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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×

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) (STDs), endogenous vaginal infections, and infections related to reproductive tract procedures.

RTIs are caused by a variety of bacterial, viral, parasitic, and fungal microorganisms, and they have major consequences that include infertility, ectopic pregnancy, chronic pelvic pain, genital neoplasia, and enhanced transmission of the human immunodeficiency virus (HIV). The sexually transmitted infections are associated with a spectrum of acute, chronic, and pregnancy-related conditions (Brunham and Ronald, 1991); see Table 3-1. Endogenous vaginal infections include bacterial vaginosis and candidiasis, both the result of overgrowth of organisms normally present in the vagina. Endogenous infections have also been associated with prematurity and low birth weight (Gravett et al., 1986). Procedure-related infections can involve the lower or upper reproductive tract and can result in both acute sepsis and such long-term complications as infertility.

RTIs are a persistent global health problem: as syphilis preoccupied clinicians at the beginning of the twentieth century, RTIs are a major international public health problem as it ends (Holmes et al., 1990; Wasserheit, 1994; Piot and Islam, 1994). Trends in STDs have become increasingly important indicators of unsafe sexual behavior in both developed and developing countries, and changes in trends monitor the effectiveness

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×

TABLE 3-1 Major Sexually Transmitted Infection Microbial Agents and Their Effects

Sexually Transmitted Infection

Acute Disease

Chronic Disease

Pregnancy-Associated Disease

Bacterial

 

 

 

Neisseria gonorrhoeae

Urethritis; Cervicitis; Salpingitis

Infertility; Ectopic pregnancy; Chronic pelvic pain

Prematurity; Septic abortion; Ophthalmia neonatorum; Postpartum endometritis

Chlamydia trachomatis

Urethritis; Cervicitis; Salpingitis

Infertility; Ectopic pregnancy; Chronic pelvic pain

Ophthalmia neonatorum; Pneumonia Postpartum endometritis; Prematurity (?)

Treponema pallidum

Primary and secondary syphilis

Neurosyphilis; Cardiovascular syphilis; Gumma

Spontaneous abortion; Stillbirth; Congenital syphilis

Haemophilus ducreyi

Genital ulcer

None known

None known

Viral

 

 

 

Human immunode-ficiency virus (HIV)

Mononucleosis-like syndrome

AIDS

Prematurity; Stillbirth; Perinatal HIV infection

Human papilloma virus (HPV)

Genital warts

Genital cancer

Laryngeal papillomatosis

Herpes simplex virus type 2 (HSV-2)

Genital ulcer

Recurrent; genital herpes

Congenital and neonatal; HSV; Prematurity

Hepatitis B virus (HBV)

Acute hepatitis

Chronic hepatitis; Cirrhosis; Hepatoma; Vasculitis

Perinatal HBV

Parasitic

 

 

 

Trichomonas vaginalis

Vaginitis; Urethritis

 

Prematurity; Low birthweight

(?), Evidence is weaker than for other effects.

 

SOURCE: Adapted from Brunham and Ronald (1991:62).

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×

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. Unfortunately, the goal of infection-free reproductive health appears as far away today as it did 100 years ago, and we conclude that a multifaceted public health approach is necessary to get us closer to the goal of infection-free sex.

REPRODUCTIVE TRACT INFECTIONS

Measures

Estimates of the incidence and prevalence of RTIs vary according to the source of data and the methods used to detect them (Rothenberg, 1990). In most developed countries, sources generally include reportable infections (e.g., gonorrhea and syphilis), visits to office-based practices, national surveys of representative populations, and data on patients at specialized health facilities (e.g., STD clinics, family planning clinics). Unfortunately, each of these sources has limitations. Data on reported infections are affected by differences in the completeness of reporting among different health care sources. Infections diagnosed in public facilities are reported more frequently, so these data are susceptible to biases related to the characteristics of individuals who tend to use public clinics. Data from private clinicians' practices are often affected by the absence of diagnostic validation. National surveys are limited by their sporadicity and the superficial nature of the analytic variables. Data from specific health facilities suffer from the problem of patient selection bias, as well as geographic variation.

In developing countries, data sources are even less representative (Meheus, Schulz, and Cates, 1990; Wasserheit, 1989; Over and Piot, 1993; World Health Organization, 1995b). Few nations have even rudimentary surveillance systems, so RTI incidence is usually derived from patient visits to health care facilities. RTI prevalence is typically extrapolated from studies of selected high-risk populations. Although these data provide useful estimates, they must be viewed with even more caution than reports from the developed world. Studies have shown wide discrepancy between women's self-reported symptoms and medical diagnoses of prevalent conditions (Younis et al., 1993; Zurayk et al., 1995). This discrepancy could be due to two factors: RTIs are sometimes asymptomatic, and even when symptomatic, women's perceptions of the symptoms may

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×

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). Alternatively, women may recognize the symptom but may not want to report it because of stigmatization. In developing countries, research is needed on women's perceptions of reproductive health conditions in order to design better instruments to measure RTIs at the community level.

Finally, data on specific RTIs also vary by the type of infection (Centers for Disease Control and Prevention, 1994; Laga, 1994; World Health Organization, 1995b), depending on whether current or cumulative infection is being measured. In both developed and developing countries, symptomatic viral infections (measured by physician visits) occur less frequently than serologic or cytologic indicators of the cumulative number of infected persons. Thus, care must be used in making comparisons among different measures of RTIs.

Prevalence in Developed Countries

In North America and Europe, the incidence of genital chlamydial infections and viral STDs steadily increased during the 1970s and 1980s, while the incidence of gonorrhea generally declined (Gershman and Rolfs, 1991); levels of syphilis varied among different population subgroups (Wasserheit, 1994; Over and Piot, 1993). Endogenous infections such as bacterial vaginosis and candidiasis remained high, accounting for up to 5 percent of all primary care visits (Berg, 1990).

Overall, syphilis incidence rose during World War II, but fell thereafter, coinciding with the introduction of penicillin. The lowest levels were observed at the end of the 1950s, increasing from the 1960s on. A rapidly rising male-to-female ratio coincided with the spread of syphilis among men having sex with men throughout the 1970s. In the 1980s, however, probably as a result of the safer sexual behaviors stimulated by HIV prevention messages, syphilis rates in gay males declined dramatically (Rolfs and Nakashima, 1990; Webster and Rolfs, 1993). At the same time, in the United States and other developed countries with heterogeneous populations, syphilis rates climbed during the late 1980s among heterosexuals of minority races. By the mid-1990s, syphilis levels were again falling in most developed countries.

The trends for gonorrhea have been more consistent. Gonorrhea incidence generally increased in the 1960s, and then, depending on the country, declined at different points in the 1970s. In the United States, most of the decline occurred among older, white populations, with gonorrhea rates remaining high among minority races and adolescents (Webster,

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×

Berman, and Greenspan, 1993). Overall, gonorrhea is associated with a younger mean age than syphilis among all gender and race categories.

Chlamydia infections became the most prevalent bacterial STD in the developed world during the 1970s, when gonorrhea levels began declining. Chlamydia is not a universally reported infection; therefore, syndromes have been used as proxies to monitor trends. In England and the United States, nongonococcal urethritis diagnoses exceeded those of gonorrhea in the early 1970s, with the gap widening in recent years (Centers for Disease Control and Prevention, 1994). In one rural Canadian province, active surveillance showed rates of chlamydia nearly three times higher than those of gonorrhea (Alary, Joly, and Poulin, 1989). In all developed countries, chlamydial infections in women exceed those in men, and chlamydial prevalence is strongly correlated with younger age and heterosexual behaviors.

Sexually transmitted viral infections are widespread. In the United Kingdom and the United States, the numbers of symptomatic genital herpes and genital warts cases increased 5- to 15-fold during the 1970s and 1980s (Centers for Disease Control and Prevention, 1994). In the developed world, symptomatic genital herpes causes over 10 times more genital ulcer cases than does syphilis. Moreover, recent investigations have shown that symptomatic infections with herpes simplex viruses (HSV) are only a small fraction of the total prevalence (Johnson et al., 1994): for example, HSV-2 has occurred among an estimated 30 million Americans, even though less than one-quarter perceive themselves ever to have had genital herpes. Similarly, diagnoses of both symptomatic genital warts caused by the human papilloma virus (HPV) and of asymptomatic infection have increased enormously during the last two decades (Centers for Disease Control and Prevention, 1994). HPV infections of the cervix and vagina have emerged as the most common STD among sexually active adolescent populations. Since no serologic test is available to determine previous infections and HPV cannot be recovered through tissue culture, determining the full extent of these infections is extremely difficult.

The epidemiologic pattern of HIV infection in the developed world is different from that in the developing world (Over and Piot, 1993). Beginning in the mid-1970s, HIV was transmitted among homosexual and bisexual men and resulted in acquired immune deficiency syndrome (AIDS) by the early to mid-1980s. The virus entered the injection drug-using populations in the early 1980s and rapidly spread in Western Europe and North America during the decade. Limited heterosexual transmission occurred in these regions until the late 1980s; since 1989, however, the greatest proportionate increase of reported AIDS cases has been among heterosexuals and this trend is expected to continue (Centers for Disease Control and Prevention, 1995). By the end of 1996, an estimated 1.3 million

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×

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) by 1993, more than one-half came from the United States and Europe (40% and 13%, respectively) (Way and Stanecki, 1994). However, because reports from the developing world are less complete than those from the developed world, WHO estimates that cases reported by the United States actually represent less than one-sixth of the world total of AIDS cases (World Health Organization, 1995a).

Overall, in most developed countries, the incidence of classical RTIs such as gonorrhea and syphilis declined rapidly during the 1980s among middle and upper socioeconomic strata; in North America, however, the incidence of these same RTIs remained stable or actually increased within young, low-income, minority populations. HIV infection has also become entrenched in these same disenfranchised groups, and the proportion that is spread through heterosexual behaviors is increasing.

