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RHO archives : Topics : Reproductive Tract Infections

Annotated Bibliography

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Assessing the operational implications of integration

Askew I, Berer M. The contribution of sexual and reproductive health services to the fight against HIV/AIDS: a review. Reproductive Health Matters. 2003;11(22):51-73.
Sexual and reproductive health services, including services for family planning, sexually transmitted infections, and antenatal and delivery care, have made significant contributions to HIV/AIDS prevention and treatment. This review shows that STI control is important for reproductive health and HIV/AIDS control. More integrated programs of sexual and reproductive health care and STI/HIV/AIDS control should be developed to offer services, reach out to new population groups, and establish effective referral linkages.

Budiharsana, M. Integrating reproductive tract infection services into family planning settings in Indonesia. International Family Planning Perspectives 28(2):111-112 (June 2002).
To improve reproductive health services for women in Northern Jakarta, Indonesia, a pilot project was developed to introduce RTI detection and treatment services at two family planning clinics. Baseline data gathered through provider interviews and analysis of clinic medical records indicated that providers should be the main target group for intervention. Providers received two stages of training, three months apart. After the first intervention, providers abilities to correctly diagnose infections and their ability to communicate to clients the importance of partner notification and treatment showed the need for further training. This intervention showed that the family planning clinics had the necessary equipment and were well situated to reach adult, married women. However, substantial training is needed to improve providers technical knowledge and skills in STI detection, diagnosis, and treatment. Providers also need training in counseling on partner notification and dual protection. The findings also indicated that accurate clinical diagnoses of RTIs depend on access to laboratory tests, including use of microscopes available in most health centers.

Buve, A. et al. How many patients with a sexually transmitted infection are cured by health services? A study from Mwanza Region, Tanzania. Tropical Medicine and International Health 6(12):971-979 (December 2001).
This study estimated the proportion of symptomatic patients with an STI cured by primary health care services in Mwanza, Tanzania, and compared the cure rate before and after the introduction of improved STI treatment services. The study used a model to describe the various obstacles clients face in achieving a cure, along with data from an observational study in four clinics and from an intervention trial. The results show the overall cure rate achieved by health centers offering improved STI services ranged from 23 to 41 percent, while the cure rate achieved by centers prior to the introduction of improved services was less than 10 percent. These relatively low cure rates are a result of losses at each step clients and providers must take to achieve a cure: become aware of symptoms, seek care, correctly identify STI, prescribe effective treatment, obtain treatment, and complete full treatment. This study offers a more realistic picture of a clients experience in STI case management, and offers information about potential problems in effecting cures.

Chowdhury, S.N. et al. Are providers missing opportunities to address reproductive tract infections? Experience from Bangladesh. International Family Planning Perspectives 25(2):92-97 (June 1999).
This study examined family planning service delivery at 46 locations in the Dhaka, Bangladesh area, with a specific focus on management of reproductive tract infections. A total of 112 providers and 172 clients were interviewed. While most of the clients said they came to the health center for family planning, 77 percent reported at least one symptom of an RTI during their interview. Few of these women spontaneously spoke of these symptoms. Observations of service delivery showed that providers detected an RTI in only 21 percent of these clients. The study concludes that providers often failed to gather full reproductive health information from clients, and did not follow basic infection prevention practices. Client-provider interactions were usually limited to the initial reason for the clients visit, thus providers failed to take full advantage of the medical visit to provide RTI services.

Dehne, K.L. et al. Integration of prevention and care of sexually transmitted infections with family planning services: what is the evidence for public health benefits? Bulletin of the World Health Organization 78(5):628-639 (2000).
This article summarizes experiences with integrated sexually transmitted infection and family planning services. In most cases, STI services have been added to existing family planning services. STI prevention services, such as counseling and risk-reduction education, have been integrated with family planning services far more often than STI diagnosis and treatment services. Integration of STI/HIV prevention has had a positive impact on client satisfaction, and on the acceptance of family planning. It is less clear whether integration has lead to any improvements in STI risk behaviors or condom use. The authors conclude that integration has not taken place in any systematic way, nor has it produced the expected benefits. There is need for rigid evaluations of STI/FP integration activities and cost studies.

Grosskurth, H. et al. Operational performance of an STD control programme in Mwanza Region, Tanzania. Sexually Transmitted Infections 76:426-436 (2000).
This study analyzed the Mwanza sexually transmitted infections control program to assess its feasibility, the distribution of STI syndromes observed, the clinical effectiveness of syndromic management, and the quality and utilization of services. During the two years of the Mwanza intervention, 12,895 STI syndromes were treated at 25 intervention health units. The most common syndromes treated were urethral discharge (67%) and genital ulcers (26%) in men; and vaginal discharge (50%), lower abdominal tenderness (33%), and genital ulcers (13%) in women. Clinical treatment was highly effective. However, only 26 percent of patients referred to higher levels of health care actually presented for treatment, thus it is important to treat patients when they first present for care. The authors conclude that it is feasible to integrate STI services into the existing primary health care structure. The improved services attract more patients, but education could lead to improved treatment-seeking behavior. It is critical to have clear treatment guidelines, a reliable drug supply, and regular supervision. There should also be at least one reference clinic and laboratory per country to ensure monitoring of syndromes, drug resistance, and the effectiveness of syndromic management.

