Prevalence of gonococcal and chlamydial infections in commercial sex workers in a Peruvian Amazon city

"Zika is everywhere": A qualitative exploration of knowledge, attitudes and practices towards Zika virus among women of reproductive age in Iquitos, Peru

Zika virus was reported in the rainforest city of Iquitos, Peru in 2016. The potential associations between Zika and fetal neurological disorders were reported extensively in the media regarding neighboring Brazil, and led to great concern about the impact Zika could have on people's health in Iquitos when it arrived. The aim of this study was to explore the knowledge, attitudes, and preventative practices related to Zika virus and its transmission among women of childbearing age in Iquitos, Peru. Six focus group discussions with 46 women of ages 20-35 from an Iquitos district with confirmed Zika cases were conducted to explore: 1) knowledge of Zika transmission, its symptoms, and treatment, 2) attitudes regarding Zika, including perceptions of risk for and severity of Zika, and 3) preventative practices, including awareness of health promotion activities. Participants were knowledgeable about Zika symptoms and knew it was transmitted by mosquitoes, and about half had heard about the association between Zika and microcephaly, but most lacked knowledge about the associated neurological disorders in adults, its sexual transmission, and ways to prevent infection. They expressed concern for pregnant women exposed to the virus and the impact on the fetus. Participants felt at risk of contracting the Zika virus, yet had not changed preventive practices, possibly in part because their perception of the severity of this disease was low. This study reveals knowledge gaps that could be addressed via health promotion messages that might improve prevention practices to help community members protect themselves from Zika virus during this outbreak.

Structural factors that increase HIV/STI vulnerability among indigenous people in the Peruvian amazon

We examined structural factors-social, political, economic, and environmental-that increase vulnerability to HIV among indigenous people in the Peruvian Amazon. Indigenous adults belonging to 12 different ethnic groups were purposively recruited in four Amazonian river ports and 16 indigenous villages. Qualitative data revealed a complex set of structural factors that give rise to environments of risk where health is constantly challenged. Ferryboats that cross Amazonian rivers are settings where unprotected sex-including transactional sex between passengers and boat crew and commercial sex work-often take place. Population mobility and mixing also occurs in settings like the river docks, mining sites, and other resource extraction camps, where heavy drinking and unprotected sex work are common. Multilevel, combination prevention strategies that integrate empirically based interventions with indigenous knowledge are urgently needed, not only to reduce vulnerability to HIV transmission, but also to eliminate the structural determinants of indigenous people's health.

Determining a cost effective intervention response to HIV/AIDS in Peru

Background

The HIV epidemic in Peru is still regarded as concentrated - sentinel surveillance data shows greatest rates of infection in men who have sex with men, while much lower rates are found in female sex workers and still lower in the general population. Without an appropriate set of preventive interventions, continuing infections could present a challenge to the sustainability of the present programme of universal access to treatment. Determining how specific prevention and care strategies would impact on the health of Peruvians should be key in reshaping the national response.

Methods

HIV/AIDS prevalence levels for risk groups with sufficient sentinel survey data were estimated. Unit costs were calculated for a series of interventions against HIV/AIDS which were subsequently inputted into a model to assess their ability to reduce infection transmission rates. Interventions included: mass media, voluntary counselling and testing; peer counselling for female sex workers; peer counselling for men who have sex with men; peer education of youth in-school; condom provision; STI treatment; prevention of mother to child transmission; and highly active antiretroviral therapy. Impact was assessed by the ability to reduce rates of transmission and quantified in terms of cost per DALY averted.

Results

Results of the analysis show that in Peru, the highest levels of HIV prevalence are found in men who have sex with men. Cost effectiveness varied greatly between interventions ranging from peer education of female commercial sex workers at $US 55 up to $US 5,928 (per DALY averted) for prevention of mother to child transmission.

Conclusion

The results of this work add evidence-based clarity as to which interventions warrant greatest consideration when planning an intervention response to HIV in Peru. Cost effectiveness analysis provides a necessary element of transparency when facing choices about priority setting, particularly when the country plans to amplify its response through new interventions partly funded by the GFATM.

High prevalence of sexually transmitted infections among young Peruvians who have sexual intercourse with foreign travelers in Cuzco

BACKGROUND

Sexual networking in popular tourist destinations is a problem worldwide. In Peru, locals sexually interacting with travelers bridge high-risk groups, the general population, and travelers.

METHODS

A cross-sectional study was conducted in Cuzco about sexual behavior among young Peruvians who admitted having sex with travelers. A subgroup of the participants had serologic testing for Chlamydia trachomatis, Herpes simplex virus (HSV) type 2, and Treponema pallidum.

