Sexually Transmitted Infections: Progress and Challenges since the 1994 International Conference on Population and Development (ICPD)

Abstract

Background
Despite being recognized as an important challenge at the 1994 International Conference on Population and Development (ICPD), Sexually Transmitted Infections (STIs) other than HIV are one of the most neglected dimensions of Sexual and Reproductive Health (SRH). STIs, often undiagnosed and untreated, have especially harmful consequences for women and their neonates.

Progress since ICPD
During the last two decades, substantial knowledge and experience have accumulated in behavior change programming during the global response to the HIV epidemic which can also be used for prevention of STIs. There has been progress in development and implementation of vaccines against certain STIs such as Hepatitis B (HBV) and the Human Papilloma Virus (HPV). Development of a rapid, point-of-care test for syphilis has opened the door to control this infection. Challenges: The estimated annual incidence of non-HIV STIs has increased by nearly 50% during the period 1995-2008. The growth in STIs has been aggrevated by a combination of factors: lack of accurate, inexpensive diagnostic tests, particularly for chlamydia and gonorrhea; lack of investment to strengthen health systems that can deliver services for diagnosis and management of STIs; absence of surveillance and reporting systems in the majority of countries; political, socioeconomic, and cultural barriers that limit recognition of STIs as an important public health problem; and failure to implement policies that are known to work.

Recommendations
Governments, donors and the international community should give higher priority to: preventing STIs and HIV; fully implementing behavior change interventions that are known to work; ensuring access of young people to information and services; investing in development of inexpensive technologies for STI diagnosis,treatment, and vaccines; and strengthening STI surveillance, including of microbial resistance.

Full text

Review article
Sexually transmitted infections: progress and challenges since the 1994
International Conference on Population and Development (ICPD)
☆,☆☆,★
Nuriye Ortayli⁎, Karin Ringheim, Lynn Collins, Tim Sladden
330 East 38th Street, Apt 21B, New York, NY 10016, USA
Received 15 January 2014; revised 22 May 2014; accepted 10 June 2014
Abstract
Background: Despite being recognized as an important challenge at the 1994 International Conference on Population and Development
(ICPD), sexually transmitted ınfections (STIs) other than HIV are one of the most neglected dimensions of sexual and reproductive health.
STIs, often undiagnosed and untreated, have especially harmful consequences for women and their neonates.
Progress since ICPD: During the last two decades, substantial knowledge and experience have accumulated in behavior change
programming during the global response to the HIV epidemic which can also be used for prevention of STIs. There has been progress in
development and implementation of vaccines against certain STIs such as hepatitis B and the human papilloma virus. Development of a
rapid, point-of-care test for syphilis has opened the door to control this infection.
Challenges: The estimated annual incidence of non-HIV STIs has increased by nearly 50% during the period 1995–2008. The growth in
STIs has been aggrevated by a combination of factors: lack of accurate, inexpensive diagnostic tests, particularly for chlamydia and
gonorrhea; lack of investment to strengthen health systems that can deliver services for diagnosis and management of STIs; absence of
surveillance and reporting systems in the majority of countries; political, socioeconomic and cultural barriers that limit recognition of STIs as
an important public health problem; and failure to implement policies that are known to work.
Recommendations: Governments, donors and the international community should give higher priority to preventing STIs and HIV; fully
implementing behavior change interventions that are known to work; ensuring access of young people to information and services; investing
in development of inexpensive technologies for STI diagnosis,treatment and vaccines; and strengthening STI surveillance, including of
microbial resistance.
© 2014 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/3.0/).
Keywords: Policy; Women’s health; Reproductive health; Health services
1. Background and scope of the challenge
The International Conference on Population and Devel-
opment (ICPD) in 1994 recognized the “high and increasing”
incidence of sexually transmitted infections (STIs) and,
particularly, the greater vulnerability to STIs that women
face, in part because such infections are often undetected
until complications ensue. The ICPD Programme of Action
(PoA) called for prevention and treatment of STIs to
“become integral components of all reproductive and sexual
health services”(Para 7.32). It further stipulated “that all …
family planning providers, should be given specialized
training in the prevention and detection of …sexually
transmitted diseases”(PoA 7.31) and provide “accessible,
complete and accurate information about various family
Contraception 90 (2014) S22 –S31
☆
This paper is not under consideration at any other journal. It is a
revised and shortened version of a background paper with the same title,
presented at the “ICPD Beyond 2014 Expert Group Meeting on Women’s
Health: Rights, Empowerment and Social Determinants”organized by
UNFPA-WHO in Mexico City during September 30–October 3, 2013.
