An estimated 30 million episodes of STI/RTI occur every year in the country. Sexually Transmitted Infections (STI) and Reproductive Tract Infections (RTI) enhance chance of acquiring and transmitting HIV infection by 4-8 times.
Individuals with STI/RTI have a significantly higher chance of acquiring and transmitting HIV. Moreover STI/RTI are also known to cause use infertility and reproductive morbidity. Controlling STI/RTI helps decrease HIV infection rates and provides a window of opportunity for counselling about HIV prevention and reproductive health.
Provision of Sexually Transmitted Infections (STI)/Reproductive Tract Infections (RTI) services is aimed at preventing HIV transmission and reducing reproductive morbidity. Treatment and control of STI/RTI reduces the transmission rate of HIV infection by more than 40%. Control of STI/RTI is the most cost effective means of preventing new HIV infection. Enhanced Syndromic Case Management (ESCM), with minimal laboratory tests is the cornerstone of STI/RTI management under National AIDS Control Programme.
I. Salient Features:
Syndromic Case Management (SCM) is the cornerstone of STI/RTI management, being a comprehensive approach for STI/RTI control endorsed by the World Health Organization (WHO). This approach classifies STI/RTI into syndromes, which are easily identifiable group of symptoms and signs and provides treatment for the most common organisms causing the syndrome. Treatment has been standardized through the use of pre-packaged colour coded STI/RTI drug kits. SCM achieves high cure rates because it provides immediate treatment on the first visit at little or no laboratory cost. However, it goes hand in hand with other important components like counselling, partner treatment, condom promotion and referral for HIV testing.
II. Tasks, Personnel and Structures:
STI/RTI services are provided through specified clinic settings in government sector as well as and through involvement of preferred private providers. Health workers (HW), ANM, Accredited Social Health Activists (ASHA) and Link Workers (LW) are also actively engaged in conduction of STI/RTI prevention and health promotion activities and refer individuals with STI/RTI symptoms to PHC, Block PHC, Community health centres (CHC) for management of the STI/RTI cases. STI/RTI clinical services are provided at Sub district level through health facilities (PHC/Block PHC/ CHC/Divisional hospitals/Urban Health Posts etc) using the Syndromic Case Management approach. Laboratory services wherever available are used to corroborate syndromic diagnosis. trained counsellor.
• STI/RTI Service in Government Health Facilities:
Presently NACO supports at-least one STI/RTI clinic per district in the country. These clinics are called Designated STI/RTI clinic. These clinics function from existing health care delivery system using their space, staff and other resources. NACO has provided support to these clinics to provide high quality STI/RTI services through audio visual privacy, furniture and instrument for conducting internal examination, provision of central supply of colour coded STI/RTI drug kits, RPR kits and consumable for conducting basic laboratory test and computers for maintaining digital records. Each of these clinics is also provided with one trained counsellor.
•• Provision of STI/RTI Services in High Risk Group Population:
The provision of a standardized package of STI/RTI services to High Risk Group (HRG) population is an important component of the Targeted Intervention projects. All the HRG population receives packages of services which includes:
1. Free consultation and treatment for their symptomatic STI complaints
2. Quarterly medical check-up
3. Asymptomatic treatment (presumptive treatment)
4. Bi-annual syphilis and HIV screening
Preferred Private Provider approach has been rolled out to scale up STI/RTI services to HRG population under TI Projects. These providers are selected by the community members through focused group consultation. This approach has enhanced access to services for the HRG. Under this approach, all the HRG receives free STI/RTI treatment and the providers receive a token fee per consultation. Over 3000 preferred providers are providing STI/RTI services to the HRG. All these preferred providers are trained using a standardized curriculum on syndromic case management. Colour coded STI/RTI drug kits have also been made available to these providers for free treatment of sex workers, MSM and IDU, and data collection tools are also provided to them. The involvement of private practioners for providing STI services to HRG at such a large scale are one of the few success attempted globally.
• Regional STI/RTI Training and Research Centre:
Seven Regional STI training, reference and research centres have been strengthened by NACO. The role of these centres is to provide etiologic diagnosis to the STI/RTI cases, validation of syndromic diagnosis, monitoring of drug resistance to gonococci and implementation of quality control for Syphilis testing. Three more centres are being set up under NACP IV. There are forty five state reference centres linked to these regional STI centres, which are further attached to designated clinic, CHC and PHC in each of the state for providing laboratory support for managing difficult STI cases. The state reference centre are trained and mentored by Regional Centre for carrying out etiologic diagnosis of STI.
• Communication on STI/RTI Service Delivery:
Sexual and Reproductive health services at designated clinic have been branded “Suraksha Clinic” (meaning protection). The branding has been done to overcome the stigma attached to STI and to promote sexual health services. To generate demand for STI/RTI services a communication strategy is ongoing through specially designed TV and radio campaigns. The campaign address issues of fear and reluctance in seeking treatment.
• Convergence with NRHM:
STI/RTI services are also an integral part of services provided at all government health facilities including PHC/CHC. At each of these health facilities a standardized service delivery protocol is followed, free STI drugs are provided to the patients, medical and paramedical staff are trained and monthly reports on STI/RTI indicators are reported from these facilities in existing HMIS.
Convergence has been strengthened at the national level through constitution of a joint working group and development of national operational framework for STI/RTI services delivery at sub-district health facilities. National technical guidelines and training modules for medical officers and paramedical staff for STI/RTI services have been developed jointly.
• Partnering with Organized Public Sector, Public Sector Undertaking and Professional Organization:
The major proportion of patients with STI/RTI seek services from the vast network of private health care delivery systems ranging from freelance private practitioners to large public hospitals. Also, many populations are accessing services from public health care systems under other sectors like railways, ESI, armed forces, CGHS, railways, port hospitals as well as health facilities of public sector undertakings like Coal India Ltd, SAIL etc. It has been felt that reaching out to maximum numbers of people suffering from STI/RTI is not possible without partnership with private sector and organized public sectors. NACO has initiated partnership with organized public sectors and private sectors through professional associations to support the delivery of STI/RTI services with the objective to reach the populations presently not covered by the public health care delivery system.
• Pre-packed STI/RTI colour-coded Kits:
The pre-packing of STI/RTI drug kits has helped to standardize the treatment. The colour coded STI/RTI kits have been provided for free supply at all government STI/RTI clinics, CHC/PHC and TI NGOs. These colour coded drug kits are procured centrally by NACO and dispatched to all SACS and district level consignees, and are being distributed to facilities for use. The pre-packaging of the drugs is being recognized as one of the global innovation in STI programme management. States have also been provided the specifications of the same to facilitate procurement at their end.
• Counseling of STI/RTI clinic attendees:
A trained counselor is provided at every designated STI/RTI clinic to counsel the patients attending these clinics towards risk assessment, compliance to treatment, partner treatment, referral for syphilis and HIV testing and condom usage.