Do pre-exposure prophylaxis (PrEP) users engaging in chemsex experience their participation as problematic and how can they best be supported? Findings from an online survey in Belgium

BACKGROUND

Chemsex involves the use of psychoactive drugs in a sexual context and is a growing phenomenon among men who have sex with men (MSM) and pre-exposure prophylaxis (PrEP) users. Investigating how its negative consequences can be avoided is important. The objective of this study was to explore the perceived impact of chemsex, the willingness to reduce chemsex activities and associated risks and preferred interventions to do so among PrEP users.

METHODS

We analysed data from an online survey among PrEP users in Belgium. Chemsex was assessed in two questionnaires distributed between September 2020 and January 2022.

RESULTS

A total of 326 participants completed the baseline questionnaire, and 186 the follow-up questionnaire. About one in three participants (36.5%, 119/326) reported engaging in chemsex, and half of those (49.6%, 59/119) were willing to reduce chemsex-related risks. The most preferred strategies for reducing risks were online support via an app (37.3%, 22/59) and face-to-face counselling with a health care professional (30.5%, 18/59). Among those reporting recent chemsex in the follow-up questionnaire, about one in five (21.9%, 14/64) wanted to reduce or stop chemsex activities. About 23.4% (15/64) also reported experiencing negative consequences of chemsex on their health, social or professional life.

CONCLUSION

Our findings show that one in four PrEP users engaging in chemsex experienced negative consequences of these activities and about one in five was willing to reduce or stop chemsex activities. We recommend embedding comprehensive chemsex support in the PrEP package of care and developing novel tools and interventions in order to reach maximum impact.

Non-Consensual Sex and Help-Seeking Behavior Among PrEP Users in Belgium: Findings from an Online Survey

Non-consensual sex poses a threat not only to sexual health but also to mental and physical health in general. HIV pre-exposure prophylaxis (PrEP) users might be particularly vulnerable to non-consensual sex because of interplaying factors such as mental health disorders, a high number of sex partners, engagement in chemsex, and the widespread use of dating apps. The objectives of this study were to assess the occurrence of non-consensual sex, its associated factors, and related help-seeking behavior among PrEP users. We analyzed data from an online survey among PrEP users in Belgium (09/2020-02/2022). Almost one in five participants (34/187, 18.2%) reported having ever experienced non-consensual sex. The most reported form was having sex against one's will, followed by having been given drugs against one's will, and having had sex without a condom against one's will. The vast majority of those who had experienced non-consensual sex (29/34, 85.3%) did not seek help afterward, mostly due to a lack of perceived need (21/29, 72.4%). Reported barriers to seeking help were shame (6/29, 20.7%) and lack of awareness of help services (3/29, 10.3%). Having experienced non-consensual sex in the past five years was associated with younger age and suicidal ideation in a multivariable logistic regression model. We conclude that addressing barriers to non-consensual sex help services is crucial to maximize their use and minimize the consequences of non-consensual sex experiences. PrEP consultations also represent an opportunity to offer such help given PrEP users are already familiar with these PrEP services and engaged in care.

Effect of Vitamin C Supplementation for Pregnant Smokers on Offspring Airway Function and Wheeze at Age 5 Years: Follow-up of a Randomized Clinical Trial

Importance

Vitamin C supplementation (500 mg/d) for pregnant smokers has been reported to increase offspring airway function as measured by forced expiratory flow (FEF) through age 12 months; however, its effects on airway function at age 5 years remain to be assessed.

Objective

To assess whether vitamin C supplementation in pregnant smokers is associated with increased and/or improved airway function in their offspring at age 5 years and whether vitamin C decreases the occurrence of wheeze.

Design, Setting, and Participants

This study followed up the Vitamin C to Decrease the Effects of Smoking in Pregnancy on Infant Lung Function (VCSIP) double-blind, placebo-controlled randomized clinical trial conducted at 3 centers in the US (in Oregon, Washington, and Indiana) between 2012 and 2016. Investigators and participants remain unaware of the treatment assignments. Forced expiratory flow measurements at age 5 years were completed from 2018 to 2021.

Interventions

Pregnant smokers were randomized to vitamin C (500 mg/d) or placebo treatment.

Main Outcomes and Measures

The primary outcome was the prespecified measurement of FEF between 25% and 75% expired volume (FEF25-75) by spirometry at age 5 years. Secondary outcomes included FEF measurements at 50% and 75% of expiration (FEF50 and FEF75), forced expiratory volume in 1 second (FEV1), and occurrence of wheeze.

