Program issues in delivering targeted STI services through the public sector in the Greater Mekong region

This review discusses the delivery of targeted STI services for both female sex workers (FSWs) and other high-risk groups through the public sector in the Greater Mekong region. Vaginal discharge algorithms for the general population are also discussed. High STI rates that justify targeted interventions have been reported recently amongst FSW in Cambodia, Lao PDR and Vietnam. Such interventions need to take into account the different patterns of sex work in the three countries. In Cambodia, there are large numbers of brothel-based FSWs although this pattern is changing as more brothels are closed by the authorities. In Lao PDR, services targeted towards reducing the burden of HIV/STI in FSW/service women are probably best delivered through NGO-led clinics. In Vietnam, commune based district health centers appear to offer better services for FSW than STI clinics. Male clients of FSW are an important group to target, but reaching such a heterogeneous population is difficult. Provision of quality STI drugs to those places where men present with STI symptoms should be a priority. The optimal way to manage STIs in FSWs is still unclear in this region. Clinical and laboratory specialists are keen to promote laboratory tests for STIs but there is an over reliance on direct staining techniques. In areas with high STI prevalences, periodic presumptive treatment could offer an effective option to reduce STI levels in high-risk groups until syndromic management algorithms are evaluated for local use. Social patterns of sex work are changing continually and require close monitoring in the future so that services can be adapted to these changes.