Theoretical Foundation

STD syndromic management relies on clinical syndromes (for instance, vaginal discharge, genital ulcer, or urethral discharge) and, in some cases, assessments of an individual patient's risk for STD infection to make presumptive diagnoses of selected STDs. In many areas where definitive diagnostic tests generally are not available and/or where use of the tests and consequent treatment delays are not practical, syndromic diagnosis may offer a feasible approach to the management of STDs in men and women.

A fundamental goal of STD control programs is early detection and treatment of disease, preferably at the point of first encounter between the patient and the health system. In many countries, STD patients are seen more often in private facilities (private physicians, clinics, or pharmacies) and primary health care settings than in specialized STD clinics. Therefore, an effective and efficient public health program needs a tool that is rapid, inexpensive, simple, accurate, and can be implemented on a large scale by health providers with diverse levels of expertise and training.

Etiologic diagnosis of most STDs can be difficult, particularly in women. While simple diagnostic tests are being investigated, the range of existing laboratory tests appropriate for low-resource settings is limited. Both gonococcal and chlamydial infections in women currently have to be diagnosed through culture techniques that are expensive and technically demanding or through antigen/genomic detection (available tests are expensive and not always appropriate in low-resource settings). Gonococcal infections in men can be diagnosed through microscopy, assuming a microscope and trained microscopist are available. RPR/VDRL and TRUST tests can be used to screen for syphilis but require serum or plasma.

Even in settings with access to reliable laboratory facilities, the delays inherent in reporting test results hinder the timely treatment of STD cases. Referral of cases, even in a well-structured health system, remains problematic in practice due to constraints in time, resources, and social barriers. Delays in treatment can undermine the confidence a patient has in health providers; STD patients expect a health worker to make a prompt and reasonably accurate diagnosis. Furthermore, delays in treatment result in loss of follow up to a significant proportion of clients.

It is generally agreed that the use of appropriate syndromic diagnosis protocols in well-managed, adequately monitored facilities with ready access to therapeutic drugs would be a considerable improvement over how STDs currently are managed in many settings. The small proportion of patients who have access to STD services in many developing countries are often diagnosed according to a given provider's "best guess" as to the cause of specific symptoms and treated with available drugs that may or may not be appropriate. Experience has shown that even highly skilled STD specialists will misdiagnose or miss concurrent infections in a significant proportion of cases when making diagnoses on the basis of their own clinical experience.^13,14

Flowcharts, on the other hand, rationalize and standardize clinical decision making. Their use can also standardize diagnosis, treatment and referral. Such standardization makes STD reports from different health facilities comparable; simplifies STD data collection and analysis, which in turn facilitates surveillance and planning (e.g., the purchase of drugs and other supplies); facilitates supervision of health care workers since the approach is the same in every health facility; ensures STD patients receive the same treatment for a given condition in every health facility, thereby enhancing confidence in health services; and delays the development of antimicrobial resistance of sexually transmitted microorganisms.