Chapter 4
Preventing and Treating Sexually Transmitted Infections

In 1995, the global HIV/AIDS prevention community was electrified by the publication of the results of a research project on sexually transmitted infections (STIs) that had been conducted in Mwanza, in western Tanzania. The project, conducted by AMREF, the London School of Hygiene and Tropical Medicine and several other investigators, was designed to discover whether improved treatment of STIs could lower the number of new HIV infections.

Because STIs that cause ulcers or inflammation of the genital tract are known to raise vulnerability to HIV infection as much as tenfold, the study called for improving STI management at six health centers for two years, then comparing the incidence of HIV infections to that of another cohort that had not received treatment. The findings: consistent and correct STI treatment reduced new infections by a stunning 42 percent.

Because STIs are so widespread in developing countries such as Tanzania, the results offer real hope for an effective public health solution — comprehensive STI diagnosis and treatment programs — to curbing HIV infection. But the study confirmed something perhaps equally important: how to actually accomplish this ambitious and potentially costly goal with limited resources through the use of a technique called syndromic management.

An Effective, Affordable Approach

Syndromic management of STIs — the diagnosis and treatment methodology used for the Mwanza study — has long been a cornerstone of prevention for AIDSCAP programs, including TAP. This approach, first developed by the World Health Organization, allows primary health care workers to diagnose and treat most STIs without expensive (and often unavailable) lab tests or lengthy and complex medical training.

Using easy-to-follow diagnostic guidelines designed for each region's STI prevalence and antibiotic resistance patterns, practitioners of syndromic management assess their patients' symptoms and prescribe medication for all possible STIs that cause those symptoms. Since full treatment and counseling are completed during the first visit, patients usually don't need to return for follow-up. In addition to diagnosis and treatment, patients also receive advice on condom use and other prevention methods and are encouraged to refer partners who may also be infected, a way to help identify women whose asymptomatic STIs would not prompt them to seek treatment.

Recognizing the value for Tanzania of this cost-saving alternative approach to STI treatment, TAP has been in the forefront of syndromic management training for all levels of health professionals in regions throughout the nation. Early in the project, TAP contracted with three primary health care training institutes — the Centre for Educational Development in Health in Arusha, the Primary Health Care Institute in Iringa and the Infectious Disease Centre in Dar es Salaam — to provide training in syndromic management to private sector health clinics and hospitals throughout TAP's nine cluster regions. All clusters are asked to identify local private health care centers that serve their communities and to help select the individual health practitioners from each facility who will receive training.

But cluster support is critically important in a more fundamental way: cluster-trained peer educators use every opportunity to discuss STIs with their audiences and explain the importance of seeking immediate and appropriate treatment. Peer educators in the Iringa and Tanga clusters in particular are prepared to refer clients who suspect they may have an STI to local clinics.

Building Capacity in STI Treatment

Since the beginning of TAP, 788 medical personnel have received extensive training from the three training institutions — 10 days of workshops, including two days of supervised, hands-on "practicals" — and have enthusiastically taken what they've learned back to their home facilities.

"Working through these prominent national training centers has been critical for sustainability," said Richard Steen, AIDSCAP's Africa Region STI officer. "This training now has an institutional basis that remains even after the project ends."

A limited analysis of the effectiveness of these efforts was conducted using patient encounter forms filled out by trainees after diagnosing each STI case using syndromic management. They revealed that more than 93 percent of the patients had received the proper diagnosis, based on the STI symptoms each presented to the practitioner. Seventy percent of the patients received the recommended drugs for their symptoms. And more than 97 percent of 250 patients who returned to the clinic for follow-up reported either cure or improvement in their conditions. These figures stand in sharp contrast to baseline data collected in 1994 before training began, which showed that patients received correct STI treatment less than 10 percent of the time.

"These numbers are an impressive indicator of the success of this training," said Steen. "Another, 'softer' indicator of success is the high demand — all the TAP clusters say they have health workers clamoring to participate, and the training centers can barely keep up."

Two other TAP syndromic management training efforts have targeted specific kinds of health care workers. One project, directed by AMREF, was designed to train clinicians working with women along Tanzania's trucking routes, where STIs are rampant and HIV seroprevalence rates are considerably higher than among the general population. A second, smaller-scale training effort in Dar es Salaam early in the project, conducted by Muhimbili University, trained pharmacists — the only health professionals that many Tanzanians suffering from STIs consult — to use syndromic management techniques to evaluate their customers' symptoms and dispense effective medications. An assessment of the pharmacists' accuracy in diagnosis post training revealed that their skills improved significantly.