Syndromic approach to STD case management: where do we go from here?

In the absence of aetiological tests for the diagnosis of individual sexually transmitted diseases (STD), the syndromic approach has been developed as an effective and appropriate case management strategy. Algorithms provide guidance to healthcare workers and ensure standardised approaches to case management. The syndromic approach, utilising currently available algorithms, works well in the management of people with symptomatic urethritis, genital ulcer disease, and vaginitis. Owing to the frequently asymptomatic nature of gonococcal and/or chlamydial cervicitis, and the lack of specific defining risk factors and/or signs and symptoms, the syndromic approach performs less well in the identification and management of women with cervicitis. The syndromic approach can and should be adopted for the management of patients with urethral discharge, genital ulceration, vaginal discharge, and cervical signs. Further research is needed to improve the identification and management of cervical infections; to guide policy makers in selecting the most appropriate disease control strategy; to improve utilisation of available and future tests; to develop affordable, rapid, and simple diagnostic tests; and to develop STD vaccines.

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.

HIV, STD and their current impact on reproductive health: the need for control of sexually transmitted diseases.

STD and HIV are the second most important cause of Disability Adjusted Life Years lost in women in the developing world. Reasons for this are multiple, and include their higher vulnerability for STD and HIV, poor health care seeking behavior and lack of accessible and acceptable services. There is considerable synergism between family welfare services and STD programs: complications and sequelae of STD affect the reproductive tract and child health and survival; reproductive and child health and survival are the focus of family welfare programs. Family welfare services are thus well positioned to incorporate STD and HIV prevention and control measures. This is feasible, although practical and logistical problems need to be addressed. Where indicated, pilot integration projects can assess the cost-effectiveness and outcome of such programs.

Sexually transmitted diseases and HIV infection: implications for control and prevention.

PIP: The most important mode of HIV spread globally is heterosexual intercourse. This article focuses upon the relationship between traditional sexually transmitted diseases (STD) and HIV infection, and considers the implications for STD control as a strategy to prevent HIV infection. Evidence is accumulating that the relationship between STD and HIV infection is threefold as follows: the presence of an STD is a marker of risk behavior for HIV infection, STDs are biological cofactors for HIV transmission, and concurrent HIV infection increases the virulence of some STD pathogens. Unprotected sexual intercourse with multiple partners predisposes one to infection with traditional STDs. The same behavior has also been shown to be a risk factor for HIV transmission. The incidence of both HIV infection and other STDs therefore indicates the practice of high risk sex behavior in a community. An increased incidence of HIV infection has been found in people with genital ulcer disease. It is therefore likely that genital ulcerations caused by traditional STDs provide easy entry or exit points for HIV. Since traditional STDs are important cofactors of HIV transmission, controlling STDs would be an important strategy in the fight against HIV/AIDS. STD control is based upon prevention through information, education, and communication aimed at reducing the level of unsafe sexual behavior, and diagnosing and treating STDs. Syndrome-based STD case management should be integrated into first-level health care services in the public and private sectors to develop effective, accessible, and acceptable services to people at increased risk of infection with STD. The support of specialized STD clinics and STD specialists will be needed.^ieng

The provision of safe blood--policy issues in the prevention of human immunodeficiency virus transmission.

The AIDS epidemic has focused attention on the constraints and deficiencies present in many blood transfusion services in the developing world. We discuss a variety of options for reducing transfusion-related HIV transmission, and suggest how new transfusion strategies may be implemented. We show that a transfusion service cannot rely solely on the screening of donor blood for anti-HIV antibodies and that a more comprehensive approach is needed. Important components of this approach include donor selection and improved clinical practice, in which blood and blood products are prescribed only when really necessary.

AIDS: is health education the answer?

In the absence of a vaccine or effective treatment, prevention of infection with the human immunodeficiency virus (HIV) is presently the only feasible option for the control of AIDS. Most transmission is related to high risk behaviours, and attempts to change these behaviours are key objectives of many AIDS Control Programmes. Health Education, or Information, Education and Communication (IEC) strategies have been developed to achieve these objectives. Yet few evaluations of health education programmes have been carried out, and the intimate relationship between AIDS and other sexually transmitted diseases is often ignored. Behaviour has a multitude of determinants, and consequently no simple approach focusing on one aspect of behaviour can be expected to be successful. Not only does knowledge need to be imparted, but attitudes, beliefs, social- and peer-group norms need to be addressed. The development of IEC programmes is hampered by the specific routes of transmission of the HIV, involving sensitive areas of human behaviour, and by a lack of knowledge about these behaviours. Nevertheless, a number of seemingly successful programmes have been carried out. Active participation of the target groups appears to be a key factor in success. Although health education makes intuitive sense, rigorous documentation and strict evaluation is necessary to provide its justification and to maximize the potential of this strategy.