Improving quality of sexually transmitted disease case management in rural South Africa

Trends and correlates of sexually transmitted infections among sexually active Ugandan female youths: evidence from three demographic and health surveys, 2006-2016

BACKGROUND

Female adolescents and young women have the highest risk of curable sexually transmitted infections (STIs) globally. Data on the prevalence of STIs among young women in Uganda are limited. In this study, we investigated the time trends and correlates of STIs among adolescent girls and young women (15-24 years) in Uganda.

METHODS

We estimated the percentage of women 15-24 years from three recent consecutive Uganda Demographic and Health Surveys (2006, 2011, and 2016), who reported suffering from genital sores, and or genital discharge or any other varginal complaints acquired after sexual intercourse within 12 months of the studies and examined the changes over time. A pooled multivariable logistic regression was used to examine the correlates of reporting an STI in the last 12 months preceding the study. Svyset command in Stata was used to cater for the survey sample design.

RESULTS

The pooled self-reported STI prevalence was 26.0%. Among these young women, 22.0, 36.3, and 23.1% reported a sexually transmitted infection in 2006, 2011, and 2016 respectively. Between 2006 and 2011, there was evidence of change (+ 14.3%, p < 0.001) in STI prevalence before a significant reduction (- 12.0%, p< 0.001) in 2016. Youths aged 20-24 years reported a higher STI prevalence (27.3%) compared to young participants (23.6%). Correlates of reporting an STI among rural and urban young women were: having multiple total lifetime partners (adjusted odds ratio (aOR 1.6, 95% CI 1.4-1.6), being sexually active in the last 4 weeks (aOR 1.3, 95% CI 1.1-1.6), and being affiliated to Muslim faith (aOR 1.3, 95% CI 1.1-1.6) or other religions (aOR 1.8, 95% CI 1.1-2.9) as compared to Christian were more likely to report an STI. Living in Northern Uganda compared to living in Kampala city was found protective against STIs (aOR 0.5, 95% CI 0.3-0.7).

CONCLUSION

The prevalence of STIs was high among female youths, 15-24 years. This highlights the need for a comprehensive STIs screening, surveillance, and treatment programme to potentially reduce the burden of STIs in the country.

Partner notification and treatment for sexually transmitted infections among pregnant women in Cape Town, South Africa

Curable sexually transmitted infections (STIs) including Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV) are associated with adverse pregnancy outcomes. Partner notification is an important component of STI control as it has been shown to prevent re-infection and reduce infectious burden. Between October 2017 and February 2019, we conducted a cohort study of women attending antenatal care in Cape Town, South Africa. Self-collected vulvovaginal swabs were tested for CT, NG, and TV using Xpert® assays at first antenatal visit, during the third trimester, and postpartum. At the visit following a positive diagnosis, women were asked if they notified their partner and if their partner was treated. Among 242 participants, 97% reported being willing to notify partners if they tested positive and 78% thought their partner would be willing to treat the STI. Of the 73 women who were diagnosed with one or more STIs and reported having a sex partner, 93% reported notifying their partner and 63% reported their partner was treated. Younger maternal age was associated with partner notification and treatment (OR = 3.82; 95%CI = 1.34-10.90). Acceptability of partner notification was high in pregnant women, but partner treatment was low. Future interventions to improve partner notification and treatment are needed.

Global Research on Syndromic Surveillance from 1993 to 2017: Bibliometric Analysis and Visualization

Syndromic Surveillance aims at analyzing medical data to detect clusters of illness or forecast disease outbreaks. Although the research in this field is flourishing in terms of publications, an insight of the global research output has been overlooked. This paper aims at analyzing the global scientific output of the research from 1993 to 2017. To this end, the paper uses bibliometric analysis and visualization to achieve its goal. Particularly, a data processing framework was proposed based on citation datasets collected from Scopus and Clarivate Analytics’ Web of Science Core Collection (WoSCC). The bibliometric method and Citespace were used to analyze the institutions, countries, and research areas as well as the current hotspots and trends. The preprocessed dataset includes 14,680 citation records. The analysis uncovered USA, England, Canada, France and Australia as the top five most productive countries publishing about Syndromic Surveillance. On the other hand, at the Pinnacle of academic institutions are the US Centers for Disease Control and Prevention (CDC). The reference co-citation analysis uncovered the common research venues and further analysis of the keyword cooccurrence revealed the most trending topics. The findings of this research will help in enriching the field with a comprehensive view of the status and future trends of the research on Syndromic Surveillance.

