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program has prevented the harmful effects of syphilis on the unborn child in 388 women, given that treatment is 100% effective. This would result in a cost of US$ 56 per averted case. The real effectiveness can be estimated at 50% to 70% because of late treatment or reinfection. Hence, the cost per case averted will vary between US$ 95 and US$ 112. Discussion Syphilis seroprevalence among pregnant women in Nairobi has decreased significantly in recent years. The RPR seroprevalence was 7.2% in 1993, 4.5% in 1996, and 3.4% in 1998 (Temmerman 1999). This decline might be the result of different intervention programs and improved health care services, including the syphilis control program, which may have had an independent effect. Hence, the program may also have had an indirect influence on the spread of HIV in this population. Overall, the clinics performed well in screening and treating RPR-seropositive women and their partners. The partner notification rate of 53% reported here is twice as high as for nonpregnant patients with an STD other than HIV who attended the same Clinic (Gichangi 2000). Concern about the unborn baby seems to motivate future fathers to get treatment (Pido 1993, Njeru 1995) and may help women to inform their partners despite the threat of possible physical abuse (Temmerman 1995). The effectiveness of the treatment may be limited because women in Kenya tend to come late for prenatal care (Temmerman 1993, Pido 1993). It is also hampered by weak screening performance in field conditions. In 1993, only 17% of RPR-positive results and 1.2% of RPRnegative results were found to be false, but monitoring and external supervision were very intensive in the early years (Jenniskens 1995). The observed reduction in the quality of the test over a 6-year period raises questions about the viability of the programs. In addition, false-positive reactions might be higher in the presence of HIV (Nandwani 1995, Joyanes 1998, Fonck 2000). Cost-effectiveness estimates of syphilis screening during pregnancy vary widely, depending on the underlying assumptions (Hira 1991, Stray-Pedersen 1980, Abyad 1995, McDermott 1993, Schmid 1996). According to a World Bank study, the prevention of congenital syphilis by routine screening and treatment is one of the most cost-effective interventions for improving child health (World Bank 1993). Our findings underscore this statement, but they also stress technical, logistic, and financial drawbacks that have been pointed out by others (Temmerman 1993, Jenniskens 1995, Rutgers 1993). PREVENTION OF SEXUALLY TRANSMITTED INFECTIONS INCLUDING HIV 71
One should keep these problems in mind when planning HIV mother-to-child transmission programs, an area where testing and antiretroviral treatment have many more implications than with syphilis testing. The question remains whether case detection and treatment is the best option. An alternative strategy could be mass treatment with penicillin in pregnancy. With a cost of US$ 1.50 per dose and an estimated acceptability of 75%, the total cost for such a program would be US$ 30,799, similar to the cost of US$ 30,966 for the current program in Nairobi. With this strategy, 1075 true-positive cases (75%) would be treated compared with 583 now. If the treatment is effective in 50% of the cases, the cost per averted case of congenital syphilis would be US$ 86, a reduction of 23%. The systematic administration of antibiotics during pregnancy may also have a positive impact on pregnancy outcome (Temmerman 1995, Gichangi 1997). Similarly, routine treatment would reduce the negative aspects of contact tracing. Concerns of mass treatment, however, are the potentially increased resistance patterns and the massive use of needles and syringes. Syphilis control during pregnancy is an effective intervention, especially in high-prevalence areas, but it requires careful monitoring, quality control, and close supervision. PREVENTION OF SEXUALLY TRANSMITTED INFECTIONS INCLUDING HIV 72
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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
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 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: Table 1: Syphilis Rapid Plasma Reag
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
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
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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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