Prevalence in Developing Countries

The epidemiology of RTIs in developing countries differs greatly from that in developed countries (Wasserheit, 1989; Brunham and Embree, 1992; Over and Piot, 1993; Piot and Islam, 1994; World Health Organization, 1995b). Overall, RTIs are a more frequent health problem in developing countries. WHO estimates at least 333 million new cases of curable STDs occurred globally in 1995 (World Health Organization, 1995b), mostly in developing countries. RTIs are among the top five causes of consultation at health services in Cameroon, representative of many African countries; and among adults, RTI is the leading diagnosis (Meheus, Schulz, and Cates, 1990). In Zimbabwe, up to 10 percent of the population had a documentable RTI (Laga, 1994). Intensive studies of women in India, Bangladesh, and Egypt have found RTI rates ranging from 52 percent to 92 percent, less than one-half of which were recognized by the women as abnormal (Bang et al., 1989; Wasserheit et al., 1989; Younis et al., 1993; Singh et al., 1995). Among RTI syndromes, the etiology of genital ulcer infection differs significantly from that in the developed world: syphilis and chancroid are the major causes of genital ulcers in tropical countries, with genital herpes accounting for a smaller proportion (Brunham and Ronald, 1991). Table 3-2 shows the prevalence of RTIs among pregnant women in some developing countries for which there are data.

Syphilis in developing countries remains at levels that were seen in developed countries a century ago. One must be cautious in looking at the data, however, because a seropositive serological test for syphilis

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×

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

a Diagnosis is based on Treponema Pallidum Haemagglutination test (TPHA) and Fluorescent Treponemal Antibody test (FTA-Abs).

b Diagnosis is based on culture of vaginal secretion.

SOURCE: Data from World Health Organization (1986), Wasserheit (1989), and Over and Piot (1993).

could be due to sexually transmitted infection or to previous infection with nonvenereal treponematoses (Larsen, Hunter, and Creighton, 1990). WHO estimates that in 1995, approximately 12 million new cases of adult syphilis will occur worldwide, with the greatest number in South Asia and sub-Saharan Africa (World Health Organization, 1995b). With this limitation in mind, past syphilis infections among pregnant women have ranged from less than 1 percent in Saudi Arabia to more than 33 percent in Swaziland (see Table 3-2). In one population of rural Somalia, nearly one-quarter of men and women in the general population had past evidence of syphilis (Over and Piot, 1993). Overall, syphilis is highly prevalent in developing countries, and considerable risk for congenital syphilis exists in many areas (Brunham and Embree, 1992).

Gonorrhea, like syphilis, is more prevalent in developing countries

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×

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). These frequencies have been extrapolated mainly from attendance at general health care centers or from special surveys of prevalence in population groups that may not be representative. Surveys of gonorrhea in pregnant women have ranged from one-half of 1 percent in Malaysia to 40 percent in Uganda (see Table 3-2). Among women visiting family planning clinics, rates have ranged from 2 percent in Swaziland to 17 percent in Kenya (Wasserheit, 1989). WHO estimates that approximately 62 million new cases of gonorrhea will have occurred in 1995 among adults worldwide; the largest number will be in South Asia and sub-Saharan Africa (World Health Organization, 1995b).

Genital chlamydial infections in the developing world have a prevalence similar to those in the developed world, both occurring at high levels. Among pregnant women, chlamydial infections are more frequent than gonococcal, with rates ranging from 6 percent in Nigeria to 29 percent in Kenya (see Table 3-2). Among men with symptoms of urethritis, rates of chlamydial infection (as measured by nongonococcal urethritis) appear to be lower than in the developed world. However, because chlamydia causes less symptomatic infections, patients may not be motivated to seek treatment in resource-poor areas where health care is difficult to obtain (Laga, 1994). WHO estimates that approximately 89 million new cases of chlamydia will have occurred in 1995 among adults worldwide; again, as with syphilis and gonorrhea, the greatest number will be in South Asia and sub-Saharan Africa (World Health Organization, 1995b).

Chancroid is highly endemic in many tropical countries, in particular Southeast Asia and eastern and southern Africa (Piot and Islam, 1994). The global incidence of chancroid is probably equivalent to that of syphilis. (There is a resurgence of interest in this infection due to the availability of new methods for detecting the causative organism, Haemophilus ducreyi.) In both developed and developing countries, commercial sex workers and their clients play a crucial role in the spread of chancroid.

On the basis of extrapolations from selected local studies, WHO estimates trichomoniasis is the most common curable STD (World Health Organization, 1995b). Trichomonal infection is frequently asymptomatic in men. Prevalence rates among women attending antenatal clinics range from 12 percent in Kenya to 47 percent in Botswana (World Health Organization, 1995b). Cross-sectional screening has found this infection in 11 percent of Nigerian adolescent women (Brabin et al., 1995). WHO estimates that 170 million new cases of trichomoniasis will have occurred in 1995 among adults worldwide, especially in developing countries (World Health Organization, 1995b).

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×

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). Likewise, HPV has been the most prevalent RTI found in selected studies, even in comparison with vaginal bacterial infections (Singh et al., 1995). In Asia and elsewhere, hepatitis B virus (HBV) is widespread (Lemon and Newbold, 1990); this virus is transmitted not only among sexual partners, but also from mothers to their newborns.

HIV infection in the developing world has been predominantly transmitted through heterosexual behaviors (Way and Stanecki, 1994). By the end of 1996, more than 22 million persons were infected worldwide, of whom 14 million were in sub-Saharan Africa (UNAIDS and World Health Organization, 1996). The HIV epidemic emerged later in Asia; however, rapid increases have occurred in both South and Southeast Asia. A striking increase in the percentage of HIV-infected commercial sex workers in Thailand and India, for example, provides a harbinger of future levels of HIV infection among the general population in these countries.

The level of endogenous RTIs among women in developing countries is typically even higher than that of the traditional STDs. In rural India, with careful physical examination and laboratory investigation, 92 percent of women were found to have genital infections (Bang et al., 1989). Less than one-half of these women had reported any RTI symptoms when interviewed prior to being examined. Similar situations were found both in Egypt (Younis et al., 1993) and in another region in India (Singh et al., 1995). The type of dominant endogenous infection varied among the populations, although bacterial vaginosis and candidiasis were both common. Until recently, the inability to mount a coordinated prevention response, even in the face of the pervasive HIV epidemic, has led to continued high levels of all RTIs in developing countries.

DETERMINANTS OF RTIs

Many factors affect the current high level of RTIs in both developed and developing countries (Wasserheit, 1994; Holmes, 1994; Cates and Holmes, 1992), and the factors differ not only from nation to nation, but also from community to community. Three interrelated environmental levels affect RTI patterns: physiological microenvironment, personal behavioral environment, and sociocultural macroenvironment. These levels can be further stratified according to specific effects related to the organism, the host, or the situation under which transmission occurs.

At the microenvironmental level, microbiologic, hormonal, and immunologic variables most directly influence individual susceptibility, infectiousness, and the development of RTI sequelae. These microenvironments

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×

are shaped, in part, by the personal environments created by an individual's sexual and health-related behaviors (Wasserheit, 1994).

Substance use behaviors also affect reproductive health. Most direct and dramatic is the role of intravenous drug use in HIV transmission, which has been prominent in the developed countries and in parts of Asia and Latin America. Use of alcohol and other drugs is associated with casual sex (Ferry, 1995), sexual violence and coercion, resulting in unwanted exposure to infection. Besides affecting acquisition of infection and the development of sequelae, personal behaviors mediate risk of exposure to infection. They are, therefore, the determinants that most directly affect changing infection patterns characterized by the emergence, maintenance, or reemergence of RTIs at a community level.

Individual behaviors and risk are, in turn, molded by powerful macroenvironmental forces that include socioeconomic, demographic, geographic, political, epidemiologic, and technological factors. Over the past 20 years, the profound changes that have occurred in the macroenvironment of both the developed and developing worlds have largely shaped patterns of RTI prevalence.

Physiological Microenvironments

Trend data are not available for most of the biological indices of the microenvironments that affect RTI patterns. For example, although it is known that the vaginal flora and acidity (pH) of the microbiological microenvironment influence susceptibility to RTIs (Hillier et al., 1992), it is not known how these factors have changed over time in either developed or developing countries. Similarly, manifestations of the hormonal microenvironment—such as the size of the zone of cervical ectopy, the penetrability of the cervical mucus, the patency of the cervical canal, the phase of the menstrual cycle, and possibly even the composition of seminal and prostatic fluids—may contribute to susceptibility to RTIs or their sequelae (Ehrhardt and Wasserheit, 1991).

Trend data are obtainable, however, for a few of the microenvironmental parameters. By altering cervicovaginal ecology, modulating vaginal pH, or other mechanisms, one RTI may increase susceptibility to other RTIs and their complications (Wasserheit, 1992). Thus, recent increases in RTIs may have fueled some of the changing disease patterns biologically, as well as epidemiologically. Moreover, high levels of RTIs have been implicated in the rapid spread of HIV—particularly among homosexual men in the developed countries and heterosexual men and women in Africa and Asia (Over and Piot, 1993). Decreases in the age of menarche, a manifestation of the nutritional and hormonal microenvironment, have been documented in both developed and developing countries (Rees,

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×

1993). Competing factors that influence the immunological microenvironment, such as nutrition, pregnancy, HIV infection, and prior exposure to STDs, can also be traced over time in some populations.

Personal Behavioral Environments

Both sexual and health-related behaviors affect the prevalence of RTIs; see Figure 3-1.

Sexual Behaviors

Risky sexual behaviors have been one of the primary determinants of changing patterns of RTIs, including HIV infection. Early sexual debut appears to be associated with subsequent patterns of multiple sexual partners and sex with risky partners in both developed and developing countries (Kost and Forrest, 1992; Caraël et al., 1995). Furthermore, the hormonal microenvironment is age dependent: for young adolescents, behavioral risk factors such as multiple, risky partners combine with biological risk factors such as large zones of cervical ectopy to cause high RTI rates.

Both commercial sex (exchange of sex for money or drugs) and specific sexual practices (such as anal intercourse, intercourse during menses, or "dry sex") have also been linked to increased risk of RTIs or their sequelae (Caraël et al., 1995). Occupations that require long intervals away from home (e.g., truck drivers, migrant workers, military personnel) also place persons in higher risk personal environments. In developing countries, marked variability exists among different nations in the reported level of risky sexual behaviors (Cleland and Ferry, 1995). For

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)

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×

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.

