Haiti

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.