):9-l 3 MALAWIMEDIOURNAL;16(l March 2004

Evaluationof syndromic management of sexually transmitted infections in Blantyre, Malawi Makoka MH", Komoldfe O.O" 'Lilongwe Central Hospital,Lilongwe, Malawi and bDepartmentof Microbiology, College ofMedicine' Malawi of Medi€ine, P/Bag 360, Blantyre 3, Address correspondence to: professor O.O,Komolafe, Department of Microbiology, College Malawi, Email:[email protected]

SUMMARY

Sixty-Iive consecutive patients presenting to the sexually transmitted inf€ctions (STI) clinic' QueenElizabeth Central Hospital (QECH), Blantyre were interviewed and six health centres were yisited to ass€ssthe quality of syndromic management of STIs and also to evaluate the successof partner tr€atment of index cases,The results show€d that more females (55%) than males (457o) presentedand 699o of interviewed patients were between 17 - 25 years. Age range was between 17 and 56 years and rnedian age was 27. Married people predorninated at 69Vo while singles were only 20Vo. 66V.,20Vo and l4Vo were index cases,sexual partners and repeat cases respectively while 337o of the

attendees had had an STI within the preYious 3 months' Approdmately 957a of patients had formal education and 97o had religious affiliations. When compared to previously used criteria' the resutt of this survey showed that information dissemination, health education and counselling of patients with STIs were poor with on\y 29Vo being adequately managetl' We also observed that orl'y 2OVoof part,r"t ,""." treated in this study. Health centers lacked the n€cessary equipment, personnel and supplies to adequately provide syndromic management services' Furthermore, record keeping in these centres rYas poor.

pital in Malawi and the teaching hospital of the University of transmitted sexually Malawi, College of Medicine. Malawi, including In developing countries top disamong the are Design: Exit interviews were cooductedat the QECH to deter(STIs) comPlications and their infections In services.'r healthcare mine levels of patient satisfaction'their socio-demographicproseek easecategoriesfor which adults for a larger account STIs file, issuesof partner treatmentand to further evaluatethe praccurable women of child-bearing age, any other lost than tice of service providers. Sixty-five consecutivePatientswere number of disability adjusted life-years r disorden related interviewed using a standardizedEnglish questionnaire also group of diseases apart from matemity HIv to facilitate phrasedin Chichewa,the lingua franca in Malawi' now known Sexually transmittedinfections are {'and that show IINAIDS6 i'acility assessment; A standardized checklist was used in each figures releasedby transmission, areas major urban clinic to obtain an inventory of drugs,equipmentand staff availHIV prevalenceamong male STI Patientsin from 377o presently ranges able for STI management Data on STI cases were obtained of Malawi was as high as 54.8% and paramount from the clinics' montlly returns for the period of March to to 70%.r Effective management of STI is, therefore' not only August, 2001. The data sought were number of new cases, to the r€duction of HIV incidence.s This is shategic the harbours which repeat visits and of Partners treated. for Malawi but the entire sub-saharan Africa Statistical analysis; Quantiiative data were analyzed using Epi highest HMAIDS diseaseburden in the world.e approach Info software version 6.4 . Content analysis was done to elicit One such management intervention is the syndrornic and effective as an major themesfiom open endedquestions. which was introduced by WHO/I'INAIDS setunder-resourced appropriate case management stategy in tings where laboratory facilities for the aetiologic diagnosis and Besults detectionof asymptomaticinfections are largely non-existent''u socio-demograPhicProfile which 45 (699o) were The syndromic approachwas adoptedin Malawi in 1993under A total of 65 patients were interviewed of age was 2i7 years' Their The median group. 25 age Health in the 17 the John Snow Incorporatd/support to AIDS and Family 66Vo of these 1' figure in summarized is syndromic age distribution (JSUSTAFH) project, An effective and successful 2070were while visits repeat were l47o n"\v quality of sew*ti"nt, *"r" management of STIs are dependent on both the "ases, ratio was female male to The traced. been and had patients partners that ice provided and health-seeking behaviour of both in out carried l:l-2. their Dartners."': The few studiesthat have been interviewed at the STI other-countriesshowed STI case managementto be generally Figure 1: Age distribution of patients (n=65) 'r'ta Clinic, QECH poor. The aims of the present study werc to determine the socio demographic characteistics of patielts presentingwith STIs, assess the quality of syndromic managementsewice provided including iacilities at the study centres and eYaluate the success of g g partner tleatment of index casesin Blantyre city' Malawi.

