Rapidly Expanding Access to Care for hiv in Tanah Papua (reach) 2012 2016
Annex 7: Sexually transmitted infections programming
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- Bu səhifədəki naviqasiya:
- How will we do it
- Will it work
- How will we know
- Will the benefits last
Annex 7: Sexually transmitted infections programmingThis annex is designed as a stand-alone document on STI control in Tanah Papua. It is provided as background to the STI section of the program description, (see section 2.5). It will also be used as for strategic planning on STI control with local counterparts at provincial and district level in Tanah Papua during the REACH program. There are three sections. Section 1 provides a brief background on general approaches to STI control and describes the toolbox of STI control strategies that we will use for designing STI control activities in Tanah Papua. Section 2 looks at what we know about STIs and existing STI control programming in Tanah Papua. Section 3 covers strategic approaches and key activities and maps out two broad strategic approaches: Improve the quality of STI diagnosis and treatment at district hospital and puskesmas level (3.1); and targeted STI interventions for high prevalence populations including PPT, enhanced syndromic management and syphilis screening (3.2). A7.1 Background on approaches to STI control There are three big-picture things we know about STIs:
We need to remember these three points when we are designing STI control programs. Table 15 looks at what each of these three things means for STI control. Table 15: What we know about STIs and what that means for STI control
There is a toolbox of evidence-based STI control strategies that we will use (see Box 2). The tool box has two parts:
Box 2: Toolbox of STI control strategies
These strategies rely on treatment without a laboratory diagnosis. This is called presumptive treatment. We will now look at the situation in Tanah Papua and draw on the tool box of STI strategies to design a program of STI control activities most likely to reduce STI prevalence in Tanah Papua. A7.2 STIs and STI programming in Tanah Papua Based on available data, gonorrhoea, chlamydia and syphilis are the highest documented burden STIs in Tanah Papua with particularly high prevalence rates among FSWs. A7.2.1 Gonorrhoea and chlamydia Table 16 summarizes the gonorrhoea and chlamydia data for Papua and West Papua from the IBBS rounds in 2009 and 2011. On any one day 35-60 per cent of FSWs in Tanah Papua will have either gonorrhoea or chlamydia. The data suggest that rates may have been lower in sites that had implemented PPT in the period before the surveillance e.g., Jayapura. A7.2.1.1 Gonococcal resistance to antibiotics Indonesia has recent data on gonococcal antimicrobial sensitivity in Tanah Papua. In 2004, seventy two gonococci isolates from Papua were tested by the WHO Collaborating Centre in Sydney and confirmed resistance to penicillins, tetracyclines and fluoroquinolones.48 Following this survey the recommended treatment for gonorrhoea in National STI Guidelines was changed to cefixime. A further survey in Wamena in May 2011, linked to the IBBS, confirmed current sensitivity to cefixime.49 At a country level gonococcal antimicrobial sensitivity surveys are recommended on a three-yearly basis. Table 16: Gonorrhoea and chlamydia data for Papua and West Papua, IBBS 2009 and 201150
A7.2.2 Syphilis Control of syphilis is more achievable than control of gonorrhoea, chlamydia or other STIs. The tests for syphilis are cheap and can be easily conducted at the clinic level. Effective drugs (injectable penicillin) are available and effective control strategies have been demonstrated internationally. While we have syphilis data from multiple rounds of IBBS conducted in Tanah Papua, the syphilis results have often been poorly interpreted with inclusion of all past syphilis infections leading to overestimates of the prevalence of active infection. This is a common problem in Indonesia but could be easily corrected by review of raw data using the Government of Indonesia standardized case definition for active syphilis (TPHA positive, RPR greater than or equal to 1:8). Of the recent reported IBBS data, the 2007 data are the most reliable and indicate that syphilis is concentrated among FSWs, with less than 10 per cent prevalence of active infection among direct FSWs in Jayapura and Sorong.51 Effective syphilis control is achievable in Tanah Papua and the key is to focus on the early diagnosis and treatment of infectious syphilis. In terms of syphilis, there are four groups in the population:
