|Sexually Transmitted Diseases (STD) Prevention: New Challenges, New Approaches (AIDSCAP/FHI - USAID, 1996, 47 p.)|
by Frieda Behets
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 resisted changes in the way STD cases were managed. But in the meantime, they had learned that lack of information about STDs often resulted in ineffective treatment throughout Haiti. During the seminar, they acknowledged that conditions in Haiti called for low-technology, more public-health-oriented approaches to STD management than had been used in the past.
Having results from local studies that supported recommendations for new STD guidelines was the key to the shift in providers' attitudes, according to Dr. Eddy GcAIDSCAP resident advisor in Haiti.
The resistance was so strong at first, he said. I think you overcome it with scientific proof
Dr. Gclso attributed providers' acceptance of the need for changes in STD management to communication among all groups interested in STD control in Haiti, frequent and consistent technical assistance and training, and support for Haitian health professionals' participation in international meetings where new approaches to STD control were discussed. These efforts led to the first national consensus on guidelines for managing STDs.
After the Coup
The consensus-building process began in 1992, the year after Haiti's first democratically elected president had been ousted by a military junta. Haitians were already beginning to suffer the effects of an international fuel embargo and sporadic political violence.
Not surprisingly, Haiti's response to STDs also was in disarray. There was no national STD control program. Little was known about the country's STD problem or about STD care in the public or private sector. Local health providers re- ported that patients preferred self-medication, particularly for STDs. Ampicillin and tetracycline could easily be bought on the street.
Although other internationally sponsored development activities had been halted after the coup d't, HIV prevention activities continued as part of donors' humanitarian assistance to Haiti. Direct collaboration with the military government was not permitted, but assistance could be provided through nongovernmental organizations (NGOs).
Changing the behavior of health care providers is at least as difficult as changing the behavior of STD patients.
Therefore, when AIDSCAP decided to focus on STD control as part of its HIV prevention efforts, it looked for a strong private sector partner. The Centres pour le Dloppement et la SantCDS), a large NGO providing care to more than half a million poor, primarily urban Haitians, had the infrastructure and an interest in developing an STD control strategy.
Our hope was that as CDS'STD control program became stronger, other institutions would want to join the effort, Dr. Gcxplained.
To learn more about STD case management practices in Haiti, researchers from AIDSCAP, CDS and the University of North Carolina at Chapel Hill (UNC) conducted an evaluation at five of CDS' primary health care centers in Citoleil. The research team interviewed health care providers, observed interactions between patients and providers, and reviewed laboratory logbooks and patient files.
The study revealed that more than 90 percent of the clinicians treated urethral discharge with penicillin or ampicillin, even though tests at the national reference laboratory showed that at least 60 percent of gonococcal strains were resistant to these antibiotics. Treatment of another cause of urethral and vaginal discharge-chlamydia infection-was essentially ignored. Sexual partners of STD patients were seldom referred for treatment and pregnant women were rarely screened for syphilis.
Based on these findings, an STD control strategy for CDS was proposed to an ad hoc advisory committee with representatives from CDS and other local NGOs, international donors and one traditional healer. The strategy would be implemented by training clinicians in comprehensive STD case management, including prevention education and counseling. Pregnant women would be screened for syphilis to prevent congenital syphilis and drug lists would be updated to include drugs effective against gonococcal infections.
Because of the limited laboratory diagnostic capabilities available in Haiti, the strategy was based on the syndromic approach to STD management. This approach involves treating for the most common causes of an STD syndrome during a patient's first visit to a clinic rather than trying to determine the exact cause of a group of symptoms and signs. For example, clinicians were advised to prescribe drugs to treat both gonococcal and chlamydial infections in patients seeking treatment for urethral discharge or cervical infections.
CDS accepted this proposal, which was based on the World Health Organization's (WHO's) algorithms for treating urethritis and cervical infections, but other members of the committee did not. Since none of the available local data showed the importance of chlamydial infection, many providers believed it was rare among Haitians. Others were simply opposed to using the syndromic approach to manage any STD syndrome, even though most acknowledged that laboratory tests were not always available and laboratory results were often unreliable.
In 1993 researchers from AIDSCAP, CDS and UNC conducted a baseline survey of STDs among 1,001 patients at two CDS antenatal clinics. It was the first study to look at STD prevalence in a group drawn from the Haitian population rather than from STD patient rolls. Pregnant women were studied because they were easily accessible yet fairly representative of the population.
The survey found that almost half the women had at least one STD. Eleven percent tested positive for syphilis, 34 percent had trichomoniasis, 10 percent had chlamydial cervical infection and 4 percent had gonococcal cervical infection.
Perhaps most important was the finding that chlamydial infection was much more common than gonorrhea. This discovery validated the use of the WHO treatment algorithm in Haiti, helping convince local providers and decision makers that men with urethritis and women with cervical infection should be treated for both chlamydial and gonococcal infections.
