Guidelines for the management of sexually transmitted infections in female sex workers

Transcription

1 WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC WORLD HEALTH ORGANIZATION Regioal Office for the Wester Pacific STI, HIV ad AIDS Focus Uited Natios Aveue (P.O. Box 2932) 1000 Maila, Philippies Fax: (632) , , Tel: (632) Web site: Guidelies for the maagemet of sexually trasmitted ifectios i female sex workers PRICE: IN DEVELOPING COUNTRIES: ISBN

2 WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Guidelies for the maagemet of sexually trasmitted ifectios i female sex workers July 2002

3 ISBN The World Health Orgaizatio welcomes requests for permissio to reproduce or traslate its publicatios, i part or i full. Applicatios ad equiries should be addressed to the Office of Publicatios, World Health Orgaizatio, Geeva, Switzerlad, or to the Regioal Office for the Wester Pacific, Maila, Philippies, which will be glad to provide the latest iformatio o ay chages made to the text, plas for ew editios, ad reprits ad traslatios already available. World Health Orgaizatio 2002 Publicatios of the World Health Orgaizatio ejoy copyright protectio i accordace with the provisios of Protocol 2 of the Uiversal Copyright Covetio. All rights reserved. The desigatios employed ad the presetatio of the material i this publicatio do ot imply the expressio of ay opiio whatsoever o the part of the Secretariat of the World Health Orgaizatio cocerig the legal status of ay coutry, territory, city or area or of its authorities, or cocerig the delimitatio of its frotiers or boudaries. The metio of specific compaies or of certai maufacturers products does ot imply that they are edorsed or recommeded by the World Health Orgaizatio i preferece to others of a similar ature that are ot metioed. Errors ad omissios excepted, the ames of proprietary products are distiguished by iitial capital letters.

4 Table of cotets Preface Ackowledgemets Abbreviatios Itroductio iv v vi vii Chapter 1 Female sex workers i Asia 1 2 Orgaizatio of STI services for female sex workers 3 3 Cliical services 12 4 Comprehesive case maagemet 24 5 Reportig ad moitorig 28 6 Traiig health care providers 31 7 Educatig care seekers 34 8 Social services 37 Aex 1 Essetial compoets of a 100% CUP 43 2 Laboratory diagosis of STIs 45 3 History takig ad examiatio 62 4 Flowcharts for the diagosis ad treatmet of STI-associated sydromes 67 5 Treatmet of specific STIs 74 6 Reportig 89

5 Preface HIV/AIDS was first detected i Asia i the early to mid-1980s. Sice the, more tha six millio people i the regio have become ifected. I the year 2000 aloe, it is estimated that more tha died of AIDS i Asia - about 1500 a day. Estimatios put the umber of curable sexually trasmitted ifectios (STIs) i the regio at over 30 millio cases every year (WHO Wester Pacific Regioal Office estimatios). Wome are particularly vulerable to STIs because, compared with me, they are less empowered to egotiate safer sexual activity with their parters, they ofte remai asymptomatic, ad serious complicatios of STIs occur more commoly i wome. The cosequeces of such complicatios ot oly affect the wome cocered, but ca also affect their ewbor ifats. STI cliics have a special role to play i reducig STIs, icludig HIV/AIDS. However, vulerable wome i geeral have difficulty i accessig health care, especially STI care, due to such factors as moralistic ad judgemetal attitudes amog health workers, services isesitive to wome s eeds, ad, i may cases, poverty. Female sex workers (FSW), despite beig at higher risk of acquirig ad trasmittig STIs, face additioal barriers such as discrimiatio ad their ow fear of beig pealized for their illegal professio. Udoubtedly, there is a great eed to provide high quality, acceptable ad accessible STI services for these margialized wome. Icreasig awareess of these issues has led to efforts beig made to provide better STI ad reproductive health services for FSW i Cambodia, Chia ad Viet Nam. Steps have also bee take to develop STI services for FSW i Fiji, Mogolia ad the Philippies. Based o the experieces of these pilot projects ad programmes, these guidelies have bee developed to provide appropriate techical guidace for the provisio of cliical ad social services for female sex workers. The developmet of these guidelies was made possible through collaboratio betwee WHO Headquarters (Departmet of Wome s Health), ad two uits i the WHO Wester Pacific Regioal Office (the Sexually Trasmitted Ifectios, Icludig HIV/AIDS Focus ad the Reproductive Health Focus). That collaboratio eabled a more comprehesive approach to be take to providig services to female sex workers, the wome most i eed of a supportive eviromet for their health.

6 Ackowledgemets The Wester Pacific Regioal Office of the World Health Orgaizatio would like to thak the coutry ad agecy experts who reviewed these guidelies, with particular thaks to Dr. Ahmed Latif ad Dr. Jamie Uhrig for their cotributios.

7 Abbreviatios AIDS DNA ELISA FSW FTA-Abs HIV HSV KOH LCR LE MHA-TP PCR RNA RPR STI TPHA acquired immuodeficiecy sydrome deoxyriboucleic acid ezyme-liked immuosorbet assay female sex workers flourescet trepoemal atibody absorptio test huma immuodeficiecy virus herpes simplex virus potassium hydroxide ligase chai reactio leukocyte esterase microhaemagglutiatio assay polymerase chai reactio riboucleic acid rapid plasma reagi sexually trasmitted ifectio(s) Trepoema pallidum haemagglutiatio assay The World Health Orgaizatio recommeds that the term sexually trasmitted disease (STD) be replaced by the term sexually trasmitted ifectio (STI). The term sexually trasmitted ifectios has bee adopted as it better icorporates asymptomatic ifectios. I additio, the term has bee adopted by a wide rage of scietific societies ad publicatios. Reproductive tract ifectios ecompass three mai groups of ifectio, particularly i wome, ad sometimes i me. These groups are edogeous ifectios i the female geital tract (e.g. cadidiasis ad bacterial vagiosis); iatrogeic ifectios that may be acquired through o-sterile medical, persoal or cultural practices; ad classical STI. Curretly, research is beig coducted to better uderstad the determiats of edogeous ifectios. They are ot primarily sexually trasmitted; thus, cliical ad public health actios recommeded for STI may ot apply to them. Give the curret state of kowledge ad uderstadig of these ifectios, treatmet of parters is ot recommeded as routie public health practice. Reassurace ad patiet educatio are critical with regard to the ature of edogeous ifectios. (From WHO guidelies for the maagemet of sexually trasmitted ifectios. WHO/HIV_AIDS/ WHO/RHR/01.10)

