Introduction

Reaching sexually active men and women of reproductive age with information and services that can enable them to more actively control their risk of STD infection, treat existing infection, and reduce transmission through sexual partners is a key issue for health programs.

Several studies have demonstrated that certain STDs can increase the risk of HIV transmission. ^1,2,3,4,5,6 Along with the rising rates of STDs, these studies have fueled a consensus on the need for a wider, more holistic view of reproductive health, one that integrates STDs services into those of family planning (FP) and maternal child health (MCH). While the control of STDs is seen as an important reproductive health care strategy in itself because the immediate symptoms of STDs can be acute and the longer-term gynecologic, obstetric and neonatal complications can be serious for women and infants, it is also a primary strategy in reducing the spread of HIV.

Traditionally, STD control (including HIV) programs have not taken women's special circumstances into account. They have been predominantly clinic and urban-based, treating three men to every one woman.⁷ This apparent bias in service has occurred despite existing knowledge that women are more vulnerable biologically than men to contracting an STD (including HIV), the physical consequences of having an STD are more serious for women than for men, and women are more likely to be asymptomatic than men.^8,9,10,11 In addition, the socio-cultural and economic inferiority of women in most countries often ensures that they are unable to follow the STD prevention strategies currently being promoted, that is, reducing the number of sexual partners, using condoms consistently and correctly and having STDs treated. For women in stable unions, usually their partner's behavior rather than their own is a key determinant of their susceptibility to infection.^12,13

STD programs have also focused on "high-risk" populations such as symptomatic patients, commercial sex workers or truck drivers, whereas MCH/FP programs focus largely on the broader population of sexually active women and have wider coverage, providing clinical and outreach services to both rural and urban women. MCH/FP programs therefore represent a means of providing the necessary base for integrated services that reach wider (female) populations who may not use health services at any other time.

Key Issues in Integration

While there is consensus on the need and the rationale to integrate STD services into reproductive health services, many questions remain concerning what should be included in the services, at what level integration should occur and under what circumstances. Some of the benefits and limitations are presented in Table 1.

What Should be Included in Integrated Services?

Integrating behavior change communication that encourages STD prevention and improved health seeking behavior activities into existing MCH/FP services is clearly an essential component of any model for providing integrated services. This means that at a minimum, STD/HIV risk assessment and prevention services should be provided in all MCH/FP clinics.

Many common STDs are known to have an adverse effect on pregnancy outcomes.^14,15,16 Of the major STDs, however, the only one for which detection and treatment for antenatal women is recommended is maternal syphilis (see Chapter 8). Therefore, integrated services should also include syphilis testing and treatment for all antenatal women attending MCH/FP clinics.

The following table proposes three types of STD services along with the corresponding infrastructure needs.

The goal of integrating STD services into reproductive health services can be accomplished by taking different approaches (see Table 3, Chapter 13). Some of these approaches involve offering services directly, and others involve arranging for referral to services offered elsewhere. For example, managers of four integrated programs serving populations with high HIV prevalence in East Africa saw HIV counseling and testing as an essential component of any STD control program being implemented within MCH/FP clinics. However, they also felt that HIV testing (and its associated counseling) was both difficult and sensitive, and beyond the capacity of their standard MCH/FP clinics and staff. Consequently, all four programs made arrangements for clients who exhibited symptoms of advanced HIV infection, or who specifically requested an HIV test, to be referred elsewhere for testing and associated counseling.¹⁸

In some locations, STD services will already be available in the area, and MCH/FP providers can share the responsibility for the provision of these services with other workers. Referral to other service providers, either within or outside the institution, may occur. If referral is used, it is important that MCH/FP clients actually receive the services that are needed. Consequently, a follow-up system for the referrals with close communication between providers is essential. The existing referral system may need to be strengthened to ensure close communication, or a new system may need to be established.

