HOLOGRAPHIC OVERVIEW

This SYNOPSIS booklet discusses the importance of Syndromic Management of Sexually Transmitted Diseases (STDs) through a holographic approach. Holography is a special photographic technique that produces images of three dimensional objects. This photographic record is called a hologram, and one of its main applications is that any fragment of the hologram can regenerate the entire image, even if the fragment is extremely small. In other words, if a negative from an ordinary picture is cut into two, the print from each half would only show half of the picture. Conversely, if a holographic negative is cut in two, the print from each half would show the entire picture. If these halves are cut again, the print from any one of the pieces will reconstruct the whole picture.^3,4,5

Utilizing the holographic model, this booklet was written such that any one of the sections (holograms) will provide the reader with an understanding of the whole subject matter. First, we describe the entire strategy or topic of discussion in one sentence, the widespread definition and/or our own definition of the subject (Hologram 1). Next, we present a one-paragraph abstract of the topic (Hologram 2), expanding upon the original definition. Then, we present the topic by providing a summary or recapitulation of the main points of each of the sections of the booklet (Hologram 3). Finally, the entire strategy is again presented by virtue of the complete text of the booklet (Hologram 4).

We anticipate that the Holographic Overview of STD Syndromic Management will benefit both the seasoned professional and the novice. It provides a quick, general overview of the syndromic approach as well as context and background. It also directs the reader to specific sections that may be of greatest interest or that the reader would like to review first or at a later date. Thus, we hope this approach will enable the reader to make fuller use of the booklet as a reference guide, as it provides a simple and concise definition of STD Syndromic Management, a brief description of the topic, a summary of the discussion, and finally, the complete text — all in one document.

The reader should note that while we have tried to include the key issues surrounding STD case management in this SYNOPSIS, the booklet is not meant as an exhaustive discussion of all of the issues regarding the critical role of the syndromic approach in the fight against HIV/AIDS.

The Whole Strategy

Hologram 1: The Definition

STD Syndromic Management is the diagnosis and treatment of selected STDs based on the identification of a syndrome through a clinical flowchart. A syndrome is a group of symptoms (what the patient feels or has noticed) and easily recognized signs (what the health care provider finds on examination) associated with a number of well-defined etiologies (the specific organisms causing disease). Once a syndrome has been identified, treatment can be provided for the majority of the organisms responsible for that syndrome. A clinical flowchart is a step-by-step standardized guide to medical decision making.

The Whole Strategy

Hologram 2: The Abstract

The control of sexually transmitted diseases is an essential component of all public health programs. Controlling STDs is important because they not only cause great morbidity but as studies have shown, left uncontrolled, they significantly increase the spread of HIV. The worldwide burden of STDs — primarily gonorrhea, chlamydial infection, trichomoniasis, syphilis and chancroid — is staggering. The World Health Organization (WHO) estimates that between 150 to 330 million new cases of curable STDs are transmitted each year. The development of syndromic management guidelines and other efforts to improve STD prevention and control at "points of first encounter" within the health system were prompted by the rapid spread of the HIV/AIDS pandemic. One reason for this new attention to STDs is obvious: the sexual behaviors that lead to STDs also promote the spread of HIV. Consequently, STD Syndromic Management has proven to be the best approach that can be offered to patients presenting with STD symptoms. It is adapted to primary health care settings in developing countries, and makes it possible for almost every health care worker to offer prompt diagnosis and treatment to patients with STD symptoms without the need for sophisticated laboratory tests. In order to assure well-accepted, quality STD care, accurate and validated syndromic algorithms are not sufficient. Continued training and supervision of health care providers is of utmost importance. This can only occur in an environment of cooperation between implementing agencies and a grassroots mandate that this public health approach to patient care is quality care for the individual as well as for the community.

The Whole Strategy

Hologram 3: The Summary

Introduction

Developing country health providers at all levels, in both the public and private sectors, are confronted with many patients with STDs. STD-related complaints are among the most common reasons why adults seek health care in many countries. However, primary health care facilities in developing countries and other resource-poor settings face many constraints in the management of patients with STDs. Comprehensive case management of STDs is the cornerstone of STD control. This includes the diagnosis and treatment of the patient, partner treatment, health education, and condom education, promotion and distribution. Prompt and effective case detection and treatment result in immediate benefits for individual patients, and reducing the duration of patients' infectiousness decreases the incidence and prevalence of STDs in the population.

HIV infection is not equally distributed around the world. It is estimated that 68 percent of all infections are found in Sub-Saharan Africa, 10 percent in Latin America and the Caribbean, 7.5 percent in Southeast Asia, 7.5 percent in North America and 6 percent in Europe. Similarly, STDs are not equally distributed globally. Between 40 and 50 percent occur in Southeast Asia, 20 to 25 percent in Sub-Saharan Africa, 10 to 11 percent in Latin America and the Caribbean, 5 to 6 percent in Northern Asia and Eastern Europe, and 1 to 2 percent in North America. STD prevalence rates vary from country to country due to under-recognition, incomplete reporting and/or delays in reporting.

Studies have shown that STDs enhance the transmission of HIV, both infectiousness and susceptibility. Therefore, improving STD prevention and treatment represents one of the main HIV prevention strategies. Critical to the development of optimal strategies for HIV prevention and control is understanding the role of other STDs in the transmission of HIV, the role of STDs in the progression of HIV disease, and the role of HIV infection in alterations of natural history, diagnosis, or response to therapy of STDs. In a landmark pilot study in Mwanza, Tanzania, the use of the syndromic approach to STD treatment reduced HIV incidence by 42 percent. Subsequent research in Malawi and Cote d'lvoire documented that STDs are associated with higher HIV infection rates and that STD treatment can make HIV-positive men less infectious.