A national evaluation using standardised patient actors to assess STI services in public sector clinical sentinel surveillance facilities in South Africa

OBJECTIVES

Quality concerns in STI service delivery and missed opportunities for integration with HIV testing and prevention services in South Africa have been well documented. This national evaluation aimed to evaluate current utilisation and adherence to national STI guidelines, including partner notification and integration with HIV services, for diagnosis and management of STIs.

METHODS

Facility surveys assessed infrastructure and resource availability, and standardised patient (SP) assessments evaluated quality of STI care in 50 public clinics in nine provinces in South Africa. The primary outcome was the proportion of SPs receiving essential STI care, defined as: offered an HIV test, condoms, partner notification counselling and correct syndromic treatment. Weighted proportions were generated, and SP findings were compared by gender using χ² tests with Rao-Scott correction.

RESULTS

More than 80% of facilities reported medications in stock, with the exceptions of oral cefixime (48.3%), oral erythromycin (75.1%) and paediatric syrups. Among 195 SP encounters, 18.7% (95% CI 10.7% to 30.5%) received all hypothesised essential STI services: offered HIV test (67.1%), offered condoms (31.4%), partner notification counselling (70.2%) and recommended syndromic treatment (60.7%). Men were more likely than women to be offered all services (25.1% vs 12.3%, p=0.023), recommended treatment (70.7% vs 50.9%, p=0.013) and partner notification counselling (79.9% vs 60.6%, p=0.020). Only 6.3% of providers discussed male circumcision with male SPs, and 26.3% discussed family planning with female SPs.

CONCLUSIONS

This evaluation of STI services across South Africa found gaps in the availability of medications, adherence to STI guidelines, condom provision and prevention messaging. Limited integration with HIV services for this high-risk population was a missed opportunity. Quality of STI care should continue to be monitored, and interventions to improve quality should be prioritised as part of national strategic HIV and primary healthcare agendas.

Quality of Sexually Transmitted Infection Case Management Services in Gauteng Province, South Africa: An Evaluation of Health Providers' Knowledge, Attitudes, and Practices

BACKGROUND

The sexually transmitted infection (STI) clinical encounter is an opportunity to identify current and prevent new HIV and STI infections. We examined knowledge, attitudes, and practices regarding STIs and HIV among public and private providers in a large province in South Africa with a high disease burden.

METHODS

From November 2008 to March 2009, 611 doctors and nurses from 120 public and 52 private clinics serving patients with STIs in Gauteng Province completed an anonymous, self-administered survey. Responses were compared by clinic location, provider type, and level of training.

RESULTS

Most respondents were nurses (91%) and female (89%), were from public clinics (91%), and had received formal STI training (67%). Most (88%) correctly identified all of the common STI syndromes (i.e., genital ulcer syndrome, urethral discharge syndrome, and vaginal discharge syndrome). However, almost none correctly identified the most common etiologies for all 3 of these syndromes (0.8%), or the recommended first or alternative treatment regimens for all syndromes (0.8%). Very few (6%) providers correctly answered the 14 basic STI knowledge questions. Providers reporting formal STI training were more likely to identify correctly all 3 STI syndromes (P = 0.034) as well as answer correctly all 14 general STI knowledge questions (P = 0.016) compared with those not reporting STI training. In addition, several providers reported negative attitudes about patients with STI that may have affected their ability to practice optimal STI management.

CONCLUSIONS

Sexually transmitted infection general knowledge was suboptimal, particularly among providers without STI training. Provider training and brief refresher courses on specific aspects of diagnosis and management may benefit HIV/STI clinical care and prevention in Gauteng Province.

The effect of syndromic management interventions on the prevalence of sexually transmitted infections in South Africa

OBJECTIVES

Few studies have assessed the effect of syndromic management interventions on the prevalence of sexually transmitted infections (STIs) at a population level. This study aims to determine the effect of syndromic management protocols that have been introduced in South Africa since 1994.

