In India, these infections are no more limited to high-risk groups or in some specific geographic areas in the cities but are now prevalent all over the country.

As per NACP III action plan 40 million new episodes of curable STI/ RTIs per annum occur in India. Prevalence of suggestive symptoms of STIs/RTIs as per ICMR, 2005; multi-centric study, NIRRH, Mumbai [1] are - Women: 23 – 43%; Men: 4 – 9%.As per Community-based laboratory supported STI/RTI prevalence study 2002 (ICMR-NACO), 6% among adult population was found to be having STIs/RTIs [1]. Most important among all these is India is having 2.4 millions of living HIV infected patients (UNAIDS) [3].

Measures for preventing sexual transmission of HIV and STIs are the same, as are the target audiences for interventions. Moreover, STIs also facilitate HIV transmission. Monitoring trends in STIs provides valuable insight into the likelihood of the importance of sexual transmission of HIV within a country and the impact of behavioural interventions.

The 11 Member countries of the South East Asia Region (SEAR) endorsed WHO’s “Regional Health Sector Strategy on HIV (2011-2015)” in Jaipur, India, to meet these challenges and has recognised inadequately trained health care providers and poor quality and unregulated medical services as important factors due to which STI control programmes often fail. Healthcare providers (HCPs) play an important role in reducing the burden of STI and stemming the spread of STI through effective prevention and case management.

Expanding services for screening and testing for STIs and provision of good quality STI management into primary health care, sexual and reproductive health services and HIV services have been recognised as major proposed country actions [5]. This is to ensure provision of effective treatment at first encounter. For primary care settings in lowand middle‐income countries, syndromic management of STIs in patients presenting with consistently recognized signs and symptoms has been advised.

Under Syndromic management diagnosis is based on the identification of syndromes which are a combination of the symptoms the client reports and the signs the health care provider observes. The recommended treatment is effective for all the diseases that could cause the identified syndrome and provides single-dose treatment as far as possible [1].

• To determine awareness and opinion regarding Syndromic approach towards STI / RTI case management among the practitioners in private sector.
• To compare the results with the previous large scale studies and to provide suitable recommendations.

The present study was a Cross sectional study in urban Patiala. Patiala is one of the 5 major cities of Punjab, a northern region state in India. Study population was qualified health care providers in private sector. Firstly, lists of private practioners were procured and compiled after collecting information from different sources such as members list of Indian Medical Association (Patiala Chapter), private practitioners list available with Pharmacist association, online resources, information from private sector hospitals and members list of National Integrated Medical Association (Patiala Chapter). Quacks, faith healers and non degree holder practioners were excluded from the study population. Permission was granted by Institutional review and ethics committee.

The health care providers (HCPs) under the study area were categorised into two categories based on their qualification. Category 1(Group A) included allopathic practitioners employed either in private health institutions or engaged in own private practice. Doctors trained in indigenous Non allopathic medical systems such as Ayurveda and Homoeopathy were grouped in Category 2 (Group B).

Group A study population was then reduced to general MBBS practitioners and specialists of Medicine, General Surgery, Dermatology and Gynaecology only to make the target population more specific. The other private practioners practising super speciality services and specialists of other streams were excluded.

Sample size calculated keeping allowable error at 10% was found to be 89. It was extended and round figured to 100. Since, no. of practioners in both the selected groups was almost equal so50 each from both the categories were selected. Though NACO guidelines for STI case management were more relevant to Category 1 but Category 2 was included in the study, because of the fact that a

Most common condition countered by both the groups was lower abdominal pain and less common were inguinal bubo, genital warts in both the groups. Major difference was seen in cases of HIV, Hep B & C countered during practice where only 28 % non allopathic practitioners had observed any known case of HIV in comparison to 54 % of allopathic practitioners. Among Group B, 50% and 20 % have countered HBs Ag+ (Hep-B) and HCV +ve (Hep-C) cases respectively in comparison to 78 % and 54 % respectively in Group A.

