NOTES FROM THE FIELD - PRACTICAL ISSUES IN UPGRADING STD SERVICES BASED ON EXPERIENCE FROM PRIMARY HEALTH-CARE FACILITIES IN 2 RWANDAN TOWNS

Objective: In order to assess the feasibility of upgrading STD managem ent at the primary healthcare level in Rwanda, a project was piloted i n a health centre and a hospital dispensary in two up country towns. M ethods: Nurses trained in syndrome based management treated all patien ts with genitourinary complaints at first visit without laboratory res ults. They provided condom demonstration and risk reduction advice, an d gave coupons for partner referral. Principal findings and decisions were recorded on individual patient records. Partners presenting refer ral coupons were treated presumptively and their records linked to the index case. Results: Three quarters of symptomatic patients seen at t he two primary healthcare facilities were women. With training and sup ervision, nurses applied the syndromic STD management guidelines corre ctly in over 90% of cases. Symptomatic treatment failure at first foll ow up visit varied from 0% for male urethritis to 27% for genital ulce r, the one condition that was not treated syndromically. Four fifths o f women presenting with vaginal discharge had clinical signs of cervic itis, and the presence of cervical signs was 86% sensitive for presenc e of leucocytes on cervical Gram stain. Conclusions: With adequate pos t-training supervision, nurses were able to apply the syndromic STD ma nagement guidelines and a high degree of clinical improvement was achi eved. Syndromic algorithms that recommend treatment for all common pat hogens at the first visit had higher rates of symptomatic cure at foll ow up than the algorithm employing a sequential treatment approach. Cl inical and laboratory evidence suggests a high prevalence of cerviciti s in this population of women seeking care.