Research in to the integration of STI prevention

and management intoreproductive health services

in Africa

Dr. Ian AskewFrontiers in Reproductive Health

Population CouncilNairobi, Kenya

Why STI prevention and management?

STIs are a major public health problem in the region RTIs and HIV infection have adverse, often serious

consequences on pregnancy, infant’s and women’s health

STIs are a proven co-factor for HIV transmission

Some RTIs may also be co-factors (e.g. BV)

Early detection and treatment of STIs demonstrated to be effective HIV reduction strategy

The problem

RTIs and HIV infection are actually common among ‘low-risk’ women

Untreated women and their partners continue to serve as a reservoir for infection in the community

Women with symptoms have problems accessing care from STI clinics

Diagnostic facilities are lacking at most MCH/FP health facilities in the region

RTIs / STIs are prevalent among ANC/FP Clients

32

6050

8

2114

0102030405060708090

100

ZimbabweFP

Nakuru ANC Nakuru FP

Any RTI

Any STI

Why integrate STI services with ANC/FP services?

Existing STI services not easily accessible for women

The vast majority of pregnant women attend ANC clinics women using FP visit clinics

Anticipated efficiencies because of existing staff skills and service procedures

Knowledge gaps

Lack of clear and common definition of integration

Inadequate knowledge, skills and experience with providing services using an integrated approach

Lack of information on the effectiveness and cost of integration strategies

Research activitiesto address gaps

Situation Analysis studies of clinic-based services in Ghana, Kenya, Zambia, Botswana, and Zimbabwe

Case studies of programs in Mombasa and Nakuru, Kenya and Busoga district, Uganda

Intervention studies to improve STI detection and management in Nakuru, Kenya and Zimbabwe

Findings with policy and program implications

Programs were providing “integrated services” without national policies, service provider guidelines and standards to support them

Basic physical infrastructure, supplies and medications had not been reviewed to correspond with service needs

Service providers and communities had not been involved in the design and introduction of the changes leading to poor commitment by providers and utilization by users

Integration was taking place at the health facilities but not at the program or donor levels

What types of “integration” have been tried?

1. Most emphasis on case management of symptomatic clients using syndromic approach

2. Some efforts to detect cases among asymptomatic clients (e.g. risk assessment, examination)

3. Some efforts at promoting prevention (e.g. education on STIs, promotion of safer sex, including condom use)

4. Antenatal syphilis screening in some sites

5. Early introduction of HIV VCT and PMTCT in antenatal clients

1. Case management of symptomatic women

Improve health-seeking behavior of symptomatic women

- Education on symptoms- Awareness of need to seek treatment at clinic facilities

Effective diagnosis of symptomatic women

- Laboratory (very rare)- Clinical assessments (encouraged where pelvic exams undertaken)- Syndromic (promoted as standard)

Appropriate treatment of RTIs / STIs

Appropriate partner management for RTIs / STIs

2. Detection and management among asymptomatic women

Case finding through risk assessment and/or clinical assessment, with syndromic management if suspected

Mass or targeted laboratory screening (mainly ANC clients)

Mass or targeted presumptive treatment (not in ANC/FP clinic settings)

Syndromes among women

Vaginal discharge

Genital ulcers

Pelvic inflammation

Assumptions in syndromiccase management

Clients with RTIs have symptoms and signs

Clients with symptoms are aware of and worried

about them

Clients visit and report symptoms to health

providers

Health providers listen to clients symptoms, assess

and correctly interpret the information obtained

Assumptions in syndromic case management (cont.)

The techniques used to interpret the information

obtained from clients are reliable

Clients identified to have STIs are started on

proper treatment

Clients started on treatment will comply fully

The treatment is effective for all common causes

of the syndrome being treated

But….. syndromic management of vaginal discharge is

ineffective

Why?

A framework for evaluating

RTI management strategiesStep 1

Clients with any RTI

Step 2

Clients with any RTI symptom or sign

Step 3

Clientsreporting symptoms

Step 4

Providers’ correctly interpretReportedsymptoms

Step 5

CorrectMedications,Counseling& condompromotion

Step 6

Partner notification and treatment

No

YesYes

No

No

Yes

Yes

Yes

YesNo

No

No

Symptoms / signs not always indicative of an RTI

Proportion of women with a symptom / sign who do not have an RTI

64

33

46

0

10

20

30

40

50

60

70

80

90

100

Zimbabwe FP Nakuru ANC Nakuru FP

Using syndromic management can lead to wrong diagnosis, over-treatment and possible wrongful partner notification

Clients under-report symptoms

Half of clients found to have clinical signs of an RTI did not report a symptom, and so clinical assessment is essential

% of clients with RTI signs that reported symptoms

93

37

12

47

0 20 40 60 80 100

Zimbabwe

Nakuru ANC

Nakuru FP

Total

Staff do not always follow protocols

Over one third of clients having a symptom and/or sign are not managed syndromically

% of clients with RTI symptom/sign managed syndromically

53

72

68

64

0 20 40 60 80 100

Zimbabwe

Nakuru ANC

Nakuru FP

Total

And let us not forget…….

Many women with an RTI do not have symptoms, and so can only be detected through mass screening or presumptive treatment

% of asymptomatic clients having an RTI

29

56

49

0

10

20

30

40

50

60

70

80

90

100

Zimbabwe FP Nakuru ANC Nakuru FP

And that…..

