RHO archives : Topics : Reproductive Tract Infections

Annotated Bibliography

This is page 2 of the Reproductive Tract Infections Annotated Bibliography. This page contains:

• Best approaches to partner notification
• Men and reproductive tract infections
• Increasing adolescent access to RTI/STI services
• Improving client-provider interaction

To access more bibliographic entries, visit page 1 or page 3, or return to the complete list of topics covered in the Reproductive Tract Infections Annotated Bibliography. Be sure to use the Glossary if you are unfamiliar with any of the terms on this page.

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Best approaches to partner notification

Desormeaux, J. et al. Introduction of partner referral and treatment for control of sexually transmitted diseases in a poor Haitian community. International Journal of STD & AIDS 7:502–506 (1996).
The goal of this study was to evaluate knowledge and attitudes regarding STIs and the acceptability of a proposed antenatal STI screening and treatment program, including partner management. A total of 384 women out of 1001 women enrolled in an antenatal STI baseline evaluation were treated for STIs at a private health care clinic in a poor Haitian community. Antenatal women found to have a STI were asked to refer their partner for STI treatment. Focus group discussions found that participants knew and could describe some common STI syndromes including urethral and vaginal discharge and genital ulcers, knew that a pregnant woman could transmit a STI to her child, and knew that all sex partners needed to be treated for STIs. Of the 331 male partners named by the infected women, 101 (30%) came to the clinic through index referral, and an additional 38 (11.5%) presented themselves as a result of provider referral. This study showed that voluntary partner referral for STI treatment is feasible in this poor Haitian community without major drawbacks.

Fenton, K.A. et al. Partner notification techniques. Sexually Transmitted Diseases 16(4):669–672 (1998).
This paper reviews some of the techniques currently used for partner notification and considers methods for improving the strategy. It presents the rationale for partner notification and discusses the different techniques and tools used. The paper discusses several techniques for improving the effectiveness of partner notification, including follow-up home visits by health care workers, and identification and use of social networks to access certain high-risk groups.

Hawkes, S. and Mabey, D. Partner notification for the control of sexually transmitted infections: effectiveness in resource poor settings is unproved [editorial]. BMJ 327:633–634 (September 20, 2003).
This editorial highlights the need for methodologically sound research in partner notification in resource poor settings. A systematic Cochrane Review (see Mathews et al. 2002) identified only two randomized controlled studies on partner notification in developing countries. Should strategies seen to be effective in more developed settings be applied elsewhere? Given the lack of specificity of many diagnoses of STIs (often using syndromic management) in developing countries, there are high levels of overdiagnosis of STIs, especially among women. Power relationships, especially concerning sex, differ significantly across cultures. The authors suggest that promoting partner notification may be a misuse of resources and determining what is appropriate and acceptable to individuals in a variety of limited-resource communities is needed.

Koumans, E.H. et al. Patient-led partner referral enhances sexually transmitted disease service delivery in two towns in the Central African Republic. International Journal of STD & AIDS 10:376–382 (May 1999).
This study evaluated the effectiveness of a patient-led partner referral program for STI treatment in Bambari and Bria in the Central African Republic. From October 1993 to February 1996, providers saw 5,232 patients in Bambari, the country's second largest city, and 4,320 patients in Bria, a diamond mining town. Patients being treated for an STI at the main hospital in each town were offered vouchers to give to their partners. Each voucher permitted treatment at low or no cost. The program emphasized good quality counseling of index patients. In both towns, more than 90 percent of index patients, both men and women, accepted vouchers for reported partners. Index patients with a least one partner in the last 30 days were more likely to accept a voucher than those reporting no recent partner. Overall, index patients successfully referred 3,119 partners, mostly men. These referred partners made up 33 percent of all patients treated, and 40 to 50 percent of index patients successfully referred at least one partner. It is possible that many patients had difficulty finding casual partners to refer, and reaching these hard-to-reach partners may require new approaches.

