Good Counselling Vital for Clients with STDs

Good counseling for people infected with a sexually transmitted disease (STD) helps them comply with treatment, understand their contraceptive choices and encourages them to notify partners.

Infected individuals who continue to be sexually active, particularly those who are HIV-positive, need to understand ways to prevent transmission to others and may need effective contraception to prevent unintended pregnancy.

An STD can seriously endanger a pregnant woman's fetus. Some STDs, such as herpes and syphilis, can cause spontaneous abortion, premature birth and stillbirth. Some, such as gonorrhea and chlamydia, can cause eye infections and blindness in babies born to infected women. Syphilis, HIV and herpes can be transmitted to newborns, potentially causing chronic disease and death. In addition, herpes can lead to mental retardation in babies.

Latex condoms, when used consistently and correctly, offer the best protection against transmission of STDs, including HIV, but are not highly effective in preventing pregnancy in typical use. Modern methods that are very effective contraceptives - intrauterine devices (IUDs), pills, injectibles, implants and sterilization - do not prevent STD transmission.

Male Condoms
Considerable laboratory research has found that quality latex condoms prevent the passage of HIV and other STD-causing organisms. Studies among condom users also indicate that condoms used consistently and correctly protect against STD infection.

Three large studies show that consistent condom use provides measurable protection against HIV in heterosexual couples where one partner is HIV-infected and the other is not. The studies compared how often uninfected partners became infected in couples using condoms with varying consistency. With consistent condom use, the HIV infection rate among the uninfected partners was less than 1 percent per year. Inconsistent condom use, however, was observed to be as risky as not using condoms at all.

Making condoms readily accessible can markedly reduce the risk of transmitting STDs. In Thailand, where sex workers dramatically increased condom use - achieved through a government program that made condoms widely available at sex establishments in the country- cases of gonorrhea and chancroid in men visiting government hospitals declined by approximately 85 per cent over four years. Syphilis declined by 68 percent.

Female Condoms
Laboratory studies show that polyurethane, the material used in female condoms, blocks the passage of organisms that cause STDs. Human studies of this device are limited. One study involving more than 100 women diagnosed and treated for trichomoniasis indicated that subsequent, consistent use of the female condom protected against recurrences of the STD. Inconsistent female condom use, however, was observed to be as risky as not using female condoms at all. More research on the female condom's effectiveness in preventing STD transmission in humans is needed, but experts believe the device is a promising option for STD prevention.

Some research indicates that overall condom use increases when couples have access to both male and female condoms, rather than male condoms only.

In a randomized study in Thailand in which 249 female sex workers had access to both types of condoms and 255 female sex workers had access to only the male condom, there was a 17 percent reduction in unprotected sexual acts in the group that had access to both kinds of condoms, compared with the male condom-only group. This reduction, as well as a 24 percent decrease in STD incidence in the male/female condom group compared with the male condom-only group, suggest that the female condom can prevent common STDs and is an attractive alternative to male condoms for some people.

Differences in the incidence of gonorrhea, chlamydia and trichomoniasis among women offered both types of condoms versus those offered only male condoms are being investigated in a large FHI study of Kenyan agricultural workers.

Spermicides
In the laboratory, nonoxynol-9 (N-9) inactivates many sexually transmitted pathogens, including HIV. Some experts have been encouraged by small studies that show a small protective effect of N-9 against STDs in humans. However, the largest randomized controlled trial of N-9 to date - an FHI study in Cameroon of the use of N-9 film in a group of appro~tnateh-1,300 sex workers -indicated that N-9 did not confer am, additional protection to women against HIV, gonorrhea or chlamvdia infection beyond that provided by condoms.

The study could not conclusively determine whether N-9 film alone offered any protection from HIV or other STDs since participants were encouraged to use condoms every time they had sex.

FHI believes more research is needed to determine whether various N-9 products protect against STDs/HIV and, if so, to what extent. FHI and others continue to investigate various formulations of N-9, as well as other potential microbicides.

Hormonal Methods
Hormonal methods do not protect people from STDs, including HIV, and there are theoretical concerns that their use may increase the risk of some infections.

Research in monkeys has demonstrated that progesterone enhances vaginal trans-mission of simian immunodeficiency virus, prompting concern about hormonal method use by women. While results from human research have been inconsistent, a recent study of the effect of hormonal contraception on the risk of heterosexual transmission of HIV-1 in approximately 800 Kenyan female sex workers found that women using depo-medroxyprogesterone acetate (DMPA) had an increased incidence of HIV-1 infection. Overall, 27 percent of 111 women who became HIV-1 infected were using DMPA within 115 days of serocon-version.