STUDY DESIGN

A mathematical model of sexual behaviour patterns in South Africa was used to model the incidence of HIV, genital herpes, syphilis, chancroid, gonorrhoea, chlamydial infection, trichomoniasis, bacterial vaginosis and vaginal candidiasis. Assumptions about health seeking behaviour and treatment effectiveness were based on South African survey data. The model was fitted to available STI prevalence data.

MAIN OUTCOME MEASURES

Reductions in STI prevalence due to syndromic management.

RESULTS

Between 1995 and 2005, there were significant reductions in the prevalence of syphilis, chancroid, gonorrhoea, trichomoniasis and chlamydial infection. In women aged between 15 and 49, syndromic management resulted in a 33% (95% CI: 23-43%) decline in syphilis prevalence, a 6% (95% CI: 3-11%) reduction in gonorrhoea prevalence, a 5% (95% CI: 1-13%) reduction in the prevalence of bacterial vaginosis and a substantial decline in chancroid. However, syndromic management did not significantly reduce the prevalence of other STIs. For all STIs, much of the modelled reduction in STI prevalence between 1995 and 2005 can be attributed to either increased condom usage or AIDS mortality.

CONCLUSIONS

Syndromic management of STIs can be expected to decrease the prevalence of curable STIs that tend to become symptomatic, but has little effect on the prevalence of STIs that are mostly asymptomatic.

Partner notification for sexually transmitted infections in developing countries: a systematic review

BACKGROUND

The feasibility and acceptability of partner notification (PN) for sexually transmitted infections (STIs) in developing countries was assessed through a comprehensive literature review, to help identify future intervention needs.

METHODS

The Medline, Embase, and Google Scholar databases were searched to identify studies published between January 1995 and December 2007 on STI PN in developing countries. A systematic review of the research extracted information on: (1) willingness of index patients to notify partners; (2) the proportion of partners notified or referred; (3) client-reported barriers in notifying partners; (4) infrastructure barriers in notifying partners; and (5) PN approaches that were evaluated in developing countries.

RESULTS

Out of 609 screened articles, 39 met our criteria. PN outcome varied widely and was implemented more often for spousal partners than for casual or commercial partners. Reported barriers included sociocultural factors such as stigma, fear of abuse for having an STI, and infrastructural factors related to the limited number of STD clinics, and trained providers and reliable diagnostic methods. Client-oriented counselling was found to be effective in improving partner referral outcomes.

CONCLUSIONS

STD clinics can improve PN with client-oriented counselling, which should help clients to overcome perceived barriers. The authors speculate that well-designed PN interventions to evaluate the impact on STI prevalence and incidence along with cost-effectiveness components will motivate policy makers in developing countries to allocate more resources towards STI management.

Low effectiveness of syndromic treatment services for curable sexually transmitted infections in rural South Africa

Objectives:

Syndromic sexually transmitted infection (STI) treatment remains a cost-saving HIV prevention intervention in many countries in Africa. We estimate the effectiveness of syndromic treatment for curable STIs in rural KwaZulu-Natal, South Africa, and the trend in STI prevalences before and after the introduction of syndromic treatment in 1995.

Methods:

Data were available from various clinical studies, surveys of public and private health providers, the general population and women attending antenatal, family planning and child immunisation clinics in rural northern KwaZulu-Natal between 1987 and 2004. Overall effectiveness was defined as the estimated proportion of the annual number of symptomatic curable STI episodes cured by syndromic treatment based on separate estimates for six curable STI aetiologies by gender.

Results:

Median overall effectiveness was 13.1% (95% CI 8.9 to 17.8%) of symptomatic curable STI episodes cured. Effectiveness increased to 25.0% (95% CI 17.3 to 33.8%), 47.6% (95% CI 44.5 to 50.8%) or 14.3% (95% CI 9.9 to 19.4%) if 100% treatment seeking, 100% correct treatment provision or 100% cure were assumed, respectively. Time-trends were difficult to assess formally but there was little evidence of decreasing STI prevalences. Including incurable but treatable herpes simplex virus (HSV)-2 ulcers in the effectiveness calculation would halve the proportion of ulcers cured or correctly treated, but this reduction could be entirely countered by including episodic antiviral treatment in the national guidelines.

Conclusion:

Overall effectiveness of syndromic treatment for curable STIs in rural KwaZulu-Natal remains low and there is little evidence of reduced curable STI prevalences. As syndromic treatment is likely to be a cost-saving HIV prevention intervention in South Africa, innovative strategies are urgently needed to increase rates of treatment seeking and correct treatment provision.

