Controlling sexually transmitted diseases – includes related articles
Robert Lande
While AIDS seizes the headlines, other sexually transmitted diseases (STDs) create devastation of their own. In women STDs can lead to pelvic inflammatory disease, causing lifelong pain, infertility, and ectopic pregnancy, which can kill. Children are born with blinding eye infections. Men are left infertile. People die of advanced stages of syphilis. Furthermore, STDs multiply the transmissibility of HIV, the AIDS virus, as much as ninefold.
STDs are nearly as common as malaria–more than 250 million new cases each year, at least one million of which will be HIV infection. Some developing-country family planning, antenatal, and maternal and child health clinics find that as many as 1 or 2 women in every 10 are infected with an STD.
The Syndromic Approach
Many health care providers lack time or equipment to diagnose STDs with laboratory tests, and many patients may not return for test results. Therefore providers often diagnose based on clinical judgment, and often they are wrong.
The syndromic approach to STD patient management, which bases diagnosis on a group of symptoms and treats for all diseases that could cause that syndrome, could make diagnosis more accurate without extensive lab tests and allow treatment with a single visit. Combined with better drug supply, the approach could make STD services more widely available through primary care clinics. The World Health Organization, working with STD experts, has developed step-by-step procedures, leading from presenting symptoms through diagnosis to treatment, to help providers use the syndromic approach. A chart published with this issue of Population Reports offers guidelines for syndromic case management, both with and without a microscope or other laboratory tests.
Beyond Diagnosis and Treatment
Effective clinical services are the heart of STD control programs. A full-fledged STD control program also requires:
* A structure to support STD services in primary health centers.
* A reliable drug supply.
* Referral clinics.
* Epidemiologic surveillance to identify the most prevalent STDs and to track the effectiveness of various antibiotics.
* Primary health care providers who “think STDs,” watch for their signs, counsel those at risk of STDs, and treat or refer those who are infected.
* Training suited to each practitioner’s role in STD services.
* Condoms, readily and cheaply available and heavily promoted to the public. In addition, women urgently need more effective barrier methods that they can control.
* Counseling to help STD patients understand their illnesses, take medication correctly, and prevent future infections. Women often need special help to protect themselves.
* Mass-media communication to alert people to STDs, encourage them to seek treatment, promote condoms, and support mutual monogamy.
* Methods of notifying the sexual partners of STD patients so that they, too, can be treated.
What Role for Family Planning Programs?
Family planning providers can help prevent STDs by promoting and supplying condoms and spermicides and by counseling clients. Also, providers need to assess clients’ risk of STDs, especially if they want intrauterine devices. Many programs want to do more. At the least, they can ask clients about STD symptoms and refer them elsewhere for diagnosis and treatment. More difficult but more valuable is screening every client, since STD infections often produce no immediate symptoms in women. A few programs diagnose and treat STDs. STD prevalence and program resources vary, and each family planning program must decide how it can help.
Most STDs can be treated. All can be prevented. STD programs have reduced spontaneous abortion due to syphilis in Zambia, made gonorrhea a rarity in Sweden, and avoided thousands of AIDS cases in Kenya by preventing other STDs. Similar successes around the world require a commitment to making STD prevention and treatment widely available.
The Toll of STDs
Sexually transmitted diseases (STDs) are everywhere. Gonorrhea, syphilis, and now AIDS are the most widely known, but there are more than 20 other STDs. On average an estimated 685,000 people are infected every day with an STD. Every year there are about 250 million new cases, nearly as many as of malaria [137] (see Figure 1).
The consequences of STDs can be devastating: infants, infected at birth, with blinding eye infections or pneumonia; women suffering chronic abdominal pain, ectopic pregnancy, or infertility; and men with infertility. Women may suffer social consequences as well: telling a husband about an infection may lead to beatings and divorce, and husbands may abandon infertile wives. Syphilis can maim or kill infants, and it kills adults as well, sometimes years after the initial infection. Indirectly, STDs also kill through spontaneous abortion, ectopic pregnancy, and cervical cancer.
Recent evidence reveals that common STDs contribute to the spread of AIDS. Infection with chancroid, chlamydia, gonorrhea, herpes, syphilis, trichomoniasis, or the less common STDs Donovanosis (granuloma inguinale) and lymphogranuloma venereum makes a person more likely to become infected with human immunodeficiency virus (HIV) if exposed to the AIDS-causing virus through sexual contact (see box, p. 6). Neglected for many years, programs to diagnose, treat, and prevent these STDs are now becoming an important component of AIDS prevention programs.
The Extent of STDs
The high incidence of STDs among women attending antenatal, family planning, or gynecological clinics indicates the extent of the STD problem. For example, in studies in developing countries up to 18% of these patients have gonorrhea, up to 17% have syphilis, and up to 30% have trichomoniasis (see appendix table, p. 31).
Sexually transmitted diseases are a major public health problem in both developed and developing countries, but prevalence rates apparently are far higher in developing countries, where STD treatment is less accessible. Among women, syphilis prevalence rates may be 10 to 100 times higher in developing countries; gonorrhea rates may be 10 to 15 times higher; and chlamydia rates may be 2 to 3 times higher [315]. Incidence rates also are higher. For example, the annual rate of new gonorrhea infections in large African cities is 3,000 to 10,000 per 100,000 population, or as many as one in every 10 people. By comparison, in the US the annual incidence of gonorrhea was 233 per 100,000 population in 1991, and in Sweden, about 30 per 100,000 in 1987 [11, 68, 305].
Among developing regions STDs appear to be more common in Africa than in Asia or Latin America. In a review by Judith Wasserheit, a median of 20% of women attending family planning, antenatal, or other clinics in Africa had trichomoniasis, for example, while the median prevalence in Asian studies was 11% and in Latin American studies, 12% [313].
Youth have high rates of STDs [28, 73, 101, 174, 212, 307, 326]. In a study at Kenyatta National Hospital in Nairobi, for example, 23% of women ages 15 to 19 seeking antenatal care had gonorrhea, chlamydia, or herpes [174]. In the US women ages 15 to 19 have the highest incidence of gonorrhea, and men ages 15 to 19 have the second highest incidence of any age group [305].
In many countries clinic surveys are the best available indicators of STD levels. The true extent of STDs in the general population remains unknown for several reasons:
* Both men and women may suffer from asymptomatic STDs, but women more so than men. For example, 70% of women and 30% of men infected with chlamydia may be asymptomatic as well as 30% of women and 5% of men infected with gonorrhea [132, 309].
* Many people with STDs do not seek care, and in developing countries people are not routinely screened for STDs when they seek other health care.
* Because of the stigma attached to STDs, many people seek care from providers who do not report cases.
* Some governments are reluctant to admit to a high prevalence of STDs. The AIDS epidemic is beginning to change this attitude, however.
The few studies in developing countries report mixed trends. For example, between 1987 and 1991 in 15 of 21 Latin American countries, the incidence of gonorrhea decreased, while in 12 countries the incidence of primary, secondary, or congenital syphilis increased [338].
