Sexually Transmitted Infections in Sub-Saharan Africa

From the summary

Preventable, curable sexually transmitted infections (STIs) continue to severely compromise the health of people in sub-Saharan Africa. Evidence over the past decade has revealed that the presence of an STI can also make it easier for the Human Immunodeficiency Virus (HIV) to pass from one person to another. Because the treatment of STIs can slow HIV transmission rates while improving overall public health, affordable and sustainable STI services should be incorporated into national public health policies and strategies.

Given the limited resources available in many countries, syndromic case management using pre-packaged STI treatment (PPST) kits can increase access to effective STI treatment. Syndromic management can be used outside the clinical setting, and in clinical settings where no laboratory diagnostics are available, to effectively and safely treat several STI syndromes. PPST kits can provide all treatment essentials in one package, improving adherence to proper and full treatment, prevention, and partner referral. In addition, the social marketing of PPST kits, especially with generic drugs, makes them affordable to the general public and highly cost-effective compared to existing treatment practices. Syndromic management with PPST kits can offer a "one-stop shopping" intervention to improve STI treatment.

Currently in sub-Saharan Africa, the only application of STI syndromic management with social marketed PPST kits is the treatment of gonococcal and chlamydial urethritis in men. However, it is possible to treat female sexual partners of men with urethritis, or to design a PPST kit to treat other STI syndromes in men and women, although diagnosis might require a clinical exam. A review of pilot PPST programmes in sub-Saharan Africa reveals several key ingredients to programme success, including formative research, provider training, targeted distribution, consistent monitoring, a permissive regulatory environment, affordability, and advocacy, information, education, and communications (IEC).

Advocacy among the governmental regulatory authorities and private sector health providers also may be necessary: authorities are concerned with controlling the distribution of antibiotics to avoid an emergence of drug-resistant strains; providers, in addition to ensuring the provision of appropriate medical care, are concerned with the viability and profitability of their practices. Sufficient time and funding for programme development; advocacy, introduction, and evaluation are generally the most significant considerations for any PPST intervention.

Social marketing PPST kits through private sector outlets such as pharmacies and drug sellers have the potential to achieve significant health impact. Investment in blister packaging discourages kit cannibalisation and facilitates treatment adherence. The social marketing organisation can control the quality of inputs, and creative IEC and promotional activities can encourage men to seek treatment in a timely manner and notify their sexual partners, thereby increasing programme reach. By training private providers and distributing treatment through the private and commercial sector outlets where people currently seek treatment, the social marketing of PPST kits holds promise as an effective and affordable method to deliver necessary STI treatment services, especially for men.

The introduction of PPST kits in a setting that has already embraced syndromic case management and an essential drug list including World Health Organization-recommended antibiotics for treating STIs—coupled with the use of generic drugs—could result in an affordable kit independent of donor subsidies. Syndromic management using PPST kits is feasible on a drug cost-recovery basis. PPST kits can be an important part of an overall national strategy for improved STI treatment and management, and consequently, reduced HIV infection. The kits can be introduced in existing health care services; it is not necessary to create a new service-delivery infrastructure. For all PPST programmes, reaching female sexual partners remains an important challenge.

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