An increasing understanding of the links between HIV and other sexually transmitted diseases has led to an emphasis on more community-oriented STD prevention and treatment strategies.
In the fifteenth century, when Europeans first began to recognize the existence of sexually transmitted disease (STD), patients suffering from syphilitic ulcers were offered a special cure for their malady. It consisted of a toxic salve of mercury, pork fat, vinegar and sulfur rubbed deep into the sores, followed by 30 consecutive days of hard sweating in a steam room -- a remedy usually more lethal than the disease itself.1
It took 500 more years for scientists to find a better alternative in antibiotics. By that time, a revolution in thinking about the causes, the treatments and the social meanings of STDs had occurred.
During the past decade, medical and social responses to STDs have evolved again, provoked by the emergence of the HIV/AIDS epidemic. As evidence builds that STD infection may increase transmissibility of HIV as much as ninefold, greater attention is being paid to STD control -- and new approaches are emerging that could significantly expand the scope and the scale of STD treatment and education in developing countries.
"We're turning from a clinical orientation, which limits the focus to the individual STD case, to a public health approach, which deals with STDs as a community health problem," said Dr. Gina Dallabetta of the AIDS Control and Prevention (AIDSCAP) Project.
STDs in Developing Countries
Among women in developing countries, syphilis prevalence rates may be 10 to 100 times higher than in developed countries; gonorrhea rates may be 10 to 15 times higher. One study in Kenya showed that 23 percent of women ages 15 to 19 seeking care at an antenatal clinic suffered from gonorrhea, chlamydia or herpes. In many of the same countries -- particularly in Africa -- HIV infection rates are similarly high, and researchers are trying to explain why.
"We're noticing that HIV-positive people who have other STDs are simply more infectious," said Dr. Myron Cohen, a microbiologist who is chief of infectious diseases at the University of North Carolina Medical School. "For example, preliminary findings on seropositive men show that those with untreated urethritis shed far more viral particles than those without another STD."
Epidemiologists are also building impressive evidence revealing the linkages between HIV and other STDs. Findings from a pathbreaking prevention study conducted in Mwanza, Tanzania, confirm that improved treatment of STDs can reduce the incidence of HIV infections. During the two-year study, broad-scale treatment of STDs within a cohort of 1,000 using the least expensive effective drugs led to an astonishing 42 percent decline in new HIV infections.
Results like these offer considerable incentive to make improved STD prevention and treatment a primary HIV prevention strategy. But for developing countries, where resources are scarce, pursuing such ambitious public health goals is difficult.
The etiologic diagnosis of STDs that is standard throughout wealthier countries requires diagnostic tests, well-stocked laboratory facilities and highly trained medical personnel -- resources that many poverty-stricken countries cannot afford. Clinical diagnosis, based primarily on visual cues and the practitioner's prior experience and knowledge, is inexpensive but unreliable in differentiating between STDs. Many of the antibiotics required for STD treatment are also expensive and often unavailable in developing countries. Developing diagnostic and treatment alternatives that are both accurate and affordable has become a priority for STD/HIV prevention efforts.
Syndromic Management of STDs
Of central importance to the success of the Mwanza experiment was the use of syndromic diagnosis and management of STDs in the region's health centers. First formulated by World Health Organization (WHO) experts in the late 1980s, the syndromic approach offers treatment for the most common causes of STD syndromes (sets of symptoms) when the patient first seeks medical care. Rather than order expensive and time-consuming lab tests to pinpoint the pathogen causing the syndrome -- say, genital ulcers -- the practitioner prescribes all the antibiotics and therapies necessary to treat all locally prevalent STDs that could create ulcers, such as chancroid and syphilis. With every causal base covered, the likelihood of a cure rises dramatically.
"In the absence of resources to provide more specific diagnoses through lab testing, syndromic management allows clinicians to maximize their bets when they place patients on treatment regimens," said Dr. Willard Cates Jr., Family Health International's corporate director of medical affairs.