Evidence from developed countries also shows mixed trends. The incidence of chlamydia is increasing in North America and some European countries [282]. Chancroid and primary syphilis are becoming more common in the US [97, 270]. In contrast, the incidence of gonorrhea has been decreasing in Canada, Sweden, the UK, and the US, and the incidence of primary syphilis has decreased in Sweden [11]. [TABULAR DATA OMITTED]
Complications and Sequelae
STDs take their greatest toll through their sequelae–conditions resulting from the spread of STD pathogens (bacteria or viruses, for example) from the point of infection to another part of the reproductive tract or another part of the body. Chlamydia, gonorrhea, and syphilis can have severe sequelae (see Table 1). Human papilloma virus may cause cervical cancer 5 to 30 years after the initial infection [273].
Some sexually transmitted diseases threaten the fertility of both men and women. In women STD pathogens migrate up from the lower reproductive tract, causing pelvic inflammatory disease (inflammation of the uterus, fallopian tubes, ovaries, or other pelvic structures), chronic pelvic pain, and infertility (See Figure 2). Sexually transmitted diseases, mainly chlamydia and gonorrhea, cause most cases of pelvic inflammatory disease [249, 321]. An estimated 8% to 20% of women with untreated cervical gonorrhea develop pelvic inflammatory disease [79, 145, 320]. In a Swedish study begun in 1960, one of the largest studies of pelvic inflammatory disease, 18% of women with pelvic inflammatory disease had chronic pelvic pain compared with about 5% of women who had not had pelvic inflammatory disease [321]. Often the first symptom that women with chlamydial infection notice is the pain of pelvic inflammatory disease. At that point any damage to the fallopian tubes is irreversible.
Pelvic inflammatory disease can cause infertility. Without treatment 55% to 85% of women with pelvic inflammatory disease may become infertile [321]. In some areas pelvic inflammatory disease is a common cause of women’s infertility. In a study in Zimbabwe 84% of 135 infertile women with abnormal fallopian tubes had a history of pelvic inflammatory disease [67]. Many women may lose their fertility without ever realizing that they had pelvic inflammatory disease. For example, in 14 studies of women with blocked fallopian tubes, 40% to 80% did not report that they had had pelvic inflammatory disease [197].
STDs also can increase a woman’s risk of ectopic pregnancy, a condition that can kill from sudden and severe internal bleeding when the out-of-place pregnancy ruptures the fallopian tube. Studies in the 1980s in developing countries found that ectopic pregnancy caused 1% to 15% of all maternal deaths [189]. Pelvic inflammatory disease, by permanently scarring and narrowing the fallopian tubes, increases the risk that a pregnancy will be ectopic by 7- to 10-fold [321]. A US study found that genital chlamydial infection more than doubled a woman’s risk of having an ectopic pregnancy [52].
In men infertility may follow an infection that spreads from the urethra (where it is described as urethritis) to the epididymis (epididymitis) (see Figure 2). In men under age 35 the most common cause of epididymitis is gonorrheal or chlamydial infection [26]. Before antibiotics became available, 10% to 30% of men who had gonorrhea developed epididymitis, and 20% to 40% of men with epididymitis became infertile [220].
Some STDs attack the fetus and infant. In two-thirds or more of pregnant women with syphilis, the infection spreads to the amniotic sac and infects the fetus [334]. About 40% of infected pregnancies end in spontaneous abortion, stillbirth, or perinatal death [68]. Gonorrhea or chlamydia may spread to the eyes of babies as they pass through the cervix and vagina. Without preventive therapy 2% to 50% of infants exposed to the gonorrhea-causing bacteria Neisseria gonorrhoeae during birth develop eye infections (ophthalmia neonatorum) [109, 151, 255]. In a number of developing countries ophthalmia neonatorum afflicts 5% of newborns [191]. Without treatment ophthalmia neonatorum permanently damages the vision of 1% to 6% of affected infants [88, 229]. Chlamydia also may spread to the lungs of newborns and lead to chlamydial pneumonia.
Economic Costs
Sexually transmitted diseases and their sequelae are costly to individuals and the health care system. Many people with STDs seek care from private providers, where they may pay one-quarter to one-third of their monthly earnings for drugs [162, 198]. Also, STDs reduce the productivity of men and women in the prime of their lives. For example, in urban areas of sub-Saharan Africa with a high prevalence of STDs, syphilis causes the loss of an estimated 9 productive days per capita per year for the entire urban population; HIV infection leads to the loss of 48 days [215].
Clinics and hospitals must devote much of their time and resources to patients with STDs. In a province of Mozambique, for example, 10% to 15% of visits to primary health clinics are for STD treatment [21]. In reports from sub-Saharan Africa pelvic inflammatory disease accounts for 17% to 40% of gynecological admissions to hospitals; in Asia, 3% to 37% [189].
Reducing the Toll of STDs
Timely and effective care for STDs can reduce their toll by preventing transmission and sequelae. To provide care for the most people, STD services need to be widely available. Several steps are important:
* Adopting a quick, simple, and effective way to diagnose and treat STDs. Microscopes and laboratory tests permit specific diagnosis. Many health care providers lack equipment or time to await test results, however. They manage STD patients by relying on symptoms (what the patient notices) and easily observable signs (what the provider notices). Often STDs can be identified by syndromes (groups of symptoms). The syndromic approach to case management, now being promoted by the World Health Organization (WHO), gives providers a systematic way to use this information (see p. 9).
* Making effective services accessible. Most important is offering STD services in primary health centers, which serve the most people. The syndromic approach can help primary health care providers to diagnose STD patients. At the same time, primary health care providers need help and support from STD experts in district and provincial hospitals and in national STD centers. Such support includes ensuring a steady supply of drugs, training, managing difficult cases referred by the primary care providers, and conducting surveillance of STD prevalence. Training private providers also would help to make STD services more accessible (see pp. 13-19).
* Getting people with STDs to treatment. There are a variety of approaches: mass-media communication to alert people and inform them about STDs, screening people for STDs when they seek health care for other reasons, notifying the sexual partners of STD patients that they should seek treatment, and setting up special programs for high-risk populations (see pp. 19-25).
* Encouraging people to avoid STDs by following what Philippine health secretary Juan Flavier calls the ABCs of safe sex: “A for abstinence. If you can’t abstain, B for be faithful, and if you can’t be faithful, then use C for condoms” (see pp. 25-27). Effective and accessible STD service providers have made a difference in STD control. For example, in Zambia the national STD program reduced the number of new STD cases at University Teaching Hospital in Lusaka from about 18,000 in 1985 to about 5,000 in 1991 [290]. The number of spontaneous abortions due to syphilis during pregnancy also has declined. In Sweden providers have helped to make gonorrhea a rare disease. In Nairobi an estimated 6,000 to 10,000 people have avoided HIV infection because of the work of an STD prevention program (see Table 2).
Managing STDs
Effective management of STDs, as of most diseases, requires that patients and health care providers cooperate in a series of steps leading to a cure:
1 Obtaining information: Providers ask questions about patients’ health and sexual activity; patients answer questions completely and truthfully.
2 Performing a physical examination: Patients are willing to be examined; providers check patients for signs of STDs.
3 Diagnosing and treating patients: Providers know the signs and symptoms of STDs and have the right drugs to treat them; patients can obtain the drugs, and they take the full course as directed.
