Syndromic Management of Sexually Transmitted Infections Dr. Suraj Chawla
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 Syndromic case management (SCM) Management Kits Partner management Client education & counseling Advantages of SCM Disadvantages of SCM Challenges regarding SCM
BackgroundSTIs/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 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.
BackgroundSituation 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/
BackgroundSituation 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 HealthProblem 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
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 oftransmission Biological - Age / Sex - Immune status Behavioural - Personal sexual behaviour - Poor menstrual and personal hygiene Social - Status of women in society - Sexual violence - Child marriages
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 providersside 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 Lack of knowledge Misconceptions Asymptomatic infections Reluctance to discuss sexual matters Stigma Fear of judgmental attitude of providers Reluctance for physical examination
Operational model of the role of healthservices in STI case management Population with STI Aware and worried Seeking care Correct diagnosis • Promotion of health care seeking behaviour Correct treatment • Improve quality of care • Attitudes of personnel Treatment completed Cure
Operational model of the role of healthservices in STI case management Population with STI Aware and worried asymptomatic STI Seeking care Correct diagnosis • Partner notification • Case finding • Screening Correct treatment • Selective mass treatment Treatment completed Cure
Objectives of STI casemanagement To provide appropriate antimicrobial therapy in order to: Obtain cure of infection Decrease infectiousness 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 Accurate diagnosis Treatment at first encounter Rapid cure with effective drugs Condom promotion Partner notification Education/ Counselling
Comprehensive STI casemanagement History taking and symptoms Examination Treatment Client and partner(s)
Essential Steps In STI CaseManagement Syndrome Assessment Contact tracing (diagnostic tools) Compliance Diagnosis Treatment 5Cs Confidentiality Condom use (screening tests) Counseling 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 Sexual behaviours Specific exposures Socio-demographics/other high risk markers: young age marital status: not living with steady partner partner problems History of impaired reproductive health i.e. History of past STI
Rapid Laboratory TestsMay be used to narrow the spectrum of initial therapy. Theyinclude: 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 CaseManagement CLINICAL ASSESSMENT: Aetiology based on clinical appearance AETIOLOGIC: Lab isolation of the causative organism SYNDROMIC CASE MANAGEMENT (SCM) MIXED
Traditional Clinical Approach:Advantages Simple Inexpensive Can be used in any setting Immediate diagnosis Immediate treatment No lab expense
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 Exact diagnosis using laboratory tests Avoids over-treatment Avoids wrong treatment/adverse effects May avoid antibiotic resistance Asymptomatic infections can also be detected
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 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 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? 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:ProvidersSub-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:ProvidersDistrict 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 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:ProvidersHigh-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 CaseManagementREQUIREMENTS: Adequate medical history Good sexual history Complete STI clinical examination Management guidelines Good supply of effective drugs
How syndromic management worksThrough 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 ChartsEach 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 (based on history & clinical examination) Decision box An action to take(what you need to do) Action box
Limitations of syndromic management inVaginal DischargeUnfortunately, syndromic management for abnormalvaginal discharge is less accurate in the diagnosis andmanagement of cervicitis. Use local prevalence data, if available Risk assessment Partner treatment
Vaginal Discharge: Causes Vaginitis CervicitisCaused by Trichomoniasis (TV), Caused by Gonorrhoea andCandidiasis and Bacterial Vaginosis ChlamydiaMost common cause of vaginal Less common cause of vaginaldischarge dischargeEasy to diagnose Difficult to diagnoseNo complications Major complicationsTreatment of partner unnecessary, Need to treat partnerexcept for TV
Vaginal Discharge: Risk Assessment Risk Factor Score Partner has urethral discharge 2 New partner in last 3 months 1 More than 1 partner last 3 months 1 Not living with steady partner 1 Age less than 21 years 1 [If risk score 2 and over, treat for cervicitis]
Criteria for Selection of Drugs High efficacy (at least 95%) Low cost Acceptable toxicity and tolerance Organism resistance unlikely to develop or likely to be delayed Single dose Oral administration Not contraindicated for pregnant or lactating women
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 Risk reduction Client education and counselling Referral, as necessary
Kits under NACP III for syndromic management of STIs/RTIsKit No. Syndrome Colour ContentsKit 1 UD, ARD, Cervicitis Grey Tab. Azithromycin 1 g (1) and Tab. Cefixime 400 mg (1)Kit 2 Vaginitis Green Tab. Secnidazole 2 g (1) and Tab. Fluconazole 150 mg (1)Kit 3 GUD (Non Herpetic) White Inj. Benzathine penicillin 2.4 MU (1)and Tab. Azithromycin 1 g (1) and Disposable syringe 10 ml with 21 gauge needle (1) and Sterile water 10 ml (1)Kit 4 GUD (For patient Blue Tab. Doxycycline 100 mg (30) and Tab. allergic to penicillin) Azithromycin 1 g (1)Kit 5 GUD ( Herpetic) Red Tab. Acyclovir 400 mg (21)Kit 6 LAP Yellow Tab. Cefixime 400 mg (1) and tab. Metronidazole 400 mg (28) and Cap. Doxycycline 100 mg (28)Kit 7 IB Black Tab. Doxycycline 100mg (42) and Tab. Azithromycin 1 g (1) UD- Urethral Discharge, ARD- Ano-rectal discharge, GUD- Genito ulcerative disease, LAP- Lower abdominal pain, IB- Inguinal bubo
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 partnertreatment 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 pregnantclient/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 pregnantclient/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.
Importance of Client Educationand 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 Help clients resolve current infection Prevent future infections Make sure sex partners are also treated and educated.
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.… 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 ClientEducation Use every place where client is likely to visit Use every interaction as an opportunity Use various media Reinforce consistent messages
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 toSyndromic 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 Tendency to overtreat – justifiable in high prevalence settings (>20%) Decreased specificity 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 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 ……… 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 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 http://www.authorstream.com/UserPresentations/sharamesh/-205632-rti-sti. 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.