Operational performance of an STD control programme in Mwanza Region, Tanzania

Objectives: To describe important details of the design and operational fea tures of the Mwanza sexually transmitted diseases (STD) control programme. To assess the feasibility of the intervention, the distribution of STD synd romes observed, the clinical effectiveness of syndromic STD case management , the utilisation of STD services by the population, and the quality of syn dromic STD services delivered at rural health units. Methods: The intervention was integrated into rural primary healthcare (PHC ) units. It comprised improved STD case management using the syndromic appr oach, facilitated by a regional programme office which ensured the training of health workers, a reliable supply of effective drugs, and regular suppo rt supervision. Five studies were performed to evaluate operational perform ance: (i) a survey of register books to collect data on patients presenting with STDs and reproductive tract infections (RTIs) to rural health units w ith improved STD services, (ii) a survey of register books from health unit s in communities without improved services, (iii) a survey of register book s from referral clinics, (iv) a home based cross sectional study of STD pat ients who did not return to the intervention health units fur follow up, (v ) a cross sectional survey of reported STD treatment seeking behaviour in a random cohort of 8845 adults served by rural health units. Results: During the 2 years of the Mwanza trial, 12 895 STD syndromes were treated at the 25 intervention health units. The most common syndromes were urethral discharge (67%) and genital ulcers (26%) in men and vaginal disch arge (50%), lower abdominal tenderness (33%), and genital ulcers (13%) in w omen. Clinical treatment effectiveness was high in patients from whom compl ete follow up data were available, reaching between 81% and 98% after first line treatment and 97%-99% after first, second, and third line treatment. Only 26% of patients referred to higher levels of health care had presented to their referral institutions. During the trial period, data from the coh ort showed that 12.8% of men and 8.6% of women in the intervention communit ies experienced at least one STD syndrome. Based on various approaches, uti lisation of the improved health units by symptomatic STD patients in these communities was estimated at between 50% and 75%. During the first 6 months of intervention attendance at intervention units increased by 53%. Thereaf ter, the average attendance rate was about 25% higher than in comparison co mmunities. Home visits to 367 non-returners revealed that 89% had been free of symptoms after treatment, but 28% became symptomatic again within 3 mon ths of treatment. 100% of these patients reported that they had received tr eatment, but only 74% had been examined, only 57% had been given health edu cation, and only 30% were offered condoms. Patients did not fully recall wh ich treatment they had been given, but possibly only 63% had been treated e xactly according to guidelines. Conclusions: This study demonstrated that it is feasible to integrate effec tive STD services into the existing PHC structure of a developing country. Improved services attract more patients, but additional educational efforts are needed to further improve treatment seeking behaviour. Furthermore, cl ear treatment guidelines, a reliable drug supply system, and regular superv ision are critical. All efforts should be made to treat patients on the spo t, without delay, as referral to higher levels of care led to a high number of dropouts. The syndromic approach to STD control should be supported by at least one reference clinic and laboratory per country to ensure monitori ng of prevalent aetiologies, of the development of bacterial resistance, an d of the effectiveness of the: syndromic algorithms in use.