MINI PROJECT – CNCD

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DR. HAMMAD HABIB

ROLL NO. 07
MSPH 2009 – HSA ISLAMABAD

STDs IN
COMMERCIAL SEX
WORKERS
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PRESENTATION FORMAT:
INTRODUCTION

BURDEN OF DISEASE

STRATEGIES

BUDGET & GANTT CHART

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INTRODUCTION

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 STI
“Sexually transmitted infections (STIs) are
infections that are spread primarily through
person-to-person sexual contact.”1

30 different sexually transmissible bacteria,

viruses and parasites have been found. Many
of them including HIV and syphilis, can also be
transmitted from mother to child during
pregnancy and childbirth, and through blood
products and tissue transfer.1

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Dr. Hammad Habib (CNCD)
 SEXUALLY TRANSMITTED DISEASES

VIRAL
BACTERIAL AIDS PROTOZOA
HSV
Syphilis Warts
Trichomoniasis
Human papillomavirus
Gonorrhea (HPV) Candida albicans
Chancroid Hepatitis B virus
Cytomegalovirus

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 Commercial sex workers
“A sex worker is a person who works in the sex industry,
specifically, a person who commercially trades in sex or sexual
stimulation.”2
Some sex workers are paid to engage in sexually explicit
behavior which involve varying degrees of physical contact with
clients (prostitutes, escorts, dominatrices); pornography models
and actors engage in sexually explicit behavior which are filmed
or photographed.
Other sex workers are paid to engage in live sexual
performance, such as web cam sex and phone sex and
performers in live sex shows.3

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MAIN SYNDROMES OF COMMON STDs

Urethral discharge
Genital ulcers
Inguinal swellings Scrotal swelling
Vaginal discharge
Lower abdominal pain
Neonatal eye infections
(conjunctivitis of the newborn)
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SYPHILIS
Is a systemic and highly
infectious STD that usually
begins with mucous membrane
and quickly becomes systemic.
“bad blood ,” pox, lues, or a
“zipper cut”
Treponema pallidum
– spirochete

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Syphilis cont . . .
Syphilis is caused by a bacteria
Incubation Period: 10-90 days (average 21 days)
Can cause infections in men, women, and unborn babies during
pregnancy
SUSCEPTIBILITY: Universal
No natural immunity
OCCURRENCE: Widespread
Primarily involving young persons between 15 – 34 yrs
More prevalent in urban than rural areas
M>F
High prevalence among male homosexuals

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Syphilis cont . . .
Direct Contact-
– infectious exudates from moist early lesions of skin and
mucous membrane, body fluids and secretions
– Blood Transfusion
– Transplacental Transfer syphilis neonatorum
Indirect Contact
– Health Professionals developed primary lesions on
hands after examination of infectious lesions
STAGES OF SYPHILIS:
•PRIMARY SYPHILIS
•SECONDARY SYPHILIS
•TERTIARY SYPHILIS

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 Testing & Treatment for Syphilis
Easily detected by a blood
test; and

Easily cured with

antibiotics;

Any damage done to the

body cannot be repaired.

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 GONORRHEA
Gonorrhea is sometimes called clap, drip, dose, strain, gleet or the
whites

Incubation period: 1 – 14 days

A bacteria causes gonorrhea

Can cause infections in men, women, and new babies

The person can easily pass it on to sex partners and babies during
childbirth

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Gonorrhea Symptoms in Men
Discharge from the penis (may be thick,
milky white, yellowish, or greenish)
Burning on urination

Complications in Men
Swollen or tender testicles (epididymitis)
Disseminated gonococcal infection (DGI)

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Gonorrhea Symptoms in Women
Usually asymptomatic
Painful urination
Abnormal vaginal bleeding
Pain during sex

Complications in Women
Bartholin’s Abscess
Pelvic inflammatory disease (PID)
Disseminated gonococcal infection (DGI)

Testing & Treatment for Gonorrhea

Easily detected by a urine test or swab; and
Easily cured with antibiotics; but
Any damage to the body cannot be repaired.

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 CHLAMYDIA
Can cause infection in men, women, and newborn babies
Chlamydia is caused by a bacteria
Incubation Period: 2-3 weeks
The person can pass it on to sex partners and to babies
during childbirth

Symptoms in Men:
Usually asymptomatic
Discharge from the penis (may be runny, whitish)
Burning on urination
Complications, if not treated
– Swollen and tender testicles (epididymitis)

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Dr. Hammad Habib (CNCD)
Chlamydia cont . . .
Symptoms in Women:
Usually asymptomatic
Abnormal vaginal discharge
Pain during sex
Complications, if not treated:
– Pelvic inflammatory disease (PID)

Testing & Treatment for Gonorrhea

Easily detected by a urine test or swab; and
Easily cured with antibiotics; but
Any damage to the body cannot be repaired.