Results

Of the 251 pregnant smokers included in this study, 125 (49.8%) were randomized to vitamin C and 126 (50.2%) were randomized to placebo. Of 213 children from the VCSIP trial who were reconsented into this follow-up study, 192 (90.1%) had successful FEF measurements at age 5 years; 212 (99.5%) were included in the analysis of wheeze. Analysis of covariance demonstrated that offspring of pregnant smokers allocated to vitamin C compared with placebo had 17.2% significantly higher mean (SE) measurements of FEF25-75 at age 5 years (1.45 [0.04] vs 1.24 [0.04] L/s; adjusted mean difference, 0.21 [95% CI, 0.13-0.30]; P < .001). Mean (SE) measurements were also significantly increased by 14.1% for FEF50 (1.59 [0.04] vs 1.39 [0.04] L/s; adjusted mean difference, 0.20 [95% CI, 0.11-0.30]; P < .001), 25.9% for FEF75 (0.79 [0.02] vs 0.63 [0.02] L/s; 0.16 [95% CI, 0.11-0.22]; P < .001), and 4.4% for FEV1 (1.13 [0.02] vs 1.09 [0.02] L; 0.05 [95% CI, 0.01-0.09]; P = .02). In addition, offspring of pregnant smokers randomized to vitamin C had significantly decreased wheeze (28.3% vs 47.2%; estimated odds ratio, 0.41 [95% CI, 0.23-0.74]; P = .003).

Conclusions and Relevance

In this follow-up study of offspring of pregnant smokers randomized to vitamin C vs placebo, vitamin C supplementation during pregnancy resulted in significantly increased airway function of offspring at age 5 years and significantly decreased the occurrence of wheeze. These findings suggest that vitamin C supplementation for pregnant smokers may decrease the effects of smoking in pregnancy on childhood airway function and respiratory health.

Trial Registration

ClinicalTrials.gov Identifier: NCT03203603.

Hair and nail nicotine levels of mothers and their infants as valid biomarkers of exposure to intrauterine tobacco smoke

INTRODUCTION

Tobacco use remains the single most modifiable cause of adverse pregnancy outcomes. It is crucial to be able to accurately quantify the burden of tobacco exposure on both the mother and fetus to have better measures of efficacy with interventions being studied.

METHODS

This is a descriptive and exploratory study conducted within a randomized controlled trial. Pregnant smoking and non-smoking women were followed from ≤22 weeks' gestation through delivery with monthly maternal smoking questionnaires, urine cotinine levels, and collection of maternal and infant hair and nail samples, at delivery. Nicotine was extracted and measured (ng/mg) using high-performance liquid chromatography with electrochemical detection.

RESULTS

Forty-six mother-infant dyads (34 pregnant smokers and 12 pregnant non-smokers) had successful completion of maternal and infant hair and nails samples. The median hair nicotine levels of the smoking mothers and their infants was significantly higher than those of the non-smokers (1.015 vs 0.037 ng/ mg, p<0.05 for the mothers; 0.445 vs 0.080 ng/mg, p<0.01 for the infants). Similarly, the median nail nicotine levels for smoking mothers and their infants were significantly higher than the non-smokers (2.130 vs 0.056 ng/mg, p<0.01 for the mothers; 0.594 vs 0.132 ng/mg, p<0.05 for the infants). We found a moderate but significant correlation between maternal hair and nail nicotine (r=0.64, p<0.001), infant hair and nail nicotine (r=0.64; p<0.001), maternal and infant hair nicotine (r=0.61, p<0.001), and maternal and infant nail nicotine levels (r=0.58, p<0.001).

CONCLUSIONS

Our study shows that both infant hair and nail nicotine levels are valid biomarkers of intrauterine tobacco smoke exposure, and can be used to identify prenatal smoke exposure, correlating well with the level of maternal nicotine exposure.

Impact of vitamin C supplementation on placental DNA methylation changes related to maternal smoking: association with gene expression and respiratory outcomes

BACKGROUND

Maternal smoking during pregnancy (MSDP) affects development of multiple organ systems including the placenta, lung, brain, and vasculature. In particular, children exposed to MSDP show lifelong deficits in pulmonary function and increased risk of asthma and wheeze. Our laboratory has previously shown that vitamin C supplementation during pregnancy prevents some of the adverse effects of MSDP on offspring respiratory outcomes. Epigenetic modifications, including DNA methylation (DNAm), are a likely link between in utero exposures and adverse health outcomes, and MSDP has previously been associated with DNAm changes in blood, placenta, and buccal epithelium. Analysis of placental DNAm may reveal critical targets of MSDP and vitamin C relevant to respiratory health outcomes.

RESULTS

DNAm was measured in placentas obtained from 72 smokers enrolled in the VCSIP RCT: NCT03203603 (37 supplemented with vitamin C, 35 with placebo) and 24 never-smokers for reference. Methylation at one CpG, cg20790161, reached Bonferroni significance and was hypomethylated in vitamin C supplemented smokers versus placebo. Analysis of spatially related CpGs identified 93 candidate differentially methylated regions (DMRs) between treatment groups, including loci known to be associated with lung function, oxidative stress, fetal development and growth, and angiogenesis. Overlap of nominally significant differentially methylated CpGs (DMCs) in never-smokers versus placebo with nominally significant DMCs in vitamin C versus placebo identified 9059 candidate "restored CpGs" for association with placental transcript expression and respiratory outcomes. Methylation at 274 restored candidate CpG sites was associated with expression of 259 genes (FDR < 0.05). We further identified candidate CpGs associated with infant lung function (34 CpGs) and composite wheeze (1 CpG) at 12 months of age (FDR < 0.05). Increased methylation in the DIP2C, APOH/PRKCA, and additional candidate gene regions was associated with improved lung function and decreased wheeze in offspring of vitamin C-treated smokers.

