Behavioral Risk Factors Associated with STDs

A growing body of research on sexual practices contributing to the spread of AIDS in industrialized and developing countries throws some light on the spread of other STDs because of the association between AIDS and STDs. But many of the findings remain tentative or even speculative and require further investigation in a variety of settings. Specific sexual marital and reproductive customs associated with STD transmission sometimes appear to cluster along ethnic, social, class, occupational or residential lines. In many cases, however, high-risk behaviors transcend social or geographical boundaries to affect a broad spectrum of the population. The following behaviors are thought to facilitate the spread of STDs:

• Rites of passage such as initiation of young males into sexual intercourse with experienced females.

• Arranged marriages, seduction, or sexual abuse of young girls by older sexually active men.

• Early sexual debuts of young women combined with multiple sexual partners.

• Societal tolerance of multiple sexual partners for males and (in some settings) females before or during marriage.

• High frequency of divorce and remarriage, especially when divorce results from STD induced infertility of either partner.

• Prolonged sexual abstinence following childbirth, when accompanied by a husband's casual extramarital sexual activity.

• Polygyny, especially where taking a second wife is a response to the STD-induced infertility of the husband or first wife, or when the sexual relations of at least one person extend beyond the polygynous unit.

• Frequent or prolonged separation of spouses due to labor migration, especially when males patronize prostitutes or have casual sexual encounters.

• The availability of significant populations of single, separated, or divorced women seeking sexual contacts in exchange for money, gifts, favors, or pleasure.

• Infrequent use of condoms or spermicides in sexual intercourse.

• Other sexual practices such as forced intercourse or anal intercourse in homosexual or heterosexual encounters.

Although most of these examples come from African studies, it is important to note that high risk behaviors art found in many populations in both developing and industrialized countries. For instance, in the United States sexual activity begins early for many girls, and is often combined with multiple sexual partners and infrequent condom use.

Diagnosis and Treatment

Early diagnosis and treatment of lower tract infections is the most effective and least expensive means to prevent upper tract infections. Despite the scarcity of medical resources in most developing countries, some simple steps can be taken to diagnose and treat common RTIs. For example, routine screening and treatment for infection can be incorporated into family planning, prenatal, and maternal and child health services. For many women, these contexts are more socially accept able than clinics specializing in STDs.

In settings that can accommodate pelvic examinations, two inexpensive clinic-based techniques (each costing only a few cents) are available for diagnosis of such vaginal infections as bacterial vaginosis and trichomoniasis. They are the pH dipstick-a strip of paper which changes color- and potassium hydroxide for the detection of characteristic odor in vaginal secretions. The diagnosis of cervical infections is more difficult, however, as the cervical Gram stain, which is the standard screening test for gonococcal and chlamydial infections, requires a microscope and some skilled interpretation. In addition, compared to more sophisticated tests for these infections, its accuracy is limited. Improved rapid, inexpensive and easy-to-use diagnostic tests for chlamydia and gonorrhea are urgently needed for resource-poor settings, as are simple diagnostic tests for syphilis and chancroid. Where resources permit, the increased use of PAP smears to detect pre-cancerous cervical lesions associated with HPV could also save women's lives.

In settings where neither pelvic examinations nor laboratory studies are possible, treatment must be based on the patient's symptoms and the health provider's knowledge of the prevalence of different types of infection in the community and awareness of potential complications. If a woman complains of vaginal discharge, for example, she is usually treated for gonorrhea first because gonorrhea can result in PID. Chlamydia or bacterial vaginosis, the two other RTls that may ascend to the upper tract, are usually treated only if symptoms persist following therapy for gonorrhea and for trichomoniasis. This approach may be inappropriate and it reflects the fact that in most developing countries there is no information about the prevalence of chlamydia or bacterial vaginosis. More important, since women with RTIs are frequently asymptomatic, many of them will be missed by a system that relies solely on symptoms for treatment decisions. For instance, in a setting where laboratory studies cannot be performed and infections leading to PID are suspected to be common, it may be advisable to administer preventive antibiotics prior to a transcervical procedure such as an IUD insertion or abortion.

Barriers in the Search Information and Answers

The task of ascertaining the prevalence, causes, and consequences of RTIs in developing countries is complicated by many factors such as:

• Published studies of RTIs in developing countries are limited in number, especially in parts of Asia and Latin America, and they usually test only for classical STDs such as gonorrhea and syphilis.

• Many studies focus on specialized groups such as prostitutes or clients of STD clinics and do not provide data that can be generalized to larger populations. Studies that focus on prenatal or family planning clinic clients or hospital patients typically under represent rural and low income populations.

