FROM THE STI CONTROL & MANAGEMENT DESK OF UNIVERSAL HEALTH

                                          No condom No sex 

Part Three

1.11 How STI management can help

Treatment and cure from STIs decrease -

• Susceptibility to HIV
• Concentration of viral load in genital secretion
• Shedding of HIV in genital secretion
• STIs & HIV both associated with unprotected sex with multiple partners. So same measure that prevent STIs can also prevent sexual transmission of HIV
• Spread of HIV infection in the community
• Reduces serious complications of mothers & children like cervical cancer, ectopic pregnancy, infertility, still birth

1.12 Objectives of STI Management and control:

·        To prevent new infections

·        To treat those who are symptomatic & seeking treatment

·        To treat those who are symptomatic but not seeking treatment

·        To treat those who are symptomatic, seeking treatment without success due to lack of quality STI services

·        To identify and treat those who are asymptomatic

·        To treat the partners of the cases

1.13 Basic approaches of prevention and control of STIs

There are three basic approaches to prevent and control STIs: -

1. Reduction of STI load/burden of the community (prevalence)
2. Reduction of  new STI cases (incidence)
3. Strengthening STI reporting and surveillance

Table 1: Reduction of STI prevalence

Major activities •         Quality STI services •         Early diagnosis and treatment of STIs among high risk groups •         Presumptive treatment of STIs •         Simultaneous treatment of the partners of the STI cases •         Promotion of STI services and health seeking

Table 2: Reduction of STI incidence

Major activities •         STI prevention by correct and consistent use of condom •         Creating sufficient awareness on STIs and HIV through strategic communication •         Prevention of STI relapse/re-infection after treatment by consistent safe sex •         Creating enabling environment of safe sex •         Practice of non-penetrative sexual acts •         Practice of abstinence, fidelity, delayed sexual debut •         This is applicable to prevention of sexual route of HIV transmission as well

Table 3: Comprehensive package of STI Services

Syndromic management of STIs Etiologic management of STIs Presumptive Treatment for asymptomatic infections Treatment of the partners STI Screening through risk assessment & screening tests Condom promotion Information Education Communication Promotion of services and health seeking

            (Peer Educators of STI clinic of Sanur, Bali, Indonesia)

FROM THE STI CONTROL & MANAGEMENT DESK OF UNIVERSAL HEALTH

Part Two

1.5 STI Transmission Dynamics

Many of the STIs, especially those among female are asymptomatic. They create serious reproductive health complications if remain untreated or incompletely treated. Infertility, still birth, ectopic pregnancy, repeated abortions and cervical carcinoma are some of the grave complications of STIs in females. Asymptomatic STIs take a major share of the STI load of the community. Moreover, poor decision making and lack of access to appropriate services affects treatment outcome among females.

Many STIs remain hidden due to stigma. People seek medical care in places such as unqualified practitioners, pharmacists of the medical shops, street ‘doctors’ and receive improper and ineffective treatment. Recurrence is common among STIs such as genital herpes, genital warts. In general viral STIs are difficult to treat.

Asymptomatic, hidden, maltreated and recurrent STIs are responsible for the STI load of the community (STI prevalence). This STI load acts as the potential reservoir of the sexually transmitted diseases and infections.

New STI cases (STI incidence) appear due to continuing unprotected sexual activities, especially, among those who have multiple sexual partners. The new cases of STIs add on the existing STI load of the community. Unprotected sexual acts with many partners help to spread STIs and consolidate the community burden of STIs.  This is a vicious cycle.

1.6 Flow of STI & HIV Transmission through sexual and perinatal routes

Transmission of STIs is common among high risk groups because of sexual acts with multiple partners either as a profession (sex workers) or as a preference (MSM, Transgender). Clients and partners of the sex workers act as the bridge because they carry the infections back to the relatively low risk groups (house wives, spouses of the clients of the sex workers). STIs like HIV, syphilis and gonorrhoea are also transmitted from infected mother to the child.

1.7 Factors facilitating STI in HIV positive individuals

• Poor immune status
• Lack of awareness on STIs
• Low risk perception specially those on HAART
• Desperateness in sexual expression and behavior
• Absence of proper counseling system

1.8 Non STI genital conditions which increase vulnerability to HIV

• Poor genital hygiene
• Anal intercourse as it is more likely to injure tissues of receptive partner
• Exposed adolescent girls as cervix is less effective barrier to HIV and less production of mucus in the genital tract
• Post menopausal period due to thinning of genital mucosa and less production of mucus in the genital tract
• Unprotected sex during menstruation due to abrasions of the skin or mucus membrane
• Sexual violence like rape resulting in genital injury

1.9 Complications of STI

• Cervical cancer
• Ectopic Pregnancy, Infertility
• Miscarriage & stillbirth
• Foetal transmission
• CVS & CNS complications
• HIV infection

1.10 Challenges of STI management in women

• Asymptomatic infection more frequent (chlamydial/gonorrhoeal cervicitis)
• Delay in treatment seeking
• Complications more serious than men