lntroduction

s I

Materialsand Methods

Setting: The study was conductedin the STI clinic at QECH, and six primary health centres (PHC) in and around the city of organBlantyrewhich includedone ran by a non-Sovemmental hos referral ization (Banja La Mtsogolo). QECH is the largest

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Evaluation of syndromic management

Married couples comprised 6970 of the patients inten'iewed while 207o were single (tig.2). One-third of the patients had a STI in the previous three months. Figure 2: Marital statusof patients interviewed at the STI clinic, QECH (n=65) 3%

was given to 98Vo. A partner notification (PN) card was given to 4370 and condom use was demonstratedto only 9Vo(Table2). 84Voof the patients waited for more than an hour for a consultation which lasted less than 5 minutes in 68Voof cases(fig. 4a & 4b). Ninety four percent found the consultation room private enough and all patients (lOOVo)said the attitude ofthe attending staff was good.

Divorced

Table 1: Indicators of the quality of health education piovided to patients

8%

Yes(Vo) (n = 61)

Wereyou told rltefttllowing?

2. 3.

That you can be re-infected if your partner is not treated?

4.

That STI can facilitate HIV transmission?

53 (82Ea) 9 (f4Vo)

12 (.18%) l'0 (15Vo) How to prevent STI? That your paftner can be infected without showing symptoms? 8 (12Vo) 43 (6674) That your partner must be treated?

5. 6.

Married

19 (297c)

That your illness is sexuallytransmitted? That you should take all of your treatment?

l.

7.

Thble 2: Indicators of the quality of casemanagement Thirty patients (467o) had secondary education, 26 (4OVo)had primary education,3 (57o)had tertiary education and6 (9%o)had no education at all. Overall 95Voof the patients had some formal education. With respectto occupation, 35 (547o)were in the informal business sector 16 (2470) were in formal occupation (drivers, teachers,guards employed by security companies,etc) and 14 (22%olwerehousewives. While 27 (41.67o) did not know the source of their infection, spouse (24.6Vo), regular partner (21.5Vo) and casual parlner (9.27o)were other sourcesof infection (fig. 3).

Yes(9o) (n = 64)

Did the nurse do the.following? l.

Take a complete history'/

4t (637o)

2.

Offer a physical examination?

3.

36 (55Va) 7 (1.17o)

4.

Give you condoms? Te1l you where to get condoms from?

5.

Demonstrate how to use a condom?

6.

Give you a partnercardl

1.

Give you medication?

3 (5Va) 6 (9Vo) 28 (1390) 63 (98o/o)

Figure 4(a): Time patients spent waiting for consultation

Figure 3: Source sexual contact of patients interviewed at the STI Clinic, QECH

s;z? .*

30- 60 min Waiting hme

Casualpartner

Regular partner

Spouse

Don'tknow

Source

Figure 4(b): Time patients spent in consultation

Only 2 (3.17o)patients admitted contacting infection from commercial sex workers (CSW). Almost all patients (97%o)hadrchgious affiliations and Roman Catholic, Church of Central Africa Presbyterian and Seventh Day Adventists had the most adherents, in order of frequencY. Assessment of quality of services provided at the STI clinic' QECH Concerning information dissemination, information about asymptomatic partners was the least likely to be given to patientswhile that on taking all the treatmentswas the most consistently given (Table 1). A comprehensivehistory was taken in 637o, aphysical examination was done in 55Voand medication Malawi Medical Journal

1 0m i n

Consultation time

1 1 E v a l u a t i o no f s y n d r o m i cm a n a g e m e n t

of facilitiesat the studycentres Assessment in the PHC Ii;i"*

it an inventory of equipment and supplies

who had T[ble 7: Summaryof specialquestionsto partners (n=13) responses beentracedandtheir

When did index case come?