Hardee, K. and Yount, K.M. From rhetoric to reality: delivering reproductive health promises through integrated services. Family Health International, Women's Studies Project (August 1995) Available at: www.fhi.org/en/wsp/wspubs/rhetor.html).
This paper provides an historical view of experiences in formulating, implementing and evaluating integrated services of national public-sector programs in developing countries. The two main target audiences are those who have been involved in family planning and other reproductive health programs and those who advocate for the integration of reproductive health services. The paper identifies policy and service delivery challenges and discusses issues such as type of services, costs, and funding.

International Council on Management of Population Programmes. Managing quality reproductive heath programmes: after Cairo and beyond. Report of International Seminar December 2-6, 1996; Addis Ababa, Ethiopia (1997).
Top managers of population and health programs and representatives of international agencies gathered at this seminar to exchange knowledge and experiences on the latest developments in the field of population program management. This seminar report presents the discussion of five specific themes in managing quality reproductive health programs: (1) institutional structures for program implementation, (2) expanding reproductive health services, (3) adolescent/youth reproductive health programs, (4) enhancing gender sensitivity and participation of men, and (5) improving quality of care. The discussion on expanding reproductive health services reviews some programs that have successfully integrated RTI services with other existing services.

Kariba, J.W. et al. Integration of STI and HIV/AIDS with MCH-FP services: a case study of the Nakuru Municipal Council's project on strengthening STD/AIDS control. Population Council, Operations Research and Technical Assistance Africa Project (April 1997).
This document reports on the experience of a project in integrating STI and HIV/AIDS services with existing MCH-FP services in Nakuru, Kenya. A situation analysis of clients and health providers at seven health facilities in the project area identified several facility factors that needed improvement and strengthening: staff skills in risk assessment, history-taking, and clinical assessment of clients receiving family planning, antenatal and STI services. The report highlights the obstacles that hindered the integration of STI and HIV/AIDS services with already existing clinic services. These included the lack of basic equipment and supplies; non-availability of IEC materials, absence of checklists or guidelines on STI diagnosis and treatment; a law preventing nurses from administering antibiotics; inadequate partner notification and contact tracing; and severe shortages of drugs for treating non-STI ailments. However, the assessment revealed that all seven facilities had the basic physical infrastructure necessary to provide high-quality integrated health care services, including the management of STIs and HIV/AIDs.

Lush, L. et al. Integrating reproductive health: myth and ideology. Bulletin of the World Health Organization 77(9):771-777( 1999).
This paper reviews progress on integration of HIV/STI and primary health care services since 1994 in Ghana, Kenya, Zimbabwe, and South Africa. Integration in Ghana, Kenya, and Zimbabwe has meant the addition of new activities to the existing primary health care services, which focus on women and children. While better collaboration between vertical services has been emphasized, in practice little has changed. External donors, who support vertical programs, have contributed to the practical problems of integration. In South Africa, however, political commitment to comprehensive primary health care at the provincial level has permitted better integration of HIV/STI services. While the South Africa model seems more effective, the most realistic approach may be to encourage better negotiation and compromise between those influencing reproductive health services. International donors also need to take into account the political, financial, and managerial limitations within developing countries.

Magwaza, S. et al. Improving care for patients with sexually transmitted infections in South Africa. Nursing Standard 17(8):33-38 (November 6, 2002).
In collaboration with district health service supervisors, a two-page questionnaire was developed to assess the quality of care and health services for STIs offered at the clinic level. The district quality-assessment instrument (DISCA) was developed in 1997 to enable district clinic supervisors to systematically improve the quality of care of patients with STIs. The instrument was pilot-tested at six clinics in three districts in South Africa. District clinic supervisors received 45 minutes of training on STI syndromic management, quality of care and its assessment and use of the instrument. Each supervisor then conducted assessments in two clinics. The average time of assessment was 35 minutes. Based on the pilot study, the instrument was revised and includes information on the accessibility of STI services, provision of safe examination and treatment, syphilis screening and treatment for pregnant women, staff training, and availability of STI drugs and correctness of treatment (through review of ten patient records). The DISCA offers a low-cost way to promote improved STI care delivery at the district and clinic levels, although its ability to determine clients’ perceptions of care.

Mayhew, S. Integrating MCH/FP and STD/HIV services: current debates and future directions. Health Policy and Planning 11(4):339-353 (1996).
This article reviews information important to integration of STI/HIV services with FP/MCH services. After a brief presentation of the rationales for the integration of these services, the article discusses several areas of concern, including technical and programmatic, clinical, and provider issues. It states that there is limited documentation of case studies of integrated reproductive health services. The article concludes by suggesting directions for future research, including the need for country-specific guidelines and multidimensional frameworks, and the appropriateness of a policy-analysis approach.

OFarrell, N. Sector-wide approaches and STI control in Africa. Sexually Transmitted Infections 77(3):156-157 (June 2001).
In this editorial, the author questions the effectiveness of sector-wide approaches (SWAps) to health care funding in developing countries and their effect on STI control. A number of funding organizations, including the World Bank, the World Health Organization, and the Department for International Development, have used SWAps to provide funds to the health sector in a country, and to help health ministries determine spending priorities. If project-based funding is to be eliminated, the author proposes that funding of STI control activities may need to be "fenced" or protected. Although integrated STI and reproductive health services offer many benefits, these primary care clinics have little experience in offering specialized STI services to men. Similarly, targeting of specific groups for STI/HIV prevention and treatment services has proven effective in many countries. Instead of eliminating the funding for these services, there may be need for their expansion. Optimal use of resources for STI control may require a combination of horizontal and vertical approaches.