Liu, H. et al. Stigma, delayed treatment, and spousal notification among male patients with sexually transmitted disease in China. Sexually Transmitted Diseases 29(6):335–343 (June 2002).
Male clients attending an urban clinic in Hefei, China, for STI treatment were interviewed and specimens analyzed for infection. The majority (80%) of these symptomatic men felt stigmatized by their infection. Those with higher education were more likely to feel stigmatized. Twenty-eight percent of the patients had been symptomatic for more than one week prior to seeking treatment, and 17 percent had had symptoms for more than two weeks. Multivariate analysis showed that those with a university education or who had sex with other partners in the previous three months were more likely to seek early treatment. Those with "other urethral discharge" or with syphilis or herpes were more likely to delay treatment. The most common reasons for delaying treatment were that it did not make any difference to wait (69%), that they were afraid to be seen by others (53%), and that they worried about the high cost of treatment (35%). Among the patients currently living with their spouse, only 23 percent said they were willing to inform their spouse of their STI status. Multivariate analysis showed that feeling stigmatized was associated with unwillingness to inform the spouse. Forty percent of the men reported having sex after the start of symptoms, and 83 percent of the married men continued to have sex with their wives.

Mathews, C. et al. Evaluation of a video based health education strategy to improve sexually transmitted disease partner notification in South Africa. Sexually Transmitted Infections 78:53–57 (2002).
A video based on South Africas popular radio and television soap opera, Soul City, was used to promote partner notification for STIs among people attending a busy public health clinic. A before/after quantitative study and qualitative interviews showed improvements in self-efficacy about notifying casual partners. The rate of contact cards returned per index patient increased from .20 to .27. Patients and providers enjoyed the video, but patients perceived confused messages about the relation between STIs and HIV. With development of an improved video, this type of health education intervention could be a cost-effective, acceptable way to improve partner notification.

Mathews, C. et al. Strategies for partner notification for sexually transmitted diseases (Cochrane Review). In: The Cochrane Library, Issue 4. Oxford: Update Software, Ltd. (2002)
This review compares different strategies for partner notification of STIs. Eleven randomized controlled studies with 8,014 participants were analyzed; only two studies were in developing countries. There is moderately strong evidence that provider referral alone, or the choice between patient or provider referral increases the rate of partners seeking medical evaluation when compared with patient referral alone. Contract referral (health personnel contact partners if they have not appeared for evaluation by a certain date), for patients with gonorrhea, also leads to more partners receiving medical evaluation than patient referral. Nurses providing verbal health education, along with patient-centered counseling by lay workers, results in small increases in the rate of partners treated. There is need for studies evaluating the effect of provider training and patient education, for studies in developing countries, and for studies assessing a broader range of outcomes, including harmful effects of partner notification.

Nuwaha, F. et al. Efficacy of patient-delivered partner medication in the treatment of sexual partners in Uganda. Sexually Transmitted Diseases 28(2):105–110 (February 2001).
This study compared the efficacy of patient-based partner referral (PBPR) with patient-delivered partner medication (PDPM) among patients attending an STI clinic in Kampala, Uganda, between November 1999 and January 2000. A total of 383 patients (187 women, 196 men) with an STI as assessed by syndromic management were included. Women presenting with vaginal discharge also were examined with a speculum and microscopy. All patients received information about the importance of partner referral and treatment, and 192 were randomly allocated to the PDPM group and 191 to the PBPR group. The patients had similar background characteristics. Patients in the PBPR group were given contact slips to pass to their sexual partners. These slips provided information about the importance of seeking health care, and requested that partners take the slip with them to the clinic. Patients in the PDPM group were given medications to take to their sexual partners. Both groups were told to return to the clinic in two seeks. In the PDPM group, 237 partners were identified and 74 percent were reported treated. In the PBPR group, 234 partners were identified and 34 percent were referred to the treatment clinic. PDPM was clearly more effective overall, and was even more effective for women and for casual partners. The data are limited by the possibility that some of the PBPR partners could have received treatment elsewhere and were lost to follow-up. In the PDPM group, partner treatment is based on reporting by the index patient, and could be inaccurate. Despite these limitations, this study shows that PDPM is more effective than PBPR for the treatment of sexual partners in an STI clinic setting. Such a program depends, however, on a continuous supply of STI medications.

Nuwaha, F., Faxelid, E., et al. Psycho-social determinants for sexual partner referral in Uganda: quantitative results. Social Science & Medicine 53:1287–1301 (2001).
Interviews with 236 women and 190 men attending an STI clinic in Kampala, Uganda, were used to investigate the factors that influence sexual partner referral. The Attitude-Social Influence Self-Efficacy model was used a theoretical framework. Data were collected at first contact on intention, attitude, subjective norm, self-efficacy, partner type, and past behavior in referring partners. One month later, partner referral was assessed. For women, intention, self-efficacy, and previous behavior were the best predictors of partner referral. For men, intention, partner type, and previous behavior predicted partner referral. The strongest predictors of intention to refer for women were self-efficacy, attitude, and partner type. For men, the strongest predictor was attitude, followed by partner type and self-efficacy. Further analysis showed that attitudinal beliefs were the most important cognitive factors affecting partner referral for men, while self-efficacy beliefs were most important for women. These findings suggest that compliance with partner referral can be improved by taking into account gender perspectives. For women, measures that improve their self-efficacy and their ability to talk with their partners could be helpful.

