Gender,sexual health and reproductive health promotion

The underlying factors of poverty, migration, marginalization, lack of information and skills, disempowerment, and poor access to services which affect HIV/STD risk are also closely related to those which affect sexual and reproductive health. Reproductive health problems include unplanned and unwanted pregnancies, unsafe abortions, pregnancy-related illness and death, and STDs including HIV/AIDS. This interrelationship between factors is leading increasingly to the integration of HIV/STD education and prevention within the broader framework of sexual and reproductive health promotion. Such intervention allows the possible reinforcement of the impact of interventions upon important underlying factors and behaviors linked to individual, family, and community vulnerability to HIV/STDs as well as other reproductive health problems. Integration will also optimize the use of increasingly scarce resources and increase the likelihood of responses, interventions, and programs being sustainable. Sexual and reproductive health, placing HIV/STD prevention into context, and focus upon men are discussed.     

Zambia's STD control programme: a model for Africa?

The annual incidence of sexually transmitted diseases (STD) in Zambia is 34 per 10,000 population with an 1.9:1 male:female ratio. Complaints related to STDs is the third most common reason for attending health establishments and constitute a significant burden upon limited financial health resources already overwhelmed by other programs such as leprosy and nutrition. STDs are therefore a major health problem in Zambia, constituting 10% of adult outpatient attendances in both hospitals and primary health care centers. Due to the enormous health, social, and economic consequences of STDs, the Zambian health ministry launched in 1980 the national STD control program, a program which is particularly important in recent years given the appearance of HIV infection and increasing evidence that concomitant STDs are significant cofactors in the sexual transmission of HIV. Program objectives are to assess the extent and nature of STDs in Zambia on the basis of existing institutional data and population sample surveys, to improve the management of STDs through the establishment of specialized STD clinics at provincial and district levels, to train in-service personnel to man STD clinics, to increase public awareness of STDs by health education and factual information, and to coordinate research, treatment, and preventive activities to reduce the incidence of STDs. Program implementation, program activities, and achievements thus far are discussed.     

The fight against sexually transmitted diseases in Ivory Coast: what strategies can we use in the face of HIV/AIDS?

In the AIDS era, sexually transmitted diseases (STDs) have become a major health problem in developing countries, particularly in Africa. Delays in the diagnosis and treatment of such infections may result in complications, many of which primarily affect women. Epidemiological studies in Abidjan have shown that more than 10% of the pregnant women attending antenatal clinics present STDs potentially serious for their own health or that of their infants (gonorrhea, chlamydia infection, genital ulcers or active syphilis). There is evidence that STDs increase the transmission of HIV and that improving the syndromic management of STDs reduces the incidence of HIV infection. This provides a strong argument in favor of controlling STDs in areas of high HIV prevalence. In Ivory Coast, as in other African countries, a STD control program has been integrated into the AIDS control program since 1992, as recommended by the World Health Organization. During the first six years of the STD program, considerable progress was made in some areas, but not without difficulty. Simple syndrome-based decision trees have been adopted for the management of STDs in primary health care. Clinical studies have shown these therapeutic algorithms to be effective. At the same time, effective and affordable drugs for treating STDs were added to the list of essential drugs in Ivory Coast, after an international invitation to tender. The entire staff of the public health sector in Abidjan has been trained in syndromic STD management. Training is now being extended to other parts of Ivory Coast, including the private health sector and, in particular, private nurses. The surveillance of syndromic STDs, mainly genital ulcers in both sexes and urethral discharge in men, facilitates monitoring and evaluation of the STD program, following health care activities and adapting orders for drugs for treating STDs to real needs. In the near future, some parts of the STD program will be strengthened, particularly the management of sexual partners of STD patients and reduction of the cost of STD treatment for pregnant women.     