In resource-poor settings such as the Tanzanian countryside, the benefits of syndromic management are many. First, precious health care funds need not be spent on lab tests which, depending on the country's technical resources, may not even be reliable. Second, one-stop treatment solves a problem endemic to developing countries: patients who are too anxious, too busy or too poor to return for follow-up. Third is the opportunity for syndromic management practitioners to give face-to-face prevention counseling and training in condom use and other prevention methods to patients, the final step in most syndromic protocols.
A fourth advantage is that the syndromic method does not require costly graduate-level medical education. Less-skilled health workers as well as physicians can be trained in the method, which uses simple flow charts to guide the practitioner to the proper diagnosis and treatment.
The AIDSCAP Project, WHO, the joint United Nations Programme on HIV/AIDS (UNAIDS), the Pan American Health Organization (PAHO) and other international health agencies are working with governments and nongovernmental organizations (NGOs) to actively promote syndromic management. Frequently, they encounter resistance.
"Developing countries have a tendency to believe that development means acquiring more sophisticated technology -- which to them means testing," said Dr. Cohen. "It becomes a matter of convincing health ministers and national medical associations that, in the case of syndromic management, what they might see as 'less' really is more."
Other obstacles can slow the adoption of syndromic management. Baseline research is needed to determine the algorithmic protocols, which differ from place to place depending on which STDs are locally prevalent. Regional data on the effectiveness of antibiotics for specific STDs also must be gathered. Another major challenge is getting all parties in the health care and STD/HIV prevention community to the table to agree on national protocols.
In Haiti, a country beset by political unrest and widespread poverty, giant steps have been made toward adopting a single set of guidelines for syndromic management. A working group of health agencies and NGOs, including AIDSCAP, the University of North Carolina, PAHO, an NGO coalition from the Central Plateau region, the Cornell-GHESKIO research group and the Centre pour le Développement et la Santé shared observations from their clinics and used the results of a 1993 baseline study to reach a consensus on syndromic management guidelines.
AIDSCAP, a major proponent of syndromic management, has been involved in the research, promotion and facilitation of similar efforts to create national syndromic guidelines and improved care at points of first encounter in 19 countries throughout the developing world.
Improving Drug Delivery
All too often, self-treatment is the route that many STD patients in developing countries take to avoid hours spent in clinic waiting rooms, embarrassment at being seen at STD clinics, and high doctor's fees and prescription costs. They may feel more comfortable asking pharmacists, traditional healers, street peddlers and even friends and family members for treatment suggestions.
The dangers are obvious. Misdiagnosis of one's own STD means that it's unlikely the drug the patient finally takes will be effective. Most poor patients can't afford a complete course of antibiotics, and buy amounts insufficient to treat the STD. The drugs they're told to buy may not work at all because their STD is resistant to the antibiotic. The STD is never cured, and the patient may unknowingly infect others while suffering ever more serious damage from the disease.
One innovative solution is prepackaged drug therapy for STD syndromes, available by prescription or over the counter from pharmacists trained to diagnose symptoms and provide counseling. The M-STOP pilot project in Cameroon, a joint effort of AIDSCAP, Population Services International and the Institute of Tropical Medicine, offered attractive, affordable kits containing antibiotics, condoms, informational brochures, instructions and other materials to men with symptoms of urethritis.
The project soon ran into difficulty when supporters at the Ministry of Health were replaced by skeptics who limited M-STOP's distribution to a handful of health clinics serving very specific populations. Resistance from health care providers at some of those clinics further limited use of the kits.
With lessons learned about how to gain greater acceptance from the medical community and health officials, AIDSCAP is now working with the Nepalese Chemists and Druggists Association, donor agencies and NGOs to implement a prepackaged drug therapy project in nine districts in the Central Region of Nepal. Research has shown that a high percentage of STD cases in Nepal are treated by chemists (pharmacists) and other health providers outside the national system of clinics and hospitals. Nepalese officials and health leaders, whose support was recruited as early as possible, are collaborating with enthusiasm in project planning.
Other pharmacy-focused approaches are being tested in developing countries. In Thailand, where pharmacists are frequently consulted by patients with STD symptoms, AIDSCAP and the Program for Appropriate Technology in Health (PATH) conducted a pilot project to train pharmacists and drugstore staff in STD diagnosis and drug prescription. AIDSCAP and PATH worked closely with two pharmacists' associations in Chiang Mai province to develop training activities that improved pharmacists' ability to manage STD cases. The project has inspired pharmacist training efforts by the European Community and other donors in Thailand.
