Preview Chapter 1

Introduction

This chapter provides an overview of the STD epidemic's epidemiology, the STD relationship to HIV, the socioeconomic consequences, and ways to mitigate the impact.

The STD Epidemic

Magnitude

STDs rank in the top five disease categories for which adults in developing countries seek health-care services, with sub-Saharan Africa carrying the largest burden. Globally, approximately 333 million new cases of curable STDs occur each year.

Determinants of STD Epidemiology

Determinants can be categorized as the physiological microenvironment, the behavioral/personal environment and the sociocultural macroenvironment. (See Table 3 for examples).

STD Consequences: Health, Social and Economic

In women between 15 and 44 years of age, the morbidity and mortality due to STDs, excluding HIV, are second only to maternal causes. Socially, STD consequences such as infertility can lead to abusive behavior, divorce and commercial sex. Economically, the cost of diagnostics can exceed the per capita national healthcare budgets of many low-income countries.

The Challenges of STD Control

STD control depends on a synergistic relationship between numerous elements which, when combined with improved clinical case management, hold out the promise of a highly effective approach.

• Behavior change, key to STD prevention, is the end result of health messages that have been absorbed by community members through mass media and interpersonal strategies.

• Health-seeking behavior is both a function of attitudes toward disease and sex, and the accessibility and quality of healthcare facilities that deal with STDs.

• Condom promotion requires good quality and affordable condoms as well as community support for condom use.

• The syndromic approach to STD management is pragmatic in that it does not require lab facilities, and, patients are treated when they come in so they are not lost to follow-up.

• Effective, available and affordable drugs are a major condition for successful STD management.

• Often partner management, an STD case management cornerstone, is not implemented fully because of the social stigma and the lack of established systems.

• Screening asymptomatic individuals, especially women, is limited by the unavailability of inexpensive, accurate and rapid diagnostics.

• Because core groups are disproportionately infected with STDs, special efforts should be directed toward them.

• Good STD management involves a clear delineation of staff responsibilities and ongoing staff training as well as coordination with related programs.

• Training and updating providers in the syndromic approach to STD case management gives them a strategy that is efficient and respectful of patients.

• Laboratories play an essential role in epidemiological and microbiological surveys, antimicrobial susceptibility studies and in the validation of treatment and management approaches.

• Surveillance, and monitoring and evaluation are the basis for sustaining an STD case management program and keeping it relevant and effective.

• Research–epidemiological, behavioral and operational–is needed for planning and revising STD case management programs.

The Policy Environment

Managers can advocate for policy changes that can improve a country's capacity to deal with STDs. Areas for review include resources, restrictive provisions and access to services.

Conclusion

Managers must work internally and externally to build the appropriate infrastructures and coalitions needed for halting the destructive effects of STDs.

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Introduction

Although sexually transmitted diseases (STDs) have been causing significant morbidity and mortality for years, it is only with the advent of the human immunodeficiency virus (HIV) that STD control is now receiving higher priority in both developed and developing countries. This is because STDs increase the transmission of HIV and have similar behavioral risk factors.^1,2 Globally, it is estimated that as many as 333 million new cases of curable STDs occur each year.1 The indisputable facts that STDs produce serious economic, social and health consequences, made more clear by their association with HIV, and that all STDs are preventable and many are curable, make it incumbent on governments, communities and donors to meet the challenge of STD prevention and control.

Modeling the dynamic effect of STD prevention or cure on subsequent HIV and STD rates illustrates a dramatic effect. By curing or preventing one hundred cases of syphilis among an STD high-risk (core) group, approximately 109 new HIV infections and 4,132 new syphilis cases could be prevented in the next ten years.³ The prospect that the consequences of STDs, including HIV infection, can be prevented, is a hopeful one.

"It is truly remarkable that this high rank [of STDs] in terms of both burden and potential health gain is not reflected in higher specific expenditure for the control of HIV infection and CSTDs (classic STDs). Neglected training, poor diagnostic and therapeutic capabilities, high rates of quasi-irreversible sequelae and insufficient research and development efforts (at least for classic STDs) are all symptoms of this inadequate response."³

This chapter explores the epidemiology of STDs, and the epidemic's health and socioeconomic consequences in developing countries. It also looks at the challenges which, if met, could mitigate the impact of STDs. The challenges are considerable. In many countries, the health-care systems are already strained dealing with other health problems. STDs, as they are classically diagnosed and treated, demand a level of provider time and diagnostic facilities that many countries do not possess. The stigma associated with STDs, the limited resources and limited access to suitable health care for those most at risk (women and youth), and the lack of affordable and effective drugs are just some of the constraints to STD control. There are also constraints within countries served by STD programs. For example, many beliefs and practices about STDs interfere with effective treatment.

