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

Prevalence and risk factors of three curable sexually transmitted infections among women in Nairobi, Kenya

BACKGROUND

Sexually transmitted infections (STIs) are a major public health problem, especially in developing countries. The complications of untreated STIs in the female genital tract and their role in adverse pregnancy and perinatal outcomes have been well documented. The prevalence of STIs in Kenya among women in the general population has not been extensively studied and there is a lack of guidelines for screening of non-pregnant women. Knowledge of the prevalence of curable STIs among this population can provide a basis for integrating STI screening in family planning clinics.

METHODS

A cross-sectional study was conducted between May and September 2013 at the family planning (FP) clinic at Kenyatta National Hospital (KNH) in Nairobi, Kenya. A total of 261 participants aged 18-49 years were enrolled; with data from 249 participants being analysed. An interviewer-administered questionnaire was used to gather socio-demographic data and assess for risk factors. Each participant was screened for Trichomonas vaginalis (TV) by wet mount microscopy; Neisseria gonorrhoeae (GC) by culture and Chlamydia trachomatis (CT) by PCR.

RESULTS

The prevalence of CT was 13% (33/249), TV 0.4% (1/249) and GC 0% (0/249). All the infected women reported having had only one sexual partner in the previous 1 year. The age group prevalence for CT was highest in the 25-29 years age group (21%). The syndromic approach to the management of STIs showed a low specificity (vaginal discharge, 65.7%; lower abdominal pain, 60.6%) and positive predictive value (vaginal discharge, 14%; lower abdominal pain, 11.5%) for the two commonly used symptoms when compared to the gold standard of CT PCR.

CONCLUSION

A high prevalence of CT was identified among women attending the FP Clinic at KNH. The study reinforces the need to implement regular screening for STIs among FP clinic attendants. It also reveals the need to review the usage of the syndromic approach for the management of STIs.

Male involvement in sexual and reproductive health in the Mendi district, Southern Highlands province of Papua New Guinea: a descriptive study

BACKGROUND

Lack of male involvement and support for sexual and reproductive health services is seen by many Papua New Guinean women as a barrier to accessing services. Poor utilization of services by both men and women is reflected in high maternal mortality and high rates of HIV/AIDS and sexually transmitted infections in the Southern Highlands Province. It is therefore important to understand the type of services provided, men's perceptions of these services and the Health Sector's capacity to involve men in its programs.

METHODS

Information from interviews of married men, officers in charge of health facilities, and information from a focus group discussion with village leaders was collected to assess possible constraints to reproductive and sexual health care delivery.

RESULTS

Although many men had heard about antenatal care, supervised births, family planning and sexually transmitted infections including, HIV/AIDS, many were unaware of their importance and of the types of services provided to address these issues. There was a very strong association between men's literacy and their knowledge of Sexual and Reproductive Health (SRH) issues, their discussion of these issues with their wives and their wives' utilisation of sexual and reproductive health services. Some men considered SRH services to be important but gave priority to social obligations. Although men made most decisions for sexual and reproductive issues, pregnancy, child birth and rearing of children were regarded as women's responsibilities. Knowledge of HIV/AIDS appeared to have changed sexual behaviour in some men. Services for men in this rural setting were inadequate and service providers lacked the capacity to involve men in reproductive health issues.

CONCLUSION

Poor knowledge, socio-cultural factors and inadequate and inappropriate services for men hampered utilization of services and impaired support for their wives' service utilization. Programmatic and policy initiatives should focus on improving service delivery to accommodate men in sexual and reproductive health.

Trichomoniasis: clinical manifestations, diagnosis and management

Trichomonas vaginalis was originally considered a commensal organism until the 1950s when the understanding of its role as a sexually transmitted infection (STI) began to evolve. Trichomoniasis has been associated with vaginitis, cervicitis, urethritis, pelvic inflammatory disease (PID), and adverse birth outcomes. Infection with T vaginalis could have an important role in transmission and acquisition of HIV. T vaginalis is site specific for the genitourinary tract and has been isolated from virtually all genitourinary structures. Asymptomatic disease is common in both men and women, thus screening for disease is important. Various sociodemographic factors have been correlated with presence of T vaginalis, and may be used to predict infection. Diagnosis is usually made from wet mount microscopy and direct visualisation, which are insensitive. DNA amplification techniques perform with good sensitivity, but are not yet approved for diagnostic purposes. In areas where diagnostic methods are limited, management of trichomoniasis is usually as part of a clinical syndrome; vaginal discharge for women and urethral discharge for men. A single dose of metronidazole is effective in the majority of cases. Outside of the United States, other nitroimidazoles may be used and are as effective as metronidazole. Metronidazole resistance is an emerging problem, but its clinical importance is not yet clear. Concomitant treatment of sexual partners is recommended.

The power of information and contraceptive choice in a family planning setting in Mexico

OBJECTIVES

This study measured the effect of information about family planning methods and STD risk factors and prevention, together with personal choice on the selection of intrauterine devices (IUDs) by clients with cervical infection.

METHODS

We conducted a randomised, controlled trial in which family planning clients were assigned to one of two groups, the standard practice (control) group in which the provider selected the woman's contraceptive and the information and choice (intervention) group. The study enrolled 2107 clients in a family planning clinic in Mexico City.