Only 14 % among Group A and only 2 % among Group B in the present study had ever undergone any training on STI/ RTI. It clearly shows lack of training among private practioners. When the participants were asked about their willingness to undergo short training/ CME/Seminar on STI/RTI/ HIV, 58 % of the participants in Group A were willing to attend while in Group B 74 % had shown interest. It indicates higher interest to gain knowledge among non-allopathic private practioners.

Table 1:Qualification and experience of the Participants

Table 2: Conditions/ signs/ symptoms countered in patients in OPD

Those who were not aware of syndromic approach were briefly told about it, in predefined terms that “It is the approach being advised by International and National agencies to go for treatment regimens available as kits based on the identification of consistent groups of symptoms and easily recognized signs (syndromes), which will deal with the majority or most serious organisms responsible for producing a syndrome complimented by appropriate laboratory investigations where facilities exist.” Then their opinion regarding this approach was asked, findings are being presented in Table 4.

Regarding treatment modality being used by the practioners in management of STI/ RTIs, 98% among Group A which comprises Allopathic practioners uses allopathic drugs while 2 (4%) of them told about using NACO advised kits at any moment during their practice (Table 5). The participants in Group B, although comprising of Non allopathic practioners but 74 % admit prescribing allopathic medicines in such patients along with Ayurvedic and Homeopathic medicines which is worth consideration.

Since, it has been shown by the previous studies that majority of patients in Punjab [9], we can also say in India [10] prefer consulting private practioners and more often non allopathic. So, it becomes important by itself that quality of STI management practices must be ensured by involving private practioners.

A study in a nearby city Ludhiana concludes that the most common symptoms reported by the women sufferers were urinary (dysuria 57.8%, frequent urination 53.3%), followed by dyspareunia (26.7%), unusual vaginal discharge (24.4%) and vaginal itching (22.2%). 64.4% of those with symptoms were untreated, 68.7% of those treated reported partial relief, most of those treated preferred private doctors, and the partners were not treated [12].

Similarly in Karnataka among the interviewed medical practitioners two-thirds reportedly received STI patients and one-half received HIV/AIDS patients. Almost all these practitioners treat STI patients but only 1/3rd treat HIV/AIDS patients. Most common symptoms observed in male STI patients were genital sores/ulcers, genital discharge/dripping and burning pain on urination followed by genital itching, redness/ inflammation in genital area, and groin swelling.

CME, seminars or printed educational material and treatment guidelines. This becomes more important when these private practioners especially Non allopathic practioners themselves recognise need for such trainings and are willing to undergo trainings on STI/RTI management.

As many of the practioners are not aware of Suraksha Clinics, how can one hope that these practioners will refer such patients to such designated centres for HIV testing, ICTC for counselling. This further lends its effect on missed out cases of HIV.

Since, practice of syndromic case management of STIs is presumed to be dependent on the HCP’s individual opinion and attitude towards syndromic case management hence it is beneficial to know about their opinion.

To raise the rates of treatment and prescriptions as per WHO advised strategy of Syndromic management, confidence building and appropriate knowledge to the health care providers is a must. Only then we can hope that the adopted strategy can be turned into practice if negative perceptions among practioners would be handled carefully.

It is of serious concern that almost 3/4^th of Non allopathic practioners are using allopathic medicines in such cases along with Ayurvedic/ Homeopathic medication.Neither they are qualified for it nor are they adopting ‘Syndromic approach’. Such practices will likely result in drug resistant cases.

The present study was one of the first of its kind done in north India. Although similar studies have been conducted in other states such as Gujarat and Karnataka but no baseline data was available for this region.

Since, adequate management with appropriate medication is the right of every citizen and it is the responsibility of the administration to provide so and moreover the need for training and supervision has been felt at every aspect in this study whether in terms of refreshing their knowledge, developing attitudes or monitoring the practices of managing the STI/ RTI patients.

It is expected that these results will also be useful for agencies and individuals involved inthe fight against STI/HIV/AIDS elsewhere in the country.