Worldwide, sexually transmitted infections (STIs) continue to be a major cause of morbidity and mortality. Global estimates suggest that more than 340 million new cases of syphilis, gonorrhoea, chlamydial infection and trichomoniasis occurred throughout the world in 1999.1
Congenital syphilis, prevention of which is relatively easy and cost‐effective, may still be responsible for as many as 14% of neonatal deaths.2
Up to 10% of those women who are untreated, or inadequately treated, for chlamydial and gonococcal infections may become infertile as a consequence.2
On a global scale, up to 4000 newborn babies each year may become blind because of gonococcal and chlamydial ophthalmia neonatorum.2
There is evidence that STIs may enhance both the transmission and acquisition of HIV infection, and that improved control of STIs may slow down HIV transmission.3
The prevention and control of STIs is not an easy task. Epidemiological patterns of STIs vary geographically and are influenced by cultural, political, economical and social forces. Many affected by STIs are in marginalised vulnerable groups. The asymptomatic nature of some STIs remains a challenge to healthcare providers in areas of the world where laboratory screening tests are unaffordable.
The World Health Organization's “Global Strategy for the prevention and control of sexually transmitted infections: 2006–2015” was presented to Member States at the 59th World Health Assembly in May 2006. The World Health Assembly endorsed the Global Strategy and urged member states to adopt and draw on it in order to ensure that national efforts to achieve the United Nations' Millenium Development Goals include plans and actions for the prevention and control of STIs.2
The objectives of the Global Strategy are (a) to increase the commitment of both national governments and international development partners to STI prevention and control activities, (b) to promote both reallocation of existing resources and mobilisation of funds to support these activities, (c) to ensure that initiatives, policies and laws related to incountry provision of STI care are non‐stigmatising and gender‐sensitive, and (d) to facilitate better networking between all relevant partners and institutions in order to scale up and sustain interventions for STI prevention and control.
The Global Strategy has technical and advocacy components.2
The technical component includes promotion of healthy sexual behaviour, delivery of good‐quality STI care (Box 1), reliable supply of essential commodities and medicines, strengthening of support components and review of policies, laws and regulations regarding STI control. The advocacy component addresses the need for an effective STI advocacy campaign to raise awareness and mobilise resources at the national and international level.
WHO, with other international partners and governments, is in the process of elaborating an Action Plan for the implementation of the Global Strategy structured around the technical and advocacy components of the Strategy. It sets out priorities (Box 2), actions, a time frame and performance indicators, for implementing the Strategy at global and regional levels. A draft of the Action Plan was reviewed at a stakeholders' consultation in Geneva in June this year. This meeting brought together government representatives, bilateral donor agencies, representatives from Member States in the WHO Regions, laboratory experts and other scientists. Each WHO Region will select countries of focus where scaling up the priority interventions may be supported more intensively.
In terms of support components, the lack of effective STI surveillance systems in many countries presents a major challenge. Surveillance of clinical syndromes is easier to establish in resource‐poor countries than more costly and technically demanding microbiological surveillance systems. The success of STI syndromic management does, however, rely on up‐to‐date local knowledge of the pathological agents causing the syndromes (aetiological surveillance) and the antimicrobial susceptibility profile of bacteria such as Neisseria gonorrhoeae. In order to undertake microbiological surveillance studies in resource poor areas of the world, investment will be required to strengthen regional laboratories. As part of surveillance initiatives, it will be necessary to define minimum essential sets of STI syndromes and standardised laboratory investigations, in order to allow comparisons between countries and regions.
Retention of trained staff in STI programmes remains a threat to maintaining quality in incountry programmes. Efforts are required to raise the profile of the STI control programme within the health system. Preservice curricula and inservice training for STIs should be strengthened and emphasis placed on the link between STIs and HIV and other reproductive health services such as family planning and antenatal care.
The success of the strategy will depend upon the ability of different disciplines, at various levels of the health system, to implement the activities in a collaborative manner. STI control programmes need to be linked to both national HIV prevention and sexual and reproductive health programmes. However, collaborative activities should also be developed or enhanced with government departments dealing with education, youth, labour and tourism. In many countries, it will also be important to increase involvement of the private health sector.
It will be important to monitor the success of the Global Strategy from now until 2015. This will involve monitoring and evaluation of national plans in order to ensure that populations at risk of STIs have access to prevention information and condoms, and to timely diagnosis and treatment. Sufficient monitoring and evaluation tools exist, but their use is lacking in many countries. Therefore, the focus should be on advocating for a broader culture of monitoring and evaluation and enhancing existing activities.
The Global Strategy document is an important advocacy tool, but its objectives will only be met through an effective dissemination and advocacy strategy at the global and national levels, involving governments and other key stakeholders. It will be a challenge for many governments to effectively implement the technical components of the Strategy over the next 9 years, given competing health, economic and political concerns, but the investment in the prevention and treatment of STIs will contribute towards the attainment of international development goals related to reproductive health, including the Millenium Development Goal (MDG) 4, target 5, reducing the under‐five mortality; MDG 5, target 6, reducing maternal mortality; and MDG 6, target 7, halting and reversing the spread of HIV.
Those working in the STI field as health professionals, in non‐governmental organisations and in international agencies should use every opportunity there is to influence those able to initiate change to improve STI control and prevention activities globally. We have the Global Strategy—now it is time for action.
Box 1: Good‐quality STI case management
Comprehensive case management of sexually transmitted infections must have, as a minimum, the following components:
- correct diagnosis
- effective treatment
- health education and counselling for risk avoidance and risk reduction for sexually transmitted infections, including HIV infection
- promotion and provision of condoms, and information on their correct and consistent use
- notification and treatment of sexual partners
Reproduced from World Health Organization,2
Box 2: Priority 1 activities for immediate intervention
- Build on success. Scale up of services for diagnosis and treatment of sexually transmitted infections (use syndromic management where diagnostic resources are limited)
- Control congenital syphilis as a step towards elimination
- Scale up sexually transmitted infection prevention strategies and programmes for HIV‐positive persons
- Upgrade surveillance of sexually transmitted infections within the context of second‐generation HIV surveillance
- Control bacterial genital ulcer disease
- Build on success. Implemented targeted interventions in high‐risk and vulnerable populations
- Implement age‐appropriate comprehensive sexual health education and services
- Promote partner treatment and prevention of reinfection
- Support roll‐out of effective vaccines (against hepatitis B and human papillomavirus and, potentially, herpes simplex virus type 2 infections)
- Facilitate development and implementation of universal opt‐out voluntary counselling and testing for HIV among patients with sexually transmitted infections
Adapted from: World Health Organization,2