8 Itroductio Sexually trasmitted ifectios (STIs) are ifectious diseases that are trasmitted from perso to perso durig sexual cotact, ot ecessarily vagial itercourse. A large umber of bacteria, viruses, fugi ad other orgaisms may be sexually trasmissible ad may result i disease. Most bacterial, fugal ad parasitic ifectios ca be cured with atimicrobial agets. O the other had, most viral ifectios caot be cured. Ativiral drugs ca sometimes cotai the progressio or effects of viral ifectios, although such treatmets are ofte expesive, are iaccessible to may idividuals, ad may have substatial side effects. Persos with sexually trasmitted ifectios are ifectious to their sexual parters eve though they may have o symptoms or sigs of ifectio. I fact, may people - me ad wome - have STIs without symptoms or sigs, although they ca develop serious complicatios. STIs are a public health problem because of their potetial to cause serious complicatios such as ifertility, chroic disability ad death i me, wome ad childre. STIs ca affect the foetus, eoate ad ifat, resultig i eye ifectio, blidess ad peumoia. The public health importace of STIs has take o a eve greater dimesio with the advet of huma immuodeficiecy virus (HIV) ifectio. HIV ifectio is sexually trasmissible, is ot curable ad leads to the acquired immuodeficiecy sydrome (AIDS). Persos with sexually trasmitted ifectios are ifectious to their sexual parters eve though they may have o symptoms or sigs of ifectio. STIs (icludig HIV) are commo amog idividuals who practice high-risk sexual behaviour. Sexual parters of idividuals with high-risk sexual behaviour (e.g. parters of me havig uprotected sex with sex workers) are also at higher risk of STI, eve though they may ot practice high-risk behaviour themselves. MODES OF BEHAVIOUR ASSOCIATED WITH STI ACQUISITION AND TRANSMISSION Havig cocurret multiple sexual parters; Frequetly chagig sexual parters; Havig uprotected sex with multiple parters; Havig uprotected sex with sex workers. High-risk sexual behaviour is facilitated by a umber of factors. Higher STI rates may be observed amog idividuals who fid themselves i high risk situatios: FACTORS FACILITATING HIGH-RISK SEXUAL BEHAVIOUR, STI ACQUISITION AND TRANSMISSION Beig far from usual social eviromet ad/or family; Usig alcohol ad/or recreatioal drugs; Exchagig sex for moey, material goods or drugs.

9 VIII GUIDELINES FOR THE MANAGEMENT OF STIs IN FEMALE SEX WORKERS Female ad male sex workers; Cliets of female or male sex workers - who are ofte youg ad mobile idividuals (e.g. migrat workers, military, police). The objective of STI cotrol programmes i geeral is to reduce the icidece ad prevalece of STIs ad related complicatios. To achieve this objective, programmes aim to: (1) reduce the risk of STI trasmissio durig sexual itercourse by use of codoms; (2) reduce the rate of sexual parter chage through behaviour chage; (3) reduce the period of ifectiousess i persos ifected by STI through early effective treatmet; ad (4) idetify ad treat parters. To achieve these goals, it is recommeded that STI maagemet ad cotrol services should be available at all levels of the health ifrastructure, i both the private ad the public sectors. The table below shows that STI ifectios are highly prevalet amog female sex workers (FSW) ad that chlamydial ifectio is the most commo STI amog sex workers i the Wester Pacific Regio, followed by goorrhoea ad syphilis. Prevalece of sexually trasmitted ifectios i female sex workers selected coutries Prevalece rate of ifectio (%) i selected studies Coutry Year of study (umber tested) Goorrhoea Chlamydia Syphilis HIV Australia 1991 (214) Cambodia 1996 (427) Chia 2000 (505) Japa 1993 (824) Malaysia 1998 (370) Philippies 1999 (200) Sigapore Viet Nam 1996 (295) (Ref. WHO Wester Pacific Regioal Office)

10 INTRODUCTION IX Female sex workers are ofte reluctat to atted regular cliics because they are ofte badly treated, stigmatized or rejected. However, sice there is strog evidece that FSW ad their cliets are a key core group for STI ad HIV sexual trasmissio i most of Asia, providig proper STI services to them, sometimes through STI cliics specializig i sex workers or employees of the etertaimet idustry, is a essetial compoet of effective STI prevetio ad cotrol. I both Cambodia ad Thailad, the 100% Codom Use Programme (100% CUP), implemeted amog establishmet-based sex workers, has bee successful i rapidly icreasig codom use i high-risk situatios ad i reducig the trasmissio of STI, icludig HIV ifectio, amog sex workers ad the geeral populatio. This targeted itervetio has had a dramatic effect o HIV trasmissio amog the geeral populatio. Oe of the compoets of the 100% CUP is the regular STI check-up of etertaimet establishmet workers (see Aex 1). These guidelies have bee developed to provide guidace to public health specialists ad health professioals o how to develop or improve STI services for female sex workers. Oe of the objectives is to support the expasio of the 100% CUP strategy, which has bee show to cotribute to a reductio i STI ad HIV trasmissio. The guidelies iclude guidace o cliical care, HIV cousellig ad testig, educatio for behaviour chage, promotig the use of codoms ad social services. Female sex workers are ofte reluctat to atted regular cliics because they are ofte badly treated, stigmatized or rejected.