☆☆
Authors have not received any financial compensation for writing this
paper, except that three of them are UNFPA staff, and one had been a
consultant for UNFPA in the team that wrote a report on ICPD progress.
None of the authors have any conflict of interest.
★
Authors would like to thank Ms. Adrienne Germaine and Dr. Rachel
Snow for reviewing earlier versions of the background paper and providing
valuable advice in strengthening it.
⁎Corresponding author at: 330 East 38th Street, Apt 21B, New York,
NY 10016, USA. Tel.: +1 212 297 5001, + 1 90 533 776 52 01.
E-mail addresses: ortayli@unfpa.org,nortayli@gmail.com (N. Ortayli).
http://dx.doi.org/10.1016/j.contraception.2014.06.024
0010-7824/© 2014 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/3.0/).

planning methods, including …their effectiveness in the
prevention of the spread of HIV/AIDS and other sexually
transmitted diseases.”(PoA 723 b). Recognizing that the risk
of transmission is greater from men to women and that
women are often powerless to protect themselves (PoA
7.28), the ICPD urged the development of “strategies to
ensure that men share responsibility for sexual and
reproductive health, including family planning, and for
preventing and controlling STIs, HIV and AIDS.”(Para
8.27) [1]. However, the fight against STIs, other than HIV,
has been one of the least visible areas of sexual and
reproductive health (SRH), remaining underfunded despite
its close links to the HIV epidemic. A chief factor
contributing to this invisibility is a lack of national STI
surveillance systems capable of identifying the considerable
magnitude and scope of the problem, and monitoring
progress or lack thereof. Currently, only a small minority
of countries consistently collect STI surveillance data, and
even these are subject to limitations in data quality and
completeness [2]. Surveillance of antimicrobial resistance
within newly emerging gonococcal strains is similarly
lacking, with rates of multidrug-resistant gonorrhea increas-
ing worldwide and contributing to increases in gonorrhea
incidence. Enhanced surveillance is needed to track this
problem [3–5]. Furthermore, STI diagnoses often go
unreported due to weaknesses in health systems. The difficulty
of collecting reliable data on STIs is compounded by shortages
of trained human resources, inadequate laboratory facilities
and other constraints, such as asymptomatic presentation,
which together compromise accurate diagnosis. Owing to the
sexual nature of transmission, STIs are also often stigmatized,
and many individuals with symptoms do not seek testing or
treatment, while others receive inaccurate diagnoses. In the
absence of good surveillance data, there is a lack of public and
political awareness of the magnitude of the problem. STI
screening and treatment are not given priority within public
health services, nor do STIs receive the political, socioeco-
nomic and cultural attention they warrant.
In recent years, as new HIV infections were plateauing or
declining in many regions, the World Health Organization
(WHO) estimated that incidence of the four major curable
bacterial/protozoan STIs (chlamydia, gonorrhea, syphilis
and trichomonas) increased by nearly 50%. Using the limited
available data [6], WHO estimated the total number of new
infections with these four agents to have risen worldwide
from 333 million in 1995 [7] to 499 million in 2008 [2]. This
50% increase is only partially attributable to increased
population. For example, chlamydia has risen by nearly a
fifth, consistent with a 21% increase in global population over
that period, while gonorrhea rose by 70%. New syphilis
infections have slightly decreased, probably owing to
existing, extensive antenatal testing [2]. Regional differences
in STI incidence are widespread: e.g., Africa has the highest
number of new syphilis infections, probably related to limited
accessibility of care (Table 1 and Fig. 1). Higher levels of
untreated STIs in sub-Saharan Africa are linked to higher
HIV transmission rates and have been postulated to have
contributed to the higher prevalence of HIV in that region [8].
While developing country data are scarce, evidence from the
United States suggests that nearly half of STIs occur among
young people 15 to 24 years of age [9] (Fig. 2).
Viral STIs are incurable, and they also affect large
populations: an estimated 536 million people are living with
herpes simplex virus (HSV) type 2, and approximately 291
million women at any given time have a human papilloma virus
(HPV) infection [10]. Moreover, viral hepatitis, particularly
hepatitis B (HBV), can be sexually transmitted and is a growing
health concern, potentially leading to liver disease and cancer.
About 240 million people live with chronic HBV infection.
