STIs 4: Addressing Staff Concerns about Syndromic Management

Addressing Staff Concerns about Syndromic Management

Staff and colleagues may voice a number of concerns about the use of the syndromic approach to STI management. The following are some of the most common criticisms of the approach raised by clinicians, along with a response to each criticism.

1. The syndromic approach does not use a service provider’s clinical skills and experience like the clinical approach does.
Many clinicians find it difficult to accept that using a clinical judgment alone could be a problem. However, studies have shown that even highly experienced STI specialists using clinical diagnosis will often fail to make the correct diagnosis. Studies show not only that clinical diagnosis is accurate for only 50% of STI cases, but that clinical diagnosis also misses mixed infections (when the client has more than one STI).

2. The approach does not seem scientific enough.
The algorithms (flow charts) used in syndromic management are based on epidemiological studies conducted throughout the industrialized and developing world. A number of validation studies comparing syndromic diagnosis with laboratory-assisted diagnosis have found them to be similar in terms of accuracy. As a result, syndromic diagnosis has been adopted in many settings all over the world.

3. It is better to treat the client for the most common cause first, and then to treat the client for a second cause only if the client’s symptoms do not improve.
It is more effective to treat the client immediately than to require return visits for additional treatment. In many settings, it is difficult for clients to make repeat visits to a clinic. Additionally, if a client is not cured of symptoms by the initial treatment, the client is less likely to return to the clinic for additional treatment—or may even seek inappropriate alternatives or self-treatment. In addition, clients who become asymptomatic or are not treated for other potential causes of the syndrome immediately may continue to spread the infection to partners.

4. The syndromic approach wastes money: It requires us to waste a lot of drugs by treating clients for infections they may not have.
Studies have shown that the syndromic approach actually makes STI care less expensive in the long run because:

The equipment, skills, and systems needed to make an etiological diagnosis are expensive.
Failed treatment or incorrect clinical diagnosis that results in inappropriate or incomplete treatment make the cost of treating clients higher because they have to be treated again, may develop complications that are more expensive to treat, and may continue to spread the infection.

5. What about the increased potential for antibiotic resistance with this approach?
Antibiotic resistance occurs when people do not take enough antibiotic to cure an infection completely. With the syndromic approach, providers are encouraged to give standardized treatment using the most effective medications available for a given syndrome. Providers are also encouraged to use single-dose therapy whenever possible, thereby preventing problems with client compliance. Better communication between providers and clients also makes it more likely that clients will continue to take the medication as requested after they leave the health facility.

6. Why not include simple laboratory tests as well?
When laboratory tests are included in the process, clients must wait for the results—and they may not return to the facility for treatment after testing. During this time, they remain infectious and complications can occur. Simple tests (such as Gram stains and wet mounts) are justified only when the appropriate technology is readily available, quick, and consistently accurate—and when clients can get results before they leave the clinic.

Adapted from the WHO training publication: STD Case Management — The Syndromic Approach for Primary Health Care Settings, Module 2.