GHENT UNIVERSITY Karoline FONCK - International Centre for ...

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The association between HIV and the STD was examined (Table 5). Gonorrhea, bacterial vaginosis, RPR seroreactivity, CIN, and genital warts and ulcers were significantly associated with HIV infection. After multivariate analysis, all factors except syphilis seroreactivity remained significantly associated with HIV infection. The presence of genital ulcers was significantly associated with RPR seroreactivity (P < 0.00). Discussion Table 5 : Association between STD and HIV Type 1 among 520 female patients, Nairobi, Kenya. Univariate OR (95% CI) Multivariate OR (95% CI)* N. gonorrhoeae 2.2 (1.1-4.4) 3.7 (1.3-10.7) C. trachomatis 0.4 (0.1-1.2) RPR positive 2.6 (1.2-5.5) 2.6 (1.0-7.0) T. vaginalis 0.9 (0.5-1.5) C. albicans 1.1 (0.7-1.7) Bacterial vaginosis 1.9 (1.2-3.2) 2.1 (1.1-3.9) Genital warts 3.0 (1.5-6.2) 5.6 (2.1-15.0) Genital ulcers 2.8 (1.7-4.8) 3.1 (1.5-6.4) CIN 3.2 (1.9-5.6) 3.7 (1.8-7.6) *Multivariate analysis including the sexually transmitted disease significant in univariate analysis Twenty-nine percent of women were infected with HIV. A cross-sectional study of the female population attending this clinic has not been done before; hence, we cannot compare with earlier prevalence rates. Studies in family planning clinics in Nairobi show much lower HIV rates (Temmerman 1998). However, among women with STD-related reports in public health facilities frequented by the same population as the one attending the STD clinic, similarly high HIV prevalence rates have been found (Fonck 2000, Ndinya-Achola 1997). An alarming finding in our study was that by the age of 20 years, 28% of women were HIV infected. This is similar to findings of other studies performed in east Africa (Konde-Lule 1997). Women in the younger age groups are infected with HIV at high rates because of a complex sociocultural and economic background. Specific interventions for HIV prevention among the youth are therefore urgently needed. The prevalence of gonococcal or chlamydial infection in this study was rather low (6% and 4%, respectively) and corresponds to prevalence rates among asymptomatic persons (Colvin 1998). The prevalence of genital ulcers was 12%, but we did not study the etiologic diagnosis of the genital ulcers. However, other studies performed in the same Nairobi clinic show that there has been a decrease over time in the relative proportion of Haemophilus ducreyi while the importance of herpes simplex virus as the cause of genital ulcers is increasing. In 1991, 68% of ulcers were culture positive for H. ducreyi (Fast 1982), whereas this value was reduced to 31 % in 1997 (Malonza 1999). In the last study, 23% of cases were caused by syphilis infection, 16% by HSV, 15% by mixed infections, and 15% were of unknown origin. The prevalence of CIN in this population of STD patients was 13%, which is similar to the PREVALENCE AND RISK FACTORS OF STI 29
prevalence found in a family planning clinic in Nairobi; however, family planning clients are often perceived as a low-risk population (Temmerman 1998). We failed to demonstrate an association between trichomoniasis and HIV infection, which has been reported by others (Draper 1998). Although the wet mounts were done in the clinic by the study physician, this was made impossible during several months because of power interruptions in Nairobi. The association between chlamydia and HIV did not reach statistical significance but showed a trend toward protection, which has been shown by others (Minkoff 1999). There is no definite explanation of this finding, but one possibility might be that we used enzyme-linked immunosorbent assay for the detection of C. trachomatis. The more sensitive polymerase chain reaction technique was not yet available; hence, chlamydia prevalence is probably underreported and might have contributed to the lack of a significant association with HIV. Also, selection bias may explain this finding. Minkoff et al. explain the negative association by suggesting that HIV positive women have an increased condom use and, hence, have lower STD prevalence rates. This explanation might be true in the United States, but is certainly not the case in the setting where we worked, in which people seldom know their HIV status. Few women claimed to have had more than one sexual partner in the last 3 months. A 3month period was used in this study as to minimize the recall bias. We think that most of these women did have only one sexual partner and, hence, must have been infected by their spouse or regular partner, as stipulated in other studies (Quigley 1997). If HIV and STD prevention campaigns aim for a significant impact, the transmission between regular partners will have to be addressed. This will be challenging, as women find it difficult to negotiate safe sex with their spouse. More gender-sensitive prevention campaigns and womenempowerment strategies will be needed. However, without strong commitment from the government, enforcing laws to protect women against rape, sexual abuse, and violence in their home, this aim will be difficult to achieve. Few of the classic risk factors studied were significantly associated with genital infections. This might be explained by the low occurrence of these risk factors in this population and, hence, the relative lack of power to prove an association. Some trends did emerge for all STDs, such as positive associations with factors relating to sexual behavior. This study confirms that having multiple partners simultaneously heightens the risk for STDs more than the number of new sex partners (Morris 1997). PREVALENCE AND RISK FACTORS OF STI 30