WHO identifies nine infections with a predominantly
sexual mode of transmission in the International Classifica-
tion of Diseases [11]. This paper focuses on the four
common curable bacterial/protozoan STIs that contribute to
most STI-related morbidity and mortality globally: chla-
mydia, gonorrhea, syphilis and trichomonas. While all STIs
have specific diagnostic tests and treatment regimens, many
preventative, management and surveillance aspects are
applicable more broadly for all STIs.
It is beyond the scope of this paper to address the HIV
epidemic in any significant depth, other than to highlight
some of the connections between HIV and other STIs,
particularly similar programming strategies. The response to
the HIV epidemic has been unparalleled, marked by
extraordinary activism, political commitment, resources
and significant gains in health and rights. Achievements
have been striking, particularly in the last decade, among
them a promising trajectory of considerably fewer new HIV
infections and AIDS-related deaths, and some notable but
Table 1
Estimated number of new cases of four bacterial STIs by WHO region (2008).
1
Numbers of new cases (millions).
Bacterial STI Africa Americas Southeast Asia Europe Eastern Mediterranean Western Pacific
Chlamydia trachomatis 8.3 26.4 7.2 20.6 3.2 40.0
Neisseria gonorrhoeae 21.1 11.0 25.4 3.4 3.1 42.0
Treponema pallidum 3.4 2.8 3.0 0.2 0.6 0.5
Trichomonas vaginalis 59.7 85.4 42.9 22.6 20.2 45.7
Total 92.6 125.7 78.5 46.8 26.4 128.2
1
WHO. Global incidence and prevalence of selected curable sexually transmitted infections —2008, 2012. Downloaded at http://www.who.int/
reproductivehealth/publications/rtis/stisestimates/en/index.html on May 21, 2013.
S23N. Ortayli et al. / Contraception 90 (2014) S22–S31

precarious gains in human rights. While new HIV infections
have steadily declined since the peak in 1997, the increased
availability of life-extending antiretroviral treatment has led
to an increase, to 34 million, in the number of people living
with HIV globally [12]. HIV is the fifth most common cause
of death for adults and a leading cause of death in women of
reproductive age [13].
Global HIV prevalence today, among adults 15 to
49 years old, is 0.8% and is below 1% in all regions, except
sub-Saharan Africa, where prevalence is 4.7%. In this most
severely affected region, 57% of 22 million persons living
with HIV over age 15 are women [12]. As with other STIs,
biological factors, gender-based violence, sexual coercion
and lack of access to information and services are among
the key factors that promote increased vulnerability of
womenandgirlstoHIV[12]. HIV is the only STI for
which functioning surveillance systems are generally in
place. The relative success of HIV surveillance demon-
strates that with political commitment, adequate resources
and a rapid point-of-care test appropriate for low-resource
2
WHO. Global incidence and prevalence of selected curable sexually
transmitted infections —2008, 2012. Downloaded at http://www.who.int/
reproductivehealth/publications/rtis/stisestimates/en/index.html on May 21,
2013.
3
Downloaded from: http://www.cdc.gov/std/stats11/figures/5.htm on
May 30, 2013.
-
1.0
2.0
3.0
4.0
5.0
6.0
7.0
Africa Americas South-East Asia Europe Eastern
Mediterranean
Western Pacific World
Percent
Chlamydia Gonorrhoea Syphilis Trichomonas
STI data: http://apps.who.int/iris/bitstream/10665/75181/1/9789241503839_eng.pdf; Population Data: www.who.int/whosis/whostat/2010/en/
Fig. 1. Estimated total population prevalence (%) of bacterial STIs, WHO Health Regions, 2008.
2
Fig. 2. Chlamydia—rates by age and sex, United States, 2011.
3
S24 N. Ortayli et al. / Contraception 90 (2014) S22–S31

settings, surveillance systems for other STIs are feasible for
many low-income countries.
1.1. STIs can lead to serious health problems for women
STIs and complications resulting from them are among the
top five reasons that adults seek health care [14]. Aside from
HIV, other STIs may also pose serious reproductive health
concerns for women and their infants. STIs, principally
untreated chlamydia, are the major underlying cause of
infertility among women. Up to 40% of women with untreated
chlamydia or gonorrhea will develop pelvic inflammatory
disease (PID), and one in four of these women will become
infertile. Women with PID are also 6 to 10 times more likely to
have an ectopic pregnancy, putting women’s lives at risk and
inevitably leading to fetal loss. Up to half of such ectopic
pregnancies are the result of a previous PID. Women with
untreated syphilis have a 25% probability of stillbirth and a
14% probability of neonatal death. It is estimated that,
globally, up to 4000 newborn babies become blind every
year because of eye infections attributable to untreated
maternal gonococcal and chlamydial infections [15].