RESULTS

Eighty-eight subjects volunteered for blood sampling. Their mean age was 22.9 years (+/-4.1) and 53.4% were male. The majority were single (86.2%), but 12.6% had a stable relationship. The median number of sexual partners in the 3 months prior to the study was 2 [interquartile range (IQR): 1-4]. During that period, 43.1% reported foreign partners, 28.4% reported foreign and Peruvian partners, 17% reported Peruvian partners, and the remaining 11.5% reported combinations of Peruvian, foreign, and sex workers partners. The median number of foreign partners in the 12-month period prior to the study was 4 (IQR: 2-8). Only 25.3% reported consistent condom use. Alcohol (69%) and drugs (36.8%) were commonly used before sexual activity. Seventy-eight percent tested positive for HSV type 2, 25% for C trachomatis, and 1.1% for T pallidum.

CONCLUSIONS

The core group of young Peruvians we report on demonstrated a high-risk sexual behavior and a high prevalence of sexually transmitted infections. Our results underscore the need for education on safer sex practices among this group and among travelers.

[Bacterial, mycobacterial and fungal opportunistic infections in HIV-infected immigrants: diagnosis and treatment]

The number of HIV infected immigrants has increased sharply in Spain. These patients are prone to contracting several different types of opportunistic infections, including bacterial, mycobacterial, fungal and parasitic infections. The present article provides an in-depth review of bacterial and fungal infections, with particular emphasis on those not endemic in our country.

Expansion of HIV and syphilis into the Peruvian Amazon: a survey of four communities of an indigenous Amazonian ethnic group

BACKGROUND

In 2004, cases of HIV and syphilis were reported in an indigenous community in the Peruvian Amazon. This study sought to determine the prevalence of HIV and syphilis in four remote communities of the same indigenous ethnic group located further from an urban center than the original community, and to identify risk factors for HIV and syphilis transmission.

METHODS

Rapid and confirmatory tests for HIV and syphilis were performed. A questionnaire elicited demographic information, risk factors for sexually transmitted infections, and knowledge/beliefs about HIV/AIDS.

RESULTS

We collected 282 blood samples and conducted interviews with 281 (99.6%) participants. The confirmed syphilis prevalence rate was 3.2% (9/282; 3.7% (5/135) for men and 2.7% (4/147) for women). The confirmed HIV prevalence rate was 0.7% (2/282), with both infections in men who had sex with men (MSM). Self-reported MSM activity was 39.7%. There was poor knowledge about HIV infection, transmission, and prevention, and low acceptance of known prevention methods.

CONCLUSIONS

HIV and syphilis are now prevalent in remote Amazonian communities of an indigenous group in Peru. Expansion of the HIV epidemic into the Amazon requires an urgent public health response.

Low educational level: a risk factor for sexually transmitted infections among commercial sex workers in Quito, Ecuador

Few studies have assessed the effect of educational level on sexually transmitted infections (STIs) and risk-taking behaviours among commercial sex workers (CSWs). This study analysed this association among female CSWs in Quito, Ecuador. Eighty-five CSWs were given a Spanish-language questionnaire on behaviours, socioeconomics and demographics. The correlation between years of education and number of prior STIs was calculated. Three groups of varying education level were formed and risk factors were analysed by Chi-square tests and analysis of variances. Lower educational level was associated with more STIs (r= -0.36; F=4.2; P=0.04), poorer knowledge of HIV/AIDS (P=0.03), earlier first prostitution (P=0.05) and first sex (P=0.00), willingness to engage in group sex (P=0.05) and work on the street (P=0.02), and presence of non-paying sexual partners (P=0.05). CSWs with lower educational levels were disproportionately afflicted with STIs and participated in more high-risk behaviours. Low educational level may predispose CSWs to STIs and associated risk factors.

