A population-based study of syphilis and sexually transmitted disease syndromes in north-western Tanzania. 1. Prevalence and incidence.

OBJECTIVE--To determine the prevalence of syphilis and the prevalence and incidence of self-reported STD syndromes in the population of Mwanza Region, North-Western Tanzania. METHODS--A population-based random cluster sample survey, stratified by rural, roadside or urban residence, of 4173 individuals aged 15-54 years was performed in 1990-91. The seroprevalence of syphilis (using TPHA and RPR) and the prevalence and incidence of self-reported genital ulcer syndrome (GUS) and genital discharge syndrome (GDS) were determined. RESULTS--Active syphilis was detected in 9% of the adult population, while 15% had serological evidence of past or current infection. Seroprevalence was significantly lower in the rural than in the roadside and urban populations, but there was little difference between men and women. Amongst men, a history of GDS was reported by 28%, and a history of GUS by 14%, with point prevalences of 2.3% and 1.3% respectively. Annual incidence among men were 6.8% for GDS and 3.6% for GUS. Women reported these conditions less frequently. There was little difference between the strata in the prevalence or incidence of reported STD syndromes. CONCLUSION--Sexually transmitted diseases represent a major public health problem in both the rural and urban populations of Mwanza Region.     

Empirical observations underestimate the proportion of human immunodeficiency virus infections attributable to sexually transmitted diseases in the Mwanza and Rakai sexually transmitted disease treatment trials: Simulation results

BACKGROUND AND OBJECTIVES: Population attributable fractions (PAF) from observational studies may under- or overestimate the contribution of cofactor sexually transmitted disease (STD) to human immunodeficiency virus (HIV) spread. Empirical PAF estimates from the Mwanza and Rakai trials indicated the proportion of HIV infections attributable to STDs was higher in Mwanza than Rakai. GOAL OF THIS STUDY: Estimate the "true" proportion (PAFM) of HIV infections attributable to STDs in the Mwanza and Rakai STD trial populations and explore how the evaluated interventions prevented HIV infections. STUDY DESIGN: The STDSIM model was used to simulate the 2 populations at the baseline of the trials (with no STD treatment interventions) and counterfactual scenarios in which STD cofactor effects on HIV spread were removed either at the start of the trials or 2, 10, and 20 years into the HIV epidemics. Similar methods were used to quantify the contribution of the cure of each STD to overall HIV impact in each site. RESULTS:: In Mwanza, the highest PAFM for the effect of any single STD over the 2 years of the trial was due to chancroid (40%). The PAFM for all curable STD was 65%. In Rakai, herpes simplex virus type 2 (HSV-2) was the most important STD (PAFM = 23%); the PAFM for curable STD was 20%. In both sites, the proportion of new infections due to treatable STD decreased over time. The decrease was greater for Rakai, where a behavioral risk reduction that preceded the trial reduced STD prevalence. In both sites, the importance of HSV-2 increased later in the HIV epidemics and STD increased transmission of HIV more than acquisition of HIV. In the Mwanza trial, treatment of chancroid contributed most to preventing new HIV infections. CONCLUSIONS: PAFs calculated from empirical data underestimated the contribution of STD to HIV spread in the Mwanza and Rakai trial populations because STD effects on HIV transmission (as opposed to acquisition) were not captured in the observationally based studies.     

Risk factors for sexually transmitted diseases among women attending family planning clinics in Dar-es-Salaam, Tanzania.

BACKGROUND: Identification of risk factors for sexually transmitted diseases (STDs) assists in development of treatment algorithms, which are potentially important components of STD control when microbiologic facilities are limited. METHODS: A cross-sectional study was performed to assess STD and HIV risk factors of 2285 women attending three family planning clinics in Dar-es-Salaam, Tanzania during 1991-92. Women were interviewed and examined for signs of STDs. Specimens were taken for laboratory diagnosis of HIV, other sexually transmitted organisms, and Candida albicans. RESULTS: The prevalence of gonorrhoea was found to be 4.2%, prevalence of trichomoniasis was 14.3%, and positive syphilis serology was found in 2.5% of women. Unmarried women were at increased risk of trichomoniasis (age-adjusted OR = 1.48 95% CI [1.12, 1.95]), gonorrhoea (age-adjusted OR = 1.81 95% CI [1.14, 2.86]) and syphilis (age-adjusted OR 1.5 [0.84, 2.68]). An increasing number of sexual partners in the past five years was associated with an increased risk of all STDs. Current use of the oral contraceptive pill was positively associated with gonorrhoea, multivariate OR = 1.75 95% CI [1.05, 2.93]. The prevalence of candidiasis was 11.5% and was not associated with any of the demographic or behavioural risk factors examined. Clinical diagnostic algorithms for STDs in this study population had relatively low sensitivity and low positive predictive value. CONCLUSION: Being unmarried and having a higher number of sexual partners were consistently associated with each STD, while the associations for other risk factors varied between STDs, emphasising the complexity of STD distribution. Further development of diagnostic algorithms and other methods for screening women for STDs are needed to reduce the impact of STDs and HIV in developing countries.     

