Reproductive health services have typically been categorised as maternal and child health and family planning services. Only recently has the importance of including sexually transmitted diseases (STDs) on the list of reproductive health services been realised. As the linkage between STDs and human immune deficiency syndrome (HIV) infection becomes stronger, more attention is becoming focused on STDs. Control and prevention programmes for STDs/HIV are feasible to implement in refugee settings when the timing and available resources are carefully considered during programme planning. This article will present some basic information about STDs and HIV and will discuss some of the issues surrounding the implementation of STD/HIV control and prevention programmes in refugee settings.
Collectively, there are over 25 different bacteria, viruses, protozoa and ectoparasites that comprise the list of STDs. The more classically recognised diseases include bacterial infections: gonorrhea, syphilis, chlamydia and chancroid; and viral infections: HIV, herpes and hepatitis B. Gonorrhea, syphilis, chlamydia and chancroid, four common treatable STDs, rank within the top 25 causes of healthy days of life lost in subSaharan Africa, demonstrating that STDs pose a significant health threat. Prevention and control measures are clearly required to slow the growing incidence of acute infection, limit complications and better define their role in facilitating transmission of HIV.
Among the global adult population, the World Health Organization (WHO) estimated in 1995 an incidence of over 333 million curable STDs. The same report also claimed that STDs collectively rank second among diseases for which intervention is possible among women of 1544 years of age. In addition, WHO estimates that at least 18 million people worldwide have been infected with HIV, the virus which causes AIDS. Little research has been conducted on STDs or HIV in refugee settings and it is therefore more difficult to determine the magnitude of these conditions among refugees. Assessing the potential burden of HIV/STDs in a refugee population is difficult and consideration should be given to the rates of infection in their home country and within the country where they are residing. Review of the data available from country of origin and host country can help in assessing the potential seriousness of this problem in the refugee population, which will assist in determining health intervention priorities.
Factors that place a refugee at risk for STDs/HIV STDs/HIV spread more rapidly in conditions of poverty, powerlessness and social instability conditions at their extremes during refugee emergencies. Refugees have few resources to protect themselves and a desire to be well-informed or well-intentioned does not necessarily offer them protection. This situation makes the refugee population particularly vulnerable to STDs/HIV. Other factors that can enhance the rapid spread of STDs and HIV in a refugee setting could include any or all of the following points.
The first responsibility of responders in an emergency situation is to assist those at risk of imminent death from starvation, injury, exposure and disease. Comprehensive primary health care services are typically established later in the emergency, as the situation stabilises and more resources become available. Although control and/or prevention of STDs and HIV may not be a prominent feature in each stage of the emergency it should be acted upon appropriately at each point in the development of the emergency response, depending on the needs of the refugee population.
Until recently, STD/HIV control and prevention has not been seen as a high priority in refugee settings particularly in the early phase of an emergency because it is not an immediate threat to life. However, the recent diaspora of more than two million Rwandans pouring over their borders into neighbouring Zaire, Tanzania and Burundi forced a change in attitude by many of the national and international relief agencies. Never before had there been an emergency of such magnitude in a country with such a high HIV prevalence. It soon became clear that HIV control, at a minimum, must fit into the response equation during the emergency.
In the acute phase of an emergency, STD/HIV interventions typically remain a relatively low priority but some interventions should be implemented to help prevent HIV transmission, including: protection of women and children from exploitation; ensuring safe blood transfusions; access to condoms on demand; and availability of standard materials and equipment to ensure universal precautions (to protect against exposure to blood and body fluids) for health workers who care for potentially infected persons.
Stability within refugee camps begins to occur incrementally as essential needs are met and health services are established. Morbidity and mortality trends change as the relief effort progresses to stabilisation, allowing national and international relief agencies to shift their attention to other health issues such as STDs. Strategies to contain the HIV epidemic should continue in this phase and additional strategies should include the control of other STDs and implementation of behaviour modification interventions to help decrease high-risk behaviours that facilitate the spread of STDs/HIV.
In general, the four objectives of an effective STD/HIV control and prevention programme are:
The WHO model of STD/HIV control and prevention recommends a comprehensive approach including components which encourage:
Incorporating the above components into an STD control programme in a refugee setting can be particularly challenging. Some of the barriers to effective implementation include: limited or absent laboratory services; limited training of health personnel in STD management; inadequate supplies; and lack of appropriate examination areas. Furthermore, the stigma attached to STDs serves as a deterrent to care-seeking behaviour even in refugee settings that have stabilised and have well-established health facilities. One advantage, however, is the availability of well-trained persons due to widespread unemployment in refugee settings. These valuable human resources can be identified and trained in STD/HIV control and prevention to enhance their existing skills so they can participate in the effort to control STDs.
