|Sexually Transmitted Diseases (STD) Syndromic Management (AIDSCAP/FHI, 1997, 54 p.)|
|INTRODUCTION OF STD SYNDROMIC MANAGEMENT IN LAC|
Encouraging the adoption of syndromic management required considerable effort at the policy level as well as research to validate and adapt WHO algorithms in different settings. AIDSCAP worked with local officials and providers to build consensus on the need for a standardized approach to STD management and to develop national guidelines for syndromic management of STDs. The success of this collaborative process laid the foundation for subsequent efforts to strengthen STD services.
AIDSCAP worked to improve STD care at points of first encounter through technical assistance and training in syndromic management, communication, and STD program management for providers, managers and pharmacists. Despite initial resistance to the syndromic approach, follow-up assessments of the STD care provided by trainees in different countries found marked increases in the percentages of clients receiving effective treatment.
The following case studies give good examples of the process several different Latin American and Caribbean countries experienced with the introduction of STD syndromic management into their countries.
In February 1995, more than 70 Haitian health care providers and officials from medical and community organizations meeting at a seminar in Port-au-Prince agreed on the need for national STD guidelines outlining a new approach to diagnosis and treatment.
Just three years earlier, many of the same medical decision makers had opposed changes in the way STD cases were managed. In the meantime, however, they had learned that lack of information about STDs often resulted in ineffective treatment throughout Haiti.
Having results from local studies that supported recommendations for new STD guidelines was the key to this breakthrough, according to Dr. Eddy Gcthen AIDSCAP Resident Advisor in Haiti. "The resistance was so strong at first," he said. "I think it was overcome with scientific proof."
A series of AIDSCAP-supported studies provided the information needed to change the providers' minds. The first, an assessment of STD case management at five of the primary health care centers run by the NGO, Centre pour Ie Dloppement et la SantCDS), in Citoleil revealed that more than 90 percent of the clinicians were treating urethral discharge with an ineffective drug. Another cause of urethral and vaginal discharge chlamydial infection was essentially ignored. Sexual partners of STD patients were seldom referred for treatment, and pregnant women were rarely screened for syphilis.
As a result of these findings, CDS adopted the syndromic approach to STD management in all of its clinics. Staff received training and guidelines for providing STD care at the primary health care level. Since clinicians might not have the time to focus on prevention, nurse-counselors were trained to counsel patients and their partners on safer sexual behavior and condom use.
CDS also ensured systematic prenatal screening at its ante-natal clinics. The Pan America Health Organization donated a one-year supply of drugs for treating common STDs; CDS was able to replenish its stocks by charging patients a modest sum for drugs.
Other organizations and providers, however, still resisted change. Many providers, believing chlamydial infection was rare among Haitians, did not think it was appropriate to treat both gonococcal and chlamydial infection in patients seeking treatment for urethritis or cervicitis, as the WHO recommends. Others were simply opposed to using the syndromic approach, even though most acknowledged that laboratory tests were not always available and that laboratory results were often unreliable.
In 1993, a survey of STDs among 1,000 patients at two CDS ante-natal clinics revealed that chlamydial infection was much more common than gonorrhea. This information paved the way for acceptance of the WHO syndromic approach. The next year, a coalition of 13 NGOs working on HIV/AIDS prevention in Haiti's Central Plateau began a program similar to CDS's.
Evaluations of the two programs showed they had improved STD case management significantly. The percentage of CDS clinicians treating urethral discharge properly had increased from less than 10 percent to 69 percent. In the newer NGO coalition program, 56 percent of the clinicians who were evaluated reported giving effective treatments for urethral discharge. Clinicians and nurse-counselors in both programs were promoting condom use.
Despite this progress, in 1995 there was still no standardized approach to STD diagnosis and treatment in Haiti. Therefore, AIDSCAP convened the February 1995 seminar to encourage Haitian organizations to reach consensus on STD case management. During this seminar, some clinicians learned for the first time that chlamydial infection was more prevalent than gonorrhea in Haiti and that most strains of gonorrhea were resistant to penicillin. After discussing the Citoleil findings and their own experiences in the field, participants agreed they should adopt a syndromic approach to managing STDs.