4 Counseling: Providers counsel patients to cure the current infection and prevent reinfection; patients follow the counseling advice and help get their sexual partners treated.
Obtaining Information
Information about patients’ health and sexual activity can help providers identify symptoms that may be caused by STDs. For example, if a patient has vaginal discharge, such information can help a provider assess the likelihood that she has an STD. If her sexual partner also has STD symptoms or if she has had more than one partner in the previous four weeks, she is likely to have an STD. Questions about sexual activity, such as these, are often the first step in screening people for STDs when they seek health care for other reasons (see pp. 21, 24). Also, asking questions about sexual activity gives providers an opportunity to explain STD transmission and prevention and to begin counseling. For example, providers should ask STD patients if they use condoms when they have sex. Patients who say that they do not use condoms or do not use them regularly should be counseled at that point. [TABULAR DATA OMITTED]
Providers may hesitate to ask about sexual activity, and patients may hesitate to answer. Often overworked, providers may not have the time to question patients fully, to reassure them, or to explain the reasons for their questions. Also, they may be uncomfortable talking about sex. Patients may fear that what they say will be revealed to others. To protect sexual partners, they may withhold information. Also, patients may feel intimidated by providers because of differences in social status or language. They may fear that providers will criticize them, or they may not understand what the provider is asking or why. Indeed, such questioning may discourage people with STD symptoms from seeking care.
Thus providers need to question patients with sensitivity and tact. To obtain a good sexual history, providers:
* Greet patients warmly and with respect.
* Find a private place to talk. Some clinics have private rooms. Where that is not available, others use movable partitions or find a secluded place out-of-doors to talk.
* Assure patients that all information is kept confidential–and make sure that it is.
* Practice asking questions to become accustomed to using sensitive language. Role-playing exercises help.
* Put patients at ease at the start by asking questions that are easy to answer.
* Speak a language in which patients can talk as easily as possible about sexual issues. Use words that patients understand. Discussion with groups of patients can help providers learn how people talk about sex and STDs [253].
* Give complete attention to each patient.
* Ask patients’ permission to bring up personal questions. Avoid dwelling on a sensative subject if patients are reluctant to answer. By bringing up the subject first, the provider allows and encourages patients to talk about it later [8].
* If possible, arrange for a provider of the same sex as the patient. If this is not possible, acknowledge that men and women do not usually discuss such personal issues. US studies find that female patients disclose more symptoms to and obtain more information from female than male obstetrician-gynecologists [318].
The Physical Examination
The physical exam allows providers to confirm the symptoms described by patients and, if possible, to check for signs of STDs. The extent of the exam depends on the space, equipment, and time available to the provider and on the patient’s willingness to be examined. Lacking a private space, gloves, or time, many providers cannot examine patients at all. Also, patients may refuse to be examined even after counseling about what will happen and why it is important. Fear of a physical exam, like fear of questions about sexual behavior, keeps some people away from care. To avoid raising anxiety, providers may decide not to do a physical exam or to observe patients rather than perform a more invasive exam.
The physical exam can be conducted at several levels, each providing more information for a diagnosis:
* Syndromes only. Providers without gloves simply observe patients. Providers with gloves can examine patients more thoroughly. Many primary care providers using the syndromic approach are limited to this level of exam.
* Syndromes plus signs from a physical exam. For women, the exam comprises an abdominal exam, a pelvic exam with speculum, and a bimanual exam. To perform a pelvic exam, a provider needs a private space, a table, a lamp, a speculum, and gloves. The speculum should be disinfected after each use–for example, by boiling it in water or by immersing it in bleach and then rinsing with sterile water. For men, a complete exam comprises examining the penis and the groin and feeling the testicles and epididymis.
* Syndromes and signs plus simple tests–for example, microscopy and testing the acidity (pH) of vaginal discharge (see p. 12). Providers take specimens during the exam: samples of fluid from genital ulcers, a urethral swab, or swabs from the vagina and cervix [185, 283].
* Syndromes, signs, and simple tests, plus blood tests and culture of specimens from genital ulcers or discharges. Generally, only providers at STD referral clinics have the laboratory facilities to perform cultures. Such providers need not take the time to test samples from all STD patients, however. National STD management guidelines can help providers decide when microscope or laboratory analysis is advisable.
The provider’s time may determine the extent of the physical exam. Managing an STD patient can take 5 to 15 minutes. In Zimbabwe, for example, health care providers spend 5 to 6 minutes with each STD patient in a visit that includes a medical and sexual history, examination, diagnosis, treatment, counseling, and condom distribution. A speculum exam for women takes longer [162]. In a one-year pilot project in Maputo Province, Mozambique, STD visits in 20 health centers averaged 15 minutes for women and 10 minutes for men, not including waiting time [22].
Diagnosis and Treatment
Providers have generally used two approaches to diagnosing STDs:
* Etiologic diagnosis: identifying the organism causing symptoms with microscopy or laboratory tests. Such tests are expensive or time-consuming. For example, culturing techniques can accurately detect chancroid, chlamydia, and gonorrhea but cost US$12 to $40 and require one to six days to incubate specimens in a laboratory [229, 283]. The widely used rapid tests for syphilis, the rapid plasma reagin (RPR) test and the Venereal Disease Research Laboratory (VDRL) test, require needles and syringes to obtain venous blood and a centrifuge to separate plasma from red blood cells [286].
* Clinical diagnosis: identifying the STD causing symptoms based on clinical experience. Even experienced STD service providers, however, often misdiagnose STDs when they rely only on their clinical experience [125]. In a South African study of 100 men and 100 women with genital ulcers, for example, clinicians correctly identified only about one-third of the cases of chancroid or syphilis in the men, about one-half of cases in the women, and less than 10% of mixed infections [210].
A third approach is:
* Syndromic diagnosis: identifying all possible STDs that could cause symptoms (see box, this page). Flow charts formalizing the syndromic approach, such as the wall chart published in this issue of Population Reports, give providers step-by-step instructions to diagnose STDs and list drugs recommended by WHO to treat them
If providers do not have the WHO-recommended drugs, they can use drugs recommended by their national STD program. If these drugs, too, are unavailable, providers can give patients prescriptions to buy the drugs from local pharmacies or shops or from pharmacies in district or provincial hospitals. It is essential that providers not give patients a partial course of drugs, which may not cure patients and can induce drug resistance (see p. 15).
Treatment includes relieving discomfort. Patients in pain may avoid urinating or drinking water and thus risk getting urinary tract infections or becoming dehydrated. Providers can advise patients to clean a genital ulcer–for example, with salt water and, if possible, to soak in dilute salt water, which can help to clean and dry up an ulcer [19, 34].
Counseling
Every STD patient should leave a clinic understanding and remembering these eight messages:
1 Cure your infection: Take all your medication as instructed even if symptoms disappear or you feel better. The symptoms may come back if you do not take all of the medication.
2 Do not spread STDs: Do not have sex again until you take all your medication as directed and you have no more symptoms. If you do not wait, you may give an STD to your sexual partner. Also, do not have sex again until your partner is treated. If you do not wait until your partner is treated, you may get the infection again from your partner. If you must have sex, use condoms with all partners.
