STD treatment - the most neglected component of HIV Intervention in India Today

[Guest guest]

Dear members,

This is in response to Kavita and Vijay’s mail.

Does someone have any idea what is happening in the Targetted Intervention (TI)

supported STD clinics? Interventionists with non medical background (majority in

number) do not feel comfortable to go through the treatment registers, treatment

cards or doctors prescriptions lying in the clinic to have a sense of the

quality of treatment. They think it is a highly technical job and can be done by

the doctors only. So why get into the hassles of it when the doctor (most of

them are part timer) is coming regularly and treating the patients. So the

killer assumption is patients are attending the clinics with STI symptoms

regularly, receiving treatment and getting cured in course of time.

Recently I had the opportunity to visit several TI supported STI clinics and

what I observed over there was something not very encouraging. I am enlisting

them one by one for the sake of the knowledge of the members.

1) There are varieties of syndromic management in practice but none of them has

much similarity with the NACO and WHO approved syndromic guideline for STD

management. (For example Genital Ulcer / GU is treated by stat dose of

Gentamicin or Ciprofoxacin tab)

2) Penicillin is not used for treating non herpetic GUs most of the time.

Doxycycline has become the popular drug for treating GUs. But duration of

treatment is highly variable (5days, 7 days, 10 days).

I investigated and found that penicillin, which is still the drug of choice for

syphilis is not used because of the fear of anaphylactic reaction though

incidence of such reaction is extremely rare. In many clinics injectable items

are unofficially banned though they are very much included in the NACO approved

guideline.

From my professional experience I can say that Doxy can be as effective as

penicillin in treating the syphilitic component of GU but it requires a prolong

treatment for 15 days in twice daily dose.

So treatment with Doxy specially needs close supervision for positive patient

compliance and completion of full course without interruption as it has lot of

gastrointestinal side effects. Counseling of the patient by the doctor is a

mandate. But that is not happening in most of the clinics and recurrence of GU

has become a common phenomenon due to incomplete treatment.

3) Syndromic diagnosis (like Urethral discharge syndrome, Vaginal discharge

syndrome) is not clearly documented in the treatment registers. Sometimes

specific diagnosis of a STI is written like Syphilis, Chancroid, Herpes,

Gonorrhea etc which is not recommendable, as the total STD management approach

is a syndromic one.

Documentation in terms of age sex & syndrome specific disease distribution, no

of old cases and new cases received treatment, no of follow up visits made, no

of patients cured clinically, no of partners treated is the most neglected and

unattended component of the STD reporting system. But they can be easily

incorporated in the reporting and monitoring system just by giving little bit

attention and interest into the issue.

From my experience I can assert the fact that analysis of the data generated

during clinical intervention activities can become very helpful to measure the

effects of a good number of program operations.

4) In some of the clinics after scrutinizing the treatment register I have

discovered that the clinic has been dealing with large number of GU cases months

after months without trying to find out the reason behind it. At any point of

time GU is the most dangerous STD syndrome with huge potential of HIV

transmission.

But the observation had never hit the people working in the clinic the way it

hit me.

I strongly feel that STD management is still the most neglected component of a

HIV/AIDS intervention program in India. But STD control activities can really

make noticeable difference in HIV transmission process. Senegal is the burning

example of it. The country has dramatically curbed the spread of HIV where one

of its crucial strategies was effective control of STIs.

Most of the STIs are curable (except the viral STIs). We are trying so many

things to check the virus but STD is still not our cup of tea.

To monitor quality of treatment one does not have to be a thorough technical

person. Syndromic management is like mathematics. To monitor a mathematical

guideline one does not need too much of technical skill except a good conception

on syndromic management of the STDs.

But the question is, are we really in the position of understanding the gravity

of the issue?

Regards and best wishes,

From

Sugata Ganguly

E-mail: <sugataids@...>