Risk factors for active syphilis and TPHA seroconversion in a rural African population

OBJECTIVES: Syphilis is an important cause of morbidity in sub-Saharan Africa, and a cofactor for the sexual transmission of HIV. A better understanding of the prevalence and risk factors of syphilis in African populations would help to formulate effective interventions for its prevention and treatment. METHODS: The prevalence and incidence of syphilis were obtained from a cohort recruited in Mwanza, Tanzania. Two unmatched case-control studies nested within the cohort provide information on potential risk factors. RESULTS: The prevalence of active syphilis (TPHA positive and RPR positive any titre) was 7.5% in men and 9.1% in women, but in youths (aged 15-19 years) the prevalence was higher in women (6.6%) than in men (2.0%). The incidence of TPHA seroconversion was highest in women aged 15-19 at 3.4% per year, and around 2% per year at all ages among men. A higher prevalence of syphilis was found in those currently divorced or widowed (men: OR=1.61, women: OR=2.78), and those previously divorced or widowed (men: OR=1.51, women: OR=1.85). Among men, prevalence was associated with lack of circumcision (OR=1.89), traditional religion (OR=1.55), and reporting five or more partners during the past year (OR=1.81) while incidence was associated with no primary education (OR=2.17), farming (OR=3.85), and a self perceived high risk of STD (OR=3.56). In women, prevalence was associated with no primary education (OR=2.13), early sexual debut (OR=1.59), and a self perceived high risk of STD (OR=3.57), while incidence was associated with living away from the community (OR=2.72). CONCLUSION: The prevalence and incidence of syphilis remain high in this rural African population. More effort is needed to promote safer sexual behaviour, and to provide effective, accessible treatment. The high incidence of syphilis in young women calls for sexual health interventions targeted at adolescents.     

STD/HIV intervention and research programme Mwanza Region,NW Tanzania

The social determinants and epidemiology of sexually transmitted disease (STD) were studied in rural communities in Mwanza Region, Tanzania, in the context of the phase specific model of STD transmission. The prevalence of HIV and syphilis was higher in communities close to main roads, and lower in communities living on islands in Lake Victoria, probably reflecting the proportion of high risk individuals in the population. The prevalence of Herpes simplex virus type 2 infection, gonorrhoea, chlamydial infection, and trichomoniasis was similar in all types of community, reflecting the fact that these infections remain in the hyperendemic phase. The transmission of STDs is fuelled by high population mobility and by the presence of high risk individuals in rural as well as roadside communities.     

Sexually transmitted infections and HIV in a rural community in the Lesotho highlands

OBJECTIVES: To conduct a knowledge, attitude, and practice (KAP) study and to determine the prevalence of sexually transmitted diseases (STDs), including HIV, in a community residing in remote, rural Lesotho. METHODS: In 1995 a cross sectional, community based epidemiological study was conducted on a population of 7500 people living in 89 villages. A total of 29 villages were randomly selected and a systematic sample of houses within villages was obtained. Questionnaires were administered to subjects after written consent was obtained. Determination of N gonococcus and C trachomatis infection was done on urine using ligase chain reaction (LCR) technology. Using blood specimens, syphilis was diagnosed by RPR and TPHA tests and HIV by a single ELISA and confirmed with a western blot. RESULTS: Questionnaires were administered to 277 women, 100 men, and 149 youths (12-15 years). Chlamydia was diagnosed in 28.4% of adults, gonorrhoea in 5.9%, syphilis in 11.3%, and HIV infection in 6.3%. All cases of HIV occurred along the main road (p = 0.001) and 72% of individuals with gonorrhoea were co-infected with chlamydia (p = 0.0001). 11.6% of women and 38.0% of men had had sex with a non-regular partner in the past 3 months and none had used condoms. CONCLUSION: A high prevalence of STDs and HIV infection was found in a population characterised by low levels of knowledge about STD/HIV, high risk sexual behaviour, and evidence of inappropriate health seeking behaviour for STDs.     

