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Reproductive Tract Infections
Overview and Lessons Learned Program Examples Bibliography Links
Research Topics RTI Forum Glossary

Research Topics

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 research topics are included in the bibliography.

Assessing syndromic management

The usefulness of risk assessment

Best approaches to partner notification

Increasing adolescent access to RTI/STD services

Changing the behavior of service providers

Assessing the operational implications of integration

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Assessing syndromic management

The lack of accurate, affordable diagnostic tests hinders effective STD control in low-resource settings. In the absence of appropriate tests, WHO and other health agencies have promoted the use of syndromic STD 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 syndromic STD management guidelines (Steen et al., 1998). However, protocols based on symptoms cannot identify and treat asymptomatic cases; syndromic management of vaginal discharge for cervicitis presents special challenges in this regard as well as in sensitivity and specificity (Mindel et al., 1998). 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 (Mathews et al., 1998). To improve the effectiveness of syndromic management, sometimes a risk assessment component 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. However, one study in Malawi found that use of the syndromic approach resulted in more effective treatment of STDs 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 STD-related syndromes and can result in more cases receiving effective treatment (Bogaerts et al., 1995; Moherdaui et al., 1998)

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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/STD infection and thus in need of testing and treatment. For example, in 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 STD laboratory services or to guide contraceptive method choice. In a 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 (e.g., family planning and antenatal clinic attenders)  (Teles et al., 1997; Vuylsteke et al., 1993, Welsh et al., 1997). Risk assessment tools may be more effective when they are adapted to local conditions (Cates, 1997; Mindel et al., 1998; Bourgeois et al., 1998, Welsh et al., 1997). 

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Best approaches to partner notification

Reaching the partner(s) of an infected client is an important component of any STD program, but it also is one of the most difficult. 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. Some studies suggest that women being treated for STDs are more likely to refer their partners than are men (Steen, 1996; van de Laar et al., 1997), that concern for the unborn child may contribute to the success of referral in an antenatal setting (Desormeaux et al., 1996), and that steady partners are more often referred by index patients than casual partners (van de Laar et al., 1997). In establishing a referral system, each program must consider its patient population, the syndromes and diseases identified in the patients, the overall STD prevalence in the community, and the availability of laboratory diagnosis (Toomey et al., 1996) . The 1997 WHO Reproductive Health Library includes a summary of a 13-study meta-analysis of partner notification for STDs. The data allowed only limited conclusions; the value of providing simple forms of patient assistance directed at improving patient referral, such as telephone calls or follow up visits, was most strongly supported. The review also suggested that provider referral resulted in higher partner referral than patient referral for HIV infection; this conclusion was not as strongly supported for patients with syphilis, gonorrhea, or chlamydial infections.

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Increasing adolescent access to RTI/STD services

Because adolescents rarely visit primary health care or family planning clinics, they may be excluded when RTI services are integrated into existing clinics (Brabin et al., 1995). Reproductive health programs that seek to reach adolescents, who are at particular risk of RTIs, must develop special programs to address their needs. It is important to determine where adolescents want to go for information and treatment. Approaches that are innovative and specially designed for adolescents are most effective in bringing sexual and reproductive health services to this population (Population Action International, 1994) . Primary care facilities may designate youth days at their own facilities or provide services at multipurpose youth centers. Use of peer educators in youth groups may be an efficient way to provide information on prevention (Merati et al., 1997). Because of their unique position, primary health care providers play an important role in the prevention and control of RTIs, particularly STDs, among adolescents (Lappa et al., 1998). (For more information, see Outlook , Volume 16, Number 3.)

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Changing the behavior of service providers

Provider discomfort and unwillingness to counsel clients about sexual practices and reproductive tract infections is a barrier to integrating RTI and family planning services. Special training techniques often are necessary to ensure that providers can talk with clients about STDs in a helpful, nonjudgmental way (Wotton et al., 1996; Ghee et al., 1996). In addition, providers may resist using a syndromic approach and/or risk assessment instead of laboratory tests. Staff need to have a good understanding of the benefits of condom use (both for disease prevention and contraception), and they must be able to demonstrate correct usage. Program experience suggests that positive provider attitudes are key to successful integration (Kisubi et al., 1997).

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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 raise questions about the logistics systems supplying the clinics. In other words, integration may affect the national systems for demand projection, procurement, and warehousing of contraceptive commodities, drugs, and vaccines. For an overview of the rationales for the integration of reproductive health services, as well as several areas of concern, see Mayhew, 1996.

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