11

12 CHAPTER 1 Female sex workers i Asia Female sex workers i Asia are a youg populatio group. Their level of schoolig ad educatio is limited or has bee curtailed by poverty ad they have ofte etered the sex trade i order to support their families fiacially. The exact umber of wome egaged i commercial sex i the differet coutries of Asia is ot kow. However, over the last decade, may Asia coutries have see a icrease i the size of their sex worker populatio ad it has bee oted that wome are eterig the sex trade at a youger age tha previously. 1 A umber of factors may explai this chage: Difficult ecoomic situatio with icreasig poverty, uemploymet ad migratio. Urbaizatio, weakeig of social etwork ad family values. Over the last decade, may Asia coutries have see a icrease i the size of their sex worker populatio. Itroductio of market ecoomies with icreasig disparities ad icreasig aspiratio to acquire material goods. I most coutries i Asia, although sex work is illegal, it appears to be tolerated. Though atioals makes up the larger proportio of persos ivolved i sellig sex, migrat FSW from eighbourig coutries are also ofte foud. Wome who ear a livig by sellig sex oly are kow as direct sex workers, while those employed i etertaimet establishmets ad who occasioally or regularly sell sex are kow as the idirect sex workers. Withi the direct sex worker group are freelace sex workers, recruitig their cliets i the streets or by other methods (e.g. mobile phoe, the Iteret) ad female sex workers who operate from brothels. Withi the idirect sex worker group are those wome who are employed i the etertaimet idustry, such as guest relatios officers i hotels, female 1 Sex Work i Asia. Maila, WHO Wester Pacific Regioal Office 2001.

13 2 GUIDELINES FOR THE MANAGEMENT OF STIs IN FEMALE SEX WORKERS beer bar attedats, waitresses, karaoke louge attedats, female attedees of roadside bars ad cafes, ightclub employees, massage parlour employees, dacers, sigers, beer promoters etc. FSW belog to differet socioecoomic strata. Access to health care for those who are more affluet is easy ad is maily through the private sector. However, sex workers i the lower socioecoomic groups ad street-based sex workers have, i geeral, oly limited access to care. They sometimes use the private or public sectors, but ofte will seek care i the iformal sector or egage i self-treatmet. Less frequetly, FSW access care through the public-sector-based health facilities such as primary care cliics, the reproductive care cliics ad, i some areas, special cliics. I some coutries, like Cambodia ad the Philippies, etertaimet idustry 2 employees eed to be registered ad udergo compulsory regular medical examiatios. 2 The etertaimet idustry comprises the hotel ad hospitality idustry, massage parlours, beer bars, ightclubs, karaoke bars, restaurats, cafes, ad roadside food ad drik outlets.

14 2CHAPTER Orgaizatio of STI services for FSW I the formal public ad private sectors, STI care ca be available i the followig facilities: Primary care cliics; I some coutries, such as the Reproductive health cetres; Family plaig cliics; Ateatal cliics; Postatal cliics; Materal ad child health cliics; Outpatiet departmets of district, regioal ad cetral hospitals; Workplace-based cliics. Philippies, etertaimet establishmets are required to have all their employees screeed for STI, ad Most of these health facilities are equipped to serve the geeral public, but are ot ready to carry out maagemet of STIs amog female sex workers. Based o reports from coutries i the regio, i most circumstaces FSW prefer to seek STI care i three types of settigs: (1) Private Geeral Practitioer cliics; those foud to be ifected are barred from workig util a certificate of good health is obtaied. (2) Special cliics, such as social hygiee cliics ad medical surveillace cetres; (3) Private pharmacies or drug sellers. The social hygiee cliic i the Philippies is a example of a special cliic aimed at reachig registered female sex workers, i.e., those who are i formal employmet i the etertaimet idustry ad require a health certificate. I some coutries, such as the Philippies, etertaimet establishmets are required to have all their employees

15 4 GUIDELINES FOR THE MANAGEMENT OF STIs IN FEMALE SEX WORKERS (see footote o page 2) screeed for STI, ad those foud to be ifected are barred from workig util a certificate of good health is obtaied. FSW also ofte seek care i the iformal sector, such as private pharmacies ot formally accredited to provide treatmet; traditioal practitioer cliics; ad drug vedors who sell atibiotics ad other medicatios. Sometimes they obtai drugs from frieds ad peers. Social hygiee cliics i the Philippies The Philippies ejoys a low rate of HIV ifectio i the geeral populatio ad high-risk groups. The coutry has more tha 50 years experiece i STI cotrol programmes. I may cities, the City Health Departmet rus social hygiee cliics, which provide STI screeig 1 ad treatmet services for female sex workers. All female eter- CASE STUDY taimet establishmet workers are madated by law to have medical examiatios weekly ad to carry a valid health certificate i order to cotiue workig. The law applies to all wome employed as waitresses, guest relatios officers, bar attedats, sigers, dacers, ad masseuses. Social hygiee cliics have bee ow i existece for several decades. Ruig of the cliics The cliics are headed by a physicia, who works with a team of urses, social workers, laboratory techicias ad clerks. Cliics are usually ope five days a week ad offer STI screeig ad treatmet services. Physical structure Each cliic usually has a registratio ad waitig area, examiatio rooms, a laboratory, ad cousellig rooms. Services provided Workers register at the cliic ad are issued with a idetity card bearig their photograph. The workers carry this card with them at all times while employed. A similar card with a photograph is kept at the cliic 1 Screeig is the process of examiig persos ot seekig health care, while case fidig is the process of examiig persos for STI whe they are seekig health care for ay reaso other tha STI-related symptoms.