Barriers to effective STI screening in a post-Soviet society: results from a qualitative study

OBJECTIVE

This qualitative study assesses knowledge about sexually transmitted infections (STI), identifies perceived barriers to STI testing, and recommends strategies to optimise participation in a home based STI testing programme.

METHODS

Five focus groups composed of 29 total participants were recruited using convenience sampling methods based on age (18-40 years), gender (male and female), and residency (Tartu region, Estonia).

RESULTS

The focus groups revealed significant knowledge deficits and a widespread attitude of denial. However, participants acknowledged that STIs are a serious problem and recommended strategies for increasing participation in an STI testing and treatment programme. Successful STI prevention programmes must address a number of challenges, including disease stigmatisation and privacy protection.

CONCLUSION

The fear of enforced disease control methods coupled with the current stigmatisation of STIs creates a serious challenge for Estonian STI prevention and treatment efforts. This qualitative study provides a good contextual reference for STI control programmes in eastern Europe.

Determinants of Choosing Public or Private Health Care Among Patients With Sexually Transmitted Infections in Uganda

OBJECTIVES

To identify variables that distinguish patients with sexually transmitted infections (STIs) who seek care in public or private health units.

GOAL

To recommend measures for improved care of patients with STIs.

STUDY DESIGN

Patients with STIs were interviewed at public (n = 101) or private health units (n = 124). Information was collected on attitudinal, normative, and self-efficacy beliefs; STI symptoms; health-seeking behavior; sociodemographic characteristics, and on partner referral.

RESULTS

Choosing private health units is favored by age >25 years, favorable beliefs towards private health units (e.g., they cure or prevent STIs and give adequate drug doses); unfavorable beliefs towards public health units (such as they make STIs chronic and have corrupt staff); not being influenced by sexual partner(s) in choice of treatment site, being likely to chose a treatment site if sexual partners were not treated free, and being likely to choose a treatment site if not recommend by a friend. This 9-variable model correctly classified 214 (95%) of the 225 patients (model chi squared = 192, 9 degrees of freedom, P <0.001).

CONCLUSIONS

Psychosocial variables markedly influence choice of health care provider. Improving quality of care will enhance STI management and help to modify the unfavorable psychosocial beliefs.

Effectiveness and cost effectiveness of syndromic sexually transmitted infection packages in South African primary care: cluster randomised trial

OBJECTIVES

To evaluate the effectiveness and cost effectiveness of syndromic sexually transmitted infection (STI) packages on appropriate treatment and preventive management during primary care consultations.

METHODS

Cluster randomised trial of 37 Durban primary care clinics randomised to use syndromic packages (containing antibiotics, condoms, partner notification cards, and written information) or not. We assessed outcomes using simulated patients who reported STI symptoms and recorded how they were managed, before and after implementation (269 and 256 simulated patient consultations). We adjusted for baseline values and intra-clinic correlation of outcomes statistically. We used health department information to estimate the extra resources needed to provide the packages to 20 clinics for 1 year and their costs.

RESULTS

Simulated patients in intervention clinics were more likely to receive appropriate syndromic STI management (correct treatment plus condoms offered plus partner notification cards offered; prevalence rate ratio 2.3; 95% confidence intervals (CI) 1.6 to 3.0) and to receive more STI advice and information (odds ratio 1.5; 95% CI 1.01 to 2.1). Women were less likely to receive appropriate syndromic STI management. The intervention increased STI information provision in women more than in men. The extra cost per extra patient appropriately managed was $1.51.

CONCLUSIONS

Syndromic packages improved syndromic STI management at a reasonable cost and should be used more widely.

Sexually transmitted disease management in Uganda's private-for-profit formal and informal sector and compliance with treatment

OBJECTIVE

The objective of this study was to investigate the management of sexually transmitted diseases (STDs) in the Ugandan private sector clinics and drug shops.

STUDY

Men with urethral discharge who had consulted clinics (264) or drug shops (141) for treatment in 5 districts were interviewed using a precoded questionnaire 1 to 3 weeks after initiation of treatment.