OHara, H.B. et al. Quality of health education during STD case management in Nairobi, Kenya. International Journal of STD & AIDS 12:315–323 (2001).
The quality of health education during STD case management in Nairobi, Kenya, is poor (38%), as measured by the World Health Organization indicator for condom promotion and contact treatment. However, this study of 142 healthcare facilities and observations of 165 providers found that scores were high for education on contact treatment (74–80%) and compliance (83%). Eighty percent of providers mentioned the need for partner treatment, 73 percent urged partner referral, and 6 percent provided drugs for partner treatment. While contact treatment can be facilitated by the distribution of contact cards by providers, in this study only 18 percent of observed patients and 10 percent of simulated patients received contact cards. Scores for counseling (52%) and condom promotion (20–41%) were much lower. Public clinics specifically strengthened for STD case management performed the best, while pharmacies and mission clinics performed the worst. Scores were higher during interviews with providers (knowledge) than during observations of their interactions with simulated clients (practice). STI health education could be improved by wide distribution of educational materials, on-going training and supervision of providers, implementation of STI case management checklists, and introduction of pre-packaged kits for STI case management.

Rothenberg, R. The transformation of partner notification. Clinical Infectious Diseases 35(8):S138–145 (October 15, 2002).
This article reviews publications from 1996–2000 that focus on traditional approaches to partner notification and newer activities involving a social network approach. The latter focuses on a client’s social network and not just their sexual contacts. These studies have shown the significance of dense networks and geographic clustering of persons involved in the transmission of STIs. Including network concepts into programmatic activities could impact both partner notification and disease transmission rates.

Schillinger, J. et al. Patient-delivered partner treatment with azithromycin to prevent repeated Chlamydia trachomatis infection among women. Sexually Transmitted Diseases 30(1):49–56 (January 2003).
This U.S. five-center randomized controlled study assessed the impact of giving women doses of azithromycin to deliver to their male sexual partners on the incidence of repeat infections with C. trachomatis. The risk of reinfection four months after initial treatment was 20 percent lower among women in the patient-delivered partner treatment group, but the difference was not statistically significant (OR, .80; 95% CI = 0.62–1.05, P = 0.102). Women in the patient-delivered treatment group reported high compliance with the intervention (82%). Preventing reinfection with C. trachomatis through patient-delivered partner treatment offers an option to traditional partner referral.

Seubert, D.E. et al. Partner notification of sexually transmitted disease in an obstetric and gynecologic setting . Obstetrics & Gynecology 94(3):399–402 (September 1999).
The goal of this study was to determine obstetrician-gynecologists' knowledge, attitudes, and practice patterns related to partner notification. A total of 222 anonymous questionnaires were sent to community, hospital-employed, and university-based physicians within a single health care system. Of the 108 physicians (49%) who responded, 36 percent were private practitioners, 38 percent were hospital employed, and 23 percent were university faculty physicians. The survey findings showed that many physicians lack adequate awareness of what conditions are reportable and the correct guidelines for partner notification. Although most physicians correctly identified the importance of partner notification for several STIs, most respondents (58%) could not identify all conditions. The great majority of respondents (89%) relied on women to notify their partners of the STI. The authors suggest that future educational efforts are needed to increase physician awareness of reportable STI conditions and to educate physicians about regulations for partner notification.

Steen, R. et al. Partner referral as a component of integrated sexually transmitted disease services in two Rwandan towns. Genitourinary Medicine 72:56–59 (1996).
The goals of this study were to assess partner referral rates at health centers with integrated STI services and to determine which factors contributed to successful referral. Of the 427 index patients seen at the two health facilities, 76 percent were women, and 58 percent accepted partner referral coupons. The ratio of partners treated to index patients accepting referral cards was 45 percent. The authors found that the majority of partners referred by index patients were regular partners and that women index patients were more successful in referring partners than men. They concluded that partner referral can be an effective strategy for reaching the at-risk population for STIs and emphasized that improved patient counseling on the importance of partner referral can increase the partner referral rate.

