Syndromic Management Of Sexually Transmitted Infections Research Articles

Intervention to improve the knowledge of sexually transmitted infections (STIs) and syndromic management among community pharmacists in Lagos state, Nigeria

Sexually transmitted infections (STIs) remain a public health problem in most parts of the world. The syndromic management approach is based on an STI syndrome and it offers many benefits in the struggle against STIs. Community pharmacists are one of the most accessible and trusted health care professionals. They are well located to reach millions of individuals with STI prevention and control messages and other strategies. This study assesses the knowledge, attitude and practice of community pharmacists of STIs and syndromic management, and provides training as an intervention. The study was a cross sectional pre and post type involving 202 community pharmacists in the 11 zones of Lagos State. Pre-tested questionnaires were self-administered to the community pharmacists before and after training on STI and syndromic management. The findings of this study showed that about 16% of the community pharmacists had good knowledge of STIs and 53% of them had good knowledge on syndromic management. After the training intervention, there was an improvement in their knowledge on STIs and syndromic management of STIs (54 and 70%, respectively). The assessment of the knowledge of community pharmacist on STIs and syndromic management shows that there is need for continuous education in these areas, especially in the early detection and management of the condition.

Prevention of sexually transmitted infections in urban communities (Peru PREVEN): a multicomponent community-randomised controlled trial

SummaryBackgroundPrevious community-randomised trials of interventions to control sexually transmitted infections (STIs) have involved rural settings, were rarely multicomponent, and had varying results. We aimed to assess the effect of a multicomponent intervention on curable STIs in urban young adults and female sex workers (FSWs).MethodsIn this community-randomised trial, baseline STI screening was done between August, and November, 2002, in random household samples of young adults (aged 18–29 years) and in FSWs in Peruvian cities with more than 50 000 inhabitants. Geographically separate cities were selected, matched into pairs, and randomly allocated to intervention or control groups with an S-PLUS program. Follow-up surveys of random samples were done after 2 years and 3 years. The intervention comprised four modalities: strengthened STI syndromic management by pharmacy workers and clinicians; mobile-team outreach to FSWs for STI screening and pathogen-specific treatment; periodic presumptive treatment of FSWs for trichomoniasis; and condom promotion for FSWs and the general population. Individuals in control cities received standard care. The composite primary endpoint was infection of young adults with Chlamydia trachomatis, Trichomonas vaginalis, or Neisseria gonorrhoeae, or syphilis seroreactivity. Laboratory workers and the data analyst were masked, but fieldworkers, the Peruvian study team, and participants in the outcome surveys were not. All analyses were done by intention to treat. This trial is registered, ISRCTN43722548.FindingsWe did baseline surveys of 15 261 young adults in 24 Peruvian cities. Of those, 20 geographically separate cities were matched into pairs, in each of which one city was assigned to intervention and the other to standard of care. In the 2006 follow-up survey, data for the composite primary outcome were available for 12 930 young adults. We report a non-significant reduction in prevalence of STIs in young adults, adjusted for baseline prevalence, in intervention cities compared with control cities (relative risk 0·84, 95% CI 0·69–1·02; p=0·096). In subgroup analyses, significant reductions were noted in intervention cities in young adult women and FSWs.InterpretationSyndromic management of STIs, mobile-team outreach to FSWs, presumptive treatment for trichomoniasis in FSWs, and condom promotion might reduce the composite prevalence of any of the four curable STIs investigated in this trial.FundingWellcome Trust and Burroughs Wellcome Fund, National Institutes of Health, Center for AIDS Research, CIPRA, and USAID-Peru.

S2.4 New technologies to support STI screening and syndromic management in resource-limited settings

BackgroundHigh quality tests for detection of STIs are available but they are neither affordable nor available to patients in resource-limited settings. For patients presenting with STI symptoms, WHO recommends the...

P5-S6.09 Using syndromic management of STI as an entry point to HIV prevention intervention in a resource poor setting

IssueAlmost all the patients who presents to the hospital with symptoms and/or signs of sexually transmitted infection have been engaged with unprotected sexual intercourse, thus they are predispose to contacting...

P1-S2.54 Repeat Gonococcal and chalymadial infections in a cohort of men who have sex with men in India

BackgroundMen who have sex with men (MSM) are found to be at increased risk for many sexually transmitted infections (STI). Among the STIs, most common are bacterial STIs such as...

