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use in Kenya. In a supplement of Sexually Transmitted Infections, published in 1998, seven
papers evaluating the performance of the WHO vaginal discharge algorithm to gonococcal
and chlamydial infections were presented. Some consistent findings emerged from these
studies, and were also observed in our study (Dallabetta 1998). The symptom of vaginal
discharge is neither sensitive nor specific as a predictor of cervical infection. Symptoms of
vaginal discharge are more likely a manifestation of a vaginal infection, candidiasis,
trichomoniasis or BV. An approach that assigns treatment for cervical infection to women
with either positive risk assessment or signs of cervical or uterine inflammation is relatively
sensitive, but so non-specific that the PPV is probably too low to warrant treatment for
cervical infection in most settings. The diagnostic accuracy of all the currently available
simple screening / diagnostic tools for gonococcal and/or chlamydial infections is poor. And
finally, the clinical skills of the providers appear to significantly influence the performance of
decision models when physical assessment is included in the model. Furthermore, one
algorithm does not fit all settings. In family planning clinics, vaginal discharge algorithms with
high specificity for diagnosis of vaginal infection would be favored. On the other hand, in an
STD clinic or sex worker clinic, high sensitivity is favored because the prevalence of cervical
infection is elevated and the risk of future transmission is often high.
Based on our finding of high prevalence rates of NG/CT cervicitis in women presenting with
vaginal discharge, it would be appropriate to administer treatment for NG and CT at first visit
at least for non-pregnant women. This however implies an increased overall cost due to the
price of the antibiotics. There is a great need for simple, cheap, and reliable screening tests
for gonorrhea and chlamydial infection. This would allow screening at antenatal, family
planning, or maternal and child health clinics, and better management for symptomatic STI
patients in developing countries. Rapid tests for C. trachomatis and N. gonorrhoeae are on
the market however have not been evaluated. There is hope that rapid diagnostic tests of
proved value will be available within a few years (Mabey 2001).
We have been able to identify some obvious weaknesses at different levels that are useful to
indicate where it might be appropriate to focus interventions. Health-seeking behavior of
those individuals aware of their disease is poor, especially for women. Education and/or
counseling on appropriate healthcare-seeking implies awareness of potential signs and
symptoms of STIs and availability of adequate STI services, but both are generally found to
be weak (WHO 1999). Innovative strategies for improved health-seeking behavior are
therefore needed. To optimize STI health care, STI services must also be offered as part of
routine primary health care by both public and private sector providers.
CONCLUSIONS 104