In 2008, an estimated 1.4 million pregnant women around
the world were infected with syphilis, 80% of whom had
attended antenatal care services. Syphilis infections among
pregnant women caused approximately 520,000 harmful
outcomes, including 215,000 stillbirths, 90,000 neonatal
deaths, 65,000 preterm or low-birth-weight babies and
150,000 congenital infections. Two thirds of these adverse
outcomes occurred among women who were neither tested
nor treated for syphilis despite an antenatal care visit [16].
STIs also significantly increase the risk of both acquiring
and transmitting HIV. Genital ulcers are estimated to cause a
50- to 300-fold increased risk of acquiring HIV per episode
of unprotected sex [15]. Even nonulcerative STIs increase
the likelihood of HIV transmission. Overall, improving
the management of STIs is an important strategy in
HIV prevention.
2. Interventions to control STIs/HIV
STIs, including HIV, are caused by microorganisms, and
their acquisition is often closely linked to certain behaviors.
“[Sexual] partnership and network formation, and the chance
of acquiring and transmitting an infection sexually are not
random; they are determined by individual factors, cultural
values, geography, demography, economics, heath service
and political and legal structures.”[17]. STIs spread most
easily when individuals, especially women, have little power
to negotiate safer sex and have poor access to health services.
Effective STI prevention and control require coordinated
efforts to address those factors that facilitate transmission or
that hamper access to prevention, detection, diagnosis and
treatment. Such strategies include promoting and supporting
community-led interventions, eliminating stigma and gen-
der-based violence, providing clinical services that respect
confidentiality, and improving collection and use of reliable
data to guide evidence-informed responses. The epidemio-
logical approach suggests concentrating efforts on high-risk
groups such as sex workers and their clients to more rapidly
control the spread of STIs [18], whereas the ICPD PoA
promotes a broader focus on ensuring universal access to STI
services as part of comprehensive sexual and reproductive
health care. Given the numerous factors that have an impact
on transmission or control of STIs, programs should
harmonize several interventions. All programs should have
a strategy that would include the following [19];
1. Primary prevention which includes health promotion
and education, school- and community-based pro-
grams, and male and female condom distribution
2. Diagnosis and management of infections, which will
build on primary prevention and add diagnostic
services, clinical services, and patient and partner
management services. Each of these elements should
be evidence based and adapted to the national/
subnational context.
3. Opportunistic testing or screening for asymptomatic cases.
2.1. Primary prevention
2.1.1. Behavioral approaches
Several behaviors decrease the incidence of STIs and HIV
including delaying sexual debut, using condoms and having
fewer sexual partners [20]. Related behavior change
interventions aim to change social norms and build the
knowledge, motivation and especially skills to support safer
sexual practices. Behavioral risk reduction programs use
counseling, information and empowerment techniques to
build motivation and capacity to practice safer sex and
change social norms. They enhance decision-making ability
for reducing risk of exposure and transmission within sexual
relationships, including condom negotiation and use. Best
described in the HIV literature, “combination prevention,”
comprised of behavioral, biomedical and structural inter-
ventions, has had demonstrated results for HIV, which are
also applicable for preventing STIs [20,21]. Key behavioral
programs include testing and risk reduction counseling,
behavior change communication, comprehensive sexuality
education, media and interpersonal communication (includ-
ing peer education), social marketing of male and female
condoms, and incentives for avoiding risk.
Globally, since 2000, there has been a steady upturn in the
practice of safer sex in most countries, which is having a
favorable impact on the downward trend in new HIV
infections [22]. A recent meta-analysis of 42 studies,
covering 67 behavioral interventions, indicated an associated
decrease in sexual risk-taking resulting in increased condom
use, and fewer STIs, including HIV [23]. Many countries,
including Kenya, Malawi, South Africa, Tanzania, Trinidad,
Zambia and Zimbabwe, are reporting favorable results from
behavioral interventions [24–27]. Comprehensive sexuality
education is indispensable for behavior change and has been
S25N. Ortayli et al. / Contraception 90 (2014) S22–S31

demonstrated to increase knowledge and decrease risk-
taking [28]. A review of 83 studies worldwide showed that
two thirds of the sex and HIV education programs improved
one or more sexual behaviors in young people [29].
Behavioral interventions can have an appreciable impact
when combined with other approaches and implemented at
scale [21]. It is, however, difficult to disentangle the relative
impact and attribution of these factors, but together these
combined approaches hold the key to effective HIV/STI
prevention. These interventions need to be brought to scale
and sustained to have impact within populations at risk [30].