Sexually transmissible infections among female sex workers: an international review with an emphasis on hard-to-access populations

Background: Women who work commercially in sex work (female sex workers [FSW]) are considered a high-risk group for sexually transmissible infections (STI), yet the level of reported pathogens varies in studies around the world. This study reviewed STI rates reported in 42 studies of FSW around the world published between 1995 and 2006 and analysed the trends and types of populations surveyed, emphasising difficult to access FSW populations. Methods:Studies were retrieved by PUBMED and other search engines and were included if two or more pathogens were studied and valid laboratory methods were reported. Results: The five most commonly assessed pathogens were Neisseria gonorrhea (prevalence 0.5–41.3), Chlamydia trachomatis (0.61–46.2), Treponema pallidum (syphilis; 1.5–60.5), HIV (0–76.6), and Trichomonas vaginalis (trichmoniasis; 0.11–51.0). Neisseria gonorrhea and C. trachomatis were the most commonly tested pathogens and high prevalence levels were found in diverse areas of the world. HIV was highly prevalent mostly in African countries. Although human papillomavirus infection was surveyed in few studies, prevalence rates were very high and its aetiological role in cervical cancer warrant its inclusion in future FSW monitoring. Hard-to-access FSW groups tended to have higher rates of STI. Conclusions: The five most commonly detected pathogens correspond to those that are highly prevalent in the general population, however there is an urgent need to develop rapid testing diagnostics for all five pathogens to increase prevention and treatment, especially in outreach programs to the most vulnerable groups among FSW.

Prevalence of Sexually Transmitted Infections and High-Risk Sexual Behaviors in Heterosexual Couples Attending Sexually Transmitted Disease Clinics in Peru

OBJECTIVES

The objectives of this study were to determine the prevalence of sexually transmitted infection (STIs) in heterosexual couples and the sexual behaviors associated with their acquisition.

GOAL

The goal of this study was to better direct educational efforts to decrease STI among heterosexual couples in Lima, Peru.

STUDY DESIGN

We conducted a case-control study in 195 heterosexual couples without HIV infection who attended 2 sexually transmitted disease clinics in Lima, Peru. A case was defined as an individual with one or more newly diagnosed STIs such as gonorrhea, chlamydia, trichomoniasis, herpes simplex, syphilis, mycoplasma, or ureaplasma.

RESULTS

Thirty-three percent of individuals (41 men and 89 women) had at least one STI and 26 couples (13%) had the same STI detected. Men who have sex with men (MSM) accounted for 13% of all men, had higher rate of STIs and higher risk behaviors than non-MSM. Ureaplasma infection was the most prevalent STI found in both men and women and was associated with oral sexual contact. In heterosexual pairs, condom use during anal sex occurred less than 10% of the time.

CONCLUSIONS

The heterosexual couples in sexually transmitted disease clinics have high-risk behaviors and STIs are frequent. The educational effort concerning prevention of STIs requires higher effort.

Epidemiology, pathogenesis and treatment of pelvic inflammatory disease

Pelvic inflammatory disease, the infection and inflammation of the female upper genital tract, is a common cause of infertility, chronic pain and ectopic pregnancy. Diagnosis and management are challenging, due largely to a polymicrobial etiology which is not fully delineated. Signs and symptoms of this syndrome vary widely, further complicating diagnosis and treatment. Due to the potential for serious sequelae, a low threshold for diagnosis and treatment is recommended. Since pelvic inflammatory disease has a multimicrobial etiology including Neisseria gonorrhoeae, Chlamydia trachomatis and anaerobic and mycoplasmal bacteria, treatment of pelvic inflammatory disease should be broad spectrum. Recent treatment trials have focused on shorter duration regimens such as azithromycin and monotherapies including ofloxacin, although data are sparse. Research comparing sequelae development by differing antimicrobial regimens is extremely limited, but will ultimately shape future treatment guidelines. Several promising short-duration and monotherapy antibiotic regimens should be evaluated in pelvic inflammatory disease treatment trials for compliance, microbiological and clinical cure, and reduction of subsequent adverse reproductive and gynecological morbidity.

Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiologic studies

BACKGROUND

Studies of condom use to reduce risk of most sexually transmitted infection provide inconsistent results. This inconsistency is often attributed to methodologic limitations yet has not been assessed systematically.

OBJECTIVES

The objectives of this study were to review studies of condom use and risk of gonorrhea and chlamydia, and to evaluate the importance of 4 key design and measurement factors on condom effectiveness estimates.

DESIGN

We reviewed studies published 1966-2004 to assess risk reduction for gonorrhea and/or chlamydia associated with male condom use.

RESULTS

Of 45 studies identified, most found reduced risk of infection associated with condom use. All studies reviewed had methodologic limitations: only 28 (62%) distinguished consistent from inconsistent use; 2 (4%) reported on correct use or use problems; 13 (29%) distinguished incident from prevalent infection; and one (2%) included a population with documented exposure to infection. Eight of 10 studies with 2 or more of these attributes reported statistically significant protective effects for condom use versus 15 of 35 studies with zero or one attribute (80% vs. 43%, P = 0.04).

