GHENT UNIVERSITY Karoline FONCK - International Centre for ...
GHENT UNIVERSITY Karoline FONCK - International Centre for ... GHENT UNIVERSITY Karoline FONCK - International Centre for ...
In contrast with high overall STI prevalence rates observed among men (self-reported) as well as women in our various studies, we demonstrated a declining syphilis seroprevalence rate among pregnant women over the past years in Nairobi. One explanation might be the massive use of antibiotics among the general population in Nairobi, as by anecdotal evidence. Antibiotics are freely available and sold by vendors, in markets and in pharmacies without prescription. But this would not explain the high prevalence rates observed for the other STIs. Another explanation of this observed downward trend in syphilis serology may be the relative effective partner notification and treatment for syphilis during pregnancy, as we described. However, trends in reported STI cases should be interpreted with caution. Serwadda et al. (1996) indicated that an observed decrease in HIV prevalence among pregnant women of 2% resulted from a decrease of 4.3% owing to mortality and net out-migration and an increase of 2.3% owing to new infections. The declining syphilis seroprevalence rates we observed might have been confounded by several factors: lack of information on patterns of fertility, on age groups and on pattern of antenatal clinic use. An important determinant of STI transmission dynamics is the duration of the infection in a sexually active individual. In our studies, people with symptoms of STI waited long before attending a health facility. It has been shown that overall women are more likely than men to seek health care, however care for STIs appears to be an important exception for several reasons. Women infected with an STI are far more likely to be asymptomatic. When symptoms do occur, these are generally less clearly attributable to STIs. But even for women who do recognize the symptoms, presentation to an STI clinic may be too stigmaladen. An additional issue related to healthcare-seeking involves confidentiality. These concerns may constitute a serious obstacle to seek medical care. Condom use was found to be low in general but even more among women. Mathematical modeling projections showed that the strategy of increasing condom use among women in steady relationships is the least effective in reducing the incidence of HIV and this in different profiles of sexual behavior and for different levels of condom use tested. These results are in line with earlier ones based on more stylized models stressing the importance of reaching high-risk groups, or the core, in STI prevention. Inconsistent condom use delays but does not prevent HIV transmission in discordant couples (Van Vliet 2001). Studies have suggested that one risk factor associated with recurrent STI among women is continued sexual contact with a partner who failed to be treated (Fortenberry 1995). Another CONCLUSIONS 101
contributory factor may be that male partners fail to inform other partners about the need for treatment. We showed relatively high rates of partner notification among pregnant women but this was considerably lower among non-pregnant women. We confirmed that circumcision of the male partner was associated with lower HIV infection rates in their female partners. A meta-analysis conducted by Weiss et al. (2000) provides conclusive evidence that male circumcision is associated with a reduced risk of HIV infection in sub-Saharan Africa. There is compelling biological and epidemiological evidence supporting a protective effect of male circumcision on the acquisition of HIV infection and ulcerative STDs in men in sub-Saharan Africa (Quigley 2001). However, there are still many unknowns. These relate to the mechanisms and the role of the foreskin in the acquisition of HIV, the existence of confounders in the attribution of causality, and the expected effect of male circumcision on HIV in different populations (Van Dam 2000). There is little experience concerning the practicability, feasibility, acceptability, and cost-effectiveness of male circumcision as an HIV intervention. The effect of male circumcision on male and female risk behavior and condom use is not known, but behavioral changes related to circumcision status that result in reduced protection and increased risk-taking could well reduce the beneficial effect of male circumcision. It might therefore be premature to recommend male circumcision in currently non-circumcising communities. While we cannot fully explain the situation observed, behavior change may have played a role. The relatively low STI prevalence rates among FSWs in our studies may at least in part be due to interventions among sex workers. The importance of changes in sexual behavior has been demonstrated by data suggesting that in a number of developed and developing countries public health campaigns targeting at reducing the spread of STIs have been effective in reducing the prevalence and incidence of these infections (Gerbase 1998). The high levels of HIV infection among adolescents in our studies highlight the importance of interventions targeted at young people and their partners. While behavior change interventions, condom promotion, promotion of improved healthseeking behavior for the general population are needed, interventions targeted towards the high groups should continue. Results from simulation models indicate the merit of continued focusing of interventions on high-risk groups irrespective of the pattern of sexual behavior, even in epidemics that have already spread to throughout the general population (Van Vliet 2001), as is the case in Kenya. CONCLUSIONS 102
