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.     

Syphilis, gonorrhoea, and drug abuse among pregnant women in Jefferson County, Alabama, US, 1980-94: monitoring trends through systematically collected health services data

OBJECTIVE: To assess the association between self reported drug abuse and syphilis and gonorrhoea among pregnant women, Jefferson County, Alabama, United States, 1980-94. STUDY DESIGN: We analysed a prenatal care database and assessed the association of self reported drug use with seropositive syphilis and gonorrhoea using prevalence rates, multiple logistic regression models, and the Pearson correlation coefficient (r) for trends. RESULTS: Overall, 5.5% of the women acknowledged drug abuse, 1.4% had seropositive syphilis, and 4.8% had gonorrhoea. In a multivariate analysis, drug abuse was associated with syphilis (odds ratio 2.9, 95% confidence interval 1.6, 5.3) but not with gonorrhoea. Trends in the annual prevalence of drug abuse closely paralleled trends in the annual prevalence of syphilis, including simultaneous peaks in 1992 (drug abuse, 9.1%; syphilis, 3.2%). There was no such parallel trend between drug abuse and gonorrhoea. Annual prevalence of drug abuse correlated with the prevalence of syphilis (r = 0.89, p = 0.001) more than with the prevalence of gonorrhoea (r = 0.45, p = 0.201). CONCLUSION: Among pregnant women, an increase in drug abuse was closely associated with an epidemic of syphilis, but not of gonorrhoea. Systematically collected prenatal care data can usefully supplement surveillance of diseases and behavioural risk factors associated with them.     

Chlamydial and gonococcal reinfection among men: a systematic review of data to evaluate the need for retesting

This study aimed to systematically review and describe the evidence on chlamydia and gonorrhoea reinfection among men, and to evaluate the need for retesting recommendations in men. PubMed and STI conference abstract books from January 1995 to October 2006 were searched to identify studies on chlamydia and gonorrhoea reinfection among men using chlamydia and gonorrhoea nucleic acid amplification tests or gonorrhoea culture. Studies were categorised as using either active or passive follow-up methods. The proportions of chlamydial and gonococcal reinfection among men were calculated for each study and summary medians were reported. Repeat chlamydia infection among men had a median reinfection probability of 11.3%. Repeat gonorrhoea infection among men had a median reinfection probability of 7.0%. Studies with active follow-up had moderate rates of chlamydia and gonorrhoea reinfection among men, with respective medians of 10.9% and 7.0%. Studies with passive follow-up had higher proportions of both chlamydia and gonorrhoea reinfections among men, with respective medians of 17.4% and 8.5%. Proportions of chlamydia and gonorrhoea reinfection among men were comparable with those among women. Reinfection among men was strongly associated with previous history of sexually transmitted diseases and younger age, and inconsistently associated with risky sexual behaviour. Substantial repeat chlamydia and gonorrhoea infection rates were found in men comparable with those in women. Retesting recommendations in men are appropriate, given the high rate of reinfection. To optimise retesting guidelines, further research to determine effective retesting methods and establish factors associated with reinfection among men is suggested.     

Part time female sex workers in a suburban community in Kenya: a vulnerable hidden population

BACKGROUND: In sub-Saharan Africa, female sex workers (FSWs) are a vulnerable high risk group for the acquisition and transmission of sexually transmitted infections (STI) and HIV. OBJECTIVES: To study parameters of sexual behaviour and knowledge of STI and HIV, to describe health seeking behaviour related to STI, and to measure the prevalence of gonorrhoea, chlamydia, syphilis, and HIV-1, to provide baseline data for targeted STI and HIV prevention interventions. METHODS: In a cross sectional survey with snowballing recruitment, between February and March 2000, 503 self identified FSWs in a suburb in Mombasa, Kenya, were interviewed with a structured questionnaire and screened for gonorrhoea, chlamydia, syphilis, and HIV-1. RESULTS: The mean number of sexual partners in the previous week was 2.8 (SD 1.6). The mean number of non-regular clients and regular clients in the previous week was 1.5 (1.0) and 1.0 (0.9) respectively. The median weekly income from sex work was $US15. A total of 337 (67%) women had an alternative income in the informal sector. 146 (29%) and 145 (45%) never used a condom with a client and non-paying partner respectively. The prevalence of gonorrhoea, chlamydia, and syphilis was 1.8%, 4.2%, and 2.0% respectively. The overall HIV-1 seroprevalence was 30.6%. CONCLUSIONS: There is a large need for intensive STI and HIV prevention interventions in part time FSW.     

