The syndromic approach to treatment of sexually transmitted diseases in low-income countries: issues, challenges, and future directions.
BACKGROUND
Sexually transmitted diseases (STDs) are a major cause of adult morbidity worldwide. In 1991, the World Health Organization (WHO) introduced the concept of the "syndromic approach" to managing sexually transmitted diseases in low-income countries, however, there has been some controversy regarding the ongoing use of this approach.


OBJECTIVE
(1) To understand the use of the syndromic approach to managing sexually transmitted diseases in low-income countries, and to determine if evidence supports its continued use. (2) To help Canadian doctors understand the past STD management of immigrant patients from low-income countries, and evaluate the direct effect (if any) of such medical practices to the patient's health and perception of health in Canada.


METHODS
Medline was searched under the key words "sexually transmitted diseases," "developing nations," and "syndrome," as well as "algorithms," "prevention and control," and "WHO." Research articles and data were also accessed from the Web sites of WHO, UNAIDS, Reproductive Health Online (JHSPH), and the Centers for Disease Control and Prevention (USA). Data were selected based on the relevance to the topic, and research articles assessed from a methodological perspective. Most research articles were of Level II-2 evidence or lower as described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam.


RESULTS
In resource-poor countries, the use of the syndromic approach is appropriate for high-risk groups and for symptomatic individuals. However, it is still a poor screening approach when applied to asymptomatic cases, particularly in women. Risk scoring and simple laboratory tests help to increase the algorithmic sensitivity of the syndromic approach.


CONCLUSIONS
Syndromic management involves making clinical decisions based on a patient's symptoms and signs. Until inexpensive, simple, and accurate STD diagnostics are developed and made available for use in low-income countries, a modified syndromic approach is the most feasible method of STD management in these countries. It is useful for Canadian physicians to be aware of this approach especially when caring for women from these countries.
McMaster University, Hamilton, ON, Canada.
Lynda
L
Redwood-Campbell
James
J
Plumb
D000465:Algorithms; D002170:Canada; D004641:Emigration and Immigration; D006801:Humans; D016239:MEDLINE; D011203:Poverty; D012749:Sexually Transmitted Diseases / Q000175:diagnosis / Q000517:prevention & control / Q000628:therapy*; D014944:World Health Organization