This publication documents the experience of the world's largest international HIV/AIDS prevention project, which was implemented by FHI and its partners in 45 countries. It describes lessons learned during AIDSCAP, with examples and project profiles, in 10 technical and programmatic areas: behavior change communication, improving prevention and treatment of sexually transmitted diseases, prevention marketing, policy development, behavioral research, evaluation, gender and HIV/AIDS, management, AIDS care and support, and cross-border interventions.

Table of Contents

Making Prevention Work

1. Behavior Change Communication: From Individual to Societal Change

2. Improving STD Prevention and Treatment (See Below)

3. Prevention Marketing: Condoms and Beyond

4. Policy Development and HIV/AIDS Prevention: Creating a Supportive Environment for Behavior Change

5. Behavioral Research: Using Results to Design Behavior Change Interventions

6. Evaluating HIV/AIDS Prevention Programs: Developing New Tools for Meaningful Measurement

7. Women, Men and HIV/AIDS: Building Gender-Sensitive Programs

8. Managing HIV/AIDS Programs and Building Capacity to Sustain Prevention Efforts

9. Prevention and Care: Mutually Reinforcing Approaches

10. Crossing Borders: Reaching Mobile Populations at Risk

Partners and Acronyms

2. Improving STD Prevention and Treatment

The more than 333 million curable sexually transmitted infections that occur every year worldwide are a significant cause of incapacitating illness, death, infertility and fetal loss. Yet until the onset of the HIV/AIDS epidemic, the global burden of sexually transmitted diseases was largely ignored.

STD services in most countries show the effects of decades of neglect. Many, if not most, people prefer self-treatment -- however ineffective or incomplete -- to the inconvenience and embarrassment of seeking treatment at a specialty STD clinic. Lack of confidence in STD services is common and often justified: drug shortages, inadequate information about drug resistance, limited access to laboratory diagnosis, and health care workers' lack of knowledge or reluctance to treat STDs all contribute to the poor quality of care.

Recognizing the need to make STD treatment more effective and accessible, the World Health Organization's Global Programme on AIDS promoted an approach that enables health care workers to treat people who have symptoms suggestive of an STD during a single clinic visit. Syndromic management -- the recognition of a group of clinical findings and patient symptoms and treatment for the major causes of those symptoms -- makes it possible to manage the majority of symptomatic STDs without sophisticated laboratory tests or specialized skills, which means that STD patients can receive appropriate medications at primary health care facilities.

The development of syndromic management guidelines and other efforts to improve STD management and prevention at "points of first encounter" with the health system were prompted by the rapid spread of the HIV/AIDS epidemic. One reason for this new attention to STDs is obvious: the sexual behaviors that lead to STDs also promote the spread of HIV. But early in the HIV/AIDS epidemic, results of epidemiological and laboratory research suggested that STDs actually enhance HIV transmission. Given this evidence of a link between HIV and other STDs, AIDSCAP made improving STD prevention and treatment one of its main HIV prevention strategies when the project began in 1991.

Since then, the results of several important studies have confirmed the validity of this strategy. In a landmark pilot study in Mwanza, Tanzania, use of the syndromic approach to STD treatment that AIDSCAP has advocated worldwide reduced HIV incidence by 42 percent. And recent research in Malawi produced strong biological evidence that STD treatment can make HIV-positive men less infectious.¹

Along with mounting evidence of the connection between STD treatment and HIV prevention, the past five years have brought recognition that STD control is by no means a purely medical intervention. Policymakers, health care providers and community members all have important roles to play in providing accessible, acceptable and effective STD services.

Expanding Access to Effective Treatment

AIDSCAP's primary accomplishment in STD programs was to further develop and increase the use of syndromic management of STDs at points of first encounter in 18 countries throughout the developing world. Through research, advocacy, consensus building, training and information dissemination, the project made an important contribution to promoting worldwide acceptance of this proven approach to improving access to effective STD treatment.

Encouraging adoption of syndromic management required considerable effort at the policy level as well as research to validate and adapt WHO algorithms in different settings. AIDSCAP worked with local officials and providers to build consensus on the need for a standardized approach to STD management and to develop national guidelines for syndromic management of STDs. The success of this collaborative process laid the foundation for subsequent efforts to strengthen STD services.