This chapter sets the stage for the other chapters in this book. They address the role of STD managers in STD prevention and control through strategies such as behavior change, condom promotion and syndromic management. STD program managers have an enormous opportunity to significantly improve the health of the populations they serve. STDs pose a worthy focus for national-level efforts. There is support in the literature for and a growing global awareness of the importance of STD prevention and potential for STD control. Indeed, if progress can be made in decreasing STDs worldwide, significant decreases in HIV infections and maternal and infant morbidity and mortality will follow.

The STD-HIV Relationship

Numerous epidemiologic and biologic studies now support the fact that STDs, both ulcerative and non-ulcerative, enhance HIV transmission.⁴ In addition, it appears that HIV alters the natural history of some STDs.⁵ HIV has been identified in the genital tract of both males and females and found to be both cell-associated and cell-free.⁶ HIV has also been isolated from the exudates of both male and female genital ulcers.^7,8 The shedding of HIV in genital fluids is increased by STD-related inflammatory responses and exudates from lesions, making men and women who are STD-infected and HIV-positive more infective.^9—11 Furthermore, it has been found that when women have gonorrhea or chlamydial infection there is a disproportionate increase in CD4 lymphocytes, the HIV target cell, in the endocervix.¹² Studies have shown that treating STDs reduces the percentage of men in whom HIV is detected and the amount of HIV in ejaculate.^10,13 In a recent community-based, randomized trial in the Mwanza district of rural Tanzania, treating STD-symptomatic individuals using the syndromic approach reduced HIV incidence in the study population by 42 percent.¹⁴

The STD Epidemic

The Magnitude

For several decades, STDs have ranked among the top five categories for which adults in developing countries seek health-care services.¹⁵ Although in Northern and Western Europe there has been a spectacular decline in the incidence of STDs, particularly gonorrhea and syphilis, the situation in North America is more variable with increases continuing in inner-city minority populations.¹⁶ In developing countries both the prevalence and incidence of STDs are still very high, with STDs making up the second cause of healthy life lost in women of 15 to 45 years of age after maternal morbidity and mortality.¹⁷ In men, if HIV and other STDs are combined, sexually transmitted infections account for nearly 15 percent of all healthy life lost in this age group.¹⁸

STDs can be categorized as curable and incurable. The common curable STDs are gonorrhea, chlamydial infection, syphilis, trichomoniasis, chancroid, lymphogranuloma venereum and donovanosis. The STDs that are preventable but not curable are the viral STDs and include human immunodeficiency virus, human papilloma virus, hepatitis B virus, and herpes simplex virus. Of the World Health Organization-estimated 333 million new cases of curable STDs in adults annually, there are 12 million new cases of syphilis, 62 million new cases of gonorrhea, 89 million new cases of chlamydial infection and 170 million new cases of trichomoniasis.¹ Table 1 shows the yearly incidence of curable STDs in 15-to-49-year-olds worldwide, with sub-Saharan Africa carrying the largest burden:¹

In addition to curable STDs, it is estimated that as of mid-1995, about 18.5 million adults, and more than 1.5 million children, cumulatively, have been infected with HIV worldwide. It is projected that cumulative worldwide totals of HIV infections will reach 30 to 40 million by the year 2000.¹⁸ Table 2 illustrates by continent the estimated distribution of HIV-infected adults (including AIDS cases) alive as of mid-1995.

Determinants of STD Epidemiology

An understanding of the determinants of STD epidemiology is important in designing a multifaceted approach to STD control that acknowledges the limitations of any single intervention.¹⁹ These determinants can be categorized as the physiological micro environment, the behavioral/personal environment and the sociocultural macro environment.²⁰ Examples of each of these three broad categories are listed in Table 3.

Data from the U.S. and Europe indicate that adolescents and young adults are at higher risk of acquiring STDs for reasons related to influences from each of the three environments described above. ²¹ Data from the developing world is more limited but it is estimated that one in twenty adolescents contracts an STD each year. ²² Adolescents may be more likely to have multiple sexual partners, either sequential or concurrent partners, rather than long-term sexual relationships.

