Syndromic management of sexually transmitted diseases at primary care level, Mozambique
- Correspondence to: Dr Julie Cliff, Faculdade de Medicina, Universidade Eduardo Mondlane, CP 257, Maputo, Mozambique;
- Accepted 25 October 2001
Objective: To assess STD management in primary healthcare facilities where STD clinics and syndromic management guidelines had been introduced.
Methods: In 26 health facilities in selected sites, we observed management of all STD patients presenting in the adult general or STD clinic. We assessed the referral system by analysing patient registers.
Results: 408 STD patients (65% in STD and 35% in general clinics) were observed. 70% were women. Women were examined less (26% against 75%, p<0.0001), had laboratory tests ordered more (74% against 45%, p=0.0002), were more often diagnosed syndromically (57% against 38%, p=0.008), and received less advice on condom use (19% against 87%, p<0.001) and contact treatment (47% against 81%, p=0.04). Examination, laboratory requests, diagnosis, and treatment were not significantly different in the STD and general clinic. Health education was better in the STD clinic (condom advice 47% against 8%, p <0.001). Only 41% of referred patients presented to the STD clinic.
Conclusions: The better performance of STD clinics in health education was offset by high referral losses. A proposed integration of STD treatment into general outpatient clinics and better implementation of syndromic management and health education should improve STD case management at primary level in Mozambique.
In 1985, the World Health Organization (WHO) developed simplified treatment guidelines for STD treatment at primary healthcare level.1 After several revisions of the guidelines, WHO now recommends purely syndromic management.2
Since 1988, the Mozambican Ministry of Health (MOH) has progressively introduced sexually transmitted disease (STD) clinics at public primary level facilities (health posts and health centres). Health workers have been trained to use simplified treatment guidelines that include syndromic management. This one-off study aimed to assess the quality of STD management and the effectiveness of referral to the STD clinic at selected sites.
We carried out the study in 26 primary care facilities in Maputo and Quelimane cities and Manica and Tete provinces in 1995–6. Either all or randomly selected facilities were chosen. All STD patients presenting to the general adult or STD clinic were observed for one or two consecutive days. STD clinic frequency varied from daily to weekly.
We used a modified version of the WHO recommended protocol for observing STD case management.3 Denominators varied, as the whole process could rarely be observed in the same patient, because of referral to the laboratory, mother and child health services, and the STD clinic.
Where possible, we collected retrospective information in each general clinic on 100 consecutive patients who were referred to the STD clinic. We considered the patient as lost during referral if their name did not appear in the STD clinic register within the next 15 days.
We observed 408 patients—267 (65%) in STD and 141 (35%) in general clinics—at different stages of the consultation; 32 of the 42 health workers (38 males and four females) observed had received training in STD management guidelines; 286 (70%) patients were women (71% and 69% in the STD and general clinic, respectively). Table 1 shows the presenting symptoms.
Only 54/206 (26%) eligible women were examined, compared to 64/85 (75%) eligible men (p<0.0001). Laboratory tests were requested in 153/206 (74%) women and 38/85 (45%) men (p=0.0002). Syndromic diagnoses were more frequent in women (57% against 38%, p=0.008) (table 1).
Rapid plasmin reagin syphilis serology that was not recommended in the guidelines was requested in 147/291 (51%) patients. Physical and/or laboratory examinations were performed in only 33 of the 126 patients diagnosed aetiologically.
The STD and adult general clinic did not differ significantly in the proportion examined, laboratory tests requested, diagnosis, and treatment.
Only 38/197 (19%) and 118/197 (60%) women were advised on condom use and contact treatment respectively, compared to 59/68 (87%) and 62/68 (91%) men (p<0.001; p=0.04); 91/193 (47%) and 156/193 (81%) patients were advised on condom use and contact treatment, respectively, in the STD clinic compared to 6/72 (8%) and 34/72 (47%) in the general clinic (p<0.001; p<0.001).
Of 1193 STD patients seen in the general clinic, 54% were referred to the STD clinic. Of those, only 41% presented at the STD clinic.
Introduction of STD clinics and simplified treatment guidelines and many years of training and supervision have resulted in a functioning STD service at the primary care level. The high proportion (70%) of women patients seen confirms that primary level STD services tend to treat more women than men, in contrast with secondary level STD clinics.4
The STD clinic performed better than the general clinic in health education. This advantage was offset by large patient losses during referral to the STD clinic. Adherence to guidelines for laboratory use was poor, and referral to the laboratory probably contributed to patient losses.
Rapid and effective treatment of patients with STDs using syndromic management offers a means to interrupt transmission of HIV and other STDs.5 A proposal by the MOH to integrate treatment in the general clinic and introduce purely syndromic management should remedy some of the deficiencies found in this study.
All authors participated in the study design, fieldwork, data analysis, and writing.