RESULTS

Seventy-seven percent of patients sought treatment within 1 week of onset of symptoms but only 7% were properly managed (treated according to National Guidelines, told to use a condom or abstain, and to refer their partner). The reported cure rate was 47% and only 9% were treated according to National Guidelines. Eighteen percent of patients used condoms during treatment, 36% persuaded their partner to go for treatment, and 87% completed the recommended treatment course. Of patients not reporting cure, 56% would still recommend the treatment to a friend.

CONCLUSION

Quality of STD management by private providers is poor. Improvement should occur concurrently at public and private facilities. Possible strategies include training and social marketing of prepackaged treatment for STDs.

Quality of Sexually Transmitted Infection Clinical Management and Contact Tracing Outcomes in a Remote Area of High Sexually Transmitted Infection Endemicity

OBJECTIVES

The objectives of this study were to assess health professionals' adherence to Western Australian sexually transmitted infection (STI) management guidelines and to document the outcomes of contact tracing in a remote Indigenous setting.

METHODS

This article comprises 2 parts: a retrospective clinical audit of quality of clinical STI management and outcomes of contact tracing and an analysis of completeness of relevant laboratory investigations.

RESULTS

Documented clinical STI management of index cases varied from 94% receiving treatment in accordance with the Guidelines, whereas only 48% underwent a clinical examination. Sexual contacts who underwent STI consultation had concordant (30%) and discordant (17%) STI(s). The proportion of patients with STI(s) in whom all appropriate laboratory investigations had been requested increased from 25% in 1998 to 9% to 49% in 2001-2002.

CONCLUSIONS

This study demonstrates that quality of clinical STI management comparable to that observed overseas is possible despite the challenges of healthcare delivery in a remote setting.

Barriers to asymptomatic screening and other STD services for adolescents and young adults: focus group discussions

Background

Sexually transmitted diseases (STDs) are a major public health problem among young people and can lead to the spread of HIV. Previous studies have primarily addressed barriers to STD care for symptomatic patients. The purpose of our study was to identify perceptions about existing barriers to and ideal services for STDs, especially asymptomatic screening, among young people in a southeastern community.

Methods

Eight focus group discussions including 53 White, African American, and Latino youth (age 14–24) were conducted.

Results

Perceived barriers to care included lack of knowledge of STDs and available services, cost, shame associated with seeking services, long clinic waiting times, discrimination, and urethral specimen collection methods. Perceived features of ideal STD services included locations close to familiar places, extended hours, and urine-based screening. Television was perceived as the most effective route of disseminating STD information.

Conclusions

Further research is warranted to evaluate improving convenience, efficiency, and privacy of existing services; adding urine-based screening and new services closer to neighborhoods; and using mass media to disseminate STD information as strategies to increase STD screening.

A comparison of cost-effectiveness of three protocols for diagnosis and treatment of gonococcal and chlamydial infections in women in Africa

BACKGROUND

The cost-effectiveness of different STD diagnosis and treatment approaches has not been evaluated previously.

GOALS

The goals of the study were to compare the cost-effectiveness of "gold standard" care (GS), syndromic management (SM), and mass treatment (MT) protocols for the treatment of cervical gonococcal and chlamydial infections in a hypothetical model of 1 million women in Africa.

STUDY DESIGN

A decision tree model was constructed for each of the protocols. Sensitivity analyses were conducted and 10,000 Monte Carlo simulations were run to test the robustness of the cost-effectiveness estimates to changes in underlying assumptions.

RESULTS

MT with doxycycline for chlamydia was the most cost-effective protocol in terms of cost per cure. SM protocol had the lowest total programmatic costs. For the GS protocol, using azithromycin for chlamydial infections was found to be more cost-effective than using doxycycline. For both the GS and SM protocols, the total cost of the program was most sensitive to the percentage of women seeking STD treatment and the prevalence of non-STD vaginal discharge, whereas the cost of MT was almost exclusively determined by coverage rates.

CONCLUSIONS

No single protocol carries with it all the desired conditions of an optimal cost-effective program. The treatment-seeking behavior, STD prevalence, and coverage of each locale must be evaluated to determine the most cost-effective and highest impact program. MT was found to be the most cost-effective protocol in terms of cost per woman treated when compared with the SM and GS protocols for STDs in women.

