Development of the Prevention and Control Program for STDs in Thailand

1. Development of the Prevention and Control Program for STDs in Thailand Dr. Pachara Sirivongrangson Acting Director, Bureau of AIDS,TB and STIs MOPH, Bangkok

2. Disorder and infectious agents associated with sexual transmission • Gonorrhea, nongonococcal urethritis, syphilis, chancroid, lymphogranuloma venereum, granuloma inguinale • Candidiasis, trichomoniasis, genital herpes, genital warts, molluscum contagiosum, pubic lice, scabies, cytomegalovirus infection, viralhepatitis B,viralhepatitis C, HIV

3. HIV/AIDS situation in Thailand

4. HIV/AIDS situation in Thailand 0.22% 1.01%

5. Sexual experiences among high school students % Ever had sexual intercourse Median age = 17 yrs Source: Bureau of Epidemiology, MOPH

6. Types of sex partner among male high school students % Sex partners in the past 12 months Source: Bureau of Epidemiology, MOPH

7. Condom use in the past 12 months among male high school students Always use % Median age = 17 yrs Source: Bureau of Epidemiology, MOPH

8. Condom use in the past 12 months among female high school students Always use % Median age = 17 yrs Source: Bureau of Epidemiology, MOPH

9. Condom use at first sex and last sex among male students % Median age = 17 yrs Source: Bureau of Epidemiology, MOPH

10. Risk Behaviors • 1. Number of partners • 2. Rate of new partner acquisitions • 3. Casual partners • 4. sexual orientation • 5. Sexual practice • 6. Use of barrier contraception

11. Other risk factors 1.Age 2.Gender 3.Marital status 4.Ethic origin or religion 5.Rural or urban residence 6. Alcohol 7. Drug abuse 8. Circumcision status 9. Contraceptive methods

12. Ethical consideration in STD research • Mass STD treatment • Sex worker • Microbicide study • Adolescent • Prisoner • Juvenile detention • Confidential • Sexual behavior (sexual practice, ect) • MSM, TG • IDU • STD Survey

13. STI Control Program • Basic activities of STI prevention activities (for primary and secondary prevention strategies) • Primary infection: prevent new infection • Secondary prevention: prevent complication

14. WHO recommendation for STI control Program Primary prevention measures 1. Health education and promotion of safer sex and risk reduction 2. Promotion of condoms (Wide spread availability and affordability of Condom) 3. Information campaigns on the association between HIV and STI

15. Secondary prevention 1. Promotion of early health care seeking behavior 2. Accessible, effective and acceptable care -Integration of STD care into all basic health care facilities

16. Secondary prevention 3. Promotion of early use of health care services ( STD patients and their partners) • 4.Early detection and treatment of asymptomatic infections through case finding • Screening for asymptomatic patients • eg, SY serology in pregnant women, CT tests in CSWs

17. General Determinants of STI transmission in population

18. Basic model for the reproductive rate of new infection in a population R0 = Dc • Basic reproductive rate (Ro): • represents the average number of secondary cases that arise from any new case of infection. If Ro >1, the infection will spread. • Average of likelihood of transmission of the disease pathogen () • Average rate of exposure of susceptible to infectious people in the population (C) • Average duration of infectiousness (D)

19. Intervention points according to the determinants of STI transmission Exposure of a susceptible person C  Intervention point Acquisition of infection Persistence and infectivity of infection D

20. Intervention that reduce exposure to STI (C) • Target on determinants of Sexual behavior • Potential activities: • Promotion of delayed initiation of sex among youth adolescents, abstinence, monogamy, reduce rates of sex partner change, avoidance of concurrent sexual partnerships • Clinic level Health education for risk reduction • Community-level interventions to modify community norms toward less acceptance of specific, high-risk behaviors. • School Health education program

21. Intervention that could shorten duration of infectivity (D) • Active case finding through widespread access to acceptable and good quality clinical care, screening, and contact tracing • Prompt and effective diagnosis and treatment for symptomatic persons • Clinical practice guideline (emphasis on syndromic or rapid test) • Screening practices for asymptomatic infection • Promoting awareness among potentially infected persons (having symptom of STI) • “Epidemiologic treatment” selective mass treatment • Outbreak investigation (rare disease)

22. Intervention that reduce efficacy of STI transmission during sexual exposure () • Increase consistence and correct use of barrier contraceptive methods • (eg, condom, spermicides) • Decrease specific risky sexual practices • (eg, penetrative sex) • Vaccine • Hepatitis B • HPV

23. Risk Behaviors • 1. Number of partners • 2. Rate of new partner acquisitions • 3. Casual partners • 4. sexual orientation • 5. Sexual practice • 6. Use of barrier contraception

24. Health Care Behaviors • Willingness to seek medical treatment • Referral of partners • Compliance with therapy • Vaginal douching • Choice of health care

25. Other risk factors 1.Age 2.Gender 3.Marital status 4.Ethic origin or religion 5.Rural or urban residence 6. Alcohol 7. Drug abuse 8. Circumcision status 9. Contraceptive methods

