Medical, Social, and Organizational Aspects of Implementing Territorial Programs for the Prevention of Sexually Transmitted Infections (STIs)

The dissertation examines the medical, social, and organizational aspects of implementing territorial STI prevention programs in the Ryazan Region. It analyzes trends and patterns in STI morbidity, the organization of case detection and prevention, and the effectiveness of targeted comprehensive programs and pilot projects.

Particular attention is paid to risk factors for STI infection among socially adapted and socially disadvantaged youth groups, including students in Grades 10 and 11, conscription-age young men, adolescent patients of a narcological dispensary, and adolescent girls serving sentences in a correctional colony. The results are intended to improve the effectiveness of preventive measures, optimize prevention in high-risk groups, and increase awareness among young people.

Relevance of the Study. The widespread occurrence of sexually transmitted infections (STIs) is one of the most urgent problems not only of public health but also of Russian society as a whole. Thus, during 1995–2003, between 1 million and 1.2 million patients with STIs were identified each year in the Russian Federation.

During the epidemic upswing, the incidence of syphilis in Russia increased 52-fold; the maximum rate, 276.1 per 100,000 population, was recorded in 1997. Against this background, the share of adolescent syphilis patients in the age structure of patients increased (to 7%), as did the incidence of disease among children aged 13–14 years at an accelerated pace. The incidence of early congenital syphilis has remained consistently high. More than 400,000 patients with trichomoniasis are identified annually in the country. The incidence of gonorrhea among the population is in the range of 108.2–138.4 cases per 100,000 population.

A characteristic feature of the contemporary period is a marked change in the structure of STIs. Alongside a certain decline in syphilis incidence, there is a substantial increase in infections of the 'new generation,' among which chlamydiosis is most common (115.5–126.1 per 100,000 population).

Persistent problems in organizing the detection of STI patients result in the registration of only the 'tip of the iceberg.' Persons with the disease often do not seek medical care in the initial stage and engage in self-treatment. Questions concerning full control over the activities of privately practicing organizations involved in the diagnosis and treatment of STIs cannot yet be regarded as resolved (A. A. Kubanova, Yu. K. Skripkin, 2001). During the past years, the proportion of the population covered by various types of preventive medical examinations has declined significantly, and purposeful moral and sexual education of the younger generation is not being conducted (I. V. Kalmykova, 2000; Yu. S. Pevzner, 2000).

Social and economic reforms carried out in Russia and changes in the legislative framework have brought radical changes to the life of society. As a result, the former model of STI prevention, which had included strict control over sources of infection and compulsory treatment, can no longer be used in its previous form (N. G. Filippova, 1998; I. O. Malova, 2000; L. I. Tikhonova, 2002).

In contemporary conditions, the problem of preventing STIs can be addressed only on the basis of a comprehensive approach involving targeted measures and taking into account the socioepidemiological features of disease spread (O. E. Konovalov, M. V. Baev, 2001; N. V. Luzan, 2003).

Given the existing shortage of budgetary funding for healthcare, targeted comprehensive STI prevention programs are the most optimal mechanism for implementing the relevant measures. This approach, which entails identifying key risk factors and concentrating organizational measures and budgetary resources on eliminating them, has been successfully implemented in the United States, the United Kingdom, and other countries.

However, despite the considerable scientific and practical significance of the problem, domestic literature shows a clear shortage of studies devoted to developing conceptual approaches to organizing measures to prevent STIs under contemporary socioeconomic conditions and using the experience of implementing targeted comprehensive programs.

This dissertation study was conducted as part of the Republican Scientific Program 'Public Health and Healthcare' in accordance with the research plan of Ryazan State Medical University named after Academician I. P. Pavlov (state registration no. 01200202320).

Objective and Tasks of the Study.

The objective of the study was to develop scientifically grounded proposals for improving the effectiveness of the STI prevention system through the implementation of targeted comprehensive programs.

In accordance with this objective, the study addressed the following tasks: to examine the dynamics of the prevalence of STIs and identify the 'core' risk groups among the population (using the Ryazan Region as a model); to conduct a social-hygienic assessment of the operative risk factors for STI infection; to evaluate the effectiveness of the implementation of targeted comprehensive programs and pilot projects for STI prevention; and to determine conceptual approaches to organizing STI prevention under contemporary conditions on the basis of targeted programs for their prevention.

Scientific novelty lies in the following: for the first time, a detailed sociohygienic characterization of the spread of STIs in various age-sex and socio-occupational groups of urban and rural populations was obtained, the main trends in morbidity from genital infections in one of the typical regions of Central Russia were determined; key groups and risk factors in the spread of STIs in the study area were identified; and new approaches to improving STI prevention under established socioeconomic conditions were scientifically grounded on the basis of targeted programs and pilot projects.

The practical significance of the work lies in the development and implementation of proposals to optimize STI prevention among representatives of the principal risk groups for infection by carrying out additional measures within the framework of targeted preventive programs.

Proposals were developed to raise the level of awareness among young people in educational institutions and young people from socially disadvantaged groups regarding the prevention of STIs.