PATH (Program for Appropriate Technology in Health). Assessing Program Capacity: Adding Services to Manage Reproductive Tract Infections. Unpublished (1998).
This reproductive health assessment tool is intended to help clinic managers assess program capacity for RTI/STI services by determining (1) what level of new RTI services might be provided through an existing program, and (2) what additional inputs would be required to provide the new services safely and effectively. The tool is designed to be easy to use by a program manager who has no formal training in evaluation and to produce practical, useful information for individuals making program decisions. The tool guides the assessment team through a series of questionnaires and advises on subsequent action that may need to be taken. The tool offers guidance based on four levels of service, ranging from simply providing prevention information and referral services to providing both diagnosis and treatment of specific RTIs. For more information, contact PATH .

Post, M. Providing services for sexually transmitted infections within other health programs. SARA Issues Paper (April 1995).
This paper discusses the importance of integrating services for sexually transmitted infections (STIs) with other health programs such as family planning, maternal-child health, and school health programs. It highlights key issues involved in designing new integrated delivery systems or in improving the quality and effectiveness of ongoing ones. The paper ends with a discussion of different objectives for different levels of integration, stressing the importance of clearly defining objectives and targets before planning and implementing an integrated program. The appendix reviews basic information about common STIs identified as risk factors for HIV transmission, and control measures that can be used in resource-poor settings.

Shelton, J. Prevention First: a three-pronged strategy to integrate family planning program efforts against HIV and sexually transmitted infections. International Family Planning Perspectives 25(3):23-35 (September1999).
Many programs have tried to integrate STI prevention and treatment services into existing family planning programs. The major focus has been on curing STIs through syndromic management, although this approach has its weaknesses, especially for women. The author proposes that resources could better be used by focusing on three groups at risk for STIs: high transmitters, men, and the general population. More effort should be placed on social marketing of condoms and appropriate antibiotics, especially to men. Emphasizing prevention and building on on-going prevention activities in many health sectors is the best approach to reducing STIs and HIV/AIDS on a global scale.

Wilkinson, D. et al. Population-based interventions for reducing sexually transmitted infections, including HIV infection. (Cochrane Review, 2002). In: The Cochrane Library, Issue1, 2002. Oxford: Update Software, Ltd.
A review of randomized controlled trials to evaluate the impact of population-based STI interventions found limited evidence that STI control is an effective HIV prevention strategy. However, improved STI treatment services have been shown to reduce the incidence of HIV infection in a population with an emerging epidemic and where STI are highly prevalent and treatment services are poor. There appears to be no benefit to treating all community members for STIs. However, improving STI treatment services can also improve the quality of services overall. More community-based randomized controlled trials are needed to test alternative STI control strategies, including those that affect health seeking behaviors and the quality of treatment.

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Involving the private and public sectors in STI control

Adams, E.J. et al. The cost-effectiveness of syndromic management in pharmacies in Lima, Peru. Sexually Transmitted Diseases 30(5):379-387 (May 2003).
While studies have shown that pharmacists can be trained to provide syndromic management of STIs, few assess the cost-effectiveness of the intervention. This study analyzed the cost of training pharmacy workers based on direct program costs and benefits, and from a societal perspective using costs and benefits to the wider community. Both show low cost-effectiveness ratios. From the societal perspective, training pharmacists saved an estimated US$1.51 per case adequately managed. From the program perspective, the cost was US$3.67 per case adequately managed. While this study is limited by the costs and measures of effectiveness it estimated and included, it provides a guide for assessing cost-effectiveness of managing STIs syndromically using indirect estimates of effectiveness.

Adu-Sarkodie, Y. et al. Syndromic management of urethral discharge in Ghanaian pharmacies. Sexually Transmitted Infections 76:439-442 (2000).
Training pharmacists in syndromic management of STIs in Accra, Ghana, improves the treatment of urethral discharge in clients. Fifty pharmacy outlets that had received training (intervention) were randomly selected, as were 50 outlets that had received no training. Simulated clients visited each pharmacy and described symptoms of urethral discharge to the first pharmacy employee they encountered (less than half were seen by pharmacists), and completed a questionnaire after the visit. Training resulted in improvements in the correct drug provided for urethral discharge, but still remained low (no intervention, 18%; intervention, 39%). Treatment for gonorrhea was usually correct, with (76%) or without (64%) the training intervention. Treatment for chlamydia also improved with training (31-41%), but remained low. Promotion of condoms was very poor, and few outlets offered them to clients. Training pharmacists, and other pharmacy staff, can lead to improved treatment of urethral discharge. However, future training should emphasize condom promotion.