Incident sexually transmitted infections and their risk factors in an Aboriginal community in Australia: a population based cohort study

OBJECTIVE: To identify risk factors for incident sexually transmitted infections (STI) in a remote Aboriginal community in Australia. DESIGN: A population based cohort study. SETTING: An Aboriginal community in central Australia. PARTICIPANTS: 1034 Aboriginal people aged 12-40 years, resident in the study region, seen during the period 1 January 1996 to 30 June 1998 for STI diagnosis. MAIN OUTCOME MEASURES: Incident rate of gonorrhoea, chlamydia, and syphilis per 100 person years. RESULTS: There were 313 episodes of incident gonorrhoea, 240 of incident chlamydial infection, and 17 of incident syphilis. For gonorrhoea, risk factors were age, substance abuse, and previous prevalent chlamydial infection with a rate ratio (RR) of 3.2 in people aged 15-19 years, 1.6 in people who abused alcohol, and 3.2 in women who had sniffed petrol on a regular basis. For chlamydia, risk factors were sex, age, and a previous history of STI with a RR of 2.7 in people aged 15-19 years. Similar factors were associated with an increased risk of syphilis but the associations were not statistically significant. CONCLUSION: This study identified objective predictors of incident STI which can be used to target interventions and maximise their impact. The results of this study may well have relevance to indigenous communities in other countries that are faced with high levels of STI and substance abuse.     

Predictors of the prevalence of bacterial STI among young disadvantaged Indigenous people in north Queensland,Australia

OBJECTIVE: To identify sexually transmitted infections in rural and remote Indigenous communities in north eastern Australia and examine factors that may influence prevalence. METHODS: A cross sectional survey of 26 Aboriginal and Torres Strait Islander communities in northern Queensland was carried out. 3313 people (2862 Indigenous) aged 15 years and over resident in participating communities during the period March 1998 to December 2000. The main outcome measures were community and population prevalence of chlamydia and gonorrhoea and independently associated risk factors. RESULTS: A total of 238 cases of chlamydia, 66 cases of gonorrhoea, and 37 cases of co-infection were detected among Indigenous participants. Prevalence of chlamydia and/or gonorrhoea ranged from 23.0% among 15-19 year olds to 3.5% among those 40 years and older. In the adjusted analysis younger age, female sex, lower socioeconomic status, the use of alcohol and tobacco, and the structure of community health services were independently associated with a higher prevalence of bacterial STI. CONCLUSION: This study highlights the need for improved STI control in north Queensland Indigenous communities through strategies to improve the reach and accessibility of primary healthcare services.     

Health indicators among low income women who report a history of sex work: the population based Northern California Young Women's Survey

OBJECTIVES: We examined differences in demographic characteristics, HIV related risk behaviour, prevalence of sexually transmitted infections (STI), and HIV and other health concerns among women with and without a history of sex work. METHODS: A secondary analysis of a population based, cross sectional survey of young, low income women in northern California. RESULTS: Of the 2543 women interviewed, 8.9% reported a history of sex work. These women reported more lifetime male sexual partners, were more likely to use drugs before sex, and were more likely to have a history of having sex with partners at high risk for HIV (that is, men who have sex with men, inject drugs, or were known to be HIV positive). They were significantly more likely to have positive serology for syphilis, herpes simplex virus type 2 (HSV-2), and hepatitis C regardless of their personal injecting drug use history; however, they were no more likely to have HIV, chlamydia, gonorrhoea, hepatitis A or hepatitis B infection compared to women without a history of sex work. Women with a history of sex work were significantly more likely to have a history of sexual coercion and tobacco use. CONCLUSIONS: These data measure the population prevalence of sex work among low income women and associated STI. Women with a history of sex work have health concerns beyond STI and HIV treatment and prevention.     