% of clients with infectionsby type

29

36

25

71

64

75

0% 20% 40% 60% 80% 100%

Nakuru FP

NakuruANC

ZimbabweFP

Any STI Any non-sex RTI

Most women with an RTI have a non-sexually transmitted infection, and so partner notification needs to be handled with extreme caution

Overall utility ofsyndromic case management

1451

515

293

936

222

0

200

400

600

800

1000

1200

1400

Women infected Infected and reportingsymptoms

Reporting symptom anddiagnosed

Adding clinical exam

1451

873

515337

578

358536

0

200

400

600

800

1000

1200

1400

Women infected Infected withsymptoms or

signs

With signs /symptoms and

diagnosed

With symptoms /signs andreporting

symptoms

Algorithms havepoor predictive value

Clinical information

Type of RTIPositive

predictive value

Vaginal discharge symptom

Cervicitis

Vaginitis

9

34

Vaginal discharge sign

Cervicitis

Vaginitis

10

38

Vaginal discharge symptom and sign

Cervicitis

Vaginitis

11

41

What more can be done? Maintain syndromic management approach

and treat for vaginitis- With emphasis on education for better symptom recognition- Mandate clinic assessment and risk assessment- Use of checklist to strengthen provider performance

Do nothing for women with vaginal discharge

Promote trials of rapid low-cost tests

Improve health-seeking behaviour of symptomatic women

873

515

578

358

0

200

400

600

800

1000

1200

1400

1600

Infected and symptomatic Symptomatic and reporting

Encouraging symptom recognition and reporting could increase screening and treatment

Improve health-seeking behaviour of symptomatic women

In Uganda, over half of women with a discharge did not seek any treatment

Of those seeking treatment, only 56 percent used the formal sector

Of those using the formal sector, there was a delay of three weeks between symptom onset and clinic attendance

Consider cost-effectiveness of better case finding methods

Laboratory confirmation of symptomatic women

Mass screening for vaginitis

Mass screening for cervicitis

Presumptive treatment for cervicitis or vaginitis

Undertake cost modelling to compare alternatives prior to testing new services

3. Greater emphasis onprevention

More education on STIs and on safer sexual behaviours

Condom promotion for dual protection

Reach men and adolescents through antenatal services, community-based services and making clinics youth-friendly

Raise awareness of STIs

% new FP clients with whom HIV/AIDSand STIs discussed

18

21

17

2

5

40

26

23

14

12

0 20 40 60 80 100

Zambia

Botswana

Ghana

Zimbabwe

Kenya

STIsHIV/AIDS

STIs were discussed with less than one quarter of family planning clients

Promote safer sexual behaviours

% new FP clients with whom their sexual behaviour was discussed

34

30

5

36

0 20 40 60 80 100

Zambia

Ghana

Zimbabwe

Kenya

Sexual relations were discussed with less than one third of new family planning clients

Condom promotion

% new FP clients hearing about condoms

7

33

36

25

12

20

49

57

64

72

0 20 40 60 80 100

Zimbabwe

Botswana

Zambia

Ghana

Kenya

As pregnancy protection

As STI protection

Condoms discussed with about half of new FP clients, but are promoted for family planning rather than STI protection

What more can be done?

Reinforce case finding and syndromic management of genital ulcers and pelvic inflammation

BUT….more evidence needed for effectiveness and costs

What more can be done?

Partner notification essential for women with STIs, but crucial that exact type of infection is confirmed

Staff promote notification and give neutral contact cards

BUT….more evidence needed for culturally appropriate approaches

What more can be done?

Encourage partner attendance during antenatal care visits- Educational opportunity- Screening and treatment of male syndromes

Make standards / guidelines and clinics youth-friendly

BUT….more evidence needed on how to do this and to with what effect

What more can be done?

Greater emphasis on reaching men through community-based health programmes:

- verbal screening for STI symptoms

- Refer for treatment by syndromic management at nearest clinic

BUT….more evidence needed of how to do this and with what effect

Antenatal syphilis screening

- an integration success story in Nairobi, Kenya?

Original model

Women had blood taken during first visit

Blood sent for testing to central laboratory using VDRL and TPHA tests

Results sent back to clinic after 2-4 weeks

Women testing positive referred to the STD clinic for treatment

Decentralized model(1992, 9 clinics)

On-site testing of women by clinic staff Use of the RPR test Treatment of women on-site by clinic

staff Active promotion of partner notification

and treatment

Review of new strategy (1993) Virtually all (99.9%) clients screened (blood taken

and tested)

6.5% (2.7-9%) tested positive

87% of the positives received treatment (74.6-100%)

Same day treatment

48% of partners also treated at the same clinic as the client (37.3-72.9%)

Approaches in standard clinics Some women referred to the nearest pilot clinic for testing

If positive she is either:

- treated at the pilot clinic and takes a letter to the referring clinic indicating treatment

- she takes her result back to the referring clinic and gets treated there Some women have specimen sent from referring clinic to

pilot clinic for testing and are referred for treatment at referring clinic

Clients in all clinics are counseled and given a slip for inviting partners to come for treatment

Sustainability of program(case study, 1999)

% ANC clients screened

62

100

81

51

0

10

20

30

40

50

60

70

80

90

100

% ANC clients screened

1989 beforepilot project

1993 after pilotproject

1998/99 pilotclinics

1998/99standardclinics

% positive ANC clients treated

9

87

95 95

0

10

20

30

40

50

60

70

80

90

100

% positives treated

In pilot clinics…

85% pregnant women screened

95% of positives treated

70% of partners treated

Syphilis prevalence declining from 7.3% to 3.2% (1995-1999)

Incremental cost per ANC client = $1.00 ($6.60$7.60)

Making decisions about integration

Public good versus individual health

Effectiveness and cost-effectiveness

- of alternative strategies- of doing or not doing integration

Evidence-based decision-making - do we know what does and does not work?