[Integration of STD services. How to reach and involve men and women]. / Integration des services MST. Comment toucher et impliquer les hommes et les femmes.

PIP: In Kenya, a sexually transmitted disease (STD) program implemented in 10 medical centers in Nairobi allows nurses to diagnose syphilis based on symptoms, have blood tests conducted to confirm syphilis, prescribe treatment, and provide counseling. About 5% of pregnant women in Kenya have syphilis but do not know that they are infected or are afraid to seek sexually transmitted disease treatment in health centers. This program tests all pregnant women for syphilis during the prenatal examination. Once syphilis is confirmed, the nurse educates the pregnant woman about syphilis and tells her that syphilis poses a risk to her baby and that she can be treated for syphilis. The nurse must also emphasize the need to treat the pregnant woman's sexual partner. Even though most women agree that the partner must be informed, many fear that the partner will react violently. Each pregnant woman with syphilis receives several partner notification cards asking the partner to go to a health center. The card does not mention syphilis. Once at the center, the man is told that his partner has syphilis. He is told that syphilis can affect the baby. Usually, the men are concerned about the baby. The men receive education on condom use and sexual practices because they have more control and initiative in sexual activity matters. Even though the men and women are advised to abstain from sexual intercourse for a week after treatment, some men have difficulty following this advice. The nurse discusses options relevant to both sexes (e.g., condom use with all partners). It is difficult for women to propose condom use because these decisions are to be made by the men. Women can learn how to use a condom and how to persuade her partner to use the condom. Some women sleep in a separate room or return to their family if their partner insists on sexual intercourse. Almost all pregnant women involved in the project were successfully treated and their partners were informed. More than 50% of the partners were successfully treated. The nurses are pleased with the program.^ieng

Syphilis control in pregnancy: decentralization of screening facilities to primary care level, a demonstration project in Nairobi, Kenya.

A decentralized syphilis control program in pregnant women was implemented in nine Nairobi City Council antenatal clinics between July 1992 and August 1993, whereby pregnant women were screened for syphilis, treated before leaving the clinic if RPR seroreactive, and counselled on the importance of partner treatment and sexual abstinence during treatment in order to protect their unborn babies from getting congenital syphilis. A total of 13,131 pregnant women were screened for syphilis (RPR test), 87.3% of seroreactive women were treated on site and 50% of partners returned to the clinic and were treated. The prevalence of RPR reactivity was 6.5%. Based on other data the program could theoretically have prevented 413 cases of congenital syphilis at a cost of approximately 50 USD per prevented case. This demonstration project shows that decentralized prevention of congenital syphilis in antenatal clinics by nurses is feasible and inexpensive and should receive priority in resource allocation in reproductive health and child survival programs.

The duration of breastfeeding by HIV-1-infected mothers in developing countries: balancing benefits and risks.

How best to advise mothers infected with human immunodeficiency virus type 1 (HIV-1) in developing countries regarding breastfeeding is an important issue that has generated considerable debate. Previous studies have addressed this problem by means of mathematical models, but without considering the issue of the duration of breastfeeding. A mathematical model was developed to compare the age-specific risks of mother-to-child HIV transmission versus the excess mortality due to not breastfeeding. In this model it is assumed that both the risk of mother-to-child transmission of HIV through breast milk and the relative risk of not breastfeeding do not vary with age. The model indicates that, in HIV-1-seropositive mothers, the decrease in child mortality afforded by breastfeeding may exceed the risk of mother-to-child HIV-1 transmission only during the first 3-7 months of life. Thereafter the risk of HIV-1 transmission probably exceeds the mortality benefit of breastfeeding. Experimental studies of counselling HIV-1-infected mothers to limit their duration of breastfeeding should be considered in the setting of developing countries.

HIV, breast-feeding and under-5 mortality: modelling the impact of policy decisions for or against breast-feeding.

A computer model was developed to assess the impact on under-5 child mortality of breast-feeding practices in developing countries in the context of HIV infection. The model was used to estimate the effect on mortality of cessation of breast-feeding among mothers HIV-positive and mothers HIV-negative at birth, for both urban and rural settings. Using parameter values for a hypothetical East African country, cessation of breast-feeding in urban areas was predicted to result in increases in under-5 mortality of 108% for children of mothers HIV-negative at birth, and 27% for those HIV-positive at birth, with slightly larger increases in rural areas, suggesting that breast-feeding should continue to be promoted. A sensitivity analysis was conducted to identify critical values of key variables for which a review of policies encouraging breast-feeding is indicated. This showed that, even under extreme assumptions, cessation of breast-feeding among mothers HIV-negative at birth (but at risk of acquiring HIV during the lactation period) would increase under-5 mortality. For mothers HIV-positive at birth, the key variables are the additional risk of vertical transmission attributable to breast-feeding, the under-5 mortality rate (U5MR) in breast-fed children, and the relative risk of mortality in non-breast-fed compared to breast-fed children. Depending on the values of these key variables, there may be some urban populations with low U5MR in which the positive and negative effects on under-5 mortality of a policy change are finely balanced. However, no change in policy should be made in these areas until more precise information is available on the key variables, and the many adverse consequences of such a change have been fully explored.

PIP: A computer model was developed to assess the impact on under-5 child mortality of breastfeeding practices in developing countries in the context of HIV infection and then used to estimate the comparative effects on mortality of ceasing breastfeeding among HIV-seropositive (HIV+) and HIV-seronegative (HIV-) mothers at birth in rural and urban settings. Employing parameter values for a hypothetical East African country, it was found that ceasing breastfeeding in urban areas would result in increases in under-5 mortality of 108% for children of HIV-mothers at birth and 27% among children of mothers HIV+ at birth; slightly larger increases would result in rural areas. These results suggest that breastfeeding should continue to be promoted. Even under extreme conditions, discontinuing breastfeeding among HIV-mothers would increase under-5 mortality. For HIV+ mothers, however, whether or not the policy of promoting breastfeeding should be reviewed hinges upon the values of the additional risk of vertical transmission attributable to breastfeeding, the under-5 mortality in non-breast-fed children, and the relative risk of mortality in non-breast-fed compared to breastfed children. It is possible that some urban populations have under-5 mortality which is so low that it may be a close call as to whether breastfeeding is ultimately positive or negative for child survival. Even so, no change in policy should be made until more precise information on the key variables is obtained and the potential adverse consequences of such a policy change are fully explored.