Academic journal article Bulletin of the World Health Organization

Integration of Prevention and Care of Sexually Transmitted Infections with Family Planning Services: What Is the Evidence for Public Health Benefits?

Academic journal article Bulletin of the World Health Organization

Integration of Prevention and Care of Sexually Transmitted Infections with Family Planning Services: What Is the Evidence for Public Health Benefits?

Article excerpt

Voir page 635 le resume en francais. En la pagina 636 figura un resumen en espanol.


Numerous reasons have been proposed why services for prevention and care of sexually transmitted infections (STIs) should be integrated with family planning (FP) services. The expectations associated with integration have included expanding STIs service coverage, reducing STI morbidity, diversifying the services to improve their quality, be more responsive to the needs of women, and making service delivery more efficient and ultimately less expensive. The two principal rationales that led policy-makers to consider integration of STI and FP services were the recognition that STIs constitute a major public health problem in developing countries and the expectation that FP programmes which more broadly promote reproductive health will be more attractive to clients, will enhance contraceptive use, and will lead to greater exercise of reproductive intentions and well-being (1).

The need for expansion of STI services is further strengthened by the high STI incidence in many developing countries (2-4), the established association of STIs with increased transmissibility of human immunodeficiency virus (HIV) (5-7), and the finding that treatment of symptomatic STI may significantly lower incidence of HIV infection (8). In East Africa, which has the highest STI prevalence in the world (2), MCH (mother and child care) services, which are often combined with FP services, are attended by more than 90% of women (9). The combination of STI prevention and care with FP/ MCH services has therefore been proposed as one way of increasing access to STI services for women.

The recommendations of the 1994 International Conference on Population and Development (ICPD), held in Cairo, increased the impetus for integration of reproductive health services, and for specific attention to STI prevention and care (10). The proposed re-definition of "family planing programmes to emphasize helping individuals to achieve their reproductive intentions in a healthful manner" (11) has been endorsed by many governments (12). Integrating STI prevention and care into FP programmes was regarded as an achievable first step towards such a goal (13). Implicit in the expectations from STI/FP integration has been the assumption that it will improve access, information, and client-provider interaction, and thus the overall quality of FP services.

So far there is little concrete evidence on whether integration actually confers improvements in service quality and client satisfaction. Neither is there much evidence with regard to the other two expected positive outcomes: improvements in STI care coverage and in service delivery efficiency. Experimental studies to evaluate algorithms to treat vaginal discharge, an important component of STI care among women, suggest a low accuracy of currently affordable diagnostic tools (3). Perhaps even worse, fears have been voiced that the association of FP with the less respectable STI (prevention or care) services and with "the whole sphere of extramarital sexual activity" (14) might lower the acceptance and use of modern FP methods by conventional clients.

In general, the absence of systematic documentation on such integration is compounded by the lack of uniformity in what is meant by integration. At its simplest, dedicated service providers, on their own initiative, may respond to client needs for an increased array of reproductive health services and start implementing tasks such as STI risk education or condom promotion. In other instances, integration may involve the training of providers in counselling and/or in clinical care as well as modifications in logistics supply (15). Experience with the integration of FP with interventions other than STI programmes suggests that optimal packages of activities may be highly location-specific (16). Without a clear idea of what type of STI/FP integration is being promoted, it is not surprising that while opinions about the likely impact are abundant, the actual evidence is scarce. …

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