Just yesterday 2 days ago >2 days ago

8 (62ckl I (S-zct I (\ck I

How were You notified?

Verbal + notification card Verbal onlY Came together

6 (46%t 1 (8ctc t

Yes response

Indicators 1. The protocolsof syndromicmanagementwere displayed

5 (837a)

2. The clinic had in stockthe necessarydmgsfor syndromicmanagement

4 (67sa)

3. There was a reportedproblem with supplyof drugs

2 (33Vo)

4. Vaginal speculumand light sourceavailable

3 (SOVo) 6 (.lffiVo)

5.Therewerc postercthat add€ssedHIV/AIDS

Frequenct

Response

Question

Table 3: Availability of equipment and supplies in primary health care clinics n=6

6 (46%t

TableS:STlcasesseenat6studycenffes(March-August2001

6. There were Postenon other STIs

4 (61%)

7. The clinic distributedfiee condoms

5 (83V0)

Bangwe

8. There was a rcpolted problem with condom supply

I (l'71o)

Lhllomom

9. There was a partrer notification cardin use

1 (1'7Vo)

l0.There was at leastone flained HIV counselorat the clinic

2 Q37o)

PHC

New

Limbe Ndirande Ndirande BLM Zingwangwa

Partner treatment

Total

Tables 4 to'7 area surnmary of issuesof partner treatment and six table 8 is a summary of casesseenat the study centresin the 2001' months preceding this study' i.e., March 2001 to August

Partner t:)

2537(ND) 6803(ND) 11s41(ND) 206sND) Not Available Not Applicable

Repeat

0 31r 1625

Total

35 2848 6803 13166 2065 24908

ND = Entries not differentiated

Discussion

the greatest Young adults are a sexually active group and bear yea.rsand 21 of age median burdeii of HIV infectionsu. with a that the shown again has a 75'hpercentile at 31 years this study Table 4: Summary of patients' reasonsfor partner treatment STIs' by affected (n=51\ econolically productive group is particularly married were 69Vo youth Even though most of the patients were, behavFrequency (F\g.2). TLis meansthat STI preventative measuresand group' target this for iouial changemessagesshould be tailored (447a) 25 source the most For complete cure Whereas 41.57oof the patients did not know 12 (217o) their from it load To reduce infection contact of their infections, 24'67o had contracted 6 (llVa) It is (Fig' 3)' To avoid re-infection spouses and 21 .6Vofrom their regular pafiners (ll%a) 6 partsexual body one Sexual partners regarded as apparentlyeasierto use a condom with a new casual 5 (9Va) sexual Protectlon ,r", o, *lit a commercial sex worker than with a regular 4 ('7Vo) consistent partner' Don't know pafiner. When it comes to a regular sexual 4 (170) is so becausea Other ure of the condom is difficult to achieve' This and a senseof tfust developsrelegating the condom their null attitude and cases index to questions special of Summary 5: Table to an emotional barrier that is to be avoided' a moral one as responses(n=43) STIs are not only a medical problem but also believed their marriage spouseshad infected 34 ('79Vo) 24.6Voof thecases Yes Will you notifY Your Partner? in the moral them (Fig. 3). This representsa critical breakdown 3 (]Vo) No not only in lies 6 (I4Vo) structure of the society-the solution for which Don't know psychosocial the in the technical and clinical domain but also 21134(19.47o) Yes Will the notified partner come for treatment? of the religious bodies and the family' 2134(5.9va) and moral contribution No affiliation' since 9'7Vo of interviewed patients had religious Don't know 5134(14;7V") in other as Furthermore among pregnant women' in Malawi of because What will you say to Your Partner? developing countries, STIs pose additional problems (59.37o) 10/21 and storY morbidity Nar-rate whole pregnancy outcomes and higher infant 8127(29.6Vo) adverse "The (Doctor/HosPitai) saY.." is therefore need to encouragereligious bod2127(.7.4Vo) mortality.liThere "You have infected me" the church in particular' to actively participate ll21 (3.1V0) ies/organizations, "Let's go to hosPital" in the fight against STIs including HIV/AIDS' providers shows that the and The performance assessmentof service Table 6: Summary of special questionsto repeat-visit cases In a study quatity of STI servicesis very poor (Tables 1 and2)' their resPonses(n=9) to have conductedin rural SouthAfrica,16 patientswere defined of the three any been appropriately counselledif they were told 2 (22Vo) When did you first come?