P5-S6.19 Prevalence and incidence of sexually transmitted infections among female sex workers in two cities in India: implications for STI control strategies

BackgroundIndia is a large country with marked heterogeneity in prevalence of sexually transmitted infections (STIs) which has implications for STI control strategies. The study objective was to measure the prevalence...

HPV Vaccination to Prevent HIV Infection: Time for Randomized Controlled Trials

Despite many years of rigorous evaluation of a variety of interventions, HIV incidence rates in parts of Africa remain unacceptably high. A recent review identified 37 randomized controlled trials testing interventions to reduce HIV incidence.1 Except for 3 randomized controlled trials of male circumcision2‐4 and 1 trial of syndromic treatment of sexually transmitted diseases,5 and, recently, 1 trial of a vaginal microbicide,6 no significant reductions in HIV incidence were observed. In some trials of vaginal microbicides, trial participants in the active treatment arm actually had increased HIV incidence rates.7 Trials with candidate vaccines have been equally disappointing.8 A recently completed trial of a prime-boost strategy conducted in Thailand showed statistically significant, but limited, protection against HIV.9 Nevertheless, even vaccine optimists think that a preventive HIV vaccine is many years away. Sexually transmitted infections (STIs) were identified as important cofactors for HIV transmission early in the epidemic.10,11 Many prospective observational studies showed that the presence of ulcerative and nonulcerative STIs increased the likelihood of HIV transmission.10,11 Several interventions were based on this observation including mass treatment with antibiotics,12 improved syndromic management of STIs,5,13 and herpes simplex virus (HSV)-2 suppressive treatment.14 Null findings of these interventions should be interpreted with caution. Failure to show an effect does not necessarily mean that the STI is not causally associated with HIV. As Barnabas and Wasserheit highlight,15 the stage of the HIV epidemic in which an intervention trial is conducted may significantly influence observed efficacy. Another possible reason for the failure of these trials to demonstrate efficacy is that the intervention may not have adequately controlled the STI or its biologic effects.

Population-based biomedical sexually transmitted infection control interventions for reducing HIV infection

Population-based biomedical sexually transmitted infection control interventions for reducing HIV infection

The effect of syndromic management interventions on the prevalence of sexually transmitted infections in South Africa

Objectives Few studies have assessed the effect of syndromic management interventions on the prevalence of sexually transmitted infections (STIs) at a population level. This study aims to determine the effect of syndromic management protocols that have been introduced in South Africa since 1994. Study design A mathematical model of sexual behaviour patterns in South Africa was used to model the incidence of HIV, genital herpes, syphilis, chancroid, gonorrhoea, chlamydial infection, trichomoniasis, bacterial vaginosis and vaginal candidiasis. Assumptions about health seeking behaviour and treatment effectiveness were based on South African survey data. The model was fitted to available STI prevalence data. Main outcome measures Reductions in STI prevalence due to syndromic management. Results Between 1995 and 2005, there were significant reductions in the prevalence of syphilis, chancroid, gonorrhoea, trichomoniasis and chlamydial infection. In women aged between 15 and 49, syndromic management resulted in a 33% (95% CI: 23–43%) decline in syphilis prevalence, a 6% (95% CI: 3–11%) reduction in gonorrhoea prevalence, a 5% (95% CI: 1–13%) reduction in the prevalence of bacterial vaginosis and a substantial decline in chancroid. However, syndromic management did not significantly reduce the prevalence of other STIs. For all STIs, much of the modelled reduction in STI prevalence between 1995 and 2005 can be attributed to either increased condom usage or AIDS mortality. Conclusions Syndromic management of STIs can be expected to decrease the prevalence of curable STIs that tend to become symptomatic, but has little effect on the prevalence of STIs that are mostly asymptomatic.

Population-based seroprevalence of HSV-2 and syphilis in Andhra Pradesh state of India.