AIDSCAP improved STD care at points of first encounter through technical assistance and training in syndromic management, communication and STD program management for providers, managers and pharmacists. Despite initial resistance to the syndromic approach, follow-up assessments of the STD care provided by trainees in different countries found marked increases in the percentages of clients receiving effective treatment.

Management training was critical to ensure that managers could provide the support and guidance necessary for successful implementation of syndromic management. With AIDSCAP support, managers of STD and HIV/AIDS control programs in developing countries attended international and regional training courses on STD program management. AIDSCAP also created a handbook for STD program managers -- the first publication of its kind -- that is being used in training courses and as a reference guide worldwide.²

Recognizing that failure to seek prompt STD care is often a result of stigma, lack of knowledge about STDs and providers' attitudes toward STD patients, AIDSCAP placed increasing emphasis on improving communication between providers and clients and between STD programs and communities. In 1994, the project developed a rapid ethnographic methodology for conducting qualitative studies to identify ways to make STD programs and outreach efforts more responsive to the communities they serve. The results of targeted intervention research (TIR) studies conducted in nine African countries are being used to strengthen patient-provider relations and to promote symptom recognition, accurate behavioral risk assessment, treatment-seeking, and condom use for STD prevention. Publication of the Targeted Intervention Research Manual, which was disseminated to STD programs and international organizations, will enable program managers to conduct their own TIR studies with technical assistance from local social scientists and STD specialists.³

While working with colleagues to strengthen STD prevention and management through existing health care and family planning facilities, AIDSCAP also explored alternative approaches to expanding access to these services. Field tests in Nepal and Thailand demonstrated that training in syndromic management can improve the advice pharmacists and drugstore personnel give their customers about STD treatment. AIDSCAP's experience with the first pilot study of the provision of prepackaged STD therapy yielded important lessons for future research to assess this approach. And the preliminary results of an AIDSCAP-sponsored study of targeted periodic presumptive treatment in South Africa showed dramatic reductions in STD prevalence among sex workers and their clients.

Program-related research on STD prevalence, antibiotic resistance, community perceptions of STDs, and partner referral strategies also contributed to efforts to improve STD prevention and management. In many cases, AIDSCAP-sponsored prevalence studies produced the only data on STDs in a country. Local data on prevalence and resistance were often the key to reversing opposition to the syndromic approach and revising essential drug lists.

Studies were conducted in more than 16 countries to advance AIDSCAP's STD strategy. AIDSCAP shared this wealth of experience with colleagues throughout the world by publishing more than 25 articles in peer-reviewed journals and presenting more than 40 abstracts at international and regional conferences.

Lessons Learned

Consensus and Communication

• Building the foundation for improving care at points of first encounter requires intensive effort at the policy and program management levels.

Engaging the commitment and resources of public health officials and STD managers and providers demands significant technical assistance and consensus building. AIDSCAP's experience in Haiti, where such efforts led to national consensus on STD guidelines and improvements in service delivery, shows that the time and resources necessary to orient and train policymakers, managers and providers are well worth the investment (Box 2.1).⁴

• Biologic studies of STD prevalence and antibiotic susceptibility in a country are essential to building consensus on national STD treatment guidelines.

The local data that these studies generate can help convince STD program managers and health care providers to adopt the syndromic approach to STD management. AIDSCAP found that once managers and providers understood the magnitude of the STD problem in their country and the ineffectiveness of many of the current treatment practices, they were more likely to appreciate the benefits of a simple, standardized approach that increases access to effective treatment.

• Findings from rapid ethnographic studies of community perceptions of STDs can improve communication between provider and patient.

AIDSCAP recognized the importance of understanding community perceptions, beliefs and practices related to STDs and developed an ethnographic tool to study them.³ The results of AIDSCAP-sponsored targeted intervention research (TIR) are being used to improve clinic- and community-based communication with STD clinic clients and potential clients in nine countries (Box 2.2).

Improving Access

• Research findings from several countries confirm the impression that many people seek treatment for STDs outside the formal medical system.

For example, AIDSCAP studies in two African countries documented a significant amount of self-treatment and treatment seeking in the informal sector. In Ethiopia, 61 percent of the men and 41 percent of the women interviewed had sought treatment at a pharmacy or from a local injector or traditional healer before consulting at a health center. In Cameroon, 50 percent of male patients with a history of acute urethritis during the previous 12 months had treated themselves with drugs bought at pharmacies or in the market.Their reasons for self-treatment were long waits at clinics, the need to wait for laboratory results before getting a prescription, the cost of lab tests, and the cost and effectiveness of the drugs prescribed by health providers.