3 Help your sexual partners get treatment: Tell them to come for treatment or else bring them in.
4 Come back to make sure you are cured: If you still have symptoms, you can get more medicine to cure your infection.
5 Stay cured with condoms: Always use condoms with any occasional sexual partners and, if possible, with your steady partner. If using condoms is not possible, using spermicides provides some protection.
6 Keep safe by staying with just one sexual partner: If you have sex with several people, there is more risk that one may have an STD and infect you. If possible, encourge your partner to stay just with you.
7 Protect yourself against AIDS: Sexually transmitted diseases increase your risk of getting AIDS.
8 Protect your baby: Go (or send your wife) to an antenatal clinic within the first three months of pregnancy for a physical exam and syphilis test.
Although these messages are obviously critical, STD providers often neglect counseling [150, 166, 194, 261]. For example, in a US study involving 60 STD patients, one-quarter received no information about preventing STDs [261].
Counseling can be challenging. Patients may resist counseling messages, and providers may lack training. For some patients avoiding STDs is not enough motivation to use condoms or to avoid sex until cured; providers often see the same people returning for treatment [72]. Others may not understand how STDs spread or why their sexual partners need treatment; they need to understand the reasons for the counseling messages. Patients, especially adolescents, may underestimate their risk of getting an STD. Some patients may understand the risks but not change behavior until they sense that others in their community have changed [6]. Men may prevent women from changing their behavior.
To counsel well, providers need to be empathetic, nonjudgmental, honest, and respectful of patients (see Population Reports, Counseling Guide, J-36, December 1987). Providers also need to take time to counsel. Communicating all counseling messages thoroughly may take 20 minutes. Few providers can spend that much time with each patient. Thus in some programs specially trained counselors talk to patients after they have seen a doctor, nurse, or nurse-midwife.
Providers can use a number of techniques to help patients complete treatment and remember and follow the counseling messages. For example, they can:
* Help patients decide how they best can remember to take the medication, such as taking it at the same time every day;
* Write down the instructions and messages or give the patient a brochure;
* Discuss past attempts at prevention, try to find out why they failed, and help resolve these problems;
* Ask patients if they need help to follow the counseling messages;
* Help women and men practice for a discussion of STDs and safe sex with their sexual partners;
* Repeat the counseling messages;
* Ask the patient to repeat the instructions [7, 33, 95].
In particular, counseling for condom use requires special skills and information. Patients need to hear more than simply, “Use a condom.” Counseling should emphasize the following points:
* Have a condom before you need it. (Providers should always give patients a supply of condoms, tell them where to get condoms, and advise them to store condoms in a cool, dark place, if possible.)
* Use a condom with every act of sexual intercourse unless you are sure that neither you nor your partner has an STD.
* Roll the condom on after the penis becomes erect. (Providers should show patients how to put a condom on–by demonstrating on a model of a penis, a banana, or a broom handle, for example–and then let the patient demonstrate.)
* Do not use oil or oil-base lubricants such as petroleum jelly, which damage latex condoms. In contrast, water-based lubricants–for example, glycerin and K-Y Jelly–are safe, as is spermicidal foam.
* After ejaculation hold the rim of the condom while you withdraw.
* Throw the used condom away or bury it where children cannot find it. Do not reuse condoms.
Counselors should ask patients about attitudes, problems, or concerns about using condoms and discuss how patients will talk to their partners about condoms (see Population Reports, Condoms–Now More Than Ever, H-8, September 1990).
Encouraging patients to get their sexual partners to treatment also is an essential part of counseling (see pp. 24-25).
Getting Services to the People
Clinical services are the heart of most STD programs. Clinical service providers screen, diagnose, treat, counsel, follow-up, and refer. Making these services accessible and effective is crucial. Three elements contribute:
* A program structure that can provide STD services to most people where they first seek care,
* Public and private providers offering appropriate treatment, and
* A steady supply of appropriate drugs to treat STDs.
The Structure of STD Services
The structure of an STD services program must serve the main function of providing accessible clinical services. Programs have been structured in several different ways:
* An integrated structure, in which staff of primary health clinics, outpatient departments of district and provincial hospitals, family planning programs, and antenatal clinics are trained to provide STD services (as in Viet Nam, Zimbabwe, and other countries) [9, 162, 228];
* A vertical structure, in which provides specializing in STD management are stationed in primary care clinics and in STD clinics in district and provincial hospitals (as in Senegal and Sri Lanka) [226, 228].
* A structure combining integrated and vertical services (as in India, the Philippines, Thailand, and Zambia). In Zambia, for example, STD services are offered in primary health clinics and in STD clinics in district hospitals [114]. Like national ministries, the health departments of large cities may also set up a combined structure. The city of Harare, Zimbabwe, for example, offers services in primary health clinics and stand-alone STD clinics [162].
Program planners need to weigh the advantages and disadvantages of integrating STD services or setting up separate STD clinics. Some people prefer to go to integrated clinics because the reason for their visit is not obvious, as it would be at an STD clinic. Also, when family planning and antenatal care providers are trained in STD management, they may be able to screen clients for STDs when the clients are seeking care for other reasons (see pp. 21, 24). Thus they can identify women who have asymptomatic STDs [228]. Integrated services may lack funding, however, and staff may be overworked or have no STD training.
In theory, in single-purpose STD clinics highly trained providers offer comprehensive STD services. In reality, however, like multipurpose clinics, many STD clinics lack equipment and drugs, and staff may be overworked and have little time for each patient. In addition, women are reluctant to attend such clinics because they treat mostly men. Also, staff in some STD clinics treat women rudely [228].
Whatever structure is chosen, programs need to set standard of STD management by issuing national guidelines and by training and supervising providers, to evaluate diagnostic tests and drug treatment, to conduct surveillance of the prevalence of STDs, and to work with policy-makers [325]. These functions can be performed by one or more “centers of excellence,” universities, or research institutes [226]. The AIDS Task Force of the European Communities offers training courses on the planning and management of STD programs in developing countries [337].
Mobilizing Providers
As in any health care program, training and supervising government service providers can improve STD services. STD programs also should collaborate with private providers to reach people who do not go to public clinics.
Training. Schools for health professionals have neglected STD training [73, 190, 227, 332]. Medical schools, for example, may offer only classroom instruction on STDs and only in dermatology, preventive medicine, or urology courses [190, 243, 291, 332]. Students receive little or no clinical training on STDs. Training has been neglected in part because the development of penicillin and other antibiotics has led doctors to think that STDs are easily treated [82, 178].
There are exceptions in some schools. For example, medical schools in Chile and in some states of Brazil offer specialty training in STDs [332]. In Zambia STD officers are physician’s assistants who study clinical medical sciences for three years and then attend a 3-month STD course that covers epidemiology, diagnosis, management, counseling, and communication skills [133]. Also, medical students in Zambia receive six weeks of STD training; clinical officers receive three weeks of training; and nurses receive two weeks [114].