Health-Related Behaviors

Health-related behaviors are also a crucial component of the personal environments affecting RTI patterns (see Figure 3-1). Several of these behaviors, such as early health care utilization, compliance with therapy, and provider screening, primarily affect the distribution of the curable bacterial RTIs by reducing the duration of infectiousness and by preventing the occurrence of long-term complications.

Other health-related behaviors, such as contraceptive use, vaginal douching, and circumcision, may influence RTI patterns more broadly. Correct and consistent condom use decreases the risk of STDs, including HIV infection (Roper, Peterson, and Curran, 1993; Cates and Stone, 1992). The new polyurethane vaginal sheath (the "female condom") has also been shown to decrease the risk of some STDs (Soper et al., 1993). Chemical barrier methods (spermicides) apparently decrease rates of bacterial cervical infection, although their influence on viral RTIs remains unclear (Feldblum and Joanis, 1994). Hormonal contraceptive use, in contrast, may increase the risk of chlamydial cervicitis, but it seems to decrease risk of symptomatic pelvic inflammatory disease (PID). Both of these effects are probably mediated by hormonally induced changes in the microenvironment, such as expanded zones of ectopy and decreased penetrability of cervical mucus. Use of both hormonal methods and the intrauterine device (IUD) may increase RTI risk by reducing the likelihood of using condoms (Wasserheit, 1994).

Male circumcision is associated with lower levels of both bacterial and viral STDs (Moses et al., 1994). Moreover, close correlation exists between areas in Africa with high percentages of circumcision and low STD and HIV rates. Douching has been associated with higher rates of upper genital tract infection (Wolner-Hansen et al., 1990), although whether this effect is confounded by a self-treatment response to vaginal symptoms remains unclear.

Data on health care utilization, compliance with therapy, and provider screening behaviors are also quite limited. Clearly, financial and social barriers to early and effective care disproportionately affect adolescents and people in poor communities, both of whom are particularly common in developing countries.

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×

The Sociocultural Environment

The most difficult taks in addressing infection-free reproductive health lies in affecting the macroenvironmental forces, both in developed and developing countries; see Figure 3-2. Such factors as poverty, the low status of women, racism, social upheaval, and migration promote high-risk sexual behaviors, primarily because they increase economic marginalization (Aral and Holmes, 1990). These social and economic factors also result in fragile or nonexistent public health infrastructures, thus presenting barriers to health-related behaviors among the populations most in need of services. Communities of high RTI prevalence result. Extreme social upheaval may ultimately precipitate extensive outmigration and the spread of infection (Wallace, 1988).

The demographic characteristics of the populations frequently compound the problem. Young age composition and sex ratio imbalance are linked with many of those factors, as well as with RTI risk behaviors. In developing countries, relatively large and growing segments of populations are sexually active adolescents and young adults. Moreover, the gender imbalance in sexual relationships contributes to community situations

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).

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×

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). In developed countries, poverty is associated with other factors that are correlated with infection, including substance abuse, commercial sex, poor access to health services, and young age at first intercourse. In developing countries, the absence of preventive and curative services among poor and poorly served populations perpetuates high RTI prevalence.

These socioeconomic trends have been accompanied in many places by changes in the political environment that further limit access to public-sector RTI care: at the same time that RTI levels are rising, the public health infrastructure in many countries is deteriorating (Mosley, Bobadilla, and Jamison, 1993). Ironically, these trends have occurred despite advances in diagnostic and therapeutic technologies that could improve RTI prevention efforts.

CONSEQUENCES OF RTIs

RTIs have serious implications for reproductive health. For example, chlamydia and gonorrhea significantly reduce a woman's chances of becoming pregnant. Moreover, virtually every organism that is sexually transmitted can be passed to the fetus or infant—often with tragic consequences.

Pelvic Inflammatory Disease

''Pelvic inflammatory disease" (PID) has come to represent clinically suspected endometritis or salpingitis that has not been objectively confirmed pathologically or visually (i.e., by laparoscopy) (Kahn et al., 1991). Investigations over the past decade have emphasized the polymicrobial nature of PID. In general, three major groups of microorganisms play an etiologic role in PID: Neisseria gonorrhoeae, Chlamydia trachomatis, and a wide variety of anaerobic and aerobic bacteria. A leading hypothesis is that N. gonorrhoeae and C. trachomatis initiate tubal infection and that anaerobic and aerobic bacteria from the cervix or vagina are secondary invaders (Cates and Wasserheit, 1991).

In some European locations, N. gonorrhoeae has been cultured in fewer than 10 percent of samples taken from women diagnosed with PID (Cates et al., 1990), while in some developing world populations, N. gonorrhoeae has been cultured in up to 80 percent of women diagnosed with PID (Cates, Rolfs, and Aral, 1990). This variation is probably due to true differences among the populations studied and variations in the severity

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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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.

Teenagers have a particularly high rate of PID, especially when the data are corrected for level of sexual activity (Shafer and Sweet, 1989). In the United States, for example, sexually active 15- to 19-year-old females have a one in eight estimated lifetime risk of suffering PID (Shafer and Sweet, 1989). Rates are probably higher in developing countries, given the higher prevalence of infection and more limited access to care. As described above, biological, behavioral, and social determinants raise the risk of RTIs among teenagers, so creative interventions are needed to reach this high-risk age group.

The role of atypical (also called "subclinical" or "silent") PID in causing adverse reproductive sequelae is becoming increasingly apparent (Cates and Wasserheit, 1991). Atypical salpingitis accounts for a sizable proportion of tubal infertility. Many investigations have found that more than one-half of women with documented tubal occlusion reported no history of previous PID, despite serologic evidence of past chlamydial or gonococcal infection (Cates and Wasserheit, 1991). Moreover, morphologic and physical analysis of tubal epithelium from women with distal tubal obstruction found extensive ultrastructural damage, even among women who had no knowledge of previous PID (Patton et al., 1989). Women with atypical salpingitis had levels of tubal abnormalities similar to those with overt salpingitis. No demographic or clinical determinants have been found that differentiate women with atypical salpingitis from those with symptomatic PID (Cates, Joesoef, and Goldman, 1993). Thus, clinical evidence of symptomatic PID is not a necessary precursor for the eventual development of tubal dysfunction or obstruction.

Infertility

Women with a self-reported history of PID are more likely to be infertile than those without. A WHO multicenter study of infertile couples showed the proportion of infectious causes of infertility in different parts of the world: in Africa, nearly four-fifths of couples had an infectious etiology, compared with about two-fifths of infertile couples in other developing countries and one-fifth of couples seeking infertility services in developed countries (Cates et al., 1985).

Infertility as a consequence of RTI occurs primarily through the damage caused by salpingitis, which in turn leads to tubal dysfunction and occlusion. Usually this damage involves antecedent lower genital tract infections with either N. gonorrhoeae or C. trachomatis.

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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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. Despite wide variations in study design, results uniformly document that tubal infertility is significantly associated with previous chlamydial infections (Cates and Wasserheit, 1991). The majority of women with tubal infertility have no prior history of clinical PID; thus, the role of subclinical (or chronic) tubal inflammation in the pathogenesis of tubal infertility is quite important.

Ectopic Pregnancies

After fertilization, postinfectious tubal occlusion can still influence pregnancy outcome through its effect on potentially fatal ectopic implantation. In developed countries, the public health effects of ectopic pregnancies have been well documented: both increased incidence and decreased death-to-case rate (Centers for Disease Control and Prevention, 1994). Several factors have contributed to these trends, but the most powerful etiologic correlate is PID (Chow et al., 1987). Moreover, many of the other conditions frequently associated with ectopic pregnancy—lower genital tract infection, past IUD use, postabortal infection, and pelvic surgery—have a primary link with PID. However, few studies have examined the pathogenesis of ectopic pregnancy. The roles of such possible cofactors as douching, previous abdominal or pelvic surgery, and cigarette smoking are not known. Finally, as with tubal infertility, the preventive impact of antibiotic treatment for PID has not been firmly established.

Pregnancy Outcomes and RTIs

Nearly all RTIs can significantly influence pregnancy outcomes for both mothers and neonates (Cates, 1995). Vertical transmission, resulting in congenital infection, is a particularly serious outcome of perinatal RTIs; see Table 3-3. Fetal wastage, low birth weight, and prematurity are also adverse pregnancy outcomes commonly associated with RTIs.

Gonorrhea

Among pregnant women, the incidence of gonorrhea has ranged from less than 1 percent to 7.5 percent in developed countries and from 2 percent to 30 percent in developing countries. The majority of pregnant women with gonococcal infection are asymptomatic. Preterm delivery, premature rupture of membranes, and histologic evidence of chorioamnionitis

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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TABLE 3-3 Neonatal Effects of Reproductive Tract Infections

Organism

Maternal Infection Rate (%)

Infant Effects

Transmission Risk from Infected Mother

Treatment of Neonate

Prevention

Neisseria gonorrhoeae

1-30

Conjunctivitis, sepsis, meningitis

Approximately 30%

Screening: maternal culture; ocular prophylaxis

Penicillin, Ceftriaxone

Chlamydia trachomatis

2-25

Conjunctivitis, pneumonia, bronchiolitis, otitis media

25-50% conjunctivitis; 5-15% pneumonia

Screening: maternal culture; ocular prophylaxis

Erythromycin

Treponema pallidum

0.01-15

Congenital syphilis, neonatal death

50%

Serologic screening in early and late pregnancy

Penicillin

Herpes simplex virus

1-30

Disseminated, central nervous system, localized lesions

35 recurrent at delivery, 30% primary at delivery

Cesarean delivery if lesions present at delivery

Vidarabine, Acyclovir

Human papilloma virus

10-35

Laryngeal papillomatosis

Rare

None

Surgery

Human immunodeficiency virus

0.01-20

Pediatric AIDS

22-39%

Pregnancy prevention; Zidovudine prophylaxis

Zidovudine

 

SOURCE: Adapted from Cates (1995).

