AIDS Prevention And Control Project Voluntary Health Services
Item
- Title
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AIDS Prevention And Control Project
Voluntary Health Services
- extracted text
-
QUALITY STD CARE
TRAINING MODULE
''
FOR PRIVATE MEDICAL PRACTITIONERS
USAID
APAC project is administered by Voluntary Health Services, Chennai
with financial assistance from United States Agency for International
Development under bilateral agreement with the Government of India.
APAC-VHS
Chennai
TRAINING MODULE
For Private Medical Practitioners
October 1998
AIDS Prevention And Control Project
Voluntary Health Services
1
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CONTENTS
Page
Foreword
4
Introduction
5
Module I
Epidemiology of HIV/AIDS and STD
8
Session 1
Epidemiology of HIV/AIDS
9
Session 2
STD and HIV/AIDS
25
Module II
Quality STD Care
35
Session 3
Problems in Management of STD
36
Session 4
Syndromic Case Managements
44
Session 5
Preventive Components of Quality Care of STD
57
Module III
Condom Promotion and Behavioural
Change Communication
60
Session 6
Condom Promotion
61
Session 7
Counselling and Behavioural Change Communication
69
Module IV
HIV/AIDS in General Practice
76
Session 8
Clinical Features and Management of HIV/AIDS
77
Session 9
Universal Barrier Precaution in General Practice
83
Session 10
Social and Ethical Issues in HIV/AIDS
87
Session 11
Documentation and Follow-up
95
3
*
FOREWORD
Acquired Immuno Deficiency Syndrome is a disease of late 20th century and the
universal consensus is that sexually transmitted diseases form an important co-factor in
the transmission of HIV. While HIV/AIDS do not have a cure now, sexually transmitted
diseases are curable. The AIDS Prevention and Control Project (APAC) sees this linkage
between STD and HIV as the basis for developing intervention strategies for the
prevention and control of HIV/AIDS.
Research studies conducted by APAC and others reveal that there exist great variations
in the treatment of STD conditions, and minimal contributions towards preventing
sexually transmitted diseases. Therefore there is a need to orient General Practitioners on
quality STD care to enable them to recognise their crucial role in this context. APAC has
planned to organise massive training programme to train medical and paramedical
persons in "Quality STD Care". APAC's strategy to develop a Module to strengthen the
skills of the General Practitioners is an attempt in this direction. The Module contains
epidemiology, clinical features and guidelines for prevention and control of sexually
transmitted diseases. This module is primarily designed to be used during the training
programmes for General Practitioners. It can also be integrated with any other training
programme for the Allopathic medical practitioners.
The Training Module is a joint effort of APAC and the Chennai School of Social Work. We
wish to record our appreciation for the assistance provided by experts from Christian
Medical College, Vellore, Government Rajaji Hospital, Madurai, PSG Institute of Medical
Science & Research, Coimbatore, General Hospital, Chennai, Tamil Nadu State AIDS
Control Society, Family Planning Association of India, Madras University as well as the
Training Institutions. It is hoped that the Training Module will be a valuable technical tool
in STD/HIV/AIDS prevention and control to those working in this field and will be of
benefit to the community.
DR. P. KRISHNAMURTHY,
Project Director,
AIDS Prevention And Control Project,
Voluntary Health Services.
Chennai,
29.10.98
4
INTRODUCTION
Need and purpose
This Training Module is aimed at General Practitioners (GP) in Tamil Nadu. A recent STD
Health Facility Survey for Chennai city, conducted by the Tamil Nadu AIDS Control
Society, indicates that a majority of patients with STD (90.23%) avail private medical
care, while only 9.75% avail government hospital facilities. Therefore the need to train
General Practitioners to diagnose STD early and to treat them appropriately is critical in
this context. Evidence from some research studies demonstrates that there exists a great
degree of variation in treatment of STD conditions. The Training Module is directed at
standardising treatment of various STD conditions.
The Training Module has been initiated in Tamil Nadu due to the concerted efforts of
Central Government and donor organisations to tackle the HIV/AIDS problems in this
State. It is well known that Tamil Nadu is the State with the highest reported prevalence
of HIV/AIDS, with the largest number of AIDS deaths. Further, Tamil Nadu is relatively
more open to innovative approaches.
The main goal of the Training Module is to provide a standardised learning aid to General
Practitioners. The Training Module recognises the crucial role of General Practitioners in
intervention strategies for the prevention and control of STD and HIV/AIDS. The Training
Module aims to strengthen the present skills of general practitioners and develop newer
and more appropriate skills for the delivery of quality STD services using a standardised
treatment pattern.
5
i \
Users and target audience
The target audience is General Practitioners who are within the formal sector of private
medical care.
The module is to be used as a training tool by qualified trainers and resource persons of
medical institutions. The manual can be used to train groups of 15-25 participants, this
range being the best for training. The trainers should be :
•
Well
versed
in
Training
Methodologies
in
general
and
participatory training approach in particular
Experts in Public Health, Epidemiology and STD/HIV/AIDS
Specialists in STD care
Skilled in adopting communication techniques
General objectives of the training module
To make General Practitioners aware of the need for quality STD
care and the important role they play in this
To introduce General Practitioners to the concept of Syndromic
Case Management
To enable General Practitioners to acquire skills in using
Syndromic Case Management for STD treatment
To encourage General Practitioners to develop a positive attitude
towards preventive STD care aspects such as Partner treatment,
Follow-up, Counselling and Condom promotion
To introduce General Practitioners to ethical, social, and legal
issues related to STD/HIV/AIDS practice
6
/ >
Organisation and contents
The training module is broadly divided into four sub-modules giving a vivid description
on epidemiology and public health issue of STD/HIV/AIDS, problems in managing STD
and quality STD care through syndromic case managements, prevention of STD and
AIDS through condom promotion and behaviour change communication,
managements of HIV/AIDs and importance of universal barrier precautions in general
practice, values of ethical practice while caring for STD and AIDS patients and the need
for documentation and recording.
7
Module I
Epidemiology of
HIV/AIDS and STD
8
Session 1
EPIDEMIOLOGY OF HIV/AIDS
General objective
The trainees should be able to appreciate the various aspects of the HIV/AIDS problem
in order to realize the Private Medical Practitioner's role in its prevention and control.
Learning objectives
At the end of the session, the trainees should be able to :
Recognize the magnitude of HIV/AIDS problem and appreciate
the need for preventive measures
Describe the epidemiology of HIV/AIDS and the natural history of
HIV infection/AIDS
Identify and list out the risk behaviour for STD/HIV to
prevent/control HIV/AIDS
The magnitude of HIV/AIDS problem
The global context
The number of AIDS cases reported to the Global Programme on AIDS (GPA) in adults
and children rose to 1,169,811 by mid-1995 from 985,119 in 1994. This represents
almost a 20% increase in one year. But GPA believes that the true number of cases may
be four times this, in the region of 4.5 million. The estimate takes into account under
diagnosis, under-reporting and delays in reporting.
9
The number of AIDS cases is only a fraction of the number of people estimated to have
been infected with HIV who, in turn, are likely to go on to develop AIDS. According to
GPA estimates, about 18.5 million adults and more than 1.5 million children have been
infected with HIV since the beginning of the pandemic in the late 1970s/early 1980s.
Fig. 1 shows that next to Sub-Saharan Africa, South and South East Asia has the largest
number of HIV positive individuals - 5 million out of the global total of 27.9 million.
Future Projections
Table 1 : Estimated Adult Population and HIV Prevalence in mid-1993 and
by 2000.
Mid 1993
2000
Estimated
HIV
Prevalence
Estimated
Population
aged 15-49
years (1990)
Projected HIV
Prevalence
Projected
Population
aged 15-49
years
Australia,
Europe &
North America
> 1.2 million
646 million
1 million
675 million
Latin America
& Caribbean
>1.3 million
227 million
> 2 million
282 million
Africa
> 6.5 million
289 million
> 9 million
397 million
Asia
2 million
1527 million
8 million
1843 million
Global Total
> 11 million
2689 million
> 20 million
3197 million
"Macro"
region
10
1>
Fig.1
ESTIMATED DISTRIBUTION AS OF MID 1996, OF ADULTS AND
CHILDREN INFECTED WITH HIV SINCE LATE 1970s
(GLOBAL TOTAL : 27.9 MILLION)
cz
_________________
Eastern Europe & Central Asia
31,000
l
EAST ASIA & PACIFIC
36,000
Western Europe
640,000
North America
1.2 million
North Africa & Middle East
220,000
3ZZ
Latin America & Caribbean
1.6 million
ye
F
South & South-East Asia
5 million
k
____
Sub-Saharan-Africa
19 million
Source : NACO Country Scenario
December 1996
11
\ Australia
23,000
Table 1 gives the future projection about the HIV prevalence by the year 2000, when
more than 20 million people will be HIV Positive globally. And the WHO projection is that
there will be a cumulative total of 30-40 million HIV infections in men, women and
children, of whom more than 90% will be in developing countries.
AIDS situation in India
Since the first AIDS case was registered in Mumbai and HIV positive reported in Chennai
in 1986, 5167 cases of AIDS have been reported to the Ministry of Health and Family
Welfare from the 32 States and Union Territories till 28th February, 1998. Much of the
increase is attributable to better case finding and reporting which have resulted from
various intervention activities, but it is still highly probable that the epidemic continues
to increase.
Fig.2 : AIDS SITUATION IN INDIA
NEW CASES REPORTED TO NACO PER YEAR
3500 - ---------------------------------------------------------------------------------------------- “
-i
3000 2500 2000 -
■ Cases
CM
1500 1000 -
SB
500 co
0
in
a 8
5
g §
June
1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997
Reported cases of AIDS and HIV positives are only the tip of the iceberg. Table 2 shows
the reported number of AIDS cases in different States of India :
12
Table 2 : AIDS CASES IN INDIA (Reported to NACO)
(As on 28th February, 1998)
State/Union Territory
(Indians)
42
22
3
Andhra Pradesh
Assam
Bihar
Daman & Diu
1
Dadar Nagar & Haveli
0
Delhi
212
Goa
12
Gujarat
134
Haryana
1
Himachal Pradesh
9
Jammu & Kashmir
2
Karnataka
120
Kerala
105
Madhya Pradesh
134
Maharashtra
2513
Manipur
301
Nagaland
10
Orissa
2
Pondicherry
132
Punjab/Chandigarh
100
Rajasthan
54
Tamil Nadu
1092
Uttar Pradesh
109
West Bengal
57
All India Total
5167
13
t
AIDS Cases
AIDS situation in Tamil Nadu
India adopts a policy of not screening all suspects for HIV. Also, it is impossible to test
every individual to determine his positivity status and is not warranted either. Therefore
effective methods of estimating HIV positives, AIDS cases and their deaths have been
developed. Using such methods, it is estimated that in Tamil Nadu, there are 2,32,141
HIV positives and 25053 deaths due to AIDS as of June 1998 (Fig.3).
Fig.3
HIV/AIDS TRENDS IN TAMIL NADU
4
350000
300000 250000 200000 150000 -
100000 -
50000 -
0 -Ch1988
1992
1990
1994
1998
1996
2000
2002
YEAR
1988
1990
1992
1994
1996
1998
2000
2002
HIV
43
3014
23721
76589
153566
232141
294996
337108
AIDS
0
7
243
2362
10793
30968
65781
113474
DEATHS
0
4
147
1608
8111
25053
56158
100897
14
I
It should be noted that the magnitude of the problem (AIDS cases are not so high even
in 1998, but in the next two to three years, the number of deaths will increase enormously
and by 2002 more than 1 lakh people might die due to AIDS) will continue for many more
years, until the already infected HIV Positive people will die of full-blown AIDS.
HIV epidemic progression in Tamil Nadu
In Tamil Nadu HIV epidemic progression (1993 - 96) in various population groups
indicates a rising trend of HIV positivity status among the high risk groups such as STD
patients and truckers as related to the general population. The present low prevalence
among pregnant women will also go up in the next 2 or 3 years because the infection
will spread to the general population (Fig.4).
Fig.4
TRENDS OF HIV POSITIVITY AMONG HIGH RISK
GROUPS IN TAMIL NADU 1993 - 1998
16 -I
14.67
14 -
-O- STD
-*■ Truckers
-A- TB Patient
-M- Pregnant Mothers
11.23.
12 "
9.36
10 -
7.8
8 -
6 -
4.39
4 “
0.69
2 0
0.95
X——M ----- - -------- *---------M
-—
*
t ' ’
i ' 1 r ’
r »
i
Sep-93 Sep-94 Apr-95 Oct-95 May-96 Sep-97 Mar-98
t—i—»—i—*'
15
Need for preventive measures
The increasing trends of HIV positivity and its later conversion to AIDS cases and deaths
due to AIDS itself warrant the need for urgent action. In addition, the following issues
related to the problem also reinforce the need to start preventive measures urgently.
The impact of AIDS
Effect of the pandemic on population
During the 1990s, the impact of AIDS will be the greatest in large urban areas of Saharan
Africa, especially in Eastern and Central Africa where, today, in some cities as many as a
quarter to one-third of all adults aged 15-49 will be infected with HIV. In such cities, AIDS
deaths in youths, children and in those aged 15-49 may reduce expected population
growth by over 30% and the adult mortality rate may be upto three times.
AIDS and socio-economic development
AIDS strikes the economically productive population on whom society relies for
production and reproduction. They are the ones who grow crops, work in mines and
factories, run the schools and the hospitals, govern the country.
AIDS and its effect on family
As the earning family members die of AIDS, their elderly relatives are left without support
and their children become orphaned.
