Since the early 1990s there has been evidence that some reproductive tract infections (RTIs) enhance the transmission of HIV, the virus that causes AIDS. Because of this finding, the Programme of Action developed at the 1994 International Conference on Population and Development in Cairo endorsed the integration of the diagnosis and treatment of these conditions into maternal and child health/family planning programs. To encourage this integration, public health institutions have developed screening tools intended to assist in the diagnosis and management of various RTIs, including such sexually transmitted infections (STIs) as gonorrhea and chlamydia. (These STIs are 50 percent to 300 percent more prevalent among women than among men.)

These tools were created because standard laboratory tests to identify some STIs are expensive and require equipment that is generally unavailable to clinics in developing countries. The primary screening approach developed, syndromic management, diagnoses infection based on the presence of vaginal discharge, lower abdominal pain, or other symptoms, signs, or risk factors, rather than on laboratory tests. Clinics began using this method before it had been adequately evaluated.

Three recent studies conducted by Population Council researchers and their colleagues find that the syndromic approach is not an effective strategy for diagnosing or managing gonorrhea, chlamydia, and other RTIs among women. One study was a meta-analysis, which reviewed and evaluated 32 peer-reviewed, published studies of the syndromic approach for detecting chlamydia and gonorrhea. The other two studies assessed the efficacy of the method when used to diagnose and manage chlamydia, gonorrhea, trichomoniasis, candidiasis, and bacterial vaginosis. One study took place at the Nakuru Municipal Council family planning and antenatal care clinics in Kenya. The other was designed to obtain information that would enable the Zimbabwe National Family Planning Council to develop the most appropriate and cost-effective approach to managing RTIs in its clinics.

Low sensitivity, high false-positive rate
All three studies found that the syndromic management approach has low sensitivity (correctly identifying women who have the condition), moderate specificity (correctly identifying women who are not infected), and results in high false-positive rates. The meta-analysis, for example, revealed that the average sensitivity of the method in groups of women with a moderate prevalence of gonorrhea and chlamydia (an average of 7 percent) is about 35 percent. Specificity in that situation is roughly 75 percent, but the false-positive rate is approximately 90 percent. The study in Zimbabwe arrived at similar conclusions, while the Kenya study indicated that the approach correctly identified only about 5 percent of family planning clients with RTIs and 16 percent of women with RTIs who attend antenatal clinics.

These results show that clinicians do not identify the majority of women with infections when they use the syndromic approach and that they needlessly expose many uninfected women to treatment and the stigma associated with infection. One reason for the failure of this method is the fact that a large number of women with RTIs have no clinical signs or symptoms suggestive of an infection.

“The syndromic approach to diagnosing cervical STIs in women is not helpful and is potentially harmful because it reduces the time in which physicians can be doing something else that is known to be beneficial for clients,” emphasizes Beverly Winikoff, director of the Council’s Reproductive Health Program and an author of the meta-analysis study. The authors of the meta-analysis also note that these findings probably overestimate the validity of the syndromic approach because, in everyday use, physicians are unlikely to be as thorough in their application of the method as they were during the various studies.

Recommendations
These findings highlight the importance of developing simple, inexpensive, and valid field diagnostics, particularly for identifying and treating women with gonorrhea and chlamydia. The researchers acknowledge that there is no simple, inexpensive way to effectively diagnose women with gonorrhea and chlamydia. They recommend that health care workers systematically educate and communicate with clients in order to reduce the amount of unsafe, unprotected sex; promote condom distribution in both clinical and nonclinical settings; and improve counseling services to increase clients’ knowledge, perception of personal risk, and skills to negotiate condom use.

Sources
Sloan, Nancy L., Beverly Winikoff, Nicole Haberland, Christa Coggins, and Christopher Elias. 2000. “Screening and syndromic approaches to identify gonorrhea and chlamydial infection among women.” Studies in Family Planning 31(1): 55–68. (PDF)

Maggwa, Ndugga, Ian Askew, Caroline Marangwanda, Sithokozille Simba, Hazel Dube, Rick Homan, Barbara Janowitz, Ahmed Latif, and Peter Mason. 1999. “Demand for and cost-effectiveness of integrating RTI/HIV services with clinic-based family planning services in Zimbabwe.” Africa OR/TA Project II report. Nairobi, Kenya: Population Council.

Solo, Julie, Ndugga Maggwa, James Kariba Wabaru, Bedan Kiare Kariuki, and Gregory Maitha. 1999. “Improving management of STIs among MCH/FP clients at the Nakuru Municipal Council health clinics.” Africa OR/TA Project II report. Nairobi, Kenya: Population Council.

Outside funding
The John D. and Catherine T. MacArthur Foundation, The Andrew W. Mellon Foundation, The Rockefeller Foundation, and the United States Agency for International Development

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