Syndromic management of sexually transmitted infections: Is it time for the World Health Organization to revise its algorithms?

Abstract

According to the World Health Organization (WHO),

more than 300 million individuals around the world

are infected each year with some type of sexually

transmitted infection (STI).1 Although these

estimates are more than a decade old, they continue

to provide an order of magnitude on the burden of

this type of disease. Further analysis of these

estimates suggests that most of this burden is felt by

low and middle income countries especially in sub

Saharan Africa, south and south-east Asia, Latin

America and the Caribbean.

Due to the high cost of laboratory tests

recommended for the diagnosis of STIs, at times it

becomes difficult in low-income countries that these

tests be carried out for all persons presenting as

suspected cases or potential carriers. To address this

issue, WHO developed guidelines for the syndromic

management of STIs especially when the main

symptoms are pain on urination, urethral discharge

and ulcers or sores.2 Since the application of WHO

guidelines commenced in early 2000s, the outcome

of their application has differed among countries,

some studies supporting the role of guidelines in the

effective treatment of the patients while others

reporting findings which do not lend support for

these guidelines.3-9 Relatively more studies suggested

poor performance of syndromic management in

correctly identifying patients with disease5-7, 9 Some

studies showed high sensitivity with an increased

number of false positives resulting in over

diagnosis;3,4 another study with effective syndromic

treatment was still unable to identify asymptomatic

cases or carriers.8

Both

types

of

findings,

over

diagnosis or missing a

case, have significant

implications

at

patient level as well

as family or societal

level depending upon

the norms and culture

of the country or

region. Over-diagnosis results in over-treatment and

unnecessary use of antibiotics, which have been

found to be an important cause of drug resistance

resulting in no cure or partial cure with conversion to

carrier state. Apart from drug resistance,

inappropriate use or over treatment of antibiotics

also poses an economic burden on already

compromised health systems in these countries.

Wrong labeling of individuals with a diagnosis of STI

may create inter-spousal mistrust at family level for

the source of infection especially when the partner

considers himself or herself as free of disease. This

may also result in stigmatization at societal level

especially in sub-urban and rural areas where

information sharing by interpersonal communication

is commonly practised.

The fear of diagnosis or stigmatization especially

after recurrent infections may urge some individuals

to self-medicate with antibiotics; this is not an

unusual phenomenon in low-income countries where

little or no distinction is made between the

prescriptions versus over-the-counter medications,

and may be another cause of drug resistance in such

settings.