- Page 51 and 52: Table 2: Healthcare-seeking behavio
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- Page 57 and 58: C HAPTER 5 DIAGNOSIS AND MANAGEMENT
- Page 59 and 60: discharge and abdominal pain-two co
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- Page 63 and 64: One of the peripheral health center
- Page 65 and 66: Evaluation of Algorithms The result
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- Page 69 and 70: C HAPTER 6 PREVENTION OF SEXUALLY T
- Page 71 and 72: Table 1: Syphilis Rapid Plasma Reag
- Page 73 and 74: One should keep these problems in m
- Page 75 and 76: The use of mailed reminders did not
- Page 77 and 78: Table 1: Characteristics of women w
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- Page 83 and 84: esistance patterns in bystander flo
- Page 85 and 86: In univariate analysis, the odds ra
- Page 87 and 88: Widows, divorcees and separated wom
- Page 89 and 90: They did not report much condom use
- Page 91 and 92: The low prevalence of the other STD
- Page 93 and 94: There is some evidence that frequen
- Page 95 and 96: Table 1. Characteristics of HIV- po
- Page 97 and 98: A significantly higher prevalence o
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- Page 105 and 106: use in Kenya. In a supplement of Se
- Page 107 and 108: with intensive behavioral change in
- Page 109 and 110: C HAPTER 8 FINAL REMARKS STIs illus
- Page 111 and 112: to protect themselves and be empowe
- Page 113 and 114: Bell G, Ward H, Day S et al. Partne
- Page 115 and 116: Fleming D and Wasserheit J. From ep
- Page 117 and 118: Jackson DJ, Rakwar JP, Chohan B et
- Page 119 and 120: Manning B, Moodley J, Ross SM. Syph
- Page 121 and 122: Oberlander L, Elverdam B. Malaria i
- Page 123 and 124: Serwadda D, Gray R, Wawer M et al.
- Page 125 and 126: Van Dam J, Anastasi MC. Male Circum
- Page 127 and 128: WHO Collaborating Center on HIV/AID
- Page 129 and 130: S UMMARY Sexually transmitted infec
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- Page 135 and 136: Nous avons démontré que le coût
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contributory factor may be that male partners fail to in<strong>for</strong>m other partners about the need <strong>for</strong><br />
treatment. We showed relatively high rates of partner notification among pregnant women<br />
but this was considerably lower among non-pregnant women.<br />
We confirmed that circumcision of the male partner was associated with lower HIV infection<br />
rates in their female partners. A meta-analysis conducted by Weiss et al. (2000) provides<br />
conclusive evidence that male circumcision is associated with a reduced risk of HIV infection<br />
in sub-Saharan Africa. There is compelling biological and epidemiological evidence<br />
supporting a protective effect of male circumcision on the acquisition of HIV infection and<br />
ulcerative STDs in men in sub-Saharan Africa (Quigley 2001). However, there are still many<br />
unknowns. These relate to the mechanisms and the role of the <strong>for</strong>eskin in the acquisition of<br />
HIV, the existence of confounders in the attribution of causality, and the expected effect of<br />
male circumcision on HIV in different populations (Van Dam 2000). There is little experience<br />
concerning the practicability, feasibility, acceptability, and cost-effectiveness of male<br />
circumcision as an HIV intervention. The effect of male circumcision on male and female risk<br />
behavior and condom use is not known, but behavioral changes related to circumcision<br />
status that result in reduced protection and increased risk-taking could well reduce the<br />
beneficial effect of male circumcision. It might there<strong>for</strong>e be premature to recommend male<br />
circumcision in currently non-circumcising communities.<br />
While we cannot fully explain the situation observed, behavior change may have played a<br />
role. The relatively low STI prevalence rates among FSWs in our studies may at least in part<br />
be due to interventions among sex workers. The importance of changes in sexual behavior<br />
has been demonstrated by data suggesting that in a number of developed and developing<br />
countries public health campaigns targeting at reducing the spread of STIs have been<br />
effective in reducing the prevalence and incidence of these infections (Gerbase 1998). The<br />
high levels of HIV infection among adolescents in our studies highlight the importance of<br />
interventions targeted at young people and their partners.<br />
While behavior change interventions, condom promotion, promotion of improved healthseeking<br />
behavior <strong>for</strong> the general population are needed, interventions targeted towards the<br />
high groups should continue. Results from simulation models indicate the merit of continued<br />
focusing of interventions on high-risk groups irrespective of the pattern of sexual behavior,<br />
even in epidemics that have already spread to throughout the general population (Van Vliet<br />
2001), as is the case in Kenya.<br />
CONCLUSIONS 102
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