Therapeutic Algorithms for the Management of Sexually Transmitted Diseases at the Peripheral Level in Cote d'Ivoire: Assessment of Efficacy and Cost

La Ruche, G., Lorougnon, F., Digbeu, N., Bulletin of the World Health Organization

In the acquired immunodeficiency syndrome (AIDS) era, adequate management of sexually transmitted diseases (STDs) is a primary concern in Africa. Assessed in this study is the clinical efficacy and feasibility of WHO-recommended therapeutic algorithms for genital discharges and ulcers, diagnosed without laboratory tests, for use at the primary health care level. Drugs were sold on a cost-recovery basis and included intramuscular ceftriaxone and oral ciprofloxacin for single-dose therapy of gonorrhoea and chancroid.

During April 1993 in 10 peripheral health care centres in Abidjan, Cote d'Ivoire, a total of 207 patients were followed up, including 89 cases of male urethritis, 92 cases of vaginal discharges and 26 cases of genital ulcers; clinical success, assessed 7 days after the onset of therapy, was, respectively, 92%, 87%, and 100%. Less than 10% of the 207 patients were referred to the next care level, an acceptable rate from a public health point of view. Medical adherence to the algorithms was excellent for urethral discharges and genital ulcers but poor for vaginal discharges, partly because of intentional therapeutic modifications, without detriment to success. For drugs, the average cost per cure was 1546 francs CFA (US$ 5.60) (maximum, 2980 francs CFA (US$ 10.70)). Effective and affordable treatments for STDs are necessary for their realistic case management in Africa.

Introduction

The control of sexually transmitted diseases (STDs) is of major importance in Africa particularly since the emergence of the acquired immunodeficiency syndrome (AIDS). Since it affects the productive population, STD-linked morbidity is responsible for economic loss in the community[1]. Delays in diagnosing and treating such infections with antibiotics explain the frequent complications and sequelae. Such complications affect chiefly women (pelvic inflammatory disease, postpartum infections, ectopic pregnancy, infertility, and chronic pelvic pain); however, men are also affected (urethral stricture and epididymitis), as are infants (neonatal conjunctivitis and respiratory disease). Neisseria gonorrhoeae and Chlamydia trachomatis are the principal bacteria responsible[2] and must be the primary target of STD control programmes in sub-Saharan Africa. Evidence has emerged that ulcerative or inflammatory STDs enhance transmission and acquisition of human immunodeficiency virus (HIV)[3]. Appropriate management of STDs aims to minimize their complications and reduce the incidence of HIV.

The emergence of strains that are resistant to cheap antibiotics poses a problem for the treatment of gonorrhoea, the principal cause of male urethritis, and for chancroid, the commonest genital ulcer in Africa. An effort must be made to obtain effective drugs to these STDs, preferably in single-dose regimens. Finally, the drugs must be affordable for patients in developing countries; fluoroquinolones and some third-generation cephalosporins could meet these requirements. Adoption of standardized therapeutic strategies, adapted to local situations, will make the management of STD patients and their sex partners easier and more effective. Such STD treatment guidelines must be applicable at the primary health care level[4], i.e., they do not require microbiological investigation.

The aims of the study were to assess the clinical efficacy and the feasibility, including cost, of therapeutic algorithms for the management of genital ulcers and discharges in men and women, within the peripheral health care centres, in Abidjan, Cote d'Ivoire, in the absence of laboratory tests.

Materials and methods

Recruitment of patients and follow-up

Consecutive patients presenting at ten peripheral health care centres in five of the ten districts of Abidjan, the principal city of Cote d'Ivoire, were eligible for enrolment in the study. The patients (males or females aged >12 years) presented either genital ulcers or discharges, and gave their verbal consent for inclusion in the study. Health care centres were selected in order to ensure varied recruitment in the public sector. Included were three general medicine and three gynaecology clinics at the community level, two military health establishments, and two school health services.

Within each centre, one clinician (a physician in 9 instances and a male nurse in one instance) was trained for the study. The clinician recorded anamnestic and clinical data for each participant on a standardized form, then applied the therapeutic algorithm (decision-tree) corresponding to the patient's condition. Drug distribution took place at the end of this first visit, either in the centre's pharmacy, if it existed, or directly by the clinician in school and military centres. Drugs were sold systematically to the patients on a cost-recovery basis. Patients who could not pay or who refused to do so were excluded from the study. In addition to drugs, patients received advice on STD prevention and on partner notification; they were also given free condoms. …

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Publication information: Article title: Therapeutic Algorithms for the Management of Sexually Transmitted Diseases at the Peripheral Level in Cote d'Ivoire: Assessment of Efficacy and Cost. Contributors: La Ruche, G. - Author, Lorougnon, F. - Author, Digbeu, N. - Author. Journal title: Bulletin of the World Health Organization. Volume: 73. Issue: 3 Publication date: May-June 1995. Page number: 305+. © 1990 World Health Organization. COPYRIGHT 1995 Gale Group.

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