This document discusses the development of syndromic practice guidelines for primary care in high HIV prevalence settings. It argues that standardized case management can improve diagnosis, treatment, and referral. Common outpatient conditions like respiratory infections, malaria, and STIs represent a large portion of health service visits. While disease presentations in early stage HIV may not differ from non-infected individuals, adequate management of selected conditions can reduce mortality and improve quality of life for those with HIV. Further research is still needed on treating certain conditions like pneumonia to help develop standardized syndromic guidelines.

1. Syndromic approaches for common outpatient conditions in adults: a priority revitalising primary care Bawoh. M PhD.

2. Service delivery at primary care Multi-purpose health worker is expected to: See all types of clients attending services < 5 years, > 5 years, young and old, men and (pregnant) women, HIV(+) and HIV(-) Perform all functions Health promotion, prevention, care and service management Manage all disease types Acute, chronic, communicable, non-communicable Irrespective of HIV status

3. Why syndromic guidelines for primary care? Care currently not standardized Standard practice guidelines are known to improve process, quality and outcome of care Majority of patients present first at primary care level Possibilities to confirm diagnoses are very limited Etiological diagnosis not necessary, as long as treatment is correct No knowledge of HIV status Care as entry point for prevention

4. Standardised case management: experiences and successes Integrated Management of Childhood Illness Syndromic Approach to STIs DOTS strategy to control tuberculosis Practical Approach to Lung health (PAL)

5. Benefits of standardised case management Standardisation of diagnosis and treatment Standardisation of referral Case management at appropriate level of care Rationalisation of drug use Strengthening primary care to cope with common outpatient conditions, including HIV and its related diseases

6. Development of syndromic practice guidelines: a priority September 2000: Rockefeller consultation Formation of a Syndromic Management Working Group and preparation of background paper April 2001: “AIDS care in Africa meeting” Development and research on syndromic practice guidelines for high HIV prevalence settings is a priority

7. Ongoing and planned research Development by doing syndromic guideline development in Zimbabwe and Uganda incorporating existing STI, PAL and IMCI experience Strengthening the evidence base appropriate selection of diseases and interventions to include in the guideline for high HIV prevalence areas closing the guideline - implementation gap evaluation of implementation

8. Deciding on case management priorities for primary care General health service attendance (proxy to disease episodes and demand for care of all people attending first level facilities) Disease episodes encountered in HIV-infected individuals (proxy to demand for care) Cause specific mortality Response to treatment

9. General health service attendance 1.5 million OPD visits, 1998, Zimbabwe 1. Acute respiratory infections 27% 2. Malaria 11% 3. STIs 10% 4. Skin disorders 7% 5. Diarrhoea 3% Adult HIV rate 2000 25%

10. Disease episodes in Kenyan cohort of HIV-infected people

11. Diagram demonstrating CD4 count for different diagnoses Asympto Feb Illness Upper RTI Pneumo Vag cand UTI STI Folliculitis Oral cand Chronic diarh Diagnoses associated with immunosuppression 0 500 1000 1500 CD4 Count

12. Excess mortality in the era of HIV Age specific mortality rates for diarrhea in 1983 and 1995 Age groups 1983 1995 Deaths per 1000 population

13. Existing evidence that treatment is important Pelvic inflammatory disease Cohen, et al. 1997 & Bukusi et al. 1998 Bacterial pneumonia Gilks, et al. 1996 Tuberculosis Ackah, et al. 1995 Strengthen Health Care System Mwanza STI study: reduced HIV incidence Grosskurth, et al. 1995 Reduced mortality in hospitalized HIV patients Arthur, et al. 2000 40% HIV presumably died of 1 st OI Sewankambo, et al. 2000 Evidence Response to treatment in HIV infected persons

14. Survival of cohort in Nairobi who received primary health care, compared by initial CD4 count Gap: No comparison group with “usual” access to care

15. Conclusions Frequent disease presentations in early stage HIV infected adults are not different from common outpatient complaints of non-infected adults Adequate management of selected conditions reduces case fatality of acute illness and increases quality of life and survival (?) in HIV positive people

16. Collaborating institutions Biomedical Research and Training Institute, University of Zimbabwe, Harare Kenya Medical Research Institute, Nairobi London School of Hygiene and Tropical Medicine, UK Nuffield Institute for Health, Leeds, UK University of California San Francisco, USA University of Washington, Seattle, USA Clinical Research Centre, State Medical Academy, Russia World Health Organization

17. Gaps in knowledge of treatment efficacy Pneumonia Acute bronchitis Sinusitis Dermatoses Folliculitis Chronic diarrhea

18. Research & development of evaluation indicators and process Clinical outcome Referral pattern & rate of hospitalization Incidence of OIs Survival Validation indicators Cost of care Quality of life