AIDS and its effect on medicare
At institutional level, it will result in a high Bed Occupancy & Medicare
cost
At General Practitioner level it will mean larger proportion of HIV/AIDS
cases than in routine practice and need for routine universal precautions
16
C
Natural history of HIV infection/AIDS
The natural history of any disease refers to the stages through which a disease passes, in
the absence of any intervention. Clear knowledge of natural history of a disease helps in
identifying the stages at which appropriate intervention for prevention or control of the
disease can be undertaken.
Pre-pathogenesis period
Human Immuno-deficiency Virus (HIV)
•
HIV belongs to the family of Retro viruses
•
There are two types of HIV Virus : HIV Type 1 and Type 2
•
Both Types are prevalent in India, Type 1 is more frequently
reported
•
HIV Type 1 is a more virulent pathogen than Type 2
Flg.5
STRUCTURE OF HIV VIRUS
llpW envelope
pie
P24
Reverse
—Transcriptase
RNA
Glycoprotein G.P - 120
17
Host factors
Age & Sex
The spread of HIV infection occurs most frequently in the age group of 20 to 50 years.
Globally, out of one million newly infected cases, 50 per cent are females. In India
according to NACO, however, the male to female ratio is 3:1. APAC sponsored
community prevalence study in Tamil Nadu shows almost equal ratio between males and
females.
Susceptibility of infection vis-a-vis sexual practices
•
The receiving partner is at a greater risk than the insertive
partner, in both vaginal and anal intercourse.
The risk of
transmission from male to female is higher than transmission
from female to male because female is the recipient partner in
sexual intercourse.
•
Anal sex carries a higher risk than vaginal sex
•
Oral sex and deep kissing carry low risk relatively
•
A good degree of protection is provided to persons using
condoms. The safety depends upon the type of condom and its
correct and regular use
High Risk Behaviours
Based on the epidemiological characteristics of HIV infection, certain high risk behaviour
groups, who are likely to be harbouring infection more frequently than the general
population, have been identified.
People with multiple sex partners (commercial sex workers, men
who are away from their families for long periods, as they are
likely to have extra-marital sex) and homosexuals
•
Injecting drug users, because they share needles and syringes
18
>
•
People requiring frequent transfusions
haemophiliacs, thalassemics etc
of
blood
e.g.
Routes of transmission
•
Sexual intercourse (heterosexual or homosexual), when one of
the partners is infected
Transfusion of infected blood
•
Use of contaminated needles / syringes
•
From an infected mother to her baby
Fig.6
PROBABLE SOURCE OF INFECTION (NACO Dec. 96)
OTHERS 9.0%
BLOOD PRODUCT
INFUSION 0.8%
SPOUSE
INFECTION
1.3%
HOMOSEXUAL 0.7%
HETERO
-SEXUAL 73.1%
BLOOD
TRANSFUSION
6.9%
I.V.D. USERS
8.2%
19
Table 3 : INTENSITY OF DIFFERENT MODES OF TRANSMISSION
Modes of transmission
Intensity
Sexual intercourse*
- Vaginal
- Anal
0.1 - 1.0 %
2.
Blood transfusion
90 - 95 %
3.
Perinatal
20 - 40 %
4.
Injecting drug use
0.5 - 1.0 %
5.
Needle type exposure
(health care settings,
needle stick injury,
tattooing etc.)
S. No.
1.
*
0.5 %
Although efficiency of this mode of transmission is low, it
accounts for the commonest mode of transmission because the
absolute number of risk intercourse is more.
Pathogenesis period
The natural history of HIV infection begins as soon as virus enters the body of a
susceptible host through any of the routes of transmission as discussed earlier (sexual,
parenteral and perinatal).
•
HIV infects predominantly T helper (CD 4) Lymphocyte
•
As the numbers and functions of CD 4 cells decline, immune
deficiency sets in
•
As immune deficiency progresses, the subject develops secondary
(opportunistic)
infections
and
malignancies
and
further
constitutional signs and symptoms of the diseases contracted
20
Window period and period of latency
6 weeks - 3 months
From 3 months
After 2 to 1 0
upto 2-1 0 years
years
HIV antibodies reach
Anybody who has
Signs and
a high titre approximately
the virus is a carrier
symptoms of a
3 months after the
and can infect
disease
virus has entered the
others
manifest
If the tests like
He/she has no
These can be
ELISA & Western
symptoms of the
grouped under
Blot are performed
disease at this
major and / or
within three months,
stage. The person is
minor conditons
they may be reported
considered HIV
as negative. This is
positive as revealed
known as the Window
by a positive test.
body
Period
However the patient
A person can be an
Dies due to
will be in a carrier
unknown carrier for
opportunistic
state transmitting
many years before
infections and /
the disease to others
the virus has
or AIDS
by all routes
destroyed much of
mentioned
the immune system
that he/she falls ill.
Window Period
HIV Positive
Period of Latency for AIDS from the
AIDS Case
time of HIV infection
Diagnosis
HIV infection is diagnosed by blood tests for antibodies
HIV antibody tests usually done are :
21
1. ELISA test 2. Western Blot test
•
ELISA test is also specific and less expensive. Commonly used for
screening at blood banks, voluntary testing etc.
Western Blot test, though more specific, is costly. Confirmation
can also be done by using results from 3 consecutive ELISA tests
from different kits
HIV antigen can be detected through PCR test and viral load
assessment tests.
Using these tests has shrunk the Window
Period but these two tests that can detect presence of HIV virus
early are available in few places at Chennai
How HIV infection is not spread?
HIV infection will not spread through casual contact, such as
At work place or schools
Coughing or sneezing
Sharing cups, glasses, plates and other eating utensils
Through water or food
Handshakes
Touching or hugging
Mosquitoes and other insect bites
Wearing clothes of infected persons
Going to swimming pools or public baths
Using telephones
Using toilets
22
How can transmission of HIV infection be prevented?
By observing the ABCs of safe sex viz. Abstaining from sex or
practising safer sex by not exposing a partner or oneself to body
fluids such as semen and vaginal secretions; Be faithful to your
sexual partner; Condom use: when used properly, prevents
semen, vaginal secretions or blood from entering the body
Not sharing contaminated needles, syringes or other skin
piercing equipment with others, since they may be contaminated
with blood
Not reusing contaminated needles and syringes employed for
medicinal purposes before properly autoclaving them
Screening blood and blood products for HIV
•
Autologous blood transfusion
23
FACTS SHEET
Epidemiology of HIV/AIDS
lobal Problem : There is a global problem of AIDS/HIV which is increasing alarmingly
(more than 20 million by the year 2000 AD).
argest number of AIDS cases in India next to Maharashtra is in Tamil Nadu.
ositive Cases : There are 4,50,000 estimated HIV positive cases in Tamil Nadu (1998).
(Refer STD prevalence study of APAC)
eaths : 1 lakh people are expected to die due to AIDS by the year 2002.
igh Risk Behaviour includes having multiple sex partners, sex with casual partners and
not using condoms, injectable drug uses and homosexuality.
oute of transmission : Sexual intercourse, infected blood transfusion, contaminated
needles / syringes, infected mother to baby.
indow Period upto 6 weeks to 3 months from HIV contact.
ests to be done only after counselling : detect antibodies - ELISA and more specific, the
Western Blot test.
ormal Carrier : HIV positive person, outwardly normal and can live normally for
5 to 10 years, is infective, but not through casual contact.
nd stage of HIV infection is AIDS, the body succumbing to opportunistic infections.
are and Counselling : Both HIV positive and AIDS cases require counselling for family
care and support.
24
Session 2
STD AND HIV/AIDS
General objective
To understand the magnitude of STD and the relationship between STD and HIV/AIDS
for Prevention and Control of HIV/AIDS.
Learning objectives
At the end of the session, the participants will be able to :
•
Understand the magnitude of STD in India
Recognize the role of STD in transmission of HIV/AIDS
Recognize the special problems of STD in women
STD - the problem
In answering problem, we need to explore three issues :
•
The extent of STD in the population, and
The complications caused by STD when patients are not treated
effectively,
The link between STD and transmission of HIV.
STD, including HIV, are caused by the same high-risk sexual behaviour.
Having multiple partners and changing partners often are risky and expose
people to STD.
25
Extent of the problem of STD
Worldwide in 1995, the World Health Organization estimated that there were over 330
million new cases of curable STD (Gonorrhoea, Syphilis & Trichomoniasis)
Fig.7
ESTIMATED NEW CASES OF CURABLE STD AMONG ADULTS, 1995 (WHO)
rrx
(
18 million
16 million
7^
14 million
7
9.7 million
23 million
7”
150 million
65 million
36 million
1 million
GLOBAL : 333 MILLION
26
I \
Magnitude of problem in India
The total annual incidence of all STD in India is estimated at around 5 per cent
(TNSACS/NACO). Thus, it is estimated that each year approximately 40 million new
infections with STD occur. They must be tested and kept under surveillance for HIV.
Prevalence of STD in Tamil Nadu was 15.8% in the age group of 15 - 45 years as per a
research study conducted by APAC in 1997 (includes HIV and hepatitis 'B').
Who is affected?
STD including HIV Infection, are widespread throughout the world. They affect sexually
active people of both sexes. So STD occur in both males and females. However, statistics
rarely show an equal distribution between men and women, nor do they show an equal
distribution between different age groups.
Distribution of STD by age and sex
For both males and females, rates of STD tend to be the highest in the 15-30 age group,
decreasing in later ages.
Most large studies show that, after the age of 19, cases occur more or less equally in both
sexes. However, there is usually a slight male preponderance. There are several possible
reasons, some perhaps more obvious than others:
Sexually transmitted infections often produce no symptoms or
only mild symptoms in women. So, fewer women come forward
for treatment and therefore they fail to appear in statistics;
•
Services in general may be more accessible to men than women.
For example, where men migrate to urban services and therefore
are more likely to appear in statistics;
•
Cultural and economic constraints might also prevent a
proportion of women from attending for treatment;
•
A large number of men might be infected after practising unsafe
sex with a small number of sex workers;
27
Older men in the later part of reproductive age group may be
more sexually active than women of the same age;
Men are more likely to change partners than women
However, it must be remembered that the problem of STD in women is hidden
revealed
by surveys undertaken at antenatal, family planning
as
and gynaecological
clinics. They show a high prevalence of STD among the women and mostly they are
asymptomatic.
STD transmission
In many developing countries throughout the world, sexually transmitted diseases (STD)
rank among the top five conditions for which adults seek health care (WHO/UNAIDS).
These diseases are important for two reasons: their magnitude and their potential for
causing serious complications.
The advent of the human immunodeficiency virus (HIV), another sexually transmitted
infection, has drawn attention to the urgent need for prevention and control of STD.
This section will help you to answer three questions:
How are STD transmitted?
What types of behaviour increase the risk of transmission?
What biological and social factors influence transmission?
Mode of transmission of STD
As the name implies, the main mode of transmission of STD is through unprotected
penetrative sexual intercourse (vaginal or anal). Other modes of transmission include:
mother-to-child: during pregnancy (HIV and syphilis), at delivery
(gonorrhoea and chlamydia) or after birth (HIV)
Transfusions or other contact with blood or blood products
(syphilis, HIV)
28
Behaviours influencing transmission
If the main mode of transmission of STD is through sex then the following factors
increase risk of infection:
Risk behaviours
•
Having more than one sex partner
•
Having a partner who has other partners
•
Having sex with 'Casual' partners, commercial sex workers or
their clients (partners whose other contacts are not known and
whose status in terms of STD is not known)
•
Continuing to have sex with person having symptoms of STD
Not using a condom In any of the above situations exposes both partners
to a high risk of infection.
Social factors that influence transmission
Failure to follow 'safe sex' measures, such as using condoms
Approval of multiple partners by social acceptance like 'Devadasi
System'
•
Delay in getting STD treatment
•
Not taking the full prescribed course of treatment for STD
•
Failure to bring in sexual partners for treatment for STD
•
Myth that having sex with a virgin young child cures STD
29
Biological factors that influence transmission
Apart from behavioural and social factors, certain biological factors also increase
transmission of STD
Age
The nature of the vaginal mucosa and cervical tissue in young women makes
them very susceptible to infection. Young women are specially at risk in
cultures where they marry or become sexually active during their early
teenage.
Cender
STD are primarily transmitted to women through vaginal intercourse. It is easier for
a woman to be infected by a man than for a man to be infected by a woman in this
way. This is because women have a larger surface exposed (i.e. the vagina) during
penetrative sex as well as the fact that the infected semen stays longer in the
vagina.
STD - a Cofactor in transmission of HIV/AIDS
AIDS is an STD
AIDS is an STD because the primary mode of transmission is through the sexual route.
The individual and social environmental facors for sexual behaviour are the main cause
for both infections. Whereas most of the STD will present with one symptom or the
other, AIDS is almost totally asymptomatic until in the later stages.
Link between STD and AIDS
Both STD and HIV predominantly have the same route of
transmission, i.e. the sexual route
Risk behaviour in individuals predisposed to STD and HIV is just
the same
30
/ \
Other STD make it easier for HIV to be transmitted from one
partner to the other. For instance, the mere presence of
chancroid, chlamydia, syphilis and trichomoniasis may increase
HIV transmission, maybe three to nine times in heterosexual men
Infection with HIV affects other STD by making them more
resistant to treatment, e.g. single dose treatment for chancroid
fails at least six times more often in HIV infected individuals than
in others
•
STD clinic / General Practitioner's clinic provides an important
access point for people at high risk, for both STD and HIV
infection, not only for diagnosis and treatment of STD but also
for education and prevention
Trends in STD incidence and prevalence can be used as indicators
of change in sexual behaviour and thus to measure the trends in
HIV transmission and impact of AIDS control interventions based
on behavioural change
STD as a Co-factor
Even though the sexual route is the main mode of transmission of AIDS, HIV is not so
readily transmitted (Table 3 in Session 1). In fact compared to diseases like
Hepatitis 'B' and Syphilis, HIV is far less infectious. It is estimated that the risk of infection
with HIV through sexual route is between 1 in 1000 (0.1 %) and 1 in 100 (1 %) exposures.
