(introduction...)

The syndromic approach to STD case management includes a comprehensive public health approach to patient care. In addition to diagnosis and treatment, comprehensive case management includes partner treatment, health education, and condom education, promotion and distribution. To remind health care workers of these aspects of case management, short messages could be added to the flowchart as shown in Figure 8.

Figure 8 · Counsel regarding sexual risk reduction · Review compliance with treatment regimen · Promote condom use · Encourage partner notification and partner treatment.

Partner Treatment

Partners of patients with an STD are likely to be infected themselves and should be offered treatment. Partner notification and referral can be one of the most important ways to detect and treat asymptomatic patients. Confidentiality, a non-judgmental attitude and the absence of coercion are important for the success of partner notification. The WHO recommends epidemiological treatment (treatment based solely on the diagnosis of the index patient without any laboratory investigation) be given to all partners.²³

An important implication of the low positive predictive value of some flowcharts is the over treatment of partners, resulting in unnecessary drugs given and the psychological cost of inappropriate labeling.

The syndromic approach to STD case management includes a comprehensive public health approach to patient care.

Health Education

Patients seeking STD treatment may be particularly receptive to educational messages, recognizing the personal vulnerability evidenced by their symptoms. With HIV in the picture, people are more likely to welcome advice. Health education focuses on reducing risky behavior, such as through the use of condoms or other mechanical barriers, and stresses the importance of partner treatment. As time is usually very limited during a consultation, there is a real danger this opportunity for face-to-face education will be missed.

Condom Distribution

The global effectiveness of condoms for preventing STDs depends on the efficacy of the method and user acceptability. Condom demonstration by the health care provider during the contact with the STD patient is a good way to recruit new users.

Adding Strategies

The syndromic approach to STD management is not the complete solution to STD control. It works well for urethral discharge in men, genital ulcer disease in both men and women, and pelvic inflammatory disease, but is less than optimal for managing vaginal discharge, even with the addition of a risk assessment. Moreover, syndromic management was never designed as a tool for identifying infection in asymptomatic people. Greater support is required for additional approaches, including partner referral and treatment, services targeting high-risk populations, and comprehensive syphilis screening of ante-natal women. Rapid, inexpensive, simple diagnostic tests for gonococcal and chlamydial infection are urgently needed to improve the management of STDs in women.

Syphilis Screening and Treatment

Although treatment for syphilis is included in the syndromic algorithms for genital ulcers, many cases of syphilis could be missed by using this criteria alone because a person could be infected with syphilis without having a genital ulcer. Fortunately, there is a simple and cost-effective laboratory test that can be used to screen patients for syphilis and that can provide results the same day as the patient visit. This test is best utilized among patient populations that have a high rate of infection, such as at STD clinics, STD patients in primary care settings, or in ante-natal clinics where untreated syphilis can have catastrophic effect on birth outcomes. As an example, Jamaica decentralized and implemented just such a screening program in an attempt to reduce their high syphilis rates. Laboratory aides and assistants with little laboratory experience learned how to perform syphilis blood tests at the clinic sites. And although some people were skeptical that this level of health worker could perform the test accurately, a quality control assessment confirmed 96 percent of the results of the syphilis tests performed by the lab aides. In Jamaica, syphilis screening is now available at 76 ante-natal clinics and 17 STD clinics. As a result, 68 percent of those who test positive for syphilis are treated the same day, and 85 percent received treatment in less than one week. This contributed to the 50 percent decline in infectious syphilis found over a 2 year period.²⁴

Training

Most traditional health care training is based on an etiologic model. Thus, the syndromic approach to STD management is a new concept to most health care workers. Therefore, the retraining of health care clinicians, whether they are physicians, nurse practitioners or public health nurses, is an important component of initiating this approach into a public health system.

Clinical training of STD personnel can be difficult and must reflect reality and be problem-oriented. Flowcharts are useful training tools for this purpose because they are based on the presenting symptoms and show the path of diagnostic reasoning to reach a proper diagnosis and to prescribe the best treatment. The skills of history taking and physical examination must not be neglected in this approach. Health care workers must still learn to ask the most relevant questions, including questions on sexual behavior, and to look for the most important physical signs. Active participation of students in the logical, step-by-step construction of flowcharts is educationally beneficial and facilitates their acceptance and use.

The following are important components of training in the syndromic approach to STD management:

- National STD guidelines and flowcharts must be established before training and should be the basis of the training module.

- Local data and local examples are important to convince participants of the utility of the training.

- Careful and proper training of the trainers is essential for a high quality transfer of ideas.

- All training must be followed up with frequent supervisory visits. It has been proven in numerous instances that merely providing training without follow-up reinforcement will produce poor results.