1. Research in to the integration of STI prevention and management into reproductive health services in Africa Dr. Ian Askew Frontiers in Reproductive Health Population Council Nairobi, Kenya

2. 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, infants and womens 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

3. 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

4. RTIs / STIs are prevalent among ANC/FP Clients

5. 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

6. 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

7. Research activities to 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

8. 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

9. 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

10. 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

11. 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)

12. Syndromes among women Vaginal discharge Genital ulcers Pelvic inflammation

13. Assumptions in syndromic case 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

14. 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

15. But….. syndromic management of vaginal discharge is ineffective Why?

16. A framework for evaluating RTI management strategies Step 1 Clients with any RTI Step 2 Clients with any RTI symptom or sign Step 3 Clients reporting symptoms Step 4 Providers correctly interpret Reported symptoms Step 5 Correct Medications, Counseling & condom promotion Step 6 Partner notification and treatment No Yes No Yes No

17. Symptoms / signs not always indicative of an RTI Using syndromic management can lead to wrong diagnosis, over- treatment and possible wrongful partner notification

18. 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

19. Staff do not always follow protocols Over one third of clients having a symptom and/or sign are not managed syndromically

20. 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

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

22. Overall utility of syndromic case management

23. Adding clinical exam

24. Algorithms have poor predictive value Clinical information Type of RTI Positive 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

25. 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

26. Improve health-seeking behaviour of symptomatic women Encouraging symptom recognition and reporting could increase screening and treatment

27. 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

28. 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

29. 3.Greater emphasis on prevention 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

30. Raise awareness of STIs STIs were discussed with less than one quarter of family planning clients

31. Promote safer sexual behaviours Sexual relations were discussed with less than one third of new family planning clients

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

33. 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

34. 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

35. 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

36. 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

37. Antenatal syphilis screening - an integration success story in Nairobi, Kenya?

38. 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

39. 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

40. 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%)

41. 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

42. Sustainability of program (case study, 1999)

43. 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)

44. 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?