Nevertheless, the large size of population and the frequency of exposure account for this
route as the most important method of spread.
But in the presence of other sexually transmitted diseases, especially those that produce
genital ulcers, there is a five-fold increase in the risk of transmission of HIV. This is
explained by the fact that a co-existing ulcerative disease makes it easier for HIV to gain
entry into the body through the ulcerated area. In addition, the virus accumulation and
shedding is more in ulcerated areas in the HIV carrier. Exposed blood vessels like during
menses make it easier for it to be transmitted. It is also proved that even non-ulcerative
31
/ •
STD conditions in females result in T4 lymphocyte accumulation in the cervix, thus
rendering them more vulnerable for HIV infection.
Commercial sex workers, long distance truck / van drivers and cleaners, travelling men,
construction workers, rickshaw-pullers and hostel based students are relatively more
prone to sexual promiscuity and therefore to STD. This is also confirmed by the HIV sero
prevalence corresponding to similar behaviour pattern.
The enhancing role of other STD on HIV transmission explains the need for prevention
and early treatment of other STD as an effective measure to contain the HIV pandemic.
Due to this reason, WHO has an integrated STD programme in the Global Programme
on AIDS (GPA). This has already borne results as shown by the experience in developing
countries like Tanzania which, through effective control of STD, has decreased the
incidence of HIV by 42%.
Women and STD
Past observations have shown that STD are more easily transmitted to women from men
than vice versa. This being so, HIV also should be more easily transmitted to women from
men than the reverse. In Tamil Nadu, the data from the Department of STD,
Government Rajaji Hospital, Madurai, shows that in the period between 1986 and 1992
as many as 78.5% of women infected with HIV were Commercial Sex Workers (CSWs)
with more than 70% of them having one or more STD conditions as a co-factor. But in
1993-94, an increasing trend for HIV infection among housewives (whose only risk factor
is a promiscuous husband with frequent STD infections) has been observed. Most of
these women never knew that they had an STD.
Sexually Transmitted Diseases (STD) have implications which are rather more serious in
women than in men. The symptoms and sequelae of STD vary from men to women and
the latter experience a greater psychological stress.
Asymptomatic STD are more frequent in women. Very often the disease presents at a
concealed site, not visible to the female patient. Moreover, the common symptom
of
STD in a woman, namely, 'the discharge' is exhibited by many common and non STD
32
/ >
conditions, and masks early recognition of STD in such women and so there is delay in
seeking treatment or is not treated at all.
The long-term complications of STD are far more serious in women than in men. The
important complications are risk of cancer, infertility, miscarriage, stillbirth, risk of ectopic
pregnancy and inadvertent transmission of pre-natal infection with a high rate of
morbidity and mortality.
Their access to special treatment centres like a STD clinic is less. This is due to several
social and cultural factors including non availability of appropriate health service.
33
FACTS SHEET
STD and HIV/AIDS
ach year 40 million new infections with STD occur in India.
isk behaviour includes multiple partners, having a partner who has other partners, sex
with casual partners, homosexual behaviour, non use of condoms.
ommercial Sex Workers, long distance truck drivers, travelling men, construction
workers and hostel based students are relatively more prone to promiscuity and therefore
to STD.
ocial factors that influence transmission are, not following "safe sex", delay in getting
treatment, not taking full course of treatment, failure to bring partners for treatment.
IDS is an STD, as the primary mode of transmission is sexual.
Hiv transmission risk is increased by STD because of the same risk behaviour and
because of presence of ulcer and other reasons.
w omen and STD : easily transmitted, mostly asymptomatic, delay in seeking treatment
and long term complications are more serious.
roblems in STD care include shortage of trained personnel, delay in diagnosis and
treatment, lack of compliance to treatment of patient and partner, no counselling.
uality care for Prevention of STD cases will prevent / control AIDS Pandemic.
34
Module II
Quality STD Care
35
f v
Session 3
PROBLEMS IN MANAGEMENT OF STD
General objective
The General Practitioners will be able to know and tackle the complexities of giving
'total' treatment for STD patients and to understand the special problems in providing
STD services to women.
Learning objectives
At the end of this session, the participant will be able to :
•
Adopt "total treatment" for STD patients
Understand the problems in ensuring treatment compliance,
partner treatment and follow-up of STD cases
Be aware of clinical issues specific to women and STD including
the need to look out for asymptomatic cases and their
management
Be aware of the need to maintain records of STD case
management
"Total treatment" of STD patients
For Quality Care of STD, the following important aspects of management should be
taken into account:
Compliance with treatment
Partner treatment
36
Follow-up
Referral for treatment failure or complications
Problems in STD case management
In a treatment setting where STD patients are managed, certain problems are often
encountered. The common and important problems are :
•
Delay in seeking treatment
•
Compliance with treatment
•
Partner management
Follow-up
Referral of cases with complications
Maintenance of case records
Delay in treatment
It is well known that most STD patients delay seeking treatment. A study conducted at
a Madurai STD clinic revealed that the average duration of symptoms prior to attending
STD clinic was 13 days for men and 30 days for women.
It is not the patient taking
treatment who spreads the disease, but it is the one who does not initiate treatment.
Reason for delay in treatment
The major reasons for delay in seeking treatment are the stigma and ignorance
associated with STD. Many men and women want to conceal their disease as long as
possible; women in particular are slow to recognise the symptoms of STD and to avail
of treatment.
Attending public STD clinic is a painful experience for many men and
women.
Feeling of shame, guilt, anxiety and fear further adds to their difficulties.
Again the
negative attitude of the health providers, the inaccessibility of the clinic, the inconvenient
37
working hours of the clinic, long waiting time, lack of privacy in certain set up, too many
hospital procedures and frequent change of physician etc. add to the delay in seeking
treatment.
Compliance with treatment
Non-compliance with treatment of STD affects the outcome of management, leads to
complications, produces inestimable costs, both economic and human, and also results
in frustration of the treating physician.
The factors pertaining to the patients are ignorance, fear of being identified in a STD
clinic, anxiety / fear of tests and treatment, financial constraints, distance from residence
to clinic and patient's own beliefs.
In a treatment setting, factors leading to non-compliance are negative attitude of some
healthcare providers, inconvenient working hours, prolonged waiting time, delayed
treatment, complicated treatment regimens, lack of privacy, inadequate time spent with
the patient, insistence of clinic personnel to bring the partner(s), frequent change of
physician and too many hospital procedures.
The 'stigma' associated with STD, societal ignorance of STD/HIV/AIDS and social
disapproval of promiscuity, prostitution and homosexuality also hinder the treatment
compliance of STD patients.
REMEDIAL MEASURES for Non-compliance are :
For the Patient
Education and counselling of the patients
In the treatment setting
US’
Providing a treatment setting with privacy
Convenient working hours
US'
Minimal waiting time
usr
Personnel with non-judgmental and empathetic attitude and
38
■s’ Facilities for early diagnosis and treatment through use of simplified
treatment regimens, as suggested in the flowcharts for syndromic
management of STD, will achieve a better compliance with treatment of
STD patients
Partner management
Partner management is an essential component of total treatment of STD; otherwise the
patient is very likely to acquire re-infection from the untreated partner(s). A general
practitioner should aim at the "simultaneous treatment" of partners of STD patients. In
a clinic-based study at Madurai, the partner treatment rate was as low as 30%. Among
the married patients only 28% brought their spouses for treatment. The reasons for low
partner treatment rate were :
The fear of the disease will become known to partners
Inability to bring the 'Primary contact' who was CSW
Fear of being identified in the STD clinic by others
•
Strained marital relationship
•
Unwillingness of partners to attend STD clinic
•
More often, it was the asymptomatic status of STD in the
partners
Follow-up & referral
Follow-up is essential to assess the outcome of the treatment and whether
total
treatment is achieved.
In case of treatment failure, health provider should find out whether failure is due to noncompliance of the treatment or due to complication.
In this process he can initiate
action to retreat or to refer the patient to a specialist or to higher centre for further
management.
Certain
problems
include treatment failure,
drug
resistance,
complications or late sequelae like sterility, neuro-syphilis, eye complications, stricture
urethra etc.,
39
Maintenance of case record
Maintenance of records for STD case management services is 'the tool' for follow-up. It
should be done whenever possible even though it may be too difficult for a busy general
practitioner to maintain extensive records. STD record should have details such as name,
age, sex, correct and complete address, complaint and duration of treatment given,
history of drug allergy, previous STD and partner treatment. Patient counselling and
condom usage details should also form an essential feature of any recording system.
Due to the importance accorded to the need for maintaining records, a separate session
is earmarked elsewhere in this module.
Special problems in providing STD care to women
Sexually Transmitted Diseases (STD) have implications which are rather more serious in
women than in men, and the symptoms and sequelae of STD vary in women and the
latter experience a greater psychological stress.
Challenges in Diagnosis and Management of STD in women
Asymptomatic STD are more frequent in women. Very often the
disease presents at a concealed site, not visible to the female
patient. Moreover, the common symptom of STD in a woman,
namely, 'the discharge' is exhibited by many common and non
STD conditions, and masks early recognition of STD in such
women
The long-term complications of STD are far more serious in
women than in men. The important complications are risk of
cancer, infertility, miscarriage, stillbirth, risk of ectopic pregnancy
and inadvertent transmission of pre-natal and peri-natal
infections with a high rate of morbidity and mortality
The important STD like syphilis, gonococcal infection, chlamydial
infection, herpes simplex infection, trichomoniasis and human
papilloma viral infection pose special problems for women
40
While many of these STD manifest as overt diseases in men who
seek early treatment, in case of women the symptoms are not so
well defined and are often similar to those of other diseases.
Therefore, women with STD delay seeking treatment or seek
treatment from a variety of health providers like traditional health
care deliveries
•
Syphilis in pregnant women has a special connotation with many
deleterious effects.
It is associated with foetal wastage.
from
and
miscarriage
stillbirth,
late
manifestations
Apart
like
malformation of teeth interstitial keratitis may persist throughout
the life of the infected child with resultant 'stigma'
In gonorrhoea, the commonest primary site of infection is
endocervix and most women are asymptomatic.
Detection of
gonococcal infection in women is both cumbersome and costly.
It requires a 'culture', the result of which can be available after a
delay of a minimum of 24 hours, and which requires special
'selection media' and handling. A common and serious sequele
of gonococcal infection in women is the spread of infection to
the endometrium and fallopian tubes, leading to Pelvic
Inflammatory Disease (PID).
The sequelae of PID include
peritonitis, tubal abscesses, ruptured ectopic pregnancy, infetility
and chronic or recurrent infection necessitating hysterectomy.
Gonococcal PID is not easily diagnosed as there is no standard
laboratory test and the criteria for diagnosis of PID vary widely.
The treatment of PID is also complex and controversial.
The
treatment regimens for PID have high failure rates
•
In sexually transmitted Chlamydial infection, the commonest
presentation is 'asymptomatic endocervicitis' in women, while it
is symptomatic urethritis in men.
Like gonococcal infection,
untreated chlamydial cervical infection can ascend to the
fallopian tubes and cause PID. Although chlamydial infection of
the cervix is expected to be common in women, it is rarely
41
/ >
diagnosed. This is due to the fact that it is often 'symptom free'
and a confirmatory test like Chlamydial culture is technically
difficult and expensive. This diagnostic facility is available only in
a few selected laboratories. Under these circumstances, treating
the female partners of men with Non-gonococcal Urethritis
(NGU), a common aetiological agent of which is chlamydia,
would be the correct epidemiological approach but this is not
routinely done
•
Herpes Simplex Virus (HSV) infection in women, too, poses
special problems
Infected women have increased risk of developing cancer in cervix
i®’ Inadvertent transmission of the virus to the newborn during
delivery can lead to a life threatening neonatal herpes
In view of this, women with recurrent episodes of disease are
advised to have a routine Pap smear done every year to detect
pre-cancerous change at the earliest.
The infection of the
neonate can be prevented by Caesarean section for women with
HSV infection in the birth canal at term.
•
Trichomoniasis is the commonest cause of vaginal discharge in
women.
In fact, trichomoniasis is the commonest STD in
women.
Though not serious, trichomoniasis is an annoying
disease causing much mental and physical distress. Though the
disease is frequently associated with copious, frothy vaginal
discharge with an unpleasant odour and itching, it is at times
asymptomatic, the disease being diagnosed by a routine
microscopic examination of wet film of the vaginal discharge.
Asymptomatic cervical infection has been found to be associated
with abnormal Pap smears
•
Human Papilloma Virus (HPV) causes warts.
In women, warts
may be too large or extensive and are often difficult to treat.
Warts increase in size enormously during pregnancy and severe
42
infection may complicate vaginal delivery.
It is possible that a
woman may harbour the zwart virus' without an overt disease
but may have Cervical Intra-epithelial Neoplasia (CIN)
To summarise
The consequences of STD are more serious in women than
in men
The signs and symptoms for many STD are not well defined and
are often similar to those of other diseases
Also for various reasons, women delay seeking treatment
Their access to special treatment centres like STD clinic is less
These are challenging issues that need to be addressed by the General Practitioner and
for this the initial step is to be aware of these special problems in women and be on the
lookout for them to be able to reduce missed opportunities for treatment.
43
Session 4
SYNDROMIC CASE MANAGEMENT
General objective
The trainee should be able to acquire clinical knowledge and skills in the use of
standardised treatment regimens for STD syndromes in primary health care settings.