Observations of sexually transmitted disease consultations in India

Objectives: To assess the quality of sexually transmitted disease (STD) case management provided in public and private health facilities in selected areas of Madras, Tamil Nadu, India, in order to make recommendations for improving the quality of care and promote the syndromic approach to STD treatment.Methods: Structured observations of consultations for STDs in health care facilities. Scoring of the observations according to standards for history taking, examination, treatment and provision of basic health promotion advice allows evaluation of STD case management.Results: With STD treatment adequacy scored against Indian national guidelines (which recommend aetiologic treatment), history taking, examination and treatment were satisfactory in 76 out of 108 (70%) of observed consultations. However, if STD treatment adequacy is scored with respect to the syndromic approach towards selected STD (male urethritis and non herpetic genital ulcer for both sexes), only 8 out of 81 (10%) of the patients were satisfactorily managed. During 32 out of 108 (30%) of the consultations, advice on the use of condoms in order to prevent STD or HIV/AIDS was given. Instructions regarding how to use condoms were offered to seven (6%) patients and condoms were only provided to one patient (1%). Patients were urged to refer their partner(s) for treatment during 29 (27%) of consultations. A criterion of adequate use of the STD consultation for health promotion, requiring both promotion of condoms and encouragement to refer partner(s) for treatment, was met during 13 (12%) of consultations.Conclusions: Monitoring and improving the standards of care at facilities at which STDs are treated have become key roles of STD/HIV/AIDS programmes. The present report suggests that in Madras the activities of medical practitioners who treat STD patients are far from ideal at present. Improvements would involve simplifying existing treatment guidelines by promoting the syndromic approach to STD management, continuing education programmes for health care providers in the public and private sectors and repeat assessments and feedback of the quality of STD care.     

HIV/STDs in minority women: educational and medical interventions to alter the spread

HIV is but one form of sexually transmitted disease (STD). Many of the other STDs, especially those that produce ulcerating lesions, such as herpes simplex, syphilis, and chancroid, are associated with increased shedding of HIV if the individual is seropositive, and with increased risk of infection if a seronegative individual with that type of STD has unprotected intercourse with an HIV-positive partner. Thus, control and treatment of other STDs is very important in the management and prevention of the spread of HIV/AIDS.     

Mobile health units and STD control

Sexually transmitted diseases (STDs), especially genital ulcers, facilitate HIV transmission. Prevention and control of STDs could reduce HIV transmission in sub-Saharan Africa where the STD prevalence is still high. The principles of primary health care (PHC) should guide coordinated or integrated AIDS and STD programs in sub-Saharan Africa. WHO recommends implementing the following AIDS prevention and control activities: district-based epidemiological surveillance, education and communication efforts, blood safety, nursing care, counseling, and activities targeting youth, women, and workers at risk. PHC funding is still low in sub-Saharan Africa, even though health professionals have been involved in intensive efforts to mobilize and coordinate national and international financial support for AIDS control programs. Expenditures on infrastructure and training beyond current practical levels are needed to achieve WHO recommendations. The POD from the Shanning Group can address sub-Saharan Africa's problems with using mobile clinic/laboratory facilities. The major problems are cost and difficult terrain. The POD is a modular demountable unit that can be removed from the vehicle for use as a self-supporting facility. The vehicle is then free for other uses. The POD's uses span from a simple examination and STD treatment facility to a sophisticated laboratory conducting basic STD testing as well as HIV and hepatitis ELISA testing. In fact, the POD can serve both roles simultaneously. The Shanning Group also has an audio-visual POD which can present STD educational material to a wide audience.     

Sexually transmitted disease, ethnomedicine and health policy in Africa.

Compared with both industrialized countries and other less developed parts of the world, most of sub-Saharan Africa suffers inordinately from sexually transmitted diseases (STDs). It has high prevalence rates of traditional STDs, such as gonorrhea and syphilis, and if accurate seroprevalence surveys were to be done, it would probably prove to have the highest HIV seropositive incidence in the world. Unlike the pattern in the West, AIDS is primarily a heterosexually transmitted disease in Africa. This appears to be largely because of the prevalence of other untreated or improperly treated STDs. Therefore to lower the incidence of STDs would be to curtail the spread of HIV infection. The problem becomes how exactly to accomplish this. Most STD cases are never even presented at biomedical health facilities; they are presented to traditional healers. Both healers and their patients seem to believe that traditional STD cures are more effective than 'modern' cures, although the former are probably biomedically ineffective. While there is scant ethnomedical literature on STDs in Africa, the present paper presents Swaziland findings and related evidence from other African societies that the ultimate cause of several common STDs is believed to be the violation of norms governing sexual behavior, requiring traditional rather than biomedical treatment. Traditional healers therefore need to be a central part of any scheme to lower the incidence of STDs.     

AIDS Programmes at the Workplace: A Scoresheet for Assessing the Quality of Services

Little data is available on the extent or comprehensivenessof AIDS prevention activities at South African workplaces. Across-sectional postal survey was performed of all members ofthe local occupational health nursing association in the areaof greater Cape Town in 1994 to assess the quality of such programmes.Use was made of an index to score services based on their comprehensiveness,using criteria based on recommendations previously identifiedin the South Africa literature on AIDS control. The presenceof a workplace policy on AIDS was the strongest predictor ofhigh quality AIDS prevention activities. Substantial numbersof companies reported sending staff for HIV-related training,and the presence of training was non-significantly associatedwith higher quality services with regard to HIV prevention.Treatment of sexually-transmitted diseases (STDs) was reportedin slightly over half of the sample. Given the central importanceof STD treatment for the prevention and control of AIDS, improvementsin STD management at the workplace may significantly assistattempts at the public health control of the HIV epidemic. Inaddition, worker involvement in the planning, management andimplementation of AIDS prevention activities is also limitedat present and needs attention. Recommendations for the useof a scoring system to promote evaluation of AIDS programmesin the workplace are made.     