Banjarattanaporn, P. et al. Men with sexually transmitted diseases in Bangkok: where do they go for treatment and why? AIDS 11 (Suppl. 1):S87-S95 (1997).
The goal of this study was to describe and identify predictors of health-care seeking behavior among men with STIs in Bangkok, Thailand. A total of 213 men participated in the study and completed interviewer-administered questionnaires on risk behavior, patterns of treatment-seeking for current and past STIs and attitudes toward health care. Of the participants, 101 were recruited at government clinics, 50 at private clinics, and 62 at drugstores. Two-thirds of all participants had had a previous STI. Of the participants, 39 percent of men initially seen at drugstores, 29 percent seen at private clinics, and 19 percent seen at government clinics sought subsequent treatment. Failure to respond to therapy was the primary reason for seeking additional care. Patients at drugstores and general private clinics received the least amount of counseling or STI testing, while those attending specialized private STI clinics received the most comprehensive services. Attitudes toward government clinics were uniformly positive regardless of the site of enrollment; conversely, about 50 percent of patients at drugstores felt that the advice and treatment they received were inadequate. Convenience, affordability, and lack of embarrassment were associated with choice of treatment site. The authors concluded that STI/HIV control in Thailand must focus on improved treatment and counseling at the point of first encounter in the health care system, particularly in the private sector. Syndromic case management, incorporation of STI care at other public clinics, and the recognition that more men practice unsafe sex with partners other than sex workers could improve STI control.

Bista, K.P. et al. The practice of STI treatment among chemists and druggists in Pokhara, Nepal [letter]. Sexually Transmitted Infections 78(3):223 (June 2002).
This brief letter reports on the findings of a study of the quality of STI case management from a random sample of chemists and druggists at 75 medical shops in the Pokhara Municipality Area of Nepal. Registry data were reviewed for January-December 1999, and 37 medical shops were randomly selected for visits from simulated clients complaining of urethral discharge (22) or vaginal discharge (15). Of the 6374 STI cases, 31 percent presented with vaginal discharge, 26 percent with pelvic inflammatory disease, 22 percent with urethral discharge, and 21 percent with genital ulcer disease. Seventy percent were making their first contact for care. Based on the simulated client visits, only 24 percent of shops dispensed the correct medication and dosage for treatment of urethral discharge and vaginal discharge according to national guidelines. Although almost all clients were made to feel welcome, given a private consultation and were asked about health history, risk counseling, partner notification and promotion of condom use was done far less frequently. While this study did not distinguish between trained and untrained providers, it is clear that training needs to be expanded and intensified.

Brugha, R. and Zwi, A. Improving the quality of private sector delivery of public health services: challenges and strategies. Health Policy and Planning 13(2):107-120 (1998).
This paper presents a model for identifying the influences on private providers, mainly private medical practitioners, and offers strategies for improving the quality of their management of public health conditions. The authors review some of the lessons and conclusions that can be drawn from the published results of interventions to improve health care delivery in high- and low-income countries, as well as their potential strengths and limitations. Finally, the article outlines categories of interventions that should be considered and evaluated for improving provider practices, identifying research priorities, and involving key stakeholders in the identification of multifaceted interventions to improve quality of care and health outcomes.

Brugha, R. and Zwi, A. Sexually transmitted disease control in developing countries: the challenge of involving the private sector (Editorial). Sexually Transmitted Infections 75(5):283-285 (October 1999).
This editorial discusses the importance of public-private health-sector partnerships for STI control. It also provides an overview of the challenge of involving the private health sector in STI control activities in developing countries. The editorial calls for greater recognition and rigorous evaluation of the potential for private-sector involvement in STI treatment and control. In order to achieve this, collaborative, synergistic approaches involving STI and health systems' policy makers, program managers, providers, users, and researchers will be needed.

Chalker, J. et al. Private pharmacies in Hanoi, Vietnam: a randomized trial of a 2-year multi-component intervention on knowledge and stated practice regarding ARI, STD and antibiotic/steroid requests. Tropical Medicine and International Health 7(9):803-810 (September 2002).
This multi-component intervention to improve the knowledge and stated practice of staff working in private pharmacies in Hanoi, Vietnam, resulted in significant improvements. Over 17 months, this randomized controlled trial worked with 22 matched pairs of intervention and control pharmacies on sexually transmitted diseases, acute respiratory infections, and dispensing of antibiotics and steroids. The three interventions included: prescribing regulations enforcement, face-to-face education about treatment guidelines, and peer influence. After the interventions, more drug sellers stated they would ask about the health of the partner (P = 0.03) and more said they would advise condom use (P = 0.01) and partner notification (P = 0.04). Although not statistically significant, more pharmacies said they would sell the correct drug treatment. Improvements were also noted in ARI and prescribing. These interventions cost less than US$200 per pharmacy, which indicates improvements in knowledge and stated practice can be made at modest cost.

Chalker, J. et al. STD management by private pharmacies in Hanoi: practice and knowledge of drug sellers. Sexually Transmitted Infections 76: 299-302 (2000).
A study of 60 private pharmacies in Hanoi, Vietnam, found that pharmacists and drug sellers provided treatment even when inappropriate, and none gave syndromically correct treatment. Five simulated clients visited each of the pharmacies and presented a scenario about a friend with a urethral discharge. Of the 297 encounters, drug treatment was provided in 250 cases (84%), yet no one gave the correct combination of drugs for treatment according to the national guidelines. In 55 percent of the encounters no questions were asked of the client, and no advice was given in 61 percent of the visits. According to questionnaires administered after the simulated client visits, and contrary to what they practiced, 51of 69 (74%) respondents said they would refer clients to a doctor instead of treating. Few pharmacists and drug sellers provided advice about partner notification and condom use. There is urgent need to educate private pharmacists in Vietnam.