STD Syndromic Management

An effective and efficient public health program needs a tool that is rapid, inexpensive, simple, accurate and that can be implemented on a large scale by health providers with diverse levels of expertise and training. The syndromic approach is the answer to many of the obstacles to efficient STD case management in developing countries. It allows health care workers to make a diagnosis without sophisticated laboratory tests. It is based on clinical syndromes and, in some cases, assessments of an individual patient's risk for STD infection. Etiologic diagnosis of most STDs can be difficult, particularly in women. Even in settings with access to reliable laboratory facilities, the delays inherent in reporting test results hinder timely treatment of STD cases. Flowcharts rationalize and standardize clinical decision making. Their use can also standardize diagnosis, treatment and referral. The advantages of syndromic management include: can be implemented on a large scale, rapid and simple, high sensitivity in most cases, laboratory tests are not necessary, cost effective, clinicians at any level and expertise can succeed with this approach, and simplifies data collection and surveillance. Finally, theoretical analysis indicates that the cost per patient managed through syndromic diagnosis could be four times less than through clinical diagnosis and seven times less than etiologic diagnosis. The disadvantages include the following: tends to over treat due to decreased specificity, does not perform well in low prevalence settings, ignores asymptomatic cases, may overuse expensive drugs, management of cervical infection is problematic, and notifying sexual contacts without proof of infection in the index case can be problematic.

Designing STD Flowcharts

A team of public health specialists should design diagnostic and therapeutic flowcharts for use at the national level. Key design people include the coordinators of national programs, including STD/AIDS control, primary health care, essential drugs, family planning and maternal and child health. It is advisable also to involve gynecologists, microbiologists, genito-urinary specialists and pharmacists to ensure their cooperation and increase the acceptance of the flowcharts. Background information on local etiologies of STD syndromes is essential in designing an STD management flowchart. Decisions on the most cost-effective treatments must be based on local or regional antimicrobial susceptibility patterns, results of treatment trials, toxicity data and the cost of the drugs. Flowcharts should be adapted to the level of development of the health services in order to ensure efficient management of STDs. Local and cultural perceptions about STDs and health-seeking behavior also determine the usefulness of certain flowcharts. The original WHO flowcharts were developed for six syndromes: urethral discharge, vaginal discharge, pelvic inflammatory disease, genital ulcer disease, swollen scrotum and neonatal conjunctivitis. The first four are discussed in this SYNOPSIS.

Other Components of Comprehensive STD Case Management

The syndromic approach to STD case management includes a comprehensive public health approach to patient care. In addition to diagnosis and treatment, comprehensive case management includes partner referral and treatment, health education, and condom education, promotion and distribution. Services targeting high-risk populations and comprehensive screening of syphilis for ante-natal women should also be included, along with the re-training of health care providers, whether physicians, nurse practitioners or public health nurses.

Introduction of STD Syndromic Management in LAC

The adoption of syndromic management requires considerable effort at the policy level as well as research to validate and adapt WHO algorithms in different settings. A consensus must be developed with local officials and health care providers on the need for a standardized approach to STD management and national guidelines for syndromic management of STDs. The success of this collaborative process lays the foundation for subsequent efforts to strengthen STD services in a country. 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 the different countries found marked increases in the percentages of clients receiving effective treatment. These and other findings, as well as many lessons learned and recommendations, are derived from the experiences of introducing STD Syndromic Management in the five AIDSCAP priority countries in Latin America and the Caribbean — Haiti, Jamaica, Brazil, Honduras and the Dominican Republic.

Lessons Learned

Lessons learned from the introduction of STD Syndromic Management are classified into four categories:

1) Building Consensus and Communication: building the foundation for improving care at points of first encounter requires intensive effort at the policy and program management levels; biologic studies of STD prevalence and antibiotic susceptibility in a country are essential to building consensus on national STD treatment guidelines; and training alone is not enough to implement syndromic management into an existing health care system.

2) Development and Implementation of STD Flowcharts: a single, universally applicable model for STD flowcharts does not exist; flowcharts should be validated in a field audit to assure efficacy; and a flowchart will always be a compromise between diagnostic accuracy and technical and financial realities.

3) Improving Access to STD Care: STD Syndromic Management is perfectly adapted to primary health care settings; research findings from several countries confirm the impression that many people seek STD treatment outside the formal medical system; the achievements of an STD control program depend to a large extent on the successful management of STDs at a patient's point of first encounter with the health care system; and drug availability is the most essential component of the clinical management of STDs.

4) Detecting Asymptomatic STDs: current risk assessment strategies are not a valid tool for identifying STDs in women without symptoms; partner referral is possible in a variety of settings; health workers without any laboratory experience can be trained to perform accurate syphilis blood tests, making it possible to expand syphilis screening of pregnant women.

Recommendations

The following steps are recommended in order to establish a comprehensive STD case management system: collect data regarding local STD prevalence, antimicrobial susceptibility patterns and STD beliefs and practices; review epidemiological data to reach consensus on national STD treatment guidelines; continue training and supervision of health care providers in syndromic management, program management and rapid diagnostic tests for STDs; work to ensure required drugs are available; improve traditional STD services with alternative or non-traditional approaches; promote early treatment seeking behavior and partner referral systems; conduct syphilis screening and/or treatment for pregnant women.