26. Why STI need to be given priority (WHO new global strategy: 2006-2015) • Global estimation: 340 million new cases of syphilis, gonorrhoea, chlamydia and trichomoniasis occur in men and women aged 15–49 • Overall, STI prevalence rates continue to rise in most countries, including developed countries. • Many STIs can have severe long-term consequences (infertility, ectopic pregnancy ect) • In unborn and newborn children, STI can produce serious and often life-threatening conditions, such as congenital syphilis, pneumonia and low birth weight. • STIs amplify the risk of HIV transmission • HPV is a proven precondition for the development of carcinoma of the cervix

27. WHO: Specific actions proposed in the new global strategy (2006-2015) • Scaling-up of STI diagnosis and effective treatment using syndromic management and/or laboratory testing to more than 90% of primary point-of-care sites • Expansion of point-of-care testing and treatment of syphilis in pregnancy to over 90% of women attending antenatal care services • Implementation of enhanced national programmes of second-generation HIV surveillance, which includes STI biomedical and behavioural surveillance • Implementation of targeted interventions that address populations at higher risk of STIs (including provision of STI services to persons living with HIV) • Provision of services to improve young people’s knowledge and skills for infection prevention by providing age-appropriate comprehensive sexual health education and services

28. (WHO) The global strategy: enabling interventions (National level) • Increase the commitment of national governments, policy-makers, national and international partners for STI prevention and control • Advocate for resource mobilization and reallocation of resources to be focused on priority programmatic areas where they are likely to have the greatest impact • Promote policies, laws and initiatives on STI control that support non-stigmatizing, culture- and gender-sensitive STI programmes and services. • Harness the strengths and capacities of all partners and institutions in order to scale up and sustain interventions for STI prevention and control

29. Public health systems for implementing STI Prevention • Health promotion and behavioral intervention • Clinical and laboratory services • Partner services • Outbreak response • Surveillance, information systems, and epidemiologic analysis • Professional training • Research and evaluation • Leadership and management

30. STI services

31. Vertical program and horizontal program Advantage Vertical (STI Clinic) Horizontal (general care) -Well equipped clinic -Well train staff -Good diagnostic services -More accessible -Used more by women -Less stigmatizing

32. Disadvantage Vertical Horizontal - Access often restricted for much of population - Stigmatizing - Expensive • - Quality of patient care can be variable • - Overwork and poorly trained staff • Poor diagnostic services • Limited drugs

33. Good quality care and management - appropriated drug (efficacy, low cost) - education - counseling - treatment of sexual partners Treatment: rely on - efficacy - acceptability - low cost - antibiotic resistance considerations

34. Partner notification Partner management - epidemiology treatment - Laboratory diagnosis (if available) - education and counseling

35. Targeted interventions • There are now many well-known mature projects around the world that focus on providing STI services to sex workers, MSM and injecting drug users. • STI services for these and other high-risk population groups need to be scaled up universally, making them a regular component of primary and sexual and reproductive health care.

36. Intervention in Commercial Sex workers

37. Definition of sex work: A person (women, man,or child) who exchanges sexual services for an immediate cash or in-kind return.

38. The Roles of Sex Workers and their clients in the Epidemiology and control of STD • Basic reproductive rate > 1 (Ro) • Transmission efficiency of the disease pathogen () • Rate of partner change (C) • Average duration of infectiousness (D) R0 = Dc

39. Risk determinants CSW; Risk behaviors • - Number of partner • Rate of new partner acquisition • Use of barrier contraception No. of Clients/night Condom use

40. Control of STI among CSWs and their clients • Intervention Strategies • 1.Directed at sex work: • Criminalizing prostitution • Penalizing clients of prostitution • Regulating legalized prostitution • Reducing the supply of prostitutes • Reducing the demand of prostitutes Legal approaches

41. Control of STI among CSWs and their clients • Intervention Strategies (cont’) • 2.Directed at reducing STI transmission: • STD prevalence in sex worker • STD transmission from CSW to clients and from clients to sex worker

42. Development of Control Programs • No single blue print exists • The approach will vary with the country, social, culture, legal system, dynamics of sex work, and resources available.

43. People are better motivated when they feel that are acting for themselves rather than in response to external authority

44. programs -Unstigmatized access to health care -Convenient -Constant communication with participants: Listening to their concerns and informing them of program results

45. Difficulties • Convincing decision makers of the need • Identifying sex workers and clients

46. Program sustainability and success • Continuing political and financial support • Effective program planning, management, monitoring, and evaluation skills

47. STI services for CSW • Periodic health checkup • Clinic (government, private) • Mobile Clinic • Effective treatment ( MININUM OR FREE OF CHARGE) • Individual • Mass treatment

48. Other services • In clinic health education • Outreach health education • Psychosocial support • Occupational training opportunities • Counseling for risk reduction

49. Thailand experiences in STI Prevention and control

50. Surveillance systems