Without outreach strategies that reach and include men, integrated programs are likely to have only limited effect.¹⁹ STD risk awareness, pregnancy planning and STD prevention programs are much more likely to succeed if male commitment is solicited. Studies from Africa reveal a female bias in promoting family planning programs; yet at the same time men play the dominant role in deciding whether their partners can initiate the use of contraceptives and whether their adolescent children can receive information on reproductive and sexual health.^20,21,22 Male cooperation, compliance and consistency often determines the rate of success of condom use for both STD prevention and contraception. Some data regarding decision making suggest that men are amenable to change. For example, preliminary findings from two family planning programs that targeted men and took advantage of their influence in this area revealed significantly higher continuation rates at 24 months.^23,24 In addition, results from the Male Motivation Project in Zimbabwe, which collected prospective data on 892 men, found that men exposed to a multimedia promotional campaign were significantly more likely than other men to decide to use contraception, including condoms.²⁵

Outreach programs into which STD prevention messages, services and/or supplies might be integrated will vary by region and country but should provide linkages with services for men. They could include workplace interventions, community based distribution of contraceptives, men's sports clubs, youth associations and programs for general health outreach using selected village health workers. Outreach programs already using peer education, home visits, group talks and school visits can broaden the range of messages communicated so that STDs and HIV/AIDS are explicitly included. Integrated community-based approaches in Africa have been able to reach a wide range of audiences, including groups of youth, CSWs and men practicing highrisk behavior.¹⁸ In addition, the community workers in these programs reported being better received by their communities due to the broadening of their activities beyond family planning and the perception that they were responding to the communities' health needs in a more comprehensive manner.

When Should Integration Occur?

The existing literature suggests that some aspects of STD services are better suited to integration with MCH/FP than others, and successful programs need to be location-specific, dependent on the local STD epidemiology, organizational, financial and resource base as well as the socio-cultural values of the country.²⁶

An STD program may be vertical (see Chapter 3) in terms of its objectives, funding and central management, but may provide integrated services at the level of the community.²⁷ There is not much experience in how this works best, but managers are now finding that a mix of integrated and vertical approaches provides an opportunity to tailor the approach to support specific program goals. All managers need to assess the advantages gained by integrating some services with the advantages of maintaining elements of a vertical program.

Prior to incorporating STD services into MCH/FP settings, it is prudent to consider the need, feasibility, cost and management implications at each health care level. There may be certain activities that should be added to existing reproductive health services across the board because they are part of the core basic knowledge that all health care providers should have, such as performing STD risk assessment and conducting STD prevention activities.

There are other activities, however, that may require considerable investments of human or material resources and, therefore, should be incorporated on a more selective basis. In these cases, one strategy to follow would be to assess the prevalence levels of STDs (including HIV) in the catchment area (the higher the prevalence, the more needed the service). Other factors to consider include infrastructure issues (access to a laboratory, private examination spaces, lighting, personnel issues, and the ability to ensure adequate supplies of diagnostics). The following questions can help in deciding whether a new service is a realistic option:

• Will the clients who use the new service be the same or different from the current clients? If they are different, how will their needs be different? Consider hours of operation, privacy and confidentiality, and the need for different targeting and/or behavior change messages.

• Will the current physical resources be adequate or will additions be needed? Determine whether changes will be necessary in the buildings, laboratories, examining rooms and waiting rooms.

• Will there be a need for new personnel, or can the current staff provide the new services? Consider which types of new skills will be required (counseling, supervising community-based distribution, cold chain maintenance, e.g., diagnostics, laboratory).

• Will the new service require new commodities and will a change be needed in the current logistics system? Consider the needs for pharmaceuticals, laboratory supplies, and contraceptive, medical, or first aid supplies, and any refrigeration that these supplies might need throughout the distribution process. Consider whether the new commodities will require modifications to the existing logistics system (selection, procurement, distribution and use).

• Will there be a need for referral, and if so, which linkages need to be created and what types of follow-up systems put in place to ensure that clients actually receive the requested services?

• How will the addition of each new service contribute to the financial sustainability of the program? If the costs will be greater than the revenues, determine how these added costs will be covered. If the revenues will be greater than the costs, determine how this income will be used.