BackgroundUnderstanding the prevalence and risk factors for common causes of ulcerative genital disease in the general population would inform current STI syndromic management and HIV testing strategies in high HIV prevalence regions of India.MethodsPersons 15-49 years old from 32 rural and 34 urban clusters were sampled using a stratified random method to represent adults in the high HIV prevalence Guntur district in Andhra Pradesh state. Interviews were conducted and dry blood spots were collected on 12,617 study participants. Testing for HSV-2 and syphilis was performed.ResultsAdjusted HSV-2 and syphilis seroprevalence rates were 4.70% and 2.08% for men and 7.07% and 1.42% for women. For men, tattooing, >3 lifetime sex partners, tobacco use, and sex with men in the past 6 months were associated with HSV-2 or syphilis (ORs, 1.66-2.95, p < 0.05). Male circumcision was positively associated with HSV-2 infection (OR, 1.37, p = 0.028) though this could be due to residual confounding. In women, greater than one lifetime partner remained significantly associated with HSV-2 in multivariate analysis (OR, 2.61; 95% CI, 1.39-4.87). Among all behavioral risk factors and other covariates in women and men, HIV infection exhibited the strongest association with HSV-2 and syphilis (ORs, 8.2-14.2, p < 0.001). The proportion of individuals with HSV-2 who were HIV infected was less than the proportion with syphilis who were HIV infected (11.8% vs. 22.7%; p = 0.001).ConclusionsNearly one in four persons surveyed in this population-based study that were seroprevalent for syphilis, were also HIV infected. Common population risk factors for syphilis, HSV-2 and HIV and high rates of co-seroprevalence suggest that HIV testing, STI testing and service strategies for these would benefit from direct linkage in India.

Utilisation of Rapid Tests for Sexually Transmitted Infections: Promises and Challenges

The control of curable STIs in countries with high disease burden has been hampered by the lack of accessible STI laboratory services. Rapid tests that are sensitive, specific and easy to use have the potential to increase the specificity of syndromic management of STIs in symptomatic patients and increase access to screening of asymptomatic infection to prevent the development of long-term complications and to interrupt the chain of transmission of STIs in the population. Although most rapid tests for chlamydia and gonorrhoea have sub-optimal sensitivity, and are neither simple nor affordable, some rapid syphilis tests have been shown to have acceptable performance. These can be deployed to increase access to screening in settings where testing is not previously possible or where laboratory services are inconsistent. With more political commitment and technological advances made possible by increased funding and public and private product development partnerships, there is much optimism in the near future for point of care tests for STIs that can improve patient management and disease control. The WHO estimates that more than 380 million new cases of sexually transmitted chlamydia, gonorrhea, syphilis and trichomoniasis occur worldwide every year (1). An equal or greater number of viral sexually transmitted infections (STIs) such as those caused by herpes simplex virus and human papilloma virus also occur every year but efforts to estimate the annual incidence of these infections on a global basis have been limited. THE NEED FOR STI DIAGNOSTICS Most STIs are asymptomatic but their consequences are serious. Undiagnosed and untreated STIs can lead to long term complications (Table 1). While complications are relatively rare in men, infections in women can lead to pelvic inflammatory disease and tubal infertility, a condition, which, in some societies renders a woman worthless. STIs also cause serious adverse outcomes in pregnancy for both the women and their foetus or infant. Affordable curative therapy is available for the major bacterial STIs. Screening and early treatment are therefore critical for effective patient management to prevent the development of long term complications and to interrupt onward transmission. For infected individuals with symptoms, STI laboratory services are scarce in most high burden countries, requiring patients to travel long distances to access these services.

Provider Characteristics Among Staff Providing Care to Sexually Transmitted Infection Self-Medicating Patients in Retail Pharmacies in Kibera Slum, Nairobi, Kenya

To evaluate the characteristics of providers in management of STI self-medicating patients in retail pharmacies within the largest informal settlement in Kenya. We collected sociodemographic, training, and work history attributes among pharmacy staff from a convenience sample of 50 retail pharmacies in Kibera slum using a self-administered questionnaire. We gathered the required data in 8 weeks, collecting completed self-administered questionnaires within 7 to 14 days after distribution. Two data collectors subsequently presented at these pharmacies as mystery patients seeking care for symptoms of genital ulcer disease and gonorrhea and completed a structured observation form within 10 minutes of leaving the pharmacy. Approximately half the respondents were men aged less than 28 years. Over 90% had 12 years of formal education and an additional 3 years of medical professional training. Two thirds (66%) had been trained in Government institutions. About 65% reported that patients presented without prescriptions, and 45% noted that patients requested specific medicines but were open to advice. One-third (36%) of the patients used the pharmacy as their first point of care. Using mystery patients to evaluate syndromic management of gonorrhea and genital ulcer disease, only 10% offered appropriate treatment per the Kenya Ministry of Health STI syndromic management guidelines. Although the majority of the pharmacy staff in this informal settlement have some medical training and some experience, a very low proportion offered adequate treatment for 2 common STIs.