• Although high levels of self-treatment and limited resources for STD control in many countries compel policymakers, medical professionals and donors to consider innovative approaches to improving access to effective treatment, opposition to providing STD management outside the clinic setting is strong.

AIDSCAP field tested two alternatives to clinic-based treatment -- training pharmacy workers in syndromic management and promoting prepackaged therapy for urethritis. Two of the pilot studies encountered resistance from the medical community, and the prepackaged therapy could not be tested as planned because of lack of support from medical professionals and public health authorities.

• Training pharmacists and other drugstore personnel in the syndromic approach can improve the management of STDs in many patients who choose to self-medicate.

In Nepal, training drugstore personnel to dispense antibiotics using the syndromic approach and to provide clients with preventive education and condoms markedly improved their prescription practices. The percentage of drugstore personnel suggesting effective treatment to a "mystery shopper" with urethritis symptoms increased from 0.8 to 45 percent. Trained drugstore personnel were also more likely to suggest that their customers use condoms and refer partners for treatment. However, more than half continued to advise customers to take ineffective medications, indicating a need for additional training, supervision and support.

Researchers believe that a number of factors contribute to continuing problems with the STD management practices of drugstore personnel. Even when a pharmacist or drugstore clerk is well trained and committed to providing effective treatment, he or she is unlikely to turn away business if a customer can only afford to buy a partial prescription. Moreover, it is often difficult in a public business setting to guarantee the privacy necessary for gaining a customer's trust.

• Sales of prepackaged STD therapy in pharmacies and health facilities could increase access to effective STD care, but successful implementation requires the full support of public health officials and health care providers.

The first pilot study of this approach, conducted by AIDSCAP in Cameroon, faltered because it lacked the necessary local support. Only 27 percent of the health care providers who had been trained to prescribe prepackaged therapy for urethritis actually did so. Without a consensus on the need for syndromic management of STDs and other alternatives to traditional STD care, it was impossible to adequately assess the effectiveness of this approach.

• Patients may be more receptive to prepackaged STD therapy than providers.

Follow-up interviews with patients who had received the kit of urethritis therapy in Cameroon revealed high levels of compliance and satisfaction. More than 82 percent reported taking a full course of medication, 84 percent said they had used condoms while on the medication, and 44 percent had used the cards in the kit to refer partners for STD treatment. Providers at one of the clinics reported that clients continued to ask for the kits months after the pilot study ended.

Detecting Asymptomatic STDs

• Current risk assessment strategies are not a valid tool for identifying STDs in women without symptoms.

The main obstacle to managing STDs other than syphilis in asymptomatic women is the absence of valid, feasible and affordable case-finding and screening strategies, particularly for gonococcal and chlamydial infection. Results of studies conducted by AIDSCAP in Jamaica and Tanzania and by others attempting to define a risk profile for infected asymptomatic women have been disappointing.^5,6 These studies found that risk assessment scores derived from current flow charts are neither sensitive nor specific enough for widespread use. However, imperfect approaches that include risk assessment may be a better option than doing nothing at all, particularly in areas where STD prevalence is high. Moreover, risk assessment may continue to play a role in the management of STDs in asymptomatic women because risk scores could be used to determine who should be tested for a sexually transmitted infection when an appropriate test becomes available.

• Partner referral is possible in a variety of settings.

Reaching partners of STD patients with treatment -- a long-neglected component of STD management in most countries -- has great potential for improving STD control because it results in treatment of asymptomatic partners, particularly women. AIDSCAP's improved partner management systems in antenatal clinics in Haiti and primary health care facilities in Rwanda attained referral rates of 25 to 35 percent.^7,8

• Treating women and their partners for STDs as part of antenatal care creates opportunities to motivate men to seek treatment in order to protect the health of their children and partners.

An AIDSCAP pilot study found that almost half of the women attending two Haitian antenatal clinics had one or more STDs. Ninety percent of the women agreed to inform their partners, and 30 percent of the 331 men named by 384 women sought treatment. Health workers found that men were more willing to come for treatment when the problem was framed in the context of preserving fertility or ensuring healthy offspring. When men who had come to the clinic were asked why it was important to them to receive treatment, one of the most common responses was "to protect the child."⁷

• Health workers with no laboratory experience can be trained to perform accurate syphilis blood tests, making it possible to expand syphilis screening of pregnant women.

