An estimated 340 million new cases of largely treatable sexually
transmitted bacterial infections occur annually, of which more than 100
million are among young people aged 15 to 24. Many remain untreated
because they are difficult to diagnose or because competent, affordable
services are lacking. In addition, millions of cases of mostly
incurable viral infections occur annually, including five million new
HIV infections, of which half are among young people and 600,000 are
among infants owing to mother-to-child transmission. Uncounted numbers
of women also suffer, often silently, from disabling but largely
invisible (to statisticians) conditions such as
non-sexually-transmitted vaginal infections with discharge, severe
menstrual problems, pain during intercourse, obstetric fistulae and
Sexually Transmitted and Reproductive Tract Infections (Including HIV/AIDS)
STIs/RTIs are major causes of maternal and infant morbidity and mortality. Serious complications of some common infections include life-threatening ectopic pregnancy, pelvic inflammatory disease, pregnancy loss (early or late miscarriage), preterm labor, congenital infection of the infant, infertility, and cervical cancer. The presence of certain STIs/RTIs also increases the risk of acquiring HIV from an infected partner.
Research and data
WHO's manual for the Estimation of the Incidence and Prevalence of Sexually Transmitted Infections (2002) examines the strengths and weaknesses of current approaches to estimating the prevalence and incidence of STIs across countries, identifies those infections that are most appropriate for in-country surveillance (including their usefulness as indicators of HIV risk), discusses data collection requirements, and recommends approaches to using the data for the design of prevention and treatment programs.
Regional and country-level estimates of STIs such as chlamydia, gonorrhea, syphilis and trichomoniasis and the methodology on which the estimates are based can be found in Global Prevalence and Incidence of Selected Curable Sexually Transmitted Diseases: Overview and Estimates (2001), which also includes chapters on prevention and on antibiotic resistance. Of special interest to scientific researchers and health ministries are two manuals designed for collecting and monitoring data on HIV and other STIs/RTIs: Second Generation Surveillance for HIV (2002, on CD-ROM) and Guidelines for Sexually Transmitted Infections Surveillance (1999). These are essential resources for national reporting systems in their coverage of case methods, prevalence assessment and monitoring, tracking antimicrobal resistance, and the dissemination and use of surveillance data. For additional information on surveillance systems visit www.who.int/hiv and look for Strategic Information: Surveillance.
Community-based research methods are the topic of a collection of WHO-initiated original papers on Investigating Reproductive Tract Infections and Other Gynaecological Disorders: A Multidisciplinary Research Approach (2003) edited by Shireen Jejeebhoy, Michael Koenig and Christopher Elias and published by Cambridge University Press. The introductory chapter lays out a framework for analyzing the causes, consequences, diagnosis, treatment and prevention of STIs and other problems of the reproductive tract. The following chapters contain an abundance of information and useful guides to research designs, methodological approaches and data collection on these extremely sensitive topics. Of particular interest are the comparisons of the reliability and validity of results from women's self-reports of symptoms, physical examinations by health personnel, and laboratory analyses. Suggestions are offered for interpreting these discrepancies and improving the validity and reliability of all types of measurement techniques. Country case studies reveal significant cultural differences in women's perceptions of gynecological conditions and in research approaches. A concluding chapter offers ideas for turning research into action for more responsive STI/RTI programs and policies.
Guidelines for providers
WHO's newly revised Guidelines for the Management of Sexually Transmitted Infections (2004) is an essential resource for everyone working in the area of sexual and reproductive health, including HIV prevention. This highly readable and well-designed manual deals with sexually- and non-sexually transmitted RTIs that are likely to be present among antenatal, primary health care and family planning clients, whether adolescent or adult. STIs such as HIV and hepatitis B, which are not primarily infections of the reproductive tract, are mentioned as they relate to RTIs but are not the focus of these guidelines.
Aimed at primary health care and family planning providers, the manual explains what STIs/RTIs are, why they are important, and what can be done about them. It describes approaches to prevention, detection, treatment, education and counseling and recommends ways of reducing barriers to service use, raising awareness, and reaching populations that do not typically use reproductive health services. Chapters address the assessment of STIs/RTIs and prevention of complications in family planning visits (including their relation to contraceptive method) and in pregnancy, childbirth and postpartum care. Simple guidelines are provided for the interpretation, diagnosis and treatment of RTIs based on characteristic symptoms (the syndromic approach).
The Reproductive Health Database of the RHL contains over 20 reviews, commentaries and practical applications relating to trichomonas vaginalis, gonorrhea and chlamydia, bacterial vaginosis, and HIV as well as many items in the Effectiveness Summaries relating to antiretroviral applications in pregnancy and childbirth.
Several publications relating to STIs and HIV have been listed in earlier sections. On the integration of STI services with family planning see Exploring Common Ground: STI and FP Activities (2001) and Integrating STI Management into Family Planning Services: What are the Benefits? (1999). Various approaches to controlling STIs as a means of reducing HIV transmission are assessed in Consultation on STD Interventions for Preventing HIV: What is the Evidence? (2000).
In addition to the general manual on Safe and Effective Use of Antiretroviral Treatment in Adults (2000), the complicated issue of mother-to-child transmission of HIV is discussed from various perspectives, with research findings and tools and guidelines for practitioners, in New Data on the Prevention of Mother-to-Child Transmission of HIV and their Policy Implications: Conclusions and Recommendations (2001); Breastfeeding and Replacement Feeding Practices in the Context of Mother-to-Child Transmission of HIV (2001), and a trainers' guide to HIV and Infant Feeding Counselling: A Training Course (2000).
Policies and strategic plans
The Global Health Sector Strategy for HIV/AIDS, 2003-2007: Providing a Framework for Partnership and Action (2003) outlines WHO's strategic approach together with UNAIDS to advising health ministries on the essential interventions needed for an effective health-sector response to HIV/AIDS. The strategy is designed to support governments in policy-making, planning, priority setting, implementation and monitoring. It is also intended for international agencies, NGOs, professional and community associations, and other groups involved with HIV prevention, management and personal care. Key messages are aimed at promoting safer sexual behavior, targeting high-risk groups, providing accessible testing and counseling, expanding access to diagnosis and treatment and implementing programs to prevent mother-to-child transmission. The integration of HIV prevention and management with other sexual and reproductive health services and the strengthening of primary health system capacities are key elements of the plan.
Health system capacities for coping with HIV and other STIs are the theme of two useful publications aimed at policy makers and program managers. The first, Global Consultation on the Health Services Response to the Prevention and Care of HIV/AIDS among Young People (2004) reviews the effectiveness of interventions such as information and counseling, condom distribution for sexually active adolescents, STI treatment and care, and other outreach activities in a variety of settings in both developed and developing countries. Actions are identified to accelerate progress toward international goals.
The second, The Public Health Approach to STD Control: Technical Update (1998) is a part of the UNAIDS Best Practices Collection. In a brief and condensed format it spells out the global magnitude and significance of the problem of STIs, their association with HIV transmission, and different management modalities based on the syndromic approach (treatment response to visible symptoms) and on laboratory testing. Highlighted challenges include the frequent absence of symptoms (especially in women), people's reluctance to seek health care, the difficulty of notifying partners, widespread misunderstanding of the causes and symptoms of STIs and their cures, and substandard treatment. Essential components of a public health package for STI prevention and care include the promotion of condom use, integration of STI control into primary and reproductive health care facilities and private clinics, creation of specific services to reach high-risk populations such as female and male sex workers and adolescents, and the prevention and care during pregnancy and delivery of congenital syphilis and neonatal conjunctivitis.