• Diagnosis of some RTIs is difficult in developing countries because of shortages of trained personnel and laboratory equipment.

• Self-reported diagnoses of RTIs and accounts of sexual behavior obtained from surveys are often unreliable.

• Many women and some men with RTIs such as syphilis, herpes, chlamydia, and gonorrhea experience no symptoms.

• RTIs are often found together, making it difficult to sort out their separate causes and effects.

All of these difficulties increase the likelihood that RTIs will go untreated, that STDs will continue to spread, and that the consequences of most infections for women, men, and children will be more severe. In addition, there are other factors that complicate prevention and treatment efforts:

• With STDs, all partners must be notified of possible exposure, examined, and treated to prevent a new cycle of infection.

• Previous exposure to most RTIs does not prevent reinfection.

• Some strains of gonorrhea and of other RTI causing bacteria are resistant to routine antibiotic treatment.

• Self-diagnosis and self-medication of infected persons lead to inappropriate or incomplete therapies.

• Prolonged use of antibiotics may facilitate growth of resistant strains of bacteria, while under-treatment or reliance on ineffective or harmful folk remedies may result in the development of severe complications and further spread of infection.

• Women can transmit RTIs to their infants during pregnancy or childbirth as well as acquire RTIs from or transmit them to their sexual partners. Thus a pregnant woman becomes an unwitting, critical link between vertical and horizontal transmission of RTIs.

• Even when symptoms are present, women and men are unwilling to seek medical treatment for RTIs because of fear, denial, or lack of information.

• Girls and women in many cultures have less access to medical care than boys and men, especially in situations where they cannot leave home without permission, or where their health is less valued (by themselves and others) than that of male family members.

• Inadequate sex education and public information campaigns in many settings prevent frank and open discussion of RTIs. Cultural taboos against speaking out about sexuality and genital diseases also hinder communication about the recognition, prevention, and treatment of RTIs and STDs.

Challenges for Health and Family Planning Programs

The management of RTIs in developing countries depends in large part on adapting current programs in Family Planning, Primary Health Care, Child Survival, and Safe Motherhood to provide services for the diagnosis and treatment of these infections. These initiatives will be more successful if they are implemented within a reproductive health frame work that enables women to:

• Regulate their own fertility safely and effectively by conceiving when desired, terminating unwanted pregnancies, and carrying wanted pregnancies to term;

• Remain free of disease, disability, or the risk of death associated with sexuality and reproduction;

• Bear and raise healthy children.

Family planning programs may have difficulty in persuading clients to accept or continue contraceptive methods in settings where RTI-related infertility or pregnancy loss is common. Many studies have shown that the most common reason women give for discontinuing a contraceptive method is the perception or fear of a side effect. Regardless of whether there is a relationship, users often attribute any symptom, particularly any reproductive tract symptom, to their method of contraception. In addition, once a method is initiated, they are more likely to report a symptom that has previously gone unnoticed. In the absence of accurate diagnosis and effective education and treatment, it is far easier for a woman to blame her vaginal discharge on her contraceptive method than to consider the possibility of her husband's infidelity.

Family planning and health care providers can take a number of positive steps toward the prevention, diagnosis, and treatment of common RTIs. These include:

• Providing, in community health campaigns, information about the causes, symptoms, consequences, and sources of care for common RTIs among women and men, adolescents and children.

• Providing technically appropriate routine diagnostic and treatment services or referrals for RTIs, particularly for women at risk of acquiring PlD-related infertility during IUD insertion or abortion, and for pregnant women at risk of miscarrying or infecting their infants.

• Encouraging women to bring their sexual partners for diagnosis and treatment of STDs, and providing comfortable and supportive counseling services for both sexes.

• Strengthening efforts to improve obstetric care, including training traditional practitioners how to reduce the risk of infection during uncomplicated births and when to refer women to health centers for further attention.

• Providing safe early pregnancy termination services to eliminate risks to women's lives,health, and future fertility.

• Teaching people about contraceptive methods most likely to offer protection against infection, such as condoms for men, and barrier methods (diaphrams, cervical caps, sponges) and spermicides (foams, jellies, suppositories) for women.

• Initiating sex education programs for adolescents and adults in schools and communities that include information on sexuality, reproduction, and contraception, encourage reflection on male and female roles in society, and empower women to assume greater control over their own lives.

Despite the difficulties in obtaining accurate information about RTIs in Third World populations and in designing appropriate interventions, much can be done. The challenges are to think creatively about how existing programs can be adapted to meet women's reproductive health needs in this crucial area, and to allocate the necessary resources. Will the culture of silence prevail or can it be overcome within families, within communities, and among health professionals?