16 CHAPTER 2: ORGANIZATION OF STI SERVICES FOR FSW 5 with demographic details. The card the worker carries with her is stamped, dated ad siged at each visit after each examiatio if o ifectio is foud. If a ifectio is foud, the worker is treated but the card is withheld util she comes back for a follow-up visit ad is foud to have o more cliical symptoms. At each cliic visit, the attedee has a history take ad is examied. The examiatio icludes a speculum ad digital bimaual examiatio. Edocervical smears are take ad examied microscopically after Gram staiig. If itracellular Gram-egative diplococci are foud i the smear, the attedee is treated for goococcal ifectio with a sigle oral dose of Cefixime 400 mg. If o orgaisms are foud but there are more tha 22 polymorphouclear leukocytes per high-power field, the patiet is treated for o-goococcal cervicitis with doxycyclie 100 mg orally twice daily for seve days. Syphilis ad HIV tests are performed oce a year. If a attedee is symptomatic for vagial discharge, lower abdomial pai or geital ulcer disease, she is treated for the STI sydrome. The attedee is the couselled ad advised o cosistet codom use. The cliic also coducts outreach activities aimed at reachig freelace sex workers ad sex workers operatig from casas (illegal brothels). Fees for services The attedee pays a very small registratio fee (rages from pesos per sex worker per visit), a small fee for the drugs ad buys the codoms. Codoms are sold at a subsidized rate through the codom social marketig programme. Follow-up activities All wome are reviewed weekly. Support for the cliics Curretly social hygiee cliics are fiaced by city health departmets. Some cliics also receive support from iteratioal parters.

17 6 GUIDELINES FOR THE MANAGEMENT OF STIs IN FEMALE SEX WORKERS Providig regular STI services for female sex workers is importat, as wome with STIs may have o symptoms util complicatios develop. These services should be comprehesive, addressig ot oly cliical eeds but also the wome s social ad legal eeds. Female sex workers with STI or requirig a regular check-up will make use of those facilities they ca access ad where they perceive that they will receive the best care. Elemets affectig their choice iclude: Accessibility of health services Geographic locatio of services Services should be physically accessible to patiets. If the patiet eeds to be away from home or work for a log period of time, the the services provided will be less accessible. The ideal health facility would be oe that is withi walkig distace of where the patiet lives. To icrease service coverage, visits to etertaimet establishmets ca be orgaized (outreach services). Reachig sex workers i Phom Peh, Cambodia I 1996, the ogovermetal orgaizatio Pharmacies Sas Frotières started a mobile team itervetio for sex workers, i partership with Phom Peh Muicipal Health Departmet. A team of medical staff ad educators has bee visitig brothels every week i seve areas of Phom Peh, providig iformatio, distributig codoms ad lubricat, ad offerig STI care to sex workers o a volutary basis. All are ivited to cotact the mobile team at least oce a moth, eve whe asymptomatic. At the first cosultatio, they are treated systematically for syphilis, as well as for goococcal ad chlamydial ifectio, regardless of symptoms ad cliical sigs. At subsequet visits, all sex workers have a risk assessmet for cervical ifectio CASE ad are treated for cervicitis if positive. Those with geital ulceratio ad vagiitis STUDY are treated sydromically at each visit. The mobile team itervetio has maaged to reach most of targeted sex workers. I additio to providig STI care, sex workers are provided with educatio, codoms are distributed ad 100% codom use is advocated ad ecouraged. The mobile team itervetio is relatively costly because of the time ad umber of staff required to reach a fairly small ad scattered target populatio. However, it is the oly optio i areas of the city where o other special services are curretly available.

18 CHAPTER 2: ORGANIZATION OF STI SERVICES FOR FSW 7 Hours whe services are available The cliic should be ope at times whe the care seeker ca access services. For example, ofte sex workers will seek services i the afteroo because they work from early eveig util late at ight. Care seekers will have to be iformed of cliic opeig hours ad otices should be posted for public iformatio. Most STI care seekers, icludig sex Costs of services It is geerally recommeded that cliic attedees pay a fee for services (cliic, laboratory, medicatio), but that the cost is made affordable to most of them, particularly if they are madated to come for check-ups o a regular basis. workers, feel ashamed to have cotracted a STI. Acceptability of services Stigmatizatio Most STI care seekers, icludig sex workers, feel ashamed to have cotracted a STI. Health workers should avoid beig egatively judgemetal or moralistic. Health workers attitudes greatly ifluece the acceptability of services provided, especially to the youg FSW. Patiets with STIs should be treated like ay other patiets seekig care ad should ot be blamed for their bad behaviour. Specific programmes eed to be developed for freelace sex workers (they ofte have a higher prevalece of STIs). These wome are difficult to reach, as they fear idetificatio, arrest ad icarceratio, ad specific approaches, such as outreach ad peer educatio programmes, are particularly suited to them.

19 8 GUIDELINES FOR THE MANAGEMENT OF STIs IN FEMALE SEX WORKERS OUTREACH PROGRAMMES Sex workers are ofte described as hard to reach i terms of access to services, ad outreach has bee idetified as a importat tool i targetig these groups. Health services, HIV/STI prevetio, ad iformatio about health cliics ca be take to sex workers through outreach. Outreach to sex workers ivolves makig cotact with them o the streets, at ight ad durig the day; establishig good rapport ad trust; offerig codoms; givig them iformatio about how to reach health cliics; ad providig advice about sexual health ad STI diagosis ad treatmet. Outreach may iclude visitig etertaimet establishmets, such as massage parlours, brothels, bars, sauas etc. or havig a sex workers drop-i cetre. Drop-i cetres should be situated ear the areas where sex workers work or live. I order to set-up a outreach programme for sex workers, it is ecessary to: defie the types of sex work i the area; map sex establishmets ad estimate the umber of active sex workers; survey health-seekig behaviour; decide o types of outreach work drop-i cetre; mobile cliic; select ad trai outreach workers; coduct advocacy meetigs with etertaimet establishmet owers or pimps to build trustig relatioships; iform the police to avoid harassmet of outreach workers; provide outreach workers with codoms, lubricats, a dildo for demostratig how to use a codom, pamphlets ad various iformatio leaflets; explore the possibility of workig with ogovermetal orgaizatios; for drop-i cetres or mobile cliics, there is a eed to explore the capacity of STI cliics to exted this programme. PEER-LED EDUCATION PROGRAMMES Oe method of providig FSW with iformatio ad educatio is through activities coducted by peers. Peer leaders who are idetified by the sex workers may be traied as traiers ad should be provided with a curriculum to follow. The peer educators should egage i educatig other sex workers ad promotig the messages of safer sexual behaviour ad practices ad 100% codom use, ad should promote good healthseekig behaviour ad volutary testig for STIs ad HIV ifectio. I order to develop ad implemet peer-led prevetio activities for FSW it is ecessary to: develop educatio messages eroll the help of sex workers to develop acceptable messages by holdig a writers workshop ad the field test the messages for acceptability; develop traiig materials ad traiig curriculum for peer educators; prit the materials that will be used i traiig the educators, as well as educatig the sex workers; idetify peer leaders to act as educators; trai peer educators accordig to the curriculum ad guide them through the activities eeded to trai their peers; develop a timetable for coductig the traiig activities; commece peer-led educatio of sex workers ad supervise these iitially; review, revise ad modify the traiig materials accordig to eeds ad the allow peer-led activities to cotiue as scheduled i the timetable; moitor ad support the activities; ad evaluate the effects of the activity. Have the behaviour ad practices of sex workers i the programme chaged? Has there bee cosistet use of codoms? Has the health-seekig behaviour of sex workers improved?

