Notes from the field: practical issues in upgrading STD services based on experience from primary healthcare facilities in two Rwandan towns.

OBJECTIVE: In order to assess the feasibility of upgrading STD management at the primary healthcare level in Rwanda, a project was piloted in a health centre and a hospital dispensary in two up country towns. METHODS: Nurses trained in syndrome based management treated all patients with genitourinary complaints at first visit without laboratory results. They provided condom demonstration and risk reduction advice, and gave coupons for partner referral. Principal findings and decisions were recorded on individual patient records. Partners presenting referral coupons were treated presumptively and their records linked to the index case. RESULTS: Three quarters of symptomatic patients seen at the two primary healthcare facilities were women. With training and supervision, nurses applied the syndromic STD management guidelines correctly in over 90% of cases. Symptomatic treatment failure at first follow up visit varied from 0% for male urethritis to 27% for genital ulcer, the one condition that was not treated syndromically. Four fifths of women presenting with vaginal discharge had clinical signs of cervicitis, and the presence of cervical signs was 86% sensitive for presence of leucocytes on cervical Gram stain. CONCLUSIONS: With adequate post-training supervision, nurses were able to apply the syndromic STD management guidelines and a high degree of clinical improvement was achieved. Syndromic algorithms that recommend treatment for all common pathogens at the first visit had higher rates of symptomatic cure at follow up than the algorithm employing a sequential treatment approach. Clinical and laboratory evidence suggests a high prevalence of cervicitis in this population of women seeking care.

Partner referral as a component of integrated sexually transmitted disease services in two Rwandan towns.

OBJECTIVE: To document partner referral rates at health centres with improved STD services, and to determine factors contributing to successful referral. METHODS: Partner referral was initiated as part of the upgrading of STD services in primary care health facilities in two semi-urban Rwanda towns. After syndromic management of the presenting complaint, index patients received prevention education and condom demonstration, and were urged to refer sexual partners to the health centre for a free examination. Partner referral coupons linked by code number to the symptomatic index patient were given to facilitate referral; no identifying information was collected on partners from the index patients. RESULTS: Three quarters of the symptomatic patients seen at the two primary health care facilities were women. Overall, the ratio of referred partners to index patients was 26%. Only 58% of index patients accepted partner referral coupons. The referral rate for those who did accept coupons was 45%. Partner referral worked best for regular partners. Most index patients and partners were married and only four index patients referred more than one partner. Women index patients, especially when pregnant, were more successful in referring partners than men. Index patients who referred partners tended to be older than those who did not. Awareness of STD symptoms in the partner, and diagnosis of cervicitis were associated with a higher rate of STD symptoms in the partner, and diagnosis of cervicitis were associated with a higher rate of partner referral. CONCLUSIONS: Efforts to improve rates of partner referral should begin at the clinic level with improved counselling to convince more index patients of the importance of partner referral. Partner symptom recognition may be useful for increasing rates of partner referral. Supplementary strategies are needed to reach non-regular partners. When syndromic management is used, counselling should take into account the lower predictive values of identifying STD in women in order to avoid partner accusation. Despite limitations, patient referral of sexual partners can be an effective strategy for reaching a population at high risk for STD with minimal additional investment in health worker staff time.

PIP: Partner notification was introduced to primary care health facilities in two semi-urban Rwandan towns as part of an effort to upgrade sexually transmitted disease (STD) services and develop guidelines for STD management. Of the 427 STD patients seen at these two centers in a six-month period in 1993-94, 325 (76%) were women; 31% of these women were pregnant. STD patients were provided with syndromic treatment, STD prevention education, and condom demonstration and were urged to refer their sexual partners to the health center for free STD examination and treatment. Overall, 110 sexual partners (26%) attended the clinics as a result of this intervention. However, only 248 STD patients (58%) accepted partner referral coupons, which included the index patient's identification number and a code for the STD syndrome involved. The referral rate among those who did accept the coupons was 45%. Among the referred partners, 89 (81%) were men and 21 (19%) were women. The rates of both coupon acceptance and partner referral were highest among pregnant women (72% and 33%, respectively). 16 female (76%) and 26 male (29%) partners referred were symptomatic. Awareness of STD symptoms in the partner and a diagnosis of cervicitis were associated with higher referral rates. Partner referral was not very effective in identifying casual contacts--more instrumental to the chain of STD transmission in a community than regular partners. None of the men seen, even those who admitted multiple partners, referred more than one sexual partner for treatment; four women referred casual as well as regular partners. Experience from other studies suggests couples are more accepting of and compliant with partner treatment recommendations when they are framed in the context of treating reproductive tract infections and preserving health and fertility.