Earlier sexual debut increases the likelihood of exposure to an STD because of the longer period of sexual activity. Also, for social or economic reasons, adolescents may have difficulty using barrier methods (condoms or spermicides) that would offer protection from STD infection. Adolescents also may be more likely to have higher-risk partners. Biologically, young women appear to have an increased susceptibility due to hormonal changes and lack of immunity to certain STD pathogens. ²³ Adolescents also may have less access to STD care because of lack of awareness, lack of money or the restrictive policies of clinics. ²³

In developing countries about one half of the population is under the age of 15. Consequently a large proportion of the population is entering the period of sexual activity and the age group with the highest STD prevalence. This results in a higher absolute incidence of STD cases in the developing world and also the potential for a worsening situation.³

Migration and rapid urbanization are demographic factors that play a major role in sexual behavior within a community and, in large cities, may result in a population consisting of many more men than women. As a result, casual and commercial sex are major modes of sexual expression, increasing the risk of infection. Poverty and gender inequality also foster the need for some women to turn to commercial sex as a means of survival. Their economic success is enhanced by the large number of men away from home who become their customers. These factors along with war, the absence of diagnostic and treatment services for STDs and the impact of HIV on STD epidemiology all combine to exacerbate the STD problem in developing countries.²⁴ Factors such as age and sex present a combined biological and behavioral effect on the epidemic. Economic instability and the deterioration of health and social services are contributing factors also.

There are differences in the proportion of the population practicing high-risk behaviors. For example, variations in the percentage of people who reported commercial and noncommercial casual sex over a 12-month period in Africa varied from 10 to 45 percent for men and from 3 to 30 percent for women.^25,26

The health-care-seeking behavior of community members greatly influences the health system's ability to deliver interventions aimed at STD control. Delay in seeking treatment for STDs has a significant impact on their spread since the longer a person is infected, the more opportunities there are for transmitting the infection to others.

The Health, Social and Economic Consequences of STDs

STDs have effects that extend far beyond the individual's physical or psychological discomfort. The greatest impact of STDs is on women and children.²⁶ In women between 15 and 44 years of age, the morbidity and mortality due to STDs, not including HIV, are second only to maternal causes.³ The prevalence of curable STDs in women is highly variable by region and risk behavior. Tables 4 and 5 below illustrate this variability.

Of note is that the majority of curable STDs in women cause subclinical or asymptomatic infection. For example, gonorrhea usually causes symptoms in men, allowing them to seek treatment, whereas women are frequently either asymptomatic or have minor symptoms. There are limited diagnostics available in developing countries for routine screening of asymptomatic women or even for testing of symptomatic women^.33

Health consequences

PID and Infertility

In many parts of the developing world, pelvic inflammatory disease (PID) is the most common reason for admission to gynecological wards.³⁴ PID sequelae include infertility, ectopic pregnancy with subsequent maternal mortality, chronic pelvic pain, an increased risk of subsequent pelvic infections and a higher risk of hysterectomy.³⁴ Infertility as a result of PID accounts for 50 to 80 percent of the infertility in Africa; in Latin America, about 35 percent.³⁵ In cultures in which childbearing holds very high value, infertility as a consequence of gonococcal or chlamydial infection is tragic.³⁵

Urethral Strictures

In developing countries, one out of seven males with gonorrhea has recently been reported to develop urethral stricture. Urethral stricture is a progressive condition that sooner or later calls for urological correction.

Adverse Pregnancy and Neonatal Outcomes

Treponema pallidum, the cause of syphilis, can cross the placental barrier and infect the fetus. Neisseria gonorrhoeae and Chlamydia trachomatis also cause morbidity in the mother and neonate.³⁶ For details of the impact of STDs on women and children, see Chapter 9.

Cervical Cancer

Cervical cancer, a global problem, is attributable in many cases to human papilloma virus, types 16 and 18, in particular. In most developing countries, screening programs for early detection of cervical cancer are not implemented due to the lack of available laboratory cytology. As a result, many women present at an advanced stage of the disease leading to high rates of morbidity and mortality.³⁶

Social consequences

In addition to the health complications of STDs, it is also important to look at the painful social consequences of untreated STDs suffered primarily by women in the developing world. For many, social stigma and personal damage due to infertility and pregnancy wastage result in divorce or commercial sex work. And in Tanzania, a husband can return an infertile woman to her parents. In addition, the husband may request the return of her bride price.³⁷

The complex interaction of infertility and other social factors in African society is depicted as follows:

Marital instability caused by infertility and the spread of venereal disease caused by marital instability and sexual mobility can form a vicious cycle. The movement of abandoned or rejected barren women to urban prostitution has been noted in Niger, Uganda, and the Central African Republic. Similarly, in many of these societies, marital and sexual mobility on the part of the women is interpreted as a desperate attempt to become pregnant, and tolerance on the part of society as a means to maximize their chances of doing so . . . Once venereal disease was introduced into a community with some degree of sexual or marital mobility, its diffusion might have been assured by the existing customs. [Subsequently] the mobility itself [may have been] intensified to overcome the fertility effects.³⁸

In addition to the impact of infertility, significant conflicts arise between couples, their families who become aware, and friends who are part of their support system. There is also the psychological and emotional burden of trust that is undermined, and the subsequent energy expended by partners to resume harmonious relationships. The number of incidents of violence and abusive behavior or retribution as a result of discovering an STD probably remains undocumented. What can be understood from experience is that an STD brings emotional consequences for those involved, including depression and its medical and social effects.