Effectiveness of interventions for the prevention of HIV and other sexually transmitted infections in female sex workers in resource poor setting: a systematic review

To systematically review the evidence for effectiveness of HIV and sexually transmitted infection (STI) prevention interventions in female sex workers in resource poor settings. Published and unpublished studies were identified through electronic databases (Cochrane database, Medline, Embase, and Web of Science), hand searching and contacting experts. Randomized-controlled-trials and quasi-experimental studies were included if they were conducted in female sex workers from low and middle income settings; if the exposure was described; if the outcome was externally measurable, it was after the discovery of HIV, and if follow-up was longer than 6 months. A priori criteria were used to extract data. Meta-analysis was not performed due to the heterogeneity of studies. Twenty-eight interventions were included. Despite methodological limitations, the evidence suggested that combining sexual risk reduction, condom promotion and improved access to STI treatment reduces HIV and STI acquisition in sex workers receiving the intervention. Strong evidence that regular STI screening or periodic treatment of STIs confers additional protection against HIV was lacking. It appears that structural interventions, policy change or empowerment of sex workers, reduce the prevalence of STIs and HIV. Rigorous evaluation of HIV/STI prevention interventions in sex workers is challenging. There is some evidence for the efficacy of multi-component interventions, and/or structural interventions. The effect of these interventions on the wider population has rarely been evaluated.

Impact and Process Evaluation of Integrated Community and Clinic-Based HIV-1 Control: A Cluster-Randomised Trial in Eastern Zimbabwe

BackgroundHIV-1 control in sub-Saharan Africa requires cost-effective and sustainable programmes that promote behaviour change and reduce cofactor sexually transmitted infections (STIs) at the population and individual levels.Methods and FindingsWe measured the feasibility of community-based peer education, free condom distribution, income-generating projects, and clinic-based STI treatment and counselling services and evaluated their impact on the incidence of HIV-1 measured over a 3-y period in a cluster-randomised controlled trial in eastern Zimbabwe. Analysis of primary outcomes was on an intention-to-treat basis. The income-generating projects proved impossible to implement in the prevailing economic climate. Despite greater programme activity and knowledge in the intervention communities, the incidence rate ratio of HIV-1 was 1.27 (95% confidence interval [CI] 0.92–1.75) compared to the control communities. No evidence was found for reduced incidence of self-reported STI symptoms or high-risk sexual behaviour in the intervention communities. Males who attended programme meetings had lower HIV-1 incidence (incidence rate ratio 0.48, 95% CI 0.24–0.98), and fewer men who attended programme meetings reported unprotected sex with casual partners (odds ratio 0.45, 95% CI 0.28–0.75). More male STI patients in the intervention communities reported cessation of symptoms (odds ratio 2.49, 95% CI 1.21–5.12).ConclusionsIntegrated peer education, condom distribution, and syndromic STI management did not reduce population-level HIV-1 incidence in a declining epidemic, despite reducing HIV-1 incidence in the immediate male target group. Our results highlight the need to assess the community-level impact of interventions that are effective amongst targeted population sub-groups.

Clinicians' perspective of a training programme in syndromic management of sexually transmitted infections in Northern Tanzania

This process evaluation study was designed to investigate clinicians' perception of a training programme on syndromic management of sexually transmitted infections (STIs) and their experiences in applying the skills learnt during the course. Out of 136 eligible course participants from Arusha and Kilimanjaro regions, Tanzania, 47 were invited to take part in the study and 40 agreed to participate (85%). The research instruments consisted of a structured interview including open- and close-ended questions, a self-administered questionnaire, and an observation checklist. While the clinicians reported to be satisfied with the course itself, the results revealed insufficient practical training. The clinicians reported problems with condom promotion and partner notification, and frequent shortage of equipment and drugs in the clinics was observed. Future courses on syndromic management of STI should focus on skills training related to health education and counselling, and have a stronger emphasis on practical, clinical work. There is need to address barriers to condom promotion and partner referral.

Population-based interventions for reducing sexually transmitted infections, including HIV infection.

Population-based interventions for reducing sexually transmitted infections, including HIV infection.

Sexually transmitted infections: prevention and management.