Three years'' experience of sexually transmitted diseases in Seville, Spain.

At present there are no reliable statistics on the relative prevalences of sexually transmitted diseases (STDs) in Spain. In a report of the first three years' experience in an STD diagnostic centre between 1977 and 1979 a total of 879 patients (534 men adn 345 women) were seen. They mainly consisted of university students and the mean age was 22 years in 1977 and 23 years in the following two years. All the patients were examined for syphilis and all women for gonorrhoea and trichomoniasis. Investigations for Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma urealyticum, Candida albicans, and Herpesvirus hominis infections were carried out according to the presenting symptoms. Non-specific genital infections occurred most commonly (25.7%); chlamydia were isolated from 30% of the patients with non-gonococcal urethritis (NGU). The second commonest infection was candidosis (13.5%). Gonorrhoea, which was found in 10.6% of the patients, was diagnosed more frequently in men (13.5%) than in women (6%). No strains of beta-lactamase-producing Neisseria gonorrhoeae were detected and all were sensitive to penicillin. Syphilis was diagnosed in 4.4% of patients (2% women and 5% men). Condylomata acuminata were diagnosed in 2.8% of patients and more frequently in men (4%). Herpes genitalis and venereophobia were uncommon (1.9% and 1.2% respectively) and were diagnosed only in men.     

Prevalence of herpes simplex type 2 and syphilis serology among young adults in a rural Gambian community

OBJECTIVES: To estimate prevalence and risk factors for herpes simplex 2 (HSV2) positivity, syphilis and Chlamydia trachomatis infection among rural people aged 15-34 in the Gambia. METHODS: Questionnaires and serum samples were collected from 1076 men and women aged 15-34 during a cross sectional prevalence survey in a rural area of the Gambia. Sera were screened for antibodies to herpes simplex virus type 2 (HSV2), and for syphilis using Treponema pallidum haemagglutination assay (TPHA) and rapid plasma reagin (RPR) tests. Urine was tested by polymerase chain reaction (PCR) for C trachomatis infection. RESULTS: 28% of women and 5% of men were HSV2 ELISA positive; 10% of women and 2% of men were TPHA positive; and 7% of women and 1% of men were both RPR and TPHA positive. Out of 1030 urine sample tested only six were positive for C trachomatis. 7% of those who reported never having sex were positive for one or other of these tests. Prevalences of all STIs increased with age and were higher in women than men. Women were much less likely than men to seek treatment for STI symptoms at a health centre. Married people were at increased risk of an STI compared with single people. Jola and Fula women had a higher prevalence of HSV2 than women from other ethnic groups, and Fulas also had a higher prevalence of RPR/TPHA positivity. The limited number of sexual behaviour questions were not significantly associated with STIs after adjustment for age, marital status, and ethnic group. CONCLUSIONS: The prevalences of the ulcerative infections HSV2 and syphilis in this population are a cause for concern. In a setting where HIV1 prevalence remains low this indicates an urgent need for STI control and behaviour change programmes to prevent an HIV epidemic. Concerns about the validity of reported sexual behaviour data high light the necessity of biological markers in the evaluation of behaviour change programmes.     

Comparative rates of sexually transmitted diseases among heterosexual men, homosexual men, and heterosexual women

The prevalences of several sexually transmitted diseases (STD) among patients attending a public STD clinic were determined in a prospective study. Rates of gonorrhea, syphilis, genital herpes, trichomoniasis, nongonococcal urethritis, pediculosis pubis, scabies, and venereal warts were ascertained according to sex, sexual preference, and race. Numbers of cases of diseases not routinely reported to most public health agencies exceeded numbers of cases of diseases that are routinely reported. Rates of gonorrhea were higher among men than among women and higher among blacks than among whites. Syphilis was most common among homosexual men. Trichomoniasis was three times more frequent among blacks than among whites. Rates of nongonococcal urethritis among heterosexual men were almost twice those among homosexual men. Whites were more likely than blacks to have pediculosis pubis, scabies, and venereal warts. STD not routinely reported to most public health agencies are commonly seen in public clinics, and rates vary according to sex, sexual preference, and race.     