Economic consequences

Studies documenting the economic consequences of STDs are limited. The costs of pelvic inflammatory disease in the U.S. have been estimated to reach 3.5 billion dollars.³⁹ It also has been estimated that 5 percent of the total discounted healthy life years lost in sub-Saharan Africa is due to STDs, excluding HIV. HIV alone accounts for 10 percent of healthy life years lost.³ More studies have been conducted recently that address the economic consequences of HIV.

Direct Costs

Information about the costs of diagnosing and treating STDs in the developing world is scarce. It is known that the cost of using the most sophisticated diagnostic techniques exceeds the per capita national health-care budgets in many low-income developing countries. In fact, the cost of treating a woman for syphilis, chlamydial infection, chancroid or gonorrhea may exceed the per capita national health-care budgets. When considering the costs of screening and treating in a high prevalence area with poor laboratory facilities, it becomes evident that alternative strategies for reaching the population must be devised such as inexpensive screening tools, syndrome management or presumptive therapy without laboratory screening^.40

Indirect Costs

For women in an urban area of Africa, it has been estimated that chlamydial infection causes an average of 4.8 lost days of productive life, and for syphilis, 8.2 days per capita per year.³ The costs in infant morbidity, debility and mortality add to the economic burden placed on a society as a result of STDs. For example, it is estimated that in a country where the prevalence of syphilis in pregnant women is 10 percent, some 5 to 8 percent of all pregnancies that extend beyond 12 weeks have an adverse outcome from syphilis.⁴¹

A World Bank report notes that the sum of the days of productivity lost due to HIV, syphilis and chlamydial infection almost equals the number of days lost due to malaria and measles.³ Making treatment for curable STDs available represents one of the most cost-effective ways to improve health in the world.³

The Challenges of STD Control

Traditionally, STD control efforts have focused on diagnosis and treatment in the clinic setting. However, to have the greatest community impact, it is necessary to implement prevention activities and to find and treat cases as soon as possible.²⁴ This approach is supported by a model of health services in STD case management. The model describes the situation in which the number of people in a community who have or are at risk for STDs is far greater than the number who are seen in clinics and cured (see Figure 2.) Consequently, curative services alone contribute a small fraction to STD control efforts and will not solve the problem.

It is incumbent upon STD programs to provide intervention at the top of this diagram through educational efforts to reduce risk, make more condoms available, do case finding through partners and provide screening of antenatal women for syphilis. The synergy of efforts in this direction–prevention and case finding–in concert with improved clinical case management (the traditional focus) promises to be a more effective approach to STD control. It demands more attention to sociobehavioral aspects of STDs and the STD policy environment as well as a more consumer or patient-oriented approach to health service delivery. Once a community is educated and motivated to seek treatment for STDs, there is more pressure on clinical services to meet its demands. And once clinical services are more efficacious and user-friendly, it is more likely that the community will use them.

How accessible and acceptable services are to a community are important determinants of whether those who know they might be infected will actually seek care. Factors that detract from acceptability of services include high user fees, long waiting lines, lack of privacy, lack of empathy and acceptance by health providers and lack of effective drugs.^41—45 Indeed, in Cameroon in the early 1990s, nearly 50 percent of male patients with a history of acute urethritis in the previous 12 months decided not to seek care in the formal health sector.⁴⁵

There is increasing evidence that a large proportion, and in some settings most, STD patients seek care elsewhere, such as from traditional healers, pharmacists, friends or in the marketplace. Data from Mwanza, Tanzania, and Nairobi, Kenya, show that offering accessible and affordable care, including effective drugs, can cause a shift of health-care-seeking behavior to official medical services.²⁴ In some settings, it may be preferable to opt for more innovative approaches, such as training pharmacists or traditional healers in the syndromic approach or by allowing the social marketing of STD treatment packages^.46 (See Chapter 13.)

In most developing countries, there is a significant disparity between what is needed for STD control and what is in place. Strategies for meeting these challenges are explored in greater detail in the other chapters in this book, and referenced here. Figure 3 summarizes the biomedical and behavioral factors affecting the risk of STDs, the response, and an STD program's critical elements.