Learning objectives
At the end of this session, the participant will be able to :
•
Describe the advantages of syndromic case management
•
Classify the main causative agents responsible for different
clinical syndromes
•
Use flow-charts for Syndromic Diagnosis and Management
Prescribe Standardised Treatment regimens for STD Syndromes
STD management approaches
In general there are two approaches in the management of STD, one is based on
aetiological diagnosis and the other is clinical.
Aetiological diagnosis poses several problems, namely, to identify as many as 20 STD
causative organisms requires skilled personnel and sophisticated laboratory.
eg: Gonococcal & Chlamydial infections - require facilities like culture, which are non
existent in many a laboratory setup.
44
Primary and secondary syphilis needs dark-field microscope.
Tests for other STD like
herpes etc. are even more complicated.
Majority of patients with STD seek treatment from general practitioner's clinic or ill
equipped STD clinics which lack required facilities and skilled personnel.
services are both expensive and time consuming.
Laboratory
Similarly clinical diagnosis has
limitations. It is difficult to differentiate between various types of infections especially in
the presence of mixed infections.
For example, clinical distinction cannot always be made between gonococcal infection
and chlamydial urethritis.
There are chances of misdiagnosis, hence syndromic
approach.
>
In syndromic approach the symptoms and signs are grouped to identify the syndrome.
Advantages of syndromic management of STD
Classifying the main aetiological agents by clinical syndrome
Using the flow charts the treatment for each syndrome is prompt
and can be instituted at any first line health facility
•
There is wider access to treatment catering to a large needy
population
There are ample opportunities for preventive measures and
promotion of condom use
Syndromic case management is
•
Scientific
Simple to treat with good drug compliance
•
Free from errors in clinical judgment
•
Effective against mixed infections
•
Cost effective in the long run and does not require laboratory tests
45
Now health care providers are able to appreciate that the syndromic approach is very
effective. Indeed it is the only approach that meets the main need to control the spread
of STD by offering immediate treatment at the first visit.
In view of difficulties in
aetiological and clinical diagnosis of STD, a third approach to STD management is
introduced which is called Syndromic Case Management.
The main features of syndromic case management
Classifying the main causative agents by clinical syndrome they
produce
Using treatment flow chart for each syndrome
Treating the patients for all important causes of the syndrome
and
•
Ensuring that partners are treated, patients educated, and the
use of condom promoted
Even though STD are caused by different organisms, these organisms give rise to only a
limited number of syndromes. A syndrome is simply a group of symptoms complained
of by patients and the sign found on examination.
Responding to criticisms of the syndromic approach
The syndromic approach isn't scientific
On the contrary, it is based on epidemiological studies conducted throughout the
industrialised and developing world. A number of validation studies have been done
comparing syndromic diagnosis with laboratory assisted diagnosis. These studies found
syndromic diagnosis to be similar to laboratory-assisted diagnosis, and hence accurate.
As a result, syndromic diagnosis of STD has been adopted in many settings all over the
world.
46
rV
Syndromic diagnosis is too simple for a physician to use - it can even be
used by nurses
Simplicity does not prevent physicians from using other tools, such as a thermometer or
a stethoscope!
It is a great advantage for STD control if other service providers, in
addition to doctors, can use the syndromic approach to make a diagnosis. Simplified
«
diagnosis and treatment also frees more time for health care providers to offer education
for behaviour change.
The syndromic approach does not use a service provider's clinical skills and
experience
Many clinicians rely heavily on their own clinical judgement.
They find it difficult to
accept that using a clinical judgement alone could be a problem. Not only do studies
show that clinical diagnosis is accurate for only 50% of STD cases, but clinical diagnosis
also misses mixed infections.
1
It would be better to treat the patient first for the most common cause
and then, if the symptoms don't improve, treat for a second cause
Patients who are not cured by the first treatment may not return to the health centre and
may even seek further treatment elsewhere, resulting in an inappropriate course of
treatment. They may also become asymptomatic but still have an untreated STD, and if
they have unprotected intercourse, they may spread the infection further.
The syndromic approach wastes drugs, because patients are being over
treated
In fact studies have shown that the syndromic approach makes STD care less expensive
in the long run. The technology, skills and infrastructure needed to make an aetiological
diagnosis are expensive.
Failed treatment or a wrong clinical diagnosis that results in
inappropriate or incomplete treatment then makes the cost of treating a patient higher
because he has to be treated again and may develop complications and further spread
the infection.
47
9
The syndromic approach promotes the development of antibiotic
resistance
Antibiotic resistance emerges if people do not take enough antibiotic(s) to cure their
infection(s) completely. With the syndromic approach, providers are encouraged to give
standardised treatment using the most effective medications available for a given
syndrome. Providers are also encouraged to use single dose therapy whenever possible
thereby avoiding problems with patient compliance.
Better communication between
providers and patients makes it more likely that the patients will continue to take their
medication as required after they leave the health centre.
Good, simple laboratory tests, such as Gram stain, should be included In
STD diagnosis
When you include laboratory tests in the process, patients must wait for the results and
may not return for treatment. Also, while they are waiting, they remain infectious and
complications can occur.
Gram stain is only justified when microscopy is readily
available, quick and consistently accurate.
€
t
Identifying the Syndromes in STD
Even though STD are caused by different organisms, these organisms give rise to only a
limited number of Syndromes. A Syndrome is simply a group of symptoms complained
of by patients and the signs found on examination.
The Syndromes in STD are grouped as
Genital Ulcer
Urethral discharge in males
Vaginal discharge
Inguinal swelling
Lower abdominal pain in females
Scrotal swelling
48
*
The aim of syndromic management is to identify one of these six syndromes and manage
it accordingly.
4
It includes only those syndromes that are caused by organisms which both respond to
treatment and lead to severe consequence if left untreated. Other STD syndromes, such
as vesicular lesions (herpes), genital warts and dysuria in women, are not included in this
programme.
Using syndromic flow-charts
Because the above six syndromes are easy to identify, it has been possible to devise a
"flow-chart" for each one. Each flow-chart takes us carefully through the decisions and
actions that we need to take, leading to guidance on the condition(s) for which to treat
the patient. Once trained, the service providers will find the flow-charts easy to use; so
it is possible for non-STD specialists at any health facility to manage STD cases with the
following benefits:
•
Promptness of treatment, patients treated on their first visit
•
Wider access to treatment, treatment being available at more
♦
f
centres
•
Opportunities for introducing
preventive
and
promotive
measures such as education and distribution of condoms
Treatment for all the causative agents for the syndrome
While a clinical or aetiological diagnosis tries to treat just one causative agent, syndromic
diagnosis includes immediate treatment for all the important causative agents thus
quickly making the patient non-infectious and taking care of the mixed infections that
are common in STD.
49
I
GENITAL ULCER
Patient complains of genital ulcer(s)
♦
>
Examine patient
_________ ♦
Multiple small blister like painful lesions
I
♦_____
-Genital ulcer (open sore may be painful or painless)
-May have swollen lymph nodes In groin
♦
-Treat to relieve symptoms of Herpes
-Reassure patient that lesions will improve within 7 days
Treat for Syphilis and Chancroid
FOLLOW UP 7 DAYS AFTER CLINIC VISIT
♦
♦
No improvement
Improvement or cured
I
♦
Refer to higher care
Complete any remaining treatment
TREATMENT
SYPHILIS
Benzathine Penicillin G 2.4 million units in 2 injections (give one injection in
each buttock)
OR
Aqueous Procaine Penicillin G 1.2 million units IM injection daily for 10 days
For men and npn-pregnant women sensitive to Penicillin'
Doxycycline 100 mg orally 2 times daily for 15 days
OR
Tetracycline 500 mg orally 4 times daily for 15 days
For pregnant women sensitive to Penicillin
Erythromycin 500 mg orally 4 times daily for 15 days
(Advise those women to bring the child within 7 days of birth for screening)
CHANCROID
Erythromycin 500 mg orally 4 times daily for 7 days
Alternative Treatment
Ciprofloxacin 500 mg orally as a single dose (do not give to pregnant women)
OR
Trimethoprim 80 mg/Sulphamethoxazole 400 mg 2 tablets 2 times daily for
7 days
OR
Ceftriaxone 250 mg in a single IM dose
HERPES SYMPTOMATIC THERAPY
- Apply topical antibiotic ointments. Advise patient to wash genital area
regularly with soap and water.
- First episode - Acyclovir 200 mg orally 5 times daily for 7 days
- Recurrent episodes - Acyclovir 200 mg orally 5 times daily for 5 days
N.B. : Tetracycline and Doxycycline should not be used during pregnancy
and lactation.
STEPS FOR STD PREVENTION AND MANAGEMENT
Give all patients
1 Treatment
2 Instructions for medication and follow up
3 Education and counselling
4 Condoms
Education and Counselling for patients
1 Cure your infection
2 Do not spread STD
3 Help your sexual partners to get treatment
4 Come back to make sure you are cured
5 Stay cured with condoms
6 Keep safe by staying with just one sexual partner
7 Protect yourself against AIDS
8 Protect your baby - ask your wife to attend ANC during pregnancy
Ct
50
URETHRAL DISCHARGE
Man complains of urethral discharge and painful urination
f
-
Examine patient for urethral discharge
♦
V
Discharge seen
___
No discharge seen
♦
♦
Treat for Gonorrhoea and Chlamydia
Re-evaluate If symptoms persist
FOLLOW UP 7 DAYS AFTER CLINIC VISIT
T
H__
Cured
Discharge persists
♦
Complete any remaining treatment
Treatment regimen
followed
Treatment regimen
not followed
V
▼
Refer to higher care
Repeat treatment
STEPS FOR STD PREVENTION AND MANAGEMENT
TREATMENT
Give all patients
GONORRHOEA
Ciprofloxacin 500 mg orally in a single dose (contraindicated in
1 Treatment
pregnancy)
2 Instructions for medication and follow up
3 Education and counselling
OR
4 Condoms
Norfloxacin 800 mg orally in a single dose
OR
Education and Counselling for patients
Kanamycin 2 g IM as a single dose
1 Cure your infection
2 Do not spread STD
CHLAMYDIA
3 Help your sexual partners to get treatment
Doxycycline 100 mg orally 2 times daily for 7 days
4 Come back to make sure you are cured
OR
5 Stay cured with condoms
Tetracycline 500 mg orally 4 times daily for 7 days
6 Keep safe by staying with just one sexual partner
OR
Erythromycin 500 mg orally 4 times daily for 7 days (pregnant women)
51
7 Protect yourself against AIDS
8 Protect your baby - ask your wife to attend ANC during pregnancy
06493
VAGINAL DISCHARGE
Woman complains of
Vaginal Discharge
Risk
Assessment
Ask If patient answers 'Yes' to : Does your sexual partner have a
discharge from his penis or open sore anywhere in his genital area?
I
I
NO
YES
♦
Risk Assessment -Ve
Risk Assessment +Ve
I
f
Speculum
Available
Profuse
Discharge
I
Treat for
Gonorrhoea,
Chlamydia,
Trichomoniasis
& Bacterial
Vaginosis
Clumped
Discharge
I
Treat for
Gonorrhoea,
Chlamydia &
Speculum Not
Available
I
Speculum Not
Available
Speculum
Available
r~
_3_
Treat for
Treat for
Candidiasis &
Gonorrhoea,
Trichomoniasis
Chlamydia,
fa Bacterial
Candidiasis &
Vaginosis
Trichomoniasis
Mucopus
from
cervix
I
Treat for
Gonorrhoea
fa Bacterial
Vaginosis
&
Candidiasis
Chlamydia
Profuse
Discharge
Clumped
Discharge
J
Treat for
Trichomoniasis
& Bacterial
Vaginosis
No
Discharge
seen
I
Treat for
Candidiasis
TREATMENT
Cervical discharge on speculum examination:
Treatment for Cervicitis includes treatment for both Gonorrhoea and
Chlamydial infection.
Recommended regimen (non-pregnant women):
Ciprofloxacin 500 mg in a single dose orally
and
Doxycycline 100 mg orally twice daily for 7 days.
Alternative regimen :
Azithromycin 1 g single oral dose under supervision
(effective both for Gonorrhoea and Chlamydial infection)
In case of pregnancy :
Inj. Ceftriaxone 250 mg single IM dose
and
Erythromycin stearate 500 mg orally four times a day for 7 days
Vaginal discharge on speculum examination
Recommended regimen :
Metronidazole 400 mg thrice daily for 7 days
and
Miconazole or Clotrimazole 200 mg
intravaginally once daily for 3 days
or
Clotrimazole 500 mg intravaginally once only
or
Fluconazole 150 mg orally as a single dose
During the first trimester of pregnancy no Metronidazole must be
given, and treatment is by Miconazole only.
N.B. : Tetracycline and Doxycycline should not be used during pregnancy
and lactation.
52
STEPS FOR STD PREVENTION AND MANAGEMENT
Give all patients
1 Treatment
2 Instructions for medication and follow up
3 Education and counseling
4 Condoms
Education and Counselling for patients
1
Cure your infection
2 Do not spread STD
3 Help your sexual partners to get treatment
4 Come back to make sure you are cured
5 Stay cured with condoms
6 Keep safe by staying with just one sexual partner
7 Protect yourself against AIDS
8 Protect your baby - ask your wife to attend ANC during pregnancy
INGUINAL BUBO
Patient complains of enlarged and painful
Inguinal lymph nodes
Take history and examine
I
~
YES
Ulcer(s) present?
