Reproductive Health in Developing Countries Expanding Dimensions, Building Solutions (1997) / Chapter Skim
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40 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES 40 3 Infection-Free Sex and Reproduction Sexual relations and reproductive events should be free of infection.Reproductive tract infection (RTI) is a generic term we use to cover three types of infection: sexually transmitted diseases (and infections)
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INFECTION-FREE SEX AND REPRODUCTION 41 TABLE 3-1 Major Sexually Transmitted Infection Microbial Agents and Their Effects Sexually PregnancyTransmitted Acute Chronic Associated Infection Disease Disease Disease Bacterial Neisseria Urethritis Infertility Prematurity gonorrhoeae Cervicitis Ectopic pregnancy Septic abortion Salpingitis Chronic pelvic Ophthalmia pain neonatorum Postpartum endometritis Chlamydia Urethritis Infertility Ophthalmia trachomatis Cervicitis Ectopic pregnancy neonatorum Salpingitis Chronic pelvic Pneumonia pain Postpartum endometritis Prematurity (?
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42 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES tiveness of STD prevention programs, including those aimed at controlling the spread of the HIV. In this chapter we examine RTIs in both the developed and developing world: their magnitude and dimensions, their determinants and consequences, the available means to prevent and treat them, and the strengths and limitations of possible intervention strategies.
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INFECTION-FREE SEX AND REPRODUCTION 43 not prompt help-seeking behavior. For example, women may consider vaginal discharge a "normal" occurrence, even when accompanied by color or odor, because it is so widespread in the community (Zurayk et al., 1995)
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44 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES Berman, and Greenspan, 1993)
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INFECTION-FREE SEX AND REPRODUCTION 45 lion persons in North America, Western Europe, Australia, and New Zealand were living with HIV/AIDS (UNAIDS and World Health Organization, 1996) Among all AIDS cases reported to the World Health Organization (WHO)
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46 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES TABLE 3-2 Prevalence of Selected Reproductive Tract Infections Among Pregnant Women, Selected Developing Countries, 1980s: in percent Country Syphilisa Gonorrheab Chlamydiab Cameroon -- 14.5 -- Central Africa Republic 9.5 9.5 -- Ethiopia 16.9 -- -- Gabon -- 5.5 9.9 Gambia 11.0 6.7 6.9 Ghana -- 3.1 -- Kenya -- 6.6 29.0 Malawi 13.7 -- -- Malaysia 2.0 0.5 -- Mozambique 6.3 -- -- Nigeria 2.1 5.2 6.5 Saudi Arabia 0.9 -- -- Somalia 3.0 -- -- South Africa 20.8 11.7 12.5 Swaziland 33.3 3.9 -- Tanzania 16.4 6.0 -- Uganda 40.0 -- -- Zaire 2.0 -- -- Zambia 12.5 11.3 -- Zimbabwe -- 7.0 9.9 aDiagnosis is based on Treponema Pallidum Haemagglutination test (TPHA) and Fluorescent Treponemal Antibody test (FTA-Abs)
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INFECTION-FREE SEX AND REPRODUCTION 47 than in developed countries. Estimates for large cities in Africa suggest an annual gonorrhea rate of between 3,000 and 10,000 cases per 100,000 inhabitants (Laga, 1994)
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48 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES The level of sexually transmitted viral infections appears to be quite high. Serologic studies have found that asymptomatic herpes simplex type 2 infections are frequently more common than evidence of past syphilis (Corey, 1994)
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INFECTION-FREE SEX AND REPRODUCTION 49 ments are shaped, in part, by the personal environments created by an individual's sexual and health-related behaviors (Wasserheit, 1994)
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50 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES FIGURE 3-1 Behavioral Personal Environments that Affect RTI Patterns Sexual Behavior Health Behavior Age at coital debut Barrier contraceptive use Number of sex partners Hormonal contraceptive use Commercial sex Use of intrauterine device (IUD) Sexual practices Vaginal douching Circumcision Early health care utilization Compliance with therapy Provider screening SOURCE: Wasserheit (1994)
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INFECTION-FREE SEX AND REPRODUCTION 51 example, in 18 countries participating in a standardized WHO survey, the proportion of men reporting five or more sex partners in the past year ranged from 0 percent in Sri Lanka to 11 percent in Thailand (Caraël et al., 1995) ; for women, the level never exceeded 3 percent.