The Role of the Community and the Clinic

STD control is not successful in most countries because of several factors, including the following: clinics are either unavailable or unacceptable; providers are not adequately trained or updated; and the correct drugs are unavailable, or when prescribed, taken incompletely or incorrectly. Effective STD management includes the following elements:

• Patients must know they are infected.
• Good services and drugs must be available.
• Patients must seek care promptly.
• The correct diagnosis has to be made and the appropriate treatment prescribed.
• Drugs must be used correctly.
• Instructions about sexual activity during treatment must be followed.
• Patients must refer their partners.

Prevention is a cost-effective approach that can greatly enhance current efforts and can be implemented through clinic-based and community-based interventions.

There are challenges external to the health-care system such as community norms, beliefs and attitudes; and other challenges inherent in the health-care system. Some of these can be influenced by an STD program manager. It is useful to consider what needs to be in place for prevention efforts in both the health-care system and in the community in terms of preventive and curative services.

In the community, the forces that have an impact on interventions initiated by the health-care system are vast. They include sexual beliefs, practices regarding STDs, attitudes toward the health-care system and economic resources. Prevention here refers to both preventing the initial infection and clinic services that manage the acute infection and prevent further infections. The distinctions are outlined in Table 6.

Clinic-based and community-based interventions for STD prevention and control are synergistic in their relationship. If community members are not educated about STDs, they are less likely to recognize abnormal symptoms and come in for care. On the other hand, if members of the community do not like or have trust in the clinic services, they are unlikely to come in even when they know they might be infected. Success in STD control is likely to result in a community when the messages and outreach are launched in a clinic that offers user-friendly, efficacious services. And an excellent clinic will have more impact on an educated community that is motivated to adopt risk-reducing behaviors^.47

In any community, STD cases fall into one of four categories: asymptomatic (usually women) with no obvious symptoms; symptomatic in which symptoms are present but they are not recognized as abnormal by the patients; symptomatic and the patient recognizes the symptom as abnormal and seeks treatment; and symptomatic and the patient recognizes the symptom as abnormal but does not seek treatment.

Asymptomatic cases will only be treated if there are active efforts at case finding through partner contact and screening programs such as antenatal syphilis testing. The objective of case finding/screening is to identify individuals who are infected, but are not symptomatic, in order to treat them before they develop complications and sequelae. For symptomatic cases, one important approach that is not commonly encountered is to reach the community with messages that encourage men and women to seek care as soon as they experience symptoms. For women it is important that they understand the different types of discharge they experience and which types warrant seeking care. Early treatment can effectively reduce transmission and sequelae. Unfortunately, as shown in several studies, patients often wait as long as one month to seek care through clinic services.⁴⁸

Behavior Change

There are several components in the prevention of STDs. Behavior change is key, and efforts are channeled toward risk reduction through mass media and interpersonal initiatives. One element of this prevention strategy is no encourage community members to reduce their risk of contracting an STD by using condoms, decreasing the rate of partner change as well as change in their selection of partners. Intense, sustained interventions have better results than shorter, less intense ones.⁴⁹

One way to increase the intensity of interventions is to use a combination of mass media and interpersonal strategies. However, both approaches pose challenges. The use of mass media requires financial resources and media access, which are often unavailable. Interpersonal initiatives such as one-on-one counseling pose a challenge because they are labor-and human-resource-intensive.

It is often difficult to provide risk reduction counseling at clinic sites because of a personnel shortage and infrastructure limitations. Depending on community attitudes about the status of the provider who delivers the health message, non-physicians and non-nurses can be used to do one-on-one or group risk reduction counseling in the clinic setting. Regardless of who does the counseling or advising, training will often be necessary if they are to perform this function effectively. Training (see Chapter 6) necessitates time away from clinic work, the availability of trainers and motivation on the part of the health workers to take on this role. These are all potential constraints to the accomplishment of this challenge.