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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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. gonorrhoeae cultures of the orogastric contents of newborns. Prevention of neonatal gonococcal ophthalmia, which can lead to blindness, relies on ocular prophylaxis with silver nitrate or antibiotics at birth.

Chlamydia

The prevalence of cervical infection with C. trachomatis among pregnant women ranges from 2 percent to 25 percent in both developed and developing countries, but in most samples it is 8 percent to 12 percent. Untreated, cervical chlamydial infections in pregnancy cause approximately 20 percent higher rates of preterm delivery and low birth weight (Cohen, Veille, and Calkins, 1990). The consequences for infants of maternal infection at term include conjunctivitis and pneumonia. Ideally, prevention of chlamydial infection in pregnancy and among infants relies on detecting and treating prenatal infections. However, a tertiary prevention strategy is neonatal ocular prophylaxis with erythromycin ophthalmic ointment.

Syphilis

Syphilis can be transmitted transplacentally throughout the course of untreated maternal disease at every stage, from incubation to tertiary syphilis. The early stages, however, when spirochetemia is highest, pose the greatest risk to the fetus. Untreated syphilis in pregnant women results in adverse pregnancy outcomes, including abortion, prematurity, stillbirth, or neonatal death. Prevention depends on prenatal diagnosis and maternal treatment (Hira, Bhat, and Chikamata, 1990). Effective treatment of the mother, even late in pregnancy, generally results in cure of the fetus.

Most congenital syphilis occurs because the health care system fails either to detect maternal infection or to pursue it to adequate treatment. Current prevention recommendations for developed countries emphasize extending prenatal care where possible. In developing countries, where adequate prenatal care is largely unaccessible, screening and treatment for syphilis whenever a pregnant woman contacts a health system is crucial.

Herpes

The prevalence of symptomatic genital herpes infection among pregnant

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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women is less than 1 percent at the time of delivery (Randolph, Washington, and Prober, 1993). Intermittent asymptomatic shedding occurs from either the cervix or vulva, and the majority of neonatal herpes is transmitted from asymptomatic mothers. The role of screening in pregnancy for herpes infection is currently being evaluated. In developed countries, acyclovir may have a role in prophylaxis of infants born to mothers who demonstrate cervical infection at delivery.

Human Papilloma Virus

HPV infection is transmitted from an infected mother to her newborn during delivery by direct contact with infected cervical and vaginal tissue. Little is known about what factors may predispose the infant to symptomatic infection. No effect of maternal HPV infection on infant birth weight or gestational age has been reported; however, vaginal delivery is sometimes complicated by large warts. Although infants delivered to women with genital HPV infection occasionally have oral and anogenital warts, the most serious complication for the infant is laryngeal papillomatosis—fortunately, a rare outcome of this highly prevalent infection.

Human Immunodeficiency Virus

HIV can be transmitted from infected women to their offspring during pregnancy or soon after. Perinatal transmission rates vary from 22 percent to 39 percent, but they can be markedly reduced with zidovudine prophylaxis (Centers for Disease Control and Prevention, 1994); however, zidovudine is not generally available in developing countries. Breastfeeding has been demonstrated to be a mode of postpartum infection, particularly for infants whose mothers are infected after delivery. Clinical symptoms of HIV infection occur earlier in the course of illness among children infected perinatally than among adults. Moreover, the overall mortality rate after diagnosis of HIV infection is relatively high for those infected perinatally: one-half die before they reach 36 months of age (Brown et al., 1991).

RTI-Related Neoplasia

At least five squamous cell neoplasms—carcinomas involving the cervix, vagina, vulva, anus, and penis—have been strongly associated with HPV infection, particularly with HPV types 16, 18, 31, and 45 (Bosch et al., 1995). Squamous cell carcinoma of the cervix has also been strongly correlated with both the number of sexual partners (Buckley et al., 1981;

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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Harris et al., 1980) and (in some but not all studies) with smoking (Harris et al., 1980; Brinton et al., 1986) and HSV-2 infection (Hulka, 1982). Hepatocellular carcinoma is often caused by HBV, another sexually transmitted virus. Finally, some of the tumors associated with AIDS, namely, Kaposi's sarcoma and non-Hodgkin's lymphomas, although related to the profound immunosuppression caused by HIV, may themselves have an underlying viral etiology (Moore and Chang, 1995).

INTERVENTIONS TO PREVENT AND TREAT RTIS

The design and implementation of interventions to prevent and treat reproductive tract infections requires the effective coordination of a multifaceted public health response. Comprehensive programs must respond at both the individual and societal level, promote private and public investments in infection-free sexual and reproductive health, and encourage intersectoral coordination. Given local differences in available technological, human, and financial resources, the specific elements of programs can be expected to vary considerably in different settings, but common themes should be addressed in every program. Although many unanswered questions remain regarding the design of optimal approaches to RTI prevention and treatment, the most immediate challenge lies in the implementation of strategies already shown to be both feasible and cost-effective.

A tension often exists among the objectives of programmatic interventions, particularly for sexually transmitted infection. One objective is to relieve individual suffering and the serious personal sequelae of RTI. Another is to minimize the community impact of infections by reducing transmission. Although many interventions address these two objectives in concert, meeting these objectives may require different, complementary strategies if resources are limited.

An example of this tension often arises in regard to the traditional STD control approach that targets interventions to high-risk "core transmitters" (Moses et al., 1991). Studies show a tight cluster of some STDs, such as gonorrhea, in specific geographic areas (Rothenberg, 1983; Wasserheit, 1989). From a community perspective, the efficacy of a targeted approach is supported by cost-effectiveness modeling that demonstrates a greater benefit than other approaches, as measured by disability-adjusted life-years saved per dollar invested (Over and Piot, 1993). Others have questioned the wisdom of relying exclusively on a highly targeted approach, however, noting that such an approach fails to address the needs of individuals outside the identified core groups (Elias, 1991). Although these individuals are "less important" at a community level and may be more costly to reach, they certainly have real personal needs for

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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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). Once infected, she is unlikely to further spread infection in the community (except through reinfection of her husband or perinatally). Interventions exclusively targeted to core transmitters will not directly meet her needs for either prevention or treatment.

The trade-offs involved in choosing a particular set of intervention strategies in any given locale should be made explicit so that the various options can be the subject of discussion in the community. Where available, such choices should be guided by data concerning the relative cost-effectiveness of different intervention strategies. A mixture of responses will most often be warranted.

Different settings call for different intervention approaches. The manager of a busy family planning clinic serving women in the general population may not have a key role in controlling STDs at a community level. Clinic clients in most parts of the world are probably not responsible for transmitting infections widely within the community. In a family planning clinic, counseling to guide appropriate contraceptive choice, standardized case management of symptomatic infections, patient-initiated partner notification, prevention of iatrogenic infections, and selected screening efforts are appropriate (and feasible) programmatic interventions (Elias and Leonard, 1995). In contrast, aggressive condom promotion, regular STD screening and treatment, and clinic-assisted partner notification focused on commercial sex workers and their clients may be important intervention choices for the manager of a community's STD control program.

A cost-effectiveness analysis of options for STD control that used as an outcome measure only the reduction of STD prevalence in the community might show that scarce resources should be directed exclusively to the intense efforts aimed at core transmitters. However, as we argue further in Chapter 7, reproductive health programs have multiple related goals. For family planning programs, these include helping clients achieve their reproductive intentions in a healthful manner (Jain and Bruce, 1993). Preventing infertility by managing syndromes related to RTIs is thus part of their mission and may be important for credibility as health providers (among staff as well as clients). The type and intensity of STD prevention, detection, and treatment efforts aimed at general populations should vary, as we argue below, according to such factors as the prevalence of STDs and the effectiveness of local interventions and treatment algorithms.

Unfortunately, a failure to consider relevant intervention options in context has too often resulted in inaction. Consequently, family planning

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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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. Recognizing the important role played by family members, traditional practitioners, pharmacists, and the private sector in preventing and treating RTIs and their consequences is an important element of such a coordinated response.

Limitations in the Data on RTI Interventions

One of the major limitations in developing recommendations for RTI intervention programs is the paucity of data available concerning the effectiveness and cost of various intervention strategies. Few interventions have been thoroughly evaluated (Aral and Peterman, 1993; Oakley, Fullerton, and Holland, 1995). Even when evaluations have been attempted, too often study designs have been weak, and the results have consequently been inconclusive (O'Reilly and Islam, 1995). For example, evaluations of primary prevention efforts have rarely contained adequate controls. Programs with partial success have not often been refined and retested or replicated in other settings. Many studies accept changes in attitudes and knowledge as proxies for behavior change, a conclusion not justified by the available knowledge (DiClemente et al., 1992; Temmerman et al., 1990). At the same time, expectations of the effectiveness of behavioral interventions have often been too high, with the result that partially successful interventions have been undervalued (O'Reilly and Islam, 1995).

A further limitation relates to large degrees of variability in the quality of intervention efforts. The same intervention strategy can have diverse effects in different settings, reflecting both differences in the populations served and in local program implementation. For example, with HIV discordant couples in Europe, fewer than 50 percent of couples regularly used condoms despite repeated counseling (de Vincenzi, 1994); in California, however, there was more condom use, perhaps due to greater intensity of the intervention program, as well as an emphasis on counseling couples together (O'Reilly and Islam, 1995; Padian, Vittinghoff, and Shiboski, 1994). Generally, little information exists about "which" interventions work, and even less addresses "how" or "why" any given intervention works in a particular setting. As a consequence, there is little guidance available on how to design effective program packages, especially for individuals in the general population.

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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This lack of information has long been a concern in the field of interventions research (Chen and Rossi, 1983; Stoeckel, 1992). Many intervention efforts may have limited effects not because they lack a causal influence on the phenomenon of interest, but because they have been poorly implemented at a local level. At the extreme, program efforts may fail primarily because of unsuccessful implementation, causing program planners to abandon an otherwise promising intervention. In the health education literature, this is sometimes referred to as a "type III error"—something does not work simply because it does not actually "happen" with sufficient intensity or in the way in which it was intended (Basch et al., 1985). The discrepancy between program plans and program realities, as well as weak program effects, is well known in the area of family planning service delivery (Simmons and Elias, 1993). Much more attention must be directed to understanding the "how to" of intervention design, as well as the relative merits of different intervention strategies.

