Issues in the management of sexually transmitted diseases in Papua New Guinea

This paper outlines three important issues in the clinical management of sexually transmitted diseases (STDs) in Papua New Guinea which have, until now, gone unrecognized or been neglected. Suggestions for possible solutions are made. The high prevalence of both chlamydial and trichomonal infections in women cannot be ignored. Both of these infections have been shown to increase the transmission of HIV. The current algorithm for the treatment of vaginal discharges does not include treatment for trichomonal infection in the first instance, yet trichomoniasis has been shown to be the most common STD in community studies both here and elsewhere. Trichomoniasis is usually asymptomatic in men, but still increases the risk of HIV transmission; furthermore, it causes illness in their female partners and thus needs to be treated. The current recommended regimens for the treatment of gonococcal and chlamydial infection are complex due to the number of drugs recommended for gonorrhoea to combat the problem of drug resistance, and the length of therapy for chlamydia. Compliance with such a regimen is likely to be poor, particularly in asymptomatic partners. We need to consider the relative advantages provided by a drug which could be given as a single oral dose for chlamydia, and perhaps for both infections. Azithromycin is one possibility, as it has been shown to be effective for chlamydial infection in numerous studies, and has been found satisfactory for gonorrhoea where local isolates were susceptible. Testing of a small number of isolates from Papua New Guinea has shown that azithromycin may be suitable for use here, but further susceptibility testing needs to be performed. Utilization of services for STDs, particularly by women, is extremely low. This is due to a combination of factors involving limited knowledge of symptomatology and its significance, the asymptomatic nature of many infections, the structure of the services, health worker behaviour, and social attitudes. To address these issues we must make modifications to STD service provision, as well as provide widespread information about the potentially serious consequences of contracting STDs, including both infertility and AIDS. Possible modifications to the services are discussed, and include making routine screening available for women through currently existing services such as family planning and antenatal clinics and considering the possibility of establishing Women's Health Clinics which would provide all primary reproductive health services in an integrated manner.