STI/RTI basics
Chapter 2. Preventing STIs/RTIs and their complications

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Key points

• A comprehensive approach to STIs/RTIs includes prevention of sexually transmitted, iatrogenic and endogenous infections.
• STI prevention means reducing exposure�by using condoms and reducing numbers of sex partners. Condoms must be used correctly and consistently to prevent STI.
• Adolescents should receive support for decisions to delay sexual activity.
• The risk of iatrogenic infection can be reduced by good infection control procedures.
• Where STIs are common, the risk of iatrogenic complications following a transcervical procedure may be reduced by giving a full course of antibiotic treatment for cervical infection, if such an infection cannot be reliably ruled out.

 

As described in Chapter 1, STIs/RTIs spread in several ways:

• Sexual transmission�Many RTIs are sexually transmitted; the higher the rate of transmission in the community, the more complications there will be.
• STIs/RTIs related to medical procedures�Infection with, and complications of, STIs/RTIs may develop following medical procedures or following examination or intervention during pregnancy, childbirth, the postpartum period, family planning interventions (e.g., IUD) and gynaecological interventions.
• Endogenous infections�Some RTIs result from overgrowth of organisms that are normally present in the vagina. These RTIs may also lead to complications.

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:

• delaying sexual activity (for adolescents);
• decreasing the number of sex partners;
• using condoms correctly and consistently.

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:

• Put on the condom before any penetrative intercourse (see Figure 2.1).
• Withdraw the penis right after ejaculation (while the penis is still erect) to avoid the condom slipping off inside the vagina.
• Put on a new condom for each new act of intercourse.

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

1. Remove the condom from the package carefully, to avoid tearing.	2. Squeeze the air out of the tip of the condom.
3. Unroll the condom onto the erect penis.	4. After ejaculation, withdraw the penis from the vagina while the penis is still erect. Hold on to the rim of the condom while withdrawing to prevent it from slipping off and the semen spilling into the vagina.
5. Remove condom from penis, and tie a knot in it to prevent spills or leaks. Dispose of condom safely (where it cannot cause any hazard).

 

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

 

The female condom is a soft, loose-fitting sheath with a flexible polyurethane ring at each end. The inner ring at the closed end is inserted into the vagina. The outer ring at the open end remains outside the vagina during intercourse and covers outer genitalia.
	1. Remove the female condom from the package, and rub it between two fingers to be sure the lubricant is evenly spread inside the sheath. If you need more lubrication, squeeze two drops of the extra lubricant included in the package into the condom sheath.	2. The closed end of the female condom will go inside your vagina. Squeeze the inner ring (closed end) between your thumb and middle finger. Insert the ring into your vagina.
3. Using your index finger, push the sheath all the way into your vagina as far as it will go. It is in the right place when you cannot feel it. Do not worry, it cannot go too far.	4. The ring at the open end of the female condom should stay outside your vagina and rest against your labia (the outer lip of the vagina). Be sure the condom is not twisted. Once you begin to engage in intercourse, you may have to guide the penis into the female condom. If you do not, be aware that the penis could enter the vagina outside of the condom�s sheath. If this happens, you will not be protected.	5. After intercourse you can safely remove the female condom at any time. If you are lying down, remove the condom before you stand to avoid spillage. Before removing condom from vagina, make sure you twist it to prevent semen from spilling. Dispose of the female condom safely (where it cannot cause any hazard). Do not reuse it.