Toomey, K. et al. Partner management. In: Control of Sexually Transmitted Diseases: A Handbook for the Design and Management of Programs; Dallabetta et al., eds. AIDSCAP (1996).
This chapter of the Handbook discusses the importance of partner notification in STI management and addresses key principles involved in providing effective partner notification. The principles include voluntary participation, confidentiality, accessibility, quality assurance, and doing no harm. It outlines educational and other activities that should be included in partner notification programs. The chapter also provides information on who and how to refer, and what STI syndromes should be included in a partner notification program.

Van de Laar, M. et al. Partner referral by patients with gonorrhea and chlamydial infection: case-finding observations. Sexually Transmitted Diseases 24(6):334–342 (1997).
The goal of this study was to evaluate the outcomes of partner referral by gonorrhea and chlamydia patients attending an STI clinic in Amsterdam, The Netherlands, and to identify predictors for the success of partner referral. A total of 355 patients with a confirmed infection cooperated in partner referral and gave specific details on their sexual contacts. Collectively, the patients identified 580 sexual partners for notification, of whom 119 (20.5%) attended the STI clinic for examination and treatment and 117 (20%) were examined and/or treated elsewhere (confirmed referrals). No information was available for the remaining 344 (60%) sexual contacts. Chlamydia patients referred more sexual partners than gonorrhea patients, and women referred more partners than men. The ratio of self-referred patients to identified sexual contacts was substantially higher in female-male relationships (54.2%) than in male-female (34.4%) and male-male partnerships (32.7%). Steady partners were more often referred by patients than casual partners, especially if the casual partners were non-Dutch, clients of commercial sex workers, contacts met in less private settings, or "one-night stands." The researchers concluded that case finding through patient referral can be an effective strategy for reaching individuals at high risk for STI infection. They suggested that implementing alternative STI control strategies such as introducing peer educators at the STI clinic and adding provider referral (in addition to patient referral) may improve the effectiveness of partner referral.

Wakasiaka SN, Bwayo JJ, Weston K, et al. Partner notification in the management of sexually transmitted infections in Nairobi, Kenya. East African Medical Journal. 2003;80(12):646–51.
Partner notification can be an important tool in preventing and controlling STIs, but patients need to be informed about their own diagnosis, mode of transmission, and the need to treat all partners. Of 407 STI patients (239 female, 168 male) recruited at 16 primary health care centers in Nairobi, Kenya, between April and September 2000, 20.6 percent were primary referrals, and 2 percent were secondary referrals (23 percent overall referral rate). Patients with multiple sex partners were far less likely to refer their partners compared to those with one partner (17.9 percent versus 82.1 percent, p<0.005). Counseling on the importance of partner referral was more effective than providing referral cards (72.8 percent versus 56.8 percent). Reasons patients gave for not referring partners included being out of town (44.6 percent), fear of quarrels and violence (32.5 percent), and unknown partners (15.1 percent).

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Men and reproductive tract infections

Also see RHO's Men and Reproductive Health section.

Ahmed, H.J. et al. Etiology of genital ulcer disease and association with human immunodeficiency virus infection in two Tanzanian cities. Sexually Transmitted Diseases30(2):114–119 (February 2003).
In order to determine the etiology of genital ulcer disease (GUD) and the prevalence of HIV infection in two urban areas of Tanzania, clinical specimens were collected from 52 men with GUD in Dar es Salaam and 50 men in Mbeya. Specimens from 93 people with genital discharge were also collected in a cross-sectional study. Human simplex virus 2 (HSV-2) was the most common cause of GUD identified in the specimens from the two urban areas (63 and 34 percent). HIV infection rates among patients with GUD were 46 percent in Dar es Salaam and 52 percent in Mbeya. Among those without GUD, the HIV rates were 35 and 45 percent, respectively. Among HIV-positive men with GUD, 71 percent and 46 percent were also infected with HSV-2.

Alary, M. et al. Sexually transmitted infections in male clients of female sex workers in Benin: risk factors and reassessment of the leucocyte esterase dipstick for screening of urethral infections. Sexually Transmitted Infections 79:388–392 (2003).
Male clients of female sex workers in Benin were found to have asymptomatic STIs. Urine samples and interviews were taken from 404 men visiting prostitutes in Contonou, Benin, in 1998. STI prevalences were: chlamydia, 2.7 percent; gonorrhea, 5.4 percent; either chlamydia or gonorrhea, 7.7 percent; trichomonas, 2.7 percent; and HIV, 8.4 percent. Over 80 percent were asymptomatic. Leucocyte esterase dipstick (LED) testing of urine in asymptomatic men (n-304) showed sensitivity, specificity, positive and negative predictive values of 47.4 percent, 94.7 percent, 37.5 percent, and 96.4 percent, respectively. LED testing could be useful for detecting asymptomatic infection with gonorrhea or chlamydia in high-risk men.