Use genital ulcers flow chart
I
NO
_________ I________
Treat for lymphogranuloma venereum
Educate
Counsel
Promote and provide condoms
Partner management
Advise to return in 14 days
I
14 DAYS
_____________ |________________
Responding to treatment
Refer to higher level facility
I
YES
______ x________
Presume cured
STEPS FOR STD PREVENTION AND MANAGEMENT
TREATMENT
Give all patients
Doxycycline 100 mg orally twice daily for 14 days or
Tetracycline 500 mg orally four times a day for 14 days
1 Treatment
2 Instructions for medication and follow up
Alternate regimen:
3 Education and counselling
Erythromycin stearate 500 mg orally
4 Condoms
four times dally for 14 days.
Education and Counselling for patients
If a bubo becomes fluctuant, pus should be aspirated with a
wide-bore needle and syringe every second or third day, until
there is no aspirate. The entry into the bubo should be made
through normal healthy skin. Under no circumstances should
a bubo be incised.
1 Cure your infection
2 Do not spread STD
3 Help your sexual partners to get treatment
4 Come back to make sure you are cured
5 Stay cured with condoms
N.B. : Tetracycline and Doxcydine should not be used during pregnancy
6 Keep safe by staying with just one sexual partner
7 Protect yourself against AIDS
and lactation.
8 Protect your baby - ask your wife to attend ANC during pregnancy
53
LOWER ABDOMINAL PAIN
(Speculum and bimanual examination possible with or without microscopy)
Woman complains of lower abdominal pain
I
Take history and do abdominal examination
g
-Abdominal rebound tenderness?
- and/or guarding?
P
NO
Surgical referral
■
-Last menstrual period overdue?
-Recent abortion or delivery?
-Menorrhagia or metrorrhagia?
Gynaecological referral
NO
-Mucopus exuding from cervix?
-and/or tenderness on cervical movements?
-and/or adnexal tenderness?
-Is temperature 38° C or higher?
YES
-Treatment for PID*
-Examine and treat partners(s)[A]
-Health education and counselling
~
I
Review after 3-7 days
a
NO
t
Adnexal mass present?
Improvement
NO
_______ I____________
Advise patient to return for
re-evaluation if pain persists
YES
V
Refer to higher level care
_______ NO_______
YES
Refer to higher
level care
Continue
treatment
•For patients with IUD, remove IUD 2-4 days after starting treatment
TREATMENT FOR P.I.D.
(Conorrhoea+Chlamydia+Anaerobic infection)
Use this regimen only if patient is well enough
to take food and liquids, walk unassisted, take her medication,
and return for follow up. Otherwise, refer to higher level care.
Single dose treatment for Gonorrhoea
Ciprofloxacin 500 mg orally as a single dose
OR
Norfloxacin 800 mg orally as a single dose
OR
Ceftriaxone 250 mg IM as a single dose
OR
Cefixime 400 mg orally as a single dose
OR
Kanamycin 2 g IM as a single dose
Alternative treatment if single dose treatment is not available
Trimethoprim 80 mg/Sulphamethoxazole 400 mg 10 tablets
once daily for 3 days.
Plus Treatment for Chlamydia
Doxycycline 100 mg orally 2 times daily for 14 days
OR
Tetracycline 500 mg orally 4 times daily for 14 days
Plus Treatment for Anaerobic infection
Metronidazole 400 mg twice daily for 14 days
STEPS FOR STD PREVENTION AND MANAGEMENT
Give all patients
1 Treatment
2 Instructions for medication and follow up
3 Education and counselling
4 Condoms
Education and Counselling for patients
1 Cure your infection
2 Do not spread STD
3 Help your sexual partners to get treatment
4 Come back to make sure you are cured
5 Stay cured with condoms
6 Keep safe by staying with just one sexual partner
7 Protect yourself against AIDS
8 Protect your baby - ask your wife to attend ANC during pregnancy
N.B. : Tetracycline and Doxycycline should not be used during pregnancy
and lactation.
54
n
SCROTAL SWELLING
Patient complains of painful swelling
I
—
Injury to scrotum
Refer to higher level facility
NO
_____________1_______________
-Reassure patient and educate
-Promote and provide condoms
Swelling of scrotum
j
YES
|
Testis rotated or retracted
- Treat for gonorrhoea and chlamydia
- Educate
- Counsel
I
YES
_________I__________
- Promote and provide condoms
- Partner management and treatment
- Return In 14 days
Refer immediately to higher level care
14 DAYS
_____ i______
Tenderness and swelling confirmed
I
TREATMENT
I
YES
NO
♦
Ciprofloxacin 500 mg as a single oral dose (make sure that the patient
swallows the tablets under supervision).
Alternative regimen
Ceftriaxone 250 mg IM as a single dose
OR
Cefixime 400 mg in a single oral dose
OR
Kanamycin 2g IM as a single dose
Recommended regimen for Chlamydial urethritis :
Doxycycline 100 mg orally twice daily for 10 days (make sure that the
patient receives 20 tablets or capsules with instructions to take one
tablet in the morning and one in the evening).
Cured
♦
Refer to higher
level facility
STEPS FOR STD PREVENTION AND MANAGEMENT
Give all patients
Alternative regimen
Tetracycline 500 mg orally 4 times a day for 10 days or
Erythromycin 500 mg orally 4 times a day for 10 days or
Sulfisoxazole 500 mg orally 4 times a day for 10 days (equivalent
doses of other sulfonamides may also be used).
1 Treatment
Supportive therapy
This is a painful condition and supportive therapy with
- Bed rest
- Scrotal elevation with a scrotal support and analgesic is essential part
of management
- Advise the patient to take all his tablets and inform him about the
mode of transmission of STD and the possible complications of
infection and, in particular, epididymo-orchitis.
Education and Counselling for patients
N.B. : Tetracycline and Doxycycline should not be used during pregnancy
and lactation.
7 Protect yourself against AIDS
2 Instructions for medication and follow up
3 Education and counselling
4 Condoms
55
i Cure your infection
2 Do not spread STD
3 Help your sexual partners to get treatment
4 Come back to make sure you are cured
5 Stay cured with condoms
6 Keep safe by staying with just one sexual partner
8 Protect your baby - ask your wife to attend ANC during pregnancy
Case Studies
Dear Participant
Here are some case-studies,
Work on them using flow-chart and decide on the
management.
Case Study 1
Mr. A. says that he has a discharge from his penis. When you ask him to milk his urethra,
you notice a slight discharge at the meatus. He has no other lesion.
Case Study 2
Mr. B. reports with complaint of sore penis. On examination, you see an ulcer on the
penis but no discharge.
Case Study 3
Twentyfive year old Miss C. tells you that she has a genital discharge for the past four
weeks.
Case Study 4
Mrs. D., a housewife, complains of pain in her lower abdomen. Her periods are normal
and she is not pregnant. A week later, she returns along with her husband saying that
she feels no better after taking the drugs you gave her. This time she also has high fever.
56
Session 5
PREVENTIVE COMPONENTS OF
QUALITY CARE OF STD
General objective
The General Practitioner should be able to appreciate the role of prevention in control of
transmission of Sexually Transmitted Diseases.
Learning objectives
Identify the four preventive components of Quality Care of STD,
namely partner treatment, follow-up, compliance and condom
use and
Describe at least two approaches for partner treatment,
compliance and follow-up of STD patients
Total Treatment for STD
There are many measures of preventing STD conditions like being faithful to one partner,
reduction of sex partners and use of condoms. However, ensuring quality treatment for
STD is also one equally important way of controlling STD infection.
We will discuss
briefly in this chapter the role of ensuring quality in rendering STD treatment and how
to achieve the same.
Roles And Responsibilities of the General Practitioner in
rendering Quality STD care for prevention of STD
•
To ensure that the patient has taken full course of treatment
prescribed by the GP, i.e. comply with the drugs prescribed
57
Treatment of partners for the same STD condition and initiate the
treatment of the partner at the same time as the patient
Do follow-up of the patient to ensure that there is total cure of
the condition, not only disappearance of syndromes
Refer the patient to an STD specialist if there is no improvement
after treatment OR development of complications such as
superadded infection or sequel of the condition
The General Practitioner should be able to appreciate the role of prevention in the care
of STD. Since STD spread rapidly and need extra care during treatment for preventing
re-infections, the GP has to assure that there is
•
Completion of treatment by the patient,
This will prevent
patient from developing drug resistance
•
No opportunity for re-infection of the patient during treatment
by blocking the other natural sources of infection i.e. treating
partners concurrently
•
Adequate response to treatment by following up the patient to
ensure that the patient is totally disease free
•
No recurrence of symptoms or non-response even after
completion of treatment and that no complications such as
urethral stricture or tubal block are developed by the patient
subsequently
Advantages of prevention
•
Compliance
with
treatment
will
prevent
patients
from
developing drug resistance to common STD drugs
•
Partner treatment will break the cycle of infection-re-infection
from and to the patient and spouse. In the case of non-regular
sex partners, if treatment of such partners is possible, it will
prevent the infection from spreading to other sexual partners of
the non-regular partner, e.g. in the case of commercial sex
workers to the clients
58
•
Follow-up will ensure that there is total elimination of the
organisms, especially if the diagnosis can be clubbed with
appropriate laboratory- testing for the presence of the organism
•
Referral to higher centres for sequels of STD or for resistant cases
will help in patients developing confidence in the treatment of
the GP
Problems in implementation of prevention measures
*
These have been described under the chapter of problems in STD case management. To
reiterate, the most important problem relates to partner treatment (how to inform the
partner of the STD condition without arousing suspicion, how to convince the
asymptomatic partner about the need for treatment).
Other ones are pertaining to follow-up since the patients, for reasons of anonymity,
prefer to travel long distances to seek treatment and may therefore be not willing to
come back for a follow-up again.
Problems in compliance relate to the high cost of drugs and to the disappearance of
symptoms even within a few days of treatment and the patients being not convinced of
the need to complete the treatment.
Referral to higher centres may prevent patients from losing confidence in the GP.
Conclusions
To summarise, prevention through the above measures will ensure reduction in
transmission of STD and consequently HIV infection to a large extent.
59
e
Module III
r-
Condom Promotion and
Behavioural Change
Communication
fe
■
■Si
■'
1
ft
60
i'■
-
'•
Session 6
CONDOM PROMOTION
General objective
To motivate medical practitioners to promote preventive
measures in STD quality care
Learning objectives
To appreciate their opportunities for condom promotion and
educate the patient for correct and consistent use of condoms
To equip medical practitioners with basic counselling, and
Behavioural Change Communication (BCC) knowledge to use in
diagnostic and treatment procedure and to have a non
stigmatized approach
Role and Responsibilities of General Medical Practitioners
To utilise counselling and communication skills in STD quality care
To motivate patients to accept and adopt preventive behaviour
To promote the use of condom as part of treatment
The need
just as we search for administering ways for preventing diseases, at present one of the
most important ways for preventing STD is to promote the use of.condoms. It is a fact,
anyone who is having STD and who has had multiple sex partners is said to have high
risk behaviour. Behaviour or habits cannot be changed overnight, and it is not easy to
motivate people with high risk behaviour to abstain from sex or stick to one partner.
They will not follow the advice of even a doctor. Hence, it is essential to advise use of
condoms if we have to control STD and prevent HIV spread.
61
r\
What is condom?
It may be surprising to know that there are many who have not seen, touched, or
used a condom.
Even doctors and paramedical workers are ignorant about the
qualities of condom. They fail to recognise importance of correct and consistent use of
condoms.
This makes it imperative that doctors must explain about condom and
demonstrate how to use condom to the patient and should not take it for granted that
people know about it.
Condom is a rubber sheath, easy to use on the erect penis. While having an intercourse
semen is collected in its tip.
So fertility cannot happen and infection cannot be
transmitted both ways.
Why should one use a condom?
•
To prevent unwanted pregnancy
•
To protect oneself and partner against sexually transmitted
diseases (STD) including AIDS
62
/>
Why people do not use condom - Misconception
Reasons for not using Condom and Misconceptions about using condom
Belief
Reason
How to overcome
1.
Using condom during
sex is irritating
• Not knowing how to
use the condom
• Eradicate wrong belief
and demonstrate how
to use condom
2.
Condom will tear during
intercourse
• If one uses old condom
this could happen
• Show different condoms,
new and old (one with
expiry date passed)
3.
Condom is sticky and oily
• Sexual intercourse also is
• Educate
sticky due to the semen.
The feeling that condom is
an outside thing not part of
body makes it so.
4.
Condom reduces sexual
pleasure
• Lack of enough practice
of using condom
• Educate and demonstrate
5.
Women do not like it
• Women like what men like
• Ask women to educate
6.
Erection goes before
using condom
• Ignorance in using condom • Educate and demonstrate
Who should use condom?
Condoms are meant for the people in their reproductive age group to use it either as a
contraceptive or as a protection from contracting STD/HIV. Condom must be used by a
person who is involved in multipartner sex, or who goes to sex workers. Multipartner
sex means one having sex with different partners at different times like a sex worker.
63
How to use a condom?
Care should be taken while using condoms because improper use can damage the
condom resulting in contracting the virus or unwanted pregnancies.
The following
instructions need to be followed while using a condom.
•
Do not open the packet until the penis is fully erect
•
Open the packet carefully without damaging the condom
•
Do not unroll the condom before putting it on
•
Place the condom at the glans of the erect penis and while still
holding its tip unroll it over the full length of the erect penis.
The tip has to be pressed tightly to squeeze out the air before
unrolling over the penis
•
During intercourse make sure the condom stays in place
•
Immediately after ejaculation, the penis must be withdrawn
when it is erect by holding the ring of the condom at the base of
the penis
•
The condom should be carefully slipped off the penis with the
reservoir tip aimed downwards to avoid spillage
•
Dispose it off promptly by making a knot at the base and
throwing it into the garbage, flushing it into the toilet or burying
it. DO NOT REUSE THE SAME CONDOM
There are many who have had experience of failure in using a condom. They need
motivation and encouragement in using condom. Dispel all myths attached to the use
of condoms.