1 month

Did you notifY Your Partner?

Yes No

Reasonsfor not notifYing Partner

Partner away Relationship terminated

6 (.67Vo) 1 (lIVa)

following keY messages: i) Your illness is sexually transmitted,

ii) Your Partnermust be treated, is asymptomatic iii) Your partner may be infected even if he/she and transmission' HIV of 415(80vo) iv) STI increasesthe risk you' to glven 1l5Q0vo) v) You must take all the treatment 4 (447o) 5 (56Vo)

Malawi Medical Jouma

E v a l u a t i o no f s y n d r o m i cm a n a g e m e n t 1 2 According to this criterion only 29Eaof the patients in our survey were appropriatelycounselled (Table l) comparedto 4870 in that study.'u In addition more than four-fifths of the patients waited for over an hour to be seenand over two-thirds of them had a consultation time of lessthan five minutes (Fig. 4a and4b). Even though thesewere subjectivetime estimatesby the patientsthemselves we have here a general picture of patients having to wait for more than an hour for a very brief consultation. Certainly five minutesis insufficient to take an adequatehistory, do a physical examinationand offer the necessarySTI counselling. The most likely explanationfor such poor sewice provider performanceis understaffing.This poor quality of sewice is further reflectedin the fact that over one-thirdof thesepatientshad been teated for STI in the preceding three months, most at the same clinic. This is due to either health workers'failure to managethe initial infection successfullyor failure of patients to adhereto "safe sex" practicesand have thefucontact(s)treated.r6 The prevention and control of STIs depend on both treatment and prevention.'7Proper counsellingand educationis impoftant for both interventions. It is of concem that only two-thirds of the subjectswerc told that thei sexual contactshad to be trcat, ed as well (Table 1). Forty three percent of patientshad a PN card but did not know what it was or what to do with it. Since contacttracing is a cornerstonein the syndromic approach,it is necessarythat every patient be clearly advised to have his/her partner treated. A PN card is likely to improve the efficiency of contact hacing as it adds credibility to a verbal inyitation of a soxualpartner to attend the STI clinic and it also ensuresconfidentiality. In addition patient referral is less costly and labourintensive than provider referral where the health services take responsibility for tracing contacts. It is essentialthat STI patients do not feel stigmatized,judged, rejectedor disrespected.As the suppliesremain meager,facilities and personnelinadequate,good attitude of health workers are a powerful asset that we have and need to maintain. However, most patients were nor told thar STIS facilitate HIV tmnsmission and that their partner could be infectcd and still remain asymptomatic . It is thercfore important to organize refreshercourses/continuedmedical educationfor these service providers to improve their skills and offer supervisionof health care staff. Regarding partner treatment,this survey shows that only onefifth of the patients had their sexual partnerstreated. This is consistentwith the unpublisheddatafrom morthly retums ofthe STI Clinic.'* The proportion of partners treated over index patierltswerc 25Eoand 23% in the years 1999and 2000, respectively. Unfortunately these unheatedpartnersrepresenta pool of STIs in the community and it is very likely that the cunent situation of high STI prevalencein Malawi is to some extent due to unsuccessfulpartner notification and contact hacing campalgns. With regardsto facility assessment, most health centreswere not well equipped to provide syndromic management services, Three centres (507o)had vaginal speculum and light available but only one (177o)had the PN card in use. It is more likely that health centres in the rural ,ueas are even worse equipped and supplied. Sincethe healthcarecentresprovide the bulk of health servicesit is important that they have the necessaryequipment and suppliesnot only to provide syn&omic managementsenices, but also to meet the healthcareneedsof the community. This study has also revealedpoor record keeping in the clinics. Limbe health centre and Ndirande BLM Clinic lumped all STI casestogether without indicating how mary were new cases, Malawi Medical Joumal

