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We evaluated the validity of different algorithms for the diagnosis of gonococcal and chlamydial infections among 621 pregnant and non-pregnant women consulting for complaints of vaginal discharge in 3 City Council clinics. The mean age was 24 years and 334 (54%) were pregnant. The overall prevalence rates were: 50% candidiasis, 23% trichomoniasis, 9% bacterial vaginosis, 7% gonorrhoea, 9% chlamydia, 7% syphilis and 22% HIV. In non pregnant women, gonococcal and chlamydial infection was significantly associated with 1) demographic and behavioral risk markers such as being single, younger than 20 years, multiple sex partners in the previous 3 months; 2) symptom fever; and 3) signs including presence of yellow or bloody vaginal discharge, cervical mucopus, cervical erythema and friability. Among pregnant women only young age, dysuria and fever were significantly associated with cervical infection. However, none of these variables on itself was both sensitive and specific enough for the diagnosis of cervical infection. Several algorithms were generated and applied to the study data. The algorithm including risk markers performed slightly better than the current Kenyan algorithm. We concluded that STIs form a major problem in the Nairobi area and should be addressed accordingly. None of the tested algorithms for the treatment of vaginal discharge would constitute a marked improvement of the existing flowchart. Hence better detection tools for the specific etiology of vaginal discharge are urgently needed. An analysis of data collected through routine program monitoring indicates that syphilis serology in pregnant women has declined in Nairobi from 7.3% to 3.8% between 1993 and 1997. We analyzed routinely collected data of 1998 to describe the performance and costs of a decentralized syphilis-screening program in pregnant women. RPR seroprevalence was 3.4%. The program succeeded in screening and treating women and partners properly, but failed in performing reliable RPR tests. The cost per averted case was calculated between $95 and $112. The sustainability of this labor-intensive program is threatened by costs and logistic constraints. Alternative strategies, such as mass epidemiological treatment of pregnant women should be considered. As part of a larger study on neonatal outcome of syphilis during pregnancy, we examined the determinants of partner notification among pregnant syphilitic women. Of the 12,414 women tested for syphilis at delivery, 377 (3%) were RPR reactive. Only 53% of those women informed their partner and 36% of the partners were treated. Adverse pregnancy outcome was related to lack of treatment of the partner during pregnancy (2% versus 15%, OR 6.1, 95% CI 0.8-45). This study shows lower partner notification/treatment rates in syphilisinfected women identified at delivery than during pregnancy. These findings suggest that messages focusing on the health of the unborn child have a positive effect on partner Summary 129
notification. Innovative and locally adapted strategies for partner notification are needed in the fight against HIV/STI. A placebo controlled trial of regular antibiotic prophylaxis with azithromycin to prevent STIs and HIV in a cohort of female sex workers (FSW) was initiated in 1998. We described the baseline characteristics of 318 women screened for study enrolment. The mean age was 32 years and mean duration of sex work 7 years. The average number of clients per day was 4. High-risk behavior was frequent: 9% practiced anal intercourse, 19% sex during menses, and 3% used intravenous drugs. While 20% reported condoms use with all clients, 37% never use condoms. Despite this high-risk behavior, STI and HIV frequency was relatively low: HIV-1 27%, bacterial vaginosis 46%, trichomoniasis 13%, gonorrhoea 8%, chlamydia 7% and syphilis 6%. CIN was infrequent (3%) and tended to be more common in HIV infected FSWs. Vaginal douching was highly prevalent in this population and was significantly associated with bacterial vaginosis. In this study we have identified a large population of HIV uninfected, but high-risk, FSW. It appears feasible to access these women with prevention programs, including a proposed trial of HIV prevention through STI chemoprophylaxis. We concluded from these different studies that STI in Nairobi have already spread from high risk groups to the general population with men playing an important role as bridging group between FSWs and their spouses/regular partners. Interventions specifically targeted to men to enhance a more responsible attitude towards safer sex, while maintaining interventions directed to the high risk groups, seem necessary. We can also deduct from our results that a large proportion of people infected with STIs are not timely nor correctly treated. Several reasons appeared to be causing this: 1) health care for STIs is sought late, especially among women, and is sought from non-trained providers; and 2) the algorithm used for diagnosis of vaginal discharge is not performing very well. Innovative strategies to address these issues are urgently needed. We showed that the cost of the syphilis-screening programme in Nairobi is high while not being very effective in case finding. Presumptive treatment of all pregnant women and their partners could be considered. Mass treatment of FSWs was shown to be feasible. Summary 130
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GHENT UNIVERSITY STI PREVENTION AND
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AIDS Acquired Immune Deficiency Syn
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1.1. Sexually Transmitted Infection
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countries, the rate of reporting co
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district of Uganda randomized villa
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By identifying where significant
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4.5%, 3.9%, 67.7% and 30.1% while t
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female primary health care or anten
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The research data have been publish
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2.1. OBJECTIVES 2.1.1. General obje
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2.2.3. Laboratory procedures The mi
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C HAPTER 3 PREVALENCE AND RISK FACT
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After registration by the clinic cl
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The majority of the women were infe
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eing single, ever having been treat
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prevalence found in a family planni
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3.2. Declining Syphilis Prevalence
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Training Nurses at the antenatal cl
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We believe that the observed declin
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Wasserheit 1992, Laga 1993). In Nai
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Table 1: Demographic data of 471 pa
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women. Overall, significantly fewer
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Stigmatization by health staff also
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4.2. Health-Seeking Behavior and Se
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Between September and November 1998
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Table 2: Healthcare-seeking behavio
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Thirteen women had engaged in sex w
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Men reported more extramarital affa
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C HAPTER 5 DIAGNOSIS AND MANAGEMENT
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discharge and abdominal pain-two co
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Data were entered and analyzed in S
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One of the peripheral health center
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Evaluation of Algorithms The result
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In this study of symptomatic women,
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C HAPTER 6 PREVENTION OF SEXUALLY T
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Table 1: Syphilis Rapid Plasma Reag
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One should keep these problems in m
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The use of mailed reminders did not
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Table 1: Characteristics of women w
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Page 87 and 88: Widows, divorcees and separated wom
Page 89 and 90: They did not report much condom use
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Page 95 and 96: Table 1. Characteristics of HIV- po
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Page 101 and 102: patients. The analysis revealed hig
Page 103 and 104: contributory factor may be that mal
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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: S UMMARY Sexually transmitted infec
Page 133 and 134: connaissance des femmes sur la sant
Page 135 and 136: Nous avons démontré que le coût
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Page 139 and 140: We hebben aangetoond dat de kost va
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