Management of sexually transmitted infections (STI)-associated syndromes by part-time general practitioners (GP) in Puttalam district.

Introduction: Puttalam district shows higher rate of HIV. Considering the interaction between HIV and STI, management of STI-associated syndromes by GPs was studied. The objective of the study was to describe the management of STI-associated syndromes by GPs in Puttalam district. Method: A descriptive cross-sectional study was done in Puttalam district from 1 st February to 30 th April 2016 among 114 randomly selected part-time GPs using a self-administered questionnaire. Management of five STI syndromes was compared with national guidelines. Results: Vaginal discharge and lower abdominal pain syndromes were encountered by majority (97%) of GPs. However, vaginal discharge was considered as the syndrome with the highest possibility of an STI by majority (93%) of GPs. Urine full report (94.9%) and VDRL (77.5%) were the commonest investigations ordered by GPs. Only 4.3% of patients with urethral discharge, 4.3% of patients with vaginal discharge, 15 % of patients with genital ulcers, 10.5% of patients with scrotal swelling and 1.7% of patients with genital warts were managed according to the national guidelines. Notably none of the patients with lower abdominal pain syndromes were managed according to the guideline. Management of partners of patients with STI syndromes were done by 50.9% of GPs. Majority STI referrals to the local STI clinic (74.6%) and most of these referrals were patients with genital warts (89.5%). Conclusions: Large number of GPs is managing patients with STI syndromes. However, standard management of STI syndromes is done by only small number of GPs. Therefore, more educational and training programs on STI management for GPs are recommended.

STIs are mostly transmitted via unprotected sexual intercourse but there can be other ways of transmission as well. e.g.: via contaminated needles/ sharp instruments, blood and blood products and mother to child. Unprotected receptive anal sex is the most risky sexual practice but the disease can be transmitted in vaginal or oral sex as well. There are several factors that contribute to transmission of STIs. Among them social factors like lack of knowledge and lack of access to affordable protective mechanisms, cultural and religious reasons, inability to negotiate with the partner for safe sex: biological factors like younger age, female gender, behavioural factors like multiple partners, regular changing of partners, injectable drug use are common contributors. Having one STI makes a person vulnerable to acquire more STIs because the genitalia becomes inflamed and opens up a pathway for infections. Women are at a higher risk than men as their area of genital exposure is larger than men and they usually start sexual life earlier than men.
Main symptoms in STDs are genital, peri-anal or oral blisters and/or ulcers, discharge from urethra and/or vagina, warts in genitalia or peri-anal region, pain and swelling of testis and lower abdominal pain. But it has been found that most of the patients with STIs are asymptomatic. (70% of women and 50% of men with Chlamydia and 80% of women and 10% of men with gonorrhoea are asymptomatic) 5 Most of these STDs are curable, provided the patients are treated with the appropriate antibiotic or antiviral with the correct dose for recommended duration. If not, they may be partially treated and may transmit the disease to their sexual contacts and may become resistant for commonly used antibiotics as well.
It is very important to treat the partners in STIs because if the partner is not treated, the patient will acquire the infection again from the partner in a short time. And it is very important to educate them regarding the protective mechanisms and provide them the necessary psychological and social support. It is also important to follow up them regularly and screen them for other STIs as well. Safe sexual practices are the best methods for prevention.
Delaying sexual debut, monogamous partnership, correct and consistent use of condoms and changing from high risk penetrative sex to low risk nonpenetrative sex are among them.
In Sri Lanka, NSACP is the place where prevention and treatment programs for STIs are being implemented and monitored. There is one central STD clinic in Colombo as well as there are 30 peripheral STD clinics and 23 branch clinics scattered in Sri Lanka to control and treat STIs.
According to the publication of World Health Organization in 2007, management of Sexually Transmitted Diseases should not be exclusively done at STI clinics. 6 They can be managed by first contact medical officers according to the guidelines for syndromic approach for STI management. NSACP has published guidelines for syndromic approach for STD case management in 2001. 7 It includes treatment for current episode, health education on STIs, counselling on safe sexual practices, partner notification and treatment, condom promotion and follow up or referral to an STI clinic.

Justification:
Puttalam district is situated in North Western province in Sri Lanka. STD clinic, Chilaw is the main clinic that manages patients with STDs in the Puttalam district.
There have been 664 new patients registered in the STD clinics in 2013, of which 363 patients were diagnosed of having one or more STDs and 779 new patients were registered in 2014, of which 406 patients were diagnosed of having one or more STDs. 8,9 Total newly registered patients moved up from 11 th position in 2013 to 6 th position in 2014 in the country in comparison with other districts. 8 The most prevalent presentations to the STD clinic, Puttalam in 2014 were Non Gonococcal Urethritis, Vaginal Candidiasis, Bacterial Vaginosis, Genital Herpes and Syphilis. 9 It also showed a significant number of HIV patients in Puttalam district in 2014 with 2.3/100,000 population which became the 3 rd highest prevalence within a district in the country. 9 Considering these facts and that inadequate management of STDs can lead to increase in transmission of HIV. Therefore, it was decided to carry out a study on syndromic management of STDs by part time general practitioners in Puttalam district.