A trend linking use of high-dose oral contraceptives (OCs) and HIV-1 acquisition also was observed. However, since only 16 women in the study used high-dose pills, firm conclusions about the association could not be made. The study authors also noted that these findings were observed in a population of women with high rates of sexual exposure and other STDs, and may not apply to other populations.

Meanwhile, a recent study suggested that hormonal contraception could increase the infectivity of women with HIV. In creased shedding of HIV-1 genetic material from the cervices of women using combined OCs or DMPA was observed. Viral shed-ding increased as dose of OC increased.

While there is evidence that oral contraceptive use can increase the risk of chlamydial infection, OC use appears to de crease risks of symptomatic chlamydial pelvic inflammatory disease (PID). However, OCs may not protect against symptomatic PID, but simply mask it at the tubal or endometrial level.

A recent study has shown that women with unrecognized endometritis (inflammation of the mucous membrane lining the uterus) were four times more likely than women with recognized endometritis to use OCs. Untreated PID can increase the risk of infertility and ectopic pregnancy. Also, untreated STDs, such as unrecognized chlamydia, are risk factors for HIV transmission. Hepatitis B, caused by hepatitis B virus, is primarily transmitted by heterosexual in-tercourse. If a woman has active hepatitis B, the World Health Organization (WHO) recommends that OCs not be used since their use can adversely affect women whose liver function is already compromised. Combined injectables (Cyclofem or Mesigyna) should be withheld until liver function returns to normal or three months after the woman becomes asymptomatic. Progestin-only contraceptives (progestin-only pills, DMPA, NET-EN or Norplant) are less desirable than other methods.

Intrauterine Devices
There is serious concern that intrauterine devices (IUDs) increase the risk of PID in women with STDs, since microorganisms in the vagina can be introduced during IUD insertion through the cervix into the uterus. Thus, for these women, or women who have had an STD within the last three months, an IUD should not be inserted.

Due to concerns about pelvic infection and increased blood loss, the use of IUDs in HIV-infected women is usually undesirable. However, a recent University of Nairobi and FHI study of IUD use in about 150 HIV-infected and 500 non-infected Kenyan women showed no greater risk of overall IUD complications or infection-related complications in HIV-infected women (regardless of degree of immunosuppression) than in non-infected women at one and four months after IUD insertion.

In addition, among HIV-infected women, IUD use was not associated with increased cervical shed-ding of HIV. This suggests that the IUD can be safely used by appropriately selected HIV-infected women with regular access to medical services.

Among healthy women who are not at risk of STDs, the levonorgestrel-releasing IUD (LNg-IUD) may reduce risks of PID. In one study, the incidence of PID at three and five years of use was lower among LNg-IUD users than among Nova T users." However, these progestin-releasing IUDs are not widely available. For women with active hepatitis B, the LNg-IUD is less desirable than other methods.

Lactational Amenorrhea Method
Breastfeeding offers effective contraception for up to six months after giving birth, provided the child is fully or nearly fully breastfeeding and the mother's menstrual cycle has not returned (called the lactational amenorrhea method or LAM). However, studies suggest that one in every seven children breastfed by HIV-positive women will become infected with the virus.

The Joint United Nations Programme on HIV-AIDS, the United Nations Children's Fund and WHO note that infants of HIA-infected mothers are at greater risk of illness and death if they are breastfed, rather than given breast milk substitute, provided the substitute can be safely prepared.

However, artificial feeding substantially increases children's risk of illness and death where infant mortality is high or where sufficient milk substitute formula cannot be prepared safely (when clean water is not available, for example). In this case, the risk of death from malnutrition or infection can be greater than the risk of HN feeding through breastfeeding.

Women with unknown HN status and those who live in areas where infant mortality is high or where formula cannot be pre pared safely should still breastfeed since the practice substantially benefits the overall health of both women and infants.

A breastfeeding woman at risk for HN should use condoms. By protecting herself from HIV infection, she may protect her nursing infant as well.

Adapted from "Network"

Additional Resources:

• Good Counseling Vital For Clients with STDs: FHI
• STD Risk Reduction Counseling in the Family Planning Visit: Health Information & Education
• Treatment guidelines for sexually transmitted diseases, from CDC's Division of STD Prevention
• Women's Health Care Providers STD Counseling and Testing: Kaiser Family Foundation