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52 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES FIGURE 3-2 Macroenvironments that Affect RTI Patterns Socioeconomic Poverty Status of Women Political Public health infrastructure Social upheaval imbalance Demographic Young age structures Sex ratio Geographic Urbanization Domestic and international travel Migrant labor Technological RTI tests RTI therapies Prevention technologies (e.g., microbicides) Epidemiologic RTI prevalence Sociosexual networks SOURCE: Wasserheit (1994)
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INFECTION-FREE SEX AND REPRODUCTION 53 tions in which males have multiple sex partners and females are unable to control their exposure to sexually transmitted infections. Poverty has been a particularly important force in shaping RTI patterns (Toomey et al., 1993)
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54 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES of infection, as well as differences in laboratory standards. In general, gonococcal PID is associated with more clinically severe symptoms than chlamydial upper genital tract infections, although the latter are more insidious.
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INFECTION-FREE SEX AND REPRODUCTION 55 The etiologic role of previous chlamydial infection in causing tubal infertility has been exhaustively studied. Multiple retrospective investigations have examined the relationship between serologic evidence of past chlamydial infection and tubal infertility.
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56 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES T A B L E 3 -3 N eo na ta l E ff ec ts o f R ep ro d u ct iv e T ra ct I nf ec ti on s M at er n al T ra n sm is si on R is k In fe ct io n In fa n t fr om I n fe ct ed T re at m en t O rg an is m R at e (% )
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INFECTION-FREE SEX AND REPRODUCTION 57 amnionitis are more frequent in mothers with gonorrhea than in comparison groups. Clinical symptoms of sepsis in newborns, as well as maternal puerperal fever, have been associated with positive N
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58 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES nant women is less than 1 percent at the time of delivery (Randolph, Washington, and Prober, 1993)
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INFECTION-FREE SEX AND REPRODUCTION 59 Harris et al., 1980) and (in some but not all studies)
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60 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES the prevention and treatment of RTIs. Consider the monogamous woman who faces the risk of sexually transmitted infection solely as a result of the extramarital sexual activity of her husband (McGrath et al., 1993)
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INFECTION-FREE SEX AND REPRODUCTION 61 and maternal-child health services have often missed important opportunities to meet the needs of their individual clients, while STD control programs have focused almost exclusively on high-risk core transmitters. What is needed is a more coordinated approach in which all health programs serving those at risk of RTIs recognize the scope of the problem and design the most appropriately balanced local response.
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62 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES This lack of information has long been a concern in the field of interventions research (Chen and Rossi, 1983; Stoeckel, 1992)
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INFECTION-FREE SEX AND REPRODUCTION 63 Primary Prevention Strategies for the primary prevention of RTIs vary according to the type of infection; see Table 3-4. Primary prevention of sexually transmitted infections predominately involves personal behavioral change, with an emphasis on sexual behaviors and practices (Choi and Coates, 1994; Over and Piot, 1993)
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64 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES the technical competence of providers and adherence to infection control practices. Primary Prevention of Sexually Transmitted Infections Various behaviors determine a person's risk of acquiring a sexually transmitted infection, thereby providing several opportunities for intervention.
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INFECTION-FREE SEX AND REPRODUCTION 65 sexual activity; indeed, when an effect has been documented, these interventions have been associated with a significant delay in the initiation of sexual activity (Kirby et al., 1994; Holtzman et al., 1994; Kirby et al., 1991)
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66 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES improved knowledge and reduced risk behaviors (DiClemente et al., 1992; Aral and Peterman, 1993)
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INFECTION-FREE SEX AND REPRODUCTION 67 readily discerned. Indeed, attempts to do so based on sociodemographic characteristics often invite stigmatization, with its attendant social discrimination.