Special programs offer in-service STD training to refresh providers’ knowledge and skills and to tell them of improvements in STD management. In-service training is especially effective when conducted at a center of excellence. There trainees see high-quality care and a variety of cases, while staff at the center can learn about services at primary care clinics. By building a personal relationship between primary care providers and center staff, such training strengthens lines of supervision and referral. In Harare, Zimbabwe, for example, staff of city-run primary health care clinics, usually nurses or midwives, attend 2- to 3-week STD courses at the clinic of the central STD referral center. In groups of 8 to 10, trainees learn to take a medical and sexual history, examine patients, use a microscope, diagnose STDs, follow standard flow charts, and prescribe drugs. After the course these providers are expected to be able to care for 95% of STD cases that they see and to refer the rest [162, 163].
The Zimbabwe essential drugs program also provides inservice training. The program publishes an STD management manual to help providers dispense drugs appropriately. Of the 16 manuals produced by the program, the STD manual is one of the two most requested by providers [155, 156]. In the first year of the Mozambique pilot project, in-service training helped to reduce referrals from primary care clinics to the central hospital clinic from 8% to less than 5% of patients. Also, the program improved providers’ ability to diagnose and treat gonococcal urethritis: The proportion of referred patients who had gonococcal urethritis decreased from 42% to 23% [21].
Supervision. With supervision, primary care providers can better apply their knowledge and skills, and morale rises. Supervision can come in the course of recordkeeping or in monitoring of referrals. In Zimbabwe, for example, the Ministry of Health collects monthly STD case reports from primary health clinics through the district and provincial health officers. If more than 5% of STD patients do not respond to the standard treatment and are referred to the district level, an STD expert visits the primary clinic to find out why [162].
In some countries experts from the central referral clinic will not be able to supervise most primary health clinics. This task could then be carried out by clinical medical officers specially trained in STD management and stationed in district hospitals [148].
Collaborating with private providers and traditional practitioners. Private providers treat many people with STDs [3, 142, 170]. In parts of Latin America, for example, as many as 90% of people with STDs may go first to pharmacies or private doctors [250, 332]. In Ethiopia rural drug vendors may treat seven times the number of STD cases that are treated at all public facilities combined [139].
Only a few public STD programs work with private or traditional practitioners, however. In Kisumu, Kenya, for example, a program to prevent ophthalmia neonatorum worked with private practitioners, who are leaders of the medical community [148]. In Zimbabwe all doctors are offered STD training in continuing education seminars. Also, private practitioners receive publications of the essential drug program, including the STD treatment guidelines. STD experts address the primary care physicians’ association [162].
Pharmacists in Cameroon, Ecuador, Mexico, Senegal, Tanzania, and other countries are studying STD management [6, 60, 225, 239, 265]. In Tanzania training workshops have improved pharmacists’ management of customers with STDs: Before the training none of 43 pharmacists said that they recommended drugs from the national STD treatment flow chart, but after the training more than half did [6]. In Cameroon, in an innovative social marketing project, staff from about 200 pharmacies are being trained to sell an STD treatment package consisting of antibiotics, informational brochures, partner referral cards, and condoms [239, 240, 298]. Working with pharmacists may be difficult, however. Programs that have trained pharmacy staff in family planning have found that the people who came to training sessions often were not the ones who usually waited on customers. Also, turnover of clerks may be frequent; thus staff may leave soon after being trained [159]. [TABULAR DATA OMITTED]
Traditional practitioners–traditional birth attendants, traditional healers, injection doctors, and rural drug vendors–could play a role in STD management, depending on their roles in health care. The Zambian Ministry of Health has registered about half of the country’s traditional healers. They attend workshops that include two hours of STD training, and they are encouraged to refer patients with STD symptoms to public clinics (114). In The Gambia traditional birth attendants carry tetracycline eye ointment to prevent ophthalmia neonatorum (100). Adding STD services to the work of traditional birth attendants may further burden them, however. Other health care programs–for example, family planning and maternal and child health programs–have also recruited traditional birth attendants in some countries.
Supplying Drugs
Lack of drugs is currently one of the main barriers to effective STD services in developing countries. To ensure a reliable supply of effective drugs, programs need to:
* Order the right drugs
* In sufficient quantity and
* At a low price and
* Distribute them efficiently.
Ordering the right drugs. Programs need to know the prevalence of specific STDs in the population that they serve. To assess national STD trends, programs collect information from a sample of clinics–often called sentinel surveillance–and/or require all clinics to report STD cases.
Such surveillance also needs to identify drug-resistant strains of STDs. Drug resistance is fostered by ineffective treatment–for example, not using enough drug to cure patients completely. In this way STD pathogens are exposed to the drug and given an opportunity to mutate into resistant strains. Penicillin-resistant strains of gonorrhea now account for 25% to 80% of cases (3, 100, 151, 296).
Buying enough at low prices. The cost of drugs forces governments to buy less than they need or to buy drugs that are less expensive but also less effective. Drugs for gonorrhea treatment are especially expensive because of the high prevalence of strains resistant to older, inexpensive drugs such as penicillin and tetracycline (see Table 3). Drugs should cure 95% or more of patients (329). Some programs, however, use drugs that cure only 85% to 95% of cases for initial treatment at primary health clinics and save the more effective drugs for referral clinics. Unfortunately, many people who are not cured by the initial treatment may not go to the referral clinic (329). Programs should distribute the most effective drugs to the clinics where patients first seek care.
To buy STD drugs in the quantities necessary, governments need to:
* Buy in bulk to obtain volume discounts. In a US chlamydia treatment program, for example, drugs bought in bulk cost 60% to 80% less than single doses (304). To buy in bulk, governments need to establish standard treatment guidelines so that all providers treat STD patients with the same drugs. Drugs recommended in the guidelines must be on the national essential drug list, of course.
* Get competitive bids. Prices from one supplier, whether a distributor or manufacturer, may be three or four times higher than prices from another (175).
* Allocate more funds to buy drugs, and seek donor funding. Research showing the link between HIV transmission and other STDs has persuaded governments to increase spending on drugs or to buy drugs with money for AIDS control (114, 162).
Asking patients to pay may be acceptable in some settings. The STD program in Mozambique charged a small fee that covered the cost of drugs but not the cost of distribution and taxes (21). The many STD patients seeking care from pharmacists and other private providers clearly are willing to pay. Still, in some situations charges may deter patients from seeking care. There is little information on how charges affect use of STD services. One study in Nairobi, Kenya, reported a 60% decline in attendance at an STD clinic when patients were charged about US$1.75 for diagnosis and treatment, less than half a day’s pay for most city households (200).
Distributing drugs efficiently. Distribution of STD drugs can be improved by:
* Decentralizing to speed delivery. In Zimbabwe drugs were shifted from one central warehouse to warehouses in five of the eight provincial capitals. This change cut the time that primary health clinics must wait for orders from six months down to between four and six weeks (155, 162).
* Monitoring supplies. Primary care clinics need to keep track of drugs to prevent theft and stockouts. Supplies may need to be ordered two to nine months in advance [155]. Health care providers generally lack training in drug supply management. In Ghana, Swaziland, Tanzania, Zimbabwe, and other countries, in-service courses teach such skills [154, 257].