Representatives from local NGO and research institutions and several international organizations formed a working group to develop national guidelines for STD case management. In the fall they were joined by officials from the newly restored democratic government. The guidelines were presented and discussed at a second seminar, held in collaboration with the Ministry of Health in November 1995, for health professionals and medical decision makers. A small booklet describing the guidelines was distributed to providers in 1996.
Most national health guidelines are developed by Ministries of Health. Since Haiti's health care system collapsed during its turbulent years of military rule, development of national STD guidelines began with local institutions that later collaborated with the Ministry of Health a novel bottom-to-top approach. Now the groundwork has been set, and the government and NGOs can work together to build a national STD control program.
The establishment of STD syndromic management in Jamaica is a somewhat unique story. Jamaica was in the enviable position of having a very strong and visionary public STD control program within the Ministry of Health, whose top management agreed with the philosophy of STD syndromic management from the inception. This combined with a group of well-managed and well-attended specialized STD clinics and primary care centers that served the needs of STD patients, and the foundation for success was set.
The Jamaican STD control program, acting as a leader for STD control issues in the Caribbean basin, independently developed STD treatment guidelines and STD management tools based on WHO algorithms. These guidelines and STD management booklets, produced with the help of the Pan American Health Organization, were distributed to appropriate public sector clinics. This was followed-up by country-wide training sessions in the use of this material.
As a strategy to develop an STD reference lab, the laboratory attached to the main STD clinic in Kingston was upgraded to a working STD reference lab in a collaboration between AIDSCAP and the Ministry of Health. This laboratory upgrade made validation studies of the algorithms for vaginal discharge and genital ulcers possible, and allowed these algorithms to be revised and made country specific. In combination with an ongoing program to monitor the susceptibility of gonorrhea to antibiotics as recommended in the treatment guidelines, a system to guarantee the accuracy of the syndromic algorithms and management guidelines was successfully accomplished.
In order to ensure clinical staff were using the syndromic algorithms to guide them in STD management, programs of training new staff and providing continuing education to seasoned staff were implemented. Finally, a periodic audit of clinical care quality was adopted for quality control. In the most recent audit, 100 percent of 125 clinicians used the correct treatment for gonorrhea and syphilis based on syndromic management.
A key factor in this success was thought to be that most of the clinicians in these clinics are nurse practitioners and are more receptive to the syndromic approach, compared to a system dominated by physicians.
In the private sector, however, there were several issues surrounding the introduction and adoption of STD syndromic management. The public sector, unlike managing its own clinics, had no management control over the manner in which private STD patients were seen. Thus, any change towards a more public health approach to management would be decided by that individual private practitioner.
In Jamaica, the large, loosely organized and independent private sector provides over half the care for all STDs. Most private practitioners have some laboratory support available, although most of this support is usually off site and causes delays in treatment. This fact and its implications were discussed in a series of STD seminars attended by over half of all private sector practitioners on the island. This seminar series was organized by the Medical Association of Jamaica, the oldest professional organization in the country with a membership of over 600 and access to most of the private sector physicians in Jamaica. Instead of the non-laboratory syndromic approach, a modified syndromic management of STDs was introduced that included available laboratory confirmation and immediate treatment for symptomatic patients.
Post-seminar surveillance indicated the approach was understood by the private practitioners, but a final evaluation revealed it was not adopted on a long-term basis. It is believed repeated exposure and training by the Medical Association of Jamaica will over time modify practice behavior in the private sector from a purely clinical to a modified syndromic approach to STD management.
The project for the control and prevention of STDs in select areas of Brazil encompassed the years 1993-1997. Brazil has one of the most organized public health systems in the Americas. In Santos, for example, a network of 22 polyclinics services its half million population. However; only 1 polyclinic was providing STD services and care at the beginning of the project.
An assessment of STD case management revealed that the syndromic approach for the diagnosis and treatment of STDs was rarely used by health care workers. AIDSCAP and local counterparts initiated several projects to integrate STD syndromic management into the health care system in Rio de Janeiro, SPaulo and Santos.