Ballard, R.C. et al. Coexistence of urethritis with genital ulcer disease in South Africa: influence on provision of syndromic management. Sexually Transmitted Infections 78:274–277 (2002). Specimens were taken from 186 mine workers in Carleton, South Africa, presenting with genital ulcers to assess the appropriateness of syndromic management of genital ulcer disease in this population. Fifty-four percent of the ulcers were chancroidal, 18 percent were herpetic (HSV type 2), 6.5 percent were primary syphilitic, and 3.2 percent were due to lymphogranuloma venereum. Microscopic smears showed 53 percent of the men had urethritis, of whom 45 percent were infected with gonorrhea. Of the 55 percent with non-gonococcal urethritis, 19.6 percent had C. trachomatis or M. genitalium. The combination of drugs used to treat GUD among this group of men needs to be widened to encompass frequently occurring concomitant gonococcal urethritis and NGU.

Dennis, L. and Dawson, D. Meta-analysis of measures of sexual activity and prostate cancer. Epidemiology 13(1): 72–79 (January 2002). This meta-analysis of 36 studies suggests an elevated relative risk (RR = 1.4) of prostate cancer among men with a history of STIs, especially for syphilis (RR = 2.3). The risk of prostate cancer is also associated with increased frequency of sexual activity (RR = 1.2 for increase of three times per week) and increased number of sexual partners (RR = 1.2 for increase of 20 partners). There is no associated risk with multiple marriages, age at first intercourse, or age at first marriage. These results suggest that STIs may play a role in the development of prostate cancer.

Drennan, M. Reproductive Health: New Perspectives on Mens Participation. Population Reports J(46):1–35 (October 1998).
New information, approaches, and understanding can help men become full partners in improving reproductive health. Mens participation is especially important in the face of the AIDS epidemic. The spread of HIV is greatly influenced by mens sexual behavior. Surveys, especially of young men, provide valuable information about this under-served group. In general, unmarried young men have limited knowledge about the consequences of sexual relations and about contraception. Even when young men know about sexually transmitted infections, denial, cultural pressures, and inexperience influence them to take unnecessary risks. The lessons learned about reaching male audiences includes reaching out to young and unmarried men, using mass media to reach men, and bringing information to men where they gather. Men especially need information about condoms and should be offered a range of health services.

Gibney, L. et al. STD in Bangladeshs trucking industry: prevalence and risk factors. Sexually Transmitted Infections 78:31–36 (2002).
A cross-sectional study of 388 truck drivers and helpers was conducted at Tejgaon truck stand in Dhaka, Bangladesh. Participants were interviewed about their lifestyles and given a physical examination; urine and blood samples were collected and tested for STIs. The prevalence of diseases found included: HSV-2, 25.8 percent; syphilis, 5.7 percent; gonorrhea, 2.1 percent; and chlamydia, 0.8 percent. The only significant risk factor found for any bacterial STI was having sex with a commercial sex worker in the past year. Truck helpers were significantly more likely than truck drivers to be infected with HSV-2. High-risk sexual behaviors for STIs were common. Only 27 percent of the men had ever used a condom, and most had used them occasionally or only once. The majority (54%) reported having sexual relations with a female commercial sex worker in the last year, and almost 40 percent reported three or more partners. Twenty-one percent reported having some sexual relation with a male partner in their lifetime, and 7 percent in the last year. The high prevalence of HSV-2 and syphilis, both associated with HIV transmission, indicates that should HIV enter this low HIV-prevalence population, it could spread rapidly. Men in the trucking industry need to be made aware of the role of condoms in preventing STIs, including HIV, and the risks associated with sex with commercial sex workers.