Effect of a syphilis control programme on pregnancy outcome in Nairobi, Kenya

OBJECTIVES: To assess the impact of a syphilis control programme of pregnant women on pregnancy outcome in Kenya. METHOD: Women who came to deliver to Pumwani Maternity Hospital (PMH) between April 1997 and March 1998 were tested for syphilis. Reactive rapid plasma reagin (RPR) tests were titrated and confirmed with treponema haemagglutination test (TPHA). Equal numbers of RPR and TPHA negative women were enrolled. Antenatal syphilis screening and treatment history were examined from the antenatal cards. RESULTS: Of 22,466 women giving birth, 12,414 (55%) were tested for syphilis. Out of these, 377 (3%) were RPR reactive of whom 296 were confirmed by TPHA. Syphilis sero-reactive women had a more risky sexual behaviour and coexistent HIV antibody positivity; 26% were HIV seropositive compared with 11% among syphilis negative mothers. The incidence of adverse obstetric outcome defined as low birth weight and stillbirth, was 9.5%. Syphilis seropositive women had a higher risk for adverse obstetric outcome (OR 4.1, 95% CI 2.4-7.2). Antenatal treatment of RPR reactive women significantly improved pregnancy outcome but the risk of adverse outcome remained 2.5-fold higher than the risk observed in uninfected mothers. CONCLUSIONS: These data confirm the adverse effect of syphilis on pregnancy outcome. This study also shows the efficacy of antenatal testing and prompt treatment of RPR reactive mothers on pregnancy outcome.     

Risk factors for gonorrhoea, syphilis, and trichomonas infections among women attending family planning clinics in Nairobi, Kenya.

OBJECTIVE--To identify the risk factors for gonorrhoea, syphilis, and trichomonas infections among low risk women in Nairobi, Kenya. METHOD--In a cross-sectional study, 4,404 women attending two peri-urban family planning clinics between 1989 and 1991 were interviewed using a structured questionnaire and examined for signs of sexually transmitted disease (STD) infection. Cervical cultures for gonorrhoea, PAP smear (including microscopy for trichomonas), RPR and HIV testing were done. RESULTS--Positive cervical cultures for gonorrhoea were found in 3.2% of women, positive syphilis serology in 1.9%, and positive trichomonas microscopy in 5.2%. Genital ulcers were found in 1.9% of women. Although unmarried status and reporting more than one sex partner in the previous year were both significantly associated with each disease in the crude analysis, these associations were attenuated after controlling for each other and for other risk factors. The population attributable risks (PARs) for these factors were low (7-16%) owing to the high proportion of cases who were married and monogamous. The majority of women with microbiological evidence of infection had normal pelvic examinations. Clinical diagnostic algorithms for STDs in this population had a low sensitivity and positive predictive value. Nevertheless, a strong association between HIV seropositivity and STDs was observed. CONCLUSION--The low population attributable risks found in this study suggest that behaviour change messages directed to women, particularly if they are married have a low potential for preventing STDs. The poor performance of clinical diagnostic algorithms illustrates the desirability of testing these algorithms in a variety of populations and reinforces the need for low-cost methods of microbiologic diagnosis if populations with relatively low prevalences of these infections are to be included in programmes to diagnose and treat STDs.     

Performance of the rapid plasma reagin and the rapid syphilis screening tests in the diagnosis of syphilis in field conditions in rural Africa

OBJECTIVES: To assess the rapid plasma reagin (RPR) test performance in the field and to evaluate a new rapid syphilis test (RST) as a primary screen for syphilis. METHODS: 1325 women of reproductive age from rural communities in the Gambia were tested for syphilis seropositivity using a RPR 18 mm circle card and a RST strip. Within 1 week a repeat RPR and a TPHA test were carried out using standard techniques in the laboratory. RESULTS: Comparing field tests to a diagnosis of "active" syphilis defined as laboratory RPR and TPHA positive, the RPR test was 77.5% sensitive and 94.1% specific; the RST was 75.0% sensitive and 95.2% specific. The RST was easier to use and interpret than the RPR test especially where field conditions were difficult. In this setting with a low prevalence of syphilis in the community (3%), the chance of someone with a positive test being confirmed as having serologically active syphilis was less than 50% for both tests. CONCLUSIONS: The appropriateness of syphilis screening using RPR testing in antenatal clinics and health centres should be questioned if there is a low prevalence in the population, conditions for testing are poor, and resources limited. There is still an urgent need for an appropriate rapid syphilis test for field use.     