Health-Seeking Behavior

Health-seeking behavior is both a function of attitude towards disease and sex and the accessibility and quality of health-care facilities that deal with STDs. Several characteristics of many clinics act as deterrents to their use. These include long travel distances and waiting lines, stigma and user fees. The introduction of user fees in 1989 in Kenya and in 1992 in Zimbabwe resulted in a dramatic decline in clinic use.¹⁹

Studies have found that a common complaint of adults attending clinics for STD care is the lack of privacy and confidentiality. Patients in many communities have reported that the purpose of their visit has not been kept confidential.⁴⁸ The judgmental and unsympathetic attitudes of providers have also been found to have a profound impact on patients' opinions of services. In Ethiopia, informants in a study of STDs in a community stated that "Providers should not scold." Community members often report a preference for traditional healers who are perceived as sympathetic and caring.⁴⁴

Making STD services private and confidential, and providing them in a nonjudgmental, supportive manner are key in getting patients to come in when they have STD symptoms. It is incumbent on STD managers to ensure that clinics establish policies and design services so that patient matters are kept confidential and patients have the opportunity to be interviewed and examined in private. In addition, providers might need to participate in programs in which they can explore their attitudes toward STD patients and learn more effective ways to interact with them so that clients do not feel alienated in the clinic environment. If clients are comfortable, they are more likely to hear and accept instructions and return when necessary. (Behavior change in the clinic setting is discussed in detail in Chapter 10.)

The Promotion of Condoms and Other Barrier Methods

Condom promotion, a foundation for effective primary prevention efforts, is a challenge in many countries. Effective condom promotion requires the ready availability of good quality and affordable condoms that are properly stored. In addition, providers must be convinced that condoms are a good idea, local distribution efforts including social marketing must be effective and community attitudes must support condom use. The Ministry of Health also has to be willing and able to allocate funds to procure condoms, a situation that is not always in place. (Chapter 5 deals in greater detail with condoms and other barrier methods for STD prevention.)

STD Case Management

Prompt and effective treatment of STDs is an essential component of STD control. The goals of case management are to cure the disease, prevent complications and sequelae, prevent transmission of the treated disease to others and reduce HIV transmission. Ideally this includes early diagnosis and treatment to prevent further transmission and the development of complications. Several factors interfere with the ability of many countries to implement effective STD case management. These include the large number of asymptomatic infections in women, inadequately trained health providers, the lack of appropriate diagnostics and the lack of effective drugs.

Syndrome Management

In the case of symptomatic STDs, the syndromic approach to management–treatment based on a constellation of clinical signs and symptoms–is advocated. This approach is pragmatic in that it does not require laboratory facilities, often unavailable in many countries, and patients are treated at the time of their visit so they are not lost to follow-up. This contributes to the prevention of sequelae and further transmission. In addition, all major pathogens are treated, averting the omission of treatment due to false negative laboratory results. (Syndrome management is addressed in greater detail in Chapter 8.)

Currently, in many countries STDs are managed using clinical diagnosis or etiologic diagnosis employing suboptimal or incomplete diagnostics. Both of these approaches tend to be unreliable because many co-infections are missed. Because they were trained in treatment based on etiologic diagnoses, many physicians are reluctant to use the syndromic approach. Local data collection often highlights the inadequacies of clinical diagnosis. Training providers in the overall rationale and utility of syndrome management and in the use of flowcharts is critical to its success. Indeed, the application of this approach requires provider behavior change that can be almost as difficult to achieve as the behavior change requested of community members.

Drugs

A major condition for successful STD management is the availability of effective drugs, which are lacking in many countries. There are several major problems and, unless resolved, they obviate the potential for successful STD prevention and control efforts. The problems include the following:

• Available drugs that are ineffective due to the development of antimicrobial resistance
• Effective drugs for STDs that are available only in the private sector, subject to additional taxes and thus unaffordable to a vast majority of patients with STDs
• Effective drugs that are not included on the national essential drug list
• Health-care providers continuing to prescribe drugs to which the organisms have developed resistance despite the availability of alternatives
• Pharmacists selling drugs over the counter in doses lower than those recommended when the customer can not afford to buy the full, recommended dose
• Out-of-date or inactive drugs
• Drug vendors selling drugs that are ineffective and/or inadequate

The development of antimicrobial resistance has made the treatment of gonorrhea and chancroid more complicated and more expensive. In most African countries, approximately half or more of all gonococcal isolates are producing penicillinase, making treatment with the inexpensive penicillin useless. In addition, resistance to another inexpensive antibiotic, tetracycline, has been spreading rapidly among gonococcal strains.²⁴ Gonococcal resistance to quinolones has been reported in the U.S. and Asia.⁵⁰

It is important that there be a system of monitoring antimicrobial resistant strains of STDs as they develop, that the means of procuring more effective drugs be found and that providers be updated periodically about current recommendations. In addition, the ability of patients to pay for the most effective drugs must be considered and programs must be put into place that facilitate their ability to get the right drugs. Countries must include the most effective antibiotics for STDs on their essential drug lists, and ministries of health must confront the cost issues. It is urgent that there be a concerted effort to solve the widespread problem in most countries of the unavailability of effective drugs. One approach might be sharing the cost burden for the more expensive antibiotics between developing and developed countries.³

Even if all of the above elements were in place in a country, there would still be work to do to treat patients fully for any STD infection. The correct drug in the correct dose for the correct duration are all part of effective treatment. Currently, little effort goes into educating patients about their own drug treatment. Patients might be better able to help fight off the threat due to the increasing number of antimicrobial resistant strains if they understood the importance of taking full prescribed courses of antibiotics and had the means to purchase them.

