Improving services for prevention and treatment of STI/RTI
Chapter 6. STI/RTI assessment during routine family planning visits

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Integrating STI/RTI assessment into routine FP visits

The general recommendations for integrating STI/RTI prevention into routine FP clinic visits given here are based on the approach to client�provider interaction developed in WHO�s forthcoming publication entitled Decision-making tool for family planning clients and providers. The opportunities for addressing STIs/RTIs during the initial (method-choice) visit and routine follow-up visits are different and are treated separately.

 

Initial visit

Women attending an FP clinic for the first time are usually interested in a method of contraception�they may already have a particular method in mind�and they may have other concerns as well. These concerns may or may not include STI/RTI. There are often many issues that need to be discussed before a woman can choose and be provided with a contraceptive method that meets her needs. STI prevention is one of the issues that should be addressed.

When should the subject of STI/RTI be introduced in the initial FP visit? If it is brought up too early, the woman may feel that her family planning needs are being ignored. If brought up too late, the choice of method may need to be reconsidered. The following pages illustrate an approach to dealing with STI/RTI issues in the course of the first FP visit. Starting with the client�s �reason for visit�, a health care provider follows several steps with the client to reach a decision about a suitable method. These steps include determining the woman�s preferred method, reviewing her medical eligibility for that method, assessing her risk of current or future STI/RTI, and providing her chosen method.

 

Steps in decision-making at initial FP visit

 

We will now consider each of these steps with particular attention to assessment and prevention of STI/RTI.

 

Step 1: Discuss method preference

 

Ask if the woman already has a method in mind. The woman�s initial method preference is an important factor in subsequent successful use of a method. Women who are given their preferred method, use it longer and with greater satisfaction.

Discuss contraceptive needs. In discussing prevention of pregnancy, providers can introduce the idea of dual protection by mentioning that some methods provide better protection than others against STI.

Discuss STI protection needs. Invite the client to share her concerns about such infections. Open-ended, personalized questions (�Please tell me what concerns you have about infections that are spread by sex�) are better than closed questions (�Do you want information about STI?�) that can be easily dismissed with a simple �No�.

Describe options and help the woman make a choice. Table 6.1, later in this chapter, includes information on the effectiveness of different contraceptives in preventing pregnancy and STI.

Sexually active women and men often need dual protection to prevent both pregnancy and infection. Dual protection can be provided using a single method (condom) or combination of methods that includes the condom (dual methods). Box 6.1 gives some options for dual protection and some issues to discuss with clients.

 

Box 6.1. Dual protection options and issues

Some questions to ask: Which choice suits you best? Help clients choose the method that works best for them. Can you stick to this choice? What would make this method difficult? What would help? Will your partner help? Can the client talk with her partner about this? What is your back-up choice? For example, if the client chooses condoms, could the couple abstain if they ran out of condoms? Do you think you or your partner may have an infection? For example, pain or burning during urination, an open sore in the genital area, pus coming from his penis? Do you think your partner has other sexual partners?
	OPTIONS USING FAMILY PLANNING
	1. Male condoms or female condoms   OR	2. Condoms AND another family planning method    AND
	3. Any family planning method WITH uninfected partner
	SOME OTHER OPTIONS (these examples are particularly appropriate for adolescents)
	4. Other safe forms of intimacy	5. Delay having sex until you are ready
	AND for added protection from STIs/HIV, reduce your number of sexual partners: one uninfected partner is safest

Clients who choose the condom alone can be provided with emergency contraception for back-up protection against pregnancy in case a condom breaks or is not used (see Page 78).

 

Step 2: Look for STI/RTI

 

Assess for STI/RTI syndromes �by asking questions and/or doing examination. After a woman has chosen one or two contraceptive methods depending on whether she requires single or dual protection, the health care provider should determine whether a more thorough examination or laboratory work-up is needed to identify current infection. He/she should ask about vaginal discharge, genital ulcer, and lower abdominal pain, and whether the woman�s partner has symptoms of STI. The flowcharts in Chapter 8 can be used to manage patients with such complaints.

A pelvic examination is not required for the provision of contraceptive methods other than the IUD (to rule out pregnancy and infection and determine uterine size, shape and position), diaphragm/cervical cap (to fit the device) and sterilization (to assess the size, position and mobility of the uterus). A speculum and bimanual examination can, however, be useful for evaluating STI/RTI concerns, and detecting some asymptomatic infections (Chapter 3).

Consider STI risk, implications for contraceptive method, and need for dual protection. STI risk and the woman�s need for protection should be reviewed at this point. She may change her method preference�or add the condom�to improve her protection against STIs. It is important to keep in mind that STI risk is difficult to assess accurately, and a negative risk assessment does not mean that the woman does not need to consider STI protection.

Assess need for STI/RTI screening or treatment. The extent of the STI/RTI diagnostic or screening work-up will depend on the resources available. Symptomatic women can be managed without laboratory tests (Chapter 8). Where resources permit, screening for common asymptomatic STIs such as cervical infection, syphilis and HIV (Chapter 3), can be included in the protocol for the initial visit along with other �well-woman� screening, such as Pap smear. Following examination and STI/RTI screening, a woman may want to reconsider her previous choice of method to improve her STI protection.

The existence of a current STI/RTI is not in itself a reason to deny most methods�providers should offer treatment or referral and information or counselling on how to prevent future infection (Chapter 2 and Chapter 4). Initiation of some methods, such as an IUD and sterilization, should be delayed until the STI is cured or in accordance with national guidance. During the treatment period the woman should be advised to use condoms and, possibly, another contraceptive method.

 

Step 3: Assess medical eligibility

 

Review medical eligibility for preferred method. Next, the suitability of the preferred method or methods should be evaluated. Medical eligibility criteria (MEC) have been developed by WHO (and adopted in many countries) to assist health care providers in identifying health conditions or situations where certain contraceptive methods should be discouraged or where special precautions are advisable. For example, STI/HIV risk may influence the medical eligibility for use of the IUD or spermicides.

 

Step 4: Provide method(s)

 

The final step in the process is method provision. If the client chooses to use condoms, she will require counselling, demonstration of use, and skill-building to ensure that she and her partner can use them properly and consistently (Chapter 2 and Chapter 4). An IUD should not be inserted if the woman has a cervical infection; Chapter 2 describes steps that can be taken to ensure safe insertion. Methods other than condoms do not protect against STI, and adequate counselling should be given on dual method use to add STI protection.

 

Return visits

Clients return to reproductive health clinics for follow-up visits for many reasons, including:

• evaluation of method-related problems;
• investigation of STI/RTI symptoms;
• routine follow-up related to the contraceptive method;
• routine visits for well-woman care.

Whatever the reason, a follow-up visit is an opportunity to assess how things are going in general, and specifically in relation to her need for contraceptive and STI/RTI protection. For STIs/RTIs, the woman should be asked about current symptoms, and whether her needs for STI/RTI protection have changed. Chapter 8 describes the management of symptomatic STIs/RTIs. Chapter 3 presents options for STI/RTI screening that may be appropriate at routine follow-up visits at regular intervals. Each follow-up visit is an opportunity to promote STI/RTI prevention through education and counselling.