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A Cost Comparison of Approaches to Sexually Transmitted Disease Treatment in Malawi
Abstract
Since syndromic management of STDs requires treatment with at least two antibiotics per patient, one of the concerns raised by adoption of the syndromic approach is the cost of drugs, especially for developing countries with limited drug budgets. The objective of the current study is to compare the cost-effectiveness of syndromic management to current national practice for the management of STDs in Malawi. The actual cost of observed antibiotic treatment for 144 patients receiving same day treatment for two STD syndromes in Malawi was determined using prices from the Malawi government supply catalogue. This was then compared to the calculated cost of treatment had the same patients been managed syndromically according to national guidelines. The cost of drug treatment under current practice was similar to the cost of syndromic treatment. However, at least one-third of observed patients did not receive effective treatment for either likely cause of their STD syndrome and wastage accounted for 54% of total observed drug cost. Overall, syndromic management of STDs in Malawi would result in more effective treatment of STDs at no additional cost. Since the indirect costs of low treatment efficacy were not taken into account in this analysis, a net saving is likely to be realized with the adoption of syndromic management.
... In Malawi, a study of the costs of drugs for treating genital ulcers in men and women and urethral discharge in men compared current diagnosis and treatment practice with use of the syndromic approach 15 and found that drug costs were the same (Costello et al., 1998). The average cost per patient using the current practice was $1.06 compared with $1.07 for the syndromic approach. ...
... Mostly as a result of ineffective prescribing practices, the study showed a substantial waste of drugs in the treatment of STDs, accounting for about half the costs of the drugs in the study. Other studies in sub-Saharan Africa have shown that cost savings of 60 to 75 percent could be realized with better prescribing practices for STDs (Foster in Costello et al., 1998). A WHO analysis estimated that when all direct costs are considered, syndromic management is two to three times less expensive than clinical diagnosis and three to four times less expensive than laboratory-based etiologic diagnosis (Islam et al., 1994). ...
... In the study, in 144 patient encounters, 13 percent of STD cases were treated syndromatically with exact drugs and dosages according to the Malawi Standard Treatment Guidelines (two drugs for each syndrome). Another 56 percent received effective treatment for one disease in the syndrome and 31 percent ineffective treatment for any disease in the syndrome(Costello et al., 1998). ...
... Changes in these behaviors will in many cases require fundamental changes in societal norms, which may be difficult to effect108 .A reduction of the duration of infectiousness (d) of persons with treatable bacterial STIs such as gonorrhoea and syphilis will decrease the prevalence of these diseases109 . Reducing the duration of infectiousness will require improvement in access to health care, with expansion of STI clinic hours, and increased staffing by clinicians to accommodate more patients together with greater role of primary care clinicians in providing syndromic management110 . ...
... 5 Other than the direct effect of STIs and possible complications such as infertility, urethral stricture, ectopic pregnancy, low birthweight, stillbirth, spontaneous abortion, cervical cancer, ophthalmia neonatorum and congenital infections, the worst consequence is perhaps the increased risk of transmission of HIV infection. [6][7][8] With the emergence of HIV and AIDS it has become more difficult to distinguish aetiological causes of STIs. A syndrome-based approach to their management has therefore been developed and promoted in countries with a high HIV prevalence. ...
Background: Sexually transmitted infections (STIs) are a public health problem globally, but especially so in sub-Saharan Africa. They contribute significantly to the burden of disease in South Africa and are recognised as major contributors to the human immunodeficiency virus (HIV) epidemic, with other potential complications when not managed properly. First-line doctors play a critical role in the management of persons suffering from STIs, and need to comply with the national guidelines for STI management.
Aim: To determine the knowledge, attitudes and practices of doctors working in Jubilee District Hospital, Metsweding region, Tshwane, regarding the STI syndromic management (SM) guidelines.
Setting: Jubilee District Hospital in Tshwane North, Gauteng province, South Africa.
Methods: A cross-sectional, descriptive study using a self-administered questionnaire was conducted.
