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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions
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) or entire communities with high STD rates. A "selective mass treatment" program among female sex workers (introduced as an addition to a long-established screening program) in the Philippines had a strong initial effect on the prevalence of gonorrhea, but this effect dissipated after a few months because of high rates of reinfection (Holmes et al., 1996).
Recently, several authors have suggested that "epidemiologic" STD control may also be a worthwhile HIV intervention strategy (Wawer et al., 1995; Cates, Rothenberg, and Blount, 1996). The potential for bacterial and parasitic infections of the reproductive tract to augment the transmission of HIV (Wasserheit, 1992; Clottey and Dallabetta, 1993) makes this an attractive strategy in areas where HIV is highly endemic.
One STD mass treatment trial is currently being conducted among communities in Rakai, Uganda. Twenty-six villages have been randomly selected to receive the intervention: mass treatment of all consenting individuals aged 15-59 every 9 to 10 months with antibiotics, in addition to an intensive health education and condom distribution campaign. In 26 control villages, the population receives the health education and condom distribution campaign, but not mass treatment for STDs; people will be referred for STD treatment based on their symptoms or positive serologic test results for syphilis (Wawer, 1995). The sustainability of this type of mass treatment intervention has been questioned, however, given the high costs of the treatment regimens involved (Science, 1995). The trial may also provide further information concerning the nature of STD/HIV synergy in both asymptomatic and symptomatic populations.
When comparing a mass treatment approach with other STD treatment strategies, one should consider the estimated rates of reinfection and the feasibility of providing adequate clinic-based STD services within a population. In practice, a mass treatment approach may be best used as an initial, one-time intervention to lower overall STD prevalence, in conjunction with the establishment of adequate STD diagnostic and treatment services to sustain the reduction in STD prevalence over time.
The third set of interventions is tertiary prevention, minimizing the impact of complications of infection. The main components of tertiary prevention are clinical management of septic abortion, alarm and transport for ectopic pregnancies, the management of infertility, and cervical