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

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Key points

• STI/RTI prevention and concerns should be discussed with all family planning clients at each visit. Dual protection�against pregnancy and STI/RTI�should be promoted at every opportunity.

• Condoms can provide highly effective dual protection if correctly and consistently used�this is the only single method currently available.

• With regard to IUD use, experts make a distinction between women at �increased risk of contracting an STI� and those at �a very high individual likelihood of exposure to gonorrhoea or chlamydial infection�. The former includes, for example, women living in an area where STIs are common, and the latter includes, for example, young sexually active women who report having a partner (current or previous) with urethral discharge. WHO recommends that while there is no justification to deny an IUD to a woman simply because she lives in an area where STIs are common, IUD use would not be recommended for those with a high individual likelihood of exposure to gonorrhoea or chlamydial infection.

• Women with a high individual risk of acquiring HIV infection, or those already infected with HIV, should not use spermicides. They should not use diaphragms with spermicide unless other more appropriate methods are unavailable or unacceptable.
• Women should be asked about symptoms of common STIs/RTIs; women with symptoms should be managed using the syndromic approach.
• Ask about symptoms in the partner. Women with symptomatic partners should be treated, and treatment for the partner arranged.
• Screening for STI/RTI should be done whenever warranted�a blood test and a careful speculum and bimanual examination can identify many silent STIs/RTIs.

• Risk assessment may help identify some women who need special attention with regard to STI, but a negative risk assessment does not mean that a woman is not at risk.

 

The family planning (FP) visit is an opportunity to prevent not only unwanted pregnancies but also infection (dual protection). It is also a chance to detect some silent STIs/RTIs and to offer treatment to symptomatic women who may not otherwise use health services. How can this best be done?

While STI/RTI prevention should be mentioned at each family planning visit, it should be recognized that concern about STI/RTI is usually not the main reason for a client�s visit to the clinic. Most women attend FP clinics to obtain contraception, and health care providers should bring up STI/RTI issues in a way that addresses the client�s priorities. There are a few issues to keep in mind with family planning clients:

• In routine provider�client contact in an FP clinic it is difficult to assess an individual�s level of risk to STIs. Therefore, when meeting FP clients it may be useful for health care providers to keep in mind that all sexually active individuals are potentially at risk of contracting an STI.

• Consistent and correct use of condoms is highly effective for preventing both pregnancy and STI, and is the only single method that provides effective dual protection.

• Women with a current STI/RTI are eligible for most contraceptive methods; however, the infection should be treated appropriately and steps taken to prevent future infection.

 

For these reasons, careful attention to the client�s needs for both contraception and STI protection is essential. Some clinics use simple tools to assess a client�s risk of STI (e.g. self-administered risk-assessment questionnaires, or asking simple questions such as Does your partner have a urethral discharge? and Do you have multiple partners?). This type of assessment may be useful, but a woman may still be at risk even if she does not report any risky behaviour or risk factors. Many women are at risk of STI because of their partner�s behaviour, not their own, and are often not aware of their risk. They may be in a steady relationship that they believe is monogamous. Providers should be sensitive to these issues in discussing risk of infection with these women, who may see no need for dual protection.