A woman walks through the center of Port-au-Prince during a general strike enforced at gunpoint in October 1993. Despite political turmoil, Haitians were able to lay the groundwork for a national STD control program. (Sean Sprague/Panos Pictures)
The study results were shared with health professionals working in STD control through formal and informal presentations. They were also published in CDS' magazine and in the Journal of Infectious Diseases.
Following the recommendations generated by the baseline survey results, CDS established a comprehensive STD control program. CDS staff received training and guidelines for providing STD care at the primary health care level. Because clinicians might not have time to focus on prevention, nurse-counselors were trained to counsel patients and their partners and to promote safer sexual behavior and condom use.
CDS also reinstituted systematic prenatal syphilis screening at its antenatal clinics. The Pan American Health Organization (PAHO) 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.
In 1994, a coalition of 13 NGOs working on HIV/AIDS prevention in Haiti's Central Plateau began a similar STD control program, including prevention education for STD patients and their partners and syphilis screening for pregnant women. Again PAHO provided a one-year supply of STD drugs, and most NGOs instituted a cost-recovery system.
After two and a half years, an evaluation showed that STD case management in CDS centers had improved significantly. The percentage of 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.
By providing training to physicians, nurses and social workers, we created a core group that helped us move to consensus.
A condom promotion poster at a clinic in Port-au-Prince. (Sean Sprague/Panos Pictures)
From 1992 to 1995, AIDSCAP sponsored the training of more than 400 Haitian clinicians, counselors and laboratory technicians from CDS, the NGO coalition, and other Haitian institutions in the skills needed to provide comprehensive STD services. Most of the training was done in Haiti at the national center of excellence in STD research, training and counseling, an institution well known for its HIV/AIDS research under the name of Cornell-GHESKIO (Groupe Haitien d'Etudes de Sarcome de Kaposi et des Infections Opportunistes).
Dr. Gcstimates that 90 percent of the NGOs in Haiti have a staff member trained in STD treatment and prevention at Cornell-GHESKIO. By providing training to physicians, nurses and social workers, we created a core group that helped us move to consensus, he said.
Despite the progress made by CDS and the NGO coalition in the Central Plateau, in 1995 there was still no standardized approach to STD diagnosis and treatment in Haiti. Each of the three groups providing most of the STD care in the country - CDS, the NGO coalition and Cornell-GHESKIO - was using different treatment algorithms. CDS and the coalition had adopted the syndromic approach, but many of the national reference center's algorithms involved laboratory diagnosis.
To encourage the NGOs to agree on a standard approach to STD case management, AIDSCAP convened a seminar in February 1995 on management of nonulcerative genital infections in women. It was during this seminar that 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 that they should adopt a syndromic approach to STD case management.
Representatives of the local PAHO/WHO office, Cornell-GHESKIO, CDS, the Central Plateau NGO coalition, UNC and AIDSCAP formed a working group to develop national guidelines for STD case management. In the fall they were joined by officials from the Ministry of Health of the newly restored democratic government. The guidelines were presented and discussed at a second seminar for health professionals and medical decision makers held in collaboration with the Ministry of Health in November 1995.
Adoption of these guidelines will further improve STD case management in Haiti, but does not guarantee that all health care providers will follow the guidelines. Indeed, experience shows that changing the behavior of providers is at least as difficult as changing the behavior of STD patients. For example, clinicians are often reluctant to give up laboratory diagnosis even when it is substandard and incomplete. Because of relatively high personnel turnover in some clinics, many newly hired clinicians have not yet learned the new approach to STD care. This problem could be addressed by updating the content of STD training at the local medical school. Continued provider education and field supervision are critical.
The experience leading to the adoption of national STD guidelines in Haiti offers a number of policy lessons. First, it is not unusual for policy agreement and adoption to take many months or even years. In Haiti, the consensus-building process took three years.
A strategy for achieving a desired policy goal is essential. In Haiti, the STD strategy included working with strong local partners, conducting local studies, presenting and disseminating study results to key audiences, training and consensus building.
Haitian program specialists played a central role in moving the proposed policy agenda. The existence and persistence of a core group of committed individuals helped convince skeptics of the importance of the new approach to STD treatment.
Most national health guidelines are developed by the Ministry of Health. Because of the political situation, development of Haiti's STD guidelines began with local institutions, who later collaborated with the Ministry of Health-a novel bottom-to-top approach. The essential groundwork has been laid, and the government and NGOs can now work together to build a national STD control program.
Frieda Behefs, MPH, is a research instructor at the University of North Carolina at Chapel Hill, an AIDSCAP Project subcontractor. She has provided technical assistance in STD control in Haiti, Jamaica and Malawi.
A counseling session in a Haitian clinic. (Hally Mahler/AIDSCAP)