Syndromic Management of Sexually Transmitted Infections : Syndromic Management of Sexually Transmitted Infections Dr. Suraj Chawla Contents : Contents Background
STIs/RTIs: A public health problem
Why STIs/RTIs are more prevalent?
Objectives of STI case management
Approaches for STIs/RTIs management
Syndromic case management (SCM)
Why Syndromic case management?
Providers of SCM
Flowcharts Contents : Contents Syndromic case management (SCM)
Client education & counseling
Advantages of SCM
Disadvantages of SCM
Challenges regarding SCM Background : Background STIs/RTIs:
Sexually transmitted and reproductive tract infections are overlapping categories.
All sexually transmitted infections (STI) are not reproductive tract infections (RTI) and all reproductive tract infections are not sexually transmitted infections.
In these terms, ‘sexually transmitted’ refers to the mode of transmission, whereas ‘reproductive tract’ refers to the site of the infection.
For instance, although HIV is sexually transmitted it is not limited to the reproductive tract. Hepatitis B and C are other examples of STI that are not RTI. Background : Background Because those reproductive tract infections that are sexually transmitted generally have much more severe health consequences than the other RTIs, the STIs/RTIs term is used to highlight the importance of STI within reproductive tract infections.
The most common STIs/RTIs are trichomoniasis, chlamydia, gonorrhoea, syphilis, genital herpes, chancroid, human papilloma virus (HPV), bacterial vaginosis and candidiasis. Background : Background Situation in world
448 million new infections of curable sexually transmitted infections occur yearly.
75-85% cases occur in developing countries
In pregnant women with untreated early syphilis, 25% of pregnancies result in stillbirth and 14% in neonatal death.
Sexually transmitted infections are the main preventable cause of infertility, particularly in women.
Reference: http://www.who.int/mediacentre/factsheets/fs110/en/ Background : Background Situation in India
A nationwide community based survey conducted by NACO in 2002-2003 revealed a prevalence of 6% STIs/RTIs among adult population.
Based on this, it is estimated that approximately 30 million episodes of STIs/RTIs occur annually.
During financial year 2007-08, 2008-09 and 2009-10, around 2.6 million, 6.6 million and 8.2 million episodes of STIs/RTIs were treated at the STI clinics managed under NACP. RTIs/STIs – A Public Health Problem : RTIs/STIs – A Public Health Problem Major cause of ill health in country
Cause infertility, reproductive morbidities and systemic complications in men and women
Increases risk of HIV transmission
Increases cost to health system Slide 10: Why STIs/RTIs are more prevalent? High risk groups : High risk groups Adolescent boys and girls
Women who have multiple partners
Sex workers and their clients
Men and women who has to stay away from families for long
Men having sex with men
Partners of various high risk groups
Street children Factors increasing risk of transmission : Factors increasing risk of transmission Biological
- Age / Sex
- Immune status
- Personal sexual behaviour
- Poor menstrual and personal hygiene
- Status of women in society
- Sexual violence
- Child marriages Sexually Transmitted Diseases : Symptomatic Asymptomatic Sexually Transmitted Diseases Why women are at a higher risk? : Why women are at a higher risk? Biological differences
- Thin lining of vaginal mucosa
- Larger exposed area
- Genital fluids stay in contact for longer time
- Young women- Immature genital tract
- Symptoms less reliable indicator
Use of vaginal douches
Different socio-cultural norms for men and women Barriers – system and providers side : Barriers – system and providers side Failure to recognize magnitude
Overemphasis on lab based diagnosis
Irrational use of drugs
No standardized treatment regimen by all providers
Less emphasis on patient education and counselling
Specialized clinics carry stigma Barriers – Client side : Barriers – Client side Lack of knowledge
Reluctance to discuss sexual matters
Fear of judgmental attitude of providers
Reluctance for physical examination Operational model of the role of health services in STI case management : Operational model of the role of health services in STI case management Operational model of the role of health services in STI case management : Operational model of the role of health services in STI case management asymptomatic STI Partner notification
Selective mass treatment Objectives of STI case management : Objectives of STI case management To provide appropriate antimicrobial therapy in order to:
Obtain cure of infection
To limit or prevent high risk behaviour
To ensure that sexual partners are treated in order to interrupt the chain of transmission STI case management: Requirements : STI case management: Requirements Accurate diagnosis
Treatment at first encounter
Rapid cure with effective drugs
Education/ Counselling Comprehensive STI case management : Comprehensive STI case management History taking and symptoms
Client and partner(s) Slide 22: Syndrome
Assessment Diagnosis Treatment 5Cs Contact tracing
Counseling (screening tests) (diagnostic tools) Essential Steps In STI Case Management Risk Assessment : Risk Assessment A process of confidentially asking a patient particular questions to determine his or her chance of contracting or transmitting a RTI/STI (e.g. many women may be at risk due to the behaviour of their husbands or partners).
