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

Large-scale STI services in Avahan improve utilization and treatment seeking behaviour amongst high-risk groups in India: an analysis of clinical records from six states

Background

Avahan, the India AIDS Initiative, implemented a large HIV prevention programme across six high HIV prevalence states amongst high risk groups consisting of female sex workers, high risk men who have sex with men, transgenders and injecting drug users in India. Utilization of the clinical services, health seeking behaviour and trends in syndromic diagnosis of sexually transmitted infections amongst these populations were measured using the individual tracking data.

Methods

The Avahan clinical monitoring system included individual tracking data pertaining to clinical services amongst high risk groups. All clinic visits were recorded in the routine clinical monitoring system using unique identification numbers at the NGO-level. Visits by individual clinic attendees were tracked from January 2005 to December 2009. An analysis examining the limited variables over time, stratified by risk group, was performed.

Results

A total of 431,434 individuals including 331,533 female sex workers, 10,280 injecting drug users, 82,293 men who have sex with men, and 7,328 transgenders visited the clinics with a total of 2,700,192 visits. Individuals made an average of 6.2 visits to the clinics during the study period. The number of visits per person increased annually from 1.2 in 2005 to 8.3 in 2009. The proportion of attendees visiting clinics more than four times a year increased from 4% in 2005 to 26% in 2009 (p<0.001). The proportion of STI syndromes diagnosed amongst female sex workers decreased from 39% in 2005 to 11% in 2009 (p<0.001) while the proportion of STI syndromes diagnosed amongst high risk men who have sex with men decreased from 12% to 3 % (p<0.001). The proportion of attendees seeking regular STI check-ups increased from 12% to 48% (p<0.001). The proportion of high risk groups accessing clinics within two days of onset of STI-related symptoms and acceptability of speculum and proctoscope examination increased significantly during the programme implementation period.

Conclusions

The programme demonstrated that acceptable and accessible services with marginalised and often difficult–to-reach populations can be brought to a very large scale using standardized approaches. Utilization of these services can dramatically improve health seeking behaviour and reduce STI prevalence.

Prevalence and risk factors of sexually transmitted infections and cervical neoplasia in women from a rural area of southern Mozambique

There is limited information on the prevalence of sexually transmitted infections and the prevalence of cervical neoplasia in rural sub-Saharan Africa. This study describes the prevalence and the etiology of STIs and the prevalence of cervical neoplasia among women in southern Mozambique. An age-stratified cross-sectional study was performed where 262 women aged 14 to 61 years were recruited at the antenatal clinic (59%), the family-planning clinic (7%), and from the community (34%). At least one active STI was diagnosed in 79% of women. Trichomonas vaginalis was present in 31% of all study participants. The prevalence of Neisseria gonorrhea and Chlamydia trachomatis were 14% and 8%, respectively, and Syphilis was diagnosed in 12% of women. HPV DNA was detected in 40% of women and cervical neoplasia was diagnosed in 12% of all women. Risk factors associated with the presence of some of the STIs were being divorced or widowed, having more than one sexual partner and having the partner living in another area. A higher prevalence was observed in the reproductive age group and some of the STIs were more frequently diagnosed in pregnant women. STI control programs are a priority to reduce the STIs burden, including HIV and cervical neoplasia.

Opportunities for treating sexually transmitted infections and reducing HIV risk in rural South Africa

AIM

This paper is a report of a study to determine the aetiological distribution of sexually transmitted infections and prevalence of human immunodeficiency virus infection in selected primary health care clinic attendees.

BACKGROUND

South Africa has a high prevalence of human immunodeficiency virus and other sexually transmitted infections. Sexually transmitted infections are managed syndromically in the public sector as part of the essential nurse-driven primary care services provided at no cost to the client.

METHOD

This cross-sectional study was conducted in a rural community in South Africa between September and November 2002. A total of 277 consenting women were recruited. Vulvo-vaginal swabs were collected for screening for Neisseriae gonorrheae, Chlamydia trachomatis and Trichomonas vaginalis using DNA amplification methods and Gram stain with Nugent's score for the diagnosis of bacterial vaginosis. Seroprevalence of syphilis and human immunodeficiency virus infection were determined.