CONCLUSIONS

Vitamin C supplementation to pregnant smokers ameliorates changes associated with maternal smoking in placental DNA methylation and gene expression in pathways potentially linked to improved placental function and offspring respiratory health. Further work is necessary to validate candidate loci and elucidate the causal pathway between placental methylation changes and outcomes of offspring exposed to MSDP. Clinical trial registration ClinicalTrials.gov, NCT01723696. Registered November 6, 2012. https://clinicaltrials.gov/ct2/show/record/NCT01723696 .

Vitamin C to Pregnant Smokers Persistently Improves Infant Airway Function to 12 Months of Age: A Randomised Trial

BACKGROUND

Vitamin C (500 mg·day-1) supplementation for pregnant smokers has been reported to increase newborn pulmonary function and infant forced expiratory flows (FEFs) at 3 months of age. Its effect on airway function through 12 months of age has not been reported.

OBJECTIVE

To assess whether vitamin C supplementation to pregnant smokers is associated with a sustained increased airway function in their infants through 12 months of age.

METHODS

This is a prespecified secondary outcome of a randomised, double-blind, placebo-controlled trial that randomised 251 pregnant smokers between 13 and 23 weeks of gestation: 125 to 500 mg·day-1 vitamin C and 126 to placebo. Smoking cessation counselling was provided. FEFs performed at 3 and 12 months of age were analysed by repeated measures analysis of covariance.

RESULTS

FEFs were performed in 222 infants at 3 months and 202 infants at 12 months of age. The infants allocated to vitamin C had significantly increased FEFs over the first year of life compared to those allocated to placebo. The overall increased flows were: 40.2 mL·sec-1 for FEF75 (adjusted 95% CI for difference 6.6 to 73.8; p=0.025); 58.3 mL·sec-1 for FEF50 (95% CI 10.9 to 105.8; p=0.0081); and 55.1 mL·sec-1 for FEF25-75 (95% CI, 9.7 to 100.5; p=0.013).

CONCLUSIONS

In offspring of pregnant smokers randomised to vitamin C versus placebo, vitamin C during pregnancy was associated with a small but significantly increased airway function at 3 and 12 months of age, suggesting a potential shift to a higher airway function trajectory curve. Continued follow-up is underway.

Oral Vitamin C (500 mg/d) to Pregnant Smokers Improves Infant Airway Function at 3 Months (VCSIP). A Randomized Trial

Rationale: We reported a randomized trial demonstrating daily supplemental vitamin C to pregnant smokers significantly improved newborn pulmonary function tests. The current study tests these results in a new cohort using infant pulmonary function tests. Objectives: To determine if infants of pregnant smokers randomized to daily supplemental vitamin C would have improved forced expiratory flows (FEFs) at 3 months of age compared with those randomized to placebo, and to investigate the association of the α5 nicotinic acetylcholine receptor. Methods: A randomized, double-blind, placebo-controlled trial was conducted at three centers. Two hundred fifty-one pregnant smokers were randomized at 13-23 weeks of gestation: 125 randomized to vitamin C (500 mg/d) and 126 to placebo. Measurements and Main Results: The primary outcome was FEF75 at 3 months of age performed with the raised volume rapid thoracic compression technique (Jaeger/Viasys). FEF50 and FEF25-75 obtained from the same expiratory curves were prespecified secondary outcomes. The infants of pregnant smokers randomized to vitamin C (n = 113) had the following FEFs at 3 months of age compared with those randomized to placebo (n =  109) as measured by FEF75 (200.7 vs. 188.7 ml/s; adjusted 95% confidence interval [CI] for difference, -3.33 to 35.64; P = 0.10), FEF50 (436.7 vs. 408.5 ml/s; adjusted 95% CI for difference, 6.10-61.30; P = 0.02), and FEF25-75 (387.4 vs. 365.8 ml/s; adjusted 95% CI for difference, 0.92-55.34; P = 0.04). Infant FEFs seemed to be negatively associated with the maternal risk alleles for the α5 nicotinic acetylcholine receptor (rs16969968). Conclusions: Although the primary outcome of FEF75 was not improved after vitamin C supplementation to pregnant smokers, the predetermined secondary outcomes FEF50 and FEF25-75 were significantly improved. These results extend our previous findings and demonstrate improved airway function (FEF50 and FEF25-75) at 3 months of age in infants after vitamin C supplementation to pregnant smokers. Clinical trial registered with www.clinicaltrials.gov (NCT01723696).