Results: Forty-three of the 50 doctors employed at the hospital participated in the study. Fourteen (32.6%) of the doctors were in the 36–40-year age group. Most of the doctors (36 or 83.7%) had only the basic bachelor’s degree, and only 4 (9.3%) attended additional STI training. Only 2 respondents (4.6%) had correct knowledge concerning management of male urethritis syndrome and 10 (23.3%) regarding management of genital ulcer syndrome. In compliance with the national SM guidelines for STIs, 22 (52.4%) of the doctors said they made a diagnosis of STIs using history and physical examination. Only 7 (16.7%) said they asked their patients during every consultation about the number of sexual partners, 21 (51.7%) said they always counsel/ screen patients with STIs for HIV infection, and only 4 (9.5%) said they always filled in partner notification slips after attending to the index patient with STIs. This study demonstrated a relationship between doctors’ knowledge of the SM guidelines for STIs and their age.
Conclusion: Overall the knowledge and practices of doctors at Jubilee District Hospital were suboptimal, and training on the SM of STIs should be made available to address this. Management should introduce regular monitoring, evaluation and supportive services for the doctors regarding their management of STIs according to the guidelines.
... 5 Other than the direct effect of STIs and possible complications such as infertility, urethral stricture, ectopic pregnancy, low birthweight, stillbirth, spontaneous abortion, cervical cancer, ophthalmia neonatorum and congenital infections, the worst consequence is perhaps the increased risk of transmission of HIV infection. [6][7][8] With the emergence of HIV and AIDS it has become more difficult to distinguish aetiological causes of STIs. A syndrome-based approach to their management has therefore been developed and promoted in countries with a high HIV prevalence. ...
Background: Sexually transmitted infections (STIs) are a public health problem globally, but especially so in sub-Saharan Africa. They contribute significantly to the burden of disease in South Africa and are recognised as major contributors to the human immunodeficiency virus (HIV) epidemic, with other potential complications when not managed properly. First-line doctors play a critical role in the management of persons suffering from STIs, and need to comply with the national guidelines for STI management.
Aim: To determine the knowledge, attitudes and practices of doctors working in Jubilee District Hospital, Metsweding region, Tshwane, regarding the STI syndromic management (SM) guidelines.
Setting: Jubilee District Hospital in Tshwane North, Gauteng province, South Africa.
Methods: A cross-sectional, descriptive study using a self-administered questionnaire was conducted.
Results: Forty-three of the 50 doctors employed at the hospital participated in the study. Fourteen (32.6%) of the doctors were in the 36–40-year age group. Most of the doctors (36 or 83.7%) had only the basic bachelor’s degree, and only 4 (9.3%) attended additional STI training. Only 2 respondents (4.6%) had correct knowledge concerning management of male urethritis syndrome and 10 (23.3%) regarding management of genital ulcer syndrome. In compliance with the national SM guidelines for STIs, 22 (52.4%) of the doctors said they made a diagnosis of STIs using history and physical examination. Only 7 (16.7%) said they asked their patients during every consultation about the number of sexual partners, 21 (51.7%) said they always counsel/screen patients with STIs for HIV infection, and only 4 (9.5%) said they always filled in partner notification slips after attending to the index patient with STIs. This study demonstrated a relationship between doctors’ knowledge of the SM guidelines for STIs and their age.
Conclusion: Overall the knowledge and practices of doctors at Jubilee District Hospital were suboptimal, and training on the SM of STIs should be made available to address this. Management should introduce regular monitoring, evaluation and supportive services for the doctors regarding their management of STIs according to the guidelines.