Prescribing practices of providers also affect the success of treatment. Practices that result in ineffective therapy include polypharmacy, whereby several antibiotics with overlapping effects as well as unnecessary creams or ointments are prescribed, resulting in increased cost to the patient as well as unreasonable demands on the patient's ability to remember and comply with instructions. Inadequate or nonexistent patient education about the prescribed drug, including instructions about how, when and for how long to take it, result in poor patient compliance with the required treatment.

Another important hindrance to successful treatment is providing an incorrect prescription, whereby an antibiotic that is ineffective against the causative organism is prescribed. In addition, it is well-known that patients have great difficulty remembering to take several doses of a pill a day for several days, much less being able to afford them. Ideally, providers should try to prescribe the drug that requires the fewest doses for the shortest possible period of time and with the fewest side effects. With this sort of regimen, successful treatment of the infection is more likely. (Drug issues are more fully discussed in Chapter 7.)

Partner Management

The treatment of partners is a cornerstone of the STD case management approach. Because of the stigma associated with STDs and the accompanying social costs, and the lack of established systems, often partner notification is not executed fully. Depending on how it is implemented, partner notification can be labor-intensive, costly, and made more difficult because of the stigma attached to STDs. There are several options that are discussed in more detail in Chapter 11. Of note is that migrant labor and commercial sex trade, which lead to anonymous sexual encounters, also decrease the success of partner notification efforts.

Screening

Screening asymptomatic individuals, especially women, for STDs is limited by the unavailability of inexpensive, accurate and rapid diagnostics.³³ One major screening test, the nontreponemal syphilis test, is simple and widely available but it is not routinely used because of financial and logistical constraints.⁵¹ (A more detailed discussion of STDs and pregnancy can be found in Chapter 9.)

Interventions Focused on Core Groups

In populations in which a small number of individuals form a high proportion of sexual partnerships, the greatest impact on STD control is achieved by interventions directed at this group, which is most likely to be infected and to infect others.^3,52 In many countries, these are people in urban areas whose sexual behavior may have changed because of crowded conditions, poverty, loneliness, and alienation. Commercial sex workers, adolescents and itinerant workers often fall into this category as well. The distinguishing feature of these groups is that they have a high rate of sexual partner change. Although labeling groups as "core" can produce stigma, the concept is intended to be epidemiological rather than moral or social.

The rationale for intensive interventions with these groups is clear. Focusing on these individuals should achieve the greatest impact on the spread of STDs, partly because there is interaction between core and non-core group members at some point. This has proven effective in Thailand, where condom-only brothels have resulted in significant reductions in STD rates.⁵³ But applying the concept of focusing on core groups is challenging because in some settings groups such as commercial sex workers are not socially identifiable and, even if they were, there would be concern about stigmatizing them. Peer education has been one approach to avoiding stigmatization.³ (More details on targeting interventions can be found in Chapter 13.)

Management

The management structure of the STD control program is critical. A good relationship between the STD control program and related programs such as HIV/AIDS control, family planning, maternal and child health and health education maximizes the impact of STD control and prevention efforts. The administrative structure of the STD unit is also important. Responsibilities and lines of communication should be clear. Ongoing training in technical and administrative skills should be a priority so that a professional team does not depend on one or two key personalities. A single STD activist with a strong personality who shoulders the entire program is not sufficient. The more the wisdom is shared, the more clinic managers in outlying areas are motivated and decision making is dynamic, the more likely program initiatives will be supported and sustained over time. (STD program management is discussed in Chapter 2.)

Training

Training and updating providers in appropriate STD case management are priorities for improving STD care. The syndromic approach to STD case management is more than a solution to a resource problem. It is an approach that respects the available time that patients have by treating them at their point of first encounter with an approach that does not require their return. Also it is likely to be effective because it treats the most prevalent infections in their area. In addition, provider training that addresses the sociobehavioral aspects of STD prevention will result in clinical approaches that are respectful to the patient. This facilitates the understanding of STD transmission, treatment and prevention. Providers should progress to providing care that integrates diagnosis and treatment with risk reduction advising, condom promotion, and partner contact. (Training is more fully addressed in Chapter 6.)

