Executive summary

Although STDs have caused significant morbidity and mortality for years it is only with the advent of the human immunodeficiency virus (HIV) that STD control has received higher priority in both developed and developing countries. With its link to HIV /AIDS, STDs will continue to remain an urgent public health problem.

Proper diagnosis and treatment, counseling on prevention, condom use and partner referral are important components of STD case management. WHO Prevention Indicator 6 (PI6) measures the proportion of individuals who present with specific STDs in health facilities, who are assessed and treated in an appropriate way (according to national standards). WHO Prevention Indicator 7 (PI7) measures the proportion of individuals seeking STD care in health facilities who have received appropriate advice on condom use and on partner notification. These are the indicators measured in this study.

In Ghana, little information exists on the quality of management of STD cases in both the private and public sectors, however, anecdotal information from many countries suggests that women seek care primarily through the public health care system, while men tend to consult private physicians or go directly to pharmacie s. Therefore, this study aimed to evaluate the proportion of people receiving correct treatment in public health facilities, private clinics and pharmacies. Not only will these data assist MOH programme planners in targeting the content of training programmes for health professionals and assess adherence to the current guidelines, they will create a baseline against which future studies can be compared to determine changes in the quality of STD care.

The national guidelines for STD case management in Ghana are based on the syndromic approach, and antibiotic sensitivity studies are conducted in Ghana on an ongoing basis to ensure that algorithms are appropriate to local conditions. The objective of syndromic management, treatment by disease symptom comple x rather than by microbiological aetiology, is to provide prompt and effective treatment in one visit, in order to prevent further spread of the infections.

The three STD syndromes assessed in this cross-sectional descriptive study were urethral discharge in men, vaginal discharge in women and genital ulcer disease in both men and women, at first presentation to health services. The data was gathered through observation of the clientprovider encounter, interviews of Health Care Providers (HCP) in public and private sector facilities and simulations of vaginal and urethral discharge syndromes by mystery shoppers in pharmacies and chemical shops.

In the 241 client-provider encounters, 40 (78.4%) cases of male urethral discharge syndrome, 182 (95.8%) cases of vaginal discharge syndrome and 9 (17.6%)cases of genital ulcer disease in males and 9 (4.7%) in females were observed. Syndromic diagnoses were made in 135 cases, aetiologic diagnoses in 110 cases. In 6 cases a non-specific diagnoses was made.

Of those who made a syndromic diagnosis, an adequate history was taken in 11 (8.1%) of consultations. 68 (50.4%) of such examinations were adequate, and 73 (54.1%) of treatment given for the diagnoses made by the provider were adequate. For vaginal discharge syndrome, the questions required to adequately complete the risk assessment were asked in 2/ 41 (4.9%) of encounters observed. Of those presenting with a vaginal discharge and lower abdominal pain, only 33/102 (32.4%) were diagnosed as having a pelvic inflammatory disease.

Of those who made an aetiological diagnosis, an adequate history was taken in 17 (16.7%) and adequate examination in 60 (58.8%) and adequate treatment was provided in 48 (47.1%) of cases.

Overall, the number of providers taking an adequate history, doing an adequate examination and providing adequate treatment were 10 thus P16 was 4.1%. Only 63 (26.1%) educated their clients on condom use and 120 (49.8%) advised partner notification. The number of providers giving education on both condom use and partner notification was 56 thus P17 was 23.3% and only 8 (3.3%)carried out all activities (P16&7) adequately.

203 STD providers from the public sector and 70 from the private sector were interviewed. 76 (37.4%) of the public providers and 4 (5.7%) of the private providers used syndromic diagnoses in the management of their STD cases, and 4 (4.4%) of the public providers and 10 (14.3 %) of the private providers were using the aetiological diagnosis. The remainder used a combination of methods. 191(94.1%) of public and 70 (l00%) of private providers reported that they took an adequate history, when given the appropriate prompts by the interviewer, and 140 (69%) of the public providers and 49 (70%) of the private providers reported that they performed an adequate examination. However, when appropriateness of prescribed therapy was assessed, P16 was 1.1% compared to a P17 of 89.4%. Major constraints reported by providers include high cost of drugs and irregular supplies of drugs. Some of the drugs recommended in the National Guidelines, e.g. Ciprofloxacin and Doxycycline, were mentioned as drugs to which providers had limited access as well as lack of relevant literature.

In the pharmacy survey 317 simulations comprising 166 (52.4%) male simulations and 151(47.6) female simulations were done. 81/269(30.1%) of the attendants took an adequate history, 25/256 (9.8%) provided adequate treatment for the syndromes presented, 25/269 (9.3%) educated the shoppers on condom use and 59/269 (21.9%) advised on partner notification. The modified P16 was 8.2% and P17 was 8.9%. Only 7 (2.7%) performed all activities adequately (PI6&7).

Thus most providers are not managing the STD client satisfactorily and P16 & P17 are universally low. In addition, providers are not following management guidelines and this could adversely impact on STD and HIV transmission.

It is hoped that these data will provide information that is valuable for policy formulation in STD training and in updating management guideline. It is also recommended that (re) training be done to cover the entire country and that monitoring and supervision of providers be strengthened. In addition, the essential drug list and drug supply system should be reviewed periodically and formative research on the stigma associated with the management of STD be done urgently. An epidemiological assessment of risk based on identification of pathogens should be done to improve the diagnosis of cervicitis.

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