20 CHAPTER 2: ORGANIZATION OF STI SERVICES FOR FSW 9 Privacy ad cofidetiality Cliic attedees wat to be sure that the iformatio they provide durig history takig will ot be dissemiated to ayoe else ad that the records will be kept cofidetial. Health facilities eed to be orgaized to provide privacy ad cofidetiality durig history takig ad cliical examiatio. Well maaged health facility Services are cosidered acceptable by patiets if they do t take up too much time. Cliics should be clea ad hygieic ad should have the essetial equipmet to carry out examiatios. The health facility should have examiatio couches, specula, lights, gloves, disposable cosumables ad sterilizig equipmet. Supply of drugs ad codoms If the health facility dispeses drugs ad/ or provides codoms, cotiuity of supply should be esured, if possible at the cliic. If patiets are give a prescriptio to fill i at a outside pharmacy, cliicias should make sure o a regular basis that the drugs ad the dosage are available i the dispesary of the cliic or o the market. STI services for sex workers should be free or at least affordable to care seekers, especially if STI check-ups are madatory. Cliics should be clea ad hygieic ad should have the essetial equipmet to carry out examiatios. Professioal ad competet health care providers The professioalism of the service provider shows i history takig, physical examiatio ad cousellig / educatio. Patiets are more likely to comply with istructios if they believe that they come from competet health staff. Health care providers eed to be traied accordigly. Provisio of effective therapy Drugs prescribed for STIs should provide highly effective therapy with miimum side effects. Stadardized treatmet protocols for diagosis ad treatmet of STIs amog sex workers should be developed ad distributed, ad health workers should be traied to use them.

21 10 GUIDELINES FOR THE MANAGEMENT OF STIs IN FEMALE SEX WORKERS Miimum requiremets for health facilities providig care for persos with STIs iclude: Premises As part of a comprehesive care package, FSW At a miimum, STI health facilities must have a registratio area, a records storage room, a waitig area, a room where history is take i private, a room where patiets may be examied i private. Accordig to the protocols developed for the diagosis ad treatmet of STIs a o-site laboratory may be added to this list. ca be educated ad couselled ad provided with egotiatig skills whe they atted for STI care or screeig. Examiatio room equipmet Examiatio rooms must have a desk ad chairs, a examiatio couch, sheets, a sik with ruig hot ad cold water, towels, soap, overhead lights, a agle-poise lamp, specula ad gloves. This list should be complemeted accordig to the eeds of diagosis ad treatmet protocols. I the case of a laboratory, the list may iclude swabs, microscope slides ad cover slips, blood collectig istrumets, specime jars, blood tubes, ad trasport media to trasport specimes for microbiological tests. Health educatio material As part of a comprehesive care package, FSW ca be educated ad couselled ad provided with egotiatig skills whe they atted for STI care or screeig. This ca be doe through the use of posters, leaflets, videos or iteractio with skilled staff. Traiig of health care workers i health promotio is importat. Staffig STI health facilities eed a doctor, urses, clerks, cleaers, cousellors ad a pharmacist.

22 CHAPTER 2: ORGANIZATION OF STI SERVICES FOR FSW 11 HEALTH SERVICES Accessibility Locatio of service close to home or workplace Services available at times whe cliet ca access them Services are free or withi a affordable price rage Acceptability Services are o-stigmatizig ad o-pealizig Provider attitudes are o-judgmetal ad o-moralizig Privacy ad cofidetiality are assured Waitig times are ot too log Health facility has the ecessary equipmet for examiatio Health facility has a uiterrupted supply of drugs ad codoms Providers are professioal, competet ad capable Treatmet provided is effective i relievig symptoms ad, wheever feasible, curig the ifectio

23 12 GUIDELINES FOR THE MANAGEMENT OF STIs IN FEMALE SEX WORKERS 3CHAPTER Cliical services Maagemet of STI patiets or maagemet of FSW attedig cliics for regular health check up ecompasses: makig a diagosis (whe a laboratory is available) or presumptive diagosis (if a sydromic approach is used) of STI or usig a risk-assessmet; providig appropriate atimicrobial agets for the ifectio; providig educatio o treatmet compliace; providig iformatio o the ature of the ifectio ad the ways of prevetig ifectio; demostratig the correct use of codoms; providig codoms ad emphasizig cosistet codom use; cousellig to improve codom-egotiatig skills; arragig for treatmet of regular parters (wheever possible); ad arragig for follow-up examiatios ad regular attedaces for medical check-ups. Makig a diagosis of a STI A STI may be diagosed i three ways: A cliical diagosis may be made by idetifyig symptoms ad sigs. A etiological diagosis may be made after idetifyig a pathoge through laboratory examiatios (with or without symptoms ad sigs) (see Aex 2). A sydromic diagosis may be made after takig a history, examiig the patiet ad idetifyig the symptoms ad sigs.