Gender, sexuality, and the prevention of sexually transmissible diseases: a Brazilian study of clinical practice

Epidemiological tendencies in the spread of HIV/AIDS in Brazil demonstrate the increasing importance of heterosexual transmission to women who are not included in those traditional categories of 'risk' which have so far guided research and attempts at prevention. While more attention is now being given to other STDs as part of HIV prevention, this same view of 'risk' prevails, as does a tendency to rely on strictly quantitative indicators and conceptions which treat health care workers' beliefs and attitudes as individual phenomena. This study, an examination of clinical practices of STD management in gynecological and antenatal programs in public health posts in Rio de Janeiro, reveals the mutually-reinforcing relationship between gender norms in sexuality and gynecological clinical practices, which results in the reproduction of both gender hierarchy and vulnerability to infection by all STDs.     

Developing HIV / AIDS and STD workplace policies

Employers and/or community leaders carry the primary responsibility for setting up workplace HIV/AIDS and STD (sexually transmitted disease) policies. They should include workers from the beginning to help identify policy objectives and content. Major objectives of a workplace policy include ensuring the health and rights of workers, reducing the effects of poor health on workplace productivity, and contributing to the general welfare of the community. Clearly stated principles of workplace policy may encompass freedom from mandatory HIV testing for job applicants and workers, ensuring a safe working environment, supporting treatment of HIV/STD-related illnesses, assuring confidentiality of HIV status, establishing a climate in which HIV-positive workers feel they can tell their employers about their status, and ensuring freedom from discrimination. HIV/AIDS and STD workplace policies are likely to include management and employee training, education and support services, and observance of employee rights. Examples of heeding employee rights are application and promotion procedures that do not require HIV testing, opportunities for HIV-positive workers to do work other than their usual work when their physical condition deteriorates, establishment of and adherence to disciplinary and grievance procedures if confidentiality of HIV status is violated, and treatment for STDs and other illnesses. A few persons should be responsible for monitoring implementation of HIV/AIDS and STD workplace policy. Monitoring may consist of regular meetings to reassess and, if needed, adapt the policy; a system of feedback from employees; assessment of use of support services; and conversations with HIV-positive workers to learn of the success of the workplace program in tending to their concerns and needs.     

HIV / AIDS control programme: lessons from the VHAI-EC joint initiative

The Voluntary Health Association of India (VHAI), with financial support and technical advice from the European Commission, developed the HIV/AIDS Control Programme. The program began in January 1995. Its overall goal was to strengthen the capacities of nongovernmental organizations (NGOs) in initiating and developing HIV/AIDS interventions at the grass-roots level. Program strategies include capacity building within NGOs for effective HIV/AIDS efforts, primary prevention of HIV/sexually transmitted disease (STD) transmission through information and education and promotion of safer sex, promotion of condom use, improvement of STD control in primary health care, and advocacy and social mobilization in support of persons affected by HIV/AIDS. VHAI first invited project proposals from NGOS in Manipur, Assam, West Bengal, Bihar, Kerala, and Andhra Pradesh. Then it held a workshop for interested NGOs on policy and funding criteria. 24 NGOs were selected in the first round from all the above states, except Andhra Pradesh. The intended audiences included youth, women, migrant workers, intravenous drug users, commercial sex workers, tribals, and students. The selected projects consisted of awareness generation, needle exchange, blood safety, condom promotion, and counseling. Training programs addressed project management, counseling, and training of health personnel (medical practitioners, health workers, peer educators, and paramedical workers). State-specific communication strategies involved traditional and folk media, a condom key chain, workshops for journalists, and meetings with members of the Legislative Assembly. VHAI is developing a comprehensive communication package for lobbying and advocacy activities. The May-June 1996 mid-term evaluation found that the program helped state VHAs to work more closely with member NGOS and non-member groups and that NGOs did become familiar with HIV/STD prevention and control. NGOS had inadequate experience in project management. NGOs were able to mobilize communities, to take on innovative interventions, and to network effectively.     