Page 1 and 2: GHENT UNIVERSITY STI PREVENTION AND
Page 3 and 4: AIDS Acquired Immune Deficiency Syn
Page 5 and 6: 1.1. Sexually Transmitted Infection
Page 7 and 8: countries, the rate of reporting co
Page 9 and 10: district of Uganda randomized villa
Page 11 and 12: By identifying where significant
Page 13 and 14: 4.5%, 3.9%, 67.7% and 30.1% while t
Page 15 and 16: female primary health care or anten
Page 17 and 18: The research data have been publish
Page 19 and 20: 2.1. OBJECTIVES 2.1.1. General obje
Page 21 and 22: 2.2.3. Laboratory procedures The mi
Page 23 and 24: C HAPTER 3 PREVALENCE AND RISK FACT
Page 25 and 26: After registration by the clinic cl
Page 27 and 28: The majority of the women were infe
Page 29: eing single, ever having been treat
Page 33 and 34: 3.2. Declining Syphilis Prevalence
Page 35 and 36: Training Nurses at the antenatal cl
Page 37 and 38: We believe that the observed declin
Page 39 and 40: Wasserheit 1992, Laga 1993). In Nai
Page 41 and 42: Table 1: Demographic data of 471 pa
Page 43 and 44: women. Overall, significantly fewer
Page 45 and 46: Stigmatization by health staff also
Page 47 and 48: 4.2. Health-Seeking Behavior and Se
Page 49 and 50: Between September and November 1998
Page 51 and 52: Table 2: Healthcare-seeking behavio
Page 53 and 54: Thirteen women had engaged in sex w
Page 55 and 56: Men reported more extramarital affa
Page 57 and 58: C HAPTER 5 DIAGNOSIS AND MANAGEMENT
Page 59 and 60: discharge and abdominal pain-two co
Page 61 and 62: Data were entered and analyzed in S
Page 63 and 64: One of the peripheral health center
Page 65 and 66: Evaluation of Algorithms The result
Page 67 and 68: In this study of symptomatic women,
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
Page 79 and 80: studies, indicating that couples ar
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6.3. A Randomized, Placebo-controll
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esistance patterns in bystander flo
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In univariate analysis, the odds ra
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Widows, divorcees and separated wom
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They did not report much condom use
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The low prevalence of the other STD
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There is some evidence that frequen
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Table 1. Characteristics of HIV- po
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A significantly higher prevalence o
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There is now considerable evidence
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patients. The analysis revealed hig
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contributory factor may be that mal
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use in Kenya. In a supplement of Se
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with intensive behavioral change in
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C HAPTER 8 FINAL REMARKS STIs illus
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to protect themselves and be empowe
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Bell G, Ward H, Day S et al. Partne
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Fleming D and Wasserheit J. From ep
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Jackson DJ, Rakwar JP, Chohan B et
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Manning B, Moodley J, Ross SM. Syph
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Oberlander L, Elverdam B. Malaria i
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Serwadda D, Gray R, Wawer M et al.
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Van Dam J, Anastasi MC. Male Circum
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WHO Collaborating Center on HIV/AID
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S UMMARY Sexually transmitted infec
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notification. Innovative and locall
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connaissance des femmes sur la sant
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Nous avons démontré que le coût
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vonden we een hoge prevalentie van
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We hebben aangetoond dat de kost va
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