Moreover, behavioral interventions should be coupled with
structural approaches to eliminate gender-based violence,
child marriage and other human rights violations, which
contribute to risk of HIV and STI exposure and transmission.
2.1.2. Biomedical approaches
Improved use of condoms, together with risk reduction
counseling, is a priority STI control intervention [31]. Male
and female condoms not only are effective in protecting
against transmission of HIV but also significantly reduce the
risk of acquiring several other STIs such as gonorrhea,
chlamydia, HSV-2 and syphilis. Condoms also reduce the
risk of trichomoniasis [32] and may provide some protection
from HPV transmission [33]. Generating greater demand for
male and female condoms among specific clients at higher
risk of STIs, including youth, has yielded positive results
when policies and policy makers are consistently supportive,
myths and misperceptions about condoms have been
addressed, condom negotiation skills and correct use are
widely taught, and adequate supplies of quality male and
female condoms are distributed free or at an affordable price
through multiple channels [34].
Condom supplies in many high-burden countries are still
inadequate: 2011 estimates for Sub-Saharan Africa indicate
that only nine donor-provided condoms per year are
available for each 15–49-year-old man and that only one
female condom per year is available for every 10 women of
the same age range. Numerous countries are now engaged in
implementing comprehensive condom programming
through a strategic 10-step approach that addresses coordi-
nation, supply, demand and support [35].
Male and female condoms can also be used for protection
against unintended pregnancies, but male condoms have a
contraceptive failure rate of 18% in the first year of typical
use [36]. Therefore, “dual protection,”where condoms are
used together with a modern contraceptive which is highly
effective in preventing pregnancy, is an essential strategy for
ensuring protection against both HIV/STIs and pregnancy.
Though there has been an increase in dual-method use
especially among at-risk populations, there is still much
room for improvement [37–39].
Since ICPD, there have been efforts to develop
multipurpose prevention technologies (MPTs) for SRH to
simultaneously address diverse needs for combinations of
STI, HIV and pregnancy prevention. Currently, the only
available MPT is the female or male condom. However,
several other MPTs that could address two or more
prevention needs at the same time are in the pipeline.
Some of these include an intravaginal ring that continuously
releases tenofovir and levonorgestrel from separate ring
segments over a period of 90 days for contraception and HIV
prevention; a gel combining MIV-150, zinc acetate and
carrageenan, with combined activity against HIV and HSV;
and a vaginal ring releasing dapivirine and a hormonal
contraceptive over 60 days for contraception and HIV
prevention. Reformulated tenofovir gel is also being studied
in conjunction with the existing SILCS diaphragm as a
combined barrier contraceptive, adding sperm-immobilizing
agents and antiviral chemical protection against HIV and
HSV [40].
As with the majority of infectious diseases, use of
vaccines can be a turning point in controlling STIs.
Currently, for two STIs, HBV and HPV, there are safe and
effective vaccines. HBV vaccine is now adopted by more
than 90% of countries and is part of childhood immunization
programs [10].
The two types of HPV vaccines that are available now are
both highly efficacious in preventing infection with virus
types 16 and 18 that together are responsible for causing
approximately 70% of cervical cancer cases globally. One
vaccine is also highly efficacious in preventing anogenital
warts, a common genital disease which is virtually always
caused by infection with HPV types 6 and 11. Recently, use
of the HPV vaccine by both girls and boys was approved in a
number of industrialized countries,
4
yet the primary target
group continues to be young adolescent girls in the
remaining countries as recommended by WHO [41].
The high cost discouraged many countries with a high
burden of disease from introducing the vaccine at national
scale, until recently. With a lower public sector price and the
backing of the GAVI Alliance (formerly the Global Alliance
for Vaccines and Immunization), the vaccines can become
much more widely available [42]. WHO estimates that, with
70% vaccination coverage, current vaccines can prevent 4
million cervical cancer deaths over the next decade [10].
2.1.3. Services for diagnosis and management
Diagnosis and management of STIs present many chal-
lenges, depending on the characteristics of different agents.
Diagnosis of gonorrhea and chlamydia is especially challeng-
ing for several reasons. Firstly, up to 70% of women, and a
significant proportion of men, with either gonorrhea or
chlamydia experience no symptoms until complications
develop. Because women’s infections are more often unde-
tected due to their asymptomaticnature and since women often
have less access than men to STI testing and treatment, women
have far greater STI-related morbidity than men [43].
4
Recently, CDC USA has recommended HPV vaccine also for
adolescent boys. http://www.cdc.gov/hpv/vaccine.html.