Why risk assessment?
To determine RTI/STI treatment
To tailor patient education messages
Determine need for lab test
Determine need for specific referrals (ICTC) Risk Assessment Include : Risk Assessment Include Sexual behaviours
Socio-demographics/other high risk markers:
marital status: not living with steady partner
History of impaired reproductive health i.e. History of past STI Rapid Laboratory Tests : Rapid Laboratory Tests May be used to narrow the spectrum of initial therapy. They include:
Wet mount (vaginal discharge)
Gram stain (Urethral Discharge, Cx Mucopus)
Dark-field microscopy (Genito-Ulcerative Diseases/ syphilis)
Rapid serologic tests (HIV/GUD/syphilis) Approaches of STI Case Management : Approaches of STI Case Management CLINICAL ASSESSMENT: Aetiology based on clinical appearance
AETIOLOGIC: Lab isolation of the causative organism
SYNDROMIC CASE MANAGEMENT (SCM)
MIXED Traditional Clinical Approach: Advantages : Traditional Clinical Approach: Advantages Simple
Can be used in any setting
No lab expense Traditional Clinical Approach : Limitations : Traditional Clinical Approach : Limitations Diagnosis is often incorrect or incomplete (especially in mixed infections).
More than one STI is often present at the same time- focus is on diagnosing a single cause.
Asymptomatic infections could not be diagnosed. Aetiological Approach:Advantages : Aetiological Approach:Advantages Exact diagnosis using laboratory tests
Avoids wrong treatment/adverse effects
May avoid antibiotic resistance
Asymptomatic infections can also be detected Aetiological Approach:Limitations : Aetiological Approach:Limitations Expensive
Trained laboratory technicians are needed
Infrastructure and supplies are needed
Patient must return for test results
Patient must wait for treatment Syndromic Approach : Syndromic Approach Provision of STI/RTI care services is a very important strategy to prevent HIV transmission and promote sexual and reproductive health under the National AIDS Control Programme (NACP III) and Reproductive and Child Health (RCH II).
Syndromic case management (SCM) with appropriate laboratory tests is the cornerstone of STI/RTI management under NACP III.
SCM is a comprehensive approach for STI/RTI control endorsed by the WHO. Syndromic Approach : Syndromic Approach Diagnosis is based on the identification of syndromes, which are combinations of the symptoms the client reports and the signs the health care provider observes.
The provision of the most effective therapy at patient’s first contact with a health or medical facility.
The recommended treatment is effective for all the diseases that could cause the identified syndrome.
Provides single dose treatment as far as possible
Comprehensive to include patient education on risk reduction, counseling, condom promotion and provision, partner notification, follow up. Why Syndromic Management? : Why Syndromic Management? STI signs and symptoms are rarely specific to a particular causative agent
Laboratories are either non-existent or non-functional due to lack of resources
Dual infections are quite common and both clinician and laboratory may miss one of them
Waiting time for lab. results may discourage some patients
Failure of cure at first contact Syndromic Management: Providers : Syndromic Management: Providers Sub-district level:
Health workers (HWs), ASHA and AYUSH practitioners will conduct STI/RTI prevention and health promotion activities and refer individuals with STI/RTI symptoms to PHCs, CHCs and franchised allopathic practitioners.
STI/RTI clinical services will be provided at these locations using the SCM approach.
Laboratory services wherever available will be used to corroborate syndromic diagnosis. Syndromic Management: Providers : Syndromic Management: Providers District hospitals and medical colleges:
The services will be provided through specialists and trained physicians at designated STI/RTI clinics.
The SCM approach will be enhanced with additional laboratory facilities.
These locations will also serve as referral sites for STI/RTI services besides participating as resources for STI/RTI training, monitoring and supervision.
This service delivery will be entirely supported by NACO through State AIDS Control Societies (SACS) and District AIDS Prevention and Control Units (DAPCUs). PGIMS Scenario : PGIMS Scenario STI clinic is being run in our institute (Suraksha clinic) by Skin & VD Department.