Optimising sexually transmitted infection screening in correctional facilities: San Francisco, 2003-2005

OBJECTIVES: Sexually transmitted infection (STI) screening in correctional facilities provides access to people at high risk for STIs who might not be screened elsewhere. These screening programmes are becoming more widespread, but with decreasing funding for STI control, maximising screening impact has become increasingly important. We aimed to make recommendations about the impact of age and sex targeted screening in correctional facilities. METHODS: We compared the prevalence of chlamydia and gonorrhoea for January 2003-July 2005 among different age groups of females and males screened in San Francisco correctional facilities -- youth detention (12-17 years) and adult jail (18-35 years). RESULTS: 16 975 chlamydia tests and 13,443 gonorrhoea tests were performed. The age specific chlamydia test positivity among females aged 12-17 years, 18-25 years, and 26-30 years, respectively, was 9.6% (105/1092), 9.4% (196/2088), and 6.3% (40/639), compared with 3.3% (100/3065), 6.2% (400/6470), and 3.9% (118/3046) among males. The age specific gonorrhoea test positivity among females in these same age groups was 3.2% (34/1062), 2.7% (57/2082), and 2.4% (15/635), compared with 0.7% (7/1026), 1.2% (67/5507), and 1.0% (25/2555) among males. Of the 1198 STIs identified, 1,020 (85.1%) were treated. CONCLUSIONS: On the basis of this report and national data, STI control programmes with limited funds should prioritise screening females in youth detention first, women aged < or = 30 years in adult jail second, and men aged < or = 25 years in adult jail third. Males in youth detention should have a lower priority than young adults in jails.     

Prevalence of sexually transmitted infections among antenatal women in Vanuatu, 1999-2000

BACKGROUND: The epidemiology of sexually transmitted infections (STIs) and HIV in Vanuatu is poorly defined. GOAL: The goal was to determine the prevalence of laboratory-confirmed gonorrhea, chlamydia, trichomoniasis, syphilis seroreactivity, and HIV among pregnant women in Vila, Vanuatu. STUDY DESIGN :A cross-sectional survey of 547 pregnant women attending a first-visit antenatal hospital clinic in Vila. Laboratory testing included polymerase chain reaction on tampons for chlamydia, gonorrhea, and trichomoniasis; testing of sera for syphilis with rapid plasmid reagin; and enzyme-linked immunosorbent assay for HIV. RESULTS: The prevalence of trichomoniasis was 27.5% (150); of chlamydia, 21.5% (117); of gonorrhea, 5.9% (32); and of syphilis, 13 (2.4%). No HIV cases were detected; 214 women (40%) had > or =1 STI. Young age and single marital status were both significantly associated with infection (P < 0.001). CONCLUSION: Chlamydial infection and trichomoniasis are hyperendemic among pregnant women in Vila. Young, single women are at greatest risk for infection.     

Finding, confirming, and managing gonorrhoea in a population screened for chlamydia using the Gen-Probe Aptima Combo2 assay

OBJECTIVES: To identify the prevalence of Neisseria gonorrhoeae (NG) within a population screened for Chlamydia trachomatis (CT). To monitor confirmatory microscopy, culture, and partner findings following reactive Aptima Combo2 assay (AC2) gonorrhoea screening tests. METHODS: Between June and December 2004, all gonorrhoea screening tests performed using AC2 for clients taking part in the Liverpool Chlamydia Screening Programme were monitored. Clients with AC2 NG reactive results were referred to a local genitourinary medicine (GUM) department for confirmatory microscopy, culture, treatment, and partner follow up. RESULTS: 47 (1%) of 4680 women and eight (1.7%) of 473 men had AC2 reactive gonorrhoea screening tests. Of those clients who agreed to follow up and were tested before any treatment, supportive evidence for a gonorrhoea diagnosis was found in 37 (97%) of 38 women and all five men. In the population opportunistically screened for chlamydia, CT prevalence rates were 12% for women and 15.7% for men. Although both women and men showed a higher relative risk for NG if chlamydia positive, of the 47 women who were reactive for NG by AC2, 55% (26) were negative for chlamydia. CONCLUSIONS: Sexually transmitted infections are rising in England and reduction of gonorrhoea rates is an objective of the Department of Health Sexual Health and HIV Strategy. AC2 tests provide an acceptable and accurate means of testing for gonorrhoea in an asymptomatic population in the community. AC2 had a higher positive predictive value than might be suggested by previous clinical trials in this low prevalence population. Although antibiotic sensitivity must be monitored, AC2 testing may offer a more acceptable alternative to microscopy and culture for NG in some populations.     