S26 N. Ortayli et al. / Contraception 90 (2014) S22–S31

Secondly, tests for diagnosing chlamydia and gonorrhea
infections not only are expensive but also require sophisti-
cated laboratory facilities and highly trained staff, making it
very difficult to offer these tests in low-resource settings.
Among the four bacterial/protozoan STIs, currently, only
syphilis has an inexpensive, rapid, point-of-care test that can
be used in low-resource settings and can accurately
determine the existence or absence of infection, meeting
WHO’s Affordable, Sensitive, Specific, User-friendly,
Rapid and robust, Equipment-free and Deliverable to end
users (ASSURED) criteria for low-resource settings [44].
Trichomonas protozoan infection can be detected by
collecting a specimen during speculum examination and
identifying it under a microscope, and there is hope for
development of new tests meeting ASSURED criteria
[45].(Table 2).
Thirdly, although syndromic management is recommend-
ed by WHO for use in settings where etiologic diagnosis is
not possible, it is neither very sensitive (accurate in
confirming an STI) nor specific (correctly ruling out
infection), especially for common syndromes like vaginal
discharge among women. Syndromic management relies on
simple flowcharts to help health care workers identify easily
recognizable signs (syndromes) and provides an algorithm to
guide treatment of the most probable cause(s). Treating the
client at the first visit helps prevent complications and loss to
follow-up and provides an opportunity for client education,
counseling on safer sexual behavior, promotion or provision
of condoms, partner notification, and HIV testing
and counseling.
The syndromic approach, however, can overdiagnose
STIs, exposing women to unnecessary treatment [46] and to
possible risks, including relationship problems and even
violence, if partners are given a false alert. It can also fail, as
shown by several studies, to diagnose existing infections
[47–49]. This is especially significant given the serious
health consequences for women and infants caused by
untreated chlamydia and gonorrhea. Efforts to increase the
effectiveness of the syndromic approach by assessing the
risk of having an STI are limited by the unreliability of self-
reporting, especially in low-prevalence settings [50].
Assuming needed medications are available, compliance
with the treatment regimen is important to its success as well
as to preventing the development of multidrug resistance.
Breaking the chain of STI transmission requires preventing
reinfection and onward transmission to other sexual partners.
Providing earlier “treatment for prevention”has the potential
to significantly lessen infectivity and decrease transmission
to uninfected partner(s) [51]. Counseling on consistent
condom use also aims to prevent transmission to partners
or reinfection by partners. Partner notification is a key
strategy to reach the presenting client’s sexual partner(s),
who may themselves be asymptomatic. If left untreated,
partner(s) may suffer serious health consequences, may
reinfect the treated partner and may transmit to other
partners. Partners can be notified by the health provider or
the client. One approach, sometimes referred to as expedited
partner therapy, involves providing the client the requisite
medication or prescription to deliver to their partner(s), with
instructions for use [15]. This obviates the need for the
partner(s) to come to the clinic and can increase the potential
for partner treatment. Because partner notification can lead to
intimate partner violence and other relationship problems,
client safety must be carefully considered, especially when
notification is based on potentially inaccurate syndromic
diagnosis of infection among women [17].
2.1.4. Screening
Many people who acquire an STI do not have symptoms,
or symptoms are mild and may disappear while the infection
remains. Therefore, any efforts to determine the true extent
of STIs within the population or to control STIs require the
ability to diagnose asymptomatic infections as well as those
that are symptomatic. Several tests with high sensitivity and
specificity are available to diagnose certain specific STIs,
both symptomatic and asymptomatic.
2.1.5. Chlamydia and gonorrhea
Screening to identify and treat chlamydia among asymp-
tomatic women has been shown to reduce complications and
transmission of the infection [52,53]. However, only a handful
of countries either offer opportunistic testing of certain subsets
of women, such as those seeking contraceptive or abortion
services, or have programs which aim to screen all younger
women (below the age of 25 or 29, age varying from country to
country) [19,54–56]. Sweden’s opportunistic chlamydia
testing is an example which revealed success as well as new
challenges. Opportunistic testing for chlamydia among young
women in a variety of health care settings was introduced in
some counties in Sweden in the early 1980s (Fig. 3). Since
1988, the law has made it compulsory across the country to
provide free testing, treatment and contact tracing for any user
of services with suspected chlamydia and to report diagnosed
infections. Testing is targeted at sexually active women aged
15–29 years seeking contraception or abortion. Men are tested
Table 2
Sensitivity, specificity [43] and price
5
of rapid chlamydia, gonorrhea,
syphilis and trichomonas tests.