In the early 21st century, STI and HIV have been linked inextricably. Although the focus of this article is STI, some discussion on the diagnosis and management of individuals with HIV infection is necessary. The history of HIV diagnosis in the workplace is checkered. The authors have seen cases of prospective workers being subjected to HIV testing without their knowledge as part of a pre-employment medical examination. If the test came back positive, the men were told that they would not be employed without explanation. This approach is a breech of the human rights of the individual being tested and cannot be condoned. Any HIV testing must be done with the full and informed consent of the individual, with counseling given before and after testing to enable individuals with HIV infection to seek care and protect their families and to give individuals without HIV infection counseling on risk reduction. Men and women who present with an STI are at risk for HIV infection. With increasing options for management and secondary prevention, it is important to recognize people who are at risk. This identification should be done through HIV VCT. The location, funding, and supervision of VCT sites related to workplace populations should be a subject for serious debate. Although fears of mass layoffs after HIV testing largely have been unfounded, it is natural for workers to be fearful, unless there is a clearly articulated policy stating that the company observes and enforces nondiscriminatory practices. The workplace examples show that syndromic STI management, allied to comprehensive prevention programs, can have a genuine and measurable impact on STI prevalence. The potential interventions and partners are listed in Table 2. A community-based, randomized study in Tanzania showed that the institution of a well-managed STI syndromic management program can reduce HIV incidence by up to 40%, in the context of a rising HIV epidemic. Presumptive STI treatment for female sex workers (see Box 1) may prove useful as a short-term measure to reduce high STI prevalence rates while more sustainable preventive and curative services are established. The laboratory diagnosis of STIs remains problematic in the face of commonly available technologies of limited sensitivity and specificity and often substandard quality-assurance practices. For these and other reasons, syndromic management became the recommended strategy for treating STIs. The availability of rapid, accurate, and inexpensive diagnostics, especially for cervical infections for women, would alter management recommendations. Work is being done by the WHO and others to develop and assess low-cost diagnostics. Managing STIs and altering the behavior that leads to STIs are essential elements of any HIV prevention and management program. The issues surrounding a practical, compassionate, and comprehensive HIV program can be difficult. Numerous publications exist to help program managers navigate these issues and appropriately tailor a program to the needs of individual organizations. Some of these publications are listed in the next section.

Intervention in Rural Uganda Is Effective against Some Sexually Transmitted Infections, but Not against HIV

Neither a behavioral intervention alone nor the same intervention coupled with syndromic management of sexually transmitted infection (STI) was effective in lowering the incidence of HIV in a rural area of Uganda between 1994 and 2000. The prevention strategies had little success in changing risky behavior but they were associated with reduced incidence of herpes simplex virus type 2 (HSV-2) and syphilis and with a lowered prevalence of gonorrhea. In a six-year trial 18 communities were randomly assigned to receive the single- or two-pronged intervention or for comparison routine government health and community development services. The behavioral intervention involved information education and communication activities meant to increase participants HIV risk-related knowledge and skills; STI diagnosis and treatment services were delivered by government and private health care workers who were specially trained in syndromic management of STIs. As part of the trial social marketing of male condoms and voluntary HIV counseling and testing were provided in all 18 communities. (excerpt)

Syndromic management of sexually-transmitted infections and behaviour change interventions on transmission of HIV-1 in rural Uganda: a community randomised trial

Treatment of sexually-transmitted infections (STIs) and behavioural interventions are the main methods to prevent HIV in developing countries. We aimed to assess the effect of these interventions on incidence of HIV-1 and other sexually-transmitted infections. We randomly allocated all adults living in 18 communities in rural Uganda to receive behavioural interventions alone (group A), behavioural and STI interventions (group B), or routine government health services and community development activities (group C). The primary outcome was HIV-1 incidence. Secondary outcomes were incidence of herpes simplex virus type 2 (HSV2) and active syphilis and prevalence of gonorrhoea, chlamydia, reported genital ulcers, reported genital discharge, and markers of behavioural change. Analysis was per protocol. Compared with group C, the incidence rate ratio of HIV-1 was 0.94 (0.60-1.45, p=0.72) in group A and 1.00 (0.63-1.58, p=0.98) in group B, and the prevalence ratio of use of condoms with last casual partner was 1.12 (95% CI 0.99-1.25) in group A and 1.27 (1.02-1.56) in group B. Incidence of HSV2 was lower in group A than in group C (incidence rate ratio 0.65, 0.53-0.80) and incidence of active syphilis for high rapid plasma reagent test titre and prevalence of gonorrhoea were both lower in group B than in group C (active syphilis incidence rate ratio, 0.52, 0.27-0.98; gonorrhoea prevalence ratio, 0.25, 0.10-0.64). The interventions we used were insufficient to reduce HIV-1 incidence in rural Uganda, where secular changes are occurring. More effective STI and behavioural interventions need to be developed for HIV control in mature epidemics.

Population-based interventions for reducing sexually transmitted infections, including HIV infection.

Population-based interventions for reducing sexually transmitted infections, including HIV infection.