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RHO archives : Topics : Reproductive Tract Infections

Overview and Lessons Learned

Introduction

Reproductive tract infections (RTIs) include three types of infection that affect the reproductive tract of women and men (Population Council 2001). These are:

  1. Sexually transmitted infections (STIs)—also known as sexually transmitted diseases (STDs)—caused by viruses, bacteria, or parasitic organisms that are passed through sexual activity with an infected partner. More than 40 have been identified, including chlamydia, gonorrhea, hepatitis B and C, herpes, human papillomavirus, syphilis (Treponema pallidum), trichomoniasis, and HIV.
  2. Infections that result from an overgrowth of organisms normally present in the vagina (endogenous infections). These infections are not usually sexually transmitted, and include bacterial vaginosis and candidiasis.
  3. Infections introduced into the reproductive tract by a medical procedure (iatrogenic infections) such as menstrual regulation, induced abortion, IUD insertion, or childbirth. This can happen if surgical instruments used in the procedure are not properly sterilized, or if an infection already present in the lower reproductive tract is pushed through the cervix into the upper reproductive tract.

These three types of RTIs overlap and should be considered together. For example, some STIs, like gonorrhea or chlamydia, can be spread in the reproductive tract if not treated prior to a procedure. In addition, some non-sexual infections, such as candidiasis, can be passed on through sexual activity.

The global disease burden of RTIs, including STIs, is a major public health concern. In 1999, an estimated 340 million people were infected with a curable STI, such as gonorrhea (62 million), chlamydia (92 million), syphilis (12 million), and trichomoniasis (174 million) (WHO 2001). Non-sexually-transmitted RTIs are even more common. Nearly one million new cases of curable STIs occur each day. In 1999 there were 151 million new STI cases in south and southeast Asia (which represents nearly 44 percent of all new infections worldwide), 69 million in sub-Saharan Africa, and 38 million in Latin America and the Caribbean. Although South and Southeast Asia have the largest numbers of new cases of STIs, sub-Saharan Africa has the highest rate of new cases of STIs per 1,000 population. For more detail, please see the Country-specific Prevalence and Incidence Studies section of the Annotated Bibliography. An overview of selected curable STIs is available on the WHO website (www.who.int/emc-documents/STIs/docs/whocdscsredc200110.pdf).

HIV/AIDS is a non-curable sexually transmitted infection. In 2003, about 5 million people were newly infected with HIV, and an estimated 38 million people now live with HIV and AIDS. For more information about HIV/AIDS, please see RHO's HIV/AIDS section.

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Health risks associated with STIs

STIs are a major source of morbidity among women and men in developing countries. After maternal causes, STIs are responsible for the greatest number of healthy years lost to developing country women of reproductive age. Prevalence patterns suggest that infections are more frequent among urban residents, unmarried individuals, and young adults.

STIs are a serious health concern among adolescents (10-19 years) and young people worldwide; those aged 20-24 years face the greatest risk of infection. An estimated 5 percent of adolescents and young people contract an STI each year. For more information about adolescents, see RHO's Adolescent Reproductive Health section.

Serious long-term complications and sequelae of STIs in women, men, and newborns are well documented. It is now known that the presence of STIs, particularly ulcer-causing STIs, increases the risk of acquiring and transmitting HIV, the virus that causes AIDS (Fleming and Wasserheit 1999; Rowley and Berkely 1998; Grosskurth et al. 1995). The presence of an STI has been estimated to increase HIV transmission by three to ten times. For more information, see RHO's HIV/AIDS section (www.rho.org/html/hiv_aids_keyissues.html). In women, STIs can lead to pelvic inflammatory disease, infertility, chronic pelvic pain, tubo-ovarian abscesses, and ectopic pregnancy. STIs are also associated with particular types of cancer. Human papilloma virus (HPV) has been associated with the development of cervical cancer in women (for more information, see RHOs Cervical Cancer section). Untreated STIs in pregnant women can lead to spontaneous abortion, stillbirth, low birth weight, and gonococcal eye infections and congenital syphilis in newborns. In men, STIs can spread from the urethra to the epididymis, causing urethral stricture and infertility.

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Challenges to controlling RTIs/STIs

While not all RTIs are curable, they are all preventable. Prevention efforts aim to stop people from becoming infected, as well as to stop those infected from transmitting their infection to others (PATH 2001). Primary prevention focuses on educating people about personal risk and how to protect themselves from disease. Abstinence; consistent, correct condom use; mutually exclusive sexual relationships with an STI-negative partner; and early treatment of STIs are the most effective STI prevention options. Secondary prevention aims to shorten the duration of disease by promoting early detection and treatment, and providing acceptable, accessible, and effective care.