Evaluation of the Quality of Care for Sexually Transmitted Infections in Primary Health Care Centres in South Africa

Sexually transmitted infections (STIs) are one of the most common illnesses among adolescents and adults in developing countries. While research from other countries indicates that a lack of financial, infra-structural and human resources are central determinants of the quality of care for STIs, South African studies suggest that there are also problems in health workers' interactions with STI patients. This study investigates the quality of care for STIs at 24 primary health care (PHC) centres in four provinces of South Africa (SA). Semi-structured interviews were conducted with STI patients and health providers. In addition, in-depth interviews were conducted with a sample of STI patients, and focus group discussions were held with diverse community groupings. Simulated patients also completed questionnaires on the care they received at the centres. Frequencies were computed on close-ended questions in order to describe patterns and trends in the data. Cross-tabulations were calculated to check for gender, provincial and urban-rural differences. Composite scores were also generated for the purpose of comparing quality of care across the different participating groups. Finally, the depth interviews and focus groups were analysed thematically. The results show that PHC centres in SA are relatively well-resourced. However, problems were found in the actual encounter between health workers and STI patients, which severely undermines the quality and effectiveness of treatment. It is strongly recommended that attention be given to health providers, in particular through the provision of further training and support in relation to effective STI management.

Primary health care in the era of HIV/AIDS. some implications for health systems reform

In this article it is argued that the current emphasis on third generation reforms to health systems places at risk the empowering comprehensive agenda of second generation reforms. Using the HIV/AIDS epidemic in South Africa as an exemplar, the authors demonstrate the importance of retaining this agenda. They suggest that the emphasis on 'packaged' priority programmes with measurable outcomes, which characterizes third generation reforms, needs to be accompanied by the reorientation of primary health care providers towards an empowering comprehensive approach to care. In addition, using psychodynamic principles, they also show how certain aspects of the health care system need restructuring to provide containment and support for such care.

How many patients with a sexually transmitted infection are cured by health services? A study from Mwanza region, Tanzania

OBJECTIVES

To estimate the proportion of symptomatic patients with a bacterial sexually transmitted infection (STI) cured by primary health care services in Mwanza Region, Tanzania, and to compare the cure rate achieved by health centres before and after the introduction of improved STI treatment services.

METHODS

A model was used that describes the different hurdles patients with an STI take before they can be considered cured by the health services. The values for the input parameters for the model were taken from different studies. Data from an intervention trial as well as from a population-based study on male urethritis were used to estimate the proportion of symptomatic patients with an STI who seek care from a health centre. An observational study in four health centres where improved STI treatment services had been introduced provided estimates of the proportions of patients with an STI correctly diagnosed and treated. Patients who returned to the health centres after 1 week were interviewed about compliance. An estimate of the efficacy of treatments prescribed for STIs in health centres before the introduction of improved STI services was obtained from a study on prescription patterns for genital discharge syndrome (GDS) and genital ulcer disease (GUD).

RESULTS

It was estimated that in the catchment area of health centres offering improved STI services, 51-72% of patients with STI symptoms sought care from those health centres. About 76-85% of cases were correctly diagnosed, and of these 69-80% received efficacious treatment. Compliance with full treatment was estimated at 84%. The estimated overall cure rate achieved by the health centres offering improved STI services ranged between 23 and 41%. The proportion of symptomatic STI patients who attended a health centre before improved STI services were introduced was estimated at 39%. The estimated efficacy of the treatments prescribed was 28%. The overall cure rate achieved by these health centres was less than 10%.

CONCLUSIONS

When assessing the performance of STI case detection and management all steps have to be taken into account that are taken by patients with an STI before they can be considered cured by the health services. The intervention to improve STI services in Mwanza Region has resulted in an improvement of the cure rate of STIs achieved by primary health care centres.

Quality of sexually transmitted disease case management in Nairobi, Kenya: a comparison among different types of healthcare facilities

BACKGROUND

In Nairobi, the prevalence for sexually transmitted diseases (STDs) among attenders at antenatal and family planning clinics is substantial, but knowledge about the quality of STD case management is scarce.

GOAL

To assess quality of STD case management in Nairobi healthcare facilities.

STUDY DESIGN

All the facilities in five sublocations were enumerated. In 142 facilities, 165 providers were interviewed, observed during 441 interactions with patients who had STDs, and visited by a simulated patient.

