Sexually transmitted disease services in Madras: could their role in AIDS prevention be strengthened?

Abstract

A baseline evaluation of the quality of STD case management was conducted in five areas of Madras city in 1992, using HIV prevention indicators recommended by the World Health Organization. Eighty-four interviews and 108 observations of private and public clinic practitioners were conducted. Sixty-one percent of interviewed doctors reported making only specific "clinical" diagnoses and 17% reported making only the WHO recommended syndrome-based diagnoses while 22% reported making both types of diagnosis. The adequacy of treatment was compared against various standards, including the Indian National Guidelines for STD management. Almost half of the health care providers (HCP) reported using a treatment effective against the two main pathogens that may cause male urethritis, while 20% reported using a treatment that was not effective against either. For male ulcers only 12% of HCPs reported using treatment effective against both syphilis and chancroid. Seventy-nine percent of the HCP reported that they advised their patients to use condoms, but in 30% only of observed consultations, condoms were promoted for STD or HIV/AIDS prevention. As information concerning the relative prevalence of pathogens in different areas is unlikely to be available, there is an urgent need for the syndromic approach to STD treatment be adopted by health care providers.

PIP: During November-December 1992, in Madras, India, interviews were conducted with 84 public and private physicians who treated at least five sexually transmitted disease (STD) patients each week in Royapuram, Washerman, Evr High Road, T. Nagar, and Adyar regions of the city. Field workers also observed 108 medical consultations of 48 of the physicians interviewed. Researchers aimed to use the findings of this baseline survey to optimize STD services in order to reduce the population at risk of HIV/AIDS. 61% of the physicians interviewed made specific clinical diagnoses. 17% made only syndrome-based diagnoses. 22% used both types of diagnoses. 48% used a treatment effective against the two main pathogens for male urethritis, Neisseria gonorrhoeae and Chlamydia trachomatis. 20% used a treatment that was not effective against either of these pathogens. Only 12% used a treatment effective against chancroid and syphilis for men with genital ulcers. 29% did not use a treatment effective against chancroid or syphilis. For female genital ulcers, only 10.7% of physicians used an effective treatment against chancroid or syphilis. 21.4% provided treatment effective against neither chancroid nor syphilis in female STD patients with genital ulcers. 79% claimed to counsel their STD patients to use condoms, but only 30% were observed actually promoting condoms for STD or HIV/AIDS prevention. Physicians instructed only 6% of STD patients how to use condoms. Condoms were given to only one STD patient. These findings highlight the need for physicians and other health care providers to adopt the syndromic approach to STD treatment and for developing and evaluating innovative and effective programs of patient education in order to reduce the risk of HIV infection.