REGIONAL STRATEGY 2006 - 2015

WHO’s global strategy

WHO recently launched its Global Strategy for the Prevention and Control of Sexually Transmitted Infections for 2005-2010. The global strategy provides strong economic and public health justification for an accelerated response to STIs, and shows how such action can contribute to achieving Millennium Development Goals of reversing the spread of HIV and lowering maternal and child mortality.

The technical content of the global strategy deals with methods to promote healthy sexual behaviour, the provision of barrier methods, how to deliver effective and accessible care for STIs and how to improve methods for monitoring and evaluating STI control programmes. It points out that STIs occur with the highest frequency among marginalized populations who frequently have poor access to services and emphasizes that the public health benefits of improving coverage to these groups can be substantial.

The strategy also makes a strong case for expanding the provision of good quality STI care more widely into primary health care, reproductive health services and HIV services. It emphasizes opportunities to increase coverage by working collaboratively with c o m m u n i t y - b a s e d organizations, private providers and other government sectors. The steps needed to develop health systems capacity are explained as is the need for reliable STI surveillance to guide control efforts.

An STI control strategy for South-East Asia WHO/SEARO has developed a 3-point strategy for
accelerating STI control in the Region. The strategy provides direction for countries to review their STI epidemics and the status of their STI control programmes, and to set realistic priorities and targets. Regional experiences have been highlighted to help countries adapt successful strategies for their STI programmes. Technical guidelines and tools are available to support interventions and services promoted in the strategy.

WHY INVEST IN STI PREVENTION AND CONTROL NOW?

1. To prevent adverse pregnancy outcome. The fourth Millennium Development Goal to reduce child mortality by 2015
2. To prevent serious complications in women. The fifth MDG seeks to reduce maternal mortality by three-quarters by 2015.
3. To prevent HIV infection. The sixth MDG calls on nations to reverse the spread of diseases, especially HIV/AIDS.

GUIDING PRINCIPLES

1. Public health orientation
   Sound public health principles provide the framework for efforts to control STIs and monitor progress.
2. Enabling environment
   Active involvement of affected communities is essential both in creating the sense of ownership and increasing acceptance of the programme.
   Broad support of other community stakeholders to reduce marginalization and vulnerability and to increase access to interventions.
   Attention to gender and cultural realities that influence norms and behaviour.
3. Commitment to a multi-sectoral response
   Active involvement of civil society and international partnerships contribute to successful and sustained response.
   Involvement of private health care providers in the public health response to STIs is crucial.
4. Strong leadership
   A strong level of political and financial commitment to controlling STIs at national and local levels is needed to implement new programmes and to scale up existing programmes to reach wider populations.
   Effective programme management with sufficient technical support is most critical to ensure effective interventions and services.

An STI control strategy for South-East Asia

WHO/SEARO has developed a 3-point strategy for accelerating STI control in the Region. The strategy provides direction for countries to review their STI epidemics and the status of their STI control programmes, and to set realistic priorities and targets. Regional experiences have been highlighted to help countries adapt successful strategies for their STI programmes. Technical guidelines and tools are available to support interventions and services promoted in the strategy.

STI REGIONAL STRATEGY 2006-2015

Goal

To reduce STI-related morbidity and mortality

Objectives

1. Cut incidence in high transmission networks to interrupt transmission and reduce prevalence at population level;
2. Improve STI case management for all to further reduce morbidity and mortality; and
3. Ensure reliable data to guide the response.

Objective 1 - Cut incidence in high transmission networks

Experience from the region shows that STI transmission can be rapidly controlled by reaching sex workers and their clients with effective interventions. The main components of such interventions include:

1. Peer outreach to reach at least the most active sex workers. The most effective outreach involves sex workers themselves - female, male and transgender - to promote condoms and services to their peers.
2. Condom programmes. The most important outcome to reduce sexual transmission in commercial sex networks is to achieve high rates of condom use (see 100% CUP). Every effort should be made to influence the structure of sex work to make condom use the norm for all clients.
3. STI services. Treating STIs in sex workers and clients reduces secondary transmission and helps reduce STI prevalence as condom use is increasing; and lower STI prevalence reduces risk of HIV transmission when condoms are not used or fail.
4. Enabling environment. Sex work is illegal in most places and police action or interference from organized crime can prohibit access or disrupt interventions. Sex workers themselves may be isolated and have little power to decide whether condoms are used or how sex is performed. Sex work interventions should thus include advocacy to explain the public health objectives of the interventions.

Increasingly, these different elements are being combined in successful interventions in different settings.

In areas where STI transmission is high and existing services poor or inaccessible to those who need them, short-term interventions may be indicated to rapidly bring down high rates of curable STI. Presumptive (or epidemiologic) treatment strategies targeting core groups with high STI prevalence and exposure have been effectively used for short-term reduction of STI rates. As STI rates decline, other interventions (increased condom use, effective STI case management) are needed to sustain control.

Objective 2 - Improve STI prevention and case management for all

STI services should provide comprehensive STI prevention and case management, which includes early detection, effective treatment and prevention interventions for anyone who seeks care in any health care setting. Comprehensive STI case management limits the spread of infection to uninfected sexual partners, reduces congenital transmission and prevents the development of long-term complications among those already infected. By raising general awareness of STIs and by improving STI services in primary health care, reproductive health, youth clinics and among private providers, the community burden of STI-related morbidity and mortality can be further reduced.

