Women and Children First: The Impact of Sexually Transmitted Infections on Maternal and Child Health

Street children worldwide do not have the information, skills, health services, and support they need to go through sexual development during adolescence. This study is undertaken to systematically investigate the fit between street children’s sexual and reproductive health needs and the existing services. A cross-sectional study was conducted among 422 street children and four service providers. About 72.5% of the respondents were sexually active during data collection and 84.3% of males and 85.7% of females tended to have multiple sexual partners. More than two-thirds (67.3%) of the participants had used at least one type of substance. History of substance use (OR = 2.5; 95% CI = 1.42–4.56) and being on the street for the first one to three years (OR = 5.9; 95% CI = 1.41–7.22) increased the likelihood of having sexual activity. More than half (64.9%) of the street children did not attend any kind of sexual or reproductive health education programs. Lack of information on available services (26.5%) was the biggest barrier for utilization of local sexual and reproductive health services. From the individual interview with coordinator, the financial and networking problems were hindering the service delivery for street children. In conclusion, street children who are special high risk group have not been targeted and hence continue to remain vulnerable and lacking in sexual and reproductive health services and sexual health services are poorly advertised and delivered to them. Background . Despite the availability of rapid diagnostic tests and inexpensive treatment for pregnant women, maternal-child syphilis transmission remains a leading cause of perinatal morbidity and mortality in developing countries. In Haiti, more than 3000 babies are born with congenital syphilis annually. Methods and Findings . From 2007 to 2011, we used a sequential time series, multi-intervention study design in fourteen clinics throughout Haiti to improve syphilis testing and treatment in pregnancy. The two primary interventions were the introduction of a rapid point-of-care syphilis test and systems strengthening based on quality improvement (QI) methods. Syphilis testing increased from 91.5% prediagnostic test to 95.9% after ( 𝑃 < 0.001 ) and further increased to 96.8% ( 𝑃 < 0.001 ) after the QI intervention. Despite high rates of testing across all time periods, syphilis treatment lagged behind and only increased from 70.3% to 74.7% after the introduction of rapid tests ( 𝑃 = 0.27 ), but it improved significantly from 70.2% to 84.3% ( 𝑃 < 0.001 ) after the systems strengthening QI intervention. Conclusion . Both point-of-care diagnostic testing and health systems-based quality improvement interventions can improve the delivery of specific evidence-based healthcare interventions to prevent congenital syphilis at scale in Haiti. Improved treatment rates for syphilis were seen only after the use of systems-based quality improvement approaches. Objectives . To assess the prevalence and determinants of herpes simplex virus type 2 (HSV-2) infections among pregnant women attending mobile antenatal health clinic in rural villages in Mysore Taluk , India. Methods . Between January and September 2009, 487 women from 52 villages participated in this study. Each participant consented to provide a blood sample for HSV-2 and HIV testing and underwent an interviewer-administered questionnaire. Results . HSV-2 prevalence was 6.7% (95% confidence interval (CI) 4.4–9.0), and one woman tested positive for HIV. The median age of women was 20 years and 99% of women reported having a single lifetime sex partner. Women whose sex partner traveled away from home had 2.68 (CI: 1.13–6.34) times the odds of being HSV-2 seropositive compared to women whose sex partner did not travel. Having experienced genital lesions was also associated with HSV-2 infection ( 𝑃 value = 0.08). Conclusion . The 6.7% HSV-2 prevalence was similar to results obtained in studies among pregnant women in other parts of India. It appeared that most women in this study contracted HSV-2 from their spouses and few regularly used condoms. This finding highlights the need for public health policies to increase awareness and education about prevention methods among women and men living in rural India. We evaluated the integration of rapid syphilis tests (RSTs) and penicillin treatment kits into routine antenatal clinic (ANC) services in two rural districts in Nyanza Province, Kenya. In February 2011, nurses from 25 clinics were trained in using RSTs and documenting test results and treatment. During March 2011–February 2012, free RSTs and treatment kits were provided to clinics for use during ANC visits. We analyzed ANC registry data from eight clinics during the 12-month periods before and during RST program implementation and compared syphilis testing, diagnosis, and treatment during the two periods. Syphilis testing at first ANC visit increased from 18% (279 of 1,586 attendees) before the intervention to 70% (1,123 of 1,614 attendees) during the intervention ( 𝑃 < 0.001 ); 35 women (3%) tested positive during the intervention period compared with 1 ( < 1%) before ( 𝑃 < 0.001 ). Syphilis treatment was not recorded according to training recommendations; seven clinics identified 28 RST-positive women and recorded 34 treatment kits as used. Individual-level data from three high-volume clinics supported that the intervention did not negatively affect HIV test uptake. Integrating RSTs into rural ANC services increased syphilis testing and detection. Record keeping on treatment of syphilis in RST-positive women remains challenging. Background. Children of HIV patients are a historically neglected demographic by HIV services. It has been recommended by CHIVA that HIV services have a robust method of detecting and testing untested children. We note that no such method is either in widespread use or in the literature. Method. In December 2011, a one-page proforma to identify HIV untested children and a clear multidisciplinary pathway to test them were implemented. Twelve months later the uptake of the proforma and pathway, the numbers of patients and children identified for testing, and their outcomes were audited. Results. The proforma was completed in 192/203 (94.6%) eligible patients. Twenty-five (21.5%) of 118 identified offspring had not been tested. Ten (8.5%) of these were < 18 years old. All were reported to be clinically well. Ten children were referred for testing, seven were tested immediately, and three were tested within 18 months of identification. All children were tested HIV negative. Discussion. We have identified a method of identification that is easy and robust and provides a user-friendly safety net to empower healthcare providers to identify and test children at risk. We recommend the implementation of such strategies nationwide to prevent death due to undiagnosed HIV in children. Background . We describe a one-year evaluation study comparing SCIL intervention of mobile provision of integrated ANC/ HIV testing with an enhanced (SCIL+) intervention of community mobilization strategy providing conditional cash transfers (CCT) to women’s SHG for identifying and accompanying pregnant women to mobile clinics. Methods . Twenty pairs of villages matched on population, socioeconomic status, access to medical facilities, and distance from Mysore city were divided between SCIL and SCIL+ interventions. The primary study outcome was the proportion of total pregnancies in these villages who received ANC and HIV testing. Results . Between April 2011 and March 2012, 552 pregnant women participated in SCIL or SCIL+ interventions. Among women who were pregnant at the time of intervention delivery, 181 of 418 (43.3%) women pregnant at the time of intervention delivery received ANC in the SCIL arm, while 371 of 512 (72.5%) received ANC in the SCIL+ arm ( 𝑃 < 0.001 ); 175 (97%) in the SCIL and 366 (98.6%) in the SCIL+ arm consented to HIV testing ( 𝑃 < 0.001 ). HIV prevalence of 0.6% was detected among SCIL clinic, and 0.9% among attending SCIL+ clinic attendees. Conclusion . Provision of CCT to women’s microeconomic SHG appears to significantly increase uptake of ANC/HIV testing services in rural Mysore villages.

In 2000, all 189 Member States of the United Nations (UN) adopted the UN Millennium Declaration, committing them to pursue eight measurable targets, the Millennium Development Goals (MDGs) [1,2] to be achieved by 2015. The MDGs were intended to: (1) eradicate severe poverty and hunger; (2) achieve universal primary education; (3) promote gender equality and empowerment of women; (4) reduce child mortality; (5) improve maternal health; (6) combat HIV/AIDS, malaria, and other infectious diseases; (7) ensure environmental sustainability; and (8) develop a global partnership for development. The unprecedented effort required to achieve the MDGs addresses issues and conditions especially relevant to the health and survival of women-particularly mothers-and infants, children, and youth. Despite calls for universal access to reproductive and sexual health, no MDG addressed these issues, which are critical to maternal and child health and remain neglected [3].
The MDGs proposed dramatic reductions in, or elimination of, scourges that have plagued humankind since its beginnings including severe poverty, famine, and pregnancyrelated mortality as well as one emerging infectious disease, human immunodeficiency virus (HIV) infection, only recognized in the last decades of the 20th century, which was singled out for particular attention [1,2]. Arguably, never before has elimination of the inequalities at the root of these scourges been articulated even as a possibility, let alone as goals to be urgently pursued. But without an MDG focused on reproductive health, progress on this issue relies on its being buoyed by efforts towards addressing the eight MDGs. Progress towards achievement of MDG indicators has been impressive; some (such as the halving of the number of people living in extreme poverty) were achieved before 2015 [4]. Others, including reduction of HIV mother-to-child transmission to less than 2% [5], are either on schedule or achievable by 2016-2017. Much, however, remains to be done.