24 CHAPTER 3: CLINICAL SERVICES 13 Assessmet of risk Because a large umber (up to 80%) of wome with a STI have asymptomatic ifectios, if a wome atteds a health facility without ay symptoms, such as for a regular check-up, the oly way to exclude or cofirm a STI is to perform a laboratory ivestigatio. I the absece of laboratory facilities, attempts have bee made to idetify risk factors related to sexual behaviour ad practices ad sigs of STIs that ca be idetified durig a iterview ad ca be good predictors of ifectio. These may iclude complait of vagial discharge, fever, lower abdomial pai, the umber of cliets per day, codom use, etc. However, o reliable risk factors have yet bee idetified ad recommedatios caot be made at this stage o the use of risk factors i maagig female sex workers attedig routie examiatios. Risk assessmet ca be used withi the framework of operatioal research ad adapted for the local cotext of STIs (see example from Viet Nam). Example of Viet Nam Based o the fact that most sex workers with STIs are asymptomatic, withi the CASE framework of the 100% CUP, Viet Nam has started usig a algorithm that icludes the use of risk assessmet. This approach was based o data showig STUDY that STIs amog sex workers are commo, i particular goorrhoea ad chlamydiosis, ad that most health facilities dealig with sex workers have limited laboratory facilities. Maagemet of sex workers i Viet Nam i health facilities FIRST-TIME ATTENDEES Treat all sex workers for cervicitis ad early syphilis. Treat for vagiitis as well, depedig o sigs ad symptoms. If complait of vagial itchig ad white vagial discharge, treat for cadidiasis; if complait of frothy or offesive vagial discharge, treat for bacterial vagiosis (BV)/trichomoiasis (TV). Treat all who have ot atteded for > 3 moths as ew attedees ad treat for cervicitis FOLLOW-UP CASES Protocol accordig to facilities available A. With laboratory ad speculum B. Without laboratory, with speculum C. Without laboratory, without speculum Cotiued overleaf

25 14 GUIDELINES FOR THE MANAGEMENT OF STIs IN FEMALE SEX WORKERS Case Study cotiued A. With laboratory ad speculum Risk assessmet Complait of vagial discharge; Lower abdomial pai; More tha three cliets per day; Codom ot used with ew cliets; Fever. Treat for cervicitis if two or more out of five positive. If risk assessmet egative, determie if either Yellow discharge from cervix; 20 white blood cells per high power field; Cervical erosio/cotact bleedig; Pai o bimaual examiatio. If ay oe sig positive, treat for cervicitis Do laboratory tests ad cliical examiatio for BV, TV ad Cadida, ad treat accordigly. B. Without laboratory, with speculum Risk assessmet Complait of vagial discharge; Lower abdomial pai; More tha three cliets per day; Codom ot used with ew cliets; Fever.

26 CHAPTER 3: CLINICAL SERVICES 15 Treat for cervicitis if two or more out of five positive. Ectopic pregacy or other coditios requirig surgery should be excluded if suspected If risk assessmet egative, determie if either Yellow discharge from cervix; Cervical erosio/cotact bleedig; Pai o bimaual examiatio. If ay oe sig positive, treat for cervicitis If vagiitis with frothy discharge or discharge with offesive smell, treat for BV/TV. If vagial itchig ad white discharge, treat for Cadida. C. Without laboratory, without speculum i.e. Commue level Risk assessmet Complait of vagial discharge; Lower abdomial pai; More tha three cliets per day; Codom ot used with ew cliets; Fever. Treat for cervicitis if two or more out of five positive. Ectopic pregacy or other coditios requirig surgery should be excluded if suspected Treat for BV/TV if complait of frothy of offesive discharge. Treat for Cadida if complait of itchy, white vagial discharge. Etiological diagosis This diagosis requires a laboratory for microbiological ad serological testig of specimes (see Aex 2 o laboratory diagosis of STIs). If the cliic has the miimum required equipmet, ad persoel are traied ad experieced i performig tests, some tests may be performed quickly ad reliably o site. These iclude Gram-staiig ad microscopic examiatio of fresh wet mouts of secretios ad rapid plasma reagi (RPR) testig for syphilis performed o patiets serum.

27 16 GUIDELINES FOR THE MANAGEMENT OF STIs IN FEMALE SEX WORKERS Whe laboratory capacity is o-existet or limited, the sydromic diagosis is recommeded, ad possibly the itegratio of a riskassessmet strategy. Sydromic diagosis This approach is oly applicable to attedees who have symptoms ad sigs of STI. It is based o the observatio that a umber of sexually trasmissible pathoges produce similar symptoms (e.g. pai while uriatig) ad sigs (e.g. vagial discharge). The sydromic approach does ot apply to patiets without sigs ad symptoms. Ideally, for asymptomatic wome the laboratory will make the diagosis of possible STIs. I the absece of laboratory facilities, which is ofte the case, a strategy should be established. Stadardized treatmets are the give for the most commo orgaisms resposible for these sydromes. Sydromes ad the pathoges ivolved are show i the followig table: STI-related sydromes ad their causes STI sydrome Urethral discharge Geital ulcers Vagial discharge sydrome Suppurative iguial lymphadeitis (Bubo) Lower abdomial pai (wome) Acute scrotal swellig Neoatal purulet cojuctivitis (ophthalmia eoatorum) Pathoges N. goorrhoeae, C. trachomatis T. pallidum, H. ducreyi, Herpes simplex virus, C. graulomatis, C. trachomatis N. goorrhoeae, C. trachomatis, T. vagialis, C. albicas, ad aaerobic bacteria H. ducreyi, C. trachomatis Pelvic iflammatory disease caused by N. goorrhoeae, C. trachomatis ad other bacteria N. goorrhoeae, C. trachomatis ad other bacteria ad viruses N. goorrhoeae, C. trachomatis ad other bacteria Remember that the sydromic approach does ot apply to patiets without sigs ad symptoms.