Defining the Content of RTI Interventions

A comprehensive RTI intervention strategy requires three levels of action:

  • primary prevention—preventing the acquisition of infection: prevention of sexually transmitted infections, prevention of endogenous infections, and prevention of iatrogenic infections;

  • secondary prevention—identifying and treating established infection: management of symptomatic infections, screening for asymptomatic infections, and mass treatment approaches; and

  • tertiary prevention—minimizing the adverse consequences of such infection.

Obviously, primary prevention of infection has tremendous intuitive appeal because it diminishes the subsequent need for the other interventions. Identification and treatment of established infection is also crucial, however, as it has important effects at both the individual and community level, particularly for sexually transmitted infections. Indeed, STD case-finding efforts (a secondary prevention strategy) also prevent a large number of primary infections (or reinfections) when they are combined with appropriate clinical management, client counseling, and partner notification, referral and treatment (Cates and Holmes, 1992). Finally, concerted attempts to minimize the adverse sequelae of RTIs (e.g., tubal infertility, ectopic pregnancy, or congenital infection) are also important given the large personal, social, and economic costs of these outcomes.

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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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). Prevention of endogenous infections also requires personal behavioral change, but with an emphasis on a range of hygienic and health-related behaviors. In contrast, prevention of iatrogenic infections requires attention to issues of service quality, with an emphasis on

TABLE 3-4 Strategies for Primary Prevention of Reproductive Tract Infections

Type of Infection

Prevention Strategy

Sexually Transmitted

Delaying sexual initiation (coital debut); Reducing number of sexual partners or rate of partner change; Changing the dynamics of partner selection; Reducing nonconsensual sexual exposure; Encouraging safer sexual practices; Promoting condom use; Providing voluntary counseling and testing; Promoting use of other barrier methods; Encouraging male circumcision (?)

Endogenous

Improving knowledge of reproductive physiology and menstrual and personal hygiene; Promoting appropriate help-seeking behavior; Reducing the use of harmful intravaginal substances (i.e., douches and desiccants); Reducing the inappropriate use of systemic antibiotics

Iatrogenic

Improving access to safe delivery and abortion services; Improving infection control practices; Improving provider technical competence; Enhancing the management of service delivery (quality of care); Providing antibiotics prophylactically (?)

(?), Evidence of effectiveness or cost-effectiveness is weaker than for other strategies.

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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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. Primary prevention interventions stress either reducing an individual's risk of sexual contact with an infected person or decreasing the per-exposure probability of acquiring an infection. Secondary prevention efforts (discussed below) seek to decrease the duration of infectiousness for those STDs (primarily bacterial) that are amenable to treatment. Three factors in combination—the likelihood of contact with an infected person, the efficacy of per-exposure transmission, and the duration of infectiousness—are the principal determinants of the spread of sexually transmitted infection within a population (Anderson and May, 1988).

Strategies to reduce exposure to infections include encouraging a delay in the initiation of sexual activity, a reduction in the number of concurrent sexual partners, a reduction in the rate of sexual partner change, more careful selection of sexual partners, and efforts to reduce the incidence of nonconsensual sex. Strategies to reduce the per-exposure risk of infection include avoiding certain sexual practices, treatment of other RTIs, and the promotion of condoms and other vaginal barrier methods (see Table 3-4).

Delay of Initiation of Sexual Activity Delaying the initiation of sexual activity is especially important because of the enhanced biological susceptibility of adolescents to sexually transmitted infections and their consequences (Gotardi et al., 1984). Behavioral research findings also suggest that early coital debut is associated with a subsequent higher prevalence of high-risk sexual practices (Kost and Forrest, 1992). A recognition of the difficulties adolescents often face in obtaining reproductive health services (Karim et al., 1992; Flisher, Roberts, and Blignaut, 1992) is another reason to encourage this approach.

Several successful programs have been described (Coates and Makadon, 1995; Kirby et al., 1991; Howard and McCabe, 1990; Walter and Vaugh, 1993). The essential elements of success seem to be peer intervention approaches that stress autonomy and healthy decision making, and the provision of accurate information concerning sexuality, the consequences of unprotected sexual activity, and the available options for avoiding infection and unwanted pregnancy. Providing accurate information on sexuality to adolescents has not been shown to increase early

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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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).

Reduction of Number of Partners Encouraging a reduction in the number of sexual partners is an important means of reducing the spread of STDs. As some people, particularly young and unmarried individuals, may have only one partner at a time but high rates of partner change (''serial monogamy"), reducing the rate of new partner acquisition is also important (Anderson, 1989). It should be emphasized, however, that many currently monogamous individuals may still be at some risk of sexually transmitted infection—either through the multiple sexual partnerships of their sole sexual partner or as a consequence of infections acquired prior to a committed, mutually monogamous, relationship. This risk exists particularly for chronic viral infections, such as HPV, hepatitis B, and HIV infection, but also to those pathogens that may have long periods of asymptomatic carriage (e.g., trichomonas or chlamydia).

The risk that any particular sex partner has an STD is determined by a complex set of factors, including the overall prevalence of infection in the community, the variance in the rates of sexual partner change within that community, and characteristics of the particular sexual networks from which partners are selected (Caldwell, Orubuloye, and Caldwell, 1991; Anderson, 1989). Many of the macroenvironmental determinants discussed above serve to highly structure both the local epidemiology of infection as well as the social interactions that comprise any particular individual's network of sexual contacts. As a consequence, the same sexual behaviors can have different consequences depending on where and with whom they are practiced.

Awareness and Education Large investments have been made in mass communication efforts aimed at encouraging AIDS awareness, providing accurate information regarding the routes of HIV transmission and the available means of STD/HIV prevention, and minimizing discriminatory responses against those with HIV or perceived to be at risk of infection (Choi and Coates, 1994; Kelly et al., 1992). In general, the more successful campaigns have used a range of media, have been designed with appropriate attention to local cultural norms, and have employed audience segmentation and professional production and pretesting. Efforts to evaluate these approaches have focused primarily on their ability to improve knowledge and influence attitudes and, in this regard, have been fairly successful. However, convincing data that these approaches have, in themselves, resulted in significant behavior change are generally lacking. Indeed, a number of studies show a relatively poor correlation between

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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improved knowledge and reduced risk behaviors (DiClemente et al., 1992; Aral and Peterman, 1993). Yet public awareness and knowledge of AIDS and other infectious diseases are necessary conditions for control of diseases, even if they are not sufficient by themselves. Continued provision of information is useful even while work continues on ways to affect behavior.

Within family planning programs, HIV/AIDS information and prevention messages have been successfully incorporated into existing information, education, and communication efforts. When such efforts have been evaluated, they have accomplished their purposes without any adverse effects on contraceptive service provision. For example, in Colombia, community-based family planning field workers were randomized into two groups (Vernon, Ojeda, and Murad, 1990): the providers in the experimental group were requested to dedicate 20 percent of their time to AIDS prevention activities and encouraged to establish outreach to groups of potentially high-risk clients; the control group was to simply respond to clients' requests for AIDS information. The authors found community-based field workers could successfully incorporate AIDS prevention activities into their responsibilities without harming their contraceptive sales. A variety of other less rigorously evaluated efforts have also demonstrated the feasibility of incorporating STD and AIDS awareness efforts into existing family planning programs (Stover, 1988; Apao and Darden, 1993; Finger, 1994). Such efforts require resources, however, particularly for training and materials development. Resource limitations have limited service integration in many settings.

A broad variety of peer interventions have also been developed as primary prevention programs. These typically focus on both promoting condom use and reducing the number of partners. In one well-designed and -evaluated peer intervention among gay men in the United States, popular opinion leaders were trained to deliver HIV prevention messages to men in gay bars. The intervention was successful, producing significant reductions in unprotected anal intercourse of 15-29 percent from baseline levels (Kelly et al., 1992). The peer interventions literature is characterized by sizable variability in observed program effects, arising from broad variability in specific program approach and design, the intensity of intervention, and the outcome measures. Even more than other types of primary prevention efforts, peer interventions require further exploration, documentation, and description of the tenets for success.

Change in the Dynamics of Partner Selection Changing the dynamics of partner selection, while addressing a potentially important determinant of infection risk, is difficult. First, sexual behaviors are private. Second, the probability that a potential partner has an active infection cannot be

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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readily discerned. Indeed, attempts to do so based on sociodemographic characteristics often invite stigmatization, with its attendant social discrimination. Consequently, opportunities for intervention in this area are somewhat limited. One approach is to encourage men to refrain from the purchase of commercial sexual services. For example, it has been suggested that large industries employing sizable migrant labor forces should consider providing for the relocation of workers' spouses as a means of reducing the demand for commercial sex (Sweat and Denison, 1995). Another approach is to encourage more open communication between all sex partners concerning the risk of sexually transmitted infection and the available means of protection. This latter approach may be most important in facilitating condom or other barrier method use among intimate partners, but it may also discourage partnership with individuals unwilling to discuss and negotiate these issues. Intervention in this area will require an emphasis on skills building, not just didactic information. Other structural approaches that promote women's economic independence (e.g., changing wife inheritance laws) or aim to change harmful cultural practices (e.g., those forms of ritual cleansing that involve sexual intercourse) may also be an important means for changing the dynamics of partner selection (O'Reilly and Islam, 1995; Lamptey et al., 1995; Sweat and Denison, 1995).

Reduction of Nonconsensual Sexual Exposure Program efforts to reduce the incidence of nonconsensual sex are an important—and often overlooked—means of reducing the risk of exposure to sexually transmitted infections (Heise and Elias, 1995). In these situations, by definition, sexual partners are not selected, but some structural attempts can be made to reduce exposure to those settings where unwanted sexual activity may be encountered. Efforts to encourage more responsible sexuality among men are the most important in this regard. For example, a number of approaches—mostly involving peer interventions and the reduction of substance use—have recently been described as means for reducing the occurrence of "date rape" (Holcomb et al., 1993; Baylis and Myers, 1990; Hanson and Gidycz, 1993; Miller, 1988; Funk, 1993; Dating Violence Intervention Project, 1988).