Objectives:
To study the management of STI-associated syndromes by part time general practitioners in the district of Puttalam.

Methods
Descriptive cross sectional study was carried out among part-time GPs practising in the district of Puttalam which is located in the North-Western part of the country. It has 48 government western medicine institutes, including: one District General Hospital (DGH), two Base Hospitals (BH), 12 District Hospitals (DH), 33 Preliminary Care Health Units (PMCU) and 16 Medical Officer of Health areas (MOH). There were 386 Doctors working in these health care institutes when the study was carried out.
Doctors who were working in the government hospitals and practising as part-time GPs were considered as the population and there were 203 GPs in the sampling frame. Doctors who were on leave during the study period, specialists in medical profession, and doctors practicing other than western medicine were excluded from the population.
Simple random sampling (SRS) technique was used to select study units from the sampling frame of 203 GPs. Sample size was calculated using 95% confidence level, assumed proportion as 50% (0.5) and acceptable error as 10% (0.1). Calculated sample size was 96 and a 25% of non-response rate was then added and required sample size came as 120.
Structured self administered questionnaire was used as the data collection tool. Questionnaire was pre-tested among a group of part-time GPs outside Puttalam district and necessary adjustments were made to the final questionnaire.

Papers __________________________________________________________________________________
GPs practices on five different STI-associated syndromes (namely urethral discharge, vaginal discharge, genital ulcers, scrotal swelling, pain and tenderness in lower abdomen and genital growths) were observed.

Results
The study data collection was carried out among 114 randomly selected sample of GPs (response rate 95%)

Background characteristics
Distribution of basic characteristics of the sample is mentioned in the table 1.

Investigations ordered by GPs for STIassociated syndromes
Investigations have been performed by 102/114 GPs.
Common investigations ordered by GPs for STI-associated syndromes in the private practice are tabulated in table 3. UFR was the mostly ordered investigation by GPs.

Management of partners of patients with STI-associated syndromes
Managing partners of patients with STIsyndromes was done by 50.9% (n=58) of GPs and 30 (52.8%) out of them are managing asymptomatic partners as well. Performing investigations on partners was done by 52 GPs (45.6%) and the most commonly used investigation was UFR, as it was with the patients. (Table 6)

Percentages and numbers are not mutually exclusive
Use of antibiotics on partners of patients with STI-syndromes was done by 33 (28.9%) GPs and they were mostly similar to the antibiotics used with patients. (Table 7)   Table 7: Most common antibiotics used on partners

Health education sessions carried out by GPs for patients with STI-associated syndromes
Health education is a part of complete management of STI patients and it was done

Referral decisions taken by GPs for STIassociated syndromes
GPs mostly referred patients with genital growths (90%). Patients with lower abdominal pain were the least referred syndrome (54%). (Table 8) They mostly referred patients with STI syndromes to the local STD clinic for further follow up, and they also referred patients to other specialities as well. (Table 9)

Comparison of current management practice with the standard management for STIassociated syndromes by GPs
GPs current practice of management was co pared with the national guidelines on the management of STI-associated syndromes. Majority of GPs are not following standard treatment guidelines. However, it seems that acceptable number of GPs educate patients (87%), promote condoms (71%) and discuss about partner management (51%). (Table 10)  Partner management was done by 51% of GPs, which is not satisfactory and it should be improved. Use of antibiotics on partners was not according to the national guidelines 7 .
Health education to patients and condom promotion were satisfactory (87% and 71% respectively) but need to be further improved.

Conclusions
Experience of GPs with patients having STI syndromes was more than 50% for all the given six syndromes. Their level of suspicion on the syndromes was more than 50% except for genital growths. They mostly used UFR as the investigation for patients with STI syndromes. Antibiotics were used for management of all the given STI syndromes and different antibiotics were preferred for different STI syndromes.
Partner management was also done by some GPs and some of them managed asymptomatic partners as well. They used investigations on partners and the most common investigation was UFR. They used antibiotics on partners as well but the number was less than that of patients.
Health education and condom promotion was done at GP practice.
Some GPs referred patients with STI syndromes to other healthcare professionals, mostly to local STD clinic.
With reference to national guidelines, their use of antibiotics on patients with STI syndromes was poor.
Considering all above factors, more educational and training programs on STD management for GPs at primary health care are recommended.