity for interaction between the client and the provider (Chowdhury et al. 1999). Studies have found that clients seek out a variety of treatments for STIs, often combining traditional and professional medical sources (Ndulo et al. 2000; Manhart et al. 2000).  A study in Viet Nam found that many women suffer from RTIs but do not seek care, in part because they fear the stigma of being diagnosed with an STI (Go et al. 2002). Understanding local beliefs, preferences, and customs for treatment, along with the local terminology for RTIs/STIs can improve client-provider interactions.

Client-provider interaction also can affect patient compliance with treatment. A study in South Africa found that the use of a calendar blister package for drugs improved patient compliance with STI treatment (Wright et al. 1999). In addition to making it easier for patients to keep track of their medications, the packaging facilitated improved communication of treatment information to the patient. Such a tool can be adapted to local situations, including literacy levels, to improve compliance.

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Assessing the operational implications of integration

Adding reproductive health interventions to existing services requires addressing not only provider training, but also issues of facilities, equipment, drug availability, condom supply, record-keeping systems, patient flow, costs, supervision and monitoring. One approach is to add services incrementally (PATH 1998; Kisubi et al. 1997). Integrating services at the service delivery level may affect the national systems for demand-projection, procurement, and warehousing of contraceptive commodities, drugs, and vaccines. A study of the operational performance of integrated STI services in Mwanza, Tanzania, found it is feasible to add STI services to the existing primary health care structure (Grosskurth et al. 2000). A study in Indonesia found it feasible to add RTI services to existing family planning services, but quality services depend on well-trained providers and assurance of client privacy and confidentiality (Budiharsana 2002). Strengthening STI treatment services can improve the quality of related services (Wilkinson et al. 2002). A quality assessment tool developed in South Africa allows supervisors to identify obstacles to the delivery of quality STI care (Magwaza 2002).

Providing integrated services allows the provider to maximize a clients entry into the health care system, and presents an opportunity to identify and treat RTIs (Chowdhury et al. 1999; Shelton 1999). A study in Côte d’Ivoire found that despite a lack of accurate tools to diagnose cervical infections, offering STI care at family planning clinics is justified by the large demand, the existence of an easily identifiable group of high-risk women, and the limited costs to the family planning program (Lafort et al. 2003). Once a client seeks care, there are still several steps to complete before an STI is cured (Buve et al. 2001). Although there is widespread belief that integrated services can better meet the reproductive health needs of clients and be cost-effective, there is little evidence that integration has achieved these goals (Dehne et al. 2000). There is also concern that as health care resources become more limited and the focus on integrated services increases, specialized STI/HIV services oriented to men may be eliminated (OFarrell 2001). For an overview of the rationales for the integration of reproductive health services, as well as several areas of concern, see Askew and Berer, 2003; Lush et al., 1999; and Mayhew, 1996.

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Involving the private and public sectors in STI control

There is growing consensus that the private sector must be involved in STI treatment and control if STIs and HIV are to be effectively controlled in developing countries (Mills et al. 2002). In many developing countries, private providers often are the first point of entry to services for people who suspect that they may be infected with an STI. Private providers also are an important source of follow-up care for those who previously received STI treatment in public clinics (Msiska et al. 1997; Banjarattanaporn et al. 1997).

Health-facility surveillance indicates that half of all STI patients attend private-sector providers (Brugha and Zwi 1998; Wilkinson 1999). Although largely unregulated, private-sector services—whether provided by qualified medical practitioners, pharmacists, traditional practitioners, or other types of health care providers—generally are perceived by their clients as being more accessible, confidential, and associated with a lesser degree of stigmatization than public-sector facilities. Low-quality public-sector STI clinics that face low staff morale, drug shortages, and formal or informal user charges may push treatment seekers toward the private sector (Brugha and Zwi 1998). Cost and access can be deterrents to treatment in both the private and public sectors (Dehne et al. 2002; Gibney et al. 2002).

While there may be a common perception that the quality of private-sector care is much better than public-sector care, experience has shown that quality of care in both of these settings is often inadequate. In one study in South Africa, only 9 percent of simulated patients in public-sector clinics received comprehensive management, and only 41 percent received correct drugs (Harrison et al. 1998). Another study in South Africa found that none of the prescriptions written in private-sector clinics matched those recommended by the provincial health department, and only 9 percent were judged likely to provide adequate therapy (Connolly et al. 1999). A study comparing public- and private-sector services in Nairobi, Kenya, found the quality of STI management was poorest in private clinics and pharmacies, and highest in public clinics equipped for STI care (Voeten et al. 2001). Nonetheless, another study in Nairobi showed that the majority of men and women were seeking care in the private sector (Voeten et al, 2004). A study of private-sector services in Uganda showed poor STI management in the for-profit and informal health sectors (Jacobs et al. 2004), and in Côte d’Ivoire both private and public services attended by female sex workers were inadequate (Vuylsteke et al. 2004).

Pharmacies are often the first point of contact for clients seeking private medical treatment for STIs, yet studies indicate the quality of care is often low. Studies of private pharmacies in Brazil and Vietnam found that none provided correct treatment (Ramos et al. 2004; Chalker, et al. 2000). In Mexico City, pharmacy personnel see many clients, but are unable to diagnose or offer appropriate STI advice (Turner et al. 2003). In Nepal, only 24 percent of medical shops dispensed the correct medication and dosage for treatment of urethral discharge and vaginal discharge (Bista et al. 2002). Similarly, studies in South Africa and The Gambia found that few pharmacy workers provided correct diagnosis and treatment for STIs (Ward et al. 2003; Leiva et al. 2001). However, training private service providers, especially pharmacy workers, can improve the quality of STI care they provide (Garcia et al., 2003; Chalker et al. 2002; Mackay et al. 2002; Leiva et al. 2001; Walker et al. 2001; Mayhew et al. 2001; Adu-Sarkodie et al. 2000), and can be cost-effective (Adams et al. 2003).

Recognizing the role of the private medical and pharmacy sectors in STI care does not imply that they should be promoted at the expense of the public sector. Rather, it is agreed that provision of effective and affordable public-sector STI services is, and should continue to be, the cornerstone of STI control (Brugha and Zwi 1999). At the same time, it is important to recognize that pharmacies and traditional health practitioners play important roles in STI treatment in the private sector (Kusimba et al. 2003; (Zachariah et al. 2002; Mayhew et al. 2001). Effective public-private health-sector partnerships for STI control in developing countries will require synergistic combinations of strategies, but can result in more effective and widespread STI treatment and control.

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