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Discussion The most common pathogens found among women complaining of vaginal discharge in this study were Candida albicans and Trichomonas vaginalis. This is not surprising and has been shown in similar studies among women presenting with vaginal discharge in other African settings (Costello 1998, Alary 1998, Mayaud 1998). The prevalence of bacterial vaginosis in our study was low compared with other studies in the region (Wawer 1998, Thomas 1996) and is probably an underestimation. Indeed, we used the clinical diagnosis for bacterial vaginosis, which is subject to interpretation by the clinician. Furthermore, the identification of clue cells depends on the level of training of the person performing the microscopic examination. Also, the quality of the Gram stain might have influenced the results. The combination of these factors might have resulted in an underestimated prevalence. Overall, no cervical or vaginal pathogen or condition was found in 28% of the women. Again, this is similar to the findings in Mwanza where 23% of the women at the STD clinic and 27% at the antenatal clinic had no demonstrable pathogen (Mayaud 1998). We found a prevalence of cervical infections of 16%. Non-pregnant women had significantly more gonococcal infection, genital ulcers, and HIV infection but pregnant women had more candidiasis. The high proportion of pregnant women with an STD is a cause for concern. Gonococcal and chlamydial infections, as well as syphilis and HIV, are associated with adverse obstetric outcome (Ryder 1991, Temmerman 1992, Leroy 1998, Temmerman 1990). The results of this study show that there is an urgent need for public health measures to improve STD control during pregnancy. The prevalence of the different RTI varied between the different clinics under study. Surprisingly, the prevalence rates for most RTI were higher in one of the PHC clinics than in the STD referral clinic. Although the two PHC clinics where enrolment took place are located very close to each other, the prevalences varied here also, indicating that the populations attending the different clinics are quite different. Lower socio-economic conditions seem to be the basis for higher STI prevalences. Health staff at all levels of medical facilities should become aware that all women are to be considered at high risk, and that their treatment inclusive of health education and counseling has to be stressed. The stereotype image that only patients attending the STD clinic are at high risk has to be revised urgently so as to eliminate the stigma still attached to STDs and hence to make STD control more effective. DIAGNOSIS AND MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS 65
In this study of symptomatic women, the association of the classic clinical symptoms and signs with the presence of gonococcal and/or chlamydial infection was quite different among pregnant and non-pregnant women. Several demographic risk determinants and signs were predictive of cervical infection among non-pregnant women while hardly any were among pregnant women. As a result, the various flow charts that were tested performed systematically better in the group of non-pregnant women. The algorithm in use in Kenya as national policy had a sensitivity of 42% and a specificity of 63% for the detection of N. gonorrhoeae or C. trachomatis and thus failed to discriminate between infected and uninfected women. This algorithm relies on bimanual examination of the patients, and hence requires an examination table and gloves, items often not available in the health centers. As a result, the algorithm is, in practice, often applied without performing this examination. Furthermore, the bimanual examination is subject to interpretation and depends on the experience of the person performing it. In our study the physical examinations were done by medical doctors, and they reported almost all women in the study to have abdominal tenderness. In practice in the health centers, the examinations are performed by nurses who are less well trained; hence we can assume that the results would be worse. We therefore also tested the Kenyan algorithm but without performing the bimanual examination (algorithm B). The results are similar and in fact have a higher sensitivity. The risk score used to discriminate cervical infection, as promoted by the WHO, has been evaluated in several African settings (Mayaud 1998, Thomas 1996, Vuylsteke 1993, Diallo 1998, Mayaud 1995, Germain 1997). We used a simplified risk score without symptoms in the partner as this information is sensitive and difficult to obtain. Personal communication with health care workers and data from our other studies (unpublished) suggested that symptoms in the male partner are seldom known by the woman and are hence unreliable. This was confirmed in a study by Thomas et al. who found that only 2% of mostly married women reported partners having symptoms. Hence, including this risk factor would only increase the specificity but not the sensitivity of the flow chart. The algorithm we tested (C) was based on presence of any of the risks: being single, being less than 20 years old, having had multiple or a new partner in the past 3 months. An earlier study in Nairobi also reported being single and having multiple sex partners to be associated with gonococcal infection in pregnant women (Costello 1994). We considered that for a risk score to be applicable it has to be simple to use. The health care worker in a busy health center has no time and patience to apply scoring systems with weighted risks or calculations of scores. In our study a risk score based on presence of at least two of the risks would have resulted in a sensitivity of only 30%. DIAGNOSIS AND MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS 66
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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
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 and 30: eing single, ever having been treat
Page 31 and 32: prevalence found in a family planni
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: Evaluation of Algorithms The result
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
Page 81 and 82: 6.3. A Randomized, Placebo-controll
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
Page 99 and 100: There is now considerable evidence
Page 101 and 102: patients. The analysis revealed hig
Page 103 and 104: contributory factor may be that mal
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
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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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