An effective, affordable treatment for syphilis is available, yet hundreds of thousands of undetected and untreated maternal syphilis cases lead to fetal loss, infant death or congenital abnormalities every year. Too often, logistical and managerial obstacles impede use of the rapid, simple, inexpensive syphilis diagnostic test for routine screening in antenatal clinics. In Jamaica, AIDSCAP worked with the Ministry of Health to remove some of these obstacles in a successful effort to decentralize syphilis testing (Box 2.3).⁹

• Targeted periodic presumptive treatment of selected STDs (often referred to as "mass treatment") among epidemiologically defined "core groups" holds promise for achieving rapid decreases in communities' reservoirs of STDs.

Mathematical models have demonstrated that core groups with high rates of sexual partner exchange disproportionately increase the spread of STDs within a population. Periodic presumptive treatment offers the advantages of achieving a decline in STDs more quickly than sexual behavior change alone and reaching asymptomatic individuals who would not otherwise seek care. But careful research is needed to ensure that this approach does not promote antibiotic resistance, disrupt individuals' normal biological resistance to sexually transmitted infection, or lead to an increase in high-risk behavior.

Preliminary results of an AIDSCAP pilot test of empiric periodic treatment among sex workers in a South African mining community confirm that this strategy can be cost effective in such a setting. By offering syndromic STD treatment to all women with multiple partners referred by peer educators, the study was able to reduce STD prevalence among women using the service by 30 percent. STDs also declined among their clients and partners: the project found a one-third decrease in urethritis and a two-thirds reduction in genital ulcers among miners. Findings from interviews with study participants and focus group discussions with peer educators, as well as limited data from miners, suggest that the women and their clients have fewer casual sex partners and use condoms more often, although high-risk behavior continues. Results of a cost-benefit analysis convinced the management of the Harmony Mine to continue the intervention and expand it to other areas of the community.¹⁰

Recommendations

• AIDSCAP proposes the following steps as a comprehensive, rational approach to establishing improved, client-centered STD service delivery. Many of these steps can take place simultaneously, and it is not necessary to complete studies before adopting provisional national guidelines and beginning training.
  • Gather existing data or conduct studies to describe local STD prevalence, antimicrobial susceptibility patterns, and STD beliefs and practices.

  • Convene local health personnel to review epidemiological data and reach consensus on national STD syndromic treatment guidelines.

  • Design, conduct and evaluate training of local providers in syndromic management.

  • Use TIR results to redesign services.

  • Design, pretest and produce materials for patients and providers.

  • Design and pretest messages and materials for community members based on TIR findings.

  • Provide supportive supervision for trainees and evaluate service provision.

  • Train regional, national and local managers in program management and evaluate the results of the training.

  • Work to ensure required drugs are available.

• To improve communication between providers and clients, program managers should use rapid ethnographic studies to understand community perceptions about STDs and STD services, as well as provider attitudes toward clients.

• Given the high levels of self-treatment and lack of access to effective STD treatment found in many countries, STD and HIV/AIDS control programs should supplement efforts to improve traditional STD services with alternatives such as training of pharmacists in syndromic management and selling prepackaged STD therapy in pharmacies and health facilities. Greater emphasis on behavior change communication is also needed in both clinic-based STD services and community outreach to encourage early treatment seeking.

• STD programs should institute partner referral in order to detect and treat asymptomatic STDs, particularly in women.

• All pregnant women attending antenatal clinics should be screened for syphilis and treated. Health care workers with no laboratory experience can be trained to use the rapid, inexpensive diagnostic test for syphilis with high levels of accuracy.

Future Challenges

Adding Strategies

The syndromic approach to STD management is not the complete solution to STD control. It works well for urethral discharge in men, genital ulcer disease in both men and women, and pelvic inflammatory disease, but is less than optimal for managing vaginal discharge, even with the addition of a risk assessment. Moreover, syndromic management was never designed as a tool for identifying infection in asymptomatic people. Greater support is required for additional approaches, including partner referral and treatment, services targeting high-risk populations, and comprehensive syphilis screening of antenatal women. Rapid, inexpensive, simple diagnostic tests for gonococcal and chlamydial infection are urgently needed to improve the management of STDs in symptomatic women and to identify asymptomatic infections.

