Bridging the Gap: Conference Record [Abstract book, International Conference on AIDS (12th: 1998: Geneva, Switzerland)]

638 Abstracts 33228-33232

12th World AIDS Conference

I33228 1A voucher scheme to improve access to health services
for female sex workers reduces sexually transmitted
infections
Anna Cornelia Gorter1, P. Sandiford2, C. Villabella1. 'Inst. Centroamericano de
las Salud (ICAS), Managua, Nicaragua; 2lnst. for Health Sector Development
IHSD, London, United Kingdom
Issues: The potentially high cost-effectiveness of Sexually Transmitted Infection
(STI) prevention strategies that focus on core groups such as female sex workers
(FSWs) is well recognized. However achieving this in practice is often difficult
because these women are reluctant to attend stigmatising government-run clinics
of poor technical and human quality.
Project: We report the encouraging findings from a trial of a voucher scheme in
Managua, through which FSWs were able to choose to attend any one of a number
of public, charity or private clinics where they are given free diagnosis/treatment
of STIs and gynaecological problems. Participating clinics in different parts of the
city were selected by competitive tender, and paid at a price below the unit cost of
providing equivalent services in government-run clinics. Contracts and monitoring
guaranteed high technical quality. Vouchers were distributed directly to FSWs at
their work sites and via charity organisations.
Results: There have now been 4 distributions of vouchers over a period of
18 months. Of 4,073 vouchers distributed 1,489 were redeemed (37%) by 1,103
women. It was possible to link records for all but 19 of the FSWs who reported
having used a voucher more than once. Excluding these, 843 women redeemed
once, 180 twice, 53 in three and 27 in all 4 rounds. Most vouchers redeemed
had been received directly (82%), 17% changed hands, and <1% was sold. Over
the course of the project the incidence of gonorrhoea (used as a tracer condition
for all STIs) dropped by 71% (p < 0.05). We saw also a significant trend of
decreasing prevalence with each subsequent visit of a FSW; 14.8% to 7.4% (in
those redeeming 4 times); 18.9% to 7.5% (3 times); 10% to 7.2% (twice)(p <
0.05). One time redeemers had a prevalence of 7.3%. FSWs who used vouchers
repeatedly tended to be those with a higher initial prevalence (p < 0.01).
Lessons learned: It was demonstrated that voucher schemes offer a practical
and acceptable (ie non-stigmatising) means to improve use of sexual health services by FSWs, to reduce incidence and prevalence of STIs and to drive up the
quality of care, all at a low cost. If implemented on a larger scale voucher systems
could have an enormous impact on HIV transmission in developing countries.
33229 Baseline survey of indicators for STD case management
in primary health care facilities in Uganda
Wilford Lordson Kirungi1, J. Cutler2, F. Kambugu1, D. Kabatesi1. 1STD/AIDS
Control Programme c/o PO. Box 22375, Kampala; 2US AID/STD/AIDS Control
Programme MDH Entebbe, Uganda
Objective: To obtain baseline data on the appropriateness of clinical management
provided to patients with selected STDs (WHO/GPA Prevention indicator - PI 6)
and the proportion that receive appropriate counselling (WHO/GPA PI 7), prior
to implementation of a comprehensive programme of STD case management in
health care facilities (HCFs)
Design: Cross sectional descriptive survey.
Methods: We observed patients presenting at health facilities with STD complaints for the first time, being attended to by health care providers (HCPs).
We later interviewed the HCPs about their knowledge and attitudes of STD
management. Based on this, the indicators of STD management were calculated.
Results: A total of 170 treatment episodes were observed of 99 HCPs in 56
HCFs. The rate for PI 6 i.e. the proportion of patients that are assessed and
treated appropriately according to WHO/National recommendations was 14.3%
(61% for history, 57% for examination and 16% for appropriate antibiotic treatment). The score for PI 7 which measures overall patient education was 18.5%,
(19% for advice on condom use and 53% for partner notification). Condoms were
offered to 6% of the STD patients. A total of 170 HCPs were interviewed and
71% correctly described an adequate history while 40.6% described a proper
examination and 10% stated the recommended antibiotic treatment for various
STDs. The score for PI 6 on interview was 5.3%. Of the HCPs, 55% claim to
routinely advise use condoms and 92.4% to advise partner notification giving a
score for PI 7 based on interview of 53.9%.
Conclusions: Low baseline levels of STD case management in HCFs and
the disparity between knowledge and practice of STD case management were
revealed, as well as a missed opportunity to counsel STD patients on HIV prevention. Intensified training and support supervision of HCPs tailored to emphasise
patient counselling was recommended as well as further research to identify
provider attitudes and constraints regarding patient counselling.
80* / 33230 The value of risk assessment in the detection of
gonococcal/chlamydial cervical infections at a
Ugandan STD clinic
Elioda Tumwesigye1, F. Kambugu1, C. Whalen2. 1STD Clinic Mulago Hospital
PO Box 16331 Kampala, Uganda; 2Case Western Reserve University

Cleveland, OH, USA
Background: Neisseria gonorrhoea (NG) and Chlamydia trachomatis (CT) cause
significant maternal and neonatal morbidity and facilitate sexual transmission of
HIV. To improve the diagnosis of NG/CT cervical infection, various clinical algorithms incorporating risk assessment options have been proposed but still need
validation in countries in which they are to be applied.