Follow up cases are managed only on Tuesday during OPD hours. New cases are managed everyday.
STI kits are available free of cost to all clients.
Most common reported syndrome is herpes genitalis (Genito-ulcerative disease)
Manpower: Dr. Kamal Aggarwal- I/C,
1 SR, 2 JR and 1 Counselor Syndromic Management: Providers : Syndromic Management: Providers High-risk population groups:
STI/RTI services will be provided through targeted interventions (TIs) to high-risk groups (HRGs) through specified clinic settings. Three recommended settings are:
TI-owned static clinics for locations with >1,000 sex workers
Fixed-day, fixed-time outreach clinics for locations with smaller number of sex workers
Referral linkage with government and private STI/RTI service providers in locations with <200 sex workers
Clinics should have either on site laboratory facilities or link up with the nearest government laboratory. STI – Syndromic Case Management : STI – Syndromic Case Management REQUIREMENTS:
Adequate medical history
Good sexual history
Complete STI clinical examination
Good supply of effective drugs How syndromic management works : How syndromic management works Through a series of flow-charts:
Guides the health-care worker through the correct identification and treatment of an STI-associated syndrome
Offers a package of comprehensive care from history taking, examination & counselling /education on risk reduction and partner notification Using Flow Charts : Using Flow Charts Each flow chart is made up of three steps
The clinical problem (patient’s presenting symptom)
A decision to make usually by answering yes or no to a question (based on history & clinical examination)
An action to take(what you need to do)
Action box The Syndromes : The Syndromes Urethral discharge
Genital ulcer non-herpetic
Genital ulcer herpetic
Lower abdominal pain
Scrotal swelling Slide 42: Inguinal Bubo Scrotal Swelling Genital Ulcer Genital Ulcer Male Syndromes Slide 43: Vaginal Discharge Syndromes Identifying Syndromes : Identifying Syndromes Slide 45: Syndromic Management Flowcharts Limitations of syndromic management in Vaginal Discharge : Limitations of syndromic management in Vaginal Discharge Unfortunately, syndromic management for abnormal vaginal discharge is less accurate in the diagnosis and management of cervicitis.
Use local prevalence data, if available
Partner treatment Vaginal Discharge: Causes : Vaginal Discharge: Causes Vaginal Discharge: Risk Assessment : Vaginal Discharge: Risk Assessment Criteria for Selection of Drugs : Criteria for Selection of Drugs High efficacy (at least 95%)
Acceptable toxicity and tolerance
Organism resistance unlikely to develop or likely to be delayed
Not contraindicated for pregnant or lactating women To sum up ……… : To sum up ……… The drugs use in syndromic management are chosen based on scientific criteria
Syndromic management is a comprehensive approach which includes:
Treatment of index client
Treatment of partners
Client education and counselling
Referral, as necessary Kits under NACP III for syndromic management of STIs/RTIs : Kits under NACP III for syndromic management of STIs/RTIs UD- Urethral Discharge, ARD- Ano-rectal discharge, GUD- Genito ulcerative disease, LAP- Lower abdominal pain, IB- Inguinal bubo Slide 58: Partner Management What is Partner Management ? : What is Partner Management ? Partner management is an activity in which the partners of those identified as having RTI/STI are located, informed of their potential risk of infection, and offered treatment and counselling services. Timely management is important because… Prevention of re-infection in index client/s
Prevention of transmission in partner/s
Timely treatment of symptomatic partners
Identification of asymptomatic partners and their treatment General principles of partner treatment : General principles of partner treatment All partners who are in contact with client in last 3 months should be treated.
Partners should be treated for same infections as index client.
Advise sexual abstinence during the course of treatment
Provide condoms, educate about correct and consistent use
Refer for voluntary counselling and testing for HIV, Syphilis and Hepatitis B
Schedule return visit after 7 days Management of pregnant client/partner : Management of pregnant client/partner Fluoroquinolones (like ofloxacin, ciprofloxacin), doxycycline, sulfonamides are contraindicated in pregnant women.
Pregnant women should be treated with regimen based on cephalosporin, penicillin & erythromycin for gonorrhoea, chlamydia & syphilis.
For candidiasis clotrimazole vaginal cream/pessary is used.