Cost
The cost of STD programs is difficult to judge because only a few programs have estimated costs. The national STD program in Zambia, for example, costs an estimated US$1.3 million per year [119]. Managing STD patients at the district level costs about $7 per patient, including staff time, laboratory diagnosis, treatment, and condoms [118]. Projections have been made based on studies or pilot STD programs. For example:
* A program to prevent gonococcal ophthalmia neonatorum in a typical country in East Africa with a population of 20 million, one million births per year, and a 10% prevalence of gonorrhea among pregnant women would cost about US$65,000, or $.07 per infant treated, excluding personnel costs. The program would prevent an estimated 47,000 cases at $1.38 per case prevented [271].
* Screening and treating 1.5 million pregnant women with a 10% prevalence of syphilis in the same East African country would cost about US$900,000, or $.60 per woman, excluding personnel costs. The program would prevent 75,000 spontaneous abortions, fetal or infant deaths, or cases of congenital syphilis at a cost of $12 per sequela avoided [271] (see p. 24).
* In Mozambique managing about 39,000 STD patients and their sexual partners, testing 50,000 pregnant women for syphilis, and treating infected women would cost an estimated US$427,000 a year, or $4.80 per person, including personnel costs. The figure was estimated from the cost of an STD pilot program in Maputo City and province, an area with a population of one million [21].
These estimates depend on the prevalence of STDs in the population being served. Higher prevalence rates would increase the total treatment costs but reduce the cost per sequela avoided. By comparison, developing-country governments, donors, and users spend an average of $10 to $14 per couple per year on family planning supplies and services [160].
The extent of government and donor support for STD programs varies from country to country. In some countries governments provide most program funding, while in others donors provide most. Donors include the United States Agency for International Development (USAID), the Commission of the European Communities (CEC) and many of its member countries, the World Bank, the United Nations, and others. US AID has supported AIDS and STD prevention activities in 70 developing countries, allocating over US$158 million in bilateral assistance to these efforts between 1987 and 1991. AID plans to spend $400 million for programs worldwide between 1991 and 1996 [302]. The AIDS Control and Prevention (AIDSCAP) Project managed by Family Health International is the major AID-funded project implementing programs in developing countries. The CEC contributed almost $90 million between 1986 and 1991 to AIDS/STD programs in developing countries, not including funding for research. Member countries contributed another $188 million in bilateral assistance between 1986 and 1991 [337]. The World Bank supports more than 30 AIDS/STD projects [258].
Getting People to Services
Even when services are widely available, people must be encouraged to seek treatment–and to seek treatment early. STD programs can reach the public in a number of ways:
* Conduct communication programs;
* Set up programs for high-risk populations (see box, pp. 22-23);
* Conduct screening programs, which check people for STDs when they go to clinics for antenatal care, family planning services, or other reasons;
* Notify the sexual partners of STD patients.
Communication Programs
STD programs have promoted services for gonorrhea, syphilis, and the other nonviral STDs mainly through clinic counseling, posters, and brochures. Broadcast promotion is rare and still largely taboo, despite the growing use of the mass media for AIDS information [315]. The lack of mass-media promotion for these STD services is a lost opportunity to inform and persuade. Mass-media campaigns for AIDS prevention and for family planning have persuaded people to seek information and to use services [168, 230].
More widespread promotion of STD services and more public information about STDs are desperately needed. In both developed and developing countries, many people know little about STDs–how they are transmitted, their symptoms, how they threaten health, how they should be treated, and how to prevent them–and many are misinformed [3, 7, 42, 208, 209, 216, 310]. In Nigeria, for example, some men believe that their semen will cure their partners [3]. In the US many people say that they do not fear getting AIDS because they are not in any of the groups with a high prevalence of AIDS [7].
As a result of ignorance or misinformation, some people engage in risky sexual behavior or delay seeking treatment from a health care clinic. In studies in Nigeria and Uganda, for example, men with symptoms of urethritis waited an average of about 2-1/2 years before seeking treatment at a clinic [138, 278]. Women who delay treatment risk life-threatening complications and infertility.
Also, people may be afraid to seek care. Some people stay away from public clinics because they do not want to answer questions about their sexual partners, as has been reported in Uganda [322]. Callers to a US STD telephone hotline who were infected or who had been exposed to infection said that they did not seek care because they worried about confidentiality, the procedure for diagnosis and treatment, being humiliated by clinic staff, and the long-term consequences of infection [141].
To overcome barriers, programs have used various approaches:
* Videotapes in STD clinics. In a US program, for example, patients at an STD clinic in Baltimore saw a 10-minute videotape urging them to bring sexual partners to the clinic and to return themselves to make sure that they had been cured. Some 54% of the patients who saw the videotape returned for a test of cure, while 43% of those who did not see the videotape returned [279].
* Counseling of STD patients. A study in Nigeria tested the effect of reinforcing a social worker’s counseling with a doctor’s counseling. All patients who received expanded counseling returned for their first follow-up visit, while only three-quarters of those who did not receive the extra counseling returned [211].
* Counseling of pregnant women and influential family members. For example, in Zambia a prenatal syphilis screening program told pregnant women about STDs when they came to antenatal clinics. Young women often talk to their mothers first if they have symptoms. Therefore the program also informed elderly women about STDs when they came to a clinic for treatment of diabetes or hypertension. The program helped to increase the percentage of women attending the screening clinics in their first trimester of pregnancy from 12% in the mid-1980s to 42% in 1990-91 [114].
* Brochures. In Zambia the Copperbelt Health Education Project has published an illustrated brochure entitled What Everyone Should Know About STD, which describes symptoms, the ways STDs are spread, and ways that they are not spread. It urges people to seek treatment at a clinic and to avoid unqualified practitioners [59].
* Education of community leaders. For example, in Kenya the Nairobi STD program conducts workshops for school heads and leaders of parent-teacher associations [199, 255].
* Radio drama. For example, in The Gambia an episode of a popular weekly radio drama series broadcast in 1991 encouraged people to go to a doctor or health center for STD services rather than treat themselves [92].
* Education and clinics especially for young people. A world survey of AIDS prevention programs found that 19 of 23 developing countries had AIDS education programs in schools [177]. Other in-school activities have included health clinics [4, 326] and peer education [4, 94, 192].
The effect of communication on seeking care for STDs has seldom been evaluated beyond these examples. More evidence shows that communication programs encourage prevention of STDs, particularly condom use (see pp. 25-27).
Mass-media promotion can have a large impact, as coverage of AIDS has shown. Such coverage is especially effective when it is entertaining. In the Philippines, for example, a popular television soap opera broadcast an episode that portrayed a businessman who had become infected with HIV from a prostitute. In the week following the broadcast, visits to STD clinics in Manila doubled [66]. Also, a celebrity with an STD attracts media coverage that can bring people to clinics. US basketball player “Magic” Johnson’s announcement that he was infected with HIV was probably the main reason that requests to US public clinics for HIV tests increased by 10%, from 400,000 to 440,000, in the last three months of 1991 [95].