Connolly, A.M. et al. Inadequate treatment for sexually transmitted diseases in the South African private health sector. International Journal of STD & AIDS 10:324-327 (May 1999).
The goal of this study was to compare self-reported STI therapeutic practices of private doctors with provincial guidelines in the district of Hlabisa, South Africa. Information was gathered through semi-structured interviews that asked 11 private practitioners how they would treat three hypothetical cases of STI syndromes: male urethral discharge, male or female genital ulcers, and pelvic inflammatory disease. The results showed that in all 33 prescriptions, the treatment did not correspond exactly with provincial recommendations and only 3 prescriptions (9%) were adequate. All other prescriptions were inadequate because dose or duration was incorrect (6 case, 18%), or because incorrect drugs were prescribed (24 cases, 73%). Eight of the 11 doctors did not provide adequate treatment for any of their cases. A continuing medical education program for the doctors and their staff was devised to improve STI treatment in the private sector in Hlabisa.

Dehne, K.L. et al. A survey of STI policies and programmes in Europe: preliminary results. Sexually Transmitted Infections 78:380-384 (2002).
A first-ever survey of STI prevention and control programs and policies in 45 countries in Europe and central Asia found distinct differences between Western European countries and the newly independent states (NIS). In Western Europe, STI prevention and care is largely left to individual providers, and access to free services is quasi-universal. By contrast, in the NIS, the majority of STI services are provided by dedicated public sector clinics. While services were once offered free-of-charge, now virtually all clients have to pay for STI services. Clients in the NIS are increasingly turning to unlicensed private or semi-private practitioners, or self-medicate. Condoms are widely available in a range of outlets in Western European countries, but such outlets are limited in the NIS. A minority of countries adheres to STI policies advocated by the WHO, such as syndromic management, patient partner referral, and surveillance. The high rates of STIs in the NIS are a major public health problem, and may be important co-factors for sexual transmission of HIV.


Garcia P, Hughes J, Carcamo C, Holmes KK. Training pharmacy workers in recognition, management, and prevention of STDs: district-randomized controlled trial. Bulletin of the World Health Organization. 2003;81(11):806-814. Available at: www.who.int/bulletin/volumes/81/11/en/garciawa1103.pdf.
Fourteen of the 24 lowest socioeconomic districts in Lima, Peru, were selected for this study of the effectiveness of an intervention for pharmacy workers to improve their recognition and management of STIs. Paired districts (based on number of pharmacies, location, population size and density, and literacy rates) were randomly assigned to receive an STI intervention or a diarrhea intervention (control). The STI intervention included luncheon seminars on the recognition and management of four STI syndromes, STI/HIV counseling, monthly pharmacy visits by “prevention salespersons” who distributed information packets, condoms, and partner referral cards, and workshops for physicians on managing patients referred by pharmacists. Standardized simulated patients reported significantly better recognition and management of all four STI syndromes at the STI intervention pharmacies than at the control sites. They were also more likely to receive recommendations to use condoms and to refer partners for treatment. Pharmacist training in this context is both feasible and effective.

Gibney, L. et al. STD treatment for men in rural and urban Zimbabwe: choice of practitioner, perceptions of access and quality of care. International Journal of STD & AIDS 13:201-209 (March 2002).
In both an urban and rural sample of men, the greatest obstacle to obtaining the STI treatment they desired is cost. A survey of 457 men, focus groups, and key informant interviews revealed that most men with genital symptoms (220 cases) received treatment from allopathic practitioners (81.4%). Nine percent were treated by traditional/faith healers; 8.6 percent were treated by self, friend, or other person; and 1.4 percent were not treated. A minority of men said disrespect by the health practitioner and consultations lacking privacy were problems with their STI treatment. More men in Mbare (urban) than Gutu (rural) reported that cost prevented them from getting the care they desired at some point in their life. The deteriorating economic situation in Zimbabwe could make cost a greater obstacle to STI treatment in the future.

Harrison, A. et al. Improving quality of sexually transmitted disease case management in rural South Africa. AIDS 12(17):2329-2335 (1998).
The goal of this study was to measure the quality of STI syndromic case management in rural South Africa. The study was conducted in 10 primary care clinics in Hlabisa. Five simulated patients were trained to present with symptoms of urethral discharge and pelvic inflammatory disease (PID). Simulated patients made a total of 44 clinic visits. Researchers also conducted exit interviews with 49 STI patients at eight clinics. The results showed that 9 percent of simulated patients were correctly managed (i.e., correct drugs, condoms, and partner-notification cards were dispensed), recommended drug treatment was given in only 41 percent of visits, and appropriate counseling was given in 48 percent of visits. All patients leaving the clinic reported staff attitudes as satisfactory or good. Focus group discussions revealed that staff were knowledgeable about STIs, but lacked training in syndromic management and low morale. Surveillance data showed that 27 percent of STI patients had been treated for an STI in the preceding 3 months. The authors concluded that despite good staff knowledge and availability of most key resources such as drugs and condoms, quality of STI syndromic management is poor in this setting. An intervention comprising staff training (primary care nurses) and STI syndrome packets has been designed to improve the quality of case management.

