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In South Africa, KwaZulu-Natal (KZN) is at the centre of the HIV epidemic and sexually transmitted infections (STIs) are endemic in this province.1 Improving the quality of STI health care causes a cost effective reduction in HIV prevalence and STI incidence.2 Despite the introduction of national standard treatment guidelines (STGs), based on the syndromic management approach (where antibiotics are prescribed according to algorithms and non-medicinal aspects of care are emphasised), poor case management has been found in rural KZN clinics.3 This study determined the quality of care received by STI patients at King Edward VIII Hospital (KEH), Durban. As the province’s main academic hospital, KEH has represented the best level of health care for the average citizen of KZN since 1936. Patients with STI are managed syndromically.
The drug treatment of 97 black African outpatients with STI (73% female, average age 29 years) was compared with STGs. Patients also completed a questionnaire assessing non-drug management. Drug treatment complied with STGs in 79% of patients. When assessment included non-drug measures (partner notification cards, condoms, and correct drugs) it fell to 24% compared to 9% found among nurses, with simulated patients in rural KZN clinics.3 Although overall care appears better in the urban setting, the real difference is at the level of drug treatment (where 79% v 41% received recommended drugs), as in both cases only about a quarter of the patients who had correct drug treatment also received appropriate non-drug care. Patients had appropriate counselling in 56% of cases. This was measured in terms of receiving at least one message in each of the five categories shown in table 1. Despite 72% of patients being encouraged to use condoms, 52 patients were not shown how to do this. Of these, only 31 knew how to use them.
Care givers were interviewed and vignettes were used to compare ideal and actual practice. Barriers to patient care and possible solutions were canvassed. All care givers gave appropriate answers for the ideal management of their fictitious case, but reported a difference between ideal management and actual practice in terms of non-drug aspects of management. All care givers failed to give drug information and to promote health seeking behaviour. Barriers to patient care were lack of time, staffing shortages, and motivation. There was a perception that non-drug management was not the responsibility of the tertiary care giver.
Care givers favoured the option of introducing a packet containing information, condoms, and a referral card, which could be issued with medication. In rural KZN a similar intervention resulted in improved case management in 83% of cases compared with a control group of 12% (p<0.005).4 Such packets could help improve STI management in this tertiary setting, which has no dedicated STI clinic.
The authors wish to thank the interviewers, the staff of KEH, and the patients who participated as well as Immo Kleinschmidt and Andy Gray who gave statistical advice.