Sexually transmitted infections and risk behaviours in women who have sex with women

OBJECTIVES: To assess the prevalence of sexually transmitted infections (STIs) and blood borne viruses, risk behaviours, and demographics in women who have sex with women (WSW). METHODS: Retrospective cross sectional study using a multivariate model. Demographic, behavioural, and morbidity data were analysed from standardised medical records of patients attending a public STI and HIV service in Sydney between March 1991 and December 1998. All women with any history of sex with a woman were compared with women who denied ever having sex with another woman (controls). RESULTS: 1408 WSW and 1423 controls were included in the study. Bacterial vaginosis (BV) was significantly more common among WSW (OR 1.7, p < 0.001). Abnormalities on cervical cytology were equally prevalent in both groups, except for the higher cytological BV detection rate in WSW (OR 5.3, p = 0.003). Genital herpes and genital warts were common in both groups, although warts were significantly less common in WSW (OR 0.7, p = 0.001). Prevalence of gonorrhoea and chlamydia were low and there were no differences between the groups. The prevalence of hepatitis C was significantly greater in WSW (OR 7.7, p < 0.001), consistent with the more frequent history of injecting drug use in this group (OR 8.0, p < 0.001). WSW were more likely to report previous sexual contact with a homo/bisexual man (OR 3.4, p < 0.001), or with an injecting drug user (OR 4.2, p < 0.001). Only 7% of the WSW reported never having had sexual contact with a male. CONCLUSION: We demonstrated a higher prevalence of BV, hepatitis C, and HIV risk behaviours in WSW compared with controls. A similar prevalence of cervical cytology abnormalities was found in both groups. Measures are required to improve our understanding of STI/HIV transmission dynamics in WSW, to facilitate better health service provision and targeted education initiatives.     

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.     

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.     

Results of a randomised trial of male condom promotion among Madagascar sex workers

OBJECTIVES: To test the effect of supplementing peer promotion of male condom use with clinic based counselling, measured in terms of STI prevalence and reported male condom use. METHODS: 1000 female sex workers in Madagascar were randomised to two study arms: peer education supplemented by individual risk reduction counselling by a clinician (peer + clinic) versus condom promotion by peer educators only (peer only). STI testing was conducted at baseline and 6 months. Behavioural interviews were administered at baseline, 2, 4, and 6 months. RESULTS: At baseline, women in the peer only arm had prevalences of 16.0%, 23.6%, and 12.1% for chlamydia, gonorrhoea, and trichomoniasis respectively, with an aggregate prevalence of 38.2%. Baseline STI prevalences for the peer + clinic arm were slightly lower and 34.1% in aggregate. At 6 months, aggregate STI prevalence increased in the peer only arm to 41.4%, whereas the aggregate prevalence diminished slightly to 32.1% in the peer + clinic arm. In logistic regression analyses, the estimated odds ratios (ORs) for chlamydia, gonorrhoea, trichomoniasis, and aggregate STI were 0.7 (95% confidence interval 0.4 to 1.0), 0.7 (0.5 to 1.0), 0.8 (0.6 to 1.2), and 0.7 (0.5 to 0.9) respectively, comparing the peer + clinic arm with the peer only arm. The logistic regression OR for reported condom use with clients in the past 30 days increased from 1.1 at 2 months to 1.8 at 6 months, comparing the peer + clinic arm with the peer only arm, and was 1.4 overall (1.1 to 1.8). Adjustment for baseline factors changed the regression results little. CONCLUSIONS: The impact of male condom promotion on behaviour can be heightened through more concentrated counselling on risk reduction. Persistently high STI prevalence despite increases in reported condom use by sex workers supports the need for multidimensional control programmes.     