Doctor's role in condom promotion
Health education needs to be a part of treatment with following information
•
Explain the need for use of condom as a part of treatment
Prescribe condom to overcome embarrassment
64
Distribute condom, if possible
Display condom and information on STD prevention
Explain and demonstrate how to use the condom, if the person
is ignorant about it
Casually speak openly about it
Explain need for correct and consistent use of condom in STD
treatment
Information needs to be displayed as well as distributed - information on STD,
condom etc.
Other information on condom
To be given to the patients, this could be displayed -
•
By posters / charts
Given in hand bills
Shown in flash cards
Who should use condoms
ns*
Different types of condoms
US’
Where can one get condoms
US’
When to use condoms
US'
Quality control of condom
How does one know if a condom is of good quality?
This is very difficult to assess individually for each condom. Use the condom before the
expiry date and within two years of the manufacturing date.
At the time of use, check for any visible tears, nicks, or melting, and if present, do not
use that condom. When you buy a condom check for expiry date.
65
Can a condom be reused?
Each condom is for one use only.
No.
After use, a condom must be disposed off
promptly and properly.
Does the use of a condom reduce sexual pleasure?
Condoms do not reduce sexual pleasure, because sexual pleasure is a perceived pleasure.
Psychologically some people perceive a loss of pleasure when using a condom.
Ribbed/Dotted/Scented/Flavoured condoms, for example, are known to increase sexual
pleasure. Main problem is lack of practice and perceived uneasiness in using condom.
How should condoms be stored?
Condoms should be protected from heat, direct sunlight, pressure, and mechanical
damage. Unused condoms should be discarded if they have crossed the expiry date.
One should have one or two condoms available to use it when having sex. Women who
have multipartner sex may always keep a few ready and motivate their male partners to
prevent the spread of STD/HIV.
Use another condom if it
•
Is tom or its packaging is damaged
Has crossed the date of expiry
Is uneven or has changed in colour
Feels brittle, dried out, or very sticky
Where condoms can be obtained?
Condoms are available at Primary Health Centres (PHCs), shops and with NGOs.
However, due to shyness many do not dare to ask for one. Now costly condoms are
available in many brands.
But many do not know that low cost condoms are also
66
I >
available. People would freely buy condom if there is a sanction from the society, or if it
is available liberally everywhere.
What are the different brands of condoms available in India and
how much do they cost?
The condoms available in India are Nirodh, Delux Nirodh, Kamasutra, Fiesta, Kohinoor,
Moods, Mejestic Midnight Cowboy, Adam and many others. The price of these ranges
from Rs. 2 to Rs. 10. There are also a number of imported condoms available in India
which cost more than Rs. 10.
Nirodh - 3 for 50 paise, Delux - Five for 2 Rupees, Super Delux Nirodh - Four for Three
Rupees and others are from Rs. 6 to Rs. 20 depending on the quality, quantity and brand.
Is it okay for an HIV infected person to have sex using a
condom?
Yes, it is okay. When a person who is HIV positive, decides to have sex, it is that person's
responsibility to insist on the use of a good quality condom for every sexual act, as this
reduces the risk of spreading the infection.
Are there condoms for women?
Yes. There is a condom called Femidom. At the moment, it is very costly. It is not yet
marketed in India. Improvements on it are being worked out for universal acceptability.
67
CORRECT USE OF CONDOMS
Fig-8
1 Open the pack carefully
without damaging the
condom. Wear the conddm
only after penis becomes
fully erect
2 Press the tip of the
condom and fix it on the
erect penis
3 Hold the tip of the
condom
and slowly
unroll it to full length so
that
the
penis
is
completely covered
4 Ensure that the condom
is in position before
commencement
of
sexual intercourse
5 After ejaculation hold the
bottom of the condom
and gently withdraw the
penis
6 Remove the condom
carefully without spilling
the semen
US’
Always use condom during sexual intercourse
Dispose off used condoms and do not reuse
them
BS3
7 Dispose off the used
condom in the garbage
bin. Do not reuse
Use condoms within the expiry date
Before use ensure that the condom is intact
and undamaged
68
/>
Session 7
COUNSELLING AND BEHAVIOURAL CHANGE
COMMUNICATION (BCC)
General objective
•
To motivate medical practitioners to promote preventive
measures in STD quality care
Learning objectives
To equip medical practitioners with basic counselling, and
Behavioural Change Communication (BCC) knowledge to use in
diagnosis and treatment procedure and to have a non
stigmatised approach.
Role and Responsibilities of General Medical Practitioners
To utilise counselling and communication skills in STD quality care
To motivate patients to accept and adopt preventive behaviour
Introduction
Taking patient's history, diagnosing the disease and prescribing treatment are routine
work of any medical practitioner.
While this is easy for most diseases, for certain
stigmatised diseases like sexually transmitted diseases (STD), getting history and
motivating patient to follow treatment needs slightly more careful approach.
These
diseases are influenced by many cultural, social norms and beliefs and therefore patients
coming for treatment or even completing treatment feel inhibited. It is a very sensitive
and personal topic with several social and psychological barriers specially when we
69
<\
discuss about sex. To overcome this problem medical practitioners have to act not only
as doctors but also as motivators (for partners to seek treatment), supporters and
counsellors for continuing treatment and completing the same.
This needs careful
handling and for this, counselling and behavioural change communication methods
provide information and skills to the health providers.
Why doctors?
Doctors have a unique position in people's life.
Even in these modern days doctors'
words are equal to God's words, because of the respect and belief people have in them.
It is also a fact that most STD patients go to general practitioners and less than 20% only
go to STD specialists. Also people are careful in choosing their doctor and have chosen
you among others for their own reasons. They want care and are worried. They tend
to trust the doctor and try to follow his/her advice and are grateful. So it is the duty and
social responsibility of the doctor to give the best full treatment. Doctors could utilise
this opportunity and motivate them to complete treatment as well as change behaviours
for preventing re-infection and spread of STD/HIV/AIDS.
Counselling and BCC as a part of treatment process
Medical practitioners, in order to have maximum number of patients, find it difficult to
spend reasonable time with patient.
So the aim of this training is not to produce
counsellors but effective health providers who could use counselling and communication
skill while diagnosing and discussing with the patients.
Counselling is defined as a therapeutic communication (dialogue) between patient and
the doctor, aimed at enabling the patient to understand the nature of his/her illness,
causes, options for treatment, to take personal decision relating to their life style.
ATTENTION to patients and LISTENING to their doubts, fears and giving appropriate
RESPONSE are the core of counselling, besides observing confidentiality.
70
f >
Behaviour Change Communication (BCC)
Behaviour change communication helps the patient to understand the role of behaviour
(life style) in promoting health and the need to change it as a part of treatment.
•
Brief intervention studies in general practice have shown that five
to ten minutes of simple advice by a general practitioner and a
leaflet can motivate patient to change behaviour and follow
healthy life style.
As illustrated an iron rod be bent easily when it is red hot. In the same way a STD patient
when he comes to the doctor is "red hot", he needs treatment, and he can easily be
influenced by the doctor. All that the doctor has to do is to give a few tips, a few helpful
words. These not only awaken the person to facts but motivate him to change his
behaviour.
These could be imparted through
•
Communication skills - forming relationship
Building concern for change in the patient
US1'
Attend
■>
Patient
Doctor
Listen
<■
Understand
Doctor - Patient relationship
The doctor has to build a fruitful relationship with the patient by spending sufficient time
for attending, listening and understanding the need of the patient, if a change is
expected.
By listening to the fears and doubts expressed by patient, identify them and respond
empathically if needed. Some tips on effective and non-effective responses :
71
Verbal and Non Verbal Responses
Non Effective Responses
Effective Responses
Tone :
Tone :
Positive, assured, receptive,
encouraging, accepting
Unpleasant, cynical, judgemental, making fear
Facial expression :
Facial expression :
Open, caring, pleasant
Looks away, frowns, yawns, looks at watch
Look directly with concern
Show attention to what is being said,
Controlling, commanding
nod, acknowledge
Verbal expression :
Verbal expression :
Answer clearly to the question
Speaking too quickly
Open-ended questions, summarizing,
Directing question
Encouraging
Advice labelling and
Repeating the message
moralising
Non-stigmatised approach
Some of the attitudes of health provider can block the communication and the doctors
need to be aware of their own attitudes that can both motivate patients to come as well
as turn away the patients from them. Some such examples are given below :
"STD is a disease like any other disease"
•
"Anyone with STD is a sinner. There are many innocent victims
of STD"
•
"I will not treat an STD patient, I am not like that"
"Women never follow Doctor's instructions"
Only through non-stigmatised approach could a doctor encourage patients to come and
complete the treatment.
72
/>
Health providers feel that treating STD patient will stigmatise them.
When treating a patient with confidentiality there is no need for others to know about
the disease being treated. The health providers need to realise this and change the
attitude in view of the fact that in the coming years STD will be one of the highly
prevalent diseases in our country.
Giving information
•
Provide only relevant factual information
•
Give the information clearly with simple language
•
Do not give unwanted or controversial issues
•
Create concern for the disease. It is stated that people will
change and adopt preventive practices when they realise that
they are susceptible to a serious disease.
Motivate them with encouragement and support to change
risky behaviour
"Harm Reduction" is a part of STD control method. When patient is ready to
change he needs support which is not available in the environment, e.g. accessibility to
STD clinics.
The patients need knowledge and skill to use a condom and also how to buy it without
feeling embarrassed. Doctors' few words of encouragement can embolden them to buy
and use condom.
Medical practitioners should follow up the patient over a period to sustain these changes.
Who needs special attention
Patients who come for the first time for treatment
Patients who come for second time with STD (no change in
behaviour)
73
✓
Persons who are young, have a life style or a job that promotes
risky behaviour
Women who come with STD/RTI (Reproductive Tract Infection)
problems
Before and after lab testing for STD/HIV (suspected persons)
Women who come for ANC/PNC or FP - whose husbands may
have high risk behaviour
Information to be given and counselling
1.
Basic information on STD - transmission, link HIV/AIDS and need to control
2. Treatment procedure
Drugs compliance
Prevention of reinfection
Follow up of treatment
3. Compliance to treatment regimens (to explain to patient)
Importance of taking full treatment
•
Adverse effect, if not followed
Possible drug resistance
4. Prevention of Reinfection of STD (to explain to patient)
Safe sex behaviour
•
Abstaining from sex till full cure
Not having penetrating sex
Use of condom - correctly and consistently
Concurrent partner treatment
74
/>
5.
Partner treatment - Importance of concurrent treatment of partners who may also
be infected. So to prevent reinfection both persons should be treated concurrently.
6.
•
Problems of partner treatment
•
Compliance with treatment of partners
Follow up : The importance of follow-up and coming back to doctor
•
To clarify doubts
•
To assess the prognosis of disease
•
To reinforce prevention practices
•
To check any reinfection
7. Testing for STD/HIV/AIDS
Blood test is not available for all STD conditions
Blood test is available for HIV, but only with informed consent
•
Pretest counselling, a requirement for HIV/AIDS testing - this
involves the following
US’
Giving full information about STD/HIV/AIDS to the patients - its
consequences
US3
Consequence of test result, if it is positive and negative (Window period)
US’
Need for prevention of reinfection
US3
Need for change in behaviour
US3
Who will help the person if he/she is HIV positive
■st Partner treatment
US’
Opportunistic infection of HIV/AIDS, Psycho-Social consequences
and need for support
Referral - In case counselling or treatment is not possible the
doctor is responsible to refer the patient to another doctor, viz.
Specialist centre
csr Counsellors/Psychologists/Psychiatrists for the treatment
75
Module IV
HIV/AIDS in
General Practice
76
</
Session 8
CLINICAL FEATURES AND MANAGEMENT OF
HIV/AIDS
General objective
To acquaint the General Practitioners with medical, social and ethical aspects of HIV/AIDS
in the medical practice.
Learning objectives
At the end of the session, the participant will be able to
•
List clinical features of HIV/AIDS; and
Describe general principles of management of HIV/AIDS
Role and Responsibilities of G.P.
To be able to identify the clinical presentation of HIV/AIDS
•
To take responsibility for clinical management of HIV/AIDS
To manage HIV positive patients including preganant women in
their families in an empathetic and responsible way
Present prevalence studies conducted periodically by the State AIDS Control Society
(TNSACS), Chennai, suggest that HIV prevalence among patients attending STD clinic
could be between 14-15
percent. APAC conducted community prevalence study of
STD including HIV and the result is that HIV prevalence in the society is 1.8% among
15-45 age group which also means that one or two out of 100 people in our society
77
are likely to be a carrier of HIV infection. A general practitioner treating around 2000
patients a month could have attended, without ever knowing, on some HIV sero
positives. But this need not cause any alarm. The G.P. should keep his/her mind open for
this possibility and should suspect HIV disease as a possibility in certain clinical
presentations beside following certain precautions to prevent spread of infection in the
hospital/clinic setup.
It is important for General Practitioners to note the following points :
To recognize STD as a possible co-factor for easy spread of HIV
infection in the society and hence treat the patients as early as
possible (including the spouses)
To follow universal precaution in dealing with open wounds,
body fluids, skin piercing or invasive techniques
To speak about HIV and promote condom usage to those who
are likely to be at risk due to their behaviour
To minimize blood transfusion to the barest minimum to
encourage voluntary donors and to insist on testing every unit of
blood for HIV before transfusion
•
To suspect HIV infection as a possibility in certain clinical
presentations
To know when and how to call for a HIV test as well as when not
to test for HIV
Clinical spectrum of HIV infection
Infection runs a very prolonged clinical course, ranging from "Acute Syndrome"
associated with primary infection to asymptomatic state and onto advanced immuno
compromised state.