Jacobs B, Whitworth J, Kambugu F, Pool R. Sexually transmitted disease management in Uganda’s private-for-profit formal and informal sector and compliance with treatment. Sexually Transmitted Diseases. 2004;31(11):650-654.
Interviews were held with 405 men who had sought treatment for urethral discharge at drug shops (141) and at private clinics (264) in five districts in Uganda. Men were referred for interview by staff at the private sector facilities. Seventy-seven percent of patients sought treatment within one week of onset of symptoms, but only seven percent were properly managed. According to the patients, the cure rate was 47 percent, but only nine percent were treated according to national guidelines. Eighty-seven percent completed the recommended treatment, 18 percent used condoms during treatment, and 36 percent persuaded partners to go for treatment. Among men not reporting a cure, 56 percent would still recommend the treatment to a friend. While patient selection may have been biased by the health care providers (tending to refer those who had a better chance at a cure), the results still indicate poor quality of STI services in the private sector in Uganda. Drug shops play an important role in STI management, especially for the poor. There is need to provide training and prepackaged STI treatment in both the private and public sector to improve STI treatment outcomes.

Kusimba, J. et al. Traditional healers and the management of sexually transmitted diseases in Nairobi, Kenya. International Journal of STD & AIDS 14:197-201 (2003).
This qualitative study of the role of traditional healers in STI case management finds these providers play a modest, but significant role. In-depth interviews were held with 16 traditional healers (7 witch doctors, 5 herbalists, and 4 spiritual healers) in four slum areas of Nairobi, Kenya, in 1999. The caseload for STIs varied widely, with a median of one patient per week. All healers mentioned sexual intercourse as a mode of transmission, but misconceptions were also common. All herbalists and witch doctors provided herbal medicines for their STI patients, and spiritual healers prayed. Thirteen healers advised their patients to abstain from sexual intercourse during treatment, 11 provided information on contract treatment, 4 on faithfulness, and 3 on condom use. All healers asked patients to return for follow-up, and 13 reported referring those with persistent conditions to public or private health facilities. Although the overall caseload for STIs among these traditional healers is low, traditional healers could be trained to provide health education about STIs.

Leiva, A. et al. Management of sexually transmitted diseases in urban pharmacies in The Gambia. International Journal of STD & AIDS 12:444-452 (2001).
This study of the quality and cost of STI case management in urban pharmacies in The Gambia found that management is generally poor. Pharmacy workers in 24 urban pharmacies were interviewed, and simulated male clients visited each pharmacy. Fifteen (63%) of the pharmacies were equipped to treat urethral discharge syndrome (UDS), pelvic inflammatory disease (PID), and genital ulcer syndrome (GUS) according to the national protocols. Appropriate treatment for UDS was described by 11 percent of the pharmacy workers, but was actually provided in only 4.4 percent of the simulated client visits. None of the simulated cases of PID or GUS would have been treated appropriately. Forty-two percent of pharmacy workers advised on partner notification, 38 percent on safe sex, and 29 percent on treatment compliance during the simulated client visits. The reported costs for treatment of UDS, GUS, and PID ranged from US$2.50 to $15.00. The actual cost of treatment purchased by simulated clients ranged from US$1.50 to $9.60. Despite their poor case management, the pharmacy workers appear willing to receive more training in STI management. The authors recommend regular in-service training in syndromic management of STIs and rational drug use and provision of a simple treatment reference manual. Social marketing of prepackaged drugs and other strategies to reduce drug costs are also needed.

Mackay, B. et al. Treating STIs in Kenya: The Role of the Private Sector. Bath, U.K.: Futures Group (November 2002).
In 1998-2001, Futures Group and the African Medical Research and Education Foundation (AMREF) trained 600 private sector providers from Nyanza province in western Kenya in syndromic management. The training improved the trainees’ application of the 4Cs: counseling, compliance, condoms and contract treatment. Several follow-up surveys were conducted to better understand the experiences of clients seeking private sector services. A 1999-2000 survey found that 25 percent of adults in the province reported having an STI symptom in the previous year. Seven percent of women and 14 percent of men reported “discharge and/or burning pain on urination.” Another survey of 2,500 15-29 year olds in urban and rural markets determined where people with STIs go for treatment. Forty-four percent of respondents with an STI went to a government clinic, 37 percent sought care from an untrained private provider, and 17 percent sought care from one of the providers trained by AMREF. The third phase of this investigation involved a “mystery shopper” survey where young men and women went into medicine shops either complaining of STI symptoms, or presenting a prescription for drugs for treating an STI. While 58 percent of prescriptions were filled correctly, 21 percent of clients were told the drugs were unavailable and they should look elsewhere, and 21 percent were provided with different drugs than those prescribed. The study concludes that training private providers is a good start, but only reached about 5 percent of STI cases. To improve coverage, those with STIs need to be encouraged to use a range of available services, including government clinics. Active marketing of trained providers, and linking medicine shops with trained providers could improve the accurate diagnosis and treatment of STIs.

Mayhew, S. et al. Pharmacists role in managing sexually transmitted infections policy issues and options for Ghana. Health Policy and Planning 16(2):152-160 (June 2001).
This study assessed the role played by pharmacists in the Greater Accra Region of Ghana in the management of STIs. The study consisted of interviews with pharmacists and clients and training of pharmacists, followed by pseudo-client visits. Pharmacies are open for an average of 13 hours per day at least six days a week. Pharmacists reported seeing an average of 30 patients with an STI in the previous month. More than 60 percent of clients came for STI treatment without a prescription. Comparison of pre- and post-training showed an improvement in the prescribing regimens offered for urethral discharge, but not for genital ulcers. This study indicates that the quality of STI management offered by pharmacies could be improved through training pharmacists in appropriate diagnosis and treatment of STIs (especially urethral discharge, and possibly vaginal discharge), and encouraging referral to medical practitioners or laboratories for clients presenting with genital ulcers and unimproved vaginal discharge. Pharmacists could also take a more active role in STI prevention by offering information on STIs and promoting and distributing condoms.