Encouragement of Safer Sexual Practices Information concerning the higher relative risk of infection associated with certain specific sexual practices—such as receptive anal intercourse—can be included in health promotion messages, along with accurate information concerning the effectiveness of barrier methods of contraception. Some programs have also encouraged alternatives to penetrative sexual intercourse, sometimes referred to as "outercourse." These messages encourage couples to explore alternative

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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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). Few intervention efforts have singled out specific sexual practices, however; consequently, it is not possible to discern the relative contribution of safer sexual practices and increased use of barrier methods of contraception to the observed outcomes.

Condom Promotion When properly and consistently used, latex condoms are highly effective in reducing the spread of sexually transmitted infections (Centers for Disease Control and Prevention, 1988a; Feldlum and Joanis, 1994). Some recent data are also available concerning the effectiveness of the polyurethane vaginal sheath (female condom), and this device has been approved by the U.S. Food and Drug Administration (FDA) for marketing as a means of STD prevention (Feldblum and Joanis, 1994; Centers for Disease Control and Prevention, 1993b). Approval for several new nonlatex "plastic" male condoms is also being sought.

Efforts to promote the consistent use of good quality latex condoms, like reducing the number of partners, have been one of the principal AIDS prevention strategies for the past decade. Not surprisingly, condom promotion efforts have used many of the same approaches—and have most often been combined with—efforts to encourage partner reduction. The biggest challenge for condom promotion is encouraging use with steady partners. In many settings where men have become willing to use condoms with casual, commercial, or new partners, there is still little use within steady relationships (Van Landingham et al., 1995). Similarly, even among commercial sex workers who routinely use condoms with clients, there is a much lower rate of condom use with boyfriends (Dorfman, Derish, and Cohen, 1992).

Condom promotion efforts have included mass communication, peer interventions, and a number of innovative approaches, such as the use of street theater and commercial social marketing (see below). Condom promotion poses an additional challenge when compared with partner reduction strategies, however: not only must programs achieve the goals of accurate information provision and motivation for behavioral change, but they must also ensure that condom commodities of sufficient quality are readily available to those motivated to use them. Periodic failures in condom procurement, distribution logistics, and supply have sometimes been a major impediment to the successful implementation of condom promotion efforts.

One of the most successful strategies has been condom social marketing (Population Services International, 1994). Using the full range of

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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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).

Successful condom promotion among vulnerable groups of women, such as sex workers, has posed a number of challenges and spawned a number of innovative community approaches. Several intervention trials among sex workers in Africa using community organizing techniques and training peer educators to conduct outreach among sex workers and clients have shown consistent improvements in reported condom use (Lamptey et al., 1995; Williams et al., 1992; Wilson, Myathi, and Whariwa, 1992; Asamoah-Adu et al., 1994). More recently, some programs have begun to explore structural or "enabling" approaches to promoting condom use, which are explicitly targeted to the broader determinants of infection risk (Tawil, O'Reilly, and Verster, 1995). In these approaches, public policies that facilitate safer sexual behaviors are promoted. The most successful of these efforts has been the 100 percent condom use policy established in brothels in Thailand (Rojanapithayakorn, 1992). In this program, the Thai government made condom use mandatory: local health officials use STD rates from monthly screening of registered sex workers to assess compliance and hold brothel owners and clients responsible. Recent surveillance data suggest a dramatic decline in STD incidence in recent years (Hanenberg et al., 1994). Other structural approaches focus on changing inheritance laws and funereal customs that involve sexual exchange between the bereaved spouse and other family members (O'Reilly and Islam, 1995).

Voluntary Counseling and Testing Another tactic for primary prevention has been voluntary counseling and testing for HIV antibodies. This approach has been a cornerstone of the HIV prevention effort in the United States since the mid-1980s (O'Reilly and Islam, 1995). The effect of these interventions have been mixed, however, with considerable variability between sites (Higgins et al., 1991; Choi and Coates, 1994). As with other intervention strategies, the various effects probably reflect underlying variation in the content and intensity of the counseling and support services provided.

In general, better results have been found when both partners are counseled and in settings in which clients actively seek out the services in comparison with those in which they encounter counseling and testing in the course of seeking other services (i.e., in an STD clinic). In the only randomized, controlled trial of counseling and testing that has been published

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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(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. Given the costs of counseling and testing, mostly for adequate pre- and post-test counseling, this strategy may not be cost-effective as a way to promote condom use in developing countries. Several further evaluations are planned (O'Reilly and Islam, 1995). The most important unanswered questions concern issues of consent and the need for counseling. One study in Kenya found that, even after giving informed consent, many women did not actively request their test results, suggesting that other factors beside interest in their HIV serostatus influenced their decision to accept testing as part of a study protocol (Temmerman et al., 1995). Some researchers have suggested that the requirement for extensive counseling be abandoned; they propose instead the widespread availability of home testing for HIV, using saliva diagnostic kits (Frerichs et al., 1994). The pros and cons of the home testing debate have recently been summarized by Krieger and Stryker (1995).

Promotion of the Use of Other Barrier Methods Data concerning the use of chemical barrier methods—such as spermicides containing nonoxynol-9 and other biodetergents—for primary prevention of STDs are mixed. Similarly, published data concerning the effectiveness of other physical barriers (such as the diaphragm and cervical cap) for infection prevention are limited. Based on a review of 10 observational studies, Rosenberg and Gollub (1992) estimate that use of existing female barrier methods reduces the transmission of gonorrhea and chlamydia by roughly 50 to 75 percent. Some data also suggest that regular use of spermicides is associated with a lower risk of cervical cancer, an event known to be associated with HPV infection of the reproductive tract (Hildesheim et al., 1990). Spermicidal products are not currently approved by the U.S. FDA for use as microbicidal agents, and data concerning the efficacy of these products for prevention of HIV remain inconclusive (Cates and Stone, 1992; Feldblum and Joanis, 1994). One study of sex workers in the Cameroon demonstrated substantial protection from HIV infection among women using the vaginal contraceptive film (Zekeng et al., 1993). Another study among sex workers in Kenya, however, showed no protection and raised the concern that, in high doses, spermicides might enhance infection by causing vaginal inflammation or ulceration (Kreiss et al., 1992).

The public policy question of whether to include a broad recommendation to use chemical barrier methods as a means of infection prevention when condom use cannot be successfully negotiated is still a matter

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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of considerable debate (Stein, 1992; Rosenberg and Gollub, 1992; Niruthisard, Roddy, and Chutivongse, 1992). The New York State Health Department has produced materials outlining a "hierarchy of prevention options" that recommends using other woman-controlled barrier methods in the event that a woman is unsuccessful in negotiating condom use with her male partner (Cleary, 1994). Obviously, the availability of safe and effective vaginal microbicidal products would be an important addition to the prevention armamentarium (Elias and Heise, 1994).

Male Circumcision Given the known association between male circumcision and a lower incidence of both genital ulcer disease and HIV infection (Moses et al., 1994), some public health officials have suggested the strategy of recommending male circumcision as a means of primary infection prevention. Such an approach would require extensive community consultation, sensitivity to cultural norms, and an understanding of its potential acceptability. No published evaluations of this type of intervention are available.

Prevention of Endogenous Infection

The prevention of endogenous RTIs, such as bacterial vaginosis and candidiasis, requires efforts to improve women's and men's knowledge of reproductive physiology, menstrual and personal hygiene, health-seeking behavior, and adherence with prescribed therapy. It also requires reducing the use of harmful intravaginal substances (i.e., douches and desiccants), as well as curtailing the inappropriate use of broad-spectrum, systemic antibiotics (Wölner-Hansen et al., 1990). These latter approaches will require changing the recommendations and prescriptive practices of both traditional and allopathic health care providers, pharmacists, and family members, as well as individuals. To date, no intervention programs explicitly aiming to reduce the incidence of endogenous infections have been reported in the literature.

Prevention of Iatrogenic Infection

In contrast to preventing sexually transmitted and endogenous infections—which primarily requires personal behavioral change strategies—preventing iatrogenic infections requires intervention to improve the overall quality of reproductive health services and, in particular, transcervical medical procedures. Preventing such infections will require careful consideration of the current inadequacies of the medical care system, especially for provider training, infection control, and accessibility of services.

The greatest opportunity to prevent unnecessary morbidity and significant

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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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). Chapter 4 discusses some of the training and quality assurance efforts that could lead to lower rates of iatrogenic infection from abortion procedures. Given that a large number of septic procedures still occur in some areas, even where abortion has been legalized, successful intervention will also require ensuring an adequate number of trained abortion providers and, ultimately, the availability of safe alternatives to surgical abortion in the form of medical abortifacients that do not require transcervical procedures. Better training of providers to ensure the optimal treatment of abortion complications before infection develops will also be necessary.

Reducing the number of infections associated with other transcervical procedures, such as IUD insertion, will require more attention to adherence with infection control guidelines, improved provider technical competence, strengthening client counseling to help guide optimal contraceptive choice and proper use, and enhancing the overall management of service delivery programs. Given that some number of procedure-related infections occur even with optimal technique, the utility of antibiotic prophylaxis administered at the time of these procedures has also been investigated (Ladipo et al., 1991; Sinei et al., 1990). These results have been mixed, largely because of the unexpectedly low incidence of PID observed even among those IUD users who have received placebo regimens. Further studies, particularly studies involving new single-dose therapeutic regimens, may be necessary to fully understand the benefits and costs of use of antibiotics.