Hobbs, M. et al. Trichomonas vaginalis as a cause of urethritis in Malawian men. Sexually Transmitted Diseases 26(7):381–387 (August 1999).
Trichomonas vaginalis infection is common among women in Malawi. This cross-sectional study attempted to determine the T. vaginalis infection rate in men, evaluate a polymerase chain reaction (PCR) detection assay, and examine the effect of T. vaginalis infection on excretion of HIV in semen. T. vaginalis was found in 51 of 293 men presenting at sexually transmitted diseases and dermatology clinics in Malawi. Prevalence of infection was 20.8 percent among symptomatic men and 12.2 percent among those with no symptoms. The PCR test showed only 82 percent sensitivity, but 95 percent specificity compared with wet-mount microscopy and culture. In men with symptomatic urethritis, the HIV RNA concentration in semen was higher among men with T. vaginalis infection than among men without trichomonas. T. vaginalis was the second most common pathogen found in men with symptomatic urethritis (gonococcal infection was most common). Given the difficulty of effecting a symptomatic cure for urethritis, randomized controlled studies are needed to evaluate the effectiveness of trichomonas therapy in treating urethritis.

Klouman, E. et al. Chlamydial infection in males and consequences for their female sexual partners, an example from rural Kilimanjaro, Tanzania. International Journal of STD & AIDS 13:234–237 (April 2002).
In this cross-sectional study, 447 healthy men and 393 women aged 15 to 44 were screened for chlamydial infection as part of a larger HIV-testing and STI screening study. Prevalence was 9.6 percent in men, and 6.9 percent in women. Among the 43 chlamydia-positive men, 17 were married. Data could be matched for 12 couples. None of the 12 husbands had discharge; one had dysuria (painful urination) and three had pyuria (cloudy urine, indicating bacterial infection). Three wives tested positive for chlamydia (27%), two had pelvic-inflammatory disease, and four had pyuria. Eight of the wives of infected men and four of the husbands reported only one sexual partner in the last five years. While the index case in these couples is not known, there appears to be a high level of infection of couples. Based on all signs, symptoms, laboratory findings, and available scientific literature, the authors find that 5 to 8 of the 12 wives might be infected with chlamydia. This high rate of infection (42–67%) indicates the largely asymptomatic, chlamydia-infected men were highly contagious to their sexual partners.

Lewis, D.A. Chancroid: clinical manifestations, diagnosis, and management. Sexually Transmitted Infections 79:68–71 (2003).
Chancroid is caused by the bacterium Haemophilus ducreyi, an organism difficult to culture from genital ulcer material. Although DNA amplification techniques (M-PCR) offer improved diagnostic sensitivity, these tests require specialized equipment and skills often unavailable in resource-poor settings. Therefore, genital ulcer disease is often managed syndromically, and treated with erythromycin. Given the association of increased transmission of HIV among those with genital ulcer disease, effective treatment is important to control the spread of HIV. Some data suggest that HIV-positive and uncircumcised men are more likely to fail single-dose therapeutic regimens; therefore, these patients need more intensive follow-up.

Liu, H. et al. Is syndromic management better than the current approach for treatment of STDs in China? Sexually Transmitted Diseases 30(4):327–330 (April 2003).
Syndromic management of STIs in men is rare in China. This study evaluated the effectiveness and cost of syndromic management among 406 men attending four STI clinics in Hefei, China. A modified WHO algorithm for urethral discharge was 100 percent sensitive with a 69 percent positive predictive value. A syndromic algorithm for genital ulcers correctly treated all men with syphilis with a positive predictive value of 25 percent. The average cost per correct treatment with the current approach (clinical diagnosis and laboratory tests) was $US323.48 for urethritis and $US85.65 for syphilis. The syndromic approach would reduce these costs to $US3.15 for urethritis and $US13.54 for syphilis. Syndromic management can provide better treatment at lower cost in this setting.

Manjunath, J.V. et al. Sexually transmitted diseases and sexual lifestyles of long-distance truck drivers: A clinico-epidemiological study in south India. International Journal of STD & AIDS 13:612–617 (September 2002).
A total of 263 truck drivers or assistants were recruited at a satellite STI clinic on the Pondicherry-Tindivanam Road in South India from October 1999 to March 2001. All of the men were sexually active, and 99.2 percent reported heterosexual activity. Two-thirds had contact with commercial sex workers, and about 60 percent consumed alcohol. Thirty-nine percent (102) had an STI: HIV (15.9%), syphilis (13.3%) and HbsAg -positive (21.2%). This highly mobile group needs regular health check-ups, STI education, and condom promotion to reduce the spread of STIs, including HIV.

