1. Adherence to national guidelines in the syndromic management of sexually transmitted infections in Botswana’s primary health care Boonstra E 1, Lindbæk M 1, Klouman E 1, Ngome E 2,Romøren M 1, Sundby J 1 1 Department of General Practice and Community Medicine, University of Oslo, Norway 2 Health Research Unit, Ministry of Health, Gaborone, Botswana Publ. in: In Tropical Medicine and International Health 2003,Vol 8:604-14.

2. Abstract Adherence to National Guidelines on Syndromic Management of Sexually Transmitted Infections in Botswana’s Primary health care Design: Cross-sectional prospective field survey of 2994 consecutive consultations at 30 primary healthcare facilities in 3 districts, comprising a cohort of 224 patients with STIs. Outcome Measures: Proportion of consultations meeting set criteria for acceptable history taking, physical examination and appropriate treatment; percentage of consultations with advice on partner notification and counseling on the use of condoms; availability of antibiotics, STI algorithms, condoms and essential equipment by health facility. Results: In women (n=135), the criteria for acceptable history taking were met in 34(25%), and for physical examination in 31(23%); and in men (n=89), in 48(54%) and 51(57%) respectively. Appropriate treatment was given to 73(65%) of the women (n=112) and to 56(81%) of the men (n=69). Underprescription was found in 38(21%), overprescription in 12(7%), and incorrect prescription in 2(1%) of all consultations (n=181). Advice on partner notification was provided to 79(66%) of the women (n=120) and 71(86%) of the men (n=83). Counseling on the use of condoms was provided to 90(75%) of the women and 74(89%) of the men. In half of the health facilities, the lack of a fixed light source was the main constraint in carrying out a vaginal speculum examination. In all health facilities essential antibiotics and condoms were available. In 40% of the health facilities all STI algorithms were displayed in the consultation room. Conclusions: Adherence to national guidelines on diagnostic management of STIs was relatively poor, especially in women with STIs. One-third of the women and one-fifth of the men did not receive appropriate treatment for their STI, in spite of excellent availability of drugs. Nurses perform well on partner notification and counseling. Emphasis should be given to training of nurses in clinical examinations, particularly pelvic examinations.

3. Background and setting Background Syndromic management of sexually transmitted infections (STIs) is not ideal, and the weakness of the health services in most developing countries is a major drawback to achieving high coverage of STIs with efficacious treatment. Setting Thirty randomly selected primary health care facilities in three purposely chosen administrative districts (N=2,994), each representing a typical setting (urban, semi-urban, and rural). The survey was carried out June- November 1998 by two nurses and a pharmacy technician.

4. Study Aims Main objective To evaluate health worker ’ s adherence to national guidelines on syndromic management of sexually transmitted infections. Specific objectives To assess: - the quality of history taking and physical examination - the appropriateness of treatment - the provision of advice on partner notification and counseling on the use of condoms - the availability of essential antibiotics, equipment and STI-algorithms

5. Methods 1 Design: Cross-sectional field survey in three districts including 224 patients with STIs. Sampling unit: Primary healthcare facility (n=30) Outcome measures: 1. Diagnosis: proportion of consultations meeting criteria for acceptable history taking and physical examination (see Methods 2). 2. Treatment: - Appropriate: percentage of consultations with full adherence to national guidelines - Inappropriate: i) % unnecessary/wrong antibiotics prescribed ii) % recommended antibiotics not prescribed iii) % dose/duration of prescription incorrect 3. Partner notification and counseling on condom use: Percentage of consultations with partner notification and counseling on use of condoms 4. Availability of antibiotics, STI-algorithms and equipment: Percentage of facilities with excellent, fair or poor availability of antibiotics, STI algorithms and equipment.

6. Methods 2 Criteria for acceptable history taking and physical examination History taking Women: Abnormal vaginal discharge and/or genital ulcer and/or lower abdominal pain Pregnancy and/or missed period and/or recent delivery/abortion Recent partner change Men: Urethral discharge Genital ulcer Dysuria Recent partner change Examination Women: Vaginal speculum examination Men: Physical examination of the affected site

7. Results 1 - Materials Number of consultations: N= 224 1 By district: Gaborone (10 Cl 2 ) 102 Kgalagadi (2 Cl 2, 8 Hp 3 ) 60 Ngami (2 Cl 2, 8 Hp 3 ) 62 By health facilility: Clinics (n=14) 167 Health posts (n=16) 57 Gender: males 40%, females 60% Mean age: 30 years Staff: Nurses 86% Enrolled nurse 13% Family Welfare Educators 1% 1 Sexually transmitted infections comprised 7.5% of the total number of consultations (Botswana as a whole 6.5%); 2 Clinics; 3 Health post

8. Results 2 STI-syndrome diagnoses FEMALES n(%) Vaginal discharge syndrome 66 (49) Lower abdominal pain 35 (26) Genital ulcer syndrome 11 (8) Inguinal bubo 0 Other 23 (17) Subtotal 135 MALES n(%) Urethral discharge syndrome 32 (36) Genital ulcer syndrome 36 (42) Inguinal bubo 2 (2) Other 19 (21) Subtotal89 Total 224

9. Results 3 Acceptable quality of history taking and examination (N=224) Women Men n=135 n=89 n% n% p History taking: 34 (25) 48 (54) 0.005 Examination:31 (23) 51 (57) 0.003 Both 14 (10) 22 (25) 0.02

10. Results 4 Adherence to national treatment guidelines Appro- Inappro- priate priate STD diagnosis group n(%) n%) Women Vaginal discharge syndrome (n=66) 43 (65) 23 (35) Lower abdominal pain (n=35) 23 (66) 12 (34) Genital ulcer syndrome (n=11) 7 (64) 4 (57) Subtotal (n=112) 73 (65) 39 (35) Men Urethral discharge syndrome (n=32) 29 (91) 3 (9) Genital ulcer syndrome (n=35) 25 (71) 10 (29) Inguinal bubo (n=2) 2 (100) 0 Subtotal (n=69) 56 (81) 13 (19) Total (n=181) 129 (71) 52 (29)

11. Results 5 Availability of essential drugs, STI algorithms and equipment 1. All essential antibiotics for treatment of STIs at clinics and health posts were in stock 2.Supplies of condoms were adequate at all facilities 3. All 5 STI-algorithms were displayed in 40% of the facilities; in 50% none were displayed 4. 50% of the facilities lacked a fixed light source, which made vaginal speculum examination difficult or impossible 5. In 9 of 14 clinics and 2 of 16 health posts a gynaecological examination couch was available. In 29 of 30 health facilities an ordinary examination couch was available.

12. Individuals with STIs in the population Symptomatic infections Seek health care n♀=135 n♂=89 Adequate history ♀ 25% ♂ 54% Correct treatment prescr. ♀ 65% ♂ 81% Compliant with drug regimen Cured patient Discussion The loss of STI patients to the health care system Healthy populationSTIs Adequate examination ♀ 23% ♂ 57% STI identified and correct treatment prescribed ♀ ♂ ♂ ♀ Our study Partner notified (♀ 66%, ♂ 86%) and treated

13. Conclusions 1.Adherence to national guidelines on diagnostic management of STIs was relatively poor, especially in women 2.One third of the women and one fifth of the men did not get appropriate treatment, despite excellent availability of STI drugs 3.Nurses perform well with regard to partner notification and counseling on the use of condoms 4.Provision of antibiotics and condoms was excellent 5.Display of STI algorithms at health facilities was fair 6.Availability of essential equipment was poor.