People should be able to recognize STI symptoms, realize the importance of seeking care early and have easy access to accurate diagnosis and effective treatment. STI programmes should thus widely promote accessible and acceptable services which offer comprehensive and effective case management. Special attention should be paid to reaching people at high risk who are not addressed under objective 1, including young people, migrant workers and other male bridging
populations.

Health care seeking behaviour

A major problem in STI control is that many individuals infected with STIs are unaware of their infection or delay seeking treatment. People with STI symptoms frequently attempt to self-medicate or buy antibiotics directly from pharmacies before seeking treatment at a health care facility. Healthcare seeking behaviour can be improved by raising awareness of STIs and promoting early treatment at medical facilities. Education to raise awareness of STI symptoms and promote early use of health care facilities should be disseminated widely in communities, through outreach other counselling activities.

STI case management

The components of comprehensive case management of STI patients include:

1. making a correct diagnosis by syndrome or laboratory diagnosis
2. provision of effective treatment
3. reduction/prevention of future risk through education and counselling
4. promotion and provision of condoms, and
5. ensuring that sexual partners are notified and treated

Whenever an infection is diagnosed or suspected, effective treatment for STIs should be provided promptly to avoid development of complications and to break the chain of transmission. Patients should receive education and counselling on treatment compliance, partner management, risk reduction and condom use. Treatment or referral should be provided
for any complications.

Primary health care

STIs and other reproductive tract infections remain significant causes of preventable reproductive tract morbidity and mortality, and improved services in primary care clinics - starting with syndromic case management and antenatal syphilis screening - are cost-effective for these reasons alone.

Reproductive health care

STIs and other reproductive tract infections (RTIs) contribute significantly to women’s ill-health by increasing risk of infertility, ectopic pregnancy, cervical cancer, spontaneous abortions and HIV infection. STI prevention, detection and early treatment are thus key elements in women’s health services. Maternal and child health, and family planning clinics serve many women of reproductive age and can greatly extend the reach of STI services.

Youth friendly health services

Sexually transmitted infections are a major health risk to all sexually active adolescents. Every year one in 20 adolescents contracts a bacterial STI, and the age at which infections are acquired is becoming younger. Services for and outreach to young people should be improved.

Private providers
Efforts should be made to improve STI services wherever they are provided and to involve private and informal sectors where many people seek care.

Objective 3 - Ensure reliable data to guide response

STI control efforts should be guided by reliable STI data and information on programme coverage. Trends of short duration STIs are a more sensitive indicator of high-risk sexual activity than those based on HIV prevalence and can be monitored widely, even in underserved areas where STI control may be poor. As markers for HIV transmission, STI surveillance is a recommended component of second-generation surveillance. Yet STI surveillance remains very weak in many countries.

Where STI surveillance is not functioning well, there is insufficient information for planning, implementing and evaluating STI and HIV prevention and control programmes. The regional strategy urges countries to adopt a two-phase approach to

1. ensure that basic STI surveillance and monitoring activities are in place and are used to track trends and coverage, and
2. build on and improve the basic system to develop better estimates of STI prevalence, antimicrobial resistance, etc.

incorporating the following elements:

1. STI case reporting
2. STI prevalence assessments and monitoring
3. Monitoring aetiologies responsible for STI syndromes
4. Measuring anti-microbial resistance patterns to determine whether STIs such as gonorrhoea are sensitive to recommended treatments
5. Surveys to monitor behaviours, ideally together with STI and HIV, in key populations
6. Operations research to answer questions not addressed by routine surveillance

Special initiatives and areas of focus

The global strategy proposes several initiatives for control or elimination of specific STIs. Because of high prevalence, morbidity and mortality related to some of these infections, these initiatives are highly relevant to the South East Asia Region.

1. Control of genital ulcer disease (GUD)
2. Elimination of congenital syphilis

In addition, the regional strategy promotes several special areas of focus to improve STI control and prevent HIV transmission. These include:

1. Strengthened HIV-related services
2. Roll-out of effective vaccines
3. Wider access to drugs and appropriate technology

Next steps

Reducing the high burden of STIs in South-East Asia region is feasible and would yield large public health benefits. To accomplish this will require commitment from countries to assess their situation and take steps to improve STI prevention and control. Countries are encouraged to review their national STI control programmes and to adapt the regional strategy to their local situation. Attention should be given to setting appropriate priorities and feasible targets, with an eye to improving STI control at sufficient scale to have public health impact.

Milestones

Countries should set milestones for progress in line with their specific STI control objectives. As a starting point, the regional strategy proposes the following broad milestones for SEAR countries in 2006-2010.

Actionable items: highest priority & Targets

1. Cut incidence in high transmission networks - Reach 80% coverage of sex workers and 80% of high-risk MSM by 2010
2. Improve STI case management for all - Cover 90% of relevant primary point-of-care sites and patients by 2010
3. Ensure reliable data to guide the response - Regional and country plans: 2007. Training and implementation 2007-2010

Actionable items: second level & Targets

1. GUD control and chancroid elimination - Regional and country plans by 2007
   ● Regional chancroid elimination by 2010
   ● Reduction of ANC syphilis prevalence to below 1% in all SEAR countries by 2015
2. Congenital syphilis elimination - Regional and country plans by 2007. Implementation 2007-2010 to attain 90% ANC coverage
3. Effective vaccine roll out - 5-year plan by 2007; pilot studies: 2007-08; scale-up: 2009-10
4. Prevention strategies/programmes for HIV positive persons - Strategies, curricula and materials by end 2006; implement interventions in 90% HIV clinical services by 2007
5. Provider-initiated HIV testing and counseling for STI patients - Facilitate development and implementation of universal coverage of HIV T&C for STI patients by 2010