Vitamin C to Decrease the Effects of Smoking in Pregnancy on Infant Lung Function (VCSIP): Rationale, design, and methods of a randomized, controlled trial of vitamin C supplementation in pregnancy for the primary prevention of effects of in utero tobacco smoke exposure on infant lung function and respiratory health

Despite strong anti-smoking efforts, at least 12% of American women cannot quit smoking when pregnant resulting in >450,000 smoke-exposed infants born yearly. Smoking during pregnancy is the largest preventable cause of childhood respiratory illness including wheezing and asthma. Recent studies have shown a protective effect of vitamin C supplementation on the lung function of offspring exposed to in utero smoke in a non-human primate model and an initial human trial. Vitamin C to Decrease the Effects of Smoking in Pregnancy on Infant Lung Function (VCSIP) is a randomized, double-blind, placebo-controlled trial to evaluate pulmonary function at 3months of age in infants delivered to pregnant smokers randomized to 500mg/day of vitamin C versus placebo during pregnancy. Secondary aims evaluate the incidence of wheezing through 12months and pulmonary function testing at 12months of age. Women are randomized between 13 and 23weeks gestation from clinical sites in Portland, Oregon at Oregon Health & Science University and PeaceHealth Southwest Medical Center and in Indianapolis, Indiana at Indiana University and Wishard Hospital. Vitamin C supplementation occurs from randomization to delivery. Monthly contact with participants and monitoring of medical records is performed to document medication adherence, changes in smoking and medical history, and adverse events. Pulmonary function testing of offspring occurs at 3 and 12months of age and incidence of wheezing and respiratory illness through 12months is captured via at least quarterly questionnaires. Ancillary studies are investigating the impact of vitamin C on placental blood flow and DNA methylation.

Suppressed cellular alloimmune responses in HIV-exposed seronegative female sex workers

Particular human leucocyte antigen (HLA) polymorphisms have been associated with a reduced risk of HIV transmission. However, protective alloimmune responses expected to result from such a genetic predisposition have not been demonstrated. To this end, we analysed and compared cellular and humoral alloimmune responses in a cohort of female sex workers who remained human immunodeficiency virus (HIV)-seronegative despite more than 3 years of high-risk sexual activity (ESN FSWs) with those of low-risk HIV-seronegative female blood donors in Abidjan, Côte d'Ivoire. ESN FSWs showed significantly lower allostimulated CD69 expression and secretion of interferon-gamma, macrophage inflammatory protein (MIP)-1beta and RANTES (regulated upon activation, normal T-cell expressed and secreted) by lymphocytes than controls. In contrast, ESN FSWs showed significantly higher mitogen-stimulated CD69 expression and secretion of tumour necrosis factor-alpha and MIP-1beta than controls. Suppression of cellular alloimmune responses among ESN FSWs was associated with a higher self-reported frequency of unprotected sex. Levels of anti-HLA class I alloantibodies in plasma were not significantly different between ESN FSWs and controls. These findings indicate that frequent sexual exposure to multiple partners results in suppression rather than activation of cellular alloimmune responses. Our data support the hypothesis that suppressed cellular alloimmune responses may play a role in protection against HIV infection.

Quality of sexually transmitted infections services for female sex workers in Abidjan, Côte d'Ivoire

OBJECTIVES

To assess the quality of sexually transmitted infections (STI) care in health care facilities in Abidjan attended by female sex workers.

METHODS

A cross-sectional study was conducted in June 2000 in the 29 health care facilities and 10 pharmacies, which were reported as points of first encounter for STI care by female sex workers in a previous study on health seeking behaviour. Evaluation components included: (1) checklists of equipment and STI drugs in the facilities; (2) interviews with health care providers and pharmacists; (3) direct observation of the provider/client interaction; (4) exit interviews with women attending with STI or genital problems.

RESULTS

Private health care facilities were more expensive, had fewer clients, and had less equipment and medical staff than public facilities, with the exception of the special female sex worker clinic. A total of 60 health care providers and 29 pharmacists were interviewed. There was no difference in their scoring on syndromic approach case studies, with the exception of the nurse assistants, who scored less. Overall scores for correct treatment were lowest for the pharmacists. We observed 513 provider-client interactions, of which 161 related to STIs or genital problems in women. Questions about recent sexual contacts were asked in only 20% and preventive messages were given in only 9% of the cases with STI/genital problems. Of 161 clients interviewed, 44% complained about a long waiting time, and 39% thought the health care provider had adequately explained the problem to them.

CONCLUSIONS

The opportunity for improvement of STI case management in health care facilities in Abidjan where female sex workers go for STI care is enormous. Public and private health care facilities should be made more accessible for sex workers, and their services should be upgraded to better respond to the sexual health needs of high risk women.

Comparison of culture and different PCR assays for detection of Trichomonas vaginalis in self collected vaginal swab specimens

OBJECTIVES

DNA amplification techniques have become widely used for the diagnosis of sexually transmitted infections. For the detection of Trichomonas vaginalis, PCR techniques are not yet widely used despite the publication of several assays. The sensitivity and specificity of five independent primer sets were determined on self collected vaginal specimens obtained from female commercial sex workers.