We need to keep in mind that clinicians and public health physicians have different priorities in the management of syphilis. From a clinical management perspective the priority is to treat all people with syphilis whether it is infectious or non-infectious. Public health physicians’ priority is to stop the transmission of infectious syphilis. This means they give priority to early diagnosis and treatment of people with infectious syphilis with high titre RPR results. While clinicians should continue to provide treatment for all people with syphilis whether infectious or not, public health strategies designed to reduce the transmission of syphilis in Indonesia should focus on the control of infectious syphilis through the identification and treatment of people with infectious syphilis. To control infectious syphilis we will need to overhaul current clinical practice in Tanah Papua (and Indonesia) regarding diagnosis and management of syphilis. There is quite a large amount of testing going on – often on the wrong people, with the wrong combination of test kits, wrong diagnoses, overtreatment among sex workers, reluctance to use the first line drug (Penicillin) and non-compliance with the alternative (Doxycycline). Routine use of RPR testing with confirmatory TPHA for syphilis diagnosis appears low. This may be an unforeseen consequence of the introduction of TPHA RDT and the unfortunate misrepresentation of the TPHA RDT as a syphilis RDT in the National STI Guidelines52. Treatment: Following a court case in Semarang many doctors in Indonesia have been reluctant or have refused to give intramuscular Penicillin injections – the first line treatment for syphilis – due to the possibility of anaphylactic shock. Common practice is to prescribe doxycycline twice daily for 30 days. Compliance with this treatment is often poor, especially among sex workers, in part due to the common side effect of nausea and diarrhoea. A small study conducted by Yayasan Kerti Praja in Bali in 2001-2002 found zero compliance with a full course of doxycycline treatment amongst a sample was approximately 100 FSWs. Fortunately, health staff in Papua and West Papua appear more willing to give Penicillin injections than health staff in other parts of Indonesia.
Yaws is often raised as an issue in interpreting data on the prevalence of treponemal seropositivity (TPHA positive). The same tests that are used for the diagnosis of syphilis (TPHA and RPR) are also used to diagnose yaws and people who have been exposed to yaws in the past will have the same serological pattern as people who have been exposed to syphilis in the past (TPHA positive). Yaws is not an STI but it is caused by different subspecies (pertenue) of the same family of organisms that causes syphilis - Treponema pallidum. Yaws is mainly found in humid rural tropical regions and is also known as Frambusia. There is some evidence that yaws may still be present in Indonesia in small residual foci of infection in isolated rural areas (“where the highway ends”).53 In a survey of 37,000 people in West Sumatra in 1988, 114 cases of early yaws were diagnosed clinically, with 100 being treponemal seropositive. Whilst continued low level transmission of yaws in isolated areas would contribute to the prevalence of treponemal seropositivity in those areas there is no logical basis to suggest that yaws contributes to the higher treponemal seropositivity amongst FSWs and waria compared to low risk populations in Indonesia. It seems reasonable to assume that the higher treponemal seropositivity amongst FSWs and waria is due to sexual exposure to syphilis.
There are a number of other STIs (that are known cofactors for HIV transmission) that are likely present in Tanah Papua but are under-diagnosed, under-treated and under-reported, including chancroid, donovanosis, genital herpes and trichomonas. Chancroid, donovanosis, genital herpes and syphilis are all genital ulcer diseases and therefore are strong cofactors for HIV transmission. A review of the results of enhanced syndromic management in brothel-based FSWs could provide valuable data on the prevalence of genital ulcer disease in Tanah Papua. Chancroid (Haemophilus ducreyi) is a genital ulcer disease. There are no data available on the prevalence of chancroid in Tanah Papua. Chancroid is treatable with single dose azithromycin. This means the PPT program for gonorrhoea and chlamydia among FSWs would also be effective for chancroid. Donovanosis is a chronic genital ulcer disease with low infectivity. There are no current data available on the prevalence of donovanosis in Tanah Papua however donovanosis was historically endemic in Tanah Papua and PNG. The largest recorded epidemic of donovanosis occurred in Merauke in Papua between 1922 and 1952 where 10,000 cases were identified from a population of less than 15,000. 54 Since the introduction of antibiotics, donovanosis is less common and tends to occur in small endemic foci in populations with poor access to STI diagnosis and treatment.55 Trichomonas – Trichomonas is under-diagnosed and under-treated throughout Indonesia. The recommended treatment, metronidazole (single 2gm oral dose), needs to be added to the national EDL so it can be available at puskesmas level. There is also scope to train private pharmacists (apoteks) to prescribe metronidazole for symptoms of vaginal infection in women who are not pregnant. A7.2.4 STI laboratory capacity, diagnosis and treatment A7.2.4.1 STI laboratory capacity Most district hospital laboratories and puskesmas can conduct simple diagnostic tests for gonorrhoea (gram stain, methylene blue), syphilis (TPHA, RPR) and trichomonas (wet mount).56 There are definite areas of weakness including very weak supply chain management for laboratory reagents and supplies, use of the TPHA rapid