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In some parts of Africa, FSWs and their clients are considered to be the group at highest risk of HW infection and hence constitute an important population for targeted interventions. Studies among sex workers in Nairobi have shown a HIV prevalence rate of 67% and an annual HIV incidence of 47% (Plummer 1991). There is considerable evidence that both ulcerative and non-ulcerative STIs enhance HIV-1 transmission and acquisition (Wasserheit 1992, Sewankambo 1997, Kreiss 1994, Moss 1995, Laga 1993). STI control may therefore offer a means of reducing the spread of the AIDS epidemic. A randomized community trial in Mwanza, Tanzania demonstrated that improved management of symptomatic STIs resulted in a 40% reduction in HIV-1 incidence in the intervention arm (Grosskurth 1995). However, a randomized community trial of antibiotic prophylaxis every 10 months in Rakai, Uganda, failed to demonstrate any reduction in HIV-1 incidence, despite a significant reduction in the incidence of T. vaginalis and T. pallidum infection (Wawer 1999). It has been suggested that this discrepancy may be due to the maturity of the HIV-1 epidemic in Rakai at the time of the trial, which meant that most HIV-1 transmission was no longer driven by STIs (Hitchcock 1999). However, rates of N. gonorrhoeae, C. trachomatis and Haemophilus ducreyi were not significantly reduced by antibiotic prophylaxis, possibly due to their low frequency in the target population. In addition, the administration of antibiotic prophylaxis every 10 months may be inadequate, since it may have little effect on the natural history of STIs such as gonorrhea, which frequently resolve within weeks, even if untreated and which may quickly be re-acquired after treatment (Handsfield 1995, Costa 1985). A more feasible and logical approach in the face of a mature HIV-1 epidemic may be to target frequent antibiotic prophylaxis towards high-risk 'core' transmitter groups, such as sex workers, who are at high risk of acquiring both STIs and HIV-1 infection instead of targeting unselected populations. Hence we decided to set up a randomized trial of monthly azithromycin prophylaxis to prevent STIs and HIV-1 infection in a cohort of Kenyan sex workers from the Kibera district of Nairobi. Azithromycin, a macrolide antibiotic with a favorable side effect profile and a long tissue half-life, has demonstrated efficacy against the STI pathogens N. gonorrhoeae, C. trachomatis and H. ducreyi (Ridgway 1996). The objectives of this study were: (1) to evaluate the impact of regular routine azithromycin chemoprophylaxis on STI and HIV-1 incidence in this population; (2) to examine potential adverse effects of monthly azithromycin administration, including effects on antibiotic PREVENTION OF SEXUALLY TRANSMITTED INFECTIONS INCLUDING HIV 81
esistance patterns in bystander flora. This paper describes the study design, and the baseline characteristics of the first 318 sex workers screened in the study. Methods The study design was an open, randomized placebo-controlled clinical trial. Half of those enrolled received monthly azithromycin prophylaxis during 2 years. Only HIV-seronegative women were enrolled but all women were provided with the appropriate medical and counseling services and health education. From previous experience in Kenya, the cumulative risk of HIV-1 seroconversion among the FSWs was estimated to be approximately 30% over 2 years (Plummer 1991) and it was assumed that monthly prophylaxis with azithromycin would reduce the incidence to about 15%. With a β error of 0.2 (power of 80%) and a 2-sided I error of 0.05, the required sample size was approximately 120 in each group. A loss to follow-up of about 30% was expected resulting in a required sample size of about 170 in each group. The HIV seroprevalence in these women was estimated to be approximately 50% so about 680 women would have to be screened to identify 340 seronegative women. The FSWs were recruited through a network of peer-leaders. FSWs who were interested in joining the study presented themselves at the study clinic. At the initial visit, after informed consent and HIV pre-test counseling, a structured questionnaire on sexual behavior, reproductive and medical histories was administered. A full physical examination including speculum examination and laboratory STI and HIV testing was performed. At the subsequent visit, HIV-1 seronegative women were invited for enrolment into the trial. More counseling on the nature of the trial, and emphasis on the need for reduction in risk behavior, was given. An information form was provided to the women who were asked to return to the clinic if they should decide to join the study. Block randomization to either azithromycin one gram monthly or placebo took place. The study medication was given monthly in the clinic under direct observation. At each visit a urine specimen was obtained for later analysis for asymptomatic STIs (gonorrhea and chlamydia) using polymerase chain reaction (PCR). Any symptomatic STIs were treated according to the Kenyan National AIDS/STD Control Program guidelines. At each visit, all women were extensively counseled about the need for risk reduction. PREVENTION OF SEXUALLY TRANSMITTED INFECTIONS INCLUDING HIV 82
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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
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 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: 6.3. A Randomized, Placebo-controll
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
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
Page 131 and 132: 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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