At the onset of program implementation, supervisory staff were trained and given technical assistance in the fundamentals of the syndromic approach, methods and logistics of training sessions, and evaluation techniques.
The MOH had previously approved and printed national guidelines for the syndromic management of STDs, based on WHO guidelines and algorithms, and these were distributed to all polyclinics and health care workers. In addition, they received a pocket STD booklet with flowcharts and a list of appropriate medications and doses for STD syndromic management, a poster with the STD flowchart, and numerous copies of reference materials.
Concurrently, plans were made to conduct a study to formally validate all the national STD algorithms with a multi-center study that was conducted mid-project. This was felt to be an essential component of assuring efficacy for the future use of syndromic management.
During the life of the project, a total of 12 training courses on syndromic management were given to over 90 health centers and were attended by more than 1,000 health care workers. Additionally, in response to studies indicating pharmacists were selling drugs that were either ineffective or inadequate for the treatment of STDs, 31 private and public sector pharmacists were trained in STD syndrome recognition and management.
Several health care practitioners (HCPs) were resistant to accept the syndromic approach as a valid method to diagnose and treat STDs. Most HCPs were trained during medical school and residency to diagnose STDs based on the etiologic approach and considered the syndromic approach to be of a lesser quality of medicine. The HCPs also lacked confidence in the guidelines provided on the syndromic approach. The increase in supervisory visits to the HCPs and polyclinics to further discuss and provide instructions on implementing the syndromic approach proved useful in lessening this resistance. These visits also proved useful in the sensitization of gynecologists to STDs, since most did not consider some cases of vaginal discharge as possible STDs.
Many difficulties were faced during the implementation of this project. Most were related to the status of public health care provision, such as insufficient supplies, high turn-over of personnel, political changes and lack of infrastructure. For example, it is essential for the success of STD case management to have available drugs for the treatment of patients. However, this project depended on the Ministry of Health for STD drugs, and they arrived 10 months after the syndromic guidelines were introduced. The large time lapse between the training and the arrival of the STD drugs contributed to a general lack of motivation among the HCP and the coordinators, as they had difficulty believing the project would be carried out.
At the conclusion of implementing the syndromic approach, with its training and supervision, an evaluation to assess the level of the quality of STD care was conducted. The results indicated the syndromic approach was utilized in 50 percent of the male cases but in only 2.6 percent of the female patients. Ninety percent of the male patients reported receiving preventive messages regarding partner treatment, while just 34 percent of the female patients reported receiving these messages. Thus, while the use of the syndromic approach to diagnose and treat STDs has increased to 50 percent for men and 2.6 percent for females, it is important to note the increase was not substantially higher due to various factors. These include the overestimation of the validity of clinical signs for an etiologic approach, the resistance of STD specialists and teachers at the university to the syndromic approach and their continued teaching of the classical etiologic approach, and the influence of pharmaceutical companies on the prescription patterns of the physicians. Based on the aforementioned, additional training and refresher training were recommended, with particular focus on STD management in women.
Honduras began its efforts to improve STD case management with the introduction of syndromic management in 1995. Within the political framework, a close relationship was developed between AIDSCAP and the Ministry of Health through its Department for the Prevention and Control of STD/AIDS (DETSS), which allowed the project to respond to the needs of the National STD Control Program. An inter-institutional Committee was formed by the Resident Advisor of AIDSCAP/Honduras, the Chief of DETSS and a USAID representative, allowing for effective coordination among these institutions.
The strategy for syndromic management was implemented at the level of the four national regions that report the greatest number of AIDS cases in the country. This strategy was initiated with the identification of four Unidades de Manejo Integral de ETS (UMIETS), one in each health region. These were key existing centers for care and referral of STD cases. In order to initiate the project, AIDSCAP supported the remodeling and equipping of the facilities and training of its staff.
DETSS, with the technical assistance of AIDSCAP, prepared the Manual Nacional de Manejo Sindro de ETS (National Manual of STD Syndromic Management). This manual presents the syndromic approach with the goal of improving the quality of care and increasing access to treatment. The guidelines were developed through a participatory process. Consensus was reached amongst regional coordinators, a 10-member STD expert committee, and medical staff working in "CESAMO" (health facilities with physicians).