Organism Test Sensitivity Specificity Price
Chlamydia ICT 33%–95% N95% High
OIA
Chlamydia NAAT 97%–99% 99%–100% High
Gonorrhea ICT, OIA 54%–70% 90%–98% High
Gonorrhea NAAT 96%–100% 100% High
Syphilis ICT strip 86% (median) 99% (median) Very low
b$1
Trichomonas Wet mount 50%–54% N95% Very low
Trichomonas OSOM®
Rapid test
83%–90% 98%–100% High
ICT, ımmunochromatographic; OIA, optical ımmunoassay; NAAT, nucleic
acid amplification tests.
5
Price information is collected by UNFPA.
S27N. Ortayli et al. / Contraception 90 (2014) S22–S31

when found through contact tracing or if symptomatic. Youth
clinics have been established in many places to increase access
to services for young people, including young men. As a result,
the number of chlamydia infections decreased dramatically
during the 1990s (Fig. 3). However, in 2007, a new chlamydia
variant which could not be identified with the tests used at the
time again caused an increase in infections [57]. This
development of a new strain of chlamydia illustrates the
importance of surveillance to track STI-causing organisms and
their susceptibility to treatment. Sweden also participates in an
ongoing multicountry European gonococcal antimicrobial
susceptibility surveillance study, which has documented
growing resistance to the primary drugs for treating gonorrhea,
suggesting that gonorrhea may become untreatable using
antimicrobial monotherapy [4].
2.1.6. An example of opportunistic testing: antenatal
screening for syphilis
Syphilis, unlike many other STIs, has an inexpensive,
rapid, point-of-care test, which can be used in low-resource
settings, produces results within 20 min and confirms the
presence of infection with high sensitivity and specificity
(Table 2). Treatment of syphilis is also easy and inexpensive.
A systematic review has found that opportunistic testing of
all pregnant women who use antenatal care services for
syphilis and their treatment could reduce the incidence of
perinatal death and stillbirth attributable to syphilis by 50%,
saving about 200,000 lives per year [58]. Most countries
have policies for antenatal screening of STIs and HIV, but
implementation is uneven. In some countries, for example,
programs specifically designed to prevent new HIV
infections in infants, including by preventing HIV infection
in pregnant women and by screening and treating them for
HIV [59], did not include similarly aggressive syphilis
screening [60], despite it being part of the recommended
global strategy [61]. This is a missed opportunity which is
currently being more vigorously addressed. Lack of
universal access to antenatal care and attrition rates also
limit the success of screening programs. The most recent data
show that an estimated one in five pregnant women with
syphilis did not receive antenatal care [16].
3. Policies
3.1. Integration of SRH services, including HIV and STIs
Integrating STIs/HIV with other SRH programs involves
delivering a wide range of interventions to meet the
comprehensive needs of clients such as offering rights-
based family planning services to women living with HIV,
delivering comprehensive sexuality education for young
boys and girls, preventing child marriage, eliminating
gender-based violence, managing sexually transmitted
infections, ensuring access to female and male condoms
for dual protection (against HIV/STIs and unintended
pregnancy) and providing antiretroviral treatment as well
as cervical cancer screening.
However, in responding to the AIDS crisis, key decisions
made by global organizations and major donors led to the
widespread development of stand-alone HIV services. STI
programming was integrated neither into these HIV services
nor into “its logical programmatic base[s] in sexual and
reproductive health and rights.”[62]. Separate “vertical”
health programs have resulted in lost opportunities for
offering clients multiple services at a single visit. STI
programs were not given high priority, and efforts to prevent
HIV transmission were “largely managed through programs
that [were] funded, implemented and evaluated indepen-
dently of other STI control efforts.”[18].
Integrating STIs/HIV with other SRH programs, such as
family planning and maternal health, can better meet the
comprehensive needs of clients, ideally bringing all services
together in one place and time. A global movement began in
2004 to link HIV and all SRH services, including STIs, at
policy, systems and service delivery levels [63]. In 2009, the
Commission on Population and Development urged gov-
ernments to expand the capacity to deliver comprehensive
HIV interventions in ways that strengthen national health
and social systems by integrating them into primary health
care, as well as by integrating SRH information and services,
including for STIs, into HIV plans and strategies [64].
