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This article discusses the integration of sexually transmitted disease (STD) care within family planning (FP) programs and the cost effectiveness of integrated services in development countries. Examples are taken from experiences in Colombia, India, the US, and Kenya. The 1994 International Conference on Population and Development urged the integration of reproductive health care within FP. The more than 330 million annual new STD cases increase HIV transmission and cause pain and infertility. Women are biologically more susceptible to STDs, are more likely to be asymptomatic, and face harsher consequences, including death. Women with STDs should avoid the IUD and use barrier methods. Maintaining laboratories, training staff, and supplying drugs can overburden strained health budgets, but may lower long-term medical costs, increase productivity in employment, and decrease pain and suffering. STDs are viewed by some US health professionals as a "best buy" for being one of the least expensive of the reproductive health options. A Kenyan study found that treating STDs and providing oral contraceptives saved money by collapsing treatment into one instead of two visits. The savings were in overhead and staff costs. Evaluations of cost effectiveness should consider local STD prevalence, cultural setting, client needs, and available resources. In some cases, referral of cases to STD clinics may be the most cost-effective. A US study found that chlamydia screening for all FP clients was more cost-effective than screening selectively. Another US study found that universal screening for chlamydia would provide long-term medical savings even if prevalence was only 2%. Developing countries have the lower-cost option of offering syndromic management of STDs for symptomatic women rather than lab tests. A program in India cut costs by educating and encouraging barrier methods.
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PMID:Integrating services involves cost issues. 1229 37

Poverty may be inherited from poor parents, it may be temporarily caused by natural disasters or war, or it may be absolute. People living in absolute poverty lack basic necessities, are most likely to return to poverty despite improvements in society, are the poorest of the poor, and are the most vulnerable. The recent increase in the number of women heading poor households has led to an increasing feminization of poverty. Against this backdrop, women also have reproductive health needs exacerbated by early marriage, lack of access to family planning, malnutrition, a lack of clean water during delivery, female genital mutilation, a lack of prenatal care, failure to recognize obstetric emergencies, and inaccessible health care. Pregnancy-related morbidity can remain untreated or undiagnosed and cause untold misery, and women have less power than men to avoid acquiring HIV/AIDS or a sexually transmitted disease. Some women suffer from infertility or reproductive tract cancer. In fact, reproductive and sexual health problems account for more than 30% of the disease burden for women compared with about 10% for men. Realistic strategies to alleviate this situation include 1) developing profiles of poverty and women's reproductive health; 2) training individuals to conduct participatory research to identify and prioritize women's health needs and problems; 3) discovering the correct entry points for discussions on reproductive health priorities; 4) focusing on the household and work place; 5) using community-based monitoring tools; and 6) promoting provision of adequate health services. Employment of people-centered strategies will help the poor improve their reproductive health.
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PMID:The poverty factor: a special problem for women. 1229 59

The new politics of family planning in the 1990s has involved the articulation of a comprehensive concept of sexual and reproductive health (SRH). Following the ratification of the SRH concept and goals at recent international conferences, one major issue is how governments translate the broad statements into operational policies and programs. The authors consider the ways in which the process is occurring in Indonesia, defining SRH, and reviewing the levels of its attainment in 8 of its components in Indonesia. The policy process in Indonesia is explored with regard to pre-existing reassessments, setting important priorities and moralistic and pragmatic policy orientations. The following SRH components are discussed: family planning, infertility, maternal and child health, HIV/AIDS, sexually transmitted diseases, adolescents' needs, sexual health, and gender issues. In terms of SRH, Indonesia has achieved considerable success in addressing family planning and infant and child mortality, limited success in addressing maternal mortality and HIV/AIDS, and very little progress in addressing STDs, adolescent needs, and positive sexuality. There are few data on gender issues.
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PMID:Operationalizing the new concept of sexual and reproductive health in Indonesia. 1229 90

The United Nations Population Fund (UNFPA) is wholly funded by voluntary contributions from UN members to improve the quality and accessibility of voluntary family planning services in the most poor regions of the world. In 1997, UNFPA provided support services to 168 countries for reproductive health, including family planning, the prevention and treatment of sexually transmitted infections, HIV/AIDS, infertility, and maternal and child health care. In 1997, extremist US Representative Chris Smith, a Republican from New Jersey, led a movement in Congress to defund US contributions to UNFPA, citing China's coercive reproductive health practices even though no UNFPA funds were used to support coercive practices and UNFPA strongly opposes them. In March 1999, a bipartisan group of Senators introduced a bill in the US Senate to restore UNFPA funding. The bill, which has already passed the House International Relations Committee by a vote of 23-17, authorizes the appropriation of $25 million to UNFPA for fiscal year 2000 and $35 million for the following year, while also addressing important public health and human rights concerns.
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PMID:U.S. moves forward on international promises. 1229 39