78
According to the CDC classification, HIV infection is divided into :
Group I
Acute HIV Syndrome
Group II
Asymptomatic Infection
Group III
Persistent Generalised lymph-adenopathy
Group IV
Advanced disease presents as
Constitutional diseases
•
Neurological diseases
•
Secondary infectious diseases
•
Secondary neoplasm and
•
Opportunistic infections
The acute HIV syndrome may be present in 50 to 70 percent of people with infection,
usually 3 to 6 weeks after primary infection. The patient may have fever, pharyngitis,
headache or myalgia with occasional skin rashes or lymph-adenopathy. All these are
transient and self-limiting.
In India, a G.P. coming across these complaints is likely to mistake them for other
common ailments. Besides, HIV test may not yet be positive at this stage (Window
period).
They make a spontaneous recovery, and hence testing is not indicated.
The asymptomatic stage (clinical latency) ranges between 3 and 7 years or more. While
active viral replication with associated T4 lymphocyte depletion is going on one side, the
patient enjoys apparent health. Because the patient looks and feels healthy and also this
being the most prolonged part of the disease spectrum, virus spreads from this
patient to others most efficiently during this period. Sexual activity, drug addiction, with
79
needle sharing, blood donation as well as marriage and conception all take place during
this period and the only way to know patient's infective status is through blood tests.
Stage of generalised lymph-adenopathy : This is indicated by the presence of enlarged
lymph nodes (>lc.M) in 2 or more extra inguinal sites for more than 3 months without
any obvious cause. It should be remembered that HIV infected patients with generalised
lymphoma, are also not uncommon in HIV disease. Persistent Generalised Lymph
adenopathy is actually an immunological response by the reticulo-endothelial system to
HIV infection with an attempt to arrest the virus in the lymph nodes. PGL actually means
that patient is immuno-competent. But when immunity fails, it is preceded by regression
of the lymphnodes. Thus, in HIV disease spectrum, regression of lymphadenopathy is not
a good sign.
Advanced Disease Stage
This may present with major or minor signs.
The common major signs are
Unexplained weight loss of more than 10 percent of known
original body weight
•
Recurrent or persistent diarrhoea of more than a month's
duration
Persistent or intermittent low grade fever of more than a month's
duration
Unusual respiratory diseases - either chronic or recurrent
Neurological disorders - particularly dementia
Common minor signs are
Oral candidiasis - Characterised by glossitis with whitish plaques
in mouth and even in oesophagus
Oral Hairy leukoplakia (OHL) characterised by vertical whitish
striations on the sides of the tongue
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\
•
Preuitic dermatoses without specific cause
•
Multi-dermatomal Herpes Zoster
•
Extensive bacterial or fungal infections of the skin
According to NACO (National AIDS Control Organisation),
New Delhi, a HIV
seropositive person having two or more major signs with at least one minor sign can be
considered as suffering from AIDS.
This is not a very scientific way of diagnosing AIDS, but in the absence of more sensitive
and specific scientific technologies in India, this principle appears more suitable.
Besides the above so called major and minor signs, disseminated tuberculosis as well as
extra pulmonary tuberculosis should be viewed with suspicion.
Kaposi's sarcoma is very rare in India and diagnosis of Pneumocystis Carini Pneumonia
is also very difficult. Hence these points are not stressed in our set up.
Management
General
The most important component of Mangement is counselling. Patient should be
reassured at the same time, as he is being informed of his condtion. Sympathy,
confidentiality as well as reassurance go a long way in helping the patient face his plight.
Medical
This is directed toward HIV infection as well as opportunistic infections. Among the three
drugs that are of some effect against HIV (Azidothymidin (AZT) DDI and DDC) only AZT
is available in India. Given alone, it can lead to bone marrow depression while it only
temporarily suppresses HIV replication. Severe interaction with other common drugs is
also known. Hence one should consider the advantages and disadvantages in a given
case before venturing to prescribe this drug. Close monitoring is necessary for the
patient while receiving the drug.
81
The better method of management is addressing the opportunistic infections, most of
which are treatable.
Diarrhoea responds well to rehydration and administration
of
common anti diarrhoeals.
Respiratory infections are best managed by Tab. Cotrimoxazole
while antituberculosis therapy takes care of tuberculosis (as
effectively as in HIV negative patient).
Candidal glossitis is best controlled by clotrimoxazole mouth
paint or oral ketoconozole/fluconazole tablets.
Pruritic dermatoses respond to oral anti-histaminics and external
application of calamin lotion/liquid paraffin.
Infections are treated by appropriate antimicrobials and suitable
topical applications.
AIDS patients should not be refused treatment and can also be managed as outpatients.
Claims about cure of AIDS made by certain Traditional/Siddha Physicians in India are not
yet substantiated scientifically. Some practitioners misuse the opportunity and exploit
AIDS patients of magic cure.
Good balanced nutrition appears to prolong life. Rest and relaxation have improved the
condition of the AIDS patients. Meditation and Yoga were found to be useful in
controlling emotional stress and in confidence building.
82
ft
Session 9
UNIVERSAL BARRIER PRECAUTION IN
GENERAL PRACTICE
General objective
To acquaint the General Practitioners with medical, social and ethical aspects of HIV/AIDS
in their medical practice.
Learning objectives
At the end of this session, the participant will be able to
List Universal Barrier Precautions to be taken against all routine cases in their General
Practice.
Risk of HIV transmission in a health care setting
Transmission of HIV in a health care setting can occur from patient to health care worker,
between patients, or from health care worker to patient.
Patient to healthcare worker transmission. HIV transmission from
patient to health care worker can occur when the health care
worker is exposed to the blood of an HIV-infected person. An
example of this is parenteral exposure, such as a needle stick
injury.
HIV transmission can also occur through mucous
membrane contact, such as a splash of blood into the health care
worker's eye or mouth. Non intact skin contact can be a point
of HIV entry such as a splash of blood onto open wounds or
broken skin due to dermatitis, acne or chapped skin
83
/ >
•
Patient-to-patient transmission. Patient-to-patient spread of HIV
infection is usually by an indirect route. This transmission can
occur through blood-contaminated needles, syringes or other
equipment which have not been properly sterilized or disinfected
before use.
Patients can also be infected when they receive a
transfusion with contaminated blood or blood products
Health care worker-to-patient transmission. Transmission of HIV
from health care worker to patient appears remote and has only
been suggested in one instance
Universal precautions
Purpose
The purpose of universal precautions is to prevent transmission of
infection from body fluid and blood-borne pathogens. All health
care workers should adopt universal precautions with blood and
body fluids of all patients when there is a risk of direct exposure
to any blood or body fluids, regardless of whether HBV, HIV or
any other infection has been diagnosed in the patient. Universal
precautions should be applied because the healthcare worker
may not know who is and who is not infected.
Why ' Universal"?
Althouth the actual number of asymptomatic HIV infected
persons is not known, it is much larger than the number of
reported cases of AIDS. Patient history-taking and examination
cannot identify the majority of patients infected with HIV, HBV or
other body fluid or blood borne pathogens.
However, even
though there are no signs, infections can still be transmitted.
Also, a person when tested may be negative (in the "window
period") but infective. It is, therefore, essential to implement a
programme of infection control precautions that is used
consistently with all patients and in all healthcare settings.
84
UNIVERSAL BARRIER PRECAUTIONS
«
PROTECTS
PROTECTS
PROTECTS
PERSONNEL
PATIENT
COMMUNITY
Universal blood and body fluid precautions involve
•
Wearing gloves if there is a risk of contact with blood and body
fluids
•
Wearing eyeglasses or goggles, mask and / or gown if there is a
risk of splashing of blood or body fluids; and
•
Always washing hands before and after patient contact and on
removal of gloves
Infection Control precautions are
intended to isolate the virus and
the body fluids, not the patient.
r
Hand washing
•
Use running water
•
Liquid soap preferred to solid soap
30 seconds washing in running water - removes transient flora
Work surfaces
•
Sodium Hypochlorite 0.5 to 1 % for surface disinfection
Other precautions
•
Cover-cuts, abrasions with water proof dressings
•
Do not pass sharp instruments hand to hand
•
Do not use hand needles
85
•
Do not guide needle with fingers
Do not resheath needles
Disposal of hospital waste/disposables
SHARP INSTRUMENTS INTO APPROVED CONTAINERS
CLINICAL WASTE
DISPOSABLES
INTO WASTE BAGS
♦
SENT FOR INCINERATION
Disposal of infectious waste
Infectious wastes divided into the following two categories and disposed off as
mentioned below :
SHARPS
NON SHARPS
Into puncture-resistant
Organic Waste
Non-Collapsible
1) Dressings
container
Tissues
Placenta, Umbilical cord
Blood bags
IV lines, other catheters
• ALL INCINERATED
2) Blood, Urine, Stool
• DOWN DRAIN
86
f \
«
Session 10
SOCIAL AND ETHICAL ISSUES IN HIV/AIDS
General objectives
To acquaint the General Practitioners with medical, social and ethical aspects of HIV/AIDS
in their medical practice.
Learning objectives
At the end of this session, the participant will be able to
Recognise Social and Ethical issues arising in Diagnosis and Management of HIV/AIDS
Role and responsibilities of G.P.
•
Willingness to treat HIV/AIDS patients
•
To be aware of the need for counselling before HIV testing
•
To maintain confidentiality
•
To protect patient's rights
Social, Ethical and legal issues in HIV/AIDS control
What are the Social Issues in relation to HIV infected persons?
HIV/AIDS infection is more than a medical problem. Its association with sexuality, illness
and death often produces strong feelings. The social issues or the problems generated
in the society are mostly due to ignorance (myths and beliefs), cultural background and
indifference to issues affecting health in general. Taboo in relation to sexuality, I.V. drug
use, selling blood for earning livelihood, sex with partners other than marriage partners
often lead to disease and stigma. People infected with HIV or suffering from AIDS have
87
the same dignity and human rights as any other person. As medical officer or in private
practice one should be aware of social, ethical and legal issues related to the HIV
infection and AIDS so that you can educate the community regarding the need to
promote confidentiality of the affected. It is also important that one should educate the
society to avoid stigmatizing and discriminating against the affected individuals. It will
also help to protect one from being penalized against consumer rights.
Emotional problems of those infected with HIV/AIDS
•
Fear of dying, particularly alone
•
Loss of livelihood and ambitions and physical distress
Grief - losses they have experienced or are anticipating
•
Guilt of having infected others, sadness of family
•
Depression - Absence of cure
•
Denial of status and social responsibility
Anxiety - prognosis, rejection, concern about confidentiality
•
Anger - unlucky to catch the infection
•
Suicidal activity - way to avoid pain
(
Loss of self esteem - rejection by colleagues, family memebrs
•
Spiritual concerns - impending death, loneliness etc.
How to protect Human Rights, Discrimination and Isolation of
HIV/AIDS cases?
Worldwide, many people infected with HIV or who have AIDS are denied of their human
rights. Some are put into quarantine, imprisoned or forcibly tested. People have been
deported or denied entry into countries. There are instances where people have been
denied housing, employment or schooling or have not received care and treatment. It has
also been seen that details regarding HIV positive individuals have found prominent place
in media coverage exposing them to social identification and have also been subjected
to these abuses. A major challenge to the AIDS epidemic is to stop these abuses.
c
88
It is, therefore, important that respecting, promoting and protecting human rights are
as important as providing care to HIV positive persons.
In what way human rights are interfered with?
The form in which the human rights get interfered with is :
Discrimination and isolation: It has been seen that people are unfairly treated, because
of fear, ignorance or prejudice or may experience discrimination, because they are poor
or disadvantaged. The other great problem is that some risk groups like commercial sex
workers, injecting drug users and professional blood sellers come from sections of
population belonging to low income or poor classes. The addition of poverty and
discrimination due to their disease status induces a phenomenon of "Double
discrimination". This leads to stigmatization and additional social consequences.
The other
discrimination could be in the nature of denial of housing, employment,
education.
Being socially isolated can produce psychological feelings. This has been documented in
many cases.
What are the important ethical issues in HIV?
The most important area in relation to ethical issues has been in terms of testing for HIV
status.
The development of a test in
1985 to detect HIV infection in individuals for blood
donation who showed no signs of disease was an important landmark in AIDS epidemic.
It opened the way to protect the blood supply and allowed the identification of people,
who while apparently healthy could transmit the infection to their sexual partners and
needle sharing partners and in case of women to offspring. It did not take long to
understand that this technical advance had two aspects. One - it could make an
immense contribution to slowing the infection spread. Another - it could expose HIV
infected to stigmatization, discrimination and even loss of freedom.
89
This has resulted in a variety of official policies on HIV screening as part of national AIDS
programmes. For example in Swedish bylaw, sexual contacts of HIV positive individuals
are to be tested. In U.S.A though the policy is that there should be specific informed
consent of patient for HIV testing, testing is carried out even without consent.
Should premarital HIV testing be done?
This cannot be made mandatory as it would undermine confidentiality as a pre-requisite
for testing. But if individuals request consent to voluntary testing, it should be
encouraged.
If a husband and/or wife is HIV positive, should the couple have
a child?
It is better that they do not, as it is possible that the child born to them will also be HIV
positive (although this is not always the case). They could instead be advised to adopt
a child.
Can two HIV positive people get married?
Yes, surely, if they wish to. They must, however, practise safer sex using condoms to
prevent re-infection with HIV.