社区女性性工作者性病艾滋病干预效果评估

目的　探讨针对社区女性性工作者 (CFSWs)采用综合性干预措施预防性病 /艾滋病(STD/AIDS)的策略。方法　于 2 0 0 3年在广东省中部某乡镇社区对CFSWs开展以讲课和发放宣传资料为主 ,观看录像、同伴教育为辅的预防STD/AIDS的宣传教育活动 ;在各类娱乐场所内为CFSWs提供免费的安全套 ;在卫生院性病门诊为CFSWs提供免费的规范化的性病检查 ,派发STD/AIDS健康教育处方和开展生殖健康咨询服务工作。干预前后在知情同意情况下用相同调查表对研究对象进行面对面调查。结果　干预前后分别调查 139名和 12 5名CFSWs;研究对象对AIDS知识知晓率从干预前的 33 1%提高到干预后的 6 0 8% (P <0 0 1) ;最近一周的商业性性行为中每次使用安全套的比例由干预前的 86 2 % (81/94 )提高到干预后的 95 0 % (95 /10 0 ) (P <0 0 5 ) ;男用安全套的正确使用率由干预前的 6 0 3% (73/12 1)上升到干预后的 77 0 % (87/113) (P <0 0 1)。结论　对社区CFSWs采取宣传教育等AIDS综合干预措施能有效提高其对防病知识的知晓率和安全套使用率 ,对减缓和阻止HIV通过性乱人群向一般人群传播具有重要作用。     

参与式方法在学校艾滋病健康教育中的效果评估

目的评价参与式方法在学校艾滋病防治健康教育中的效果。方法在参与式教学前后采用相同问卷对昆明市一所中等医学专科学校267名二年级学生进行性病/艾滋病相关知识、态度对比调查。结果参与式教学前后:①艾滋病相关知识认知有变化,且差别有统计学意义(χ2=9.53,P<0.01);②性病知识认知变化大,差别有统计学意义(χ2=83.09,P<0.01);③艾滋相关态度有不同程度地改变,且差别有统计学意义(P<0.01)。结论参与式方法应用于课堂对学生的性病/艾滋病相关知识、相关态度作用明显,有利于学校更好地开展艾滋病健康教育。     

江川县舞厅暗娼性病/艾滋病健康促进干预效果评价

评价江川县性病/艾滋病健康促进与干预措施实施效果及可行性。方法：通过对县内32个舞厅的卖淫妇女实施3次性病/艾滋病健康促进与干预措施，以问卷调查进行评价。结果：性病/艾滋病知识的知晓率及高危行为改善均有显著效果。结论：实施的效果良好，并具可行性。     

Older, but not wiser: how men get information about AIDS and sexually transmitted diseases after high school

CONTEXT: As they reach adulthood, young men are less likely to use condoms and are at increased risk for exposure to AIDS and other sexually transmitted diseases (STDs). Little is known about which prevention efforts reach men in their 20s. METHODS: Longitudinal data from the 1988, 1990-1991 and 1995 waves of the National Survey of Adolescent Males are used to identify sources of information about AIDS and STDs among 1,290 young men aged 22-26. Information receipt from four main sources, the topics covered by each source and the personal characteristics associated with getting more information are all explored. RESULTS: Twenty-two percent of men surveyed discussed disease prevention topics with a health provider in the last year, 48% attended a lecture or read a brochure, 51% spoke to a partner, friend or family member, and 96% heard about AIDS or STDs from the media (e.g., television advertisements, radio or magazine). Excluding media sources, 30% of young men reported getting no STD or AIDS prevention messages in the last year. Being black or Hispanic, having had a physical exam or an AIDS test in the last year, and having discussions about AIDS or STDs with parents or a health care provider in the past were associated with receiving more information. CONCLUSIONS: Although young men who are at higher risk for STD or HIV infection are more likely than other young men to get information about disease prevention, young adult men are much less likely than adolescents to receive AIDS or STD prevention education. More prevention efforts need to be aimed at young adults.     

STDs and their impact

The artificial dichotomy between family planning services and sexually transmitted disease (STD) treatment and control has been broken by the addition of HIV to the list of STDs. Now health care workers must operate in terms of reproductive health, educating clients about both pregnancy prevention and disease prevention, including men in the loop, and securing funds for this new focus. The continuing failures of the health care profession include the facts that 1) there is no vaccine or cure for HIV, 2) women have been neglected in HIV/AIDS research, 3) women have not been helped to protect themselves (we are just beginning to develop female-control barriers and virucides). The 1992 International AIDS conference was the first session that included information on intravaginal STD/HIV prevention technology controllable by women. The only way to affect immediate changes is to continue the education of health care providers and patients. In order to do this, health care providers must broaden their thinking about behavior and prevention.     