The evidence base has been growing on how integration
strengthens health systems’ability to offer clients compre-
hensive services and how such services can optimally be
integrated. Systematic reviews of integrated service delivery
have found a positive impact on client satisfaction, improved
access to and uptake of services without a reduction in
quality, favorable health and behavioral outcomes, reduced
clinic-based STI/HIV-related stigma and cost-effectiveness
[65,66]. Much more remains to be done to fully integrate STI
services within broader SRH and HIV programs and to better
deliver STI services within primary health care settings.
6
Low N. Current status of chlamydia screening in Europe. Euro
Surveill. 2004;8(41):pii = 2566.
Fig. 3. Rates of reported genital chlamydia infection in selected countries,
1989–2003.
6
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3.2. Reaching key populations
Sex workers, their clients and other partners, men who
have sex with men and transgender people, and people who
inject drugs have a higher likelihood of contracting an STI.
However, due to marginalization, criminalization and
cultural attitudes, the access to health service for these key
populations is frequently lower than that for others. There is
now good evidence for what works for specific key
population groups [67–69]. Tailoring services for key
populations, including reducing stigma and discrimination,
is important to ensure uptake, and efforts are needed to try to
ensure universal access for these higher-risk populations.
Better linkage and integration of STI services within these
focused programs, as well as within a broader range of SRH
services for the whole community, are among the important
factors to be considered in the future direction of STI
prevention and control efforts.
4. Recommendations
4.1. Strengthening health systems
Integrating comprehensive SRH services, including for
STIs, within primary health care is a core element. STI
prevention and control require a strong health system which
can deliver all aspects of STI management in a coordinated
way (e.g., counseling, screening, diagnosis, treatment, follow-
up and partner notification). All SRH services, including
family planning, should take into account the risk for STIs and
HIV when providing information, treatment and contraceptive
choices. All clients should be instructed on the importance of
consistent condom use for HIV and STI prevention and on
how to negotiate their use. Female and male condoms should
also be made widelyavailable. Concerted efforts are needed to
ensure that all pregnant women receive ANC early in
pregnancy and that screening and treatment for syphilis are
standard components of such care.
4.2. Behavior change interventions
All sexually active women and girls should have, at a
minimum, access to information on the risks and symptoms of
STIs, including an assessment of their own vulnerability, and
how to reduce risk. Community-led interventions are needed
to provide information on STIs, prevention education,
unlimited access to male and female condoms, and referral
for diagnosis and treatment, especially in low-resource areas
lacking access to comprehensive primary health care.
Community advocacy and education should engage men in
protecting women and children from the health risks of STIs
through promoting safer sex practices, access to treatment,
preventing and addressing gender-based violence and assuring
the safety of women in partner notification. The needs of
specific key populations need to be addressed through current,
identified best practice approaches.
4.2.1. A focus on young people to reduce vulnerability
Adolescents, especially girls, need universal access to
SRH services, including HIV and STI screening, counseling
and treatment or referral. These comprehensive services need
to be respectful of their right to privacy, to confidentiality
and to make their own decisions free from coercion.
Comprehensive sexuality education including in schools
can play a much greater role in educating youth about the
health risks of asymptomatic and symptomatic infections for
both adolescent boys and girls. Such programs should help
girls develop the skills needed to combat the gender and
social factors that render women and girls vulnerable to
infection, support skills-building for negotiation and use of
female and male condoms, and instill an understanding of the
potential benefits of treatment for one’s own health and as
prevention of transmission.
4.3. Better diagnostics, vaccines and treatments
Inexpensive and accurate rapid point-of care diagnostic
tests, especially for chlamydia and gonorrhea, are urgently
needed in low-resource settings which lack laboratory facilities.
Increased investment in research to develop rapid tests and
address the high and growing rate of antimicrobial resistance is
needed, as well as accelerated research on vaccines. A high
priority should be placed on developing MPTs.
4.4. Increased STI surveillance
Global understanding of STIs and the disease burden they
cause suffers from a lack of data. To better understand the
epidemic and tailor programs effectively, greater investment
is needed to improve STI surveillance and consistent
reporting of known infections; follow up on partner
notification; and collect and report data separately for men
and women on the duration of infection, asymptomatic
infections, antimicrobial resistance patterns, etc. Surveil-
lance of STIs among women, especially of gonorrhea and
chlamydia, should not be neglected because of the lack of
rapid diagnostics. Existing diagnostics should be made
available in all countries, at least for the purpose
of surveillance.
This paper examines the current status of interventions
and responses to the growing and neglected global epidemics
of sexually transmitted infections other than HIV. While
many challenges exist, there are also opportunities to better
apply evidence-informed and human-rights-based ap-
proaches for control of STIs.
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