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Chemists and druggists working in “medical shops” play a significant part in the treatment of sexually transmitted infections (STIs) in resource poor countries.1–4 In some settings, chemists and druggists are consulted for first line treatment of STI symptoms more often than hospitals and clinics designed specifically to service such clients.1 Recent unpublished data from Pokhara, Nepal, suggest that in up to 80% of cases, treatment provided by chemists and druggists was inappropriate or incomplete.1 We report here on the quality of STI case management among a random sample of chemists and druggists from the 75 medical shops in Pokhara Municipality Area, Nepal.
Chemists and druggists working in all Pokhara medical shops, 65% of whom had received previous training in the national STD case management guidelines,5 based on WHO syndromic algorithms,6 were trained and motivated to initiate a register of all STI client visits and their treatment. Registry data from January to December 1999 were reviewed. Thirty seven registered medical shops were randomly selected for visits using the simulated client method (SCM) presenting 22 urethral discharge (UD) and 15 vaginal discharge (VD) scenarios.
Of the 6374 STI cases (68% female, 32% male), 22% presented with urethral discharge, 31% with vaginal discharge, 21% with genital ulcer disease, and 26% with pelvic inflammatory disease. Seventy per cent of STI shop clients were making their first contact for care, while 14% were coming to buy STI drugs with a prescription from a private clinic and 16% from a government facility.
Based on SCM visits, only 24% of shops dispensed the correct medication and dosage for treatment of UD and VD, as specified in the national guidelines. Frequency of dispensing either an overdosage or an incomplete dosage of the correct medication was the same (both 5%). In 43% of cases, chemists and druggists offered treatment that was incompatible with national guidelines, including drugs not meant for UD or VD treatment. Finally, in 22% of cases no medication was dispensed (fig 1). While over 95% of SCM clients were made to feel welcome, given a private consultation, and were asked about their health history, risk counselling was conducted only 57% of the time, partner notification occurred in 43% of cases, and condom use was promoted in only 35% of cases.
Seventy per cent of clients visiting medical shops for STI treatment in Pokhara Municipality Area in 1999 were there for first line treatment—findings in agreement with a recent study conducted in Ghana, which found that over 60% of STI clients came to pharmacies without a prescription.3 Although positive privacy and welcoming practices make medical shops a valuable outlet for STI treatment, only one quarter of chemists and druggists in Pokhara Municipality Area correctly dispensed medication for the treatment of UD or VD. While these data do not permit analysis of whether trained versus untrained providers were better at prescribing practices, it is clear that training efforts need to be expanded and intensified to improve STI control in this region.
This study received funding from the University of Heidelberg STD/HIV Project, Kathmandu, Nepal, which is funded by the European Union (EU) (B76211/97/044).
There are no conflicts of interest.
The authors would like to thank Mr Bishwa Bandhu Baudyal, coordinator for the NCDA programme in Pokhara, for his help in collecting the reports from each of the 75 medical halls, the Gandaki Zonal Branch of the Nepal Chemist and Druggists Association (NCDA), Pokhara, and the Nepal Chemist and Druggist Association, Central Office, Kathmandu, for their cooperation, and all chemists and druggists in Pokhara who participated in the training, data collection, and study.
Contributors KPB designed the study, oversaw data collection, and edited the paper; TES wrote the paper; MHK participated in study design, oversaw data collection, andconducted statistical analysis; PC acted as clinical advisor for the study.
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