RESULTS

For observations of patients with STDs, correct history-taking ranged from 60% to 92% among the various types of facilities, correct examination from 31% to 66%, and correct treatment from 30% to 75%. The percentage of correctness for all three aspects (World Health Organization prevention indicator 6) varied between 14% and 48%. Public clinics equipped for STD care performed best in all aspects, whereas treatment was poorest in pharmacies and private clinics. The providers trained in STD management performed better than those without training.

CONCLUSIONS

Quality of STD case management was unsatisfactory except in public STD-equipped clinics. This indicates the need for improvement by interventions such as further training in syndromic management, improved supervision, and the introduction of prepackaged syndromic management kits.

Operational performance of an STD control programme in Mwanza Region, Tanzania

OBJECTIVES

To describe important details of the design and operational features of the Mwanza sexually transmitted diseases (STD) control programme. To assess the feasibility of the intervention, the distribution of STD syndromes observed, the clinical effectiveness of syndromic STD case management, the utilisation of STD services by the population, and the quality of syndromic STD services delivered at rural health units.

METHODS

The intervention was integrated into rural primary healthcare (PHC) units. It comprised improved STD case management using the syndromic approach, facilitated by a regional programme office which ensured the training of health workers, a reliable supply of effective drugs, and regular support supervision. Five studies were performed to evaluate operational performance: (i) a survey of register books to collect data on patients presenting with STDs and reproductive tract infections (RTIs) to rural health units with improved STD services, (ii) a survey of register books from health units in communities without improved services, (iii) a survey of register books from referral clinics, (iv) a home based cross sectional study of STD patients who did not return to the intervention health units for follow up, (v) a cross sectional survey of reported STD treatment seeking behaviour in a random cohort of 8845 adults served by rural health units.

RESULTS

During the 2 years of the Mwanza trial, 12,895 STD syndromes were treated at the 25 intervention health units. The most common syndromes were urethral discharge (67%) and genital ulcers (26%) in men and vaginal discharge (50%), lower abdominal tenderness (33%), and genital ulcers (13%) in women. Clinical treatment effectiveness was high in patients from whom complete follow up data were available, reaching between 81% and 98% after first line treatment and 97%-99% after first, second, and third line treatment. Only 26% of patients referred to higher levels of health care had presented to their referral institutions. During the trial period, data from the cohort showed that 12.8% of men and 8.6% of women in the intervention communities experienced at least one STD syndrome. Based on various approaches, utilisation of the improved health units by symptomatic STD patients in these communities was estimated at between 50% and 75%. During the first 6 months of intervention attendance at intervention units increased by 53%. Thereafter, the average attendance rate was about 25% higher than in comparison communities. Home visits to 367 non-returners revealed that 89% had been free of symptoms after treatment, but 28% became symptomatic again within 3 months of treatment. 100% of these patients reported that they had received treatment, but only 74% had been examined, only 57% had been given health education, and only 30% were offered condoms. Patients did not fully recall which treatment they had been given, but possibly only 63% had been treated exactly according to guidelines.

CONCLUSIONS

This study demonstrated that it is feasible to integrate effective STD services into the existing PHC structure of a developing country. Improved services attract more patients, but additional educational efforts are needed to further improve treatment seeking behaviour. Furthermore, clear treatment guidelines, a reliable drug supply system, and regular supervision are critical. All efforts should be made to treat patients on the spot, without delay, as referral to higher levels of care led to a high number of dropouts. The syndromic approach to STD control should be supported by at least one reference clinic and laboratory per country to ensure monitoring of prevalent aetiologies, of the development of bacterial resistance, and of the effectiveness of the syndromic algorithms in use.

Syndrome packets and health worker training improve sexually transmitted disease case management in rural South Africa: randomized controlled trial

BACKGROUND

Sexually transmitted diseases (STD) are important co-factors in HIV transmission. We studied the impact of health worker training and STD syndrome packets (containing recommended drugs, condoms, partner notification cards and information leaflets) on the quality of STD case management in primary care clinics in rural South Africa.

METHODS

A randomized controlled trial of five matched pairs of clinics compared the intervention with routine syndromic management. Outcomes were measured by simulated patients using standardized scripts, and included the proportion given recommended drugs; correctly case managed (given recommended drugs plus condoms and partner cards); adequately counselled; reporting good staff attitude; and consulted in privacy.