Mills, A. et al. What can be done about the private health sector in low-income countries? Bulletin of the World Health Organization 80(4):325-330 (2002).
The private health sector in low-income countries is large, consists of a variety of providers, and is used by a wide cross-section of the population. This article reviews ways to influence the activities of private-sector providers to help meet national health objectives, especially for tuberculosis, malaria, and sexually transmitted diseases. Use of a variety of approaches, including training and regulatory and participative interventions, has helped change the activities of private-sector providers. However, less is known about influencing the behavior of consumers, and in restructuring the market. It is easier to influence the more organized formal private sector (for example, doctors, nurses, pharmacists) than the informal private sector (traditional healers, market sellers) used more frequently by the poor. More information is needed about how to influence the private health sector, especially from the demand side.

Msiska, R. et al. Understanding lay perspectives: care options for STD treatment in Lusaka, Zambia. Health Policy and Planning 12(3):248-252 (1997).
The goal of this study was to determine lay persons' perspectives in care-seeking behavior patterns for STIs in selected sub-populations in Lusaka. The study consisted of 20 unstructured group interviews, 10 focus group discussions, and four STI case simulations. The study results showed that participants preferred private facilities (including private general practitioners, private chemists, street vendors, and market stalls) to public health facilities. A large diversity of care options for STI existed in the communities, including self-care, traditional healers, medicine sold in the markets and streets, injections administered in the compounds, private clinics, health centers, and hospitals. The factors identified as influencing care-seeking behavior included lay referral mechanisms, social cost, availability of care options, economics, beliefs, stigma, and quality of care as perceived by the users. The authors provide some recommendations based on the study findings, including training health care workers in counseling and communications skills, and integrating STI services with other services.

Ramos MC, da Silva RD, Gobbato RO, et al. Pharmacy clerks’ prescribing practices for STD patients in Porto Alegre, Brazil: missed opportunities for improving STD control. International Journal of STD & AIDS. 2004;15(5):333-336.
Trained medical students visited 62 randomly chosen pharmacies in Porto Alegre, Brazil, during March 2002. These male simulated clients presented with complaints of dysuria and urethral discharge. Although Brazil law prohibits selling antibiotics without prescription, many clients turn to pharmacies for treatment of STIs. In this study, 56 of 62 pharmacy clerks provided a prescription, mostly ampicillin with probenecide (51.8%) and rosoxacin (19.6%). The treatment recommended by the Ministry of Health was not provided by any pharmacy clerk, and none of the treatments given cover chlamydia infection. The most frequent additional advice given, when asked, was to use condoms (42 of 46 clerks). Pharmacy clerks are an important source of STI treatment, but they need formal training. Overall pharmacy practices for prescribing and counseling on STIs need to be improved, but pharmacies can be an important source in control of STIs, including HIV.

Turner, A.N. et al. Diagnosis and treatment of presumed STIs at Mexican pharmacies: survey results from a random sample of Mexico City pharmacy attendants. Sexually Transmitted Infections 79:224-228 (2003).
The quality of STI advice offered to clients at Mexico City pharmacies is poor. Interviews with the first available attendant at a 5 percent random sample of pharmacies (n=57) in Mexico City revealed that most were clerks, not pharmacists, with limited training. Sixty-two percent reported seeing 10 or more clients with genital or vaginal infections per month. Attendants provided appropriate diagnoses in 0-12 percent of hypothetical cases, recommended appropriate treatment in 12-16 percent, and suggested physician follow-up in 26-67 percent of cases. Given the volume of clients seeking advice from pharmacies, training attendants in STI diagnosis and treatment could help address the burden of STIs in Mexico City.

Voeten, H, O’Hara H, Kusimba J, et al. Gender differences in health care-seeking behavior for sexually transmitted diseases. Sexually Transmitted Diseases. 2004;31(5):265-272.
According to data gathered in a population-based survey, 20 percent of men and 35 percent of women did not seek care for STIs despite reporting an STI-related complaint. Of the 291 respondents to the 1999 questionnaire administered in seven randomly selected clusters in Nairobi, Kenya, most who sought care went to the private sector (72% of men and 57% of women). Reasons given for not seeking care include because symptoms were not considered severe, symptoms had disappeared, or lack of money. Women in the study were mostly monogamous and did not relate their complaints to sexual intercourse. This further delayed care. Health education is needed to educate the population, and especially women, about the need to seek prompt care for STI-related symptoms.

