Men with sexually transmitted diseases in Bangkok: where do they go for treatment and why?

Abstract

Objectives: To describe and identify predictors of health-care seeking behavior among men with sexually transmitted diseases (STDs) in Bangkok, Thailand.

Design: Cross-sectional survey.

Methods: Men presenting with STDs were recruited from government clinics (n = 101), private clinics (n = 50) and pharmacies (n = 62). They completed interviewer-administered questionnaires on risk behavior, patterns of treatment-seeking for current and past STDs and attitudes toward health care.

Results: Two-thirds of all subjects had had a previous STD. Approximately one-half believed a partner other than a sex worker was the source of their current infection. Of the sample, 39% of men seen initially at drugstores, 29% at private clinics and 19% at government clinics sought subsequent treatment; failure to respond to therapy was the primary reason for seeking additional care. Men attending drugstores were likely to be younger, have less education and income, and to practice riskier sexual behavior. Patients at drugstores and general private clinics received the least amount of counseling or STD testing, while those attending specialized private STD clinics received the most comprehensive services. Attitudes towards government clinics were uniformly positive regardless of the site of enrollment; conversely, about 50% of clients 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.

Conclusions: STD/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. Men may be dissuaded from attending government clinics because of lack of convenience. Syndromic case management, incorporation of STD care at other public clinics and the recognition that more men practice unsafe sex with partners other than sex workers could improve STD control.

PIP: The determinants of treatment-seeking behaviors associated with sexually transmitted diseases (STDs) were investigated in a cross-sectional survey of 213 men recruited from government clinics (n = 101), private clinics (n = 50), and pharmacies (n = 62) in Bangkok, Thailand. 142 of these men had had a prior STD. 34% of men who initially attended pharmacies and 19% of those who first attended a government clinic sought multiple treatments for prior STDs because of an incomplete response to treatment. 50% of STD clients had visited a commercial sex worker in the 3 months preceding the current STD; half believed a casual or new sex partner was the source of infection. 12% of men had sex while they were symptomatic with the current STD. Advice on condom use was conveyed to 88% of government clinic patients, 94% of private clinic patients, and 52% of pharmacy customers; only 72%, 14%, and 22%, respectively, were urged to contact their sexual partner. Men with less education and symptoms of dysuria were more likely to seek care at drugstores. Also associated with seeking care at a pharmacy rather than a government site were waiting less than 7 days to seek treatment, having a travel time less than 20 minutes, and feeling able to pay for treatment. Those seeking care at pharmacies were also more likely to believe that they would recover at least as well as those treated at a government clinic and to believe they were at risk for human immunodeficiency virus infection. Possible strategies for improving STD treatment at the first point of contact within the health care system include promotion of syndromic STD management among pharmacists and general practitioners, integrated STD programs within health care services already providing care to adolescents and other high-risk groups, and strengthening the referral network to government clinics.