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HERPES SIMPLEX VIRUS (HSV)
Genital Herpes
– Causes infection in men, women, and newborns
– Herpes simplex viruses (HSV) cause genital herpes infections.
– Incubation period: 2 – 12 days
– The person can easily pass it on to sex partners and babies
during childbirth

There are 2 types of HSV: HSV-1 and HSV-2.

– HSV-2 causes most genital infections.
– HSV-1 causes oral infections (cold sores, fever blisters) and
some genital infections.

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 Symptoms of Genital Herpes

Numerous painful lesions (sores)

– On the penis, vagina, anus, buttocks, thighs, mouth, or
finger
– Last up to 4 – 21 days
Other symptoms include headache, fever, muscle
aches, swollen lymph nodes, and difficult
urination.
Symptoms may or may not come back.
Testing & Treatment for Genital Herpes
•Can be detected by: culturing the lesion blood test
•Herpes cannot be cured, but symptoms can be treated with
medicines called antivirals.

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 HUMAN PAPILLOMAVIRUS
Many types of Human Papillomavirus (HPV), some of which infect
the genital area
Incubation period unclear
Can infect men, women, and newborns
The person can easily pass it on to sex partners
The types of HPV that infect the genital area are labeled “low-
risk” or “high-risk” depending on whether they can cause cancer
or not.
Low-risk HPV types can cause genital warts.
High-risk HPV types can cause serious cervical lesions, cervical
cancer, and other genital cancers.

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Dr. Hammad Habib (CNCD)
Symptoms of Genital HPV Infection
Usually asymptomatic and brief (6 – 12 months)

Genital warts (usually infection with low-risk type

of HPV)
– Warts on the penis, vagina, anus or urethra
– Rarely may have itching, bleeding, burning, or pain
along with the warts
– May go away on their own, stay about the same, or
get worse

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Symptoms of Genital HPV Infection
Cervical lesions (usually infection with high-risk type of HPV)

– Usually no symptoms
– Detected by Pap smear
– Most will go away on their own
– Some will persist and need to be followed by health care provider
– Most women with high-risk HPV types do not get cervical cancer

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Testing & Treatment for Genital Warts
Genital Warts
– No tests for genital warts
– Several types of treatment are available
– Warts may come back

Cervical lesions and cervical cancer

– Regular Pap smears are best way to detect serious lesions
and prevent cervical cancer
– Pap smear screening is recommended for all sexually active
women

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BURDEN OF DISEASE

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 BURDEN OF DISEASE
In developing countries, STIs and their complications
rank in the top five adult diseases

According to 1999 WHO estimates, 340 million new

cases of curable STIs (syphilis, gonorrhoea,
chlamydia and trichomoniasis) occur annually
throughout the world in adults aged 15-49 years

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 333 Million InfectionsEach year, 11 of every 100 adults worldwide
are newly infected with gonorrhea, chlamydia, syphilis or
trichomoniasis—all curable STDs.

Sources World Health Organization (WHO),

An Overview of Selected Curable Sexually Transmitted Diseases, Geneva: WHO, Global Programme on AIDS, 1995

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 SITUATION IN PAKISTAN
STDs Relatively uncommon among the general
population
Higher prevalence of all STIs among members of high
risk groups
A large study from Karachi and Lahore showed that
syphilis was present in up to 60% of Hijras, 30% of
whom also had anal gonorrhea
Pakistan although is a low prevalence in terms of
HIV/AIDS, the sex industry in Pakistan is changing
rapidly and becoming increasingly complicated with
highly differentiated sub sectors

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The most authoritative studies available from Asia suggest that sex
market is vast and the Pakistan market seems to be increasingly
contributing to the markets in Middle East, Asia as well as to the
demands from London, all under the cover of dancing and singing
troupes.
Commercial sex work in Pakistan is illegal according to the Hadood
Ordinance but mostly going on under the cover of performing art.
Because of its being illegal female sex workers are being subjected to
exploitation by police, pimps and community leaders, therefore, these
groups are need to be involved as target audience.
There has been no effort to get an estimate for total CSWs in Pakistan
and their numbers.