Once the Manual Nacional de Manejo Sindro de ETS was distributed, the pilot phase of the training of UMIETS staff was conducted. This included the development of training manuals for three groups: one manual for clinical staff; one manual, focused on educational issues, for educators, psychologists, and social workers; and a technical manual for laboratory staff. These manuals focused on training methodology and tools, and on specific issues related to each of the three groups, with the Manual Nacional de Manejo Sindro de ETS as common reference. The training of clinical and lab staff on the integrated management of STDs based on the syndromic model reached health workers across the network of health services. As a result, 306 staff members from the MOH were trained, among them physicians, registered nurses, and health auxiliaries, and 241 medical and nursing staff members from the IHSS. This training resulted in more timely and better quality services as well as better access to them.
The management of STDs among CSWs is a top priority in Honduras because of their role as a core transmitter group. As in other Latin American countries, CSWs in Honduras must undergo regular STD control visits. One of the objectives of the project was to improve the quality of care and increase the coverage of STD syndromic management in this group in the UMIETS. However, this presented a particular problem in Honduras, as it has in other areas of the world, since no standard recommendations exist for STD management in CSWs. The reason for this is because if a standard risk assessment is used, all these women would be treated for gonorrhea and chlamydia which would, for all purposes, really be a program of universal treatment.
In order to resolve this issue, AIDSCAP, the Ministry of Health, STD specialists, and clinical staff from the four regions collaborated on developing a manual for STD syndromic management in CSWs. Presently, this manual is in the final stage of revisions.
Finally, a special investigation was undertaken to determine the degree of gonococci resistance in the project area. Among the most important results was the confirmation of the existence of the Betalactamas strain which is resistant to penicillin (60 percent), and the identification for the first time in the country of strains resistant to tetracycline (89 percent). Based on these findings, the treatment schemes were modified in the Manual Nacional de Manejo Sindro de ETS.
In the Dominican Republic, STD services were improved by upgrading clinical facilities, improving STD drug logistics, and developing a STD syndromic management manual for practitioners. AIDSCAP, in collaboration with local counterpart institutions, conducted 37 courses in which 854 clinicians were trained, including social workers, nurse supervisors, and educators. Both clinicians and non-clinicians were required to attend refresher courses six months after the initial training workshop. Pre and post tests were conducted for all participants. In addition, STD treatment manuals and laminated treatment algorithms were distributed to health educators and providers. Subsequently, algorithm validation research was conducted, and a reporting and referral system was developed based on syndromic management.
Despite great success in many areas, the AIDSCAP/Dominican Republic program did face several constraints. High staff turnover rate among various collaborating agencies hampered program implementation and slowed the development of national STD guidelines. Logistics problems continued to affect STD drug distribution. Many clinicians proved reluctant to introduce syndromic management (rather than etiologic) of STDs. STD surveillance was constrained by the continuing problem of STD self-treatment and under-reporting on the part of providers.
In the Dominican Republic, a significant lesson learned was that the institutionalization of the syndromic management approach to STD treatment requires a long-term commitment and continuous support. Institutional support is necessary to overcome clinician resistance to obtaining additional training in a country where continuous education is not customary. It was also felt that continuous training was necessary due to the high turnover of clinic personnel.
Historically, few resources have been devoted to STD control in the Dominican Republic. NGOs and donor organizations play strong advocacy roles for the rational distribution of STD drugs, and clinicians involved in STD treatment have been valuable advocates for appropriate drug management. However, like every country, ensuring that STD drugs are available demands political commitment from the top and a strong logistical system that is part of the overall health care system, not parallel to it.
In the development of their flowcharts, the Dominican Republic effectively designed changes in the WHO templates for their country-specific needs. Because of the high prevalence of STDs in the country, it was thought that the syndromic algorithms should emphasize sensitivity over specificity. This was done by emphasizing demographic risk factors, such as young age and single marital status. Other changes included an evaluation of men with dysuria but no discharge, and treating suspected herpes for both syphilis and chancroid.