FINDINGS

The overall prevalence of human immunodeficiency virus in the study was 43.7% (95% confidence interval 37.6-50.0) with the prevalence in family planning clinic attendees 45.5% (95% confidence interval 38.9-52.3) and antenatal clinic attendees 33.3% (95% confidence interval 19.6-50.3). The prevalence of sexually transmitted infections amongst both the antenatal clinic and family planning attendees accounted for at least 70% of cases. Fifty per cent of women had one recognized sexually transmitted infection with 17.9% of the family planning and 14.5% of the antenatal clinic attendees having infections from two recognized pathogens. All infections were asymptomatic.

CONCLUSION

Nurse-driven antenatal and family planning services provide a useful opportunity for integrating reproductive health services, human immunodeficiency virus voluntary counselling and testing and treatment of sexually transmitted infections.

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.

Comparative efficacy of two regimens in syndromic management of lower genital infections

AIM

The aim of this study was to compare the efficacy and safety of two combination regimens in the syndromic management of lower genital infection. Seventy-two non-pregnant women presenting with symptoms of lower genital infection diagnosed as vaginitis on clinical examination and lacking obvious upper genital infection were enrolled to one of the two treatment regimens as a syndromic treatment. No investigations were performed to cut the cost and to avoid the loss of patients on follow-up. Thirty-seven women (group I) were prescribed a course of clotrimazole (Imidil, Lyka) 100 mg vaginal pessaries for 6 days. Along with their partners they were prescribed 2 gm secnidazole (Secnil forte) and 150 mg fluconazole (Syscan) as a single therapy. Thirty-five women (group II) were prescribed vaginal clotrimazole as mentioned above. A combination kit containing 150 mg fluconazole, 2 gm secnidazole and 1 gm azithromycin (FAS-3 kit, Lyka) was also prescribed to both partners with the advice to take azithromycin on empty stomach, and the other three tablets after food.

RESULTS

All women in both groups were seen after 1 week for relief of symptoms and after 1 month for any recurrence. Mean parity was 2.7 and 3.0, respectively. The total symptomatic relief was observed in 67.6 and 94.3% cases, partial relief in 27 and 5.7% cases and no relief was observed in 5.4% and nil cases, respectively, in the two groups. Recurrence was seen in two and nil cases, respectively, in the two groups. Most women tolerated both the treatments well with no major side effect in any case. Treatment cost was higher in group II (Rupees 120) than in group I (Rupees 65).

CONCLUSIONS

Both combination kits with local clotrimazole were reasonably effective and safe in the syndromic approach for lower genital infections. The combination kit with azithromycin, secnidazole and fluconazole was more effective with better symptomatic relief and less recurrence rate and may be routinely recommended in all cases of lower genital infection as a cost effective, safe and effective strategy.

Gender Differences in Health Care-Seeking Behavior for Sexually Transmitted Diseases

BACKGROUND

Health care-seeking behavior for sexually transmitted diseases (STDs) is important in STD/HIV control.

GOAL

The goal of this study was to describe the proportion seeking care, patient delay, and choice of provider among men and women with STD-related complaints in Nairobi, Kenya.

STUDY DESIGN

A population-based questionnaire was administered in 7 randomly selected clusters (small geographic areas covering approximately 150 households each).

RESULTS

Of the 291 respondents reporting complaints, 20% of men versus 35% of women did not seek care, mainly because symptoms were not considered severe, symptoms had disappeared, or as a result of lack of money. Of those who sought care, women waited longer than men (41 vs. 16 days). Most men and women went to the private sector (72% and 57%, respectively), whereas the informal sector was rarely visited (13% and 16%, respectively). Relatively more women visited the government sector (28% vs. 15%). Because women were mostly monogamous, they did not relate their complaints to sexual intercourse, which hampered prompt care-seeking.

CONCLUSION

Women should be convinced to seek care promptly, eg, through health education in communities.

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.

Interventions against sexually transmitted infections (STI) to prevent HIV infection

STIs have taken on a more important role with the advent of the HIV/AIDS epidemic, and there is good evidence that their control can reduce HIV transmission. The challenge is not just to develop new interventions, but to identify barriers to the effective implementation of existing tools, and to devise ways to overcome these barriers. This 'scaling-up' of effective strategies will require an international and a multisectoral approach. It will require the formation of new partnerships between the private and public sectors and between governments and the communities they represent.

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.