The key public health interventions needed to control STIs include:

  • Promotion of safer sexual behaviors and primary prevention.
  • Condom promotion, supply, and distribution.
  • Promotion of appropriate health care-seeking behaviors.
  • Integration of STI prevention and care into many existing health care services, including primary care, reproductive health care, HIV/AIDS prevention and treatment, and private-sector services.
  • Comprehensive syndromic case management.
  • Specific targeted services for high-risk groups.
  • Prevention and care of congenital syphilis and neonatal conjunctivitis.
  • Early detection and effective treatment of symptomatic and asymptomatic infections (Mayaud and Mabey, 2004).

Women have a greater risk of RTIs than men due to physiological, social, cultural, and economic factors. Women are:

  • biologically more susceptible than men;
  • usually infected at a younger age than men;
  • more likely to suffer from complications;
  • limited in their ability to protect themselves from high-risk sex or to negotiate condom use;
  • more apt to suffer from asymptomatic infections and remain untreated; and
  • less likely to seek treatment, even for symptomatic infections.

The consequences of RTIs, including stigmatization, reproductive impairment, domestic abuse, and abandonment, can be severe for women. Women have limited ways to protect themselves. Female condoms offer some protection and may be cost-effective, but their use will depend on how they are promoted and how well they are accepted (Zachariah et al. 2004; Francis-Chizororo and Natshalaga 2004; Yimin et al. 2003; Warren and Philpott 2003; FHI 2001; Marseille et al. 2001; Jivasak-Apimas et al. 2001). Due to its limited use, the impact of the female condom on STI prevalence has yet to be proven, but it appears to be at least as effective as the male condom (French et al. 2003; Feldblum et al. 2001). (For more information on female condoms, see the Female Barrier Methods page in RHO's Contraceptive Methods section.)

Microbicides are chemical or biological substances that women can use to protect themselves from STIs. They are the only prevention option for women that, theoretically, could protect against STIs while permitting pregnancy. They could also be combined with a spermicide for contraception. There are no microbicides currently available, but researchers are testing many promising compounds (Brown 2003; Roy et al. 2001; Coggins et al. 2000; Talwar et al. 2000; Kaiser Family Foundation 2001; Zaneveld et al. 2001). For more information, please see the Contraceptive Research and Development: Microbicides page in RHO's Contraceptive Methods section.) A study in Uganda found that women preferred vaginal products to the male condom because they had greater control over these products even if their use required negotiation with their partner (Green et al. 2001). However, potential barriers to microbicide use highlighted by a recent qualitative study in South Africa include women’s lack of power, the method’s limited effectiveness in preventing HIV, and the lubrication or “wetness” associated with the method (Becker et al. 2004).

Researchers also are developing vaccines against the most common infections, including HIV, herpes simplex, human papilloma virus, hepatitis C, gonorrhea, and chancroid (Fletcher 2001). A vaccine to protect against hepatitis B is currently available.

The prevention and control of RTIs/STIs in developing countries is complicated by:

  • Lack of awareness of the magnitude of RTIs and their consequences.
  • Limited and inaccessible health care services.
  • Overburdened and under-trained health care workers.;
  • Stigmatizing attitudes of policy makers, program managers, and health care workers toward marginalized groups.
  • Competition with other important health problems for limited resources.
  • Lack of supportive supervision.
  • Lack of screening or diagnostic tests.
  • Inadequate referral systems.
  • Iinadequate health information systems.
  • Limited preventive strategies.;
  • Inadequate preventive educational efforts, especially for youth.
  • Limited access to appropriate treatment drugs.
  • Difficulty in identifying and reaching infected persons.

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Dual Protection

Several contraceptive methods provide "dual protection"—that is, simultaneous protection against pregnancy and STIs, including HIV.

Family planning providers should counsel clients on the infection protection, if any, offered by various contraceptive methods . Although providers often have this knowledge, they do not always share it with their clients (FHI 2001). Providers play a key role in promoting dual protection (Morroni et al. 2003; Mantell et al. 2003; Adeokun et al. 2002). Currently, the most effective contraceptive methods (sterilization, hormonal methods, IUDs) provide little if any infection protection, while the barrier contraceptive methods that do protect against infection (such as male and female condoms) are less effective at preventing pregnancy in typical use.

Male condoms offer the best protection against STIs, including HIV, in men and women. Male condoms are effective against a variety of viral and nonviral STIs, including gonorrhea and chlamydia (Holmes et al. 2004; Warner et al., 2004; Shlay et al., 2004; Celentano, 2004; NIAID 2001). Female condoms may also provide protection, but more research is needed to confirm their effectiveness (FHI 2001). Diaphragms and cervical caps provide modest barrier protection against bacterial and some cervical viral infections; emerging evidence indicates that their preventive effects may be greater than previously thought, as the cervix appears to be a primary site of infection. Although the spermicide nonoxynol-9 was once thought to offer protection against some bacterial infections, meta-analysis indicates it provides no significant reduction in the risk of HIV and STIs. Moreover, there is evidence that it may cause harm by increasing the rate of genital ulceration (Wilkinson et al. 2003; Wilkinson et al. 2003; Roddy et al. 2002). Some hormonal contraceptive methods have been associated with an increased risk of cervical chlamydia, but are protective against symptomatic pelvic inflammatory disease (Morrison et al. 2004; FHI 2001). For more information on these methods, see RHOs Contraceptive Methods section.

