INTRODUCTION TO SYNDROMIC MANAGEMENT OF STIs

1. INTRODUCTION TO SYNDROMIC MANAGEMENT OF STIs

2. Objectives KEY CONCEPTS you will learn: • Problems associated with classic approaches to treating STIs • Main features of syndromic case management • Various advantages of syndromic approach • Steps in using flow charts

3. Classical approaches to STI management • Etiologic diagnosis – using lab to identify the causative agent • Clinical diagnosis –using clinical experience to identify causative agent

4. Etiologic Management • Advantages:- • Avoids over treatment • Conforms to traditional clinical training • Satisfies patients who feel not properly attended to • Can be extended as screening for the asymptomatics

5. Problems of etiologic approach • Requires skilled personnel and consistent supplies • Treatment does not begin until results are available • It is time consuming and expensive • Testing facilities are not available at primary level • Some bacteria fastidious and difficult to culture (H.ducrey, C.trachomatis)

6. Problems of etiologic approach…Cont’d • Lab. results often not reliable • Mixed infections often overlooked • Miss-treated/untreated infections can lead to complications and continued transmission

7. Clinical Management • Advantages:- • Saves time for patients • Reduces laboratory expenses • Disadvantages:- • Requires high clinical acumen • Most STIs cause similar symptoms • Mixed infections are common and failure to treat may lead to serious complications • Doesn’t identify asymtomatic STIs

8. Syndromic Approach • Syndrome – is group of symptoms patient complains about and clinical signs you observe during examination • Different organisms that cause STIs give rise to only limited number of syndromes • There are seven syndromes (aim is to identify and manage accordingly)

9. Identifying Syndromes

10. Why Syndromic Approach? • STI sign 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

11. Key Features of Syndromic Management • Problem oriented (responds to patient’s symptoms ) • Highly sensitive and does not miss mixed infections • Treats the patient at first visit • Can be implemented at primary health care level • Use flow charts with logical steps • Provides opportunity and time for education and counseling

12. The Five Steps in Syndromic STI Case Management • History taking and examination • Syndromic diagnosis and treatment, using flow charts • Education and counseling on HIV testing and safer sex, including condom promotion and provision • Management of sexual partners • Recording and reporting

13. Criteria for the selection of STI drugs • Availability • Low cost • High efficacy (at least 95%) • Acceptable toxicity and tolerance (safety) • Organism resistance unlikely to develop or likely to be delayed • Single dose • Oral administration • Not contraindicated for pregnant or lactating women.

14. Frequently raised issues on the syndromic approach • Issues related to scientific ground • It is based on wide range of epidemiological studies • Validation studies have confirmed comparable accuracy of syndromic and Lab. diagnosis with limitation of syndromic management only to vaginal discharge • Syndromic case management of STI in Tanzania has shown decrease transmission HIV and STI in population (MWANZA TRIAL)

15. Frequently raised issues on the syndromic approach • Issues related to simplicity of management • Simplicity allows other health workers (other than doctors) to use the approach to make a diagnosis • It allows health workers more time to offer education for behavior change

16. Frequently raised issues on the syndromic approach • Issues related to service provider’s clinical skills and experience • studies have shown clinical judgment misses 50% of cases • Issues related to use of multiple drugs • studies have shown that it is less expensive

17. Frequently raised issues on the syndromic approach • Issues related to treating a single pathogen causing STI based on prevalence • Many patients required to return to a health centre for treatment do not do so.

18. Frequently raised issues on the syndromic approach • Issues related to the use of simple laboratory tests such as Gram’s stain • it should not be at the expense of delayed treatment or at risk of patient non return • Remember that effective treatment of people with STIs is the best way of interrupting the cycle of transmission

19. Limitations of syndromic management • Misses sub-clinical infection • Needs validation study • Require prior research to determine the common causes of particular syndromes • Needs training

20. Syndromic Flow Charts • A flow chart is a diagram (map) representing steps to be taken through a process of decision making • Can be used at any health facility • prompt treatment is provided at initial visit • many people with STI have access to treatment • provides opportunity for preventive and promotive measures

21. Each flow chart is made up of three steps • The clinical problem (patient’s presenting symptom) • Problem box • A decision to make usually by answering yes or no to a question • Decision box • An action to take (what you need to do) • Action box

22. Clinical Problem Decision Box Enlarged and Painful Inguinal Lymph nodes? Take History & Examine Use Genital Ulcer Flow Chart Ulcer (s) Present? Yes No Action Box

23. Key Points • Most STI patients present at a primary health care facility • In STI control the aim should be to give prompt effective treatment at first level of contact in the health system • Treatment of STIs is not always simple or effective