... Although this number was not compared to gold standard treatment costs, it was compared to other health programs in developing countries, including childhood immunization programs, which cost between US$12-17 per DALY saved. Thus, it would seem that syndromic treatment-in relation to other health care programs already in place-is cost-effective in Mwanza, Tanzania at the levels of sensitivity and specificity observed in the trial (Gilson et al. 1997) B.) Likewise, in a cost comparison of syndromic treatment and the current methods (mostly clinical diagnosis with some laboratory testing) used in Malawi (Costello Daly et al. 1998), it was found that the cost of treatment per patient was nearly identical (US$1.06 for current practice and US$1.07 for syndromic treatment). Costello Daly et al. (1988) conclude that since syndromic management would substantially reduce the proportion of patients treated ineffectively under current Malawian practice, while drug costs would remain the same, cost-effectiveness would actually increase. ...
... Sexually transmitted infections (STI) are also common (Banerjee A et al., 2000;Komolafe, Nkumba, Makoka, Makhalira, & Bonongwe, 2000;Wynendaele, Bomba, M'Manga, Bhart, & Fransen, 1995;Zachariah R et al., 2002;. The national syphilis seroprevalence has been estimated at between 1 and 8%, and some studies suggest that as many as 40% of attendees of urban antenatal clinics are diagnosed with one or more STIs (Dallabetta, Miotti, & Chiphangwi, 1993;Daly CC, Franco L, Chilongozi DA, & Dallabetta G, 1998). ...
Reproductive tract infections are the most venerable diseases which affect not only the reproductive tract organs but overall the whole body of an organism. RTIs can involve infection of multiple organs of the human host like the skin, brain, eyes, lymph, and urogenital, perivascular, endocrine, and reproductive systems, respectively. RTIs affect both the sexes, but the burden of the diseases is found higher in case of females as compared to males because female are more susceptible to these infections due to various life processes. RTIs are known to degrade the quality of life as these infections affect the reproductive efficiency and can even lead to infertility in both the sexes. One of the major routes of transmission of the reproductive tract infections is oral-genital sexual contact with an infected person. Other modes of STIs are bodily fluids like blood, mother’s milk, mucous secretions, exudates, transplacental secretions, etc. There is an interrelationship of microorganisms with human hosts since their existence and the slam contact of the two cannot be denied. A balanced microflora is present in the human body as a part of the system, but the disequilibrium can result in various types of RTIs. Moreover, exogenous factors can also be responsible for transmission of other types of RTIs. RTIs are most prevalent in low-income and developing countries due to following reasons: lack of awareness regarding the diseases, poor hygiene, social stigmas, lack of medical facilities, poverty, shyness, inaccessibility to condoms, sanitary pads, hand washes, hand sanitizers, traditional child delivery methods, etc. This chapter will highlight the microbes involved in RTIs, their management, prevention, and drug resistance scenario.
Objective: To know the efficacy of Syndromic approach in the management of Pelvic Inflammatory Disease in our setup. Material and Methods: The study was conducted on 150 patients both in private hospital and department of Obstetrics and Gynaecology, Khyber Teaching Hospital, Peshawar, Pakistan. Patients with signs and symptoms of mild to moderate Pelvic Inflammatory Disease were included in this study. Diagnosis and treatment were done in a single visit according to the WHO criteria. These patients were reevaluated after 1 week for improvement. Results: Patients were aged from 20-50 years. Most of the patients presented with multiple symptoms relating to the female reproductive tract. On examination multiple signs were present. Out patient management was given to all patients while 97(65%) patients returned for evaluation after one week of completion of therapy, 94(96%) patients showed improvement on examination. Conclusion: The syndromic approach to management of Sexually Transmitted Diseases (STD's) and their complications provides an effective method of diagnosis and treatment without delay.
In four treatment studies in men with urethritis, which documented the enhanced effect of sexually transmitted diseases on HIV-1 shedding, appropriate treatment of the urethritis resulted in a dramatic reduction in the HIV shedding. The effects of sexually transmitted diseases and their treatment have been found to be similar in women, but the data are much less conclusive. Prospective studies from all regions of the world continue to correlate sexually transmitted diseases with the transmission of HIV, and in a recent trial it was shown that, in symptomatic individuals with sexually transmitted diseases, improved case management successfully lowered incident HIV infection. A randomized community-based mass therapy trial is currently underway, which will demonstrate the impact of the intensive treatment of sexually transmitted diseases on incident HIV infection.
