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RHO archives : Topics : Reproductive Tract Infections

Program Examples

The RTI programs described below illustrate some of the strategies that have been developed to overcome obstacles in integrating RTI/STI services with other health programs in low-resource settings, and outline the lessons learned from program experience.

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  • Indonesia: Meeting the needs of married women for HIV/STI services at the Lentera Project overcomes staff resistance.
  • Kenya (Population Council): Identifying RTIs among family planning and antenatal care clients in Nakuru, Kenya, is difficult; prevention is essential.
  • Nicaragua: Providing adolescent reproductive health services through franchises.
  • Uganda: Expanding family planning programs to include HIV/STI services in Busoga Diocese requires community support and provider training in counseling and interpersonal skills.
  • Zimbabwe: Screening for RTIs among family planning clients is not cost-effective.

Indonesia

In an effort to control the impact of HIV/AIDS, the Indonesia Planned Parenthood Association (IPPA) chapter in Yogyakarta started a comprehensive HIV prevention project (the Lentera project) at its family planning clinic in 1993. The project added several programs to the clinic's usual services (which include counseling, menstrual regulation, infertility treatment and sexual health education) including a street outreach program to female sex workers. Evaluation of the project at one year revealed that many sex workers were more interested in sexual health issues such as STIs and infertility than in HIV/AIDS.

To better address the needs of the project's clients and increase their involvement in project activities, the Lentera project added STI services (including counseling, information and materials on STIs and their treatment, diagnosis and treatment of selected STIs, and free condoms) to the range of reproductive health services already offered at the clinic. STI services for female sex workers began in March 1995; funding for the STI management services was provided by PATH (www.path.org).

At first there was resistance to adding STI services to the clinic, primarily related to concerns that existing services would be stigmatized if STI services are offered alongside family planning services. There also was concern that serving sex workers would tarnish the clinic's reputation. Lentera staff dealt with these concerns by scheduling hours for STI services outside of regular clinic hours and physically separating the exam rooms for STI patients and regular clinic patrons.

In mid-1995, there was discussion of expanding STI services to regular clinic patrons, primarily married women who used the clinic's family planning services. This idea was met with resistance from the IPPA's board and the clinic's gynecologists. After months of discussion, it was agreed that the clinic would offer general STI services provided that:

  • nurses conducted exams and took samples for lab tests in a separate examination before the doctors met with the patient;
  • the STI lab results were kept separate from the intake folder used by gynecologists;
  • counselors informed patients they had a "reproductive tract infection" (RTI) instead of a "STD";
  • men were not informed of their wife's infection; and
  • the price of menstrual regulation did not increase for the patient.

Activities taken in preparation for providing STI services to married women included:

  • designing new patient intake and lab forms for use in STI treatment and diagnosis
  • training additional nurses in STI syndromic approach, how to record observations made during the STI examination, and how to interpret lab test results
  • training counselors about STIs and their treatment and teaching them discuss tests for RTIs as part of informed consent
  • designing educational pamphlets about RTIs and making them available in the clinic waiting room

Lessons Learned

The project provided the following lessons learned for integration of STI and family planning services:

  • Strong commitment and motivation among project staff are crucial to the project's success by facilitating implementation of project services and their integration with existing services.
  • Provision of STI services is an important component of efforts to control HIV/AIDS.
  • With training and supervision, nurses and counselors can be effective in providing diagnosis and treatment of STIs.
  • Phasing in provision of STI services within clinics allows clinic staff time to make adjustments to its systems before fully integrating the services.
  • Collaboration with local organizations and institutions helps ensure sustainability of project services and reduce cost.
  • Though barriers to integration of services exist, integration of STI services with family planning services is feasible.

For more information, please contact: Dr. Budi Wahyuni, Director, IPPA Yogyakarta, Jl. Tentara Rakyat Mataram, Gang Kapas - Badran, Yogyakarta 55231, Indonesia
Telephone: 62-274-586767; Fax: 62-274-513566; Email: [email protected]

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Kenya (Population Council)

Since 1990, the Nakuru Municipal Council has implemented a broad program to address reproductive tract infections, with an emphasis on those that are sexually transmitted. Staff at the Population Councils five health clinics received training in syndromic management of STIs, and a reference laboratory was established at one clinic. Community education activities have included a peer-education program for commercial sex workers, and IEC activities for in-school youth and for factory workers.