diagnostic test as a stand-alone diagnostic test without running RPR titres, weak laboratory quality assurance systems and SOPs and poor infection control. Laboratory capacity appears weaker in West Papua than in Papua. While there are many areas of STI laboratory capacity that need strengthening at district hospital and puskesmas level in Tanah Papua, the required level of capacity is within reach. The more sophisticated STI diagnostic tests (PCR, gonococcal culture) are carried out at the Provincial Health Laboratory and, at this stage, are not planned to be provided at district hospital or puskesmas level. A7.2.4.2 Key policies and experience Many of the key building blocks for STI control programming are in place. There are National STI Guidelines, a National STI Control Strategy (2008-2012) and a national Essential Drug List (EDL). Clinics do not always have the latest version of the national guidelines and there are standard STI drugs that are not on the EDL (see 2.4.3). On the positive side, there is valuable experience in Papua in the use of enhanced syndromic management and periodic presumptive treatment in FSWs. A7.2.4.3 National Essential Drug List WHO issues a model list of 350 essential drugs, including basic STI drugs, which many countries use as a basis for their National Essential Drug List (EDL). National EDLs are used as a basis for procurement and supply of standardized generic drugs with selection based on disease burden and cost-effectiveness. The current EDL in Indonesia does not include a number of STI drugs that are listed in the National STI Guidelines including cefixime, azithromycin and metronidazole. The National EDL is reviewed by the Indonesian MoH approximately every four years. The last revision was in 2011. In 2003, the Indonesian HIV/AIDS Prevention and Care Project (IHPCP) and FHI sent a joint submission to the Committee responsible for the review supporting the inclusion of Azithromycin (for use in FSW populations) and Cefixime in the EDL. This was unsuccessful. A7.2.5 Gaps in our knowledge of STI in Tanah Papua There are a number of important gaps in what we know about STIs in Tanah Papua including:
A7.3 Strategic approach and key activities Objective: To reduce STI prevalence in high prevalence populations in Tanah Papua Overarching Outcome: STI prevalence reduced in high prevalence populations in Tanah Papua Outcome 1: Gonorrhoea, chlamydia and syphilis prevalence reduced among sex workers Outcome 2: STI prevalence reduced among HIV-positive sex workers Outcome 3: Quality of STI diagnosis and treatment services improved at hospital and puskesmas level in Papua and West Papua Outcome 4: Increased uptake of standardized STI services for MSM and waria in selected sites How will we do it?To reduce the prevalence of STIs in Tanah Papua we need to use a combination of strategies that rely on laboratory diagnosis and strategies that rely on presumptive diagnosis. We need to use most of the STI control strategies in the toolbox (see Box 1). Countries with good access to high quality laboratory diagnosis can afford to focus on improving access to services. Countries with weaker laboratory systems, including Tanah Papua, need to include strategies that rely on presumptive diagnosis. Two broad strategic approaches are needed:
A7.3.1 Targeted STI interventions for high prevalence populations Targeted STI interventions based on presumptive diagnosis are designed as transition strategies implemented over a period of time to achieve rapid reductions in STI prevalence in high prevalence populations that have poor uptake of services. The plan over the longer term is to shift from strategies that rely on presumptive diagnosis to strategies that rely on laboratory diagnosis as prevalence drops and laboratory capacity improves. The emphasis in targeted STI interventions is on the population rather than the individual. Similarly, the challenge is to achieve high (population) participation rates rather than (individual) demand for services. The interventions are not based on waiting for individuals to decide to go to a clinic for a check-up. Health staff can go out to a brothel with a supply of doxycycline and cefixime for PPT and condoms. NGO partners can map street sex work sites and work with health staff to provide PPT medications every three months. The puskesmas and district hospitals , in partnership with local NGOs, will have a key role to play in the scale-up of standardized STI services for high prevalence populations including presumptive treatment on arrival, 3 monthly PPT, regular syphilis screening and PPT for sex workers’ boyfriends and husbands. Specific attention will be given to providing STI diagnosis and treatment for HIV-positive FSWs. Table 17 lists the recommended key strategies for each high prevalence population. This section then gives additional background on four of the recommended strategies – PPT (3.1.1), syphilis screening (3.2.2), enhanced syndromic management (3.1.3) and use of surveillance activities for STI control (3.1.4). Table 17: Key strategies for targeted STI interventions for seven populations
