Seeking ways to include men and adolescents in family planning and maternal health programs are among recent ideas for how the programs can help prevent the spread of sexually transmitted infections (STIs), including HIV.
Historically, adding STI services to family planning and maternal and child health-care programs has focused primarily on education and treatment for the traditional family planning client, typically a woman who has one partner and is seeking pregnancy prevention. Currently, in addition to finding new ways to reach men and adolescents, some family planning agencies are promoting condom use for dual protection against pregnancy and disease; are encouraging community policies that promote condoms; and are adding counseling about gender relations, which can help women convince their partners to use condoms.
"So much of the literature on integration has focused solely on the detection and management of STIs within female family planning clients through syndromic management that the bigger picture of what integration could and does include tends to get lost," says Dr. Ian Askew of the Population Council in Kenya, who has written extensively about integrating services. Syndromic management refers to diagnosis and treatment based on a client's signs and symptoms, rather than on laboratory tests, which are prohibitively expensive in some settings. Syndromic management tends to be ineffective since women can often be infected without showing symptoms.
In general, the broader approach to integrating services emphasizes prevention of HIV and other STIs over diagnosis and treatment. Besides helping traditional clients prevent infection, family planning programs focus on individuals at greater risk of an STI, especially youth and men. Efforts to reach high-risk people include social marketing programs, public education and communication efforts, and advocacy for policy changes.1
Efforts to integrate family planning and STI services increased following the 1994 International Conference on Population and Development in Cairo, which encouraged the concept. In some countries, especially in sub-Saharan Africa, integrating STI management into primary health-care services has been a national policy. Since 1996, for example, Kenya has trained nurses in STI management, improved its system for distribution of STI treatment drugs and revised national family planning guidelines to include STI management. One in every 10 adults in Kenya is infected with HIV.2
However, integrating STI and family planning services is difficult to achieve. In Kenya, a recent national survey shows only one in five family planning providers discussed STI risk factors during counseling and only one in 10 promoted the use of condoms for STI protection.3
Preventive activities
A review of integration models from around the world concluded that behavioral change messages directed at women have potential but their impact is low, particularly if the women are married and have only one sexual partner. STI prevention messages could be more productive if directed towards their male partners, the review concludes. "Behavior change promotion in family planning settings appears to have significant potential only if it succeeds either in empowering women to negotiate safe sex with their partners or in reaching out to other segments of the population, including young and unmarried women, sex workers and men," the study found. Expanding counseling programs to these broader audiences will take time, however.
In the meantime, the most feasible and immediate step toward STI prevention through family planning programs is emphasizing the dual protection offered by condoms, according to the study.4
Some integration efforts are experimenting with ways to reach men and youth. In a project among the national affiliates of the International Planned Parenthood Federation (IPPF) in Brazil, Honduras and Jamaica, STI prevention campaigns focus on men in factories and community settings, as well as on adolescents in school and non-school settings. Staff training includes ways of empowering women clients to negotiate condom use.5
IPPF programs in Brazil and Honduras have begun condom social marketing campaigns. Condoms now account for more than half of the couple-years of protection from all contraceptive use in the Brazil program.6 Policy planners from several African nations have used the Brazil and Jamaica programs as models for changes in their family planning programs, specifically incorporating "gender-sensitive programs focusing on the youth," says Antero Veiga of the IPPF Africa office.
An analysis of integration efforts in Ghana, Kenya, South Africa and Zambia, looking at 20 health facilities in each country, found "a critical need to reexamine the continuing focus on family planning service," particularly clinical services. There remains "continued relative inattention to large population groups such as men and sexually active unmarried women" who rarely use family planning or maternal and child health services.
Providing STI services to women receiving antenatal services was described in the study as an important element. Antenatal services reach four of every five women at some point during each pregnancy in three of the four countries studied.7A simple screening test can help diagnose and treat pregnant women who may have syphilis, for example. The test can be performed while the woman waits for the result, and treatment with penicillin can begin immediately. Untreated syphilis in pregnant women can cause spontaneous abortion, stillbirth, premature birth and infection in the infant. Transmission to the fetus occurs at least 20 percent of the time.
Syndromic management
As policy planners continue to search for ways to address the STI/HIV epidemics, they face discouraging findings regarding how well the syndromic management system works among family planning clients.8
Because laboratory tests for most sexually transmitted infections are too expensive in some countries, the World Health Organization (WHO) and others developed algorithms (a set of questions given in a flow chart) that providers could follow to treat a syndrome of signs and symptoms. Algorithms work well for ulcerative infections, such as syphilis and chancroid. However, when signs and symptoms are less predictive of a specific infection or there are no symptoms with an infection, the algorithms have not been successful.
For example, gonorrhea and chlamydia are usually asymptomatic in women and cannot be recognized easily using syndromic management. These two cervical infections account for about 45 percent of the new cases of curable STIs per year and can have severe consequences if untreated.