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68 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES tive expressions of sexual intimacy that do not carry a risk of sexually transmitted infection. The messages, as well as attempts to eroticize safer sex, have been effective at changing behavior on a short-term basis in peer interventions among gay men (Kelly et al., 1992; Kegeles, Hayes, and Coates, 1995)
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INFECTION-FREE SEX AND REPRODUCTION 69 techniques of commercial marketing, condom social marketing programs have used a wide range of print and broadcast media, widespread outlet distribution, and point-of-purchase advertising to greatly increase the volume of condom sales (which can plausibly be taken as an indicator of use) , even in some of the world's poorest countries (Population Services International, 1994)
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70 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES lished (Wenger et al., 1991) , subjects were randomized to receive "AIDS education alone" versus "AIDS education plus voluntary counseling and testing." Twice as many people in the second group were using condoms 8 weeks after the intervention, but that was still less than one-half of those who participated in the intervention.
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INFECTION-FREE SEX AND REPRODUCTION 71 of considerable debate (Stein, 1992; Rosenberg and Gollub, 1992; Niruthisard, Roddy, and Chutivongse, 1992)
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72 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES nificant mortality associated with iatrogenic RTIs is to eliminate the need for unsafe abortion procedures. This goal is likely to be promoted by improving the supply of contraceptive services to those who desire them, widely promoting the use of emergency contraception, and decriminalizing abortion services (Alan Guttmacher Institute, 1994; Ellertson et al., 1995)
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INFECTION-FREE SEX AND REPRODUCTION 73 are two general strategies for addressing asymptomatic RTIs: case finding or screening, an effective approach although limited by the cost of diagnosis, follow-up, and treatment; and selective mass treatment. In the latter approach, there is no attempt to identify specific infections; rather, all members of a target population believed to be at risk are empirically treated with effective therapy.
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74 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES Unfortunately, the performance of these algorithms in practice has been variable: the algorithms work well for genital ulcer disease and symptomatic urethral discharge in men; however, in the case of those syndromes most common among women -- vaginal discharge and lower abdominal pain -- their performance is less than optimal (Vuylsteke et al., 1993)
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INFECTION-FREE SEX AND REPRODUCTION 75 are given a vague referral to an STD treatment facility to which they cannot or will not go. The challenge is to refine current guidelines for clinical management of symptomatic RTIs within existing reproductive health facilities.
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76 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES an assessment of her risk status. In that population, the WHO flowchart, including risk assessment, was 84 percent sensitive and 40 percent specific for cervicitis diagnosis (Behets et al., 1995)
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INFECTION-FREE SEX AND REPRODUCTION 77 peutic interventions, efforts are also needed to improve treatment adherence (compliance) and encourage sexual abstinence for the duration of therapy among those diagnosed with STDs.
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78 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES effective when prevalence is generally low (i.e., 2-3%) ; in high prevalence settings (> 5%)
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INFECTION-FREE SEX AND REPRODUCTION 79 compliance and coverage and need to take into account local migration patterns and sexual networks. After considering these factors, STD mass treatment interventions have generally focused on treating either specific subpopulations known to have high STD rates (such as sex workers and migrant laborers)
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80 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES cancer screening. As noted above, these complications are a major source of reproductive morbidity and mortality.
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INFECTION-FREE SEX AND REPRODUCTION 81 primarily or exclusively to provide family planning services; program gaps, highlighting the need to expand services to those groups currently not reached by any reproductive health services, especially men and young adults; and research priorities. As noted above, data concerning the cost and effectiveness of the many interventions for preventing and treating RTIs and their consequences are extremely limited.
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82 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES and dispose of condoms are essential. All clinicians cannot assume that people know how to use condoms.
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INFECTION-FREE SEX AND REPRODUCTION 83 One of the problems facing program managers in large service delivery systems is the lack of well-defined mechanism for "going to scale" with successful small-scale pilot projects. This is especially a problem in the government sector in developing countries.
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84 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES 6. product development research on low-cost RTI diagnostics, therapeutics, vaccines, and woman-controlled prevention technologies, such as vaginal microbicides; and 7.
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