• Will this new service provide an opportunity for the program to cross-subsidize services in the program? Consider cross-subsidizing the cost of some services with other more profitable services (that are within the overall mandate of the program). Experience shows that the services that have the best potential of being profitable are laboratory services, curative services, sales of pharmaceuticals and treatment of STDs.

Personnel and Training Needs

In an integrated program, the role of the MCH/FP service provider will expand to include clinical services and outreach activities for STD/HIV prevention. These additional responsibilities may include:

• counseling activities and behavior change communication;
• appropriate referral for STD/HIV/AIDS services when not provided;
• service delivery for STD-infected clients, which may include HIV testing;
• follow-up support for HIV-infected clients and their families;
• distribution and management of supplies for all services; and
• training other health care providers and community groups about STD/HIV prevention.

In many parts of the world, people with STDs and HIV remain stigmatized. Many service providers may be reluctant to treat women and men they think are at risk of having STDs or HIV.^28,29 In such cases, integrating STD services and promoting condoms will require a change of attitude among service providers, pharmacists and outreach workers, as well as policymakers and the general public.

Providers without sufficient information or skills may not feel confident enough to counsel clients. In addition, providers often do not have sufficient time to provide clients with the in-depth information they need. In crowded clinics, providers often spend only a few minutes with a client. Overcrowding and rushed services at clinics also affect confidentiality, and particularly for STD/HIV clients, space for private counseling and treatment is essential.

Reaching men and women with information on STD/HIV and condom use is more difficult than reaching women with FP messages. Motivation to use condoms requires sensitive and confidential counseling provided in convenient settings to promote behavior change effectively. Providers do not always know enough about condoms to give clients accurate information about when and how to use them. Men who receive condoms from pharmacies or other non-clinic outlets often receive no information on the correct use of a condom.

Comprehensive training will need to be provided for different categories of health workers already working in the system as well as those coming into integrated programs, such as medical officers, public health nurses, pharmacists, nurse/midwives and community health workers (see Chapter 6). Training should also be provided to traditional practitioners, particularly traditional birth attendants.

Training in STD management could be organized through MCH/FP programs either by modification of existing training courses or the development of specialized courses. It should address STD/HIV risk assessment, recognition of common clinical signs and symptoms of STDs and AIDS, HIV counseling information, the use of condoms, and ways to reach people at risk of STDs.

Client Services

Clients coming to the clinic will have different needs. For some clients, especially those seeking MCH services, the waiting room offers an opportunity to meet and chat. However, privacy and confidentiality may be of paramount concern to other groups of people who may not want to be seen at the clinic or by the general public, such as adolescents seeking condoms or STD treatment. As clinics increase their services to include reproductive health services, STD treatment and counseling for youth, males, and other special groups, creating separate entrances, waiting rooms and even special clinic hours may make the difference between being able to attract and keep these clients and scaring them away.

When MCH/FP programs are expanded to include STD services, there will be a need to raise awareness in the community about STDs and to tell people that new services are available as part of regular MCH/FP care. To accomplish this, appropriate behavior change communication information, messages and materials will be needed.

Future Research

Despite a strong rationale for integrating STD services into overall reproductive health services, there is limited documentation of case studies of integrated reproductive health services. Those that exist provide mainly operational descriptions. While they suggest that integration is feasible at different levels and in different contexts, there is a lack of data on comparative costs between integrated and non-integrated services. Decision makers urgently need this data to determine whether the greater costs of staff training, drugs and clinical equipment will be outweighed by the money saved from reducing STDs. In addition, no research has been done to develop criteria or models to guide policymakers and program managers on how and at what level STD services should be integrated.

As well as this lack of documentation, one of the most crucial issues integrated programs need to address if they are to be successful is how to reach men and adolescents, as well as women.¹⁹ While STD services integrated into MCH/FP services will reach women, men are unlikely to want to utilize MCH/FP clinics. While some FP programs have tried to reach men, few programs provide reproductive health services for men. Reaching men and treating male contacts of infected women is a critical part of any effective STD program, yet there is little research on strategies for encouraging male participation in, and for reaching them through, integrated services.

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