RESULTS

At baseline, the quality of STD case management was similarly poor in both groups. Only 36 and 46% of simulated patients visiting intervention and control clinics, respectively, were given recommended drugs. After the intervention, intervention clinics provided better case management than controls: 88 versus 50% (P < 0.01) received recommended drugs; 83 versus 12% (P < 0.005) were correctly case managed; 68 versus 46% (P = 0.06) were adequately counselled; 84 versus 58% experienced good staff attitude (P = 0.07); and 92 versus 86% (P = 0.4) were consulted privately. A syndrome packet cost US$1.50; the incremental cost was US$6.80. The total intervention cost equalled 0.3% of annual district health expenditure.

INTERPRETATION

A simple and affordable health service intervention achieved substantial improvements in STD case management. Although this is a critical component of STD control and can reduce HIV transmission, community-level interventions to influence health-seeking behaviour are also needed.

STD management by private pharmacies in Hanoi: practice and knowledge of drug sellers

BACKGROUND

Prompt treatment of sexually transmitted infections may reduce the incidence of HIV/AIDS infections. With health sector reforms private pharmacies are increasingly the first and only contact with health delivery services.

OBJECTIVES

To find out how patients with STDs are treated at private pharmacies in Hanoi, and what drug sellers know about STD management.

METHODS

Five simulated clients were taught to adopt a scenario stating that their friend had a urethral discharge. They visited 60 randomly selected private pharmacies in urban Hanoi and noted all questions asked, advice offered, and treatment given. Afterwards interviewers administered a semistructured questionnaire to all people working in the 60 pharmacies.

RESULTS

Drug treatment was given in 84% of the 297 encounters averaging 1.5 drugs and 1.2 antibiotics per encounter. Quinolones were given 188 times. No dispensing was adequate for chlamydia or was in accordance with the national guidelines. No questions were asked in 55% of encounters and no advice was given in 61%. Questions on sexual activity were asked in 23% (69) of cases and about the health of the partner twice (1%). Advice to practise safe sex was given in 1% of encounters and for the partner to seek treatment only once. Of 69 questionnaires administered 51% said they would refer to a doctor, 16% said they would ask about the sexual activity 1% said they would ask about the health of the partner, 7% said they would advise using a condom, and 1% advised telling the partner to seek treatment. Even after prompting, 61% would ask no questions and 80% would give no advice.

CONCLUSIONS

Even though 74% of pharmacists and drug sellers know that they should not treat STD patients, 84% actually did. None gave syndromically correct treatment. In both the questionnaire and during the simulated client methods, numbers advising on partner notification and condom use were very poor. Educational or peer awareness interventions are urgently needed among private pharmacists in Vietnam.

STD syndrome packets: improving syndromic management of sexually transmitted diseases in developing countries

OBJECTIVE

To design, introduce, and evaluate "STD syndrome packets" containing recommended drugs for each syndrome, four condoms, a partner treatment card, and a patient information leaflet, with the goal of improving sexually transmitted disease (STD) case management.

METHODS

Packet design evolved around available packaging technology, informed by pilot testing with nurses working in primary care clinics, doctors in private medical practices, and patients with an STD, in Hlabisa, South Africa. Evaluation 1 year later included analysis of distribution records and interviews with 16 nurses and 64 patients.

RESULTS

A cheap packet (2 U. S. cents each, excluding contents) compatible with current legislation was designed and introduced to six public sector clinics and as a short pilot to five private medical practices. Four thousand eighty-five packets were distributed to the clinics, equivalent to approximately 115% of the STDs reported over that period. All 16 nurses reported using the packets, but only 63% did so all the time because of occasional supply problems. All believed the packets improved treatment by saving time (75%), improving supply of condoms and partner cards (44%), and making treatment easier (56%). Patients also responded positively, and most said they would buy a packet (up to $5) at a pharmacy (84%) or store (63%) if available.

CONCLUSIONS

The STD syndrome packets have the potential to improve STD syndromic management by standardizing therapy and improving the supply of condoms, partner cards, and information leaflets. Packets are popular with practitioners and patients, but consistent supply is essential for maximal impact. There may be scope for social marketing of the packets, which could further increase use.