Secondary Prevention

Secondary prevention—the identification and treatment of established infections of the reproductive tract—is also an important element of a comprehensive intervention strategy; see Table 3-5. Appropriate treatment relieves symptomatic morbidity, prevents the more serious complications of infection that result in additional morbidity and occasional mortality, and serves to limit the duration of infectiousness—a critical determinant in the sustained spread of sexually transmitted infection. Unfortunately, a large proportion of RTIs are asymptomatic, especially in women. This characteristic of RTIs limits the utility of approaches that only treat symptomatic infection. Thus, while clinical management of symptomatic infections is essential, it is not adequate in itself. There

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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TABLE 3-5 Strategies for Secondary Prevention (Identification and Treatment) of Reproductive Tract Infections

Kind of Identification or Treatment

Strategy

Management of symptomatic infections

Standardized case management; Encouraging prompt care seeking; Improving treatment adherence; Encouraging abstinence during treatment; Clinic-based counseling for prevention

Screening for asymptomatic infections

Serologic screening; Urine, pelvic exam(?); Case finding, especially for cervical infections (e.g., gonorrhea and chlamydia); Partner notification and referral

Mass treatment

Prophylaxis for neonatal gonococcal ophthalmia; "Epidemiologic" treatment of core transmitters and communities with high rates of RTI prevalence

(?), Evidence of effectiveness is weaker than for other strategies.

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. This approach has had limited application to date, but some interesting studies are under way.

Management of Symptomatic Infections

While a sizable proportion of RTIs are asymptomatic, many infections are symptomatic. Symptomatic men and women with RTIs can be classified with a number of clinical syndromes, including urethral discharge, vaginal discharge, genital ulcer, lower abdominal pain, and inguinal swelling. The World Health Organization (1991, 1994) has developed a set of standardized flowcharts or algorithms to help guide the clinical management of these syndromes in a variety of service settings, including those with and without microscopy facilities. Appendix A reproduces the most recent revision of WHO guidelines for the management of STD-associated syndromes.

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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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). A number of studies have shown a poor correlation between women's symptoms, clinical observations made during vaginal and pelvic examination, and the presence of infection as detected by laboratory testing (Bang et al., 1989; Wasserheit et al., 1989; Grosskurth et al., 1994; Younis et al., 1993; Zurayk et al., 1995). For example, in one study conducted in Zaire to assess the diagnostic validity of the WHO flowcharts, the hierarchical algorithms for vaginal discharge and lower abdominal pain had only 48 percent sensitivity and 75.2 percent specificity when applied to pregnant women and 54.9 percent sensitivity and 52.2 percent specificity when applied to female sex workers (Vuylsteke et al., 1993). A poor correlation with the actual presence of infection means that a large proportion of women are unnecessarily treated, while others who have infections remain undetected.

This situation is further compounded by the complexities of health-seeking behavior among men and women who experience symptoms of infection. Many people with RTI symptoms follow a sequence of therapeutic practices, beginning with self-treatment in the home and progressing through remedies provided by family members, pharmacists, and a variety of traditional healers before seeking health services from allopathic providers (Olukoya and Elias, 1994). Whether the development of health education efforts that encourage more prompt health-seeking behavior among symptomatic individuals will improve the utility of clinical algorithms remains to be tested. More timely health-seeking behavior will change the characteristics of the population presenting for syndromic management, which may influence the performance characteristics of the therapeutic algorithms. Consequently, it is important to validate standardized clinical management tools among the populations in which they will actually be used.

Although the current WHO algorithms are not ideal, standardized case management must be considered a mandatory intervention for the responsible delivery of contraceptive and other reproductive health services. Many men and women currently come to services complaining of symptoms related to RTIs. Unfortunately, providers are often poorly informed about women's perceptions of reproductive tract symptoms and the cultural idioms of symptom presentation (Zurayk et al., 1995). Failure to address a client's concern undermines the credibility of the service delivery system. Too often individuals in need of care are sent away without any attention given to their presenting complaint, or they

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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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. Ideally, this would be done in the light of data concerning the local epidemiology of infection and antibiotic resistance patterns. One benefit of such an approach would be to minimize the costly and unnecessary overtreatment of clients and potentially improve clinical outcomes through standardizing therapy, thereby allowing program managers to select the most cost-effective therapeutic regimens (again, ideally based on local data) and streamline drug procurement processes.

In refining the algorithms, one important issue that urgently requires clarification is the utility of linking syndromic management to behavioral risk screening. WHO flowcharts have included a number of screening questions regarding sexual behavior (World Health Organization, 1991). Risk assessment is positive only if patient answers yes to: Does your sexual partner have a discharge from his penis or open sores anywhere in his genital area? Or if she answers yes to two or more of the following: Are you younger than 21 years? Are you unmarried or not in union? Have you been with your husband or sexual partner for less than 3 months? Have you had more than one sexual partner in the last 4 weeks?

The purpose of these questions is to help distinguish between cervical infections (which have more serious complications and require more intensive treatment) and vaginal infections (which are more common). Given the generally poor predictive performance of the vaginal discharge algorithm, treating all women with a discharge syndrome for cervical infection has the potential to result in high levels of overtreatment with broad spectrum antibiotics, an outcome that has significant costs both in terms of resources and the possible emergence of antibiotic resistance. Unfortunately, there are few data to determine whether these questions significantly improve the diagnostic performance of the algorithms in the majority of settings in developing countries where they will be applied. As discussed further below, risk screening approaches have sometimes had paradoxical results (e.g., when applied to interventions to reduce maternal morbidity and mortality; Rooks and Winikoff, 1990). Therefore, caution must be used in recommending the combination of an essential, potentially highly cost-effective intervention strategy (standardized case management) with a behavioral risk screening approach that has had limited testing.

The combined approach may be helped by local definition of the risk screening criteria. One recent study conducted in a Jamaican STD clinic, for example, evaluated the sensitivity of diagnosing cervical infection with an algorithm designed to combine a woman's symptomatology with

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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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). Adaptation of the algorithm on the basis of local data was found to be slightly more specific, though somewhat less sensitive, and a modification of the WHO algorithm was defined for local use. Behets et al. (1995:15) concluded that ''the generation of regional data enhanced local acceptability of algorithm approaches."

Ultimately, the predictive performance of standardized algorithms may be further improved by the development of newer and simpler diagnostic tests for RTIs. Recently, a number of initiatives to promote the development of STD diagnostic technology applicable in resource-poor settings have been launched (Berkely, 1994), and there has been some early success. For example, the use of a simple dipstick test for the presence of leukocyte esterase may greatly improve screening efforts among men who either have asymptomatic urethritis or experience mild symptoms without gross discharge (Shafer et al., 1989; Mayaud et al., 1992). Rapid advances in gene amplification and the use of urine as a specimen source for antigen detection (Quinn, 1994) are also promising approaches, but they are still experimental and prohibitively expensive.

Developing an acceptable flowchart for standardizing the management of symptomatic individuals is only the first step in treatment. Experience in primary care settings routinely using flowcharts to manage other clinical conditions (e.g., acute respiratory infections in children) suggests that more operational research is needed to successfully introduce such strategies to a variety of providers in a range of clinical practice settings (Pan American Health Organization, 1983). At a minimum, the widespread use of standardized case management strategies will require a sizable investment in provider training and retraining.

Efforts to upgrade diagnostic facilities and ensure adequate antibiotic supplies are also needed. One randomized community trial in Mwanza, Tanzania, has recently shown that improved STD case management had a significant impact on HIV incidence (Grosskurth et al., 1995). Primary health care clinics in six rural intervention communities received STD health education, staff training on the use of syndromic treatment algorithms, a regular supply of antibiotics, supervisory visits, and access to an STD reference clinic. The HIV incidence was reduced by more than 40 percent in this population after the integration of this package of STD services within the primary health care system. (In comparison with randomly matched communities, the prevalence of other STDs was also consistently lower in the intervention communities, but these results were not statistically significant.)

In addition to using standardized case management to choose therapeutic

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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interventions, efforts are also needed to improve treatment adherence (compliance) and encourage sexual abstinence for the duration of therapy among those diagnosed with STDs. Clinics also have to allow sufficient time for providers to conduct appropriate counseling regarding the primary prevention of RTIs, condom use, and the importance of partner notification and treatment. Some public health researchers have suggested that the opportunity to provide such directed prevention advice may be as important as the treatment itself in reducing the spread of RTIs (O'Reilly and Islam, 1995).

Screening for Asymptomatic Infections

Interventions aimed at screening for asymptomatic infections (case finding) have historically been an important strategy for STD control. For example, serologic screening for syphilis infection is a standard component of routine antenatal care in many settings (Centers for Disease Control and Prevention, 1988b, 1993a). Providing prompt treatment for mothers has proven to be an extremely cost-effective strategy for preventing congenital syphilis, even in extremely resource poor settings (Hira, Bhat, and Chikamata, 1990; Stray-Pederson, 1983). Syphilis screening requires minimal diagnostic facility, is relatively inexpensive, requires therapy with antibiotics that could be readily available and affordable in most settings, and requires a modest level of client follow-up and treatment adherence. Therefore, the widespread implementation of screening for asymptomatic syphilis infections in antenatal clinics can be seen as a "sentinel" intervention. Yet although the necessary steps to ensure antenatal syphilis screening, maternal follow-up, and appropriate treatment are all relatively simple, they are rarely successfully coordinated in most developing country settings (Temmerman, Mohamedali, and Fransen, 1993). Successful establishment of antenatal syphilis screening could, therefore, serve as a benchmark of the programmatic capacity to design and effectively achieve more complicated interventions, such as case finding for other infections (Schulz, Schulte, and Berman, 1992).

In considering screening for other asymptomatic infections, cervical infections in women (primarily caused by gonorrhea and chlamydia) are an important priority, given the high costs associated with PID and its complications. Diagnostic screening for these infections with currently available technology is neither simple nor inexpensive, however, so such screening must be rationed. A number of studies are available to suggest that screening for asymptomatic cervical gonococcal and chlamydial infections is cost-effective in family planning settings in industrialized countries (Trachtenberg, Washington, and Halldorson, 1988; Handsfield et al., 1986; Begley, McGill, and Smith, 1989). Selective screening is most cost-effective

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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when prevalence is generally low (i.e., 2-3%); in high prevalence settings (> 5%), universal screening is the more cost-effective approach, if affordable (Marrazzo et al., 1997). Hence, in selecting those for screening, sub-populations known to have a higher prevalence of infection are sought (Over and Piot, 1993; Aral and Peterman, 1993). Again, the relative cost-effectiveness of this screening may improve as simpler and less expensive diagnostic tests become available.