A dissemination workshop, which was held jointly by the family health unit of the African Medical and Research Foundation and the Population Council, delivered the findings of a female adolescent health and sexuality survey. The study revealed that 10,000 schoolgirls drop out of school every year due to pregnancy. In addition, an alarming degree of ignorance regarding contraception, fertility, and pregnancy exists among the 10,314 schoolgirls in the sample population. One-third reported sexual experience, 18% had ever used contraceptives, and 42% had experienced abortion. It was explained in the workshop that pregnancy in immature females is likely to lead to compounded and multiple medical problems including physical damage to the girl, risk of getting sexually transmitted diseases which may lead to infertility at a later stage, and high susceptibility to HIV infection. The Catholic Church has developed a sex education syllabus, which is being used in Catholic-sponsored schools. Furthermore, other groups are dealing with equipping the youth with knowledge, skills, and attitudes to help them cope with the demands of modern life. Legal protection against sexual abuse and the role of media for advocacy were also tackled in the workshop.
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PMID:Adolescent health and sexuality. 1229 25

At present, about 250 million new cases of sexually transmitted diseases (STDs) occur in the world each year. This statistics includes 120 million cases of trichomoniasis, 50 million cases of chlamydia, 30 million cases of genital warts, 25 million gonorrhea cases, 20 million cases of genital herpes, 3.5 million syphilis cases, 2.5 million case of hepatitis B virus, 2 million cases of chancroid, and 1 million infections with human immunodeficiency virus (HIV). Among the adverse health sequelae the STDs are sterility, infertility, stillbirth, miscarriage, blindness, brain damage, and cancer. The greatest incidence of STDs is in the 20-24-year age group, followed by persons 15-19 years of age. The finding that lesions caused by some STDs can increase the risk of HIV infection by more than 300% has led governments concerned with control of acquired immunodeficiency syndrome (AIDS) to take a more aggressive stance toward the prevention and treatment of STDs. There are many obstacles to STD prevention, however, including the development of treatment-resistant strains, inadequate infrastructure for diagnostic testing and penicillin treatment, resistance to changing sexual behavior, increased travel and migration, and the practice of exchanging sex for drugs. Even in some developed countries where the rate of STD infection has finally stabilized, the level remains unacceptably high and STDs cannot be considered as under control. In developing countries, STDs have reached epidemic levels and the number of new infections reported annually shows a pattern of steady increase. The World Health Organization is urging governments to intensify STD prevention activities through funding research, health education, and more accessible clinic services.
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PMID:Sexually transmitted infections increasing -- 250 million new infections annually. 1231 65

The fourth and final issue of The Alan Guttmacher Institute's 1992 State Reproductive Health Monitor: Legislation Proposals and Actions chronicles and summarized reproductive health-related legislation introduced and acted on in the 50 states in 1992, covering abortion, family planning services, sex education, teenage pregnancy, adoption, infertility, maternal and infant care, and sexually transmitted diseases/AIDS. Arkansas, Montana, Nevada, North Dakota, Oregon, and Texas did not convene. Abortion legislation involved parental consent/notice, informed consent and waiting periods, funding, abortion/reproductive rights, abortion bans, RU-486, clinic harassment, insurance coverage, reporting requirements, fetal research/remains, postviability abortion, sex selection, clinic licensing, spousal notification, conscience clauses, counseling and referrals, feticide, and proposals for promoting "alternatives to abortion." Family planning services, sex education, teenage pregnancy, Norplant welfare reform, infertility services, surrogacy contracts, perinatal drug and alcohol abuse and family and medical leave was also covered as was HIV testing, consent, and notification, education and prevention strategies, treatment, insurance coverage, and discrimination.
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PMID:Overview. 1231 63

