Jamaica

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.