In 1998, the Population Council conducted a study to evaluate the accuracy of syndromic management at the clinics and to determine the best ways to integrate RTI services into existing antenatal care (ANC) and family planning (FP) services. A case study was undertaken in 1995, five years after initiation of the integrated program, to assess the current state of integrated services. This study found:

  • Staff did not routinely perform STI/HIV risk assessment of clients, nor did they have appropriate risk assessment check lists.
  • Staff used diagnostic algorithms developed for STI clinics, but not adapted for ANC/FP services.
  • Most facilities lacked some basic equipment and supplies required to provide quality services.
  • No cost analysis or effectiveness studies had been done to help direct sustainable services.

After the case study, equipment and a risk-assessment checklist were provided, staff received training in counseling, and plans were made for an operations research (OR) study to improve management of STIs.

The OR study collected data in 1998 from clients attending the five Nakuru Municipal Health Clinics. This included findings from clinical exams, risk factor information obtained from a checklist, and laboratory test results. These data showed:

  • 50 percent of FP clients and 59 percent of ANC clients had at least one RTI according to laboratory testing.
  • 14 percent of FP clients and 21 percent of ANC clients had one or more STIs.
  • Vaginal infections were more common than cervical infections.
  • Most women with an RTI were asymptomatic: 23 to 29 percent of those with an RTI reported one or more symptoms, and 37 to 43 percent of infected clients were found by a provider to have clinical signs.
  • Syndromic management identified a small proportion of those actually diagnosed with an RTI by laboratory testing (5 percent of FP clients, and 16 percent of ANC clients).
  • Syndromic management guidelines were more likely to correctly identify women with vaginal infections than cervical infections.
  • Collecting STI risk information from clients did not significantly improve providers ability to identify women with cervical infections.

These results confirm the limited effectiveness of syndromic management of STIs, and the need to focus on primary prevention of STIs. At workshops following the conclusion of this study, participants agreed on the following recommendations:

  • Focus on prevention. Given the problems with syndromic management, more emphasis should be put on preventive approaches. This includes condom promotion, IEC activities, counseling, and raising awareness about STIs.
  • Improve IEC for STIs/HIV. The discrepancy between clients reporting of signs and symptoms and the clinical findings suggest clients have limited knowledge of STI/HIV signs and symptoms. Providers can be trained to educate their clients in the identification of symptoms.
  • Emphasize clinical exams. Providers identified more women with RTI-related signs and symptoms than were reported by the women themselves. In addition, the providers and the clients reported they were comfortable with the exams. More FP/ANC clients should receive routine clinical exams.
  • Encourage use of standardized checklists. The checklists used in this study enabled providers to identify more clients with signs and symptoms of STIs.
  • Review partner notification strategies and educate the community that not all RTIs are sexually transmitted.
  • Emphasize effective treatment of vaginal infections (bacterial vaginosis, trichomoniasis), which are more common than gonorrhea and/or chlamydia in this population and have potential serious health effects.
  • Continue use of syndromic management in the absence of anything better.

For more information about this project, please contact:
The Population Council, P.O. Box 17643, Nairobi, Kenya.
Telephone: 254-2-713-480; Fax: 254-2-713-479: Email: [email protected]

See also: Kariba, W.J. et al. Integration of STI and HIV/AIDS Services with MCH-FP Services: A Case Study of the Nakuru Municipal Councils Project on Strengthening STD/AIDS Control. Nairobi, Kenya: Population Council, Africa OR/TA Project II (1997).

Solo, J. et al. Improving the Management of STIs among MCH/FP Clients at the Nakuru Municipal Council Health Clinics. Nairobi, Kenya: Population Council, Africa OR/TA Project II (1999).

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Nicaragua

Sexual activity begins at an early age in Nicaragua, where one in every four children is born to a mother under age 19. Adolescents are especially vulnerable to sexually transmitted infections, including HIV. Marie Stopes International (MSI) tested a new "social franchise" model for bringing reproductive health services to adolescents. The Adolescent Social Franchise project was established in Nicaraguas capital, Managua, in 1998 with two years of funding from the Innovations Fund of the UK Department for International Development (DFID).

MSI worked with the local organization, Instituto Centroamericano de Salud (ICAS, the "franchiser"), to provide clinic equipment, services, and IEC training to five organizations already working with low-income adolescents. These five "franchisers," three nongovernmental organizations, an evangelical church, and a University, contributed project space and organized IEC activities in the community. ICASs staff provided medical and psychological services at clinics established in each youth organization. IEC activities included sexuality education talks and trainings, youth promoter training, and theater and community outreach by the youth. Adolescents were also trained in service administration to enable them to manage the services themselves in the future. After one year, a mid-term evaluation found more flexibility was needed in the model to take advantage of the various strengths, resources, and needs of the youth organizations:

  • Two of the NGO franchisees shifted IEC coordination and service provision to the franchiser (ICAS), while the youth did IEC and marketing.

