Brazil

The project for the control and prevention of STDs in select areas of Brazil encompassed the years 1993-1997. Brazil has one of the most organized public health systems in the Americas. In Santos, for example, a network of 22 polyclinics services its half million population. However; only 1 polyclinic was providing STD services and care at the beginning of the project.

An assessment of STD case management revealed that the syndromic approach for the diagnosis and treatment of STDs was rarely used by health care workers. AIDSCAP and local counterparts initiated several projects to integrate STD syndromic management into the health care system in Rio de Janeiro, SPaulo and Santos.

At the onset of program implementation, supervisory staff were trained and given technical assistance in the fundamentals of the syndromic approach, methods and logistics of training sessions, and evaluation techniques.

The MOH had previously approved and printed national guidelines for the syndromic management of STDs, based on WHO guidelines and algorithms, and these were distributed to all polyclinics and health care workers. In addition, they received a pocket STD booklet with flowcharts and a list of appropriate medications and doses for STD syndromic management, a poster with the STD flowchart, and numerous copies of reference materials.

Concurrently, plans were made to conduct a study to formally validate all the national STD algorithms with a multi-center study that was conducted mid-project. This was felt to be an essential component of assuring efficacy for the future use of syndromic management.

During the life of the project, a total of 12 training courses on syndromic management were given to over 90 health centers and were attended by more than 1,000 health care workers. Additionally, in response to studies indicating pharmacists were selling drugs that were either ineffective or inadequate for the treatment of STDs, 31 private and public sector pharmacists were trained in STD syndrome recognition and management.

Several health care practitioners (HCPs) were resistant to accept the syndromic approach as a valid method to diagnose and treat STDs. Most HCPs were trained during medical school and residency to diagnose STDs based on the etiologic approach and considered the syndromic approach to be of a lesser quality of medicine. The HCPs also lacked confidence in the guidelines provided on the syndromic approach. The increase in supervisory visits to the HCPs and polyclinics to further discuss and provide instructions on implementing the syndromic approach proved useful in lessening this resistance. These visits also proved useful in the sensitization of gynecologists to STDs, since most did not consider some cases of vaginal discharge as possible STDs.

Many difficulties were faced during the implementation of this project. Most were related to the status of public health care provision, such as insufficient supplies, high turn-over of personnel, political changes and lack of infrastructure. For example, it is essential for the success of STD case management to have available drugs for the treatment of patients. However, this project depended on the Ministry of Health for STD drugs, and they arrived 10 months after the syndromic guidelines were introduced. The large time lapse between the training and the arrival of the STD drugs contributed to a general lack of motivation among the HCP and the coordinators, as they had difficulty believing the project would be carried out.

At the conclusion of implementing the syndromic approach, with its training and supervision, an evaluation to assess the level of the quality of STD care was conducted. The results indicated the syndromic approach was utilized in 50 percent of the male cases but in only 2.6 percent of the female patients. Ninety percent of the male patients reported receiving preventive messages regarding partner treatment, while just 34 percent of the female patients reported receiving these messages. Thus, while the use of the syndromic approach to diagnose and treat STDs has increased to 50 percent for men and 2.6 percent for females, it is important to note the increase was not substantially higher due to various factors. These include the overestimation of the validity of clinical signs for an etiologic approach, the resistance of STD specialists and teachers at the university to the syndromic approach and their continued teaching of the classical etiologic approach, and the influence of pharmaceutical companies on the prescription patterns of the physicians. Based on the aforementioned, additional training and refresher training were recommended, with particular focus on STD management in women.