Department of Reproductive Health and Research (RHR), World Health Organization
Sexually transmitted and other reproductive tract infections
A guide to essential practice
Improving services for
prevention and treatment of STI/RTI
Reaching groups that do not typically use reproductive health services
Prevention and management of STIs/RTIs require special attention to factors that can influence risk and vulnerability, such as age, sex, culture and occupation. This is as true for control of STIs in the community as it is for management of individual patients. If key sectors of the population, such as men or adolescents, are ignored, community control of STIs will be very difficult to achieve. Other groups, such as sex workers and their clients, and migrant and mobile workers, may be at high risk of STI yet may not know about health services or feel comfortable using them. Outreach to these groups strengthens STI control.
Men tend to have more sexual partners than women and thus more opportunity to acquire and spread STI. Men are also more likely to have symptoms when they have an STI and may seek treatment at clinics, from private doctors or directly from pharmacies or drug vendors. Access for men to quality services for prevention and treatment is thus an important component of STI control.
Reproductive health clinics should, as a minimum, offer treatment to the sexual partners of women who use their services. Some reproductive health services that traditionally served women only are now increasingly reaching out to men with a variety of preventive and curative services—including involving male partners in decision-making about dual protection (against both infection and pregnancy). Some reproductive health clinics provide special times or places for men to attend for advice and care.
In addition to broadening services to include men, reproductive health clinics should support improvement of services where men go for care (private doctors, pharmacies), and create mechanisms for easy referral, partner treatment and other needs (see Box 5.2).
Creating or supporting special services for men where they work (occupational health clinics) or meet (outreach to bars and entertainment districts) also helps ensure that they get appropriate STI care. Condoms should be made easily available where men socialize. Clinics should work with local pharmacies, drug vendors and traditional care providers to ensure that they are aware of STI guidelines and the importance of partner management (see Box 5.3).
Box 5.2. Reaching men
Box 5.3 Self-treatment
Generally, young people have higher rates of STI than older adults. There are many social, behavioural and biological reasons for this. For instance:
In some societies, adolescent girls are expected to marry early and have little or no sexual experience prior to marriage. They may still be at risk of infection, however, because their husband may have had previous partners or may have more than one partner. Young girls with an older sexual partner are at much greater risk of acquiring some infections (especially incurable infections such as HIV, HSV-2 and HPV), and are more likely to be in a relationship where the sexual activity is not wholly consensual. Biologically, for many adolescent girls—especially those near puberty—the tissue covering the cervix is more vulnerable to infection than that of older women.
Reproductive health clinics have a role to play in providing quality preventive and curative services for young people, and should attempt to make their services acceptable and accessible to them. “Youth-friendly services” are private, respectful and confidential services based on young people’s needs and concerns, provided by technically competent staff, in physically acceptable and accessible places. These services need to be acceptable to the local communities and young people should be involved in their planning and monitoring.
Box 5.4 includes some things to consider in seeking to improve the access of young people to STI/RTI prevention and treatment, and some important messages that should be passed on to them. Young people need practical information and support in relation to issues that affect their lives (including sexual activity), as well as access to services and supplies. Education that focuses only on abstinence and fidelity leaves women and girls uninformed about other ways to reduce risk of infection and unable to negotiate safer sexual activities that minimize this risk.
Making services acceptable and accessible to adolescents provides prevention and care for a group in which risk-taking is high, and has great potential to avert infections and preserve a pleasurable healthy sexual life. Barriers faced by young people in accessing services such as condoms and contraception are often due to attitudes of parents, providers and the community, including denial and discomfort about youth sexuality. These barriers need to be broken down. Outreach and peer education can help reach young people in different situations who may not have knowledge of, or easy access to, services.
In some countries the legal age of consent for medical services is different from the age of consent for sex. Health care workers need to clarify the legal status in relation to managing adolescents who are under the age of consent for medical treatment. Ideally, treatment or services should be permitted if the young person’s well-being is threatened. In a small number of countries, providing any care to adolescents or unmarried females is illegal. Community groups should advocate for changing such policies.
Box 5.4 Reaching young people
Sex workers and others with many sexual partners
Some people are more likely to acquire an STI because they change sexual partners frequently. The greater the number of sexual partners a person has, the greater the chances of becoming infected with an STI, and the greater the chance of passing it on to someone else. Interventions that successfully reach such people at high STI risk can have the greatest impact on community STI transmission (see Box 5.5).
Thus, reaching these groups with high-quality preventive and curative services is essential for community control of STI. Effective outreach, peer education and clinical services for sex workers have been developed using mobile clinics or by reserving special times at regular clinics. Such services have contributed to reducing community STI prevalence (see Box 5.3).
Box 5.5. Reaching sex workers and their clients
STI are often more common among certain groups, such as displaced and migrant populations, uniformed services, prisoners, and street children. Efforts to reach these groups with effective preventive and curative services are likely to benefit the community at large.
Postmenopausal women may or may not use reproductive health services, yet may continue to be sexually active and vulnerable to infection. In addition, women who are not at risk for pregnancy —including those who have chosen permanent contraception —may be less motivated to use condoms. It may also be more difficult for them to negotiate condom use with their partners. Counselling these women about condom use for STI protection should remain an important part of any health consultation. Screening for some STI/RTI-related conditions (such as cervical cancer) is also important for older women.
Children are also vulnerable to STI, and infection may be misdiagnosed since STIs often present differently before puberty. It is also becoming clear that sexual abuse of children is more common in many societies than previously realized. Such children should be referred to services that can provide effective, sensitive care. Chapter 10 provides information on management of sexual violence.
Infections of the male and female reproductive tract and their consequences:
Preventing STIs/RTIs and their complications
STI/RTI education and counselling
Promoting prevention of STI/RTI and use of services
STI/RTI Assessment during Routine Family Planning Visits
STI/RTI Assessment in pregnancy, childbirth and the postpartum period
Management of symptomatic STIs/RTIs
STI/RTI complications related to pregnancy, miscarriage, induced abortion, and the postpartum period
Annex 1. Clinical skills needed for STI/RTI
Annex 2. Disinfection and universal precautions
Annex 3. Laboratory tests for RTI
Annex 4. Medications