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Commercial sex is widespread in major urban Pakistan cities, on truck
routes, and near labor camps.
Furthermore, the sex workers often lacked the power to negotiate safe sex or
seek treatment for STIs15
Commercial female sex workers don’t use condom regularly. Fewer than one
in five female sex workers—and one in 20 of their male counterparts—in
Karachi and Rawalpindi said they had consistently used condoms during the
previous month

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In a study in Karachi, one in four sex workers could not
recognize a condom

In a latter study, 23% of the male sex workers had

syphilis and 36% had gonorrhoea while among the
hijras, 62% had syphilis and 29% gonorrhoea

Only 4% of male sex workers and less than 1% of the

hijras said they used a condom the last time they had
sex with a man.

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The Ministry of Health reports that from 2006 to 2007, female sex
workers were at a high risk of HIV in 12 cities across Pakistan

A survey of 4,639 female sex workers found that less than 25%
reported condom use

10% had a partner that had used injection drugs during the past
six months

Illiterate sex workers were less likely to use condoms than those
with a higher level of education

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 RTI STUDY (2004)
(Karachi & Lahore)
Karachi Lahore
SYPHILIS –
Hijras 62% 36%
MSWs 40% 13%
GONORRHEA-
Hijras 29% 04%
MSWs 18% 03%
CHLAYMEDIA-
Hijras 18% 02%
MSWs o5% 11%

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 % OF FSWS AND MSWS WHO REPORTED ALWAYS USING A
CONDOM WITH THEIR CLIENTS IN THE LAST MONTH, KARACHI
AND RAWALPINDI, 2004-2005

58.1
(%) 60 Karachi Rawalpindi

45

30
19.0 18.3 19.9 18.1 19.1
16.7
14.5 12.0
15 9.1 10.8
8.9 8.3
5.6 4.8
3 2.9 2
0
FSWs FSWs FSWs Female Male sex FSWs FSWs FSWs Female Male sex
Kothi brothel- street- sex workers Kothi brothel- street- sex workers
Khana based based workers Khana based based workers

Paying clients Non-paying clients

Source: NACP, Integrated Behavioral and Biological Surveillance,

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Pilot Study in Karachi and Rawalpindi, 2004-2005
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SOCIAL & DEMOGRAPHIC DETERMINANTS

Socioeconomic context:
– Behaviour
– Health systems
– Political change, etc.
Men-women relationships:
– Migrations
– Working context
– Couples separated during a long period
Age structure / Distribution of the population
Population density

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Determinants cont . . .
Other high risk behaviors are multiple partners,
commercial sex and condom non-use
Most STIs are transmitted from men to women more
readily than they are from women to men
In most circumstances can not control the use of
condoms due to social factors. In fact evidence from
India suggests that being married is a significant risk
factor for HIV acquisition for many women

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PROJECT

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AIM OF THE PROJECT:
Reduction in mortality and morbidity related to
sexually transmitted diseases in Pakistan.

OBJECTIVE:
To reduce incidence of STD in commercial sex
workers by 80% within three years in Pakistan

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 EXISTING POLICY AND STRATEGIES:
GLOBAL: (WHO – MAY 2006)
Since 1990 WHO has recommended a syndromic approach to diagnosis and
management of STIs
General access to quality condoms at affordable prices
Promotion of early recourse to health services
Inclusion of STI treatment in basic health services
Specific services for populations with frequent or unplanned high-risk sexual behaviours
Proper treatment of STIs
Screening of clinically asymptomatic patients, where feasible
Provision for counselling and voluntary testing for HIV infection, congenital syphilis and
neonatal conjunctivitis

Involvement of all relevant stakeholders

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 NATIONAL GUIDELINES
Pakistan has produced quality guidelines for the
management of STIs for a number of years
The syndromic approach has been tested and
found reliable in a variety of settings the World
over
The 4Cs –
– Compliance, Counseling, Condoms and Contact
(Partner) Management (with follow-up within 7 days)
Familiarity with local terms of the symptoms

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The 5 Ps Help To Assess The Risk
Of Patients
Partners

Prevention of Pregnancy

Protection from STIs

Practices

Past history of STIs

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 Limitations of the Syndromic approach
Works better for male STIs
Female algorithms work better in high risk settings
No algorithms for anal symptoms
Syphilis management which requires testing is not well addressed by these
guidelines.6
Other problems such as
(i) lack of political will due to lack of advocacy
(ii) inadequate data due to limited surveillance
(iii) lack of awareness in the rural areas
(iv) no clear policy on care and support of affected individuals
(v) no proper training for all HCPs
The majority activities were concentrated in the urban areas.