Morency, P. et al. Aetiology of urethral discharge in Bangui, Central African Republic. Sexually Transmitted Infections 77:125–129 (April 2001).
Analysis of the causes of urethritis among men at an STI clinic in Bangui, Central African Republic, found that M. genitalium is the most common cause of non-gonococcal infection. The study enrolled 410 men with urethral discharge and 100 asymptomatic controls. Urethral swabs were obtained and processed by gonococcal culture and polymerase chain reaction for testing of Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, Trichomonas vaginalis, and Ureaplasma urealyticum. Gonococcus was found in 69 percent of cases of urethral discharge, and M. genitalium was the most common pathogen found in patients with non-gonoccocal urethritis (NGU) (42%). Multiple infections are common. C. trachomatis was found in 17 percent of patients with NGU and in two-thirds of those with gonococcus. T. vaginalis was found in 18 percent of men with NGU and in 15 percent of those with gonococcus. M. genitalium causes a syndrome similar to chlamydia urethritis. T. vaginalis is weakly associated with urethritis and is often found with other pathogens. The similarity in clinical presentation, and the prevalence of multiple infections makes simultaneous treatment for gonorrhea, chlamydia, and M. genitalium most logical. The high cost of drugs effective against these three pathogens makes it necessary to treat for one infection and follow up with rational second-line algorithms for continued treatment.

OFarrell, N. Donovanosis: an update. International Journal of STD & AIDS 12:423–427 (2001).
Donovanosis, an ulcerative sexually transmitted infection with limited geographic distribution, has largely been ignored until recently. A significant epidemic of donovanosis has been identified in KwaZulu/Natal, South Africa. As is true of other ulcer-causing STIs, it may be a risk factor for HIV acquisition in men. Researchers have been able to culture the disease-causing organism in South Africa and Australia, which has led to the development of a polymerase chain reaction (PCR) test. Similarities have also been confirmed between the causative organism, Clymmatobacterium granulomatis and Klebsieela spp. Azithromycin has been confirmed as the best drug for treatment, but its use is limited due to cost. In donovanosis-epidemic areas, local syndromic management protocols need to be revised to include the management of donovanosis.

Pepin, J. et al. Etiology of urethral discharge in West Africa: the role of Mycoplasma genitalium and Trichomonas vaginalis. Bulletin of the World Health Organization 79(2):118–126 (2001). Available at: www.who.int/bulletin/pdf/2001/issue2/vol.79.no.2.118-126.pdf.
Urethral swabs were obtained from 659 male patients presenting with urethral discharge at 72 primary health care facilities in seven West African countries. Swabs were also obtained from 339 controls presenting with complaints unrelated to the genitourinary tract. Polymerase chain reaction analysis was done to test for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Mycoplasma genitalium and Ureaplasma urealyticum. N. gonorrhoeae (61.9%), T. vaginalis (13.8%), C. trachomatis (13.4%), and M. genitalium (10.0%) were most common in symptomatic men. Multiple infections were common. This study indicates that M. genitalium and T. vaginalis are important causes of urethral discharge in West African men. The frequent co-infection with any of four pathogens supports the need for syndromic management. The current WHO recommendation to give a drug effective against gonorrhea, as well as a second drug (tetracycline or doxycyline) effective against chlamydia to all patients with discharge will provide coverage for these two infections, and possibly for M. genitalium as well. The role of metronidazole in treatment needs to be examined further.

Population Council. Reproductive Tract Infection Fact Sheets. Reproductive Health and Family Planning (2001). Available at: www.popcouncil.org/pdfs/RTIfacsheetsRev.pdf.
The thirteen Reproductive Tract Infection Fact Sheets produced by the Population Council present up-to-date information related to RTIs in a clear and accessible manner. A wealth of information is included. Information specific to men and RTIs is included on pages for RTIs; prevention; treatment, and management of sexually transmitted infections; RTIs and family planning; adolescents; relationships between sexually transmitted infections and HIV/AIDS; and social issues. An extensive annotated bibliography is included.

Pulerwitz, J. et al. Extrarelational sex among Mexican men and their partners risk of HIV and other sexually transmitted diseases. American Journal of Public Health 91(10): 1650–1652 (October 2001).
The first population-based survey in Mexico of male sexual behavior indicates that a substantial number of women are at risk of STIs because of their partners sexual behaviors. Of the 3,990 men in the final sample, 15 percent of the married and cohabitating men reported extrarelational sex. Nine percent of these men reported condom use during their last intercourse—22 percent if their last sex was with a secondary partner and 4 percent if with the primary partner. Secondary partners were most often friends, coworkers, or mistresses, indicating that men often encounter these partners in their normal social circles. Of the men reporting extrarelational sex, 89 percent said their primary partner was unaware of the secondary partner, 80 percent perceived no personal risk of HIV, and 70 percent said they never placed another at risk. This lack of perceived risk, low use of condoms, and high rates of extrarelational sex indicate that many Mexican women are at risk of STIs due to their partners behaviors. Targeted interventions based on the social context of extrarelational sex could reduce STI risk among this population.