Objectives: To evaluate the validity of the clinical algorithms currently used in
Uganda and, to develop and test risk-score based clinical decision models for
diagnosis NG/CT cervical infection.
Methods: A consecutive sample of 311 women attending an STD clinic in
Kampala, underwent a structured interview and physical examination. NG cultures and ligase chain reaction (LCR) assays for NG and CT were performed.
The algorithms and clinical decision models were applied to the study population
in a simulation based on personal data and the results of the simulation were
compared with microbiological results.
Results: NG and/or CT was detected in 6.6% of the women. The hierarchical
algorithm based on reported vaginal discharge symptom had a sensitivity of
26.3% and a specificity of 57.7%. A similar one but which excludes women with
thrush like discharge had a sensitivity of 15.8% but a specificity of 71.2%. The
one recommended by the WHO and incorporating risk assessment had also a
sensitivity of 26.3% but a specificity of 79.4%. One of the nonhierarchical riskscore-based clinical decision models we developed had a sensitivity of 95% and
a specificity of 70%. Further analysis is being done to validate these risk-score
based models on a different consecutive sample of 586 women.
Conclusion: Score-based clinical decision models that incorporate sociodemographic and other factors predictive of NG/CT infection may represent
affordable alternative methods for diagnosis and screening for NG and/or CT
infections among women in resource-poor settings.
84* /33231 Increasing antibiotic resistance in gonococci in the
WHO Western Pacific Region (WPRO)
John Tapsall1, A.E.G. Ghee2, S.O. Omi2, N.F. Fee2, G.P. Poumerol2. 1The
Prince of Wales Hospital High Street Randwick NSW, Australia; World Health
Organization, Manila, Philippines
Issue: Converging epidemiological and biological studies showing the significant
role of gonorrhoea as an amplification factor in the spread of HIV have increased
interest in methods for the control of this disease. Effective antibiotic treatment
remains a mainstay of this control process, but the continuing emergence of
antibiotic resistance in Neisseria gonorrhoeae threatens this approach.
Project: A programme of continuous and long-term laboratory based surveillance of gonococcal susceptibility [GASP] has fuctioned in 20 countries in the
WHO Western Pacific Region for 6 years. A Quality Assurance (QA) programme
and standardised methods ensure validity of results.
Results: GASP has examined the susceptibility of more than 35,000 gonococci to a core group of antibiotics used in anti-gonococcal therapy. Centres
reporting on quinolone resistance [QRNG] in recent years have noted both increasing numbers of resistant isolates and high levels of resistance. In 1996
QRNG were particularly numerous in Cambodia, Hong Kong and the Philippines
and had increased substantially in Korea, Australia, China, Vietnam and Singapore. Penicillin resistance was widespread and high level tetracycline resistance
common [about 70% of strains] in Malaysia, Singapore, Cambodia and Vietnam.
All isolates were susceptible to third generation cephalosporins and almost all to
spectinomycin.
Lessons learned: Antibiotic resistance in gonococci in the WHO WPR is
increasing, requires continuous monitoring and is making effective treatment of
gonorrhoea expensive and difficult.
33232 Evaluation of the quality of sexual transmitted disease
(STD) case management in Morocco
Ahmed Zidouh1, S. Jrondi2, H. Khattabi2, L. Manhart3, T. Saidel4,
G. Dellabetta4, J. Mahjour2. 1Department of Epidemiology 14 Rue Ibnal Haitam
Agdal Rabat, Morocco; 2Department of Epidemiology Rabat, Morocco;
3University of Washington Seattle WA, USA; 4AIDScap Family Health
International Arlington VA, USA
Objective: To provide a baseline evaluation of the quality of care for STDs, prior
to the implementation of the syndromic approach to STD case management as
mean of improving the quality of that care.
Methods: Nine trained teams visited 74 public health centers, 89 private clinics
and 267 pharmacies across 21 provinces. They performed: 1) 404 direct observations of STD case management, 2) Interviews of 208 clinicians, 3) 103 exit
interviews of STD patients, 4) simulation of 158 vaginal discharges and 109 male
urethritis. WHO indicators PI-6 (proportion of patients assessed and treated in an
appropriate way) and PI-7 (proportion of patients who received basic advice on
condom and partner notification) were estimated.
Results: The PI-6 was 13.9% for male patients (69.4% for history taking, 61.1%
in physical examination, and 41.7% for correct treatment), and 0.7% for female
patients (11.4% for history taking, 10.1% in physical examination, and 26.6%
correct treatment). The PI-7 was 4.8% for male and 1.8% for female. Cause of
the disease was not explained to 84.5% of the patients, only 5.8% were offered
condoms and 1.2% were informed of the risk of HIV infection. Respectively, 23.5%
and 18.2% of the public and private clinicians reported an effective etiologic treatment for gonorrhea, syphilis, chancroid, chlamydiae, and trichomonas; none of

them could list the correct antibiotics for the syndromic treatment of urethritis,
genital ulcers and vaginal discharge. At pharmacies, only 8.2% of the providers
suggested medical consultation, 7.2% partner treatment, 1.8% indicated the use
of condom during disease, and none of them spoke about the risk of HIV infection.
Conclusion: The study provides important data on the current quality of care
for STDs in public health care centers, private clinics and pharmacies. Further
efforts of information and training of health care providers should be done. The