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 EXISTING PROJECTS

NATIONAL AIDS CONTROL PROGRAM (NACP)

NATIONAL HEPATITIS CONTROL PROGRAM (NHCP)
DEPARTMENT FOR INTERNATIONAL
DEVELOPMENT (DFID)
FAMILY HEALTH INTERNATIONAL (FHI)
WORLD BANK
UNAID
WHO
NGOs

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 NEW PROJECT > > >
Currently managed by NACP
Excellent guidelines
Limitations and obstacles

STAFF REQUIRED:
Sustainability guaranteed only if majority of existing staff & resources are utilized
New staff for new health clinics including public health professionals / epidemiologists
Existing staff especially LHS/ LHW etc
Community / social mobilizers
Not a vertical program . . .

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 PROJECT STRATEGIES
Baseline initial survey will be done
Registration ? ? ? (For getting actual data)
Mapping of CSW will be done all over Pakistan
Health education sessions (General / Specific) for CSW will be conducted
Peer counseling / peer education approach will be adapted
CSW committee will be made on local site
Ownership & honor ship will be given to CSW
Separate new health clinics will be made in the nearest possible location
for CSW with affordable & preferably free treatment & management

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Strategies cont . . .
Social mobilization will be done
Media campaigns, seminars & workshops will be held for capacity
building
Role models & success stories will be taken for practical examples
Confidentiality & secrecy will be strictly maintained
Social & political will be improved with advocacy and media help
Screening (mandatory) will be ensured for all CSW free of cost
Increased transparency in surveillance for true data
Religious & cultural constrains will be considered especially
Legislations ? ? ?
Outreach activities for highlighting issue importance within communtiy
Building local HCP capacities (Trainings & workshops) will be done

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Strategies cont . . .
Public – Private partnership will be made
Ensuring excellent hygienic practices among CSW (free soaps
& towels supply)
Involvement of epidemiologists on regular basis by hiring him
Communication channels will be made for bringing behavior
change (downstream & upstream)
Scale of services ? ?
Scale of locations ? ?
Getting to the majority of people (preferably all) ? ?

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 Further suggestions
(According to sex worker)
Sex workers should have greater involvement in creating and
implementing HIV programs.
There should be vocational training and the means for
alternative work opportunities for those who want to move out
of sex work, as well as those who are past their prime and do
not find sustainability in sex work.

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 OBSTACLES
Focus on Public sector for treatment
Private GPs very busy
STI management not part of medical
school curricula
PROBLEMS FOR TREATMENT
– Most pts with STI do not go to public sector
– Lack of time on behalf of HCPs
– Counseling - - - BCC ???

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EVALUATION, BUDGET
& GANTT CHART

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 EVALUATION
INDICATORS
PROCESS OUTCOME
1. # of CSW coming to OPD for 1. % of STDs cases
checkup
2. # of CSW screened 2. % of deaths due to STDs
3. # of literature distributed 3. etc

4. # of condoms distributed

5. # of medicine distributed

6. # of HE sessions held

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BUDGET DISTRIBUTION FOR 3 YEARS
TOTAL % % Allocated Remaining %

1st Year 100 40 60

2nd Year 70 30 30

3rd Year 30 30 00

Note: Initial budget subdivision will be for 1 year. At the end

of 1st year, next year budget will be subdivided .
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 GANTT CHART
1st YEAR
WBS Tasks Start End Duration % !st quarter 2nd quarter 3rd quarter 4th quarter
(Day Co
s) mp
let
e

1 PLANNING 3
2 BUDGET ALLOCATION 2

3 MEETING WITH HEALTH STAFF 3

4 MEETING WITH OTHER DEPT 4

5 MOU 2
6 POSTS ADVERTISEMENT 10

7 RENOVATION OF BUILDINGS 10

8 RECRUITMENTOF STAFF 10

9 PURCHASING 10
10 PRINTING / TRAINING MANNUALS 12

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 GANTT CHART
11TRAINING (PHASE1) 5

12TRAINING (PHASE 2) 10

13TRAINING (PHASE 3) 10

14EVALUATION 5

15PILOT TESTING 5

16PROJECT LAUNCHING CEREMONY 5

17REGISTRATION OF CSW 12

18REGISTRATION COMPLETES 12

19HE SESSIONS START

20HANDING OVER TO LOCAL CLINCS 7

21MASS MEDIA COMPAIGN STARTS

22FACILITIES SERVICES START

23DISTRIBUTION OF MEDICINES

24ACTIVE MONITORING

25PASSIVE MONITORING

26REFRESHER COURSES (2 DAYS)

27END YEAR EVALUATION

28PROJECT 1 YEAR COMPLETION CEREMONY

29REPLANNING FOR NEXT YEAR

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 THANKS
EXCUSE FROM <18

ACKNOWLED-
QUESTIONS??
-GEMENT

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