Observations of sexually transmitted disease consultations in India.

OBJECTIVES: To assess the quality of sexually transmitted disease (STD) case management provided in public and private health facilities in selected areas of Madras, Tamil Nadu, India, in order to make recommendations for improving the quality of care and promote the syndromic approach to STD treatment. METHODS: Structured observations of consultations for STDs in health care facilities. Scoring of the observations according to standards for history taking, examination, treatment and provision of basic health promotion advice allows evaluation of STD case management. RESULTS: With STD treatment adequacy scored against Indian national guidelines (which recommend aetiologic treatment), history taking, examination and treatment were satisfactory in 76 out of 108 (70%) of observed consultations. However, if STD treatment adequacy is scored with respect to the syndrome approach towards selected STD (male urethritis and non herpetic genital ulcer for both sexes), only 8 out of 81 (10%) of the patients were satisfactory managed. During 32 out of 108 (30%) of the consultations, advice on the use of condoms in order to prevent STD or HIV/AIDS was given. Instructions regarding how to use condoms were offered to seven (6%) patients and condoms were only provided to one patient (1%). Patients were urged to refer their partner(s) for treatment during 29 (27%) of consultations. A criterion of adequate use of the STD consultation for health promotion, requiring both promotion of condoms and encouragement to refer partner(s) for treatment, was met during 13 (12%) of consultations. CONCLUSIONS: Monitoring and improving the standards of care at facilities at which STDs are treated have become key roles of STD/HIV/AIDS programmes. The present report suggests that in Madras the activities of medical practitioners who treat STD patients are far from ideal at present. Improvements would involve simplifying existing treatment guidelines by promoting the syndromic approach to STD management, continuing education programmes for health care providers in the public and private sectors and repeat assessments and feedback of the quality of STD care.

PIP: To assess the quality of sexually transmitted disease (STD) case management in Madras, Tamil Nadu State, India, structured observations of 108 consultations with 48 doctors at 65 private and public health facilities were conducted. These observations were scored according to standards for history taking, examination, treatment, and provision of basic health promotion counseling. When scored against national guidelines (which outline an etiologic approach to diagnosis), history taking, examination, and treatment were judged adequate in 76 observations (70%). However, if STD treatment adequacy was rated according to a syndromic approach (recommended by the World Health Organization) to selected STDs (male urethritis and nonherpetic male and female genital ulcers), only 8 (10%) of 81 such patients were managed satisfactorily. Condom use to prevent further STDs was encouraged in 32 consultations (30%), but instructions on how to use condoms properly was offered to only 7 patients (6%) and condoms were provided to just 1 patient (1%). Use of the STD consultation for health promotion, defined as condom promotion and encouragement to refer sexual partners for treatment, was adequate in 13 consultations (12%). These findings suggest a need for improvements in the standards of STD care at health facilities in Madras. Recommended are measures such as simplification of existing national guidelines for the treatment and prevention of STDs, promotion of a syndromic approach to STD management, continuing education programs for providers, and repeat assessments and feedback on the quality of STD care.

Sexually transmitted disease services in Madras: could their role in AIDS prevention be strengthened?

A baseline evaluation of the quality of STD case management was conducted in five areas of Madras city in 1992, using HIV prevention indicators recommended by the World Health Organization. Eighty-four interviews and 108 observations of private and public clinic practitioners were conducted. Sixty-one percent of interviewed doctors reported making only specific "clinical" diagnoses and 17% reported making only the WHO recommended syndrome-based diagnoses while 22% reported making both types of diagnosis. The adequacy of treatment was compared against various standards, including the Indian National Guidelines for STD management. Almost half of the health care providers (HCP) reported using a treatment effective against the two main pathogens that may cause male urethritis, while 20% reported using a treatment that was not effective against either. For male ulcers only 12% of HCPs reported using treatment effective against both syphilis and chancroid. Seventy-nine percent of the HCP reported that they advised their patients to use condoms, but in 30% only of observed consultations, condoms were promoted for STD or HIV/AIDS prevention. As information concerning the relative prevalence of pathogens in different areas is unlikely to be available, there is an urgent need for the syndromic approach to STD treatment be adopted by health care providers.

PIP: During November-December 1992, in Madras, India, interviews were conducted with 84 public and private physicians who treated at least five sexually transmitted disease (STD) patients each week in Royapuram, Washerman, Evr High Road, T. Nagar, and Adyar regions of the city. Field workers also observed 108 medical consultations of 48 of the physicians interviewed. Researchers aimed to use the findings of this baseline survey to optimize STD services in order to reduce the population at risk of HIV/AIDS. 61% of the physicians interviewed made specific clinical diagnoses. 17% made only syndrome-based diagnoses. 22% used both types of diagnoses. 48% used a treatment effective against the two main pathogens for male urethritis, Neisseria gonorrhoeae and Chlamydia trachomatis. 20% used a treatment that was not effective against either of these pathogens. Only 12% used a treatment effective against chancroid and syphilis for men with genital ulcers. 29% did not use a treatment effective against chancroid or syphilis. For female genital ulcers, only 10.7% of physicians used an effective treatment against chancroid or syphilis. 21.4% provided treatment effective against neither chancroid nor syphilis in female STD patients with genital ulcers. 79% claimed to counsel their STD patients to use condoms, but only 30% were observed actually promoting condoms for STD or HIV/AIDS prevention. Physicians instructed only 6% of STD patients how to use condoms. Condoms were given to only one STD patient. These findings highlight the need for physicians and other health care providers to adopt the syndromic approach to STD treatment and for developing and evaluating innovative and effective programs of patient education in order to reduce the risk of HIV infection.