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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
Chapter 5. Promoting prevention of STI/RTI and use of services


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.


Involving men

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

Men may be more receptive to STI prevention messages if they understand that STIs threaten their health and fertility, and may endanger the lives of their wives, girlfriends and children.

Two objectives for reproductive health programmes or workplace interventions for men are:

  • To encourage men with an STI to bring or refer their partners for treatment. Since STIs are more often symptomatic in men than in women, partner management is an important way to identify asymptomatic women who need treatment.

  • To reach men with information about prevention, especially about use of condoms in commercial and casual sex encounters. This reduces the chance they will take an STI home.


Box 5.3 Self-treatment

Many people find ways to treat themselves for an STI without going to a doctor or clinic. Self-treatment is especially common among men and young people, who may buy antibiotics directly from a pharmacy without a prescription. Sex workers and their clients also often take antibiotics or other treatments in the belief that these will prevent infection.

Self-treatment should be discouraged for several reasons. First, ineffective drugs are often sold by people with minimal training (such as pharmacy sales assistants). Secondly, drugs may be sold in insufficient dosages to make treatment more affordable. As a result, the infection is not cured (although symptoms may disappear for a while) and the germs become more resistant to common antibiotics.

Health care providers should try to understand why people treat themselves. It may be because local clinics are not acceptable for various reasons, such as cost, waiting time, or perceived lack of privacy. Improving and promoting clinic services can restore confidence and reduce the amount of self-treatment.


Young people

Generally, young people have higher rates of STI than older adults. There are many social, behavioural and biological reasons for this. For instance:

  • Young people tend to have more partners and shorter relationships, so there is more opportunity for STIs to spread.
  • They may find it difficult or embarrassing to obtain or use condoms.
  • They may find it difficult to refuse sex in some situations (within the family, in exchange for goods such as school supplies, food or clothes).
  • They may not recognize situations and sexual partners where risk of infection is high.
  • They may lack knowledge about the symptoms of STIs and when to seek care.
  • They may feel uncomfortable using family planning or other reproductive health services for fear of critical and judgemental responses from staff.
  • They may not be aware of places to go for private and confidential services.
  • They may be unable to afford health services.


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

Services need to be convenient and ensure privacy and confidentiality. Barrier methods (with emergency contraception as backup) should be encouraged as contraceptive choices, and interactions should focus on building communication skills to help young people negotiate safer sex.

Safer behaviours that should be encouraged for young people include:

  • delaying onset of sexual activity;

  • learning how to use condoms consistently and correctly;

  • practising dual protection to prevent unplanned pregnancy as well as STI;

  • limiting numbers of partners;

  • avoiding high-risk sexual practices (especially unprotected vaginal or anal sex) with any partner;

  • recognizing symptoms of STI and seeking early treatment.


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

Barriers to control of STIs in commercial sex workers include poor access to effective prevention and care, as well as difficult social conditions that reduce sex workers’ ability to insist on condom use.

Services should be convenient, private and confidential. Outreach should be organized to reach sex workers who do not have easy access to services. Peer education is key to supporting sex workers in demanding safer conditions. Health workers should support legal and social efforts to reduce harassment and facilitate provision of preventive and curative services as a public health benefit.

STI/RTI services for sex workers should include:

  • condom (and lubricant) supply and promotion of consistent and correct use;

  • STI screening or presumptive STI treatment;

  • STI treatment for those with symptoms or exposure;

  • dual protection for prevention of unplanned pregnancy as well as STIs/RTIs.


Other groups

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.


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Infections of the male and female reproductive tract and their consequences:

What are RTIs?

Why STI/RTIs are important?

What can be done about RTIs?

The role of clinical services in reducing the burden of STI/RTI

Preventing STIs/RTIs and their complications

How to prevent STI

How to prevent iatrogenic infections

How to prevent endogenous infections

Detecting STI/RTI

Detecting STI/RTI


Vaginal infections

Cervical infections

Pelvic inflammatory disease

HIV counselling and testing

STI/RTI education and counselling

Key points

Privacy and confidentiality

General skills for STI/RTI education and counselling

Health education


Promoting prevention of STI/RTI and use of services

Key points

Reducing barriers to use of services

Raising awareness and promoting services

Reaching groups that do not typically use reproductive health services

STI/RTI Assessment during Routine Family Planning Visits

Key points

Integrating STI/RTI assessment into routine FP services

Family planning methods and STIs/RTIs

STI/RTI Assessment in pregnancy, childbirth and the postpartum period

Key points

Management of symptomatic STIs/RTIs

Syndromic management of STI/RTI

Management of common syndromes

STI case management and prevention of new infections

STI/RTI complications related to pregnancy, miscarriage, induced abortion, and the postpartum period

Key points

Infection in early pregnancy

Infection in lated pregnancy

Infection following childbirth

Vaginal discharge in pregnancy and the postpartum period

Sexual violence

Key points

Medical and other care for survivors of sexual assault

Annex 1. Clinical skills needed for STI/RTI


Common STI/RTI symptoms

Examining patients

Annex 2. Disinfection and universal precautions

Preventing infection in clinical settings

High-level disinfection: three steps

Universal precautions

Annex 3. Laboratory tests for RTI

Interpreting syphilis test results

Clinical criteria for bacterial vaginosis (BV)

Wet mount microscopy

Gram stain microscopy of vaginal smears

Use of Gram stain for diagnosis of cervical infection

Annex 4. Medications

Medications in pregnancy

Antibiotic treatments for gonorrhoa

Annex 5.

STI/RTI reference table


Additionnal resources


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