What are the laws concerning the official policy in India with
regard to testing?
There are variety of laws concerning the official policy with regard to testing varying
from
Mandatory testing of blood and blood products for transfusion
Testing only in high risk groups with consent
Unlinked anonymous screening for research purpose
Testing for people demanding voluntarily with pretest counselling
90
Are there other ethical issues, in relation to HIV/AIDS?
Yes - the other issues are :
•
Confidentiality about revealing the test results to patient,
spouses, employer etc.
Exclusion of HIV positive individuals from occupations involving
high risk practices like health care workers with procedures
Testing of new drugs and discoveries being claimed to cure the
disease
•
Conducting behaviour and intervention research into, and
revealing the identity expose them to social stigmatization
All these issues must be kept in mind while dealing with HIV/AIDS cases to avoid
stigmatization, discrimination and isolation.
How can medical personnel / medical institutions be held
responsible in ensuring that uninfected blood / blood products
and equipment are used?
Multipronged measures would be required.
Medical personnel / medical institutions should be increasingly
made aware of their responsibilities
•
It must be made mandatory for all manufacturers to screen blood
products for HIV
•
Consumer awareness and activism should be developed and
encouraged
•
Resorting to litigation in cases of negligence and malpractice
would
lead to accountability of medical
institutions
91
personnel and
Exercises for group work
Case Study - 1
Mr. X is a leading businessman in Bangalore. His only son is married and looking after
the business establishment. He has a lovely wife. Daughter-in-law is a nice girl and lives
with the family. The grandson is aged 2 years and very much attached to Mr. X. He
spends considerable time playing with him. In general his home is like heaven and
everybody is peaceful and happy.
Suddenly he falls ill and doctors after detailed investigations, recommend by-pass
surgery of the heart. He undergoes surgery and recovers. Every member of the family
looks after him very well and he becomes normal. He continues to support his son in the
business and leads a happy family life. During one bout of illness, he is tested for HIV and
is declared by the doctor that he is suffering due to AIDS. He is shocked and every
member of the family is informed of his positive status. The grandson is not allowed to
come near him. Food is served at a distance. He feels extremely bad and hates himself.
One day the in-laws come and want to take away their daughter and grandson. His son
looks helpless for which he blames his father. No relatives visit their house and a few of
them speak ill of his character. He wants to die. Somebody tells him to confirm the results
at Chennai. He gives the blood for testing Western Blot. After a couple of days, he and
his wife go to get the results. They are asked to give some more blood for some other
detailed blood tests.
A week later when they go to collect the results they are asked to see the counsellor. The
counsellor, after a briefing says that he is not positive for AIDS but that he is suffering due
to some type of blood cancer and he may not live long. His wife exclaimed "Thank God,
he is only suffering due to blood cancer; he is not having AIDS; I am relieved".
List the social issues and suggest remedial measures.
Case Study - 2
Mr. X is 45 years old and an exporter of garments, a very busy businessman. He tours a
lot and has all vices. He has some problem in the stomach and is admitted to a five star
92
*
hospital in Chennai. Investigations are done and doctors recommend abdominal surgery.
They fix up the operation for Friday and advise him to be prepared with empty stomach
etc. Anaesthetist certifies him O.K. Suddenly on Thursday afternoon a doctor comes and
says that he really does not require the operation and that he can be cured with
medicines and gives a list of medicines. Mr. X is a shrewd man and suspects something
fishy. He enquires further and comes to know that he was discharged due to HIV positive
status, but he definitely needs the surgery.
The same day he goes to another big hospital in Chennai and requests them to perform
the operation the very next day. His story of urgency was believed and operation was
done on the very next day. After 10 days he was fully recovered and discharged from the
hospital. While leaving the hospital he met the Director of the hospital and said that he
was HIV positive. The doctor was stunned and shocked. Then he narrated his experience
in the previous hospital and said he alone need not be blamed for this and left.
•
Briefly state the ethical issues from the above case study and how
you will rectify it.
Case Study - 3
It is a big maternity hospital in that city. An officer working in AIDS prevention activities
visits the hospital and is casually inquiring his friend about testing for HIV. He is surprised
to know that every pregnant mother is
tested for HIV and if found positive it is
prominently recorded in the case sheet. He was also told that none of the mothers who
tested positive has come back for further care or delivery. To the question whether the
hospital authorities know what was their fate, the answer was in the negative.
The officer took two addresses of recent positive cases and went to their houses. A lady
aged 55 answers him, stating that her daughter-in-law is a worst woman, uses all abusive
languages against her and adds that the daughter-in-law has been thrown back to her
parent's place.
The officer traces the address of the girl and reaches the house. He is received by the
daughter-in-law who is pregnant. She is a graduate and she narrates about the happy
93
n
life of hers, with her husband till the result of her positive status was made known. She
loved her husband who is also subsequently tested and found positive. She cries and tells
about the abuses she, her husband and her family members met with. She said that she
went to the hospital with lot of dreams about the baby to be born, but all her dreams
have been shattered. She was accusing the doctor who did the test without her
knowledge and that he alone is responsible for destroying her family and her life. She is
knowledgeable about the difference between HIV positive status and AIDS. She feels that
without knowing her positive status, she would have lived happily till the inevitable
death came or if they had told her alone, she would have managed to live respectably.
The doctor and the hospital are responsible for destroying her life and family.
•
Briefly state the ethical issues from the above case study and
suggest how you will overcome them.
94
Session 11
DOCUMENTATION AND FOLLOW-UP
General objective
The trainees should be able to appreciate the need for Documentation about STD
Syndromes for its "Total Treatment" in their clinic and understand the items to be
documented.
Learning objectives
At the end of the session, the trainees would be able to :
•
List Advantages of Recording for Follow-up and Partner
treatment
•
Recognize their Social obligations and role as a documentor for
Control of STD in the Community
•
Be familiar with the Reporting and feedback mechanism
The need for documentation
General Practitioners generally do not maintain a detailed record of the diagnosis and
treatment of routine cases while attending their practice. Various reasons like lack of
time, acute cases mostly seen or cases not coming back for treatment to the same
practitioner etc. are responsible for this.
But, for STD and other chronic diseases, recording for proper follow-up
•
Is essential for quality care
95
p
The patient with chronic suffering will also appreciate the special
•
care and attention being given to him.
When the patient comes regularly for follow-up, the doctor is
•
also impressed
Advantages of recording for follow-up and partner treatment
Follow-Up-Recording
One of the common problems with care of the STD case is patients do not come for
follow-up. Thus it is important to devise mechanisms for overcoming this problem. One
such mechanism is proper documentation of the STD case and its follow-up.
The following are the advantages of recording for follow-up; it facilitates :
Assessment of clinical cure
•
To look for treatment failure and development of drug resistance
•
Record of Referral - when treatment fails or complication arises
•
Evaluation of effectiveness of counselling - Risk behaviour change
- condom usage
Recording of partner treatment
Similarly, another problem commonly encountered in treatment of STD is treatment of
partner without which the case is likely to get re-infected. In this regard, for Quality Care
of STD, beside counselling patient and partner for treatment, it is also important to
document partner treatment.
The following are the advantages of recording for partner treatment; it helps :
•
Identify and list partners who require treatment
•
Identify what method has been followed to ensure partner
treatment - (Patient Referral or Physician Referral)
96
Record status of compliance of treatment by partner
Record clinical cure of partner when partner is seen
Social obligations as documentor
Documentation by the Doctor of cases of STD seen, in addition to the above advantages
for delivery of Quality Care of STD to his/her client also helps the Regional and National
Agencies monitoring the progress of the control programme against STD and thus
against HIV/AIDS in the area served by the Doctor. Thus, documentation and reporting
of STD cases and care given is considered a social obligation on the part of the Doctor
for a National cause.
Documentation and reporting by the treating Doctor provides the following information
by studying the trends over years for particular STD syndromes in a particular area.
Information derived from documentation and reporting :
Helps assess impact of programme in the local area
Helps review strategy for control of STD in the area
Helps plan effective Health Education Campaigns in that area
Helps liaise with other agencies (N.G.Os) in the area that could
help fight against STD in the area
Feedback from the Regional agencies to whom reporting is made can provide valuable
information back to the Doctor.
Antibiotic sensitivity/resistance
•
STD trends in the region
Plan human and material resources (eg. Drugs, Condoms) locally
Need for special campaigns/co-ordination with other agencies
Need for further research
97
Reporting and feedback mechanism
When you start maintaining individual record for case and partner treatment and follow
up, it becomes easy for the practitioner to analyze and report the particulars required
for decision making at the clinic-level as well as at the regional level.
Reporting is to be done either through mail on a monthly or a bi-monthly basis to the
Training Institution which will in turn compile it and send it to APAC Project, Chennai,
for compilation at the regional level.
Feedback will then be given by APAC to both the Training Institution as well as the
Doctor who will then have the overall view of the situation in the region and the
common problems faced by others involved in the programme.
Thus it is envisaged that through proper documentation, reporting and analysis of the
STD Case Mangement by the reporting Doctor and feedback received from the co
ordinating agency, will result in Quality STD Care and thus control HIV/AIDS.
98
QUALITY STD CASE MANAGEMENT RECORD
NAME OF CLINIC
Reg. Number:
Date of Registration :
Name of Patient :
Age :
Sex : M/F
Complete Postal Address
Complaints (Syndrome)
Duration
Name of Partner(s)
History of Drug Allergy :
Details of
Case Treatment
Follow-up 1
Date, Remarks
Follow-up 2
Date, Remarks
Follow-up 3
Date, Remarks
Partner 1
Partner 2
Partner 3
Patient Referral/
Physician Referral
Patient Referral/
Physician Referral
Patient Referral/
Physician Referral
Counselling Topics
1.
2.
3. for Condom use
Partners
Treatment
Method to ensure
Patient treatment
Treatment given
Partner Follow-up
dates & Remarks
Referral (if any) Name of Doctor:
Reason for Referral
Feedback from Doctor :
99
APAC PROJECT
for
QUALITY CARE OF STD
Mailed Questionnaire
To
Dr.
Ref. : Batch No
Dear Doctor,
Kindly spare 2 minutes of your valuable time to fill in this questionnaire and send it by post
immediately to us. This will enable us to guage the success of the Training Programme we have
conducted for you as well as to identify your practical problems and devise solutions to ensure
Quality Care of STD that will contribute to prevention and Control of HIV/AIDS.
<1/I-2/3-4/>4
1) Your workload of STD cases per month :
2) Percentage STD cases treated using Syndromic Case Management:
None/25/50/75/100
3) Percentage of STD cases recommended condom use for Case/Partner: None/25/50/75/100
4) Percentage of STD cases where partner treatment was undertaken :
None/25/50/75/100
5) Percentage of STD cases who returned for follow-up :
None/25/50/75/100
6) Percentage of STD cases given Behavioural Change Communication :
■
None/25/50/100
Kindly list any problems faced in following
"Quality STD Care"
■
Any specific information you want us to
send you
■
Any other comments you want to make
Thank you for filling up this feedback cum follow-up Questionnaire. We will immediately respond
to your requests/send our Social Worker to you.
A self-addressed stamped envelope is enclosed to send your response immediately.
With warm regards,
Yours truly
CHIEF CO-ORDINATOR
100
Format for follow-up of Allopathic Private Medical Practitioners
Name of the Doctor:
Year:
Month :
The information below will help us to strengthen the training programme that you received in
Quality STD Care and to provide you with a follow-up. Kindly co-operate with us by filling out
this form and handing it over to the social worker who comes to meet you from your training
centre.
Number of STD cases treated :
1.
Number of cases treated by Syndromic treatment
Genital Ulcer
M
F
Urethral
Vaginal
Lower
Discharge
Discharge
Abdominal Pain
M
F
F
Others (Specify)
F
M
2.
Number of Partners treated by syndrome
3.
Number of cases followed up and ensured completion of treatment
4.
5.
Number of STD cases counselled for condom use
Number of STD cases counselled for reduction of partners and other safe sex options.
Signature
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Acknowledgement
This module is the result of the combined efforts of AIDS Prevention And Control Project
of VHS and Madras School of Social Work. Many experts prepared the contents and
provided consultancy to publish this module. Their valuable contribution is gratefully
acknowledged.
Training Institutions
I.
Madras School of Social Work
32, Casa Major Road, Egmore Chennai - 600 008.
1. Dr. Jayanthi Beliappa 2. Dr. G. Vijayaram 3. S. Rema
II.
PSC Institute of Medical Science & Research
Coimbatore - 641 004
1. Dr. Surendran 2. Dr. K. Selvaraj 3. Dr. Thomas V. Chacko 4. Dr. Marina Thomas
III. Meenakshi Mission Hospital & Research Centre,
Lake Area, Malur Road, Madurai - 625 107.
1. Mrs. Beena Sivaprakash 2. Dr. Indira Athappan 3. Mr. Jacob C. Varghese
4. Dr. Lakshman Marvarkat
IV. Rajah Sir Muthiah Medical College,
Annamalai Nagar - 608 002, Chidambaram.
1. Dr. Annie J. Mani 2. Dr. Biswajit Chakraborthy 3. Dr. S. Gopalakrishnan
4. Dr. Vijaya Bhushanam
V.
Tanjore Medical College
Tanjore
Dr. R. Canesh
AIDS PREVENTION AND CONTROL PROJECT
The Voluntary Health Services, Adyar, Chennai - 600 11 3.
1. Dr. P. Krishnamurthy 2. Dr. Vijaya Srinivasan 3. Dr. Zafrullah
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AIDS Prevention
And Control Project
Voluntary Health Services
Adyar, Chennai 600 113. INDIA
Phone: 2352965, 2355048
Fax: 91-44-2355018
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