For trichomonas metronidazole cream/pessary is used in 1st trimester and tab. Secnidazole/tinidazole is used if client is in 2nd or 3rd trimester. Management of pregnant client/partner : Management of pregnant client/partner All pregnant women should be asked history of genital herpes and examined carefully for herpetic lesions.
Women without symptoms or signs of genital herpes or its prodrome can deliver vaginally.
Women with genital herpetic lesions at the onset of labour should be delivered by caesarean section to prevent neonatal herpes.
Acyclovir may be administered orally to pregnant women with first episode of genital herpes or severe recurrent herpes. Slide 63: Client Education and Counseling Importance of Client Education and Counselling : Importance of Client Education and Counselling Better compliance to treatment if clients know the logic/reasons
To reduce chance of re-infection
To enable clients change behaviour
Satisfied clients return for other services too
Satisfied clients refer others to health center Goals of Client Education : Goals of Client Education Help clients resolve current infection
Prevent future infections
Make sure sex partners are also treated and educated. What Clients Needs to Know : What Clients Needs to Know Prevention of RTIs/STIs
- Risk reduction
- Correctly and consistent use of condoms, availability
- Limiting the number of partners
Information about RTIs/STIs
- How they are spread between people
- Consequences of RTIs/STIs
- Links between RTIs/STIs and HIV
- RTI/STI symptoms - what to look for What Clients Needs to Know.… : What Clients Needs to Know.… RTI/STI Treatment
- How to take medications
- Signs that call for a return visit to the clinic
- Importance of partner referral and treatment
- Acknowledge gender inequalities Creating Opportunities for Client Education : Creating Opportunities for Client Education Use every place where client is likely to visit
Use every interaction as an opportunity
Use various media
Reinforce consistent messages Syndromic Management- Advantages : Syndromic Management- Advantages Fast—the patient is diagnosed and treated in one visit
Highly effective for most of the syndromes
Relatively inexpensive since it avoids use of laboratory
No need for patient to return for lab results
All possible STIs are treated at once
Scientifically tested in many part of the world
Easy for health workers to learn and practice for patients
Integrated into primary health care services more easily
Can be used by providers at all levels Programmatic Advantages to Syndromic Management of STIs : Programmatic Advantages to Syndromic Management of STIs Allows all STI clinicians to provide excellent care without referring
The most efficient system to realize a clinic’s dual responsibility – cure the patient and protect the community from STI Syndromic management:Disadvantages : Syndromic management:Disadvantages Tendency to overtreat – justifiable in high prevalence settings (>20%)
Overuse of expensive drugs
Asymptomatic cases not fully addressed even with risk assessment
Management of cervical infections problematic
Vaginal discharge algorithm performs poorly in low prevalence settings e.g., ANC Syndromic approach: Challenges : Syndromic approach: Challenges Many STIs are asymptomatic
Vaginal discharge is not necessarily the result of an STI
Vaginitis vs. cervicitis - overtreatment vs. under-treatment
Overuse of drugs: costs, side effects, resistance
Lack of acceptance by clinicians To sum up ……… : To sum up ……… Syndromic management is a scientific and proven approach.
Syndromic approach does not deny use of lab tests (Enhanced syndromic approach).
This approach ensures correct and complete treatment of all most common organisms responsible for a particular syndrome.
Syndromic management goes beyond pharmaceutical treatment to include client education and counselling.
The clinical skills of a doctor are well utilized in syndromic approach. References : References NACO, MOHFW, Govt. of India. Operational Guidelines for Programme managers and Service Providers for strengthening STI/RTI Services, NACO, New Delhi; Oct 2007.
MOHFW, Govt. of India. National Guidelines on prevention, management and control of RTIs including STIs. NACO, New Delhi; August 2007.
Chellan R. Socio-Demographic Determinants of Reproductive Tract Infection and Treatment Seeking Behaviour in Rural Indian Women. Population Studies, Centre for the Study of Regional Development, School of Social Sciences, Jawaharlal Nehru University. New Delhi.
Introduction to WHO Guidelines for the Management of Sexually Transmitted Infections. Vanuatu Reproductive Health Workshop. November 30-December 3, 2004.
National STI Management Guidelines of India. The National AIDS Control Programme. The World Health Organization
Lal S. Textbook of community medicine. 3rd ed. CBS: New Delhi; 2011.
Park K. Textbook of preventive and social medicine. 21st ed. Jabalpur : Banarsidas Bhanot;2011.