CONCLUSIONS

Condom use was associated with reduced risk of gonorrhea and chlamydia in men and women in most studies, despite methodologic limitations that likely underestimate condom effectiveness. Epidemiologic studies that better address these factors are needed to provide more accurate assessment of condom effectiveness.

Sex-work harm reduction

Sex work is an extremely dangerous profession. The use of harm-reduction principles can help to safeguard sex workers' lives in the same way that drug users have benefited from drug-use harm reduction. Sex workers are exposed to serious harms: drug use, disease, violence, discrimination, debt, criminalisation, and exploitation (child prostitution, trafficking for sex work, and exploitation of migrants). Successful and promising harm-reduction strategies are available: education, empowerment, prevention, care, occupational health and safety, decriminalisation of sex workers, and human-rights-based approaches. Successful interventions include peer education, training in condom-negotiating skills, safety tips for street-based sex workers, male and female condoms, the prevention-care synergy, occupational health and safety guidelines for brothels, self-help organisations, and community-based child protection networks. Straightforward and achievable steps are available to improve the day-to-day lives of sex workers while they continue to work. Conceptualising and debating sex-work harm reduction as a new paradigm can hasten this process.

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.

Monitoring trends in sexual behaviour and HIV/STIs in Peru: are available data sufficient?

OBJECTIVES

To review and summarise various types of Peruvian evidence on sexual behaviour, HIV/STI exposure and risk, and discuss how to increase its usefulness for HIV/STI risk trend monitoring in Peru.

METHODS

Review HIV sentinel surveillance conducted by the Ministry of Health; data from the Demographic and Health Surveys (DHS); and academic publications on sexual behaviour in combination with biological markers. Changes over time, quality of data, size of studies, and intended audience are discussed.

RESULTS

Data from HIV sentinel surveillance showed very high (8-23%) HIV seroprevalence among men having sex with men, but stable, relatively low figures among female sex workers (1%) and antenatal clinic patients (under 0.5%). DHS data suggest that single women increased their sexual activity throughout the 1990s but did not raise their contraceptive use accordingly, resulting in increased early conceptions. The contribution of condoms to overall contraceptive protection increased threefold in 1992-2000. According to the 1996 survey, men become sexually active 2.5 years earlier than women, but marry or cohabit four years later than women; women marry or cohabit 1.5-2.5 years after first sex, whereas men take eight years to do so. Finally, published studies confirmed dramatic differences in HIV prevalence between men who have sex with men and other populations, and also suggested patterns of bridging from men to women.

CONCLUSIONS

Data available from the three sources are numerous, although limitations of each approach reduce their monitoring utility: Ministry of Health studies should select better sentinel populations and timely process behavioural data. Future demographic surveys should incorporate an AIDS risk perspective and include men.

Condom use and the risk of recurrent pelvic inflammatory disease, chronic pelvic pain, or infertility following an episode of pelvic inflammatory disease

Among 684 sexually active women with pelvic inflammatory disease (PID) followed up for a mean of 35 months, we related contraceptive use to self-reported PID recurrence, chronic pelvic pain, and infertility. Persistent use of condoms during the study reduced the risk of recurrent PID, chronic pelvic pain, and infertility. Consistent condom use (about 60% of encounters) at baseline also reduced these risks, after adjustment for confounders, by 30% to 60%. Self-reported persistent and consistent condom use was associated with lower rates of PID sequelae.

Clients of Female Sex Workers in Lima, Peru

OBJECTIVES

The objectives of this study were to determine the prevalence of risk behaviors, gonorrhea, and chlamydia in clients of female sex workers, and to compare them with men selected from the general population.

STUDY DESIGN

We conducted a cross-sectional study of men recruited from commercial sex venues in Lima, Peru from January to February 2002. Subjects answered a survey and provided a urine sample.

RESULTS

Men reported that in the recently concluded commercial sex encounter, 95.8% used condoms, and 85.8% always used condoms with female sex workers. Only 16% reported always using condoms with their stable partners; 50.8% always used condoms with casual, noncommercial partners; and 59.6% always used condoms for homosexual anal sex. There were 8 (2%) cases of chlamydia and no cases of gonorrhea.

CONCLUSIONS

Clients of female sex workers report high rates of condom use with sex workers and a low prevalence of chlamydia and gonorrhea. It is unlikely that they constitute a bridging population.

[Prevalence of hepatitis B, hepatitis C and syphilis in female sex workers in Venezuela]

OBJECTIVE

In Venezuela, female sex workers are submitted to a preventive control of syphilis and human immunodeficiency virus (HIV). However, other very important sexually transmitted infections are not evaluated. A study was carried out to identify the sociocultural background of a group of sex workers and its association with the seroprevalence of hepatitis B and C markers, in addition to routine evaluation.