RESULTS

Only 2.1% of the clients had gonorrhoea or chlamydial infections. Significantly fewer women in the intervention group selected the IUD than the proportion for whom the IUD was recommended in the standard care group by clinicians (58.2% v 88.2%, p = 0.0000). The difference was even more pronounced among infected women: 47.8% v 93.2% (intervention v control group, p = 0.0006).

CONCLUSIONS

The intervention increased the selection of condoms and reduced the selection of IUDs, especially among women with cervical infections, for whom IUD insertion is contraindicated.

Validity of the vaginal discharge algorithm among pregnant and non-pregnant women in Nairobi, Kenya

OBJECTIVE

To evaluate the validity of different algorithms for the diagnosis of gonococcal and chlamydial infections among pregnant and non-pregnant women consulting health services for vaginal discharge in Nairobi, Kenya.

METHODS

Cross sectional study among 621 women with complaints of vaginal discharge in three city council clinics between April and August 1997. Women were interviewed and examined for symptoms and signs of sexually transmitted infections (STIs). Specimens were obtained for laboratory diagnosis of genital infections, HIV, and syphilis. The data were used to evaluate the Kenyan flow chart as well as several other generated algorithms.

RESULTS

The mean age was 24 years and 334 (54%) were pregnant. The overall prevalence rates were: 50% candidiasis, 23% trichomoniasis, 9% bacterial vaginosis, 7% gonorrhoea, 9% chlamydia, 7% syphilis, and 22% HIV. In non-pregnant women, gonococcal and chlamydial infection was significantly associated with (1) demographic and behavioural risk markers such as being single, younger than 20 years, multiple sex partners in the previous 3 months; (2) symptom fever; and (3) signs including presence of yellow or bloody vaginal discharge, cervical mucopus, cervical erythema, and friability. Among pregnant women only young age, dysuria, and fever were significantly associated with cervical infection. However, none of these variables was either sensitive or specific enough for the diagnosis of cervical infection. Several algorithms were generated and applied to the study data. The algorithm including risk markers performed slightly better than the current Kenyan algorithm.

CONCLUSION

STIs form a major problem in the Nairobi area and should be addressed accordingly. None of the tested algorithms for the treatment of vaginal discharge would constitute a marked improvement of the existing flow chart. Hence, better detection tools for the specific aetiology of vaginal discharge are urgently needed.

Screening for sexually transmitted diseases in rural women in Papua New Guinea: are WHO therapeutic algorithms appropriate for case detection?

The presence of a large reservoir of untreated sexually transmitted diseases (STDs) in developing countries has prompted a number of suggestions for improving case detection, including the use of clinical algorithms and risk assessments to identify women likely to be infected when they present to clinics for other reasons. We used data from a community-based study of STDs to develop and evaluate algorithms for detection of cervical infection with Chlamydia trachomatis or Neisseria gonorrhoeae, and for detection of vaginal infection with Trichomonas vaginalis or bacterial vaginosis. The algorithms were derived using data from 192 randomly selected women, then evaluated on 200 self-selected women. We evaluated the WHO algorithm for vaginal discharge in both groups. The prevalences of cervical and vaginal infection in the randomly selected group were 27% and 50%, respectively, and 23% and 52%, respectively, in the self-selected group. The derived algorithms had high sensitivities in both groups, but poor specificities in the self-selected women, and the positive predictive values were unacceptably low. The WHO algorithms had extremely low sensitivity for detecting either vaginal or cervical infection because relatively few women reported vaginal discharge. Simple algorithms and risk assessments are not valid for case detection in this population.

Sexually transmitted disease among married Zambian women: the role of male and female sexual behaviour in prevention and management

OBJECTIVES

Few studies have evaluated the relation between male and female sexual behaviour and STD among married African women. The objectives of this study were to identify male and female sexual behaviour associated with female STD, and to explore whether incorporating male and female sexual behaviour and male symptoms can improve algorithms for STD management in married African women.

METHODS

99 married couples with one symptomatic member (58 males, 41 females) attending an STD clinic in Lusaka, Zambia were interviewed separately about sexual and contraceptive behaviour, and had physical examinations. Diagnostic tests for Neisseria gonorrhoeae (GC), Trichomonas vaginalis (TV), and HIV were performed. Bivariate and multivariate odds ratios for the association between sexual behaviour and STD were calculated. Predictive algorithms based on current Zambian guidelines for management of STD in women were created.

RESULTS

Among women at baseline, 10% were positive for GC, 14% for TV, 52% for HIV. Female alcohol use before sex, a male's paying for sex, and a couple's having sex unprotected by condoms or spermicides were associated with female STD. Incorporation of these behaviours along with symptoms of urethral discharge and dysuria among husbands increased the predictive ability of algorithms for management of STD in women.

CONCLUSIONS

The addition of male and female sexual behaviour and male STD symptoms to diagnostic algorithms for female STD should be explored in other settings. Both husbands' and wives' behaviour independently predict STD in these women; risk reduction programmes should target both men's and women's sexual behaviour.

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.