partnersor revisit casesas is the practice at the QECH. Records ftom Zingwargwa health centre were not available despite our repeatedrequests.Accuratedala management is crucial in lhe rururing of any programrne because it enables meaningful monitoring and evaluation of servicesbeing provided. The findings in this survey,however, show that there is inadequatemonitoring of the syndromic approachand consequendythat it cannot be adequatelyevaluated. Such lack of monitoring is a reflection of the low pdodty accordedto STIs in Malawi. In these times of severe budget deficits and shortageof staff, health service managers tend to be forced to neglect important clinical and public health issues.Howevet failure to trcat all partnersof STI patientsis a failure of the syndromic approach,which has been in place for nine years. Taking cogniz;rnceof how STIs facilitate HIV hansmissionl&n and acquisition, the health system in Malawi can not continue to relegateSTIs to lower priorities. The syndromic managementof STIS in the city of Blantyre is unsatisfactoryas there are major gaps that need to be bridged. This obseNation is in complete agreementwith the conclusions reached in a similar study carried out in Kenya2O and elsewhere in other developing countries.21,22 Perhapsthe establishment of a National STI ReferenceCentre as it is the case in some countriesin the subregionmay help to tum the situation around. Such a cenhe will not only monitor and regulate syndromic managementpractice, it will also help to detect changesin disease prevalence, the emergenceof new ones, drug resistance pattem and even recommenda changein the existing algodthm, if need be. Ack otrIe.lgentents We ocknotvLedge antl uppreciute the lupport rcceivd liom tlrc entire steffofthe STI .h1iL, QECH, antl the other six health cetrtrcsuse.l in ris slud!. Thanks ako to Mr Somba of LEPRA (QF:CH) Jbt dlbwing hi\ o|.lit:z ta he setl Jbt the

References L Mayaud P, Hawkes S, Mabey D. Advances in control of sexually transmitteddiseasesin developing countries. Lancet 1998; 351 (suppl III)l

29 32 2. Concerted Action for the Syndromic Appfoach (CASA). Optimising the use of the syndromic approachlbr STI managemen!and prevention in resource p o o r s c ( i n g s . h l t e r a t i u l u l L i t e t u t u t eR ? v i e w 2 0 0 2 ; 9 : 2 4 . world-Bank. World DevelopmentRepot. Investjng in Health. New York, i. O\fod Univenity Press. 1993. L Cohen MS. Scxually transmitted diseasesenhanceHIV transmission : no longer a hypothesis. l^1],1.rt1998; 351 (suppl III): 5 7 5. \\'r$serheit JN. Epidemiological synergy : interrelationshipsbetween human immunodeficiency virxs infection a other sexually iransmitrcd '71 infections. Sc-ri.Trans. Dis. 1992;19.61 6. UNAIDS Repoft. The HIV/AIDS Epidemic in Malawi. The situation and the ResponseUNAIDS Lilongwe 2001. 7. Hades AD, Nyirenda TE, Mphasa N. et a]. Screcningfor HIV related dis easeand sexually transmitted infections in patients with tuberculosisin Mala]/Jl. MaLawi. Merl. J.2OO1:'13 (l):21 - 2'7 8. ChessonHW Pinkerton SD. Sexually transmitteddiseaseand the increasedrisk for HIV transmjssion: implicatior for cost effectiveness, analysesof sexually transmitteddiseaseprcvention inferventions. J. Acquired Imm . Def. Sytuh 2OO0;24(l): 48 56 9. GerbaseAC, Rowley Jl Meftens TE. Global epidemiology 01 sexually transmitted diseases.Iancet 1998.351(suppl III): 2 4. i0. wHO (Geneva) Publication. Managementof patientswith sexually tnnsmitted diseases. WHO Technical Report 1991. Series no. 810 11. Bosu WK. Syndromic managementof sexually transmitted diseases:Is it rational or scientific? Trop. Med. lnt. Health. 1999: ,1 (2): 114 119 12. Aral SO, PetermanTA. Do we know the effectiveress ofbehavioural interventions?k,lc"r 1998: (suppl IlI) I I 36 13. Hudson CP Syndromic managementfor sexually ftansmitted diseases: back to the drawing board.lnt. l. STD AIDS 1999: l0 (7): 423 34 14. Pettifor A. walsh J. wilkinson D et al. How effective is syndromic rnanagementofSTDS : A review ofcurent studies. S€x.Transm.Dis. (1):311 385 2OOO;27 15. Taha ET, DallabettaGA. Hoover DR et al. Trends ofHIV-l and sexually transmitted diseases among pregnant and postpartum women in urban