28 CHAPTER 3: CLINICAL SERVICES 17 Cliical procedures Iitial visit At the iitial visit, the attedee should be registered, documetatio completed, history take (see History takig o page 20) ad a physical examiatio carried out (see Examiatio o page 20). Wome with symptoms of STI should be systematically treated for chlamydial ad goococcal ifectio (studies have show that a large majority of sex workers with sigs ad symptoms of STI will have oe or both ifectios) ad for other STI sydromes, if ecessary, usig the appropriate flowchart (see Aex 4). If available, a blood test may be performed for syphilis ad HIV testig after pre-test cousellig. Wome with symptoms of STI should be systematically treated for chlamydial ad goococcal ifectio. I some cetres it may be possible to take edocervical swabs to idetify asymptomatic goococcal ad chlamydial ifectios. The attedee should be asked to retur for the laboratory results. If she has a positive syphilis test, she should be treated with bezathie bezylpeicilli 2.4 millio IU itramuscularly each week for three weeks for latet syphilis. If she is foud to be HIV-positive she should be couselled ad referred to the appropriate health facility. The available structure for follow-up of HIV-positive patiets eeds to be idetified. All wome attedig the cliic should be couselled ad ecouraged to use codoms cosistetly. Social, psychological or legal cousellig should also be provided (see Chapter 8).

29 18 GUIDELINES FOR THE MANAGEMENT OF STIs IN FEMALE SEX WORKERS Maagemet of a female employee of a etertaimet establishmet attedig a cliic o laboratory facilities available Female employee of etertaimet establishmet atteds cliic First visit Register, complete documetatio, issue idetificatio umber, issue card, take history, geeral examiatio, speculum examiatio, sed blood for syphilis ad HIV testig after pre-test cousellig Followig visits Update documetatio, update history, geeral examiatio, speculum examiatio, every 6 to 12 moths sample blood for syphilis ad HIV testig after pre-test cousellig Does attedee have sigs ad/or symptoms of STI? No Yes - Treat for goorrhoeae ad chlamydial ifectio - Maage accordig to appropriate flowchart for other STI-related sydromes (see Aex 4) - Educate ad cousel - Promote codom use - If blood test doe, ask to retur for follow up *Risk-assessmet may be used Syphilis seroposivity Yes Treat accordigly No HIV test positive (if test doe) Yes Refer No - Educate ad cousel - Promote codom use - Ask to retur after oe moth for follow-up ad/or routie examiatio If a patiet has bee foud durig a previous visit to have a positive syphilis test result, the, eve with adequate treatmet, the test will remai positive for moths. Therefore, eve if a ew test is performed six times i the ext few moths, the laboratory should be iformed that the cliet was previously positive ad that they should perform a quatitative o-specific test for syphilis.

30 CHAPTER 3: CLINICAL SERVICES 19 Maagemet of a female employee of a etertaimet establishmet attedig a cliic laboratory facilities available Female employee of etertaimet establishmet atteds cliic First visit Register, complete documetatio, issue idetificatio umber, issue card, take history, geeral examiatio, speculum examiatio, sample blood for syphilis ad HIV testig after pre-test cousellig Followig visits Update documetatio, update history, geeral examiatio, speculum examiatio, every 6 to 12 moths,sample blood for syphilis ad HIV testig after pre-test cousellig Does attedee have sigs ad/or symptoms of STI? No Yes - Treat for goorrhoeae ad chlamydial ifectio - Maage accordig to appropriate flowchart for other STI-related sydromes (see Aex 4) Take vagial ad cervical swabs ad smears ad sed to laboratory - Educate ad cousel - Promote codom use - Ask to retur for results of laboratory tests Tests idicate goorrhoea ad/or chlamydial ifectio Yes Treat for goorrhea ad chlamydial ifectio No Syphilis seroposivity (if test doe) No HIV test positive (if test doe) No Yes Yes Treat accordigly Refer - Educate ad cousel - Promote codom use - Ask to retur after oe moth for follow-up ad/or routie examiatio

31 20 GUIDELINES FOR THE MANAGEMENT OF STIs IN FEMALE SEX WORKERS Subsequet mothly visits Regular visits to the STI cliic should be ecouraged (see flowcharts o the previous pages). History takig (also see Aex 3) History takig will iform about sexual behaviour ad STI-related symptoms. Female sex workers should be asked whether they have bee usig codoms ad whether they use a codom cosistetly. Health professioals have to guaratee the cofidetiality of the iformatio collected (e.g. by usig coded registratio umbers istead of ames or, if ames are registered, by keepig the files i a locked area). Examiatio The examiatio will begi with a explaatio to the patiet of the procedure ad what may be expected from the examiatio. The followig will be performed: Geeral examiatio; Abdomial examiatio; Exteral geital examiatio; Iteral speculum examiatio; Bimaual digital examiatio; Collectio of specimes if laboratory facilities are available. The female sex worker attedig a health facility should be maaged with respect ad digity ad all the priciples goverig the maagemet of ay perso seekig care at a health facility should be observed. The followig guidig priciples should be adhered to whe maagig female sex workers: Be courteous, carig ad professioal. Esure that there is privacy whe talkig to the patiet ad whe examiig her ad assure the patiet that ay iformatio obtaied will be kept absolutely cofidetial. Allow the patiet eough time to state her problem ad discuss her eeds; do ot rush the patiet.