  • Another NGO established a mobile clinic to allow IEC and services to be provided at a number of activity centers run by the NGO.

  • Service provision and promoter training at the community-based clinic at the evangelical church were carried out by ICAS, and other activities were undertaken by the church and youth promoters.

  • A private franchise (run by a doctor and psychologist) was established at the University (income was split with ICAS), and university youth did IEC. The university decided not to take on the role of franchisee.

  • Mobile IEC and services were established by ICAS to respond to requests from non-franchised NGOs.

The project achieved its goal of setting up and testing a new model of youth reproductive health services. During an 18-month period, more than 18,000 people were reached with IEC, and more than 3,000 people used clinical services (2,100 medical visits and 900 psychological consultations). There was a significant impact on adolescents knowledge and attitudes toward sexual and reproductive health. The project generated income, mainly from non-adolescents who had access to services.

Lessons Learned

Many of the lessons learned from this project can be used to improve other adolescent reproductive health projects:

  • IEC and service delivery models need to be flexible and meet the needs of particular groups.

  • Service delivery staff need to have experience and be sensitive to adolescents.

  • IEC activities must be participative and fun.

  • Psychological services are essential for low-income adolescents who live in a violent and abusive environment.

  • Provider personality and high-quality provider interactions are more important to adolescents than technical quality.

  • Services must ensure privacy from adult community members.

  • Project design must maximize adolescent participation but not make unrealistic demands on their time.

  • Youth promoters should receive a stipend to enable them to devote time to promotional activities.

  • Franchisee organizations should have sufficient resources and familiarity with health.

  • Individuals in counterpart organizations should have decision-making power and enthusiasm.

  • The project time span should allow full development of project activities and time to gain the confidence of participants.

While this project ended in 2000, the program is implementing a similar adolescent reproductive health project without the franchise emphasis. It is also implementing four franchised reproductive health centers aimed at low-income populations.

For more information, please contact:
Claire Morris, Regional Director for Latin American Programmes, Marie Stopes International, 153-157 Cleveland Street, London W1T 6QW, United Kingdom
Telephone: 44-20-7574-7422; Fax: 44-20-7574-7419; Email: [email protected]; Web address: www.mariestopes.org.uk

Also see:
Braddock, M. and Morris, C. Social Franchising of Adolescent Reproductive Health Education and Services—Nicaragua. Final implementation report. London: Marie Stopes International (2000).
Smith, E. Social Franchising Reproductive Health Services. Can it Work? A Review of the Experience. Marie Stopes International Working Paper 5. London: Marie Stopes International (2002).

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Uganda

In response to the threat of HIV and STIs, the Family Planning Education Program (FLEP) launched a project to integrate STI/HIV services into its family planning program in Busoga Diocese, Uganda in 1992. Program managers and service providers worked with the community to identify and respond to health and program needs.

Several potential problems were identified, including: a shortage of well-trained service providers; provider biases, such as not providing services to adolescents and clients with STIs; contraceptive method preferences; and shortage of equipment and drug supplies for STI diagnosis and treatment. FLEP responded by training existing staff, developing appropriate IEC materials and activities, developing a risk assessment checklist, establishing an HIV testing system, designing mechanisms for treatment of complications, and improving clinic facilities.

The project's integration model include the following key service delivery components:

  • STI/HIV risk assessments for all clients receiving MCH/FP services from clinics in the project area.
  • STI/HIV screening of all clients receiving MCH/FP services using a diagnostic checklist.
  • Identification and referral of clients for HIV testing.
  • Diagnosis and treatment of clients with STIs using syndromic management.
  • IEC materials and activities (such as public meetings, seminars, plays, songs, and school programs) to inform and educate all clients, in-school youths, and persons living in the Busoga Diocese about STIs and HIV/AIDS.

The project's accomplishments include:

  • Village health workers (VHWs) are providing information on STIs and HIV/AIDS to all their MCH/FP clients.
  • The community has recognized the important role of VHWs in informing the public about STIs and HIV/AIDS. VHWs are invited to address church and other public gatherings whenever possible.
  • Demand for project services has increased: the number of clients seeking STI services rose 230 percent between 1994 and 1995.
  • More people are using condoms to prevent STI/HIV transmission: condom distribution nearly doubled from a quarterly maximum of 55,000 in 1992, to 107,000 in 1993, to more than 113,000 in 1994.

Several challenges arose during the implementation of the project:

  • Because of traditions and cultural attitudes, health workers found it difficult to discuss sexual behavior with clients, especially if they were relatives. Staff members have decided to refer relatives to a colleague.
  • The lack of national standardized guidelines for the management of STI/HIV makes it difficult for the project to standardize its own protocols. A limited range of STI drugs is available and treatment regimens vary from clinic to clinic because drug purchases depend on provider requests and resources available.
  • Transportation problems and treatment costs have made it difficult to establish a referral network for treating complicated STIs.
  • Partner notification and promotion of dual method use are difficult because socio-cultural barriers discourage women from initiating discussions about sexual matters with their partners.

Lessons Learned

Lessons learned from FLEP's experience in integrating STI/HIV services are:

  • Service providers' openness and willingness to discuss reproductive health issues must be accompanied by training to improve counseling and interpersonal communication skills.
  • Effective counseling and interpersonal communication skills on the part of service providers and staff are essential to promoting family reproductive health.
  • To be successful, programs must reach beyond traditional clients to underserved community members, especially adolescents and men.

For more information, please contact: Peter Savosnick, Chief of Party, Pathfinder International, DISH, Plot 20 Kwalya Close, Kololo, Kampala, Uganda
Telephone: 256-41-244-075; Fax: 256-41-250-124

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Zimbabwe

In 1998, the Zimbabwe National Family Planning Council (ZNFPC) conducted an operations research (OR) study to assess the possibility of adding diagnosis and treatment of reproductive tract infections (RTIs) to its range of services. They conducted a baseline survey to determine how prepared NFPC staff and clinic facilities were to provide integrated family planning (FP) and RTI services. As a result of this survey, ZNFPC made the following changes:

  • Clinic staff received a training update on using syndromic management to diagnose and treat RTIs.
  • A checklist was created to facilitate history taking, clinical exam, counseling, and risk assessment.
  • Strategies for ensuring drug availability were developed.

The second phase of the study involved examination of 1,634 women attending three ZNFPC clinics (Mpilo, Lister-Bulawayo, and Spilhaus). In addition to receiving clinical exams, the women were questioned using a standardized checklist, and specimens underwent laboratory testing. The data gathered showed:

  • One-third of family planning clients had at least one of the five RTIs tested in the study.
  • Most of the RTIs diagnosed were not sexually transmitted; 26 percent of clients had an RTI (candida, bacterial vaginosis), and 9 percent of family planning clients had at least one STI (gonorrhea, trichomoniasis, chlamydia).
  • Behavioral risk factors were uncommon among these clients.
  • Few clients considered themselves at risk for RTIs.
  • More than half of clients had experienced symptoms of a RTI in the 12 months prior to the study.
  • More than a third of clients diagnosed by laboratory test as having a RTI showed no symptoms.
  • Almost half (47%) of the family planning clients diagnosed with a RTI according to syndromic management did not actually have one of the five RTIs tested for in the laboratory.
  • Service providers did not always follow syndromic management guidelines.

The study also evaluated the relative cost-effectiveness of four RTI diagnostic models. None of these proved affordable to programs in low-resource settings like Zimbabwe.

  • The lowest cost screening intervention uses the syndromic approach only for family planning clients seeking RTI services (US$2.48 per client). However, according to this strategy, 75 percent of women with RTIs remained undiagnosed, and 56 percent of those treated were misclassified as infected and received unnecessary treatment.
  • Using laboratory testing increases diagnostic accuracy, but at great cost. Laboratory testing of all family planning clients cost US$25.77 per client. This would equal 20 to 55 percent of the available per capita expenditure on health care in Zimbabwe.

Due to the ineffectiveness of the syndromic approach to identifying women with RTIs, and the expense of currently available laboratory tests, there is great need for simpler and more cost effective laboratory tests. Until such tests are developed, greater efforts are needed to reduce unsafe and unprotected sex, promote condom use, counsel clients on personal risk, and educate about safer behaviors.

For more information on this study, please contact:
The Population Council, P.O. Box 17643, Nairobi, Kenya.
Telephone: 254-2-713-480; Fax: 254-2-713-479; Email [email protected]

See also: Maggwa, N et al. Demand for and Cost-effectiveness of Integrating RTI/HIV Services with Clinic-Based Family Planning Services in Zimbabwe. Harare, Zimbabwe: Zimbabwe National Family Planning Council (1999).

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