A7.3.1.1 Periodic presumptive treatment There is considerable experience in Indonesia and in Tanah Papua specifically, in the use of periodic presumptive treatment (PPT) for chlamydia and gonorrhoea with 1 g azithromycin and 400 mg cefixime.57 The Global Fund program supported three rounds of PPT amongst sex workers in selected sites in Tanah Papua in 2011.58 This recent experience in using PPT with brothel-based sex workers in Papua and West Papua is a definite plus. Unfortunately PPT has not been implemented in a way that will maximize impact. Faced with small unsustained reductions in STI prevalence health staff has started to question the usefulness of PPT. We need PPT to control STIs among FSWs in Tanah Papua. To improve the effectiveness of PPT, as measured by a reduction in the prevalence of STIs, we need to understand that PPT works best with:
PPT cannot work if FSWs have low condom use rates with clients and do not use condoms at all with their boyfriends. PPT can’t work if the boyfriends of FSWs are not treated as well. Otherwise, after taking the PPT drugs the FSW will just be re-infected. PPT needs to be high coverage, linked to condom use programs, and combined with PPT for boyfriends of FSWs. A7.3.1.2 Syphilis screening Indonesia has documented evidence of the effectiveness of syphilis screening in high prevalence populations. In 2003 the AusAID-supported IHPCP commissioned a pilot syphilis control and behaviour change program amongst waria in Bali involving Yayasan Kerti Praja and Yayasan Gaya Dewata. The baseline syphilis screen documented a prevalence of 26 per cent (35/132). The quality of case management was higher than is usual in Indonesia with high treatment coverage (97%), standard use of Penicillin injections, and short interval to treatment (9.7 days). The second syphilis screen in July-August 2003 documented a significant reduction in prevalence to 12 per cent (16/133). The keys to effective syphilis screening include
A7.3.1.3 Targeted screening using enhanced syndromic management Enhanced syndromic management (syndromic management plus simple laboratory tests) is an important STI control strategy in low resource settings but has its limitations. Even in high prevalence populations its accuracy can be limited. In 1999, AusAID supported an evaluation of syndromic management algorithms60 in Indonesia that showed that among FSWs syndromic management of cervical infections (gonorrhoea and chlamydia), with a Positive Predictive Value of 48 per cent, did not perform much better than random treatment. Enhanced syndromic management has been used for targeted periodic screening in FSW populations in Indonesia over the past ten years with varying results. As with PPT, there are a number of factors that can undermine the effectiveness of enhanced syndromic management:
The potential impact of the STI control strategy amongst FSWs will depend on a number of factors:
A7.3.1.4 Use of surveillance activities for STI control The largest scale and highest quality STI testing conducted in Indonesia, using sophisticated laboratory equipment and reagents (e.g., PCR for gonorrhoea and chlamydia), has been through the national surveillance system. The costs of sample collection, laboratory reagents and testing are centrally funded. Standard practice is that individuals who test positive, in accordance with unlinked anonymous testing methodology, are not treated. This is a wasted opportunity. Prior to 2006, the IBBS protocol in Indonesia included STI syndromic diagnosis and management for all FSWs participating in the surveillance activity. This was a heavy workload demand and implementation was variable. In 2006 FHI introduced confidential linked testing with PCR for gonorrhoea and chlamydia and serological testing for syphilis for FSWs participating in the surveillance, with client-initiated return for treatment. This is an exciting initiative that hopefully will be scaled-up in Tanah Papua and implemented more broadly in Indonesia.
There are four reasons why it is important to improve the quality of STI diagnosis and treatment at the level of the puskesmas and district hospital:
Activities:
Table 18: Standardized STI reagents and drugs by health facility
Will it work?The MoH looks to WHO for leadership on technical issues such as the case definition for syphilis, gonococcal antimicrobial sensitivity surveys, and unlinked anonymous surveillance methodology. We will need some level of WHO support to move ahead with these strategies. How will we know?The IBBS rounds will provide prevalence data for syphilis, gonorrhoea and chlamydia. In terms of implementing these changes, the REACH monitoring system will record key information for each REACH-supported puskesmas. Examples include:
In terms of providing services to high risk groups, the regular monitoring system can use clinic and quality control records to report on:
Will the benefits last?The benefits of changes to the national EDL and guidelines will last. Accurate syphilis diagnosis and effective treatment will require ongoing low cost support from the CoE post program. The best sustainability strategy for STI diagnosis and treatment for MSM and waria is increased demand from those communities for the services. Yüklə 5,63 Mb. Dostları ilə paylaş:
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