Voeten, H. et al. Quality of sexually transmitted disease case management in Nairobi, Kenya. Sexually Transmitted Diseases 28(11):633-642 (November 2001).
This study compared the quality of STI case management in the public and private sectors in five areas of urban Nairobi, Kenya. Interviews were conducted with 165 providers at 142 facilities, and 441 interactions with STI clients were observed. In addition, simulated clients visited the facilities to assess care. The outcome measure of quality used in this study is the degree to which observed provider-client interactions matched the World Health Organization protocol for history-taking, physical examination, and treatment. Among the patients observed, correct history-taking ranged from 60 to 92 percent at the facilities; correct examination ranged from 30 to 75 percent; and correct treatment ranged from 30 to 75 percent. Accuracy for all three aspects of care ranged from 14 to 48 percent. Public clinics specifically equipped for STI care performed best overall, while treatment was poorest in pharmacies and private clinics. Providers trained in STI case management performed better than those without training. Overall, the quality of STI case management in Nairobi is unsatisfactory, except in clinics equipped for STI management.

Vuylsteke B, Traore M, Mah-Bi G, et al. Quality of sexually transmitted infections services for female sex workers in Abidjan, Côte d’Ivoire. Tropical Medicine & International Health. 2004;9(5):638-643.
In June 2000, STI services in 29 health care facilities and ten pharmacies attended by female sex workers were assessed. The services were evaluated using checklists of equipment and drugs, interviews with health care providers and pharmacists, direct observations of patient-provider interactions, and exit interviews with women attending for STI or genital problems. Private-sector facilities were more expensive, had fewer clients, and were not as well equipped or staffed as public facilities. Health care providers and pharmacists scored equally for syndromic management, except for nurse assistants, who scored lower. Pharmacists scored lowest for overall correct treatment. Of 161 clients interviewed, 44 percent complained of long waiting time, and only 39 percent thought the provider had adequately explained their problem to them. There is need to improve STI case management in Abidjan, public- and private-sector facilities need to be made more accessible for sex workers, and services need to be improved to address their sexual health needs.

Walker, D. et al. The quality of care by private practitioners for sexually transmitted diseases in Uganda. Health Policy and Planning 16(1):35-40 (2001).
Many people with STIs treat themselves at home or seek treatment from private-sector practitioners rather than using public-sector services. This study evaluated the quality of STI care provided by private practitioners in a rural area of southwestern Uganda. The area is part of a randomized controlled trial of the efficacy of behavioral interventions with or without improved STI services. Interviews with 36 practitioners and 6 focus group discussions with patients found that practitioners are open to improving their services. Those who had been trained in syndromic management of STIs referred to syndromes 82 percent of the time versus 12 percent among those not trained. They stocked locally appropriate antibiotics 76 percent of the time (versus 52 percent among those not trained) and were more likely to prescribe appropriate drugs (82% versus 27%). This small study suggests that private practitioners can improve the management of STIs, especially in rural areas.

Ward, K. et al. Provision of syndromic treatment of sexually transmitted infections by community pharmacists: a potentially underutilized HIV prevention strategy. Sexually Transmitted Diseases 30(8): 609-613 (August 2003).
This cross-sectional survey of community pharmacists in the Western Cape region of South Africa assessed the current and potential role of community pharmacists in treating STIs. Of the 90 pharmacies sampled (22 percent of the 406 community pharmacies in the Western Cape), 85 participated (55 urban and 30 rural). There is a high volume of possible STI cases seen in these pharmacies. Many pharmacists understand the relationship of HIV and STIs, perceive their role in treating STIs is underutilized, and are willing to provide treatment. However, when presented with hypothetical clients, only 13 percent of urban and 17 percent of rural pharmacists identified the correct medication for male urethral discharge, and even lower percentages could correctly treat genital ulcers (8 percent urban, 0 percent rural), and vaginal discharge (0 percent in both areas). Training pharmacists to provide syndromic treatment may be a way to reduce STIs and transmission of HIV in this region.

Wilkinson, D. et al. Sexually transmitted disease syndromes in rural South Africa: Results from health facility surveillance. Sexually Transmitted Diseases 25(1):20-23 (January 1998).
The goal of this study was to conduct facility-based surveillance for STIs in order to design a control program and provide baseline measures for evaluation of interventions. Over a period of five months, 4,781 STI patients were reported, of whom 54 percent were men. Of all reported patients, 65 percent were reported by clinics and 35 percent by general practitioners. Most were diagnosed with a single syndrome. Discharge was most common (49 percent of both male and female patients), followed by ulcer (36 percent of men and 14 percent of women). Twenty-five percent of patients reported having another STI in the previous three months. The highest age-specific incidence was estimated at 16.4 percent among women 20 to 24 years of age. In response to these findings, the authors implemented a range of interventions including a mass-media campaign aimed at improving community awareness and treatment-seeking behavior for STIs; strengthening STI case management in both public- and private-sectors; and designing strategies to reduce STIs among migrant workers and their rural partners.

Zachariah, R. et al. Health seeking and sexual behavior in patients with sexually transmitted infections: the importance of traditional healers in Thyolo, Malawi. Sexually Transmitted Infections 78:127-129 (2002).
In this cross-sectional study of new 498 STI clients at a district STI clinic in Thyolo, Malawi, about half (53%) had taken some form of medication prior to coming to the STI clinic, and 37 percent of these had gotten their medication from a traditional healer. Forty-six percent of all clients reported having sex during their symptomatic period, and 74 percent had not used condoms. Clients who visited a traditional healer were female, had less than eight years of education, and lived in villages were more likely to not use condoms. Genital ulcer disease (GUD) was the most common STI in men (49%). The high level of GUD and the low levels of condom use during symptomatic infection are of concern in this high HIV-prevalence country. Efforts are needed to include traditional healers in STI prevention and control activities.

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