Screening
To screen for STDs, providers check people seeking health care for other reasons. Screening programs can:
* Get men and women to treatment who have unrecognized or asymptomatic STDs;
* Avoid sequelae in patients and, for pregnant women, in the fetus and newborn;
* Identify STDs in homosexuals, who may be reluctant to seek care and reveal their sexual orientation;
* Identify people who may not have STDs but are at risk and need counseling; and
* Provide information about the prevalence of STDs in clinic populations. [TABULAR DATA OMITTED]
When deciding whether to set up STD screening, programs need to consider the prevalence of STDs in the clinic population, the cost and accuracy of screening tests, the cost and effectiveness of treatment, the seriousness of the sequelae avoided, and the cost per adverse outcome avoided. Syphilis screening in antenatal clinics, for example, is important because it can avoid serious illness or death. Furthermore, the test is fairly accurate, and testing and treatment are cheap; the test costs about US$.10, and an injection of benzathine penicillin costs about $.40 [116, 271, 328]. The cost per adverse outcome avoided depends on the prevalence of infection in the clinic population, as illustrated using the costs of a pilot antenatal screening project in Zambia (see Table 5). Of course, some programs may screen and then refer infected patients, thus avoiding the costs of treatment.
How many infected people can screening programs identify? The answer depends on the prevalence of STDs in the population. The Mozambique project, for example, treated almost 39,000 people with STDs and their sexual partners. There are approximately 50,000 births in the province every year, and the prevalence of syphilis among pregnant women is 18% when measured by the RPR test [21]. Thus screening all pregnant women for syphilis by RPR might detect about 9,000 cases. If one-quarter of the women’s partners also were treated, the total number brought to treatment by screening would be 11,250. If syphilis prevalence were lower, of course, screening would bring fewer infected people to treatment. Because the RPR test is not 100% sensitive or specific, however, some of the women with syphilis would not be detected, and some who tested positive would not be infected. In the US a nationwide gonorrhea screening program begun in 1972 discovered about one-third of the gonorrhea cases reported between 1973 and 1975 and lowered the incidence of gonorrhea by about 20% [330].
Without tests, or if testing is too expensive, providers may use the syndromic approach to screen for STDs. Such screening may be used in place of laboratory tests or to identify people who need testing. Syndromic diagnosis can be based on patients’ description of symptoms, a sexual history, and/or a gynecological exam. For example, in Tanzania syndromic screening of women attending an antenatal clinic based risk assessment on age, number of partners in the last year, reported vaginal discharge or itching, and vaginal discharge seen on examination. The assessment assigned one or two points to each risk factor, symptom, and sign. With a score of six points or more, the assessment was considered positive. Among 97 women, the risk assessment detected five STD cases. Screening based on the gynecological exam alone detected four cases. Screening based on symptoms alone detected three cases. In fact, laboratory testing found that 7 of the 97 women had chlamydia or gonorrhea. The risk assessment cost 50% less per case treated than screening based on the gynecological exam and symptoms [107].
Ideally, each program should check its risk assessment procedure in the same way–by comparison with lab test results. Risk assessments may work well in some populations but not in others. Two US studies of chlamydia screening found that a risk assessment identified 70% and 90% of family planning clients with chlamydia [2, 111]. In contrast, another study found that a risk assessment missed three-quarters of infected women [316]. Programs may need to adapt the risk assessment to improve its predictive value. For example, the score to indicate infection may be set higher or lower to hold down costs, on one hand, or to be sure of identifying as many cases as possible, on the other.
Partner Notification
The purpose of notifying patients’ sexual partners is to treat people who are very likely to have STDs. Like screening for STDs, partner notification can get people to treatment who have asymptomatic STDs. In fact, because so many infected women are asymptomatic, notifying the sexual partners of men who seek treatment for STDs, particularly gonorrhea, may prevent more sequelae among infected women than treating only women who have symptomatic STDs [315].
Providers can use several approaches to getting sexual partners treated:
* Patient referral. The health care provider asks patients to bring or send in partners, but the provider does not ask for information about partners. Commonly, patients receive contact cards or referral slips to give their sexual partners. Other approaches include giving patients drugs or prescriptions for partners. In some areas providers refuse to treat patients until they bring partners to the clinic, but this practice may discourage people from going to STD clinics [241].
* Provider referral. Through sensitive questioning, providers obtain names and addresses of sexual partners and try to contact them by telephone, mail, or visiting [15, 241, 281].
* Patient and provider referral. The provider asks for names and addresses of partners but gives patients time–often one week–to refer them. If the patients’ partners do not appear for treatment, providers attempt to contact them [241].
When partners come to the clinic, providers may either treat them for the same STD that the initial patient had, without an examination, or else manage them as a new STD patient.
In setting up partner notification systems, programs need to consider clinic resources, the severity of the STD, and the risk to the community of not treating a partner. Patient referral is the least expensive approach, but generally less than one-third of partners, and often only 15% to 20%, appear for treatment [22, 199, 241, 323]. Provider referral can bring up to three times as many partners for treatment as patient referral [135], but it is more costly, and most clinics do not have enough staff to make visits. It may, however, be justified for serious STDs or for individuals named as partners by many STD patients [241].
Good counseling of STD patients can increase the percentage of partners who appear for treatment. In particular, women may be afraid to tell their husbands that they have an STD. In Zambia, the prenatal syphilis screening program drew almost 40% of husbands to treatment by counseling women one-to-one and using role-playing to prepare them to talk with their husbands [114, 115].
Notifying and treating partners may be difficult. Patients may be unwilling to answer questions about their sexual partners, they may not know their names or addresses, or they may lie. Almost 30% of the patients in a partner notification program in Zimbabwe, for example, gave false addresses for partners [323]. Even actual addresses may be hard to locate because streets are not well-marked. Also, some partners, especially men, do not believe that they have a disease if they have no symptoms, and thus they will not come for treatment.
Unfortunately, partner notification can deter people from seeking care. People may stay away from a clinic that requires patients to give the names and addresses of sexual partners or to bring them along. In Uganda, for example, many people go to traditional practitioners– “needle men” –for injections rather than to clinics that demand the names of sexual partners [322]. Allowing patients to refer their sexual partners can remove this obstacle.
Promoting Prevention: Condoms and Monogamy
Too many people risk infection and death by having more than one sexual partner and not using condoms. The task facing STD prevention efforts is to change this behavior.
There has been very little public promotion of condoms and monogamy expressly to prevent STDs other than AIDS. Conventionally, STD prevention strategies have focused on high-risk groups, and communication has taken the form of counseling, print materials such as brochures and posters in clinics, and presentations for captive audiences, such as films or lectures in military barracks and schools [38]. It is now being recognized that these approaches are too limited and piecemeal. Systematic approaches, based on modern theories and experience in communication and behavior change, are needed to make a real difference. At this point, most of the lessons learned come from family planning promotion and AIDS prevention (see Population Reports, Condoms–Now More than Ever, H-8, September 1990, and AIDS Education–A Beginning, L-8, September 1989).
Promoting safer sexual behavior, like any systematic promotional effort, begins with careful audience research. Surveys, focus-group discussions, interviews, and pre-testing help ensure that a promotional campaign identifies its audiences, chooses media that reach the intended audiences, and delivers persuasive messages (see Population Reports, Lights! Camera! Action! Promoting Family Planning with TV, Video, and Film, J-38, December 1989).
