Family planning and STDs: how do they mix?

Family planning and STDs: how do they mix? – sexually transmitted diseases

Most family planning programs cannot offer high-quality services without paying attention to STDs. Family planning providers need to tell clients about the STD protection that various contraceptive methods do or do not provide. They must make clear that people at risk for STDs should use condoms, whether or not they use another method. Also, for women interested in the IUD, providers must assess their risk of getting an STD and, if possible, screen them for STDs. Those who have an STD or are at risk should use another method. (See box, p. 18.)

What more should family planning programs do? Should they ask clients about symptoms and refer them to another facility for diagnosis and treatment? Should they screen all clients for STDs and refer for diagnosis and treatment? Should they also provide treatment–for one, two, or more STDs? Assessing clients’ needs–through screening studies and focus-group discussions, for example–can help programs learn what is needed. Of course, the appropriate level of STD services also depends on resources, including the drug supply.

Programs are trying a variety of approaches. Affiliates of the International Planned Parenthood Federation (IPPF) in Africa and Latin America, for example, typically provide some counseling for symptomatic clients and refer them to a government clinic for diagnosis and treatment [103, 250]. A number of programs diagnose and treat some but not all STDs. For example, the Gambia Family Planning Association treats women with candidiasis and trichomoniasis but refers all other women with STDs to government clinics [280]. A few programs provide complete services. The Asociacion Demografica Salvadorena (ADS), for example, screens family planning clients, treats patients, provide community outreach, distributes condoms, and notifies partners [5]. In the US most family planning clinics screen clients for STDs, particularly gonorrhea and syphilis, and many both diagnose and treat STDs [2, 77, 111, 172, 235, 284]. A 1990 survey of about 400 US family planning clinics found, for example, that almost all clinics screened clients for gonorrhea at the initial visit, annual visit, or when clients had symptoms, and 82% treated gonorrhea. Almost half screened for syphilis at the initial visit and treated syphilis. Almost all told infected clients to notify partners, and about one-third used staff or clinic resources to notify partners [284].

Why Strengthen STD Services?

Family planning programs have decided to strengthen STD services for many reasons:

* To serve the many people who seek care for STDs. Family planning programs in Colombia, Guatemala, the US, and other countries report that many of their clients seek treatment for STDs [10, 268, 300, 311]. Staff do not want to tell patients with STDs that they cannot help [13].

* To combat high levels of STDs and reproductive tract infections in the population served [5, 72]. In Guatemala staff of the Asociacion Pro Bienestar de la Familia (APROFAM) screened clients in 1991-92 and found that 43% had genital ulcers or candidiasis [5].

* To prevent infertility. Family planning programs are concerned with a woman’s total reproductive health and so want to prevent infertility.

* To avoid referrals that mean some clients miss care. Since clients who are referred elsewhere may not go, family planning programs that treat STDs in their clients can make sure that the infections are treated.

* To help reduce the transmission of HIV. This is one reason that ADS has set up STD services at the PROFAMILIA family planning clinic in San Salvador, El Salvador [5].

* To help women take more control over their sexual relationships. For example, women who visit the Planned Parenthood Association of Zambia fill out a questionnaire that asks about their relationship with their husbands, many of whom have extramarital sex. In small groups the women discuss how to approach the problem and rehearse dialogues that they can have with their husbands. Also, mixed groups of men and women discuss condoms and monogamy. In Guatemala APROFAM helps women deal with drinking and violence in their sexual relationships [103].

* To make money. Some family planning programs can charge for STD services. PROFAMILIA in Colombia, for example, charged about US$5.50 in 1991 for an STD consultation plus charges for diagnostic tests. The revenue from these and other gynecological and medical services helps to pay for family planning services [299].

* To serve a common clientele. Both family planning and STD programs serve a young and sexually active population. Family planning programs serve mainly women, who suffer more than men from the consequences of both unplanned pregnancy and STDs [49].

* To make use of community-based outreach. Family planning programs in The Gambia, Kenya, and other countries train community-based distributors to inform clients about STDs, to recognize signs and symptoms, and to refer people who may have STDs for treatment [93, 103, 136]. In an innovative program in Matlab, Bangladesh, Lady Family Planning Visitors have been trained to perform abdominal, bimanual, and speculum exams and to take specimens for laboratory testing from women with symptomatic STDs [314]. CBD workers also can give educational talks to community groups.

Donor agencies are helping to strengthen STD services in family planning programs. Improving the management of STDs is an important component of the AIDS prevention program of the United States Agency for International Development (US AID). For family planning programs US AID currently focuses on prevention of STDs and supports studies of the introduction of STD services into family planning programs in several countries [324]. The United Nations Population Fund (UNFPA) endorses screening for STDs by maternal and child health and family planning (MCH/FP) programs, especially to identify the cause of infertility. UNFPA recognizes, however, that most such programs cannot offer comprehensive diagnosis and treatment for STDs and need to refer clients [264]. As part of its AIDS prevention activities, UNFPA supports AIDS education in family planning communication programs, AIDS counseling and condom distribution in MCH/FP programs, and AIDS education in training of MCH/FP providers [301].