Changing Provider Behavior

In spite of efforts to improve management of STD patients through syndromic management training, many health care providers are reluctant to change their practice behaviors. Anecdotal information suggests that their reasons include prestige, profit motives and pressure from pharmaceutical companies, and the belief that certain STDs syndromes are not serious and do not warrant antibiotics. Research is needed to further understand this resistance to the syndromic approach among different groups of health care providers and to propose solutions.

Assessing Creative Approaches

The critical constraints to effective STD treatment and prevention found in most developing countries require innovative responses. More research is needed to test approaches such as empiric periodic treatment and prevention marketing of prepackaged STD therapy. These approaches must be introduced in ways that provide sound, objective evidence of efficacy that will enable decision makers to make informed judgments on the advisability of implementing them on a wider scale.

Tracking Antibiotic Resistance

A major obstacle to STD control is the ever-evolving development of resistance against antibiotics, particularly for gonococcal infections. Patterns of resistance to antibiotics may differ substantially by region and even from one country to the next, and a lack of reliable and representative data makes it difficult to adapt STD treatment guidelines for national and regional use. A global network of laboratories using a common methodology to conduct gonococcal surveillance would greatly facilitate efforts to develop, update and disseminate standardized guidelines for effective STD treatment.

Improving Reproductive Health

Despite the limitations of current tools and health infrastructures, it is possible to improve women's access to STD prevention and management by integrating these services into family planning, maternal-child health (MCH) and primary health care (PHC) programs, as AIDSCAP's experience in Nepal demonstrates. Additional training is needed to equip the staff at these clinics to counsel clients on risk reduction and to refer symptomatic women and women with clinical signs suggestive of an STD for treatment. At some clinics, staff could also learn to provide syndromic treatment for symptomatic women and for asymptomatic women through partner referral links with clinics treating men. A smaller number of clinics could provide laboratory diagnosis and treatment. Operations research is needed to determine what levels of integration are feasible and cost effective in different settings and to establish technical guidelines and procedures for incorporating STD prevention and management into family planning, MCH and PHC services.

References

1. Cohen M, Hoffman I, Royce R, et al. (1997) Treatment of urethritis reduces the concentration of HIV-1 in semen: implications for prevention of transmission of HIV-1. The Lancet 349 (9069):1868.
2. Dallabetta G, Laga M, Lamptey P (1996). Control of Sexually Transmitted Diseases: A Handbook for the Design and Management of Programs. AIDSCAP/Family Health International, Arlington, Virginia.
3. Helitzer-Allen D and Allen H (1994). The Manual for Targeted Intervention Research on Sexually Transmitted Illnesses with Community Members. AIDSCAP/Family Health International.
4. Behets F, Génécé E, Narcisse M, Cohen M, Dallabetta D. Approaches to control sexually transmitted diseases in a difficult context: the case of Haiti from 1992 through 1995. Bulletin of the World Health Organization. In press.
5. Behets F, Ward E, Fox L, Reed R, et al. Sexually transmitted diseases are common in women attending Jamaican family planning clinics and appropriate detection tools are lacking. Genitourinary Medicine. In press.
6. Kapiga SH, Vuylsteke B, Lyamuya Ef, Dallabetta G, Laga M. Evaluation of sexually transmitted diseases diagnostic algorithms among family planning clients in Dar es Salaam, Tanzania. Genitourinary Medicine. In press.
7. Desormeaux J, Behets F, Adrien M, et al. (1996). Introduction of partner referral and treatment for control of sexually transmitted diseases in a poor Haitian community. International Journal of STD & AIDS 7:502-506.
8. Steen R, Soliman C, Bucyana S, Dallabetta G (1995). Partner referral as a component of integrated sexually transmitted disease services in two Rwandan towns. Genitourinary Medicine 72:56-59.
9. Behets F, Bennett L, Brathwaite A, et al. (1997). The decentralization of syphilis screening for improved care in Jamaican public clinics. American Journal of Public Health 87(6):1019-1021.
10. Periodic Presumptive Treatment of Women at High Risk: An Intervention to Reduce the Prevalence of Curable STDs in a South African Mining Community (1997). Final Report. AIDSCAP/Family Health International, Arlington, Virginia.