Lack of effectiveness of syndromic management in targeting vaginal infections in pregnancy in Entebbe, Uganda

OBJECTIVES: To measure the prevalence of reproductive tract infections (RTIs) during pregnancy in Entebbe, Uganda, and to evaluate the current syndromic diagnosis and management approach in effectively targeting infections, such as bacterial vaginosis (BV) and trichomoniasis, that are associated with low birth weight and prematurity among newborns. METHODS: We enrolled 250 antenatal clinic attenders. Vaginal swabs and diagnostic tests were performed for BV, Trichomonas vaginalis (TV), candida, Neisseria gonorrhoeae, Chlamydia trachomatis and for HIV-1 and active (TPHA+/RPR+) syphilis infection. Same day treatment was offered for symptoms according to syndromic management guidelines. The treatment actually provided by healthcare workers was documented. Sensitivity, specificity, positive and negative predictive values were used to assess the effectiveness of syndromic management guidelines and practice. RESULTS: The prevalence of infections were: BV 47.7%, TV 17.3%, candida 60.6%, gonorrhoea 4.3%, chlamydia 5.9%, syphilis 1.6%, and HIV 13.1%. In total, 39.7% of women with BV and 30.2% of those with TV were asymptomatic. The sensitivity of syndromic management as applied by health workers in targeting BV and TV was 50.0% and 66.7%, respectively. This would have increased to 60.3% (BV) and 69.8% (TV) had the algorithm been followed exactly. CONCLUSIONS: The prevalence of BV and TV seen in this and other African populations is high. High rates of asymptomatic infection and a tendency of healthcare workers to deviate from management guidelines by following their own personal clinical judgment imply that many vaginal infections remain untreated. Alternative strategies, such as presumptive treatment of BV and TV in pregnancy, should be considered.     

Prevalence of infectious diseases in Bangladeshi women living adjacent to a truck stand: HIV/STD/hepatitis/genital tract infections

BACKGROUND: Little is known about infection rates for human immunodeficiency virus (HIV) and other diseases that can be transmitted sexually in Bangladeshi women who may be at intermediate levels of risk--that is, women who are not commercial sex workers (CSWs) but whose sexual contacts may include men at high risk for STD. This study examines HIV/hepatitis/STD and other genital tract infections in women living near Tejgaon truck stand in Dhaka, Bangladesh. METHODS: This population based study was conducted from January to December 1998. A random sample of 384 women provided urine and blood samples and participated in an interview; 261 of them also had a physical examination in which vaginal and cervical specimens were taken. Laboratory tests included PCR on urine and cervical swabs for gonorrhoea and chlamydia, culture for trichomoniasis, serology tests for syphilis, herpes simplex 2, hepatitis B, C, D, HIV1, HIV2, and clinical diagnoses of other genital tract infections. RESULTS: None of the participants tested positive for HIV. In the 261 women who had a physical examination, trichomoniasis was detected in 19.5%, chlamydia in 3.4%, gonorrhoea in 5.4%, bacterial vaginosis in 37.2%, and candidiasis in 10%. In the full sample of 384 women, with tests of urine and blood, prevalence of infection with chlamydia, gonorrhoea, syphilis, and herpes simplex 2 was detected in 0%, 6.3%, 5.7%, and 32% respectively. Almost 50% of the subjects had ever been exposed to hepatitis B, 3.6% were currently infective, 1.6% had hepatitis C, and none had hepatitis D. CONCLUSION: The high prevalence of certain of these infectious diseases indicates the need to implement prevention interventions with these women and, perhaps more importantly, with their male partners. Qualitative research is needed to provide insights into their sexual behaviour and the contexts in which high risk behaviours occur.     