METHODS

Self collected specimens were obtained from symptomatic and asymptomatic women attending a female sex workers clinic in Abidjan, Côte d'Ivoire. Two vaginal specimens were collected, the first one was processed for culture and the second was processed for PCR analysis. PCR techniques for trichomonads were performed, using the primers as reported by Riley (TVA5/TVA6), Kengne (TVK3/TVK7), Madico (BTUB 9/BTUB 2), Shiao (IP1/IP2), and Mayta (TV1/TV2). An EIA amplicon detection method was designed for each of the primer sets.

RESULTS

True positive specimens were defined as culture positive and/or two positive PCR results with EIA amplicon detection in any combination. According to this definition a prevalence of 20% was obtained compared to 7% obtained by culture. The PCR primer set TVK3/TVK7 gave the highest sensitivity (89.2%). Poor sensitivities were obtained with the primer sets TV1/TV2 (60.2%) and TVA5/TVA6 (63.9%). PCR showed a sensitivity improvement of 2.4% up to 12% when EIA was used for amplicon detection.

CONCLUSIONS

Overall, the sensitivities of the different PCR assays resulting from this study were lower than those previously described. These findings could be the result of the nature of the specimen population and suggests a strain variability.

Where do sex workers go for health care? A community based study in Abidjan, Côte d'Ivoire

OBJECTIVES

To describe health seeking behaviour of female sex workers in Abidjan, Côte d'Ivoire.

METHODS

A population based survey among a representative sample of 500 female sex workers and six focus group discussions.

RESULTS

The sites of first encounter for care for the last STI episode included a public hospital or health centre (28%), a private clinic (16%), a confidential clinic (13%), a pharmacy (13%), and the informal sector (23%). The agreement between preferred and actual services used was weak (kappa 0.16).

CONCLUSIONS

Sex workers expressed interest in seeking STI care in a wide range of public and private healthcare facilities. Those services should be upgraded to better respond to their sexual health needs.

Challenges in the conduct of vaginal microbicide effectiveness trials in the developing world

Conducting a phase III trial of a vaginal microbicide in a developing country poses several important and complex ethical challenges. As part of a process to bridge the gap between ethical theory and practice, we share our experiences in performing a phase III trial of Col 1492 (Advantage S) among female sex workers at four sites world-wide; Durban, Abidjan, Cotonou and Hat Yai. The ethical challenges included: (i) difficulties in obtaining informed consent. Participants were unable to grasp the concepts of a clinical trial for several weeks to months. In Cotonou, 30% of the women did not know the gel was tested for HIV prevention. Only 25% understood what a placebo was. In Durban, 70% of the women did not fully understand the study after 3 months; (ii) in sustaining the use of known HIV prevention strategies. Participants at the Durban site had difficulty in sustaining condom use due to financial and client preferences. Sex without condoms was worth more ($20) than sex with condoms ($10); (iii) in maintaining the confidentiality of the subject's HIV status. Novel approaches such as role plays and emphasis on other exclusion criteria were needed to maintain the confidentiality of women not included in the trial due to their HIV status; (iv) in providing care and support to the subjects who became infected with HIV during the trial. Women could only be offered routine sexually transmitted disease treatment and counselling. Anti-retrovirals were not offered. The successes and failures of the solutions attempted are described.

Cost-effectiveness of management strategies for acute urethritis in the developing world

OBJECTIVE

To recommend a cost-effective approach for the management of acute male urethritis in the developing world, based on the findings of a theoretical study.

METHODS

A model was developed to assess the cost-effectiveness of three urethritis management strategies in a theoretical cohort of 1000 men with urethral syndrome. (1) All patients were treated with cefixime and doxycycline for gonococcal urethritis (GU) and nongonococcal urethritis (NGU), respectively, as recommended by WHO. (2) All patients were treated with doxycycline for NGU; treatment with cefixime was based on the result of direct microscopy of a urethral smear. (3) All patients were treated with cotrimoxazole or kanamycin for GU and doxycycline for NGU. Cefixime was kept for patients not responding to the first GU treatment. Strategy costs included consultations, laboratory diagnosis (where applicable) and drugs. The outcome was the rate of patients cured of urethritis. Cost-effectiveness was measured in terms of cost per cured urethritis.

RESULTS

Strategy costs in our model depended largely on drug costs. The first strategy was confirmed as the most effective but also the most expensive approach. Cefixime should cost no more than US$ 1.5 for the strategy to be the most cost-effective. The second strategy saved money and drugs but proved a valuable alternative only when laboratory performance was optimal. The third strategy with cotrimoxazole was the least expensive but a low follow-up visit rate, poor treatment compliance or lower drug efficacy limited effectiveness. Maximizing compliance by replacing cotrimoxazole with single-dose kanamycin had the single greatest impact on the effectiveness of the third strategy.

CONCLUSION

Our model suggested that a cost-effective approach would be to treat gonorrhoea with a single-dose antibiotic selected from locally available products that cost no more than US$ 1.5.