METHOD

A total of 212 female sex workers who attended the control center of sexually transmitted infections (STI) in the city of Los Teques, Venezuela, were evaluated. Women were asked their age, educational background, use of contraceptive methods and condoms. Blood was drawn to determine the prevalence of syphilis, hepatitis B surface antigen (HBsAg), antibodies to hepatitis B core (anti-HBc), hepatitis C (anti-HCV) and HIV.

RESULTS

The prevalence of syphilis was 2.4%, seroprevalence of anti-HCV was 0.5%, HBsAg 3.8% and anti-HBc 13.8%. No cases of HIV were observed. Higher prevalence of hepatitis B markers was associated with a lower level of education (p<0.05) and higher age (p<0.05). It was found that 38.5% of participant women never used condoms and 25.6% did not use any contraceptive method.

CONCLUSION

It could be necessary to implement preventive programs to immunize sex workers against hepatitis B virus as well as education programs on condom use for their protection against sexually transmitted infections.

Hormonal and barrier contraception and risk of upper genital tract disease in the PID Evaluation and Clinical Health (PEACH) study

OBJECTIVE

Among women diagnosed with pelvic inflammatory disease, we examined the associations between hormonal or barrier methods of contraception and upper genital tract infection or inflammation.

METHODS

Participants were 563 patients from a treatment trial for pelvic inflammatory disease. All had pelvic pain; pelvic organ tenderness; and leukorrhea, mucopurulent cervicitis, or untreated cervicitis. Contraceptive use within the prior 4 weeks was compared among women with baseline upper genital tract gonorrhea or chlamydia, women with endometritis without upper genital tract gonorrhea or chlamydia, and women with neither upper genital tract gonorrhea or chlamydia nor endometritis.

RESULTS

Inconsistent condom use was significantly and independently associated with a 2 to 3 times elevated risk for upper genital tract infection. Upper genital tract gonorrhea or chlamydia was not significantly associated with use of oral contraceptives, use of medroxyprogesterone, condoms used consistently, nor other barrier methods.

CONCLUSION

No hormonal or barrier contraceptive method was related to a reduction in upper genital tract disease among women with clinical pelvic inflammatory diseases.

Screening for sexually transmitted diseases in human immunodeficiency virus-positive patients in Peru reveals an absence of Chlamydia trachomatis and identifies Trichomonas vaginalis in pharyngeal specimens

To determine the prevalence of sexually transmitted diseases (STDs), we screened 107 human immunodeficiency virus-positive patients in Peru, where the virus is predominantly sexually transmitted. Patients had multiple risk factors for STDs, and 38% of women and 50% of men had at least 1 STD (gonorrhea, trichomoniasis, herpes simplex, anogenital warts, or syphilis seropositivity). No chlamydial infection was detected, even though infection rates in the general population are 5%-12%. Patients receiving trimethoprim-sulfamethoxazole(TMP-SMZ) for prophylaxis or treatment of respiratory infections were least likely to have cervicitis and/or urethritis (odds ratio, 0.37; 95% confidence interval, 0.15-0.89). Although not optimal treatment, administration of TMP-SMZ is effective against chlamydial infection. We speculate that the use of concomitant medications, such as TMP-SMZ, may be inadvertently preventing chlamydial infection in this population. Another finding was the presence of Trichomonas vaginalis in pharyngeal specimens of 3 men with histories of orogenital activity. This has not been previously reported and requires further study.

Motorcycle taxi drivers and sexually transmitted infections in a Peruvian Amazon City

BACKGROUND

In Iquitos, Peru, motorcycle taxis are a common form of public transportation used both by residents and visitors.

GOAL

To evaluate the prevalence of factors associated with sexually transmitted disease risk and of Neisseria gonorrhoeae and Chlamydia trachomatis infections among motorcycle taxi drivers working in Iquitos, Peru.

STUDY DESIGN

A convenience sample of motorcycle taxi drivers was recruited through street outreach. Participants were confidentially interviewed and provided urine specimens for gonococcal and chlamydial infection testing.

RESULTS

A history of sexually transmitted disease (62%) or symptoms in the past year (35%) and of referral of clients to commercial sex workers (60%) was common. The prevalence of gonococcal or chlamydial infection was 3.5%.

CONCLUSIONS

Motorcycle taxi drivers are a major means of public transportation in Iquitos, Peru, have high personal risks for sexually transmitted disease, and interface often with at-risk persons.