Sexually transmitted infections among HIV seropositive men and women

OBJECTIVES: To determine the prevalence of identified STIs and recognised symptoms of STIs and their association with health status, substance use, and sexual risk behaviour in a sample of HIV seropositive men and women. METHODS: 223 men, 112 women, and five transsexual people living with HIV infection completed confidential surveys. Participants were recruited through community based services, community health clinics, and snowball (chain) recruitment techniques in Atlanta, GA, USA in December 1999. RESULTS: We found that (263) 78% of participants had been sexually active in the previous 3 months. For the entire sample, 42 (12%) participants reported an STI in the past 3 months and 40 (11%) experienced symptoms of an STI without indicating a specific diagnosis in that time. Gonorrhoea, chlamydia, syphilis, and newly diagnosed herpes simplex virus (HSV) were identified at similar rates among men, whereas trichomonas, gonorrhoea, and newly diagnosed HSV occurred most often in women. STIs were associated with substance use in men and women, with "crack" cocaine users having the greatest likelihood of an STI relative to non-crack users. STIs were also associated with continued practice of sexual risk behaviours. CONCLUSIONS: This sample of people living with HIV-AIDS reported high rates of diagnoses and symptoms of STIs. There were significant associations between STIs, substance use, and continued high risk sexual practices in men and women. These findings support the need for studies that confirm prevalence of STIs using clinical laboratory tests.     

HIV, the clustering of sexually transmitted infections, and sex risk among African American women who use drugs

African American women have high rates of most sexually transmitted infections (STIs), including HIV. STIs have been associated with increased HIV transmission risk. METHODS: Two hundred twenty-eight black women who used drugs completed a structured questionnaire in a central Brooklyn, NY-based research center between March 2003 and August 2005. Women were screened for HIV, herpes simplex virus-2, syphilis, gonorrhea, chlamydia, and trichomoniasis. This analysis determined if STIs cluster within individuals and if clustering and sex practices or partnerships differ by HIV status. RESULTS: Thirty-eight (17%) women tested HIV seropositive and STI prevalence was herpes simplex virus-2 (79%), trichomoniasis (37%), chlamydia (11%), and gonorrhea (2%). Few women knew themselves to be infected with STIs other than HIV. Excluding HIV, the mean number of STIs per woman was 1.3 (SD 0.7). HIV-infected women were significantly more likely than uninfected women to have multiple positive screens (1.6 vs. 1.2, P = 0.002). Women reported having both lower and higher risk sex partners. HIV-infected women were 2 times more likely than uninfected woman to report current sex work (P = 0.05), the only difference in sex risk. In a linear regression model, crack cocaine use was uniquely associated with multiple positive STI screens, excluding HIV (P = 0.002). CONCLUSIONS: Several STIs, including HIV, seem to be endemic among black women who use drugs in this community. In addition to the known geographical clustering of HIV and STIs, STIs were also found to cluster at the individual level. Multiply STI infected individuals may unknowingly, but efficiently, contribute to high STI and HIV rates.     

Demographic and behavioural profile of adults infected with chlamydia: a case-control study

OBJECTIVES: To determine which demographic and behavioural parameters are independently associated with chlamydial infection in adults. METHODS: Subjects were recruited prospectively from male and female attendees at a large clinic for sexually transmitted infections (STI). All subjects were tested for chlamydia and gonorrhoea and asked to complete a questionnaire addressing demography, sexual and non-sexual (including drug taking) behaviour, and history of STI. Cases were those attending with a new clinical episode and found to be infected with chlamydia, but who did not have gonorrhoea. A control group was selected randomly from those found to be negative on screening for both infections. RESULTS: 986 cases and 1212 controls were recruited over one calendar year. The following were found to be independent risk factors for chlamydial infection on multivariate analysis (odds ratios with 95% confidence intervals in parentheses): being unmarried (1.8; 1.1-3.1); black Caribbean ethnicity (2; 1.5-2.7). Increasing age, fewer partners, and higher reported use of condoms were associated with a lower risk of infection. CONCLUSION: Black Caribbeans are at increased risk from chlamydia after controlling for sexual behaviour and socioeconomic status. Future research should seek an explanation elsewhere-for example, in terms of differences in sexual mixing or effectiveness of healthcare interventions.     