Screening for syphilis during pregnancy in Nigeria: a practice that must continue

OBJECTIVE: To determine the seroprevalence rate of syphilis among pregnant women attending the antenatal clinics of a teaching and a state specialist hospital in Nigeria, in order to ascertain whether maternal screening should be incorporated into routine antenatal care of our hospitals. METHODS: A screening for syphilis for 505 newly registered pregnant women was carried out using the qualitative rapid plasma reagin (RPR) test. All reactive sera were then subjected to the quantitative RPR test to estimate the titre of each sample. The Treponema pallidum haemagglutination antibody (TPHA) test was used as confirmatory test of all positive RPR sera. RESULTS: A total of 50 women (9.9%) were positive for RPR; 15 (2.97%) were positive for TPHA, giving a seroprevalence rate of 2.97%. A total of 32 women (6.34%) were RPR positive at 1:2, 7 (1.39%) at 1:4 and 11 (2.2%) at 1:8. Of the women positive for RPR at 1:2, 2 were also TPHA positive, 2 of the 7 positive at 1:4 were TPHA positive, while all 11 positive women at 1:8 were TPHA positive. In all, 70% of all RPR positive women screened were biological false positives. Eleven of the 15 women had high titre active syphilis (RPR > or = 1:8, TPHA+) while 4 had low titre active syphilis (RPR <1:8, TPHA+). CONCLUSIONS: The 2.97% seroprevalence rate obtained after accounting for biological false positives was considered high. Screening for syphilis in pregnancy should be incorporated into routine antenatal practice in Nigerian hospitals.     

Serologic diagnosis of syphilis: comparison of different diagnostic methods

Diagnostic and therapeutic approaches in syphilis show wide variation. The use of only one type of serologic test is insufficient for diagnosis. However, current international recommendations cannot be applied due to various reasons (cost, availability, etc.). The aim of the study was to review serologic data of syphilis patients to determine diagnostic performance of three different methods. In 117 patients suspected of having syphilis, syphilis was diagnosed serologically and clinically. Three different methods were used for detection of antibodies: Rapid Plasma Reagin (RPR), Treponemal Chemiluminescence Microparticle Enzyme Immunoassay (CMIA) and Treponema pallidum hemagglutination (TPHA). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated for the former two methods against TPHA. The sensitivity of RPR and CMIA against TPHA was 58% and 98%, respectively. The specificity of RPR and CMIA against TPHA was 0% and 100%, respectively. Automated enzyme immunoassay systems could contribute to reducing errors that depend on the person, especially while monitoring titration changes.     

Sentinel surveillance of sexually transmitted infections in South Africa: a review

OBJECTIVES: To review studies of sexually transmitted infection (STI) prevalence in South Africa between 1985 and 2003 in selected sentinel populations. To examine how STI prevalence varies between populations and to identify the limitations of the existing data. METHODS: Studies of the prevalence of syphilis, chancroid, granuloma inguinale, lymphogranuloma venereum, gonorrhoea, chlamydia, trichomoniasis, bacterial vaginosis, candidiasis, and herpes simplex virus type 2 (HSV-2) were considered. Results were included if they related to women attending antenatal clinics or family planning clinics, commercial sex workers, individuals in the general population (household surveys), patients with STIs, patients with genital ulcer disease (GUD), or men with urethritis. RESULTS: High STI prevalence rates have been measured, particularly in the case of HSV-2, trichomoniasis, bacterial vaginosis and candidiasis. The aetiological profile of GUD appears to be changing, with more GUD caused by HSV-2 and less caused by chancroid. The prevalence of gonorrhoea and syphilis is highest in "high risk" groups such as sex workers and attenders of STI clinics, but chlamydia and trichomoniasis prevalence levels are not significantly higher in these groups than in women attending antenatal clinics. CONCLUSIONS: The prevalence of STIs in South Africa is high, although there is extensive variability between regions. There is a need for STI prevalence data that are more nationally representative and that can be used to monitor prevalence trends more reliably.     

Asymptomatic non-ulcerative genital tract infections in a rural Ugandan population

