Integration of STI Prevention and Management with Family Planning and Antenatal Care in Sub-Saharan Africa-What More Do We Need to Know?
Askew, Ian, Maggwa, Ndugga Baker, International Family Planning Perspectives
CONTEXT: The high prevalence of sexually transmitted infections (STIs) and their role in HIV transmission have made integrating STI prevention and management into existing family planning and antenatal care pro grams a goal in most resource-poor countries, especially in Sub-Saharan Africa. However, little is known about how integrated services can best be configured, and what impact they have on prevention of infection and unwanted pregnancy.
METHODS: The literature is reviewed to examine what is and is not known about integration and to identify priority areas to be addressed through research.
RESULTS: The feasibility and effectiveness of strategies that focus on the addition of either STI prevention services or detection and treatment activities are uncertain. An urgent need for research exists in three areas. The first is the development and testing of strategies that, instead of adding STI-related activities to existing family planning and antenatal care programs, seek to reorient the goals of routine consultations toward protection against the dual risks of unwanted pregnancy and infection and involvement of clients in deciding the outcome of the consultation. Second, strategies that reach male partners and facilitate access by adolescents to sexual and reproductive health services need to be developed and tested. Finally, prospective, preferably randomized studies need to be carried out to test and compare the impact of alternative integration strategies on population-level indicators of behavior and health.
CONCLUSIONS: Strategies for integration of services need to be rigorously tested to ensure that they are both feasible and effective before they are implemented.
The way in which reproductive health services are offered, or at least how policies recommend they should be offered, has been undergoing considerable revision over the past few years. In most cases, these revisions focus on reorganizing the way in which services are configured, and the configurations receiving the most attention are those that integrate STI and HIV prevention, detection and management with family planning and antenatal care. There are several reasons for this in the Sub-Saharan region. (1)
Reproductive tract infections (RTIs), particularly those that are sexually transmitted (STIs), continue to be a serious public health problem in Sub-Saharan Africa, with the World Health Organization (WHO) estimating that 12% of 15-49-year-olds have a curable STI. (2) Not only are the prevention and management of STIs important public health concerns in themselves, but the presence of some STIs enhances the sexual transmission of HIV, and STI management has been shown to be effective in reducing HIV transmission. Moreover, the Programme of Action of the 1994 International Conference on Population and Development (ICPD) emphasized reorienting health care systems to enable women to obtain comprehensive and quality reproductive health services. Finally, configuring services jointly rather than separately has perceived financial benefits for health systems.
The clients of public-sector programs providing maternal and child health care and family planning services are almost exclusively women using family planning, pregnant women and women with newborn babies-women who usually are married and are considered at low risk for STIs. Data from a variety of sources (3) indicate that in some populations, 2-7% of pregnant women and of women using family planning have a cervical gonorrheal, chiamydial or syphilis infection. Moreover, trichomoniasis-a sexually transmitted vaginal infection-has been diagnosed in 4-34% of such women. (Non-sexually transmitted vaginal infections such as candidiasis and bacterial vaginosis are also common among these women-8-38%-but present less serious consequences to the woman and her fetus or newborn.) Finally, 25-30% of pregnant women in several parts of the region are infected with HIV. …