The 10th International Conference on AIDS/International Conference on STD in Yokohama August 7-12, 1994, attracted 12,000 people from 130 countries to consider the expanding AIDS pandemic. A satellite symposium was held the day before the opening of the conference, August 6, also in Yokohama, to bring participants together to focus upon the importance of providing access to oral contraceptives and the necessity of condoms. This symposium was organized by the Japan Family Planning Association. Speakers called for the authorization of the low-dose oral contraceptive pill for Japanese women; greater condom use against HIV and other STDs; expanding the concept of reproductive health to include maternal and child health, the prevention of STDs, and infertility; clinical approaches and care for HIV-infected individuals during pregnancy and labor; and counseling to pregnant HIV-infected women.
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PMID:Family planning and AIDS on Yokohama agenda. 1231 6

Each year 250 million new cases of sexually transmitted diseases (STDs) have the potential to cause pelvic inflammatory disease, infertility, blindness, and death. Sometimes the onset of these STDs is symptomless, but the following conditions indicate the presence of an STD: genital discharge, sores, wounds, or blisters; swollen glands in the groin; cauliflower-like growths on the genitals; skin rash; lower abdominal pain in females; painful swelling in the testicles; alopecia; discharge from the eyes; and pain during intercourse. The 5 most common STDs which can be cured with antibiotics are chancroid, chlamydial infection, gonorrhea, syphilis, and trichomoniasis. By the end of 1994 in Uganda, 390 primary health units will be available for STD treatment, and most health workers will be trained in STD patient management. Since patients will receive the minimum amount of treatment needed to cure the STD, they will be well advised to use the drugs provided. Notification of all recent sex partners is also essential, and sex partners should be evaluated even if they are asymptomatic. Patients are advised to engage in safe sex behavior, including remaining faithful to a monogamous relationship and using condoms, and to seek medical advice if they develop STD symptoms or are exposed to STD. The AIDS virus is also transmitted through sexual intercourse as well as through blood transfusions, from mother to child, and through the use of contaminated needles. HIV infection progresses from a stage where it cannot be detected to an asymptomatic stage to a symptomatic stage. Chronic diarrhea, fever, and weight loss are the major symptoms. There is no treatment for HIV infection, but zidovudine (AZT) can delay progress of the disease. The most important treatment available is counseling and understanding. The Uganda AIDS Commission works to control the disease through education, treatment of STDs, provision of safe blood for transfusion, monitoring, counseling patients, and promoting research. The primary objective in the care of AIDS patients is to improve the quality of their life as much as possible.
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PMID:Telling signs and symptoms. 1231 60

Increased AIDS mortality and other preexisting conditions have contributed to agricultural productivity declines in the districts of Masaka and Rakai in Uganda. These two districts were the most fertile in Uganda and also had the highest HIV seroprevalence rates in Africa. 66% of study households experienced land use decline to some extent over the past 5 years. The 11% decline in poultry production and 32% decline in cattle production was reportedly due to poor management and loss of grazing land from overpopulation and larger scale farms. The most frequently reported reasons for crop reductions were death and sickness; these was estimated as affecting 8% of families with children under 5 years in the study area. Morbidity and mortality as a reason for the decline was reported two times as much as poverty and decline in international coffee prices. Other reasons for loss of productivity were food shortages and insecurity, loss of income, and reduced ability to respond to educational and medical needs. Cassava is replacing the culturally preferred matooke banana as a crop that is more disease-, pest-, and drought resistant. The banana weevil has been a recent problem. Marginal farming systems have been the most affected by declines in land use and livestock production, but fertile areas have not been spared the impact from AIDS and adult mortality. Poverty has decreased the use of pesticides, herbicides, and fertilizers in the districts. Policy has had an impact on agricultural practices: population growth and inheritance have added to loss of individual land holdings and contributed to fallow periods and infertility. Appropriate land management practices have not been adequately promoted in the agricultural extension service. Civil wars and the drop in coffee prices have reduced the number of farm laborers. Common grazing land has been turned over to large commercial ranches. Government should maintain research and monitoring of declines in food and cash crop production and manpower needs. Policy must be designed to respond to the complicated factors affecting productivity. High AIDS prevalence areas and marginal areas where reduced production effects would be the most severe must be given priority status. Development of cash crop alternatives must be examined and perhaps supported on an experimental basis by donor agencies. Maximum productivity should be encouraged by rural extension and education agencies. A number of other specific recommendations were made for individual survival strategies to maintain high agricultural productivity.
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PMID:AIDS and agricultural production. Report of a land utilization survey, Masaka and Rakai districts of Uganda. 1231 18


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