Another potentially important method for identifying people with asymptomatic sexually transmitted infections is through partner notification and referral efforts (formerly known as contact tracing). Identification and treatment of infected partners could also help lower the risk of reinfection for women who have been treated for STDs. Partner notification may be either passive—infected people are expected to personally notify their partners concerning the possibility of infection and the need for treatment ("patient referral")—or active—clinic staff solicit names of sexual contacts and attempt to contact them ("provider referral"). The second approach is obviously more costly, but it is also more effective (Judson and Wolf, 1978). However, studies of the effectiveness of partner notification efforts in both developed and developing country settings have had mixed results (O'Reilly and Islam, 1995; Andrus et al., 1990; Winifield and Latif, 1985; Asuzu, Rotowa, and Ajayi, 1990). More research concerning the optimal design of partner notification efforts is needed to refine this set of interventions.

Mass Treatment Approaches

Treatment of an entire group of individuals at risk of infection (without diagnosing individual infections in the population) requires that the therapy administered be safe, highly effective, inexpensive, and associated with minimal side effects. A mass treatment approach requires that the intervention be acceptable to the community concerned and that the number of infections prevented be sufficient to justify the expense and any possible risks (World Health Organization, 1986). For many years, putting silver nitrate or antibacterial eyedrops in the eyes of newborn infants as a prophylaxis against ophthalmia neonatorum caused by gonorrhea has met these criteria (Brunham, Holmes, and Embree, 1990). This intervention ranks among the most cost-effective in terms of preventing serious morbidity (preventable blindness) at exceptionally low cost (Laga, Meheus, and Piot, 1989).

Another mass treatment strategy involves the treatment of populations with high STD prevalence with antibiotics known to be effective against pathogens prevalent in those communities. To be effective at the population level, mass treatment interventions require high treatment

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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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.

Tertiary Prevention

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

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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cancer screening. As noted above, these complications are a major source of reproductive morbidity and mortality. For many of these conditions, the associated disability costs are fairly high, but so are the perceived costs of intervention. Consequently, the threshold to intervene is often quite high and a vicious cycle has developed. Because interventions have rarely been attempted, proven models for successful program development in resource-poor settings are lacking, and inexperience fuels programmatic complacency.

Strengthening the clinical management of women who go to health facilities with complications of septic abortion is a priority area for intervention. Effective programs have the potential to avert many of the deaths that occur each year as a result of unsafe abortion (McLaurin, Hord, and Wolf, 1990). A number of programs for training providers in the use of appropriate technology, such as manual vacuum aspiration, have been developed and implemented. Of course, efforts to manage the complications of septic abortion must be accompanied by concerted efforts to prevent septic abortion in the first place. Strengthening postabortion contraceptive services is an important strategy.

Another life-threatening complication of some RTIs is ectopic pregnancy. When this occurs, it typically presents as a medical emergency requiring urgent surgical intervention. Successful clinical management of this uncommon, but serious, condition will depend largely on the availability of appropriate diagnostic and transport systems to ensure safe maternity (see Chapter 4). This is particularly important for women in rural areas who must travel considerable distances to surgical facilities.

The management of infertility and the development of screening programs to detect and manage cervical neoplasms are examples of other areas where interventions are needed to manage the complications of reproductive tract infection. Recently, the WHO Special Programme on Human Reproduction has developed a manual on "simplified infertility management" for developing countries (Rowe et al., 1993). A number of pilot projects for cervical cancer screening have also been recently started (Blumenthal et al., 1994; AVSC International and Program for Appropriate Technology in Health, 1994). To date, however, little data are available concerning cost-effective interventions to reduce the impact of these complications.

RECOMMENDATIONS

We present first our general recommendations for the promotion of infection-free reproductive health. Specific recommendations are then discussed in three areas: immediate priorities for existing reproductive health programs, including those programs initially established either

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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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. With finite resources, difficult choices will need to be made. These choices will be shaped by existing facility infrastructures, health personnel, research capacity, among other factors, and should be the outcome of considered debate in local communities.

General Recommendations

  1. Policy makers and program managers should design locally relevant and culturally sensitive RTI prevention and treatment programs.

  2. The actual content of intervention programs and the challenges posed by their implementation should be accurately monitored and evaluated.

  3. The cost and effectiveness of the various intervention strategies to prevent RTIs should be evaluated and compared.

Immediate Priorities

Much can be done right now by family planning programs to respond to the concerns of their clients and staff about RTIs, STDs, and HIV/AIDS. All clinic staff need to be well-informed about HIV/AIDS so that they can answer their clients' basic questions. In this respect, it is important that staff learn to work through any fears they may have about AIDS or any judgmental attitudes they may harbor toward people with STDs. This will enable them to respond accurately and with sensitivity to those who may be infected or at risk of becoming infected.

Clinic staff also should be aware of the symptoms of RTIs so that even if diagnosis and treatment are not available on site, their knowledge can be taken into account when considering the method of family planning most appropriate for each client. Family planning programs should also consider clients' risk of exposure to RTIs in determining protocols for providing various contraceptive methods. Barrier methods, particularly condoms, could be a better option for some clients despite being considered "less effective" contraceptive methods. For some clients, the secondary benefits of RTI prevention may be as important as the primary benefit of contraception. Programs should have well-designed informational materials dealing with RTIs, STDs, and AIDS available for staff and clients. For example, simple, pictorial instructions on how to correctly use

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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and dispose of condoms are essential. All clinicians cannot assume that people know how to use condoms. Many do not, and embarrassment about such ineptitude has been shown in some studies to be a major reason why some people at risk still do not use condoms (Richters, 1994).

Program managers should encourage provision of basic RTI treatment services in clinics whenever possible. If services cannot be offered on site, providers should make the effort to learn which testing and treatment services for RTIs, STDs, and AIDS are available in their area and refer clients to these services as appropriate. Clinics and community-based distribution programs should have ample condom supplies for distribution to clients. Moreover, clients should be resupplied as quickly, efficiently, and as unobtrusively as possible.

Program Gaps

Health systems, particularly those in resource poor settings, often fail in their attempts to recognize or coordinate an effective response to RTI prevention or treatment. This failure occurs for a number of reasons, including weak management information systems, poor logistics and commodity distribution, inadequate provider training, and a narrow policy focus. Periodic disruptions of the supply of condoms and antibiotics are a particularly unfortunate example of this type of programmatic deficiency. Lapses in infection control practices are another common program failure.

The overall management of reproductive health services should be strengthened as a means to ensure implementation of interventions known to be effective. The establishment and monitoring of infection prevention standards for clinical services could be seen as a "sentinel" intervention. Infection prevention, consisting of simple measures such as hand washing, appropriate use of gloves, and adequate sterilization of instruments should be a minimum standard for all service delivery. Monitoring services for lapses in infection prevention practices will allow program managers to identify gaps in provider training and motivation, interruptions in supply and logistics systems, and difficulties in coordination between different service elements. If basic infection prevention practices cannot be ensured, it is unlikely that other, more complicated interventions for RTI prevention or treatment will succeed. This overall monitoring may best be accomplished by an explicit attempt to build an alliance with service providers as a means of promoting a general climate of organizational development within service programs. The COPE (client-oriented, provider-efficient) method of self-assessment developed by AVSC International is an excellent example of such an approach (Dwyer and Jezowski, 1995).

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×

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. Larger scale demonstration projects that are developed with the input of all relevant community groups (including government, nongovernmental service organizations, advocacy groups) and attempt to implement a broad range of RTI interventions within the constraints of a typical community's budget would be helpful in gaining experience in this area. The participation of community decision makers is an essential element for the sustainability of these intervention efforts.

Another urgent need is to expand the range of clients served by reproductive health programs. Adolescents, men, and the current users of traditional and informal sector services are examples of groups not reached through current programs. There is also a need to work with private sector services to improve the quality of their efforts to prevent and treat RTIs. Expanding services may require relaxing some of the current restrictions on nonphysician providers and changing some cultural assumptions regarding the presumed sexual abstinence of certain groups of women (i.e., adolescent, postpartum, or postmenopausal women). Correcting the current deficiency of trained female service providers through augmented training and support is also needed.

Research Priorities

Many unanswered questions concerning the optimal approach to achieving infection-free reproductive health would benefit considerably from both basic and applied research.

Seven topics should be the main priority areas for future research:

  1. local characterization of RTI epidemiology and antibiotic sensitivity—and a low-cost methodology for making such assessments;

  2. the relationships between perceptions of reproductive morbidity, syndromic presentation, and biomedical definitions of infection (including documentation of the current patterns of help-seeking behavior and the perceptions of men);

  3. sexual behavior and factors influencing decision making concerning the use of prevention technologies, such as condoms and spermicides;

  4. development and validation of case management strategies, as well as operations research on all aspects of service organization and delivery;

  5. demonstration and pilot projects, focusing on models of integrated services;

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
  1. product development research on low-cost RTI diagnostics, therapeutics, vaccines, and woman-controlled prevention technologies, such as vaginal microbicides; and

  2. documentation of the interactions of RTIs and existing contraceptive technology.

Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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×
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×
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×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
×
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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Suggested Citation:"3: INFECTION-FREE SEX AND PROTECTION." National Research Council. 1997. Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions. Washington, DC: The National Academies Press. doi: 10.17226/5500.
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Sexually transmitted diseases, unintended pregnancies, infertility, and other reproductive problems are a growing concern around the world, especially in developing countries. Reproductive Health in Developing Countries describes the magnitude of these problems and what is known about the effectiveness of interventions in the following areas:

  • Infection-free sex. Immediate priorities for combating sexually transmitted and reproductive tract diseases are identified.
  • Intended pregnancies and births. The panel reports on the state of family planning and ways to provide services.
  • Healthy pregnancy and delivery. The book explores the myths and substantive socio-economic problems that underlie maternal deaths.
  • Healthy sexuality. Such issues as sexual violence and the practice of female genital mutilation are discussed in terms of the cultural contexts in which they occur.

Addressing the design and delivery of reproductive health services, this volume presents lessons learned from past programs and offers principles for deciding how to spend limited available funds.

Reproductive Health in Developing Countries will be of special interest to policymakers, health care professionals, and researchers working on reproductive issues in the developing world.

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