Dominican Republic

In the Dominican Republic, STD services were improved by upgrading clinical facilities, improving STD drug logistics, and developing a STD syndromic management manual for practitioners. AIDSCAP, in collaboration with local counterpart institutions, conducted 37 courses in which 854 clinicians were trained, including social workers, nurse supervisors, and educators. Both clinicians and non-clinicians were required to attend refresher courses six months after the initial training workshop. Pre and post tests were conducted for all participants. In addition, STD treatment manuals and laminated treatment algorithms were distributed to health educators and providers. Subsequently, algorithm validation research was conducted, and a reporting and referral system was developed based on syndromic management.

Despite great success in many areas, the AIDSCAP/Dominican Republic program did face several constraints. High staff turnover rate among various collaborating agencies hampered program implementation and slowed the development of national STD guidelines. Logistics problems continued to affect STD drug distribution. Many clinicians proved reluctant to introduce syndromic management (rather than etiologic) of STDs. STD surveillance was constrained by the continuing problem of STD self-treatment and under-reporting on the part of providers.

In the Dominican Republic, a significant lesson learned was that the institutionalization of the syndromic management approach to STD treatment requires a long-term commitment and continuous support. Institutional support is necessary to overcome clinician resistance to obtaining additional training in a country where continuous education is not customary. It was also felt that continuous training was necessary due to the high turnover of clinic personnel.

Historically, few resources have been devoted to STD control in the Dominican Republic. NGOs and donor organizations play strong advocacy roles for the rational distribution of STD drugs, and clinicians involved in STD treatment have been valuable advocates for appropriate drug management. However, like every country, ensuring that STD drugs are available demands political commitment from the top and a strong logistical system that is part of the overall health care system, not parallel to it.

In the development of their flowcharts, the Dominican Republic effectively designed changes in the WHO templates for their country-specific needs. Because of the high prevalence of STDs in the country, it was thought that the syndromic algorithms should emphasize sensitivity over specificity. This was done by emphasizing demographic risk factors, such as young age and single marital status. Other changes included an evaluation of men with dysuria but no discharge, and treating suspected herpes for both syphilis and chancroid.