Implementation of the Study Results in Practice. The materials and recommendations contained in the dissertation found the following practical applications:

1. In conducting training seminars on an integrated approach to the management of patients with STIs and HIV/AIDS for specialists from the countries of the Commonwealth of Independent States (Baku, 2001) (letter from the WHO Regional Office for Europe dated 17.04.2001), as well as a seminar for specialists in HIV/STI control and prevention in the Republics of Ingushetia and Chechnya on the topic 'WHO Policy on the Prevention of HIV/STIs' (Moscow, 2001).

2. In developing the territorial targeted programs 'On Measures to Prevent the Spread of Diseases Transmitted by Sexual Contact (STIs) in the Ryazan Region' (Decree of the Head of the Administration of the Ryazan Region dated 20.10.2000, No. 704) and 'On Preventing the Spread of the Disease Caused by the Human Immunodeficiency Virus in the Territory of the Ryazan Region (Anti-HIV/AIDS) for 2001 and through 2005' (Resolution of the Ryazan Regional Duma dated 25.06.2003, No. 448-III ROD).

3. In developing the joint project of the CDC (Atlanta, United States) and the State Institution 'Ryazan Regional Clinical Dermatovenerological Dispensary,' 'Improving Interaction among Dermatovenereologists, Neonatologists, Pediatricians, and Obstetrician-Gynecologists for the Purpose of Strengthening Prevention of Congenital Syphilis' (letter from the U.S. Centers for Disease Control and Prevention dated 18.09.2003).

4. Practical recommendations for improving the system for detecting and preventing sexually transmitted infections were implemented in healthcare facilities in the Arkhangelsk region (letter from the Healthcare Department of the Administration of the Arkhangelsk Region dated 28.06.2004, No. 01-14/255d), the Astrakhan region (letter from the Department of Healthcare of the Astrakhan Region dated 19.11.2004, No. 271), the Kaluga region (letter from the Ministry of Healthcare and Social Development of the Kaluga Region dated 13.10.2004, No. 04/1575), and the Samara region (letter from the Ministry of Healthcare of the Samara Region dated 22.06.2004, No. 2334).

5. Proposals for optimizing STI prevention in high-risk groups are being used in the practical work of the oblast dermatovenereological dispensaries in Arkhangelsk (implementation act dated 22.06.2004), Astrakhan (9.11.2004), Vladimir (10.11.2004), Irkutsk (17.12.2002), Kaluga (6.10.2004), Pskov (9.11.2004), Ryazan (12.05.2004), and Samara (21.06.2004).

6. In preparing the methodological guidelines 'Congenital Syphilis' (Ryazan, 1999), approved by the Healthcare Department of the Administration of the Ryazan Region.

7. Proposals to raise the level of awareness among young people in educational institutions regarding STI prevention were used in developing the comprehensive program 'Education and Health,' approved by a resolution of the Head of the Administration of the City of Ryazan (April 2000).

8. Materials from the dissertation study are used in the teaching process at the departments of Ryazan State Medical University named after Academician I. P. Pavlov, Kursk State Medical University, Kuban State Medical Academy, and Tver State Medical Academy.

Public Presentation of the Work. The dissertation materials were presented, reported on, and discussed:

• at a conference marking the 60th anniversary of the Department of Dermatological and Venereological Diseases of MGSMU (Moscow, 1999);

• at a jubilee conference marking the 75th anniversary of the Tver Regional Clinical Dermatovenerological Dispensary (Tver, 2000);

• at the VIII All-Russian Congress of Dermatovenereologists (Moscow, 2001);

• at a WHO meeting, 'Prospects for Incorporating Principles of Public Health into the Prevention and Treatment of Sexually Transmitted Infections in Countries of Eastern Europe and Central Asia' (Berlin, Germany, 2001);

• at a scientific-practical conference commemorating Professor A. L. Mashkilleyson (Moscow, 2002);

• at an interregional scientific-practical conference, 'Regional Problems of the Protection of Public Health and Ways of Strengthening Public Health in Contemporary Conditions' (Penza, 2003);

• at an interregional scientific-practical conference marking the 80th anniversary of GKKBVD in Vladivostok (Vladivostok, 2004);

• at an interdepartmental meeting of Ryazan State Medical University (Ryazan, 2004).

Main Provisions Put Forward for Defense.

1. Dynamics and contemporary trends in the prevalence of STIs in various age-sex and socio-occupational groups of urban and rural populations.

2. Key factors influencing the spread of STIs among representatives of risk groups under contemporary socioeconomic conditions.

3. Effectiveness in the implementation of territorial targeted programs and pilot projects for STI prevention.

4. Ways to optimize STI prevention through the implementation in practice of targeted preventive programs, taking regional characteristics into account.

Scope and Structure of the Dissertation.

The work consists of an introduction, six chapters, conclusions, recommendations for implementation in practice, a bibliography (227 sources in total, including 44 foreign sources), and appendices. The dissertation comprises 182 pages of typewritten text and contains 57 tables and 13 figures.