STD diagnosis in a refugee setting can be complicated, but it is possible to manage using several approaches:
Clinical approach without laboratory services It is not uncommon for clinicians to make clinical diagnosis of patients who present with symptoms but have no laboratory services available to confirm their diagnosis. In this case, the health professionals or lay workers rely entirely on their clinical skills to recognise the characteristic signs and symptoms of various STD infections. An obvious limitation to this approach is that the clinician can miss non-classic presentations and concurrent infections. In addition, many infections are asymptomatic for example, 50 to 80% of gonorrhea and chlamydia infections are without symptoms. This leads to an inability to detect the infection at all when the clinical approach is used alone.
Clinical approach with laboratory services When laboratory services are added to an STD control programme, the likelihood of more effective diagnosis is achieved since today's diagnostic tests for STDs are both sensitive allowing identification of a patient with an STD and specific allowing identification of the type of infection. However, barriers can make diagnostic tests impractical for use in refugee settings: for example, the cost of the tests and equipment; the high level of skill required to perform the tests properly; and a lag time until definitive diagnosis is available, which could lead to a lost opportunity for treatment at the first patient encounter.
Diagnostic tests with the following characteristics may help overcome these barriers. Tests which:
Given the constraints of the methods available for STD diagnosis, a syndrome-based approach to STD management has been promoted in many developing countries. Syndromic management is based on the identification of common symptoms that can be associated with a group of organisms associated with the symptoms. Each syndrome is then treated with single or multiple drug regimens for specific groups of organisms. In order to improve the specificity of the method, common risk factors are identified by conducting a physical assessment and by taking a health history.
The common syndromes included in the WHO Sexually Transmitted Disease Guidelines with associated management algorithms are: urethritis in men and women; vaginal discharge in women; genital ulcer diseases (GUD); and lower abdominal pain (indicative of pelvic inflammatory disease). These algorithms have been accepted as valid and feasible methods for managing STDs in a variety of resource-poor settings. The algorithm for vaginal discharge has, however, been found to lack sensitivity and specificity and is therefore not well accepted in its current form.
The major limitation of syndromic case management is the inability to differentiate specific infections within broad syndromes. This inevitably results in overtreatment with relatively expensive and often inappropriate drugs. This in turn can contribute to the development of drug specific resistance and the inability to identify persons with asymptomatic infection.
The usefulness of the syndromic approach in STD/HIV management was recently reported in the medical journal, The Lancet. A community-based project carried out in Mwansa, Tanzania to control rapid spread of HIV demonstrated that by managing symptomatic STDs in primary health clinics using syndromic management protocols, a 42% decrease was noted in HIV incidence rate. The findings demonstrate that this diagnostic method is not only useful for STD management but for HIV control as well. The clinical approach with or without laboratory services and the syndromic management of STDs using treatment algorithms must be examined for their usefulness in relation to the prevailing circumstances. The diagnostic method used will be contingent on the setting and resources available, so that one approach may be used alone or a combination of approaches may be used.
An additional issue to consider for effective STD management is the importance of having the right drugs to treat the right infection at the right time, which is during the first patient encounter. This situation requires an effective logistics system that is linked to the medical surveillance system. Coordination of these entities helps to ensure that the correct quantities of the most appropriate drugs are procured, distributed and stored properly to support the health system. A biological obstacle to effective STD treatment is the development of drug resistance, since some STD causing organisms have the ability to become resistant to the most commonly prescribed medications. Constant use of one drug over time to treat specific infections such as gonorrhea and chancroid and misuse of antibiotics for example, not taking a complete course of medicine often leads to pathogen mutation and adaptability. Limited resources are wasted and continued transmission of the drug resistant pathogen within the community results. STD programme managers must use care and caution when selecting drugs for their programmes. National guidelines for STD treatment can be used to guide their decisions if available.
Another important consideration is coordination of activities and the establishment of functional management and supervision systems. Clear roles and responsibilities of staff members should be identified to avoid confusion and to facilitate efficient service provision. In addition, it may be necessary to identify a group to coordinate intrasectoral groups responsible for surveillance, supply, clinical training and monitoring/evaluation so that their combined functions serve to address the STD/HIV control and prevention needs of the population.
Although the challenges to STD control in refugee settings are numerous and appear insurmountable at times, efforts to control STDs/HIV need continued attention throughout the refugee emergency. Successful approaches to STD/HIV control exist and can be tailored to refugee settings. The approaches need to be adjusted and augmented as the camp conditions change. The timing of interventions, resources available and the condition of the population must be taken into account throughout the crisis so that interventions are planned and implemented appropriately. The HIV pandemic continues to have grave effects on societies globally and is here to stay for decades ahead. STD/HIV control and prevention are central themes in reproductive health and must be considered essential when delivering health services. Hence, a conscientious effort to control STDs/HIV will contribute significantly to the reproductive health status of refugee populations.
Paula Nersesian is the Program Coordinator for the Reproductive Health for Refugees Project/John Snow, Inc.
Bill Brady is the Infectious Disease Epidemiologist for the MotherCare Project/John Snow, Inc.
The full text of this article is available from: Paula Nersesian, JSI, 1616 N. Fort Myer Drive, 11th Floor, Arlington, VA 22209, USA.
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October 1996