Notes from the field: practical issues in upgrading STD services based on experience from primary healthcare facilities in two Rwandan towns.

In order to assess the feasibility of upgrading STD management at the primary healthcare level in Rwanda, a project was piloted in a health centre and a hospital dispensary in two up country towns. Nurses trained in syndrome based management treated all patients with genitourinary complaints at first visit without laboratory results. They provided condom demonstration and risk reduction advice, and gave coupons for partner referral. Principal findings and decisions were recorded on individual patient records. Partners presenting referral coupons were treated presumptively and their records linked to the index case. Three quarters of symptomatic patients seen at the two primary healthcare facilities were women. With training and supervision, nurses applied the syndromic STD management guidelines correctly in over 90% of cases. Symptomatic treatment failure at first follow up visit varied from 0% for male urethritis to 27% for genital ulcer, the one condition that was not treated syndromically. Four fifths of women presenting with vaginal discharge had clinical signs of cervicitis, and the presence of cervical signs was 86% sensitive for presence of leucocytes on cervical Gram stain. With adequate post-training supervision, nurses were able to apply the syndromic STD management guidelines and a high degree of clinical improvement was achieved. Syndromic algorithms that recommend treatment for all common pathogens at the first visit had higher rates of symptomatic cure at follow up than the algorithm employing a sequential treatment approach. Clinical and laboratory evidence suggests a high prevalence of cervicitis in this population of women seeking care.