Because the decision-making process for protection against infection and pregnancy is complex, providers should assist clients in assessing their likelihood of exposure to infection versus their likelihood of unintended pregnancy. Where exposure to infection is likely, especially to HIV, it may be most appropriate for providers to counsel clients to use condoms (Kleinschmidt et al., 2003). Where unintended pregnancy is of more concern, use of two methods (often called "dual method" use) may be appropriate (Cates and Steiner 2002; Cates and Spieler 2001).

For more information about dual protection, see RHOs Men and Reproductive Health, including the Inter-Agency Gender Working Group's theme statement on dual protection.

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Rationales for integrating RTI/STI services

The emergence of HIV and the identification of STIs as risk factors for the spread of HIV have led to a reappraisal of current RTI/STI control approaches in recent years. While efforts to control STIs historically have targeted high-risk groups (e.g., commercial sex workers), recent infection patterns have shown surprisingly high infection rates among groups considered to be at low risk (e.g., women attending antenatal clinics). Moreover, STI control efforts mainly have focused on secondary prevention approaches, such as diagnosis and treatment delivered in specialized health facilities that may not be acceptable or easily accessible to those in need.

The 1994 International Conference on Population and Development (ICPD), held in Cairo, emphasized integration of reproductive health services to meet the needs of clients, especially for STI prevention and care. The integration of RTI/STI services with other existing health services and programs often is advocated as a strategy for providing client-centered approaches to RTI/STI services and reproductive health care. The World Health Organization advocates linking STI services with HIV/AIDS services, including antiretroviral treatment (WHO 2003). Rationales for an integrated approach include:

  • Better meeting clients' needs through increased access to reproductive health care.
  • Broader outreach to underserved groups, including adolescents and men, by offering a range of clinical and preventive health services at one site.
  • Improved efficiency and effectiveness by minimizing duplication of services, maximizing scarce resources, and sharing facilities and staff responsibilities.

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Lessons learned

Programs in developing countries have demonstrated that integrating of RTI/STI prevention and control with existing health programs and services is feasible. RTI/STI services can be integrated at every level of the health care delivery system, ranging from the national level to the provincial and district levels to the service-delivery level. Although RTI/STI services commonly have been integrated with family planning services and programs, they can also be integrated with maternal and child health care services, primary health care clinics, school health programs, and HIV/AIDS prevention and control programs.

Lessons learned from efforts to integrate RTI/STI services with other health services include:

  • It is important to involve all interested parties, including providers, staff, and community members, in the design and implementation of the integration framework.
  • No one model of integration is universally effective: prevalence of disease, health-seeking behavior, and clinical capacity will determine the most effective prevention and treatment interventions in a given environment.
  • Clear, standardized service protocols and guidelines help ensure successful implementation of services.
  • Training in counseling and interpersonal communication skills can help providers openly discuss reproductive health issues with clients.
  • Training should be participatory and practical.
  • Supervision of providers at all levels is critical for continuing skill development.
  • Relying on clinical signs and symptoms for the diagnosis and treatment of RTIs (syndromic management), can be effective in resource-poor settings, although the sensitivity and specificity of some protocols (for example, for diagnosing chlamydia and gonorrhea in women) in some settings is low.
  • Collaborating with other institutions and providers can reduce the human and financial costs of implementing integrated services.
  • Making effective drugs affordable and available at the peripheral level is important for the efficient management of STIs.
  • Notifying partners of infected men and women helps STI services to reach at-risk individuals and offers opportunities to provide focused STI/HIV education.
  • Counseling about risk and helping clients choose appropriate family planning methods is an important element of any FP or STI program. (See RHO's Contraceptive Methods section.)
  • FP and reproductive health services can help prevent RTIs by promoting condoms, promoting safe-sex practices, and counseling to improve knowledge, change personal perceptions of risk, and influence behavior.
  • Improving STI control services can improve the quality of all services provided.
  • Targeted interventions to reduce STIs among certain groups, such as commercial sex workers or pregnant women, can improve the reproductive health of the larger community.

Further research is needed to determine how integrated services can best be delivered in various contexts, including within the framework of health sector reform, and to measure the impact of integrated services on indicators of health and behavior (Askew and Maggwa 2002; Foreit et al. 2002).

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