2. Control & prevention OFS.T.I. ALI ASGHAR FARAZI MD. MPH.

3. Global Estimates of curable STDs New cases l Syphilis 12 M l Gonorrhea 62 M l Chlamydia 92 M l Trichomoniasis 174 M l

4. Sexually Transmitted Infections l Caused by more than 20 micro organisms (some bacterial other viral) l Most present as: –Urethral discharge –Genital ulcers –Vaginal discharge –Swollen glands

5. Sexually Transmitted Infections a public health concern l Considerable morbidity l High incidence and prevalence l High rate of complications l Bigger problem in women and young people l Facilitate HIV transmission

6. Failure to control STIs l Low priority by policy-makers and planners in allocating resources  reasons of perceived discreditable behaviour  failure to appreciate consequences of STIs  failure to recognise the magnitude of the problem

7. Failure to control STIs (cont’d) l Control efforts mainly on symptomatic patients, usually men l Service delivery through specialised clinics only, or predominantly l Treatment strategies focused on definitive diagnosis rather than on practical decision making

8. Failure to control STIs (cont’d) l Ineffective low-cost antibiotics continue to be used for reasons of economy l Little emphasis on educational and other efforts to prevent infection l Lack of guidance on a rational, practical package of activities to pursue

9. Main aims of STI control 1.To prevent the development of diseases, complications and sequelae 2.To interrupt the transmission of sexually acquired infections 3. To reduce the risk of HIV infection

10. l Primary prevention : safer sexual behaviors and the use of condom, improving health seeking behaviors, voluntary counseling and testing, hotlines, condoms availability and accessibility. l Secondary prevention : early diagnosis and provision of care in accessible, effective and acceptable clinics. In low HIV prevalence situations, STD control is relevant for HIV control and need to be integrated in primary services.

11. 1. Prevention l Take note of social and cultural determinants l Promote safer sexual behaviour (abstinence, delayed sexual debut, etc.) l Promote use of condoms

12. Prevention education and information l STIs are avoidable, treatable and curable l Early treatment is essential l Information about asymptomatic nature of infection in some cases l Description of recognisable signs and symptoms

13. Prevention education and information l Information on where STI services are provided l Assurance that privacy, confidentiality and respect are guaranteed l Advice on assessing one’s personal risk of infection

14. STI counselling Identification of issues causing stress or anxiety l Telling the partner or spouse about the STI diagnosis l Learning about, and coming to terms with, worrying complications, e.g. infertility l Explore issues of coping with chronic/incurable infections: (HIV, Herpes, Genital Warts)

15. STI counselling Identification of issues causing stress or anxiety l Sense of guilt or blame: passing on infection to child, partner etc. l Symptoms suggestive of HIV infection l Assessment of individual risk for HIV, and decision to be screened for HIV l Reinforcement of patient’s positive decisions and choices

16. 2. STI care services Access to STI services l The public sector – Primary health care clinics (first-level care) – OPD of hospitals – Reproductive health clinics – Specialised STI clinics

17. STI care services l The private sector – Private physician providing first-level care – Workplace clinics – Pharmacists (differs from country to country) – Private STI clinics – OPD of private hospitals Access to STI services

18. STI care services l The informal sector – Traditional healers – Vendors of antibiotics – Others Access to STI services

19. 3. Effective STI care l High quality at first point of contact with a patient with STI – trained health workers – consistent availability of appropriate drugs – consistent supplies of condoms

20. 3. Effective STI care l Acceptability of STI care – Convenient opening hours – Non-judgmental staff attitudes – Appropriate staff communication skills – Affordable user fees – Confidentiality and privacy

21. Partner notification Approaches to Partner Notification l Patient referral – patient given responsibility after adequate health education – appropriate community education essential l Provider referral – health staff contact the partners – considerable human and economic resources required

22. Partner notification (cont’d) l Treat all sexual partners (c. 3 months) l Treat partners for the same STI plus any additional ones found

23. Additional activities for STI prevention and care l Promote appropriate health care-seeking behaviour l Targeting of services – sex workers – young people (10-24 years) in and out of school – long distance truck drivers – others

24. STI transmission dynamics at population level High frequency transmitters Bridging population General population

25. Additional activities for STI prevention and care (cont’d) l Case finding – individuals seeking non-STI health care Maternal and child heath services family planning services Antenatal and maternity clinics l Screening – testing for STI in individuals not seeking any health care (due regard to confidentiality and human rights)

26. Policy to integrate services l In practical terms integration of health services is defined as: bringing together common functions within and between organisations in order to: – solve common problems – develop a commitment to shared vision & goals – use common technologies and resources to achieve these goals

27. Integration process l Start from existing primary health care structures l Make the STI package simple and easy to incorporate into the clinic routine l First integrate the STI prevention and care package, then the other components l Ensure staff involvement to minimise resistance to work overload

28. l Prevention education and information to prevent STI acquisition l Improve access to STI services at all levels and outlets of health care delivery l Improve quality STI care l Promote early health care seeking behaviour l Promote effective partner notification and management Strategic areas of action: Summary

29. l Pursue a policy of integrated services l Explore mechanisms that provide for targeted services for youth, sex workers and other such population groups l Explore strategies for case finding and screening for STI, especially in women and adolescent males and females Strategic areas of action: Summary

30. با سپاس دكتر علی اصغر فرازی