Strengthening STD services can have disadvantages for family planning programs:

* Less time for family planning services. Unless more personnel are hired, staff have more to do, and clients may have to wait longer. Also, to offer STD services, family planning providers need more initial training and periodic updates. A US study recorded the additional time needed to provide services for gonorrheal and chlamydial infection at a family planning clinic. The clinic screened 364 family planning clients for STDs with laboratory tests, provided services for people who came to the clinic with STD symptoms, treated and counseled women with STDs, and followed up patients to ensure that they were cured. The clinic coordinator, nurse, clerk, and physician together spent almost two hours per client to provide some or all of these services. The nurse alone spent almost one hour per STD client. Of the 364 clients receiving STD services, 85 had one or both STDs [32].

* Additional costs. In the US study, adding these services for chlamydia and gonorrhea cost about $6,000 for three months, or 14% of the total operating expenses of the clinic [23].

* Differences in counseling. Family planning providers help clients choose a contraceptive, while providers of STD services need a direct clients to treat their disease, to avoid infecting others, and to stay cured. Combining these nondirective and directive approaches to counseling may be difficult [49].

* Difficulty of treating sexual partners. Men may be reluctant to go to a family planning clinic for treatment of STDs. Thus programs may waste time and resources treating women who are then reinfected by their partners.

* Reluctance to talk about sexuality. STD service providers need to discuss sexuality. Ironically, many family planning providers are not trained to discuss sexuality and often neglect to discuss sexuality when they help clients to choose a contraceptive [131, 184, 207].

* Possible stigma of STD services. Some staff at PROFAMILIA in Colombia were worried that the stigma of STD services would spread to family planning services, but demand for family planning has not declined since 1988, when STD services were started [300]. In contrast, another Latin American family planning association offers STD services in a separate clinic that is not obviously connected with the family planning clinic [250].

Contraceptives and Sexually Transmitted Diseases

Family planning programs need to protect clients against both pregnancy and STDs. The most effective contraceptives–voluntary sterilization, injectables, Norplant, IUDs, and the pill–do not protect against STDs. Condoms, in contrast, protect against a variety of STDs, including HIV infection [20, 64, 85, 206, 221, 345). In an analysis of nine observational studies, condom users’ risk of developing gonorrhea was about 60% that of those not using contraception. Two studies of chlamydia and two of trichomoniasis found that condom users’ risk was three-quarters that of nonusers [259]. Between 10% and 15% of women who rely on condoms become pregnant in the first year of use, however, mainly because they and their partners do not use condoms consistently or correctly [342]. Thus, for clients at risk, some providers recommend a highly effective, convenient contraceptive method–an injectable, for example–along with condoms (see Table 4).

Without strong motivation, however, clients may find it difficult to use two methods–condoms for STD prevention and some other method for pregnancy prevention. Many people, after all, have trouble using one method consistently, particularly condoms. Studies in the US of sterilized women and adolescent users of oral contraceptives have found low rates of condom use [267, 319]. In the study of sterilized women, for example, 35% were at risk for STDs, but only 22% used condoms at least some of the time. By comparison, 37% of women who were not sterilized were at risk for STDs, and 54% used condoms at least some of the time [267].

Some women are not able to persuade their partners to use condoms. What then? Some argue for more emphasis on methods that women control: spermicides, diaphragm, cervical cap, contraceptive sponge, or, as it becomes available, the female condom (a polyurethane or latex sheath that a woman can insert into her vagina before having sexual intercourse). Some studies have found that in practice the diaphragm and sponge actually provide more protection against STDs or their sequelae than condoms, probably because they are used more regularly [260]. Others, however, argue that there is too little evidence that spermicides and female barrier methods prevent STD transmission as well as condoms do. They also are concerned about reports of vaginal irritation caused by frequent spermicide use (that is, several times a day) among commercial sex workes. Such irritation can increase the risk of HIV transmission [48]. Used less frequently, however, spermicides may not cause vaginal irritation. More research is needed on [1] contraceptive methods that women control and that protect completely against STDs; [2] methods that allow women to become pregnant and still protect them against STDs–for example, a microbicide that kills STD pathogens but not sperm; and [3] couples’ willingness to use condoms and another contraceptive method at the same time.

Family planning providers, like STD service providers, need to counsel clients about STDs and stress that condoms and possibly spermicides can protect them. All family planning clients at risk for STDs, regardless of their contraceptive choice, should leave a family planning clinic knowing how to use condoms and where to get them–and, preferably, with some condoms in hand. [TABULAR DATA OMITTED]

COPYRIGHT 1993 Department of Health

COPYRIGHT 2004 Gale Group