Identifying Community Needs
Community acceptability is key to program success, and STD prevention programmers who understand local belief systems and cultural perceptions about illness, health-seeking behavior and STD infection can design more effective interventions. A rapid ethnographic methodology called targeted intervention research (TIR) can help researchers identify community attitudes that may help or hinder STD treatment and promotion of such prevention methods as condom use.
The TIR, developed by AIDSCAP in collaboration with researchers from Johns Hopkins University and the University of Washington, is based on interviews and focus group discussions with STD patients and with people living in communities served by STD programs. Unlike traditional ethnographic surveys, the TIR is targeted to answer specific programmatic questions. AIDSCAP has used the TIR successfully in Senegal and Ethiopia to study health-seeking behavior, in Zambia to design communication strategies promoting early attendance at antenatal clinics, and in the Philippines to understand how commercial sex workers avoid STD infection.
Such research is particularly valuable for formulating STD prevention and treatment programs for vulnerable "core" groups within communities. Because certain members of a population may be at higher risk for STD/HIV infection, it often makes public health sense to target limited resources in developing country programs to those sectors.
In identifying priority groups, though, it is critical to avoid stigmatization. Education and treatment projects for commercial sex workers (CSWs), for example, must be designed so that clients feel their privacy and confidentiality are guaranteed. The location and hours of service must be convenient, and the atmosphere should be comfortable and non-threatening. Early input from CSWs on such matters is one way to design successful projects from the start.
Many CSWs prefer brothel-based services because they are convenient and are more likely to be private and confidential. In Thailand, the Philippines and Indonesia, some brothel owners contract with private practitioners to attend CSWs regularly on site. In Mali, a visiting medical team provided care at brothels during hours that did not interfere with the women's work. To curb stigmatization, the team traveled to each site in buses or taxis rather than easily identified government health vehicles.
Not all successful services for CSWs are brothel-based, though. With intelligent and successful design based on input from CSWs, other kinds of sites -- primary health care and family planning clinics, mobile vans, private medical facilities -- will be acceptable, leading to lower HIV/STD infection rates among CSWs and thus the community at large. These design and planning principles are also successful with other hard-to-reach groups, such as youth and persons working away from home.
Community input of another kind is also critical to success in curbing STDs. Partner notification and referral by STD patients can dramatically increase the number of infections treated within a given community. Referral is especially valuable for reaching infected women, many of whom have no STD symptoms.
In Rwanda, for example, STD patients involved in a special study conducted by Rwandan and U.S. researchers were counseled and then given referral coupons for their sex partners. The coupons offered a free STD exam and treatment, and were coded so that clinic staff knew which treatment to give the partner based on the first patient's infection. Not all patients were willing to give the coupon to their partners -- and not all partners who were given them were willing to seek treatment -- but a significant number of partners who might not have sought treatment or have even known they were infected used the coupons.
The Challenges Ahead
STD prevention programs in developing countries continue to struggle with deep-seated structural problems. Many infected women are completely asymptomatic, and may suffer permanent and painful damage to their health and fertility and to their newborns' health because they don't know they need treatment. The drugs critical for STD treatment can be unaffordable for the health systems in developing countries, and, as STD strains become increasingly resistant to available antibiotics, replacing those medications with newer and more powerful ones will be even more costly.
Some researchers and programmers also fear that the drive to prevent and treat STDs has lost its public focus because of the far more attention-grabbing and well-funded international campaign to curb the spread of HIV. Others, though, are optimistic that the experience, knowledge and perspective acquired in recent years because of the threat of the HIV/AIDS epidemic will ultimately benefit STD prevention efforts.
"It's not easy to explain why we didn't use the public health approach to promote some of these innovative STD prevention and treatment methods before AIDS appeared," Dr. Cohen said. "But now we can build on what we've learned and expect to see positive results."
-- Margaret J. Dadian
References
- Marantz, Robin. The Lessons of Syphilis in the Age of AIDS. Civilization Magazine, November-December 1995, pp. 36-43.
