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LESSONS LEARNED

Building Consensus and Communication

- Building the foundation for improving care at points of first encounter requires intensive effort at the policy and program management levels.

Engaging the commitment and resources of public health officials and STD managers and providers demands significant technical assistance and consensus building. AIDSCAP's experience in Haiti, where such efforts led to national consensus on STD guidelines and improvements in service delivery, shows that the time and resources necessary to orient and train policymakers, managers and providers are well worth the investment. An initial assessment is necessary to determine a baseline level of care that is provided. This will be the data used to determine improvement.

- Biologic studies of STD prevalence and antibiotic susceptibility in a country are essential to building consensus on national STD treatment guidelines.

The local data that these studies generate can help convince STD program managers and health care providers to adopt the syndromic approach to STD management. AIDSCAP found that once managers and providers understood the magnitude of the STD problem in their country and the ineffectiveness of many of the current treatment practices, they were more likely to appreciate the benefits of a simple, standardized approach that increases access to effective treatment.

- Training alone is not enough to implement syndromic management into an existing health care system.

Supervision, updates, refresher courses and a commitment to change management practices are essential to integrate syndromic management into existing health care systems. Syndromic guidelines can be distributed and implemented in a standardized way on a large — even national — scale through clinical flowcharts. Moreover, flowcharts facilitate and improve training of health care workers in STD management.

Development and Implementation of STD Flowcharts

- A single, universally applicable model for STD flowcharts does not exist.

Local data on etiology and antimicrobial susceptibility are needed to design an effective flowchart. The validity and cost-effectiveness of different approaches can in many situations be estimated from the literature or assessed in special studies.

- Flowcharts should be validated in a field audit to assure efficacy.

Before the introduction of new flowcharts, feasibility and acceptability should be assessed in the given health infrastructure. This will validate acceptable levels of sensitivity and specificity.

- A flowchart will always be a compromise between diagnostic accuracy and technical and financial realities.

Improving Access to STD Care

- STD Syndromic Management is perfectly adapted to primary health care settings.

In many developing countries, a syndromic approach for the management of patients with STDs is currently being used, resulting in well accepted, quality STD care in primary health care settings. Because it is simple, rapid and does not require sophisticated laboratory tests, the syndromic approach makes it possible for almost every health care worker to offer prompt diagnosis and treatment to patients with STD symptoms.

- Research findings from several countries confirm that many people seek STD treatment outside the formal medical system.

Although high levels of self-treatment and limited resources for STD control in many countries compel policymakers, medical professionals and donors to consider innovative approaches to improving access to effective treatment, opposition to providing STD management outside the clinic setting is strong. Training pharmacists and other drugstore personnel in the syndromic approach can improve the management of STDs in many patients who choose to self medicate.

- The achievements of an STD control program depend to a large extent on the successful management of STDs at a patient's point of first encounter with the health care system.

Genital ulcers in men and women and urethritis in men can be adequately managed using a syndromic approach based on symptoms and clinical signs only. For lower genital tract syndrome in women, the concept of adding a risk score to the syndromic management holds promise as a more sensitive way to detect cervicitis. Ongoing validation and acceptability studies will further demonstrate the advantages of this approach compared with the classical clinical (etiologic) approach.

- Drug availability is the most essential component of the clinical management of STDs.

Without a consistent drug supply, patients cannot be treated appropriately, and lapses in the supply cause the community to lose confidence in the system which leads to poor care seeking behavior.

Detecting Asymptomatic STDs

- Current risk assessment strategies are not a valid tool for identifying STDs in women without symptoms.

The main obstacle to managing STDs other than syphilis in asymptomatic women is the absence of valid, feasible and affordable case-finding and screening strategies, particularly for gonococcal and chlamydial infection. Results of a study conducted by AIDSCAP in Jamaica and by others attempting to define a risk profile for infected asymptomatic women have been disappointing. This study found that risk assessment scores derived from current flowcharts are neither sensitive nor specific enough for widespread use. However, imperfect approaches that include risk assessment may be a better option than doing nothing at all, particularly in areas where STD prevalence is high. Moreover, risk assessment may continue to play a role in the management of STDs in asymptomatic women because risk scores could be used to determine who should be tested for a sexually transmitted infection when an appropriate test becomes available.

- Partner referral is possible in a variety of settings.

Reaching partners of STD patients with treatment — a long neglected component of STD management in most countries — has great potential for improving STD control because it results in treatment of asymptomatic partners, particularly women. AIDSCAP's improved partner management systems in ante-natal clinics in Haiti attained referral rates of 30 percent.

This pilot study found that almost half of the women attending two Haitian ante-natal clinics had one or more STDs. Ninety percent of the women agreed to inform their partners, and 30 percent of the 331 men named by 384 women sought treatment. Health workers found that men were more willing to come for treatment when the problem was framed in the context of preserving fertility or ensuring healthy offspring. When men who had come to the clinic were asked why it was important to them to receive treatment, one of the most common responses was "to protect the child."

- Health workers without any laboratory experience can be trained to perform accurate syphilis blood tests, making it possible to expand syphilis screening of pregnant women.

An effective, affordable treatment for syphilis is available, yet hundreds of thousands of undetected and untreated maternal syphilis cases lead to fetal loss, infant death or congenital abnormalities every year. Too often, logistical and managerial obstacles impede use of the rapid, simple, inexpensive syphilis diagnostic test for routine screening in ante-natal clinics. In Jamaica, AIDSCAP worked with the Ministry of Health to remove some of the obstacles in a successful effort to decentralize syphilis testing.