Risk factors for HIV-1 seroprevalence among family planning clients in Dar es Salaam, Tanzania

Between March and September of 1995, women receiving family planning (FP) services in three large clinics in Dar es Salaam, Tanzania were invited to participate in a cross-sectional study. Consenting women were interviewed to obtain information about HIV risk factors, and blood for HIV testing was collected. The prevalence of HIV was 16.9% (95% CI: 14.4%-19.3%). The risk of HIV increased significantly with age. Compared with married women, the risk of HIV was significantly higher among cohabiting women (age-adjusted OR = 2.3; 95% CI = 1.5-3.5) and among women who were single, divorced or widowed (age-adjusted OR = 2.3; 95% CI = 1.2-4.4). The risk of HIV was also significantly higher among hotel workers (age-adjusted OR = 4.3; 95% CI = 1.4-12.9). Women with laboratory evidence of sexually transmitted diseases were at increased risk of HIV. This study shows that HIV is a major public health problem among FP clients in Tanzania. Innovative HIV interventions are needed to reduce further spread of HIV infection.

Evidence of declining STD prevalence in a South African mining community following a core-group intervention

OBJECTIVES

To reduce the prevalence of curable sexually transmitted diseases (STDs) in a South African mining community through provision of STD treatment services, including periodic presumptive treatment and prevention education to a core group of high-risk women living in areas around the mines.

METHODS

Women at high risk for STDs attended a mobile clinic monthly for examination and counseling, and were treated presumptively for bacterial STDs with a directly observed 1-g dose of azithromycin. Gonococcal and chlamydial infection rates were measured by urine ligase chain reaction, and genital ulcers were assessed by clinical examination. Changes in STD prevalence among local miners were assessed through comparison of prevalence in two cross-sectional samples of miners taken 9 months apart, and through routine disease surveillance at mine health facilities.

RESULTS

During the first 9 months of the intervention, 407 women used the services. Baseline prevalence of Neisseria gonorrhoeae and/or Chlamydia trachomatis in women was 24.9%; 9.7% of these women had clinical evidence of genital ulcer disease (GUD). The proportion of women with incident gonococcal or chlamydial infections at the first monthly return visit (69% follow-up rate) was 12.3%, and genital ulcers were found in 4.4% of these women. In the miner population, the prevalence of N gonorrhoeae and/or C trachomatis was 10.9% at baseline and 6.2% at the 9-month follow-up examination (P<0.001). The prevalence of GUD by clinical examination was 5.8% at baseline and 1.3% at follow-up examination (P< 0.001). Rates of symptomatic STDs seen at mine health facilities decreased among miners in the intervention area compared with miners living farther from the site and with less exposure to the project.

DISCUSSION

Provision of STD treatment services to a core group of high-risk women may significantly reduce their burden of disease, and may contribute to a reduction in community STD prevalence. In the absence of sensitive and affordable screening tests for STDs in women, periodic presumptive treatment coupled with prevention education is a feasible approach to providing STD services in this population.

Chlamydia trachomatis prevalence and sexual behaviour among female adolescents in Belgium

OBJECTIVES

To determine prevalence and risk factors of Chlamydia trachomatis among female secondary school students and to develop potential selective screening strategies.

METHODS

A cross sectional survey was conducted in the 17 school medical centres in Antwerp municipality, Belgium. All female students of forms 5 or 6, who were due for their medical check up during the school year 1996-7, were invited to participate. A self administered questionnaire on general and sexual behaviour, and a first void urine sample were collected. The urine specimen was tested for C trachomatis with ligase chain reaction assay, and positive tests were confirmed with polymerase chain reaction assays.

RESULTS

2784 female students participated in the study. Their median age was 17, and 52% of them reported having sexual intercourse at least once. The prevalence of C trachomatis among sexually active women was 1.4%. Factors significantly associated with infection in multivariate analysis were number of lifetime partners, genital complaints of partner, type of secondary school, and a history of pregnancy. Selective screening of those women who are at highest risk for infection would have detected 90% of all infections, and require testing of 14% to 18% of the population.

CONCLUSIONS

The prevalence of C trachomatis was relatively low among female secondary school students in Antwerp, but unsafe sex practices were evident because of the high number of unplanned pregnancies. Selective screening strategies with a high sensitivity can be proposed, but should be assessed for acceptability, feasibility, and cost.

Indicators and the measurement of STD case management in developing countries. STD PI6&7 Working Group

The paper reviews methodologies for measuring quality of sexually transmitted disease (STD) case management through facility based assessments. These include observations and interviews of providers, as promoted by the World Health Organization's Global Programme on AIDS, and some of the viable alternatives including patient exit interviews, mystery patients, record review and patient encounter forms with supervisory visits. The paper concludes that the alternative approaches are feasible in resource poor settings and that they provide crucial data for evaluation and continued program development.

Validation of national algorithms for the diagnosis of sexually transmitted diseases in Brazil: results from a multicentre study

OBJECTIVE

To validate STD flow charts for the management of genital discharge and genital ulcer currently recommended by the National STD Control Programme in Brazil.

METHODS

A study was conducted in five Brazilian STD clinics from January to June 1995. After an interview, a clinical examination was performed by a physician, who recorded a presumptive diagnosis, based on his/her clinical experience. This diagnosis was compared with a gold standard laboratory diagnosis in order to calculate sensitivity, specificity, and positive predictive value of the clinical diagnosis. The validity of the simulated national flow charts was assessed using the same method.

