Syndromic approaches for common outpatient conditionsin adults: a priority

revitalising primary careBawoh. M PhD.

Service delivery at primary care

Multi-purpose health worker is expected to:• See all types of clients attending services

– < 5 years, > 5 years, young and old, men and (pregnant) women, HIV(+) and HIV(-)

• Perform all functions– Health promotion, prevention, care and service

management

• Manage all disease types– Acute, chronic, communicable, non-communicable– Irrespective of HIV status

Why syndromic guidelines for primary care?

• Care currently not standardized• Standard practice guidelines are known to improve

process, quality and outcome of care• Majority of patients present first at primary care

level

• Possibilities to confirm diagnoses are very limited• Etiological diagnosis not necessary, as long as

treatment is correct • No knowledge of HIV status• Care as entry point for prevention

Standardised case management:experiences and successes

• Integrated Management of Childhood Illness

• Syndromic Approach to STIs

• DOTS strategy to control tuberculosis

• Practical Approach to Lung health (PAL)

Benefits of standardisedcase management

• Standardisation of diagnosis and treatment• Standardisation of referral

• Case management at appropriate level of care• Rationalisation of drug use• Strengthening primary care to cope with common

outpatient conditions, including HIV and its related diseases

Development of syndromic practice guidelines: a priority

• September 2000: Rockefeller consultation

• Formation of a Syndromic Management Working Group and preparation of background paper

• April 2001: “AIDS care in Africa meeting”

• Development and research on syndromic practice guidelines for high HIV prevalence settings is a priority

Ongoing and planned research• Development by doing

– syndromic guideline development in Zimbabwe and Uganda incorporating existing STI, PAL and IMCI experience

• Strengthening the evidence base– appropriate selection of diseases and interventions to

include in the guideline for high HIV prevalence areas

– closing the guideline - implementation gap

– evaluation of implementation

Deciding on case management priorities for primary care

• General health service attendance (proxy to disease episodes and demand for care of all people attending first level facilities)

• Disease episodes encountered in HIV-infected individuals (proxy to demand for care)

• Cause specific mortality

• Response to treatment

General health service attendance1.5 million OPD visits, 1998, Zimbabwe

1. Acute respiratory infections 27%

2. Malaria 11%

3. STIs 10%

4. Skin disorders 7%

5. Diarrhoea 3%

Adult HIV rate 2000 25%

Disease episodes in Kenyan cohortof HIV-infected people

Disease Incidence1000 prsn-yrs

Frequency ofhealth serviceattendance

Resp tract inf 2382.1 2.4 x /yr

Skin disease 869.8 0.9 x /yr

STI 654.5 0.7 x /yr

Diarrhoea 567.7 0.5 x /yr

Diagram demonstrating CD4 count for different diagnoses

Asy

mp

to

Feb

Illn

ess

Upp

er R

TI

Pne

umo

Vag

ca

nd

UT

I

ST

I

Fol

licul

itis

Ora

l can

d

Chr

onic

dia

rh

050

010

0015

00

CD

4 C

ount

Diagnoses associated with immunosuppression

Excess mortality in the era of HIV

Age specific mortality rates for diarrhea in 1983 and 1995

Age groups

19831995

Dea

ths

per

1000

po

pula

tion

Existing evidence that treatment is important

Evidence Response to

treatment in HIVinfected persons

Pelvic inflammatory diseaseCohen, et al. 1997 & Bukusi et al. 1998

Bacterial pneumoniaGilks, et al. 1996

TuberculosisAckah, et al. 1995

Strengthen Health Care System

Mwanza STI study: reduced HIV incidenceGrosskurth, et al. 1995Reduced mortality in

hospitalized HIV patientsArthur, et al. 2000

40% HIV presumably died of 1st OISewankambo, et al. 2000

Survival of cohort in Nairobi who received primary health care, compared by initial CD4 count

Time in Cohort (days)

120010008006004002000

Cu

mu

lative

Su

rviv

al

1.0

.9

.8

.7

.6

.5

.4

Cd4 T-cell Count

> 499

> 499 censored

200-499

200-499 censored

< 200

< 200 censored

Gap: No comparison group

with “usual” access to care

Conclusions

• Frequent disease presentations in early stage HIV infected adults are not different from common outpatient complaints of non-infected adults

• Adequate management of selected conditions reduces case fatality of acute illness and increases quality of life and survival (?) in HIV positive people

Collaborating institutions• Biomedical Research and Training Institute, University of

Zimbabwe, Harare

• Kenya Medical Research Institute, Nairobi

• London School of Hygiene and Tropical Medicine, UK

• Nuffield Institute for Health, Leeds, UK

• University of California San Francisco, USA

• University of Washington, Seattle, USA

• Clinical Research Centre, State Medical Academy, Russia

• World Health Organization

Gaps in knowledge of treatment efficacy

PneumoniaAcute bronchitis

Sinusitis

DermatosesFolliculitis Chronic diarrhea

                               

Research & development of evaluation indicators and process

Clinical outcome

Referral pattern & rate of hospitalization

Cost of care

Incidence of OIs

Survival

Quality of life

Validation indicators