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Malawi. AlDs 1998: 12 (l): 197 l0-r. 16. Harfison A. wilkinson D. Lurie \l et al. lmpro\ ing qualir] of se\ually transmitted diseasecase managem.nl in rural Sou.h Africa. ,11rS 1998: 2335 12:2329 t'7. Daliabetta GA. GerbaseAC. Holme! KK et al. Problems.solutions and challengcsin svndromic managemenlof se\uall) transmitteddiseases. 6l Sex.Tre s,n.lnfe . i998: '-J tsuppl I | 5l 1 8 . UnpDblisheddala lbrm from dre STI clini€. QECH. Blanlyre. 1 9 . Fleming A. $asserheit J\- From epidemiological synergieslo public health policl and prrctice : the conribution of other sexually transmitted diseiNesto se\uaf Fansmissionof HIV infection Sex.Transtn lnf 1999;

Invitation

'15 :3 11 and disease voetenHA, OtidoJM. Qualityof sexuallytransmitted typesof amongdifTerent in Nairobi,Kenya: a comparison management facilities.S4!.Transm.Dis 200l: 28(11):633-642 healthcare 2 1 . wilknson D, HarrisonA, Lurie M et aI STD syndromepackets: in diseases of sexuallytransmitted improvingsyndromicmanagement 't€i. Trunstn.Dis 1999:26 (3): 152 156 countriesdeveloping J, LagaM et al How manypatientswith sexually BuveA, Changalucha infectionsarecuredby healthservices?A studyfrom Mwanza traDsmilted rcgio\Tanzania.Trop.Med.lnt- Health200la 6 (\2):917 -919

and Call for Abstracts

COLLEGD OF MEDICINE RESEARCH DISSDMINATION MEETING November 13th, 2OO4 Mahatma Ghandi Campus, College of Medicine University of Malawi The Annual Research Dissemisation Meeting is an imPortant oPPortunity to Present data from r€s€afch relati-ng to a[y asp€f,t of healtb in Malaei ald to be informed of the side ran€e of crurent res€arch activitics. sEdics tbat have been approved by College of a Researchcrs und€rtsling Med.ici.De Res€8rcb Etbics ComEitt c ar€ erPected to either present a poster of study design and progrcss if tort is oDgoing or subnit an abstract for oral or poster presentatioD if rort is lot comPlete. submitted abstracts are peer-reviered aDd prcs€ntations sill be oral or Poster presentation. Available media for pres€ntation include PoverPoint Presentation,

slides

and overhead Proiector. Deadline for abstract submission: October llth

2OO4

Fbrms for abstracts are available from: Mrs Thandie Kamwendo, College of Medtcine Research Oflice' P,/Bag360, Blantyre 3. .

[email protected] . [email protected] Tet: Ol 6?1 911 ext: 2O5; or Ol 674 377 Faxt OL 674 74O Malawi Medical Journal