Prevalence and risk factors of chlamydia and gonorrhea among rural Nepali women

OBJECTIVES: The epidemiology of sexually transmitted infections (STI) in rural, developing world populations is poorly understood. We estimated the prevalence and risk factors of Neisseria gonorrhoeae and Chlamydia trachomatis in a female population in rural Nepal. METHODS: We conducted a cross sectional study in a sample of 1177 postpartum women participating in a micronutrient supplementation trial in Nepal. Urine samples were collected to test for the two infections using the ligase chain reaction (LCR). RESULTS: C trachomatis was detected in 1.0% (95% confidence intervals (CI): 0.4 to 1.5) and N gonorrhoeae in 2.3% (95% CI: 1.2 to 3.4) of women. None of the women tested positive for both. Self report of all three symptoms of lower abdominal pain, pain and burning on urination, and vaginal discharge was associated with the presence of gonorrhoea (odds ratio (OR): 12.1, 95% CI: 1.3 to 115.0). Neonatal eye discharge was associated with maternal gonococcal infection (OR = 5.2, 95% CI: 1.1 to 24.9). Incidence of low birth weight was not related to these maternal infections, but very preterm delivery (<32 weeks) was higher among women positive for gonorrhoea (OR = 4.7, 95% CI: 1.0 to 22.0). In a multivariable analysis, low body mass index (<18.5) and cattle ownership were associated with gonorrhoea (p <0.05), whereas woman's literacy was associated with chlamydia (p = 0.06). CONCLUSION: We found the rates of N gonorrhoeae and C trachomatis to be low among women in this rural population of Nepal.     

Identification of chlamydia and gonorrhoea among women in rural Haiti: maximising access to treatment in a resource poor setting

OBJECTIVE: To develop a risk assessment algorithm that will increase the identification and treatment of women with cervical infection in rural Haiti. METHODS: Study participants were randomly selected from new patients who accessed services at a women's health clinic in rural Haiti between June 1999 and December 2002. This case-control study included women who tested positive for chlamydia and/or gonorrhoea based on the Gen-Probe PACE 2 laboratory test as cases. Controls were women who tested negative for both of these infections. RESULTS: Women from this area of rural Haiti had a limited level of education and lived in impoverished housing conditions. The sensitivity estimates of Haitian Ministry of Health and WHO algorithms for detecting chlamydia and/or gonorrhoea were generally low (ranging from 16.1% to 68.1%) in this population. Risk scores based on logistic regression models of local risk factors for chlamydia and gonorrhoea were developed and sensitivity estimates were higher for algorithms based on these risk scores (up to 98.8%); however, specificity was compromised. CONCLUSIONS: A risk assessment algorithm to identify women with chlamydia and/or gonorrhoea is more sensitive and less specific than the syndromic management approach advocated by WHO and adapted by the Haitian Ministry of Health. Using a risk assessment tool with high sensitivity based on local risk factors of cervical infection will maximise access to care, improve outcomes, and decrease morbidity in women who have cervical infection in rural Haiti.     

Knowledge of sex partner treatment for past bacterial STI and risk of current STI

OBJECTIVES: Effective partner management is critical in reducing the spread of bacterial sexually transmitted infections (STIs). The purpose of this study was to determine the relation between knowledge of partner treatment for a past STI and current infection in the index patient. METHODS: In a cross sectional analysis, 97 adolescent females sampled from community based health clinics reported that they had a past diagnosis of chlamydia or gonorrhoea in structured, face to face interviews. At the time of the interview, adolescents were also tested for chlamydia and gonorrhoea using urine based ligase chain reaction testing. RESULTS: 66% of the adolescents reported knowing that their partner was treated for the past infection. Those who knew their partner was treated were less likely to have a current infection, compared to those who did not know (11% v 30%, adjusted odds ratio and 95% confidence interval 4.46 (1.41 to 14.29), p<0.05). Correlates of not knowing the sex partner was treated included younger age and being in new sex partnership. CONCLUSIONS: Efforts to encourage young women to follow up directly with their partners regarding treatment may help to reduce repeat infections and further spread. Furthermore, alternative strategies such as patient delivered therapy may help with partner treatment in this vulnerable population.