(C) Lippincott-Raven Publishers.
In June 1989 a pilot study on the prevalence of STDs was performed at Kamuzu Central Hospital, Lilogwe, Malawi. Among unselected out-patients an STD prevalence of 4.4% was found. The patients were predominantly males (82.7%), the age was predominantly 20-35 yr. The distribution of the diagnoses was dominated by a relatively large proportion of "ulcer-diseases" (syphilis, chancroid and lymphogranuloma venereum) making up 67% of the patients. Almost two thirds of the patients were HIV-positive (62.4%). No significant difference was found in HIV-infection prevalence when patients with ulcer diseases were compared with patients with discharges. Among the patients with gonorrhoea a prevalence of penicillinase-producing Neisseria gonorrhoeae of 53% was found. It is concluded that a plan for the management of STDs is urgently needed as it is of paramount importance to combat STDs in order to prevent the spread of HIV-infection.
Since the clinical diagnosis of genital ulcers without laboratory confirmation is not reliable in developed countries, we postulated that clinical diagnosis alone would be no more reliable in developing countries. A presumptive clinical diagnosis of chancroid, genital herpes, syphilis, or lymphogranuloma venereum was made for 100 male patients at the Special Treatment Clinic in Nairobi, Kenya. This diagnosis was then compared to the final diagnosis determined by laboratory identification of the pathogen, by culture, or by serologic response. In 64 patients, a final diagnosis of either chancroid, syphilis, or genital herpes was established. The diagnostic accuracy varied from 75% for chancroid to 42% for syphilis and 43% for herpes. The overall diagnostic accuracy was 66%. The predictive values of positive clinical diagnoses were 84% for chancroid, 60% for syphilis, and 75% for herpes. Thus, clinical diagnosis of genital ulcer disease was not sufficiently reliable in this study.
We studied the current management of STD-related syndromes by urban health facilities in Pikine (Senegal) in 252 consecutive patients presenting with STD-related complaints, to assess the cost and effectiveness of services and to estimate the potential benefit by introducing management protocols. Most common presenting complaints for women were vaginal discharge and low abdominal pain, reported for 122 (82.9%) and 22 (15.0%) of 147 female patients. Urethral discharge and genital ulceration were reported for 80 (76.2%) and for 17 (16.2%) of 105 male patients. The average cost was 4.01 ECU (1 European Currency Unit = 1.2 US$ = 334 Franc CFA) for male patients (ranging from 0.57 to 25.70 ECU) and 12.75 ECU for female patients (ranging from 0.57 to 37.60 ECU). Only 20 of 80 patients with urethral discharge (25%) received effective treatment. Effectiveness was not related to cost of therapy or qualification of staff. Utilization of management protocols improves the quality and accessibility of care for STD, by potentially doubling effectiveness and reducing the costs for patients to 12% of the current level.
A national survey of sexually transmitted disease (STD) case management was carried out at 39 health care facilities in Malawi in 1994. Fifty-four health care providers were observed managing 150 patients presenting with selected STD syndromes and 103 providers were interviewed. STD case management was assessed by calculation of WHO/GPA prevention indicators (PIs) from observation data. The overall rate for PI-6, which measures correct assessment and treatment of STD patients was 11% (81% for history taking, 46% in physical examination, and 13% correct antibiotic treatment according to national guidelines). The score for PI-7, which measures overall patient counselling was 29% (65% for partner notification and 40% for condom advice). Although Haemophilus ducreyi is at least as common as Treponema pallidum as the causative agent for genital ulcers, only 16% of patients with genital ulcers were treated effectively for chancroid vs 56% for syphilis. Female patients received less comprehensive care than male STD patients. Only 20% of STD patients were offered condoms. Overall, the survey results support the policy decision to adopt syndromic management of STDs, and provide baseline information for planning and evaluation of a national control programme.