Laboratory Services

Depending on the size of the country, it is important that one or more laboratories be prepared to conduct the essential epidemiological and microbiological research necessary for surveillance efforts. Where possible, laboratory tests with a short turnaround time could be available to nearby clinics to assist in treatment decisions, particularly in cases that are unresponsive to the first course of treatment. The laboratory can play an essential role in epidemiological and microbiological surveys, antimicrobial susceptibility studies and in the validation of treatment and management approaches. (Chapter 12 discusses these issues in more detail.)

Surveillance, and Monitoring and Evaluation

The establishment of systems of monitoring and surveillance are key to sustaining effective prevention efforts. Monitoring antibiotic susceptibility and prevalence is the basis for updating the syndromic management flowcharts and for selecting the antibiotics that should be included on the country's essential drug list and recommended in the national STD treatment guidelines. Monitoring STD trends and cases makes it possible to project resource needs and program impact. Monitoring provider performance provides the information necessary for continued training. (Full details on surveillance can be found in Chapter 15, and on STD program monitoring and evaluation in Chapter 14.)

Research

Epidemiological research is needed to accomplish the following:

• Collect baseline data on STDs and their complications.
• Develop methods for disease surveillance.
• Learn more about the natural history and risk factors for STDs.
• Learn more about the impact of HIV infection on the natural history and response to treatment of other diseases.
• Establish the dynamics of core groups.
• Delineate the factors determining diverse epidemiological patterns.

Intervention trials and feasibility studies, demonstration projects and community-wide interventions, both behavioral and medical in nature, are needed. Examples include the impact and sustainability of risk reduction campaigns on youth, syphilis screening for pregnant women and the use of syndromic management. Operations research should address the actual cost of service delivery and the impact of syndromic management on the cost of integrating STDs into other services.³ Operations research can be very useful in assessing the feasibility of STD treatment and control in family planning and other settings. Operations research has also been instrumental in implementing decentralized services for syphilis screening and changes in laboratory screening approaches.

Behavioral research is need in designing and evaluating both services and messages. A targeted intervention research approach has been used in several countries to assess local beliefs, practices and attitudes relating to STD health-care services. The research forms the basis for the design of services and the development of educational and motivational messages. Better data are also needed on sexual behavior and its relationship to STD incidence and prevalence. This data can be used to improve knowledge about transmission dynamics and plotting spread, and in devising control programs.⁵² (See Chapter 13.)

Studies that look at the impact of STDs and other diseases are also needed to make policy choices about how to allocate resources among different disease programs. In addition, the impact of STDs on other family members is important information as is the economic impact on households.

The Policy Environment

In most countries, there are policies in several major areas affecting STD prevention and control efforts which, if changed, could enhance these efforts. As seen in Table 7, aspects of the policy environment that warrant review fall into the major areas of (a) resources for STD prevention and treatment; (b) restrictive provisions of health delivery systems, and (c) service access issues. STD managers would be wise to review these aspects of the policy environment in their countries. If the policies are restrictive or if they inhibit STD prevention and control efforts, managers can advocate for policy changes.

It is understood that factors such as poverty, gender inequities and social unrest that contribute to STD prevalence are beyond the direct influence of the STD program manager. However, a manager's influence is not limited to clinic services. STD program managers should seize opportunities to ensure condom availability, community mobilization and education, and advocate for policies that have an impact on STDs in the community.

Conclusion

The global burden of STDs and their effects is sobering. Although there are resource issues that are beyond the direct influence of providers and managers, it is possible to improve services in the areas that are within their sphere of influence. Program managers are in a position to advocate for interventions and resources that will result in STD prevention and prompt and effective treatment. Achieving improvements is within the reach of program managers who are committed to this endeavor.

The handbook is designed to assist program managers in this critically important task. It addresses the biomedical, social, behavioral, educational and management aspects of STD prevention and control. Managers are encouraged to use the handbook as a resource and to seek other opportunities for their staff to improve their practices as well. It is only through a supportive infrastructure and excellent clinical practice that there can be progress in the area of STD prevention and treatment.

Managers must meet the challenges posed by STDs by coordinating private and public practices, strengthening supportive infrastructures and community linkages, incorporating sound management practices, establishing links with other ministries, and providing active and informed support for excellence in the clinical practice of health workers at all levels. Through concerted, comprehensive efforts, strides will be made in preventing STDs and mitigating their effects.

Acknowledgments

Special thanks to Tracy Smarrella, Family Health International/AIDSCAP, for her background research and comments.

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