OBJECTIVE: To document the prevalence of asymptomatic non-ulcerative genital tract infections (GTI) in a rural African cohort. METHODS: The study population consisted of all adults aged 15-59 residing in 56 rural communities of Rakai District, southwest Uganda, enrolled in the Rakai STD Control for AIDS Prevention Study. Participants were interviewed about the occurrence of vaginal or urethral discharge and frequent or painful urination in the previous 6 months. Respondents were asked to provide blood and a first catch urine sample. Serum was tested for HIV-1. Urine was tested with ligase chain reaction (LCR) for N gonorrhoeae and C trachomatis. Women provided two self administered vaginal swabs; one for T vaginalis culture and the other for a Gram stained slide for bacterial vaginosis (BV) diagnosis. RESULTS: A total of 12,827 men and women were enrolled. Among 5140 men providing specimens, 0.9% had gonorrhoea and 2.1% had chlamydia. Among 6356 women, 1.5% had gonorrhoea, 2.4% had chlamydia, 23.8% were infected with trichomonas and 50.9% had BV.53% of men and 66% of women with gonorrhoea did not report genital discharge or dysuria at anytime within the previous 6 months. 92% of men and 76% of women with chlamydia and over 80% of women with trichomonas or BV were asymptomatic. The sensitivities of dysuria or urethral discharge for detection of infection with either gonorrhoea or chlamydia among men were only 21.4% and 9.8% respectively; similarly, among women the sensitivity of dysuria was 21.0% while that of vaginal discharge was 11.6%. For trichomonas or BV the sensitivity of dysuria was 11.7% and that of vaginal discharge was 10.5%. CONCLUSION: The prevalence of non-ulcerative GTIs is very high in this rural African population and the majority are asymptomatic. Reliance on reported symptoms alone would have missed 80% of men and 72% of women with either gonorrhoea or chlamydia, and over 80% of women with trichomonas or BV. To achieve STD control in this and similar populations public health programmes must target asymptomatic infections.     

High prevalence of sexually transmitted diseases in a rural area in Mozambique.

OBJECTIVE--To assess the extent of the sexually transmitted diseases (STDs) problem in a rural area of Mozambique. METHODS--A cross sectional study among pregnant women and patients presenting with genital complaints. Laboratory confirmation was done for gonorrhoea, chlamydial infection, active syphilis, trichomoniasis and HIV infection. SETTING--A primary health care setting in Vilanculos, Inhambane province, Mozambique. RESULTS--Evidence of one or more of the above STDs was found in 51% of 201 pregnant women, 56% of 85 women and 62% of 77 men with genital complaints. Neisseria gonorrhoea or Chlamydia trachomatis were found in 16% of pregnant women, 23% of female patients and 28% of male patients; genital ulcer disease was present in 6%, 28% and 36%, of respectively pregnant women, female and male patients. The prevalence of active syphilis was about the same in the three groups of study subjects, that is 15%. HIV infection was found in 4% of the male patients; no HIV infection could be detected in the female groups. CONCLUSION--STDs were a major health problem in this rural area in Mozambique. Though HIV infection was still low, the high prevalence of STDs indicates that the potential is there for an explosive spread of the HIV/AIDS epidemic.     

STD in Bangladesh's trucking industry: prevalence and risk factors

OBJECTIVES: This study characterises the prevalence of a broad spectrum of sexually transmitted diseases (STDs) (herpes simplex virus 2, syphilis, chlamydia, gonorrhoea), and examines associations between risk factors and infection in men working in Bangladesh's trucking industry. Given the high risk sexual behaviours of truck drivers and helpers in many contexts, as well as the direct health effects of STDs and their role in facilitating HIV transmission, it is important to understand the prevalence of STDs and associated risk factors in this population. METHODS: A cross sectional study was conducted at Tejgaon truck stand, one of the largest truck stands in Dhaka, the capital city. The study group, comprising 388 truck drivers and helpers, was selected via a two tiered sampling strategy. Of 185 trucking agencies based at the truck stand, 38 agencies were randomly selected, and a mean of 10 subjects (drivers/helpers) were recruited from each agency. Urine and blood samples were collected from subjects after an interview about their lifestyle and a comprehensive physical examination. Gold standard laboratory tests were conducted for the detection of STD. Multiple logistic regression was used to assess associations between infections and potential risk factors. RESULTS: The levels of prevalence of disease were HSV-2 (25.8%), serological syphilis (5.7%), gonorrhoea (2.1%), chlamydia (0.8%). For infection with any bacterial STD (syphilis, gonorrhoea, or chlamydia) the only significant risk factor was having sex with a commercial sex worker in the past year (OR=3.54; CI=1.29-9.72). For HSV-2, truck helpers working primarily on interdistrict routes were significantly more likely to be infected than drivers working on these routes (OR=2.51, CI=1.13--5.55). CONCLUSIONS: The high prevalence of HSV-2, and to a lesser extent syphilis, and the low levels of condom use despite high numbers of casual sexual partners, illustrate the importance of promoting condom use, particularly in commercial sexual encounters, to men in Bangladesh's trucking industry.