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Diallo 1998, Ndoye 1998, Germain 1997). This finding may reflect the general observed decline of STIs in Nairobi. Temmerman et al. described a significant reduction of syphilis prevalence since 1995 among pregnant women in Nairobi. Similarly, Moses et al. reported a decline in STD syndromes among clinic attendees in primary health care centers in Nairobi in 1998. The authors believe that this decline is a real one and suggest it to be the result of prevention and intervention programs in Nairobi. The women in our cohort reported some condom use in 63% (while 37% reported no condom use at all). In the earliest cohort in Nairobi, only 8% of the women reported some condom use (Ngugi 1988). However, after the introduction of health education and condom promotion in this cohort, the use of condoms increased dramatically resulting in over 60% of the women reporting some condom use. This most obvious explanation of this high condom use might be the existence of the community-based health education program. However, this cannot explain why the women working at home, or the group best reached by the program, reported less condom use than the other women. Mass education campaigns of the National AIDS/STD Program might possibly also have had a positive influence on behavior change within this community. Better economic factors and hence the ability to purchase the condoms might also play a role. Another factor might be the difference in characteristics of the clients, with the men frequenting the lower socio-economic sex workers refusing condoms more often. A combination of several factors is the most plausible explanation for this occurrence. The women in our study reported sex during menses and anal intercourse in 23% and 14% respectively. This is in contrast with results from the earliest cohorts of FSWs in Nairobi, where these risk behaviors were not reported at all (Plummer 1991). In the later established cohort only small numbers of women admitted to practicing anal and oral sex as well as sex during menses (Ngugi 1996). In our study, these sexual behaviors were not associated with more HIV infection probably because the women who practice them use condoms more often. We found a strong correlation between T. vaginalis infection and HIV infection. Several authors have found an association between non-ulcerative STD and HIV (Wasserheit 1992, Laga 1993). The action by which these STDs increase the susceptibility to HIV have not been defined, but potential mechanisms include: increased number of HIV target cells in the genital tract (Levine 1998); disruption of the normal epithelial barrier (Kiviat 1990); and reduction of protective T-helper and cytotoxic T-lymphocyte function (Mazzoli 1997). PREVENTION OF SEXUALLY TRANSMITTED INFECTIONS INCLUDING HIV 89
The low prevalence of the other STDs in our study might explain the failure to demonstrate associations between those STDs and HIV. The only other correlation with HIV we found was with CIN. This did not reach statistical significance probably due to the small numbers. It has been demonstrated that women with HIV are at greater risk for the development of lower genital tract neoplasia than are HIVnegative women. Among HIV-positive women, those who are more severely immunosuppressed appear to be at higher risk (Abercombie 1998). We did not have information on the status of immonosuppression among the women in our study, and hence cannot confirm this relation. However, as these women were still active as sex workers, it can be assumed that their health status was relatively good, which might further explain the failure to demonstrate a significant association. The majority of the women practiced vaginal douching and most of them used water only. Findings from other studies indicate a relation between douching with commercial antiseptics and lower HIV prevalence although they found that douching with non-commercial preparations was associated with a higher HIV prevalence (Gresenguet 1997). We equally found that vaginal douching was associated with bacterial vaginosis. In a cross-sectional study in Uganda, bacterial vaginosis was associated with increased HIV infection among younger women (Sewankambo 1997). In a subsequent longitudinal study, bacterial vaginosis was significantly associated with antenatal and postnatal HIV seroconversion (Taha 1998). Hence, we may assume that the lower HIV prevalence among women who douched in our study is probably not a true one and should be confirmed once higher numbers of women are enrolled in the study. In summary, we have identified a large population of HIV-uninfected sex workers who report high-risk behavior. It appears feasible to access these women with prevention programs, including a clinical trial. We also found that sex workers are not a coherent group and that different prevention strategies for different subgroups are needed in order to be effective. Health education programs, either at the micro or national level, seem to have had a positive impact on behavior change among FSWs, resulting in lower STI prevalence rates. Therefore, in order to reach the first objective of our study, we will have to consider increasing either the sample size or the duration of follow-up. The negative finding of our study however is the persistent low condom use despite intensive health education. This underlines the need for continuous adapted health education programs among high-risk groups as well as among the general population, especially among men. PREVENTION OF SEXUALLY TRANSMITTED INFECTIONS INCLUDING HIV 90
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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
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 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: They did not report much condom use
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
Page 133 and 134: connaissance des femmes sur la sant
Page 135 and 136: Nous avons démontré que le coût
Page 137 and 138: vonden we een hoge prevalentie van
Page 139 and 140: We hebben aangetoond dat de kost va
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