32 CHAPTER 3: CLINICAL SERVICES 21 Avoid moralizig ad beig judgemetal. Do ot criticise or belittle the patiet. Show empathy ad let the patiet kow that you care for her ad are prepared to help her. Maagemet of STI-associated sydromes VAGINAL DISCHARGE Vagial discharge may be physiological or pathological. Physiological vagial discharge is a ormal occurrece ad does ot require treatmet. Pathological vagial discharge requires treatmet as it may be due to vagial ifectio, cervical ifectio or ifectio occurrig i the geital tract above the iteral os of the cervix. Vagiitis is ofte caused by Trichomoas vagialis, Cadida albicas or bacterial vagiosis, while cervicitis is caused by Neisseria goorrhoeae or Chlamydia trachomatis. A spotaeous complait of abormal vagial discharge is most commoly due to a vagial ifectio. Bacterial vagiosis is the most commo cause, with wome complaiig of a malodorous vagial discharge. The discharge is homogeeous, sticky, grey-white i colour ad is ot copious. The diagosis of bacterial vagiosis is made o the presece of three of the followig four criteria: I the presece of a laboratory: All wome presetig with vagial discharge should receive treatmet ot oly for bacterial vagiosis, but also for trichomoiasis, which is a commo cause of vagial ifectio. Presece of a homogeeous vagial discharge; Vagial ph of greater tha 4.5; Presece of clue cells o microscopy; Positive amie test liberatio of a fishy odour after the additio of potassium hydroxide to vagial secretios (also kow as the siff test ). Therefore, all wome presetig with vagial discharge should receive treatmet ot oly for bacterial vagiosis, but also for trichomoiasis, which is a commo cause of vagial ifectio. Occasioally vagial discharge may be the result of mucopurulet STIrelated cervicitis. The cliical detectio of cervical ifectio is difficult because a large proportio of wome with goococcal or chlamydial cervical ifectio are asymptomatic. I additio, microscopy adds little to the diagosis of cervical ifectio ad is ot recommeded.

33 22 GUIDELINES FOR THE MANAGEMENT OF STIs IN FEMALE SEX WORKERS Local kowledge of the prevalece of goococcal ad/or chlamydial ifectio i wome presetig with vagial discharge is importat for the decisio to treat for cervical ifectio. The higher the prevalece, the stroger the justificatio for treatmet. Where resources permit, the use of laboratory tests to scree wome with vagial discharge could be cosidered (for guidelies see aex 4). I the absece of a laboratory: Abormal discharge is highly idicative of vagial ifectio, but poorly predictive for cervical ifectio. Abormal discharge is highly idicative of vagial ifectio, but poorly predictive for cervical ifectio. All SWs presetig with vagial discharge should, therefore, receive treatmet for goococcal ad chlamydial ifectio, TV ad BV, after excludig STI associated with lower abdomial pai (see Aex 4). GENITAL ULCERS Geital ulcers may be caused by the sexually trasmissible pathoges Haemophilus ducreyi, Trepoema pallidum, Calymmatobacterium graulomatis, Chlamydia trachomatis, ad the herpes simplex virus. I additio, there are a umber of o-sti-related causes of geital ulcers, such as, abrasios ad sores, fissurig of a tight foreski ad bacterial ad fugal ifectios. The epidemiology of geital ulcer disease varies from place to place, though data from Asia are limited. Cliically it is difficult to differetiate betwee the differet types of geital ulcer, ad makig a cliical diagosis is iaccurate, except perhaps i the case of geital lesios caused by the herpes simplex virus. I the presece of HIV ifectio the cliical patter of geital ulcers is altered ad lesios may persist for log periods. I patiets presetig with a history of geital ulcers, it is importat to cofirm the presece of geital ulcers ad the to give treatmet appropriate to the local etiologies ad atibiotic sesitivity patters. Laboratory-assisted differetial diagosis is rarely helpful at the iitial visit, as mixed ifectios are commo. I additio, i areas of high syphilis prevalece, a reactive serological test may reflect a previous ifectio ad give a misleadig picture of the patiet s preset coditio. For guidelies see Aex 4.

34 CHAPTER 3: CLINICAL SERVICES 23 LOWER ABDOMINAL PAIN Oe cause of lower abdomial pai i sexually active wome is pelvic iflammatory disease (PID), which may be caused by goococcal, chlamydial or aaerobic bacterial ifectio ascedig from the cervix ad reachig iteral reproductive orgas. Other causes of lower abdomial pai i wome that require immediate ad urget maagemet iclude acute appedicitis, complicatios of pregacy, ectopic pregacy, pelvic abscess ad peritoitis. All wome presetig with lower abdomial pai should be carefully examied for the presece of salpigitis ad/or edometritis, i.e., pelvic iflammatory disease (PID) or other surgical ad gyaecological emergecies. Symptoms suggestive of PID iclude abdomial pai, dyspareuia, vagial discharge, irregular mestruatio, metrorrhagia, dysuria, pai associated with meses, fever, ad sometimes diarrhoea, ausea ad vomitig. I practice, these patiets should be urgetly referred for a gyaecological cosultatio. For guidelies see Aex 4.

35 24 GUIDELINES FOR THE MANAGEMENT OF STIs IN FEMALE SEX WORKERS 4CHAPTER Comprehesive case maagemet The STI cosultatio provides a opportuity, ot oly Persos who have a STI have placed themselves at risk of becomig ifected with HIV as well. The STI cosultatio provides a opportuity, ot oly to treat persos with a STI, but also to educate them i ways to prevet becomig ifected i the future. This is especially true whe maagig FSW with STIs. All sex workers attedig for care should receive a complete care package ad ot merely atibiotics for the ifectio. Comprehesive case maagemet of STI icludes the followig: to treat persos with a STI, but also to educate them i ways to prevet becomig ifected i the future. makig a diagosis of the STI; providig appropriate atimicrobial agets for the ifectio; providig educatio to the cliet o: treatmet compliace; the ature of ifectio ad ways of prevetig ifectio; the correct use of codoms; cosistet codom use with regular parters ad boyfrieds; providig codoms; ad arragig for a follow-up examiatio. Makig a diagosis ad providig appropriate atibiotics for the ifectio have bee discussed i the precedig chapters. I this chapter some aspects of providig educatio ad cousellig durig a STI cosultatio, codom promotio, ad parter referral are discussed. Providig educatio The health educatio message should iclude iformatio o the followig: