Syndromic management of sexually transmitted infections

1. Syndromic Management of
Sexually Transmitted
Infections
Dr. Suraj Chawla

2. Contents
 Background
 STIs/RTIs: A public health problem
 Why STIs/RTIs are more prevalent?
 Objectives of STI case management
 Approaches for STIs/RTIs management
 Syndromic case management (SCM)
 Why Syndromic case management?
 Providers of SCM
 Flowcharts

3. Contents
 Syndromic case management (SCM)
 Management Kits
 Partner management
 Client education & counseling
 Advantages of SCM
 Disadvantages of SCM
 Challenges regarding SCM

4. Background
STIs/RTIs:
 Sexually transmitted and reproductive tract infections
are overlapping categories.
 All sexually transmitted infections (STI) are not
reproductive tract infections (RTI) and all reproductive
tract infections are not sexually transmitted infections.
 In these terms, ‘sexually transmitted’ refers to the mode of
transmission, whereas ‘reproductive tract’ refers to the site
of the infection.
 For instance, although HIV is sexually transmitted it is not
limited to the reproductive tract. Hepatitis B and C are
other examples of STI that are not RTI.

6. Background
 Because those reproductive tract infections that are
sexually transmitted generally have much more severe
health consequences than the other RTIs, the STIs/RTIs
term is used to highlight the importance of STI within
reproductive tract infections.
 The most common STIs/RTIs are
trichomoniasis, chlamydia, gonorrhoea, syphilis, genital
herpes, chancroid, human papilloma virus
(HPV), bacterial vaginosis and candidiasis.

7. Background
Situation in world
 448 million new infections of curable sexually transmitted
infections occur yearly.
 75-85% cases occur in developing countries
 In pregnant women with untreated early syphilis, 25% of
pregnancies result in stillbirth and 14% in neonatal death.
 Sexually transmitted infections are the main preventable
cause of infertility, particularly in women.
Reference: http://www.who.int/mediacentre/factsheets/fs110/en/

8. Background
Situation in India
 A nationwide community based survey conducted by
NACO in 2002-2003 revealed a prevalence of 6%
STIs/RTIs among adult population.
 Based on this, it is estimated that approximately 30
million episodes of STIs/RTIs occur annually.
 During financial year 2007-08, 2008-09 and 2009-
10, around 2.6 million, 6.6 million and 8.2 million episodes
of STIs/RTIs were treated at the STI clinics managed
under NACP.

9. RTIs/STIs – A Public Health
Problem
 Major cause of ill health in country
 Cause infertility, reproductive morbidities and systemic
complications in men and women
 Increases risk of HIV transmission
 Increases cost to health system

10. Why STIs/RTIs are more
prevalent?

11. High risk groups
 Adolescent boys and girls
 Women who have multiple partners
 Sex workers and their clients
 Men and women who has to stay away from families for
long
 Men having sex with men
 Partners of various high risk groups
 Street children

12. Factors increasing risk of
transmission
 Biological
- Age / Sex
- Immune status
 Behavioural
- Personal sexual behaviour
- Poor menstrual and personal hygiene
 Social
- Status of women in society
- Sexual violence
- Child marriages

13. Sexually Transmitted Diseases
Symptomatic
Asymptomatic

14. Why women are at a higher risk?
 Biological differences
- Thin lining of vaginal mucosa
- Larger exposed area
- Genital fluids stay in contact for longer time
- Young women- Immature genital tract
- Symptoms less reliable indicator
 Use of vaginal douches
 Different socio-cultural norms for men and women

15. Barriers – system and providers
side
 Failure to recognize magnitude
 Overemphasis on lab based diagnosis
 Irrational use of drugs
 No standardized treatment regimen by all providers
 Less emphasis on patient education and counselling
 Specialized clinics carry stigma

16. Barriers – Client side
 Lack of knowledge
 Misconceptions
 Asymptomatic infections
 Reluctance to discuss sexual matters
 Stigma
 Fear of judgmental attitude of providers
 Reluctance for physical examination

17. Operational model of the role of health
services in STI case management
Population with STI
Aware and worried
Seeking care
Correct diagnosis
• Promotion of health care
seeking behaviour
Correct treatment • Improve quality of care
• Attitudes of personnel
Treatment completed
Cure

18. Operational model of the role of health
services in STI case management
Population with STI
Aware and worried
asymptomatic STI
Seeking care
Correct diagnosis • Partner notification
• Case finding
• Screening
Correct treatment • Selective mass treatment
Treatment completed
Cure

19. Objectives of STI case
management
 To provide appropriate antimicrobial therapy in order to:
 Obtain cure of infection
 Decrease infectiousness
 To limit or prevent high risk behaviour
 To ensure that sexual partners are treated in order to
interrupt the chain of transmission

20. STI case management:
Requirements
 Accurate diagnosis
 Treatment at first encounter
 Rapid cure with effective drugs
 Condom promotion
 Partner notification
 Education/ Counselling

21. Comprehensive STI case
management
 History taking and symptoms
 Examination
 Treatment
Client and partner(s)

22. Essential Steps In STI Case
Management
Syndrome
Assessment Contact tracing
(diagnostic tools) Compliance
Diagnosis Treatment 5Cs Confidentiality
Condom use
(screening tests)
Counseling
Risk
Assessment

23. Risk Assessment
 A process of confidentially asking a patient particular
questions to determine his or her chance of contracting or
transmitting a RTI/STI (e.g. many women may be at risk
due to the behaviour of their husbands or partners).
Why risk assessment?
 To determine RTI/STI treatment
 To tailor patient education messages
 Determine need for lab test
 Determine need for specific referrals (ICTC)

24. Risk Assessment Include
 Sexual behaviours
 Specific exposures
 Socio-demographics/other high risk markers:
 young age
 marital status: not living with steady partner
 partner problems
 History of impaired reproductive health i.e. History of
past STI

25. Rapid Laboratory Tests
May be used to narrow the spectrum of initial therapy. They
include:
 Wet mount (vaginal discharge)
 Gram stain (Urethral Discharge, Cx Mucopus)
 Dark-field microscopy (Genito-Ulcerative Diseases/
syphilis)
 Rapid serologic tests (HIV/GUD/syphilis)

26. Approaches of STI Case
Management
 CLINICAL ASSESSMENT: Aetiology based on clinical
appearance
 AETIOLOGIC: Lab isolation of the causative organism
 SYNDROMIC CASE MANAGEMENT (SCM)
 MIXED

27. Traditional Clinical Approach:
Advantages
 Simple
 Inexpensive
 Can be used in any setting
 Immediate diagnosis
 Immediate treatment
 No lab expense

28. Traditional Clinical Approach :
Limitations
 Diagnosis is often incorrect or incomplete
(especially in mixed infections).
 More than one STI is often present at the same
time- focus is on diagnosing a single cause.
 Asymptomatic infections could not be diagnosed.

29. Aetiological Approach:
Advantages
 Exact diagnosis using laboratory tests
 Avoids over-treatment
 Avoids wrong treatment/adverse effects
 May avoid antibiotic resistance
 Asymptomatic infections can also be detected

30. Aetiological Approach:
Limitations
 Expensive
 Trained laboratory technicians are needed
 Infrastructure and supplies are needed
 Patient must return for test results
 Patient must wait for treatment

31. Syndromic Approach
 Provision of STI/RTI care services is a very important
strategy to prevent HIV transmission and promote sexual
and reproductive health under the National AIDS
Control Programme (NACP III) and Reproductive and
Child Health (RCH II).
 Syndromic case management (SCM) with appropriate
laboratory tests is the cornerstone of STI/RTI
management under NACP III.
 SCM is a comprehensive approach for STI/RTI control
endorsed by the WHO.

32. Syndromic Approach
 Diagnosis is based on the identification of
syndromes, which are combinations of the symptoms the
client reports and the signs the health care provider
observes.
 The provision of the most effective therapy at patient’s
first contact with a health or medical facility.
 The recommended treatment is effective for all the
diseases that could cause the identified syndrome.
 Provides single dose treatment as far as possible
 Comprehensive to include patient education on risk
reduction, counseling, condom promotion and
provision, partner notification, follow up.

33. Why Syndromic Management?
 STI signs and symptoms are rarely specific to a particular
causative agent
 Laboratories are either non-existent or non-functional
due to lack of resources
 Dual infections are quite common and both clinician and
laboratory may miss one of them
 Waiting time for lab. results may discourage some
patients
 Failure of cure at first contact

34. Syndromic Management:
Providers
Sub-district level:
 Health workers (HWs), ASHA and AYUSH practitioners
will conduct STI/RTI prevention and health promotion
activities and refer individuals with STI/RTI symptoms to
PHCs, CHCs and franchised allopathic practitioners.
 STI/RTI clinical services will be provided at these locations
using the SCM approach.
 Laboratory services wherever available will be used to
corroborate syndromic diagnosis.

35. Syndromic Management:
Providers
District hospitals and medical colleges:
 The services will be provided through specialists and
trained physicians at designated STI/RTI clinics.
 The SCM approach will be enhanced with additional
laboratory facilities.
 These locations will also serve as referral sites for STI/RTI
services besides participating as resources for STI/RTI
training, monitoring and supervision.
 This service delivery will be entirely supported by NACO
through State AIDS Control Societies (SACS) and District
AIDS Prevention and Control Units (DAPCUs).

36. PGIMS Scenario
 STI clinic is being run in our institute (Suraksha clinic) by
Skin & VD Department.
 Follow up cases are managed only on Tuesday during
OPD hours. New cases are managed everyday.
 STI kits are available free of cost to all clients.
 Most common reported syndrome is herpes genitalis
(Genito-ulcerative disease)
 Manpower: Dr. Kamal Aggarwal- I/C,
1 SR, 2 JR and 1 Counselor

37. Syndromic Management:
Providers
High-risk population groups:
 STI/RTI services will be provided through targeted
interventions (TIs) to high-risk groups (HRGs) through
specified clinic settings. Three recommended settings are:
 TI-owned static clinics for locations with >1,000 sex
workers
 Fixed-day, fixed-time outreach clinics for locations with
smaller number of sex workers
 Referral linkage with government and private STI/RTI
service providers in locations with <200 sex workers
 Clinics should have either on site laboratory facilities or
link up with the nearest government laboratory.

38. STI – Syndromic Case
Management
REQUIREMENTS:
 Adequate medical history
 Good sexual history
 Complete STI clinical examination
 Management guidelines
 Good supply of effective drugs

39. How syndromic management works
Through a series of flow-charts:
 Guides the health-care worker through the correct
identification and treatment of an STI-associated
syndrome
 Offers a package of comprehensive care from history
taking, examination & counselling /education on risk
reduction and partner notification

40. Using Flow Charts
Each flow chart is made up of three steps
 The clinical problem (patient’s presenting symptom)
 Problem box
 A decision to make usually by answering yes or no to a
question (based on history & clinical examination)
 Decision box
 An action to take(what you need to do)
 Action box

41. The Syndromes
 Urethral discharge
 Vaginal discharge
 Genital ulcer non-herpetic
 Genital ulcer herpetic
 Lower abdominal pain
 Inguinal bubo
 Scrotal swelling

42. Male Syndromes
Inguinal Bubo Scrotal Swelling
Genital Ulcer Genital Ulcer

43. Vaginal Discharge Syndromes
SYNDROMES: VAGINAL DISCHARGE
VAGINITIS TRICHOMONIASIS CERVICAL HERPES CERVICITIS

44. Identifying Syndromes
SYNDROME MOST COMMON CAUSE
Vaginal discharge Vaginitis (trichomoniasis, candidiasis)
Cervicitis (gonorrhea, chlamydia)
Urethral discharge Gonorrhea, chlamydia
Genital ulcer Syphilis, chancroid, herpes
Lower abdominal pain Gonorrhea, chlamydia, mixed anaerobes
Scrotal swelling Gonorrhea, chlamydia
Inguinal bubo LGV, Chancroid
Neonatal conjunctivitis Gonorrhea, chlamydia

45. Syndromic Management
Flowcharts

51. Limitations of syndromic management in
Vaginal Discharge
Unfortunately, syndromic management for abnormal
vaginal discharge is less accurate in the diagnosis and
management of cervicitis.
 Use local prevalence data, if available
 Risk assessment
 Partner treatment

52. Vaginal Discharge: Causes
Vaginitis Cervicitis
Caused by Trichomoniasis (TV), Caused by Gonorrhoea and
Candidiasis and Bacterial Vaginosis Chlamydia
Most common cause of vaginal Less common cause of vaginal
discharge discharge
Easy to diagnose Difficult to diagnose
No complications Major complications
Treatment of partner unnecessary,
Need to treat partner
except for TV

53. Vaginal Discharge: Risk Assessment
Risk Factor Score
Partner has urethral discharge 2
New partner in last 3 months 1
More than 1 partner last 3 months 1
Not living with steady partner 1
Age less than 21 years 1
[If risk score 2 and over, treat for cervicitis]

55. Criteria for Selection of Drugs
 High efficacy (at least 95%)
 Low cost
 Acceptable toxicity and tolerance
 Organism resistance unlikely to develop or likely to be
delayed
 Single dose
 Oral administration
 Not contraindicated for pregnant or lactating women

56. To sum up ………
 The drugs use in syndromic management are chosen
based on scientific criteria
 Syndromic management is a comprehensive approach
which includes:
 Treatment of index client
 Treatment of partners
 Risk reduction
 Client education and counselling
 Referral, as necessary

57. Kits under NACP III for syndromic management of STIs/RTIs
Kit No. Syndrome Colour Contents
Kit 1 UD, ARD, Cervicitis Grey Tab. Azithromycin 1 g (1) and
Tab. Cefixime 400 mg (1)
Kit 2 Vaginitis Green Tab. Secnidazole 2 g (1)
and Tab. Fluconazole 150 mg (1)
Kit 3 GUD (Non Herpetic) White Inj. Benzathine penicillin 2.4 MU (1)and Tab.
Azithromycin 1 g (1) and Disposable syringe 10
ml with 21 gauge needle (1) and Sterile water 10
ml (1)
Kit 4 GUD (For patient Blue Tab. Doxycycline 100 mg (30) and Tab.
allergic to penicillin) Azithromycin 1 g (1)
Kit 5 GUD ( Herpetic) Red Tab. Acyclovir 400 mg (21)
Kit 6 LAP Yellow Tab. Cefixime 400 mg (1)
and tab. Metronidazole 400 mg (28)
and Cap. Doxycycline 100 mg (28)
Kit 7 IB Black Tab. Doxycycline 100mg (42)
and Tab. Azithromycin 1 g (1)
UD- Urethral Discharge, ARD- Ano-rectal discharge, GUD- Genito ulcerative disease, LAP- Lower
abdominal pain, IB- Inguinal bubo

58. Partner Management

59. What is Partner Management ?
 Partner management is an activity in which the partners
of those identified as having RTI/STI are located,
informed of their potential risk of infection, and offered
treatment and counselling services.
Timely management is important because…
 Prevention of re-infection in index client/s
 Prevention of transmission in partner/s
 Timely treatment of symptomatic partners
 Identification of asymptomatic partners and their
treatment

60. General principles of partner
treatment
 All partners who are in contact with client in last 3
months should be treated.
 Partners should be treated for same infections as index
client.
 Advise sexual abstinence during the course of treatment
 Provide condoms, educate about correct and consistent
use
 Refer for voluntary counselling and testing for
HIV, Syphilis and Hepatitis B
 Schedule return visit after 7 days

61. Management of pregnant
client/partner
 Fluoroquinolones (like ofloxacin, ciprofloxacin),
doxycycline, sulfonamides are contraindicated in
pregnant women.
 Pregnant women should be treated with regimen based
on cephalosporin, penicillin & erythromycin for
gonorrhoea, chlamydia & syphilis.
 For candidiasis clotrimazole vaginal cream/pessary is
used.
 For trichomonas metronidazole cream/pessary is used in
1st trimester and tab. Secnidazole/tinidazole is used if
client is in 2nd or 3rd trimester.

62. Management of pregnant
client/partner
 All pregnant women should be asked history of genital
herpes and examined carefully for herpetic lesions.
 Women without symptoms or signs of genital herpes or its
prodrome can deliver vaginally.
 Women with genital herpetic lesions at the onset of
labour should be delivered by caesarean section to
prevent neonatal herpes.
 Acyclovir may be administered orally to pregnant
women with first episode of genital herpes or severe
recurrent herpes.

63. Client Education and
Counseling

64. Importance of Client Education
and Counselling
 Better compliance to treatment if clients know the
logic/reasons
 To reduce chance of re-infection
 To enable clients change behaviour
 Satisfied clients return for other services too
 Satisfied clients refer others to health center

65. Goals of Client Education
 Help clients resolve current infection
 Prevent future infections
 Make sure sex partners are also treated and educated.

66. What Clients Needs to Know
 Prevention of RTIs/STIs
- Risk reduction
- Correctly and consistent use of condoms, availability
- Limiting the number of partners
 Information about RTIs/STIs
- How they are spread between people
- Consequences of RTIs/STIs
- Links between RTIs/STIs and HIV
- RTI/STI symptoms - what to look for

67. What Clients Needs to Know.…
 RTI/STI Treatment
- How to take medications
- Signs that call for a return visit to the clinic
- Importance of partner referral and treatment
- Acknowledge gender inequalities

68. Creating Opportunities for Client
Education
 Use every place where client is likely to visit
 Use every interaction as an opportunity
 Use various media
 Reinforce consistent messages

69. Syndromic Management-
Advantages
 Fast—the patient is diagnosed and treated in one visit
 Highly effective for most of the syndromes
 Relatively inexpensive since it avoids use of laboratory
 No need for patient to return for lab results
 All possible STIs are treated at once
 Scientifically tested in many part of the world
 Easy for health workers to learn and practice for patients
 Integrated into primary health care services more easily
 Can be used by providers at all levels

70. Programmatic Advantages to
Syndromic Management of STIs
 Allows all STI clinicians to provide excellent care without
referring
 The most efficient system to realize a clinic’s dual
responsibility – cure the patient and protect the
community from STI

71. Syndromic management:
Disadvantages
 Tendency to overtreat – justifiable in high prevalence
settings (>20%)
 Decreased specificity
 Overuse of expensive drugs
 Asymptomatic cases not fully addressed even with risk
assessment
 Management of cervical infections problematic
 Vaginal discharge algorithm performs poorly in low
prevalence settings e.g., ANC

72. Syndromic approach: Challenges
 Many STIs are asymptomatic
 Vaginal discharge is not necessarily the result of an STI
 Vaginitis vs. cervicitis - overtreatment vs. under-
treatment
 Overuse of drugs: costs, side effects, resistance
 Lack of acceptance by clinicians

73. To sum up ………
 Syndromic management is a scientific and proven
approach.
 Syndromic approach does not deny use of lab tests
(Enhanced syndromic approach).
 This approach ensures correct and complete treatment of
all most common organisms responsible for a particular
syndrome.
 Syndromic management goes beyond pharmaceutical
treatment to include client education and counselling.
 The clinical skills of a doctor are well utilized in syndromic
approach.

74. References
 NACO, MOHFW, Govt. of India. Operational Guidelines for Programme managers
and Service Providers for strengthening STI/RTI Services, NACO, New Delhi; Oct 2007.
 MOHFW, Govt. of India. National Guidelines on prevention, management and control
of RTIs including STIs. NACO, New Delhi; August 2007.
 Chellan R. Socio-Demographic Determinants of Reproductive Tract Infection and
Treatment Seeking Behaviour in Rural Indian Women. Population Studies, Centre for
the Study of Regional Development, School of Social Sciences, Jawaharlal Nehru
University. New Delhi.
 Introduction to WHO Guidelines for the Management of Sexually Transmitted
Infections. Vanuatu Reproductive Health Workshop. November 30-December
3, 2004.
 National STI Management Guidelines of India. The National AIDS Control
Programme. The World Health Organization
 http://www.authorstream.com/UserPresentations/sharamesh/-205632-rti-sti.
 Lal S. Textbook of community medicine. 3rd ed. CBS: New Delhi; 2011.
 Park K. Textbook of preventive and social medicine. 21st ed. Jabalpur : Banarsidas
Bhanot;2011.