RESULTS

A total of 607 men and 348 women participated in the study. Gonorrhoea was the aetiology most frequently detected in men with urethral discharge. The sensitivity of the clinical diagnosis was far lower than the sensitivity fo the national flow chart, using the syndromic approach, for both gonococcal and chlamydial urethritis. Adding a simple laboratory test (Gram stain) to the national flow chart increased the specificity and positive predictive value for gonorrhoea. Among the women with vaginal discharge, a cervical infection was detected in 17%, a vaginal infection in 74%, and mixed infection in 9%. The sensitivity of the diagnosis for cervical infection increased from 16% (clinical aetiological approach) to 54% (when adding a syndromic approach) and to 68% when adding a risk assessment, as in the national flow charts. The cure or improved rate of genital ulcers was 96% after 1 week.

CONCLUSIONS

The results of the study will help to convince policy makers and those involved in training healthcare workers in Brazil of the public health advantages of the syndromic approach, as an essential part of STD/HIV control activities.

Evaluation of simple diagnostic algorithms for Neisseria gonorrhoeae and Chlamydia trachomatis cervical infections in female sex workers in Abidjan, Côte d'Ivoire

OBJECTIVE

To generate simple algorithms for the diagnosis of cervical infection with Neisseria gonorrhoeae or Chlamydia trachomatis in female sex workers in Abidjan, Côte d'Ivoire and to evaluate their validity.

METHODS

From October 1992 to the end of June 1993, female sex workers were interviewed and clinically examined at a confidential clinic. N gonorrhoeae was cultured on modified Thayer-Martin medium and C trachomatis was detected by polymerase chain reaction. The associations of gonococcal or chlamydial cervical infection with sociodemographic, behavioural, clinical, and biological factors were assessed and three algorithms were generated. The validity parameters of these diagnostic algorithms were calculated and compared to those of standard algorithms and mass treatment.

RESULTS

Among 683 women, cervical infection was present in 239 (35%). The sensitivity an algorithm incorporating sociodemographic and behavioural factors and symptoms, of an algorithm incorporating clinical signs and simple laboratory tests, and of a combined algorithm was 83%, 86%, and 79% respectively while the specificity was 32%, 44%, and 54%, and the positive predictive value 40%, 46%, and 48% respectively. A standard algorithm incorporating only the symptom vaginal discharge, and a standard algorithm requiring both the symptom vaginal discharge and the presence of an endocervical mucopurulent discharge on examination had a sensitivity of 44% and 18%, a specificity of 75% and 95%, and a positive predictive value of 49% and 67% respectively.

CONCLUSIONS

The algorithms generated in this study may be useful for the control of cervical infections in female sex workers in resource poor settings in the absence of rapid, inexpensive, and accurate laboratory tests for the diagnosis of cervical infections.

Evaluation of sexually transmitted diseases diagnostic algorithms among family planning clients in Dar es Salaam, Tanzania

OBJECTIVES

To determine the prevalence of sexually transmitted diseases (STDs) and to assess the validity of STD screening approaches among family planning clients in Dar es Salaam, Tanzania.

METHODS

Between March and September 1995, information about sociodemographic characteristics, contraceptive use, sexual behaviour, and medical history was obtained from consenting women (n = 908). After interview, blood and genital specimens were collected for diagnosis of STDs and HIV. Based on the information obtained at interview and clinical examination, STD diagnostic algorithms were developed and validated.

RESULTS

The prevalence of STDs was HIV (16.9%), gonococcal and/or chlamydial cervicitis (8.2%), and Trichomonas vaginalis and/or Candida albicans (27.2%). The risk of cervicitis was increased among unmarried women and among women with a husband < or = 25 years of age and women having more than one sex partners in the past 3 months or a new sex partner during the past month. Most women with cervicitis (62.2%) and vaginitis (67.6%) were asymptomatic. A screening strategy for cervicitis based on symptoms had a sensitivity of 29.7%, a specificity of 84.1%, and a positive predictive value (PPV) of 15.9%. The corresponding figures for an algorithm based on clinical signs were 20.3%, 90.2%, and 15.6%. The sensitivity of a simple risk assessment algorithm ranged from 20.3% to 73%. An approach based on both risk assessment (risk score > or = 1) and clinical signs (cervical mucopus and friability) had a sensitivity of 37.8%, a specificity of 87.5%, and a PPV of 21.4%. A syndromic approach for vaginitis resulted in a higher sensitivity than the approach based on the type of vaginal discharge.

CONCLUSION

Although there is no single screening strategy for cervicitis which can be advocated for large scale application, risk assessment might be the only cost effective strategy for identifying women with cervicitis in family planning clinics in Tanzania.

