About the guide

This Guide has been developed for use in reproductive health care settings (family planning, and maternal and child health care clinics) and focuses on women, as they are the "traditional" clients in these settings. Unlike men, women rarely go to STI clinics with their problems, and are often asymptomatic if infected. Visits to their reproductive health care provider may be their only contact with the health care system. However, throughout the document men and adolescents are also considered, given the need to reach out and offer prevention services to these groups, in order to achieve favourable public health outcomes through the prevention and treatment of STIs/RTIs.

Human immunodeficiency virus (HIV) infection is not covered extensively in this document, but references to HIV are made where necessary. This is because, while HIV is technically an STI, it is not a reproductive tract infection. Hepatitis B and C are other examples of STIs that are not RTIs, and are not covered in this Guide. For further information on HIV infection, see Annex 5 (Additional resources and suggested reading) and visit the WHO HIV/AIDS web site at http://www.who.int/HIV.

This Guide is intended to be a reference manual, and a resource to educate and to remind health care workers of the need to consider STIs/RTIs when providing other reproductive health services. It recommends prevention and care practices for patients who have or may be at risk of acquiring a reproductive tract infection. As such, it could be used for preservice or in-service health provider education and training, as a source of up-to-date, evidence-based recommendations, and as a self-education tool for health care providers on the prevention, treatment, and diagnosis of RTIs.

Programme managers can use it as a starting-point for improving policies, programmes and training on the prevention and management of STI/RTI, adapting the information and recommendations as needed to local conditions¹.

The information is grouped according to "reasons for visit". Providers are encouraged to consider the possibility of STI/RTI, educate and counsel clients about prevention, and offer necessary treatment. Providers can use the Guide as a whole, or focus on the sections that are relevant to their daily practice.

 

Terminology

Not all sexually transmitted infections are reproductive tract infections; and not all reproductive tract infections are sexually transmitted; STI refers to the way of transmission whereas RTI refers to the site where the infections develop.

 

Reproductive tract infection is a broad term that includes sexually transmitted infections as well as other infections of the reproductive tract that are not transmitted through sexual intercourse. Conversely, because STIs in most cases have much more severe health consequences than other RTIs, the term STI/RTI is used throughout the Guide to highlight the importance of STIs within reproductive tract infections. When information provided in the document is relevant to sexually transmitted infections only, the term STI is used alone.

 

Structure of the Guide

The Guide is divided into three sections:

• Section 1 provides background information on the burden of STIs/RTIs and their complications, how they spread and how they can be managed. It includes background public health information for the specific prevention and care issues that are covered in Sections 2 and 3, and reviews the basic skills and knowledge that health care providers should have in order to detect and prevent STI/RTI.
• Section 2 describes how to approach STI/RTI as an integral part of reproductive health services. It includes information on reducing risk, detecting infection and preventing complications during routine clinic visits for pregnancy, postpartum care and family planning. It also looks at some issues of importance for men and adolescents who do not typically use reproductive health services.
• Section 3 deals with management of STI/RTI�how to diagnose and treat STI/RTI-related problems�using a problem-oriented approach that permits rapid access to information. Specific problems that may be discovered during reproductive health care visits are considered here.

Each chapter begins with a summary of the information and recommendations it contains. Throughout the Guide, important steps in decision-making are explained in the text, and most recommendations are also presented in flowcharts and tables. Flowcharts can help to simplify complex problems and permit a standardized approach to management of STIs/RTIs. However, no flowchart can cover all possible clinical situations. Health care providers need to be able to recognize when to put the flowcharts aside and seek additional help. While this Guide will help health care providers to deal effectively with STI/RTI-related problems, knowing when to look beyond them can only be learned from experience.

 

20 Steps to fewer STIs/RTIs

 

Step 1	Raise awareness about STIs/RTIs and their consequences�infertility, pregnancy loss, maternal death and HIV/AIDS.
Step 2	Prepare your clinic so that people feel comfortable coming to the clinic with STI/RTI concerns.
Step 3	Promote services. Find ways to involve men in STI prevention and make sure that young people know about services and are comfortable using them. Reach vulnerable populations as one of the best ways to control STI transmission in the community.
Step 4	Provide condoms, promote use of condoms and counsel about reducing number of partners or delaying sexual activity to reduce STI risk.
Step 5	Perform transcervical procedures safely to prevent iatrogenic infection.
Step 6	Tell women about simple things they can do to prevent endogenous infections.
Step 7	Consider patient�s individual risk for STI/RTI in order to offer prevention advice or treatment.
Step 8	Counsel about STI/RTI prevention and ask about STI/RTI symptoms at each visit for family planning or antenatal care. Look for signs of STI/RTI each time you do an examination for other reasons.
Step 9	Screen for syphilis, and look at opportunities to screen for other STIs/RTIs.
Step 10	Take care not to label people as having an STI when the diagnosis is not certain.
Step 11	Educate all patients about STI/RTI prevention.
Step 12	Educate patients with STI/RTI about completing their full course of treatment and referring partners for treatment.
Step 13	Learn to counsel to support patients in changing behaviour.
Step 14	Promote dual protection to prevent both STI/RTI and pregnancy.
Step 15	Encourage early attendance at antenatal clinic. Counsel about STI/RTI prevention for a safer pregnancy.
Step 16	Screen all pregnant women for syphilis at least once during each pregnancy and make sure women with reactive tests (and their partners) are treated.
Step 17	To women who have been raped, offer emergency contraception, presumptive STI treatment, and, if available, HIV postexposure prophylaxis.
Step 18	Manage symptomatic STIs/RTIs effectively using syndromic flowcharts, or where available, laboratory-based diagnosis.
Step 19	Treat partners when an RTI is likely to be sexually transmitted but counsel the patient and partner carefully when you are not sure.
Step 20	Treat upper genital tract infections�especially infections following abortion or childbirth�aggressively to protect the woman�s life and fertility.

 

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¹ An adaptation guide for programme managers is currently under preparation by WHO.