Audience. The intended audience for STD prevention messages is usually people who tend to have several sexual partners and do not use condoms. Preliminary research must assess who these people are, where they live and work, and why they behave as they do.
Media. Factors that influence the choice of media include:
* The intended audience. Audience research should assess how the intended audience gets information–from radio, television, newspaper, peers, family members, health care providers?
* Cost. Broadcast promotion can be expensive, but it may cost very little per person reached [53]. Posters and brochures are often less expensive to produce, but they reach a smaller audience and often have less emotional impact.
* Media restrictions. In countries that do not allow brandname advertising of condoms or explicit discussion of sexual behavior in the mass media, opportunities for promoting safe sex may be limited.
Messages. Messages need to address people’s reasons for not using condoms or staying with one sexual partner. Although attitudes may differ, people throughout the world give similar reasons for not using condoms: “Using a condom is like eating candy with the wrapper on.” “I am too embarrassed to buy or use a condom.” “My partner will think that I have been unfaithful or that I am accusing him/her of infidelity.” “Condoms are too thin to stop STDs.” “They make men impotent.” “They get lost inside the woman.” Similarly, people may give various reasons for having more than one sexual partner. Men usally have more partners than women. In Zambia, for example, men say that they need several partners for regular sex, which they consider necessary for good physical and mental health, and to build self-esteem. They say that men with only one partner are old, poor, or disabled [102].
Messages can best change these attitudes by offering new images of condom use and monogamy. Thus promotional campaigns have implied that condoms are sexy and safe or that wholesome couples use them [343, 344]. In the Philippines, for example, condoms are marketed with the brandname Sensation, which has a sexual connotation, and the slogan “Make it sure, make it safe.” [343]. Since poor communication between couples may prevent condom use, advertisements should portray couples talking openly about condoms [340]. Monogamy can be depicted as the responsible behavior of a leading citizen, winning the approval and admiration of family, friends, and community. These positive appeals are more likely to change attitudes and influence behavior than exhortations to stop unsafe behavior or attempts to frighten people with the consequences of STDs [340, 344].
Messages must go beyond what audience members say about their own behavior and motivations, however. Behind these statements, patterns of behavior reflect peer group attitudes, beliefs about health and about the body, rumors and misperceptions, distrust or dislike of other groups including health authorities, and inequities of power between men and women in sexual relationships. Gender inequities are particularly important in communicating about condom use and monogamy. Rather than berating women to change their behavior, messages must help women find ways to protect themselves from STDs without risking their physical and financial well-being.
Promoting Condoms
Programs have used a variety of approaches to promote condom use. For example:
* Social marketing. In 1991 there were at least 39 social marketing programs selling condoms at discounted prices in 38 developing countries. Seven marketed condoms only for STD prevention; 13, for both STD prevention and family planning; and 19, for family planning only [252].
Some programs are purposely unclear about the type of protection that condoms offer. The brand name Protector, for example, used by social marketing programs in sub-Saharan Africa and Latin America, suggests that people should be protected but lets the customer decide what to be protected from.
* Entertainment. In Cote d’Ivoire, for example, the Social Marketing Program sponsors a TV variety show for young people. Prudence condom ads are broadcast before and after each show, and segments of the show discuss safe sex and condom use [54]. In Peru Apoyo a Programas de Poblacion produced street theater to promote safe sex and condom use among children who live or work on the street. The theater piece led to a discussion of condom use on the TV talk show Alo Guisella, seen by more than two million people [236].
* Interpersonal communication. In Zaire, for example, STD testing, counseling, and free condoms–offered to employees of a bank and a textile factory–increased condom use to over 90% among 200 HIV-discordant couples (in which one partner is infected and the other is not infected). Before the program few of the couples used condoms [113].
Interpersonal communication takes time, especially to sustain increases in condom use. Furthermore, unless initial counseling is reinforced, in time people begin to use condoms less, even couples who should have strong motivation to use them. Condom use among the discordant couples in Zaire, for example, decreased from 90% to about 85% between 1990 and 1991 [113]. Interpersonal counseling has been used extensively to promote condoms among high-risk populations (see pp. 22-23).
Portraying condom use as a community norm or a part of everyday life can help to improve the image of condoms. For example, the Caribbean Family Planning Affiliation produced a poster showing couples enjoying a barbecue on the beach, with the caption, “Condoms…because you care” [6].
Does the promotion of condoms for AIDS and STD prevention affect their use as a family planning method? Limited evidence from Colombia, Jamaica, and Mexico indicates that such promotion does not detract from condom use as a family planning method and, in fact, may increase it [213, 288]. For example, a 1988 radio campaign in Colombia promoted condoms to prevent AIDS and mentioned the family planning organization Asociacion Pro-Bienestar de la Familia (PROFAMILIA). Surveys found that the campaign improved people’s perception of condoms and did not change their attitude toward PROFAMILIA [213].
Promoting Monogamy
Efforts to promote monogamy have encouraged men to stop having sex with prostitutes and urged couples to be faithful. Also, programs have encouraged youth to delay sexual intercourse or abstain until they get married. Most such efforts have been a part of AIDS prevention programs. For example:
* In the Philippines a television commercial broadcast in 1992, part of an AIDS prevention campaign, portrayed young men in a locker room discussing their visit to prostitutes the night before. One man warns them, however, that having sex with prostitutes is dangerous and reminds them about a friend who is sick [289].
* In Uganda monogamy is promoted with the phrases “Zero grazing” (“zero grazing” means staying with one partner), “Love carefully,” and, for men in polygamous marriages, “Stay within your own paddock” [130, 214].
* The Zaire AIDS prevention program combined promotion of monogamy and condoms in the slogan “Love faithfully, or at least with prudence” [134].
* The Swiss AIDS education program uses the slogan “Stay faithful to one partner” in advertising directed at married couples [179].
To gauge their impact, these programs have measured intent, knowledge, or reported behavior. For example:
* Pre-tests and post-tests of the promotion in the Philippines found significant increases in the percentages of men who agreed with the statements, “If I am going to have sex, I will stick to one partner” and “I will not sleep with prostitutes” [289].
* In Uganda surveys of adults in rural and urban areas in 1988 found that almost 90% were aware that mutual monogamy prevented the transmission of HIV [86].
* In Switzerland surveys have found that the median number of reported lifetime sexual partners among people ages 17 to 30 declined from 3 to 2 between 1987 and 1991. The change was not statistically significant but may suggest a trend [74]. During the same period condom use in this group increased from 8% to 52% [75].
Isolating the effect of programs is difficult, of course. In Switzerland, for example, sex education in the schools may also be influencing behavior. More research is needed on the impact of programs that promote monogamy as well as on ways to measure behavior change.
Sexually transmitted diseases are both a medical and a social problem. The means to cure many STDs and to prevent all of them have long existed. But health care providers are still struggling to make STD diagnosis and treatment widely available throughout the world. Also, they are just learning how to persuade people to seek effective treatment, to use condoms, and to have fewer sexual partners. And they are just beginning to involve providers of primary health care, including antenatal care and family planning, who may be able to play a larger role in STD management and prevention. Such efforts can prevent infertility, avoid congenital infections, and slow the spread of AIDS.
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