It is in that context that the disproportionate and largely preventable toll that sexually transmitted infections (STIs) exact on women, including mothers, and infants, children, and youth, is reexamined. Women, particularly adolescent women, are especially vulnerable to STIs due to, among other factors, a larger exposed mucosal surface area, hormonal effects, changes in the protective female genital tract microflora, and the intermittent presence of ectopy, especially in adolescence [6][7][8]. These groups are also at increased risk due to sexual partnerships with older men, little power over when, where, and how sex occurs, and other social and cultural factors. However, poverty, neglect, and inequality drive much of the increased risk of women and children. The impact of STIs on maternal and child populations is greatest in low-and middle-income countries, where over 75% of STIs reportedly occur [9,10]. Within these countries and in underserved populations in industrialized countries STIs continue to disproportionately impact the most disadvantaged women and children [11,12].
This issue of the Journal of Sexually Transmitted Diseases offers heartening news about emerging tools for elimination of the impact of these illnesses and reminders that we struggle against formidable forces. Control of the worst outcomes of STIs in low-and middle-income countries is achievable [13]. Moreover, the elimination of mother-to-child transmission of syphilis and HIV infection is clearly attainable; the global commitment to elimination is based on compelling evidence that their elimination is not only possible, but also cost effective and essential to the health of their mothers [14][15][16]. But unlike the case with smallpox eradication, as long as HIV and Treponema pallidum infections exist in the human population-and they will-the threat of motherto-child transmission remains a possibility [17]. Similarly, as long as orphaning, poverty, neglect, and abuse drive children and youth to homelessness and life in "the streets" in urban settings worldwide, their vulnerability to coerced and unprotected consensual sex, as well as resultant STIs and their sequelae, will continue to be considerable [18,19].
The papers in this special issue document the tragic circumstances endured by street children in Ethiopia, the elevated risk of herpes simplex virus type 2 infection among monogamous women in India associated with their husbands' work-related travel, and innovations and challenges in the progress towards congenital syphilis elimination in Haiti and Kenya, and HIV mother-to-child transmission in India. The report from the United Kingdom describes the efforts to reach out to the population of children born to HIVinfected parents who even in high-resource environments, while at extraordinarily high risk of perinatally acquired HIV infection and orphaning, often remain invisible, untested, and underserved.
At first glance, these reports appear to be a potpourri of glimpses of the impact of STIs on the health of mothers, infants, and youth. But, in fact, they illustrate both the complex forces that sustain the persistent problem of STIs in these populations and innovative, multilevel approaches that have already resulted in progress towards elimination. The recommendations set forth in the mixed methods study to support street children in Ethiopia may seem painfully obvious but, worldwide, street children are often viewed as a public nuisance or a law enforcement issue; the tragic stories told in the focus groups illustrate how utterly at the mercy of predatory forces these youth really are [18]. Similarly, creating work opportunities for men in rural communities that do not result in long separations of stable couples may reduce the risk of STIs not only in India, where this risk is particularly well documented, but also worldwide as a critically important aspect of global development efforts [20].
The development and implementation of simple point-ofcare testing for syphilis have contributed to the identification of infected women in some of the most challenging environments on earth [21][22][23]. Similarly, innovative processes for dramatically expanding access to prenatal HIV testing and timely initiation and continuation of combination prenatal antiretroviral therapy are being successfully implemented in the most impacted populations in the world [24,25]. Nevertheless, it is clear that in efforts to eliminate congenital syphilis there are no "magic bullets. " The cascade from antenatal care availability and use, point-of-care testing, and treatment with benzathine penicillin for the pregnant woman and, ideally, her partner is very effective but often fragile; "systems improvements" that consistently guarantee and monitor response to treatment of 100% of infected women can be elusive. The use of cash incentives to microcredit women's groups based on villagers' antenatal care attendance and provision of mobile health care were associated with a dramatic increase in antenatal care enrollment and, as a result, prenatal HIV testing. In nations with large HIV epidemics, conditional cash transfers [26,27] may contribute to elimination of mother-to-child transmission. The success of case finding for children of HIV-infected parents in the United Kingdom is encouraging to all who understand that, worldwide, HIV-infected parents are often underserved and face daunting problems, and their children are an often hidden and neglected population. Identifying and providing quality services to HIV-affected families remain challenges that are increasingly recognized and addressed [28][29][30].
These reports highlight challenges, possible solutions, and inspiring successes that worldwide promise the possibility of eliminating the most devastating consequences of STIs for mothers, children, and youth. The slogan "women and children first" inspired an impressive array of reports describing approaches that may help achieve the MDG vision of a fairer, safer world for mothers, children, and youth.

Consuelo Beck Sagué Carolyn Black Stephen A. Morse
George Schmid