Department of Reproductive Health and Research (RHR), World Health Organization
Sexually transmitted and other reproductive tract infections
A guide to essential practice
As described in Chapter 1, STIs/RTIs spread in several ways:
For maximum impact on STIs/RTIs and their complications, each of these areas needs to be addressed.
How to prevent STI
The best approach to preventing STI is to avoid exposure. At this first level of prevention, the likelihood of being exposed to STI can be reduced by:
STI prevention involves prompt recognition and effective treatment of STIs when they do occur. This not only reduces the probability of complications for the individual but also prevents new infections in the community. The sooner an STI is cured, the less chance it will be transmitted to other people.
Delaying sexual activity
Adolescents can avoid STI and pregnancy, at a time when they are particularly vulnerable, by delaying sexual activity until they are older. Support for delaying sex is perhaps most important for young girls, who may face severe social and health consequences if they become pregnant or develop an STI. The bodies of adolescent girls are particularly vulnerable to cervical infections that can lead to pelvic inflammatory disease, infertility and ectopic pregnancy. Adolescents should know that they can get support and confidential information on methods—including condom use—for preventing pregnancy and STI when they decide to become sexually active.
Decreasing the number of sex partners
Limiting the number of sex partners can help reduce exposure to STI. For example, people in mutually monogamous relationships (where both partners have no other sex partners) have no risk of STI if both are free of infection. Many monogamous women with only one lifetime sex partner, however, develop an STI—their risk of infection comes from their partner’s behaviour and not their own. Sexual abstinence is another way to avoid risk of STI (although other RTIs are still possible).
Many people need strategies other than monogamy or abstinence at some point in their lives. Monogamous relationships do not provide protection from STI when they follow one another in rapid succession (“serial monogamy”). Couples who are separated from each other for periods of time may also require other strategies. Men and women whose jobs involve travel—migrant workers, vendors, truck drivers, soldiers—are more likely to have multiple partners and to return home with an STI. Whatever the circumstances, both women and men with multiple partners—or whose partners have multiple partners—need reliable protection from STI.
Correct and consistent use of condoms
Condoms are the most reliable method available for situations where people want to protect themselves or their partner from any risk of STI. Used correctly, they form a barrier that keeps out even the smallest bacteria and viruses.
Male condoms made of latex are widely available, inexpensive and highly effective. Because they are easy to carry, protection can be available at any time. To use a condom correctly:
STI can still occur despite condom use, however. Genital ulcers or warts can be transmitted through contact with parts of the body not covered by the condom. More commonly, though, people get an STI because they misuse condoms, or use them inconsistently. When handled or stored incorrectly—in wallets or in a hot place, for example—or if used with oil-based lubricants, condoms may fail. Condom breakage is usually due to incorrect use, not to defects in the device.
Most importantly, condoms can only protect against STI when they are used consistently and correctly. When used correctly during every act of intercourse, condoms can greatly reduce the risks of both pregnancy and STI (dual protection), including HIV infection. Chapter 4 includes advice on counselling patients on how to negotiate condom use with partners.
Figure 2.1. Instructions for use of a male condom
Female condoms (Figure 2.2) are becoming more widely available and have the advantage for women that their use is more in their control than use of male condoms. One type of female condom is currently on the market, under various names. It is made of polyurethane plastic, which is sturdier than latex. Only one size is made and fitting by a health care provider is not required. Unlike latex male condoms, which are weakened by oil-based lubricants, the female condom may be used with any type of lubricant without its strength being affected. It is prelubricated, but users may add more lubricant.
Female condoms may offer a similar level of protection as male condoms, but they are more expensive. Some studies have shown that the female condom is acceptable to both women and their male partners.
Despite its advantages, the female condom has some problems. The device protrudes from the vagina and thus requires the acceptance of the male partner. Also, it cannot be used at the same time as the male condom, which means it cannot provide back-up protection if the male condom breaks or slips.
Research into other female-controlled methods is under way. Microbicides (chemicals that kill RTI organisms) are being tested for their safety and effectiveness in protecting against STI and HIV, as are other barrier methods such as the diaphragm. None of these methods has yet been shown to provide protection equal to the male condom, however.
Figure 2.2. Instructions for use of a female condom
Infections of the male and female reproductive tract and their consequences:
Preventing STIs/RTIs and their complications
STI/RTI education and counselling
Promoting prevention of STI/RTI and use of services
STI/RTI Assessment during Routine Family Planning Visits
STI/RTI Assessment in pregnancy, childbirth and the postpartum period
Management of symptomatic STIs/RTIs
STI/RTI complications related to pregnancy, miscarriage, induced abortion, and the postpartum period
Annex 1. Clinical skills needed for STI/RTI
Annex 2. Disinfection and universal precautions
Annex 3. Laboratory tests for RTI
Annex 4. Medications