STD services for women at truck stop in Tanzania: evaluation of acceptable approaches

AIDS continues to be the commonest cause of death in Tanzania among those aged between 15 and 45 years. Both ulcerative and non-ulcerative sexually transmitted diseases have been identified as major co-factors in HIV transmission. Certain groups including long distance truck drivers and their sexual partners have been reported as having a disporportionate effect on the transmission dynamics of STD including HIV, in a population. In 1993 African Medical and Research Foundation decided to add an STD component to their HIV/AIDS prevention programme along the Tanzania-Zambia highway which had been targeting truck drivers and their sexual partners through peer education and condom distribution since 1989. A study to evaluate the acceptability and feasibility of four different approaches of delivering STD services, was conducted over a period of one year. The approaches for delivering STD services were: special STD services offered twice a week at a site and at hours of the women's choice, special outreach services once every three months, or STD services integrated into the nearest Primary Health Clinic. Drugs were provided at three of the four interventions. 1,330 women at seven truckstops, participated in the evaluation study. The women were generally satisfied with all approaches that included the provision of drugs. The most expensive and ineffective way of treating STD was by not providing drugs. These findings confirm the fact that it is feasible to provide STD services to women at high risk in HIV high transmission areas. These women would utilise STD services provided in a manner that suits them if mobilised and encouraged by their peer educators.

Signs and symptoms of prevalent and incident cases of gonorrhea and genital chlamydial infection among female prostitutes in Kinshasa, Zaire

Most studies that have examined the clinical features of gonorrhea and chlamydial infection have been based on prevalent cases (cases of undetermined onset). In our investigation, we compared signs and symptoms of incident (new) cases of these infections with those observed in prevalent cases (involving the same women) that were diagnosed at enrollment in a prospective study of female prostitutes in Kinshasa, Zaire. Neisseria gonorrhoeae or Chlamydia trachomatis was present at enrollment in 29.2% (225 of 771) of the women in the study. As they were followed during the study, 509 (66.0%) had at least one episode of gonorrhea or chlamydial infection. No symptom was significantly associated with these infections at enrollment or during follow-up. Clinical signs, such as endocervical mucopus (P < .001) and vaginal discharge (P = .001), were associated with both the prevalent and incident cases. However, none of these signs was simultaneously sensitive and specific for detection of these infections. The frequency of clinical signs was significantly reduced after successful treatment (all P values, < .05). This study shows that a syndromic approach to screening for gonococcal and chlamydial infections in female prostitutes is as problematic for acute incident cases as for prevalent cases. Therefore, there is still an urgent need for simple, cheap, reliable tests that could be used in sexually transmitted disease intervention programs in developing countries.

Simple algorithms for the management of genital ulcers: evaluation in a primary health care centre in Kigali, Rwanda

A cross-sectional study was conducted among 395 patients presenting with genital ulcers at a primary health care centre in Kigali, Rwanda. Using clinical data and the results of a rapid plasma reagin (RPR) test, we simulated the diagnostic outcome of two simple WHO flowcharts for the management of genital ulcers. These outcomes and a clinical diagnosis were then compared with the laboratory diagnosis based on culture for genital herpes and Haemophilus ducreyi and serology for syphilis. The prevalence of HIV infection was high (73%) but there was no difference between HIV-positive and HIV-negative patients in the clinical presentation and etiology of genital ulcer disease. The proportion of correctly managed chancroid and/or syphilis cases was 99% using a syndromic approach, 82.1% using a hierarchical algorithm including an RPR test, and 38.3% with a clinical diagnosis. In situations where no laboratory support is available, a simple syndromic approach is preferable to the clinical approach for the management of genital ulcer. If an RPR test can be included in the diagnostic strategy, patients with a reactive RPR test should be treated for both syphilis and chancroid infection.

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.

Clinical algorithms for the screening of women for gonococcal and chlamydial infection: evaluation of pregnant women and prostitutes in Zaire

A substantial proportion of women with gonococcal and/or chlamydial infection are asymptomatic. Thus active case detection is problematical, particularly in developing countries, where facilities and materials for laboratory testing are limited. We assessed the diagnostic validity of the hierarchical clinical algorithms recommended by the World Health Organization as well as that of a nonhierarchical scoring system, using data for 1,160 pregnant women (a low-prevalence group) and 1,222 prostitutes (a high-prevalence group) in Kinshasa, Zaire. Neisseria gonorrhoeae and/or Chlamydia trachomatis was detected in 6.5% and 31.0% of pregnant women and prostitutes, respectively. No single variable that was both sensitive (> 60%) and specific (> 60%) was associated with infection. A simple hierarchical algorithm based only on reported symptoms had a sensitivity of 48.0% and 54.9% and a specificity of 75.2% and 52.2% for the screening of pregnant women and prostitutes, respectively. A second algorithm that included a speculum examination had a sensitivity of only 29.3% but a specificity of 85.3% in pregnant women. When a nonhierarchical scoring system was used, the sensitivity was 72.0% and 71.0% and the specificity was 73.5% and 55.8% for pregnant women and prostitutes, respectively. Scoring systems that incorporate risk markers as well as symptoms and signs may represent affordable alternative methods of screening for gonococcal and/or chlamydial infections among women in resource-poor settings.