Reorienting health and social services

The global HIV/AIDS epidemic poses the particular challenge of how to concentrate resources and bring about results without provoking stigmatization against those groups who are highly vulnerable. AIDS-based discrimination is increasing around the world and is manifested in the unwillingness to fund programs claiming that the victims are at fault. This means that sexually transmitted diseases (STDs) and AIDS programs are responsible for promoting nondiscriminatory approaches. STD treatment programs generally provide pre- and post-test counseling, but broader antistigmatization efforts have been carried out by AIDS service organizations and nongovernmental organizations. A well-developed response to HIV/AIDS and STDs involves service and program providers, community health workers, traditional health practitioners, general and private practitioners, pharmacists, traditional birth attendants, and social workers. Outreach staff need to link with community workers and volunteers close to the client groups. HIV/STD diagnosis and treatment programs need to be coupled also with intensive community-led prevention and support activities in order to influence sexual behaviors. Programs conducted in this spirit share information more easily, provide authoritative roles for nonbiomedical workers, and have clear goals that are supported by the clients. These programs forge alliances between clients, service providers, and community leaders. The underlying concept of human rights embraces a broader perspective looking for the determinants and remedies for vulnerability to HIV/STD. HIV/AIDS/STDs must be fought to defeat both the virus and social backlash. This two-pronged struggle requires the reorientation of health and social services centering on partnerships and a conducive management style. Health and social services can be constrained by a trend toward reduced funding, but HIV-affected communities induce them to change whereby new partnerships could be forged.     

HIV prevention among truck drivers on Mexico's southern border

Mobile populations present particular challenges for the delivery of health services. This paper focuses on a highly mobile population-truck drivers who cross the Mexico-Guatemala border through Ciudad Hidalgo in Chiapas-and examines the impact of an intervention that provided information regarding STD/HIV/AIDS, and promoted condom use. Following an ethnographic study to identify key actors, interaction sites and sexual practices, a baseline questionnaire survey was administered to 307 truck drivers. Information gathered in both the ethnographic study and the survey was used to design a series of interventions to promote condom use and provide information about STD/HIV transmission. Perceptions of risk for HIV/AIDS were lower for truck drivers in the intervention group compared with the baseline survey, an effect associated with greater reported condom use by truck drivers in this group. Border crossings are strategic setting for prevention interventions regarding STD/HIV/AIDS. Strategies must be developed to capitalize upon this as part of broader health promotion efforts.     

STD screening,testing, case reporting,and clinical and partner notification practices: a national survey of US physicians

OBJECTIVES: This study presents results from a national survey of US physicians that assessed screening, case reporting, partner management, and clinical practices for syphilis, gonorrhea, chlamydia, and HIV infection. METHODS: Surveys were mailed to a random sample of 7300 physicians to assess screening, testing, reporting, and partner notification for syphilis, gonorrhea, chlamydia, and HIV. RESULTS: Fewer than one third of physicians routinely screened men or women (pregnant or nonpregnant) for STDs. Case reporting was lowest for chlamydia (37 percent), intermediate for gonorrhea (44 percent), and higher for syphilis, HIV, and AIDS (53 percent-57 percent). Physicians instructed patients to notify their partners (82 percent-89 percent) or the health department (25 percent-34 percent) rather than doing so themselves. CONCLUSIONS: STD screening levels are well below practice guidelines for women and virtually nonexistent for men. Case reporting levels are below those legally mandated; physicians rely instead on patients for partner notification. Health departments must increase collaboration with private physicians to improve the quality of STD care.     

Health education needed to improve public STD awareness in Somalia

To study public sexually transmitted disease (STD) awareness among sexually active individuals in Mogadishu, Somalia the authors interviewed 183 patients who presented at an STD clinic and 29 controls. Only 2 of 3 patients with proven STD knew that diseases can be transmitted through sexual intercourse, and only 1 of 3 non-STD controls had this knowledge. Schools were listed as the source for their STD information by only 15%, and health providers by only 5% of the STD-aware individuals. Moreover, STD awareness did not seem to impact on people's life style, since more STD-aware persons were sexually promiscuous than their unaware counterparts. The authors conclude that STD awareness is very low among the general public in Somalia. Urgent health education campaigns are necessary to slow the spread of STDs. The epidemic of HIV, the latest addendum on the list on modern STDs, could then perhaps be halted, since educating the public on how to avoid exposure to the AIDS virus presently remains the only successful strategy against this killer disease.