In an attempt to make the vaginal discharge algorithm work better, programs have developed screening tools to help identify women who have a greater risk for cervical infections. These "risk assessments" involve asking other questions beyond medical signs and symptoms, such as: Have you had sex with more than one person or with a new partner in the last three months? In an FHI-coordinated survey of risk assessments used among low-risk populations, scientists concluded that "unless risk assessments can be made more accurate, they will remain promising but ineffective in low-prevalence settings" such as family planning and antenatal clinics.9
A recent review analyzed 29 studies that have tested the use of various screening and syndromic management approaches to diagnose and treat women with vaginal discharge. "This review found little difference in the usefulness of simple screening criteria and algorithms or risk scores to identify gonorrhea and chlamydial infection among women," reported the authors from the Population Council. "These strategies consistently identify many more women incorrectly than correctly as needing treatment." Rather than spending time on ineffective care, clinicians should spend their time on providing condoms and information, the study concluded.10
A recent study of five health clinics in Nakuru, in northwest Kenya, examined the validity of the syndromic management approach in use there during the last several years. More than 900 family planning and 800 antenatal clients participated in the study, which included medical and pelvic exams, assessment of STI symptoms and signs using the vaginal discharge algorithm, and risk assessment tools. Most women found to have an infection were asymptomatic. The vaginal discharge algorithm identified only a small portion of the women who actually had a laboratory-diagnosed infection (5 percent of the family planning clients and 16 percent of the antenatal clients). The study concluded that the program should emphasize preventive approaches.11
An FHI study among family planning clients in Jamaica compared several approaches to identifying cervical infections among asymptomatic women. The WHO vaginal discharge algorithm with risk assessments (adapted for use in Jamaica) was the least accurate of the five approaches studied. Two risk assessment algorithms that weighted various factors had the highest positive predictive value but were more difficult to use. A rapid risk analysis with a urine leukocyte esterase dipstick (LED) test was nearly as accurate as the risk assessments and simpler to conduct. "Even without access to urine dipsticks, simple risk questions alone may be preferable to the WHO algorithm to identify family planning clients in need of STI counseling, referral or presumptive treatment," explains Alan Spruyt of FHI, who helped coordinate the study.12
Cost concerns
Other challenges in integrating family planing and STI services involve funding systems and the limited resources available for training, supervision, dissemination of management guidelines, and development of useful information, education and communication materials.
Wet sand cools reagents in Mali clinic.
An assumption about integration of services is that it would be more cost-effective to use existing family planning and maternal health infrastructures to manage infections rather than using separate services. Early research indicated that integrated services might be cost-effective. For example, a 1996 study of clinics in Kenya found that offering services to a symptomatic client who requested oral contraceptives during the same visit cost about U.S. $8.60, while offering the services separately would be more expensive, costing U.S. $12.40.13
However, as studies of the cost of integration have begun to address how well syndromic management works, the cost-effectiveness of integrated services seems less certain. A study in Zimbabwe concluded that screening women for STIs at family planning clinics based on their signs and symptoms is not cost-effective. The analysis included four diagnostic models, ranging from a syndromic approach at U.S. $2.48 per client to providing laboratory testing for all family planning clients at a cost of U.S. $25.77 per client.
Although the syndromic approach was least expensive, it was still unaffordable in some settings. Furthermore, it failed to detect infections in three of every four women who were infected, and more than half of those who were treated had no infection (as confirmed by laboratory tests).14
"We found that family planning providers have the technical skills to do sexually transmitted infections management, and thus adding this service is feasible," says Rick Homan of FHI, who helped conduct the study. "However, being feasible does not guarantee that the service is either cost-effective or affordable. In our study, the syndromic management guidelines were not effective in terms of the number of people treated correctly (infected or uninfected). In addition, it is not affordable for the health ministry to consider any of the diagnostic models for screening family planning clients." In the absence of cost-effective approaches to the diagnosis and management of STIs, the report recommended that family planning programs in the region put more emphasis on preventive strategies.
-- William R. Finger
References
Shelton JD. Prevention first: a three-pronged strategy to integrate family planning program efforts against HIV and sexually transmitted infections. Int Fam Plann Perspect 1999;25(3):147-52.
Askew I, Fassihian G, Maggwa N. Integrating STI and HIV/AIDS services at MCH/family planning clinics. In Miller K, Miller R, Askew I, et al, eds. Clinic-based Family Planning and Reproductive Health Services in Africa: Findings from Situation Analysis Studies. (New York: Population Council, 1998)199-216.
National Council for Population and Development, Ministry of Health, ORC Macro. Kenya Service Provision Assessment Survey 1999. Calverton, MD: ORC Macro, 2000.
O'Reilly KR, Dehne KL, Snow R. Should management of sexually transmitted infections be integrated into family planning services: evidence and challenges. Rep Health Matters 1999;7(14):49-59.
Frautschi F. Long-term outcomes of the IPPF/WHR transition project add-on: integration of HIV/STI prevention in family planning. Unpublished paper. International Planned Parenthood Federation/Western Hemisphere Region, 2000.
Mayhew SH, Lush L, Cleland J, et al. Implementing the integration of component services for reproductive health. Stud Fam Plann 2000;31(2):151-62.
Mindel A, Dallabetta G, Gerbase A, et al., eds. Syndromic approach to STD management. Sex Trans Infec 1998;74(S):S1-178.
Welsh M, Feldblum P, Chen S. Sexually transmitted disease risk assessment used among low-risk populations in East/Central Africa: a review. East Afr Med J 1997;74(12):764-71.
Sloan NL, Winikoff B, Haberland N, et al. Screening and syndromic approaches to identify gonorrhea and chlamydial infection among women. Stud Fam Plann 2000;31(1):55-68.
Solo J, Maggwa N, Wabaru JK, et al. Improving the management of STIs and MCH/FP clients at the Nakuru Municipal Council Health Clinics, 1999. In Frontiers in Reproductive Health: Electronic Library 1900-1999. New York: Population Council, 2000.
Ward E, Spruyt A, Fox L, et al. Strategies for STD detection among family planning clients in Jamaica. Unpublished paper. Family Health International, 2000.
Twahir A, Maggwa BN, Askew I. Integration of STI and HIV/AIDS Services with MCH-FP Services: A Case Study of the Mkemani Clinic Society in Mombasa, Kenya, Operations Research and Technical Assistance, Africa Project II. New York: Population Council, 1996.
Maggwa N, Askew I, Marangwanda C, et al. Demand for and Cost-effectiveness of Integrating RTI/HIV Services with Clinic-based Family Planning Services in Zimbabwe. New York: Population Council, 1999.
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