Sanchez, J. et al. The etiology and management of genital ulcers in the Dominican Republic and Peru. Sexually Transmitted Diseases 29(10):559–567 (October 2002).
Syndromic management of genital ulcers is recommended in resource-poor settings, but algorithms must take into account risk factors, patterns and causes of disease, and antimicrobial resistance in the local area. In the Dominican Republic, 81 men with genital ulcers and 63 men in Peru were interviewed and lesions were tested for T pallidum, H ducreyi, and herpes simplex using multiplex polymerase chain reaction (M-PCR). Serologic HIV tests were also done. In the Dominican Republic, 5 percent were positive for T. pallidum, 26 percent for H. ducreyi, and 43 percent for herpes simplex. In Peru the positives were 10 percent, 5 percent, and 43 percent respectively. The WHO algorithm for treating syphilis and chancroid was 100 percent sensitive, but had a positive predictive value of 24 percent, and an overtreatment rate of 76 percent. Herpes causes 43 percent of genital ulcer disease in these groups. Modifying the algorithm to treat only men without vesicular lesions resulted in a sensitivity of 88 percent, and a positive predictive value of 27 percent. The overtreatment rate dropped to 58 percent. M-PCR testing was more sensitive than standard tests and more specific and sensitive than clinical diagnosis.

Steen, R. Eradicating chancroid. Bulletin of the World Health Organization 79(9):818–826 (2001).
Chancroid, resulting from infection with Haemophilus ducreyi, is a common cause of genital ulcers. In areas where chancroid is epidemic, genital ulcers are common. These areas also have some of the highest rates of HIV infection. Simple hygiene and male circumcision reduce the risk of chancroid, which is easily treated with antibiotics. H. ducreyi depends on rapid partner change for its survival. Chancroid outbreaks are easily controlled when effective curative and preventive services are made available to sex workers and their clients. Eradication of chancroid is a feasible public health goal. This can be done by protecting sex workers and their clients from exposure to STIs and by improving the availability of STI treatments.

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Increasing adolescent access to RTI/STI services

Also see RHO's Adolescent Reproductive Health section.

Brabin, L. et al. Reproductive tract infections and abortion among adolescent girls in rural Nigeria. Lancet 345:300–304 (February 4, 1995).
This study investigated reproductive tract infections and other indicators of reproductive health among unmarried adolescent girls in a rural community in southeast Nigeria. A total of 868 women were interviewed and examined: 458 aged 20 and above and 410 aged 12–19. Survey findings revealed that nearly 44 percent of those less than 17 and 80 percent aged 17–19 years were sexually active and at least 24 percent had undergone an induced abortion. Vaginal discharge was reported by over 80 percent of adolescents and 63 percent of women over 20. Among girls under age 17, 20 percent had symptomatic candida, and 11 percent had trichomonas infections. Among those aged 17–19, chlamydia was found in over 10 percent, and symptomatic candidosis in 26 percent. Forty-two percent of sexually active adolescents had experienced either an abortion or a STI. This study showed that sexually active adolescents in this rural community in Nigeria are at risk of reproductive tract and sexually transmitted infections. The authors concluded that health care services for adolescents in this community are needed and should include sex education, contraceptive provision, and access to treatment for reproductive tract infections.

Brieger, W. et al. West African Youth Initiative: outcome of a reproductive health education program. Journal of Adolescent Health 29(6):436–446 (December 2001).
The West African Youth Initiative (WAYI) project was designed to improve knowledge of sexuality and reproductive health, and promote safer sex behaviors and contraceptive use among sexually active adolescents in Ghana and Nigeria. A cross-sectional baseline survey (October 1994 to January1995) assessed knowledge and behavior in intervention and control communities prior to implementing peer-education interventions. Peer-education activities then took place at secondary schools and among out-of-school youth. Random samples of youth were interviewed to evaluate the impact of the interventions. A total of 3,585 interviews (911 at baseline, and 908 at follow-up in the intervention sites; 873 at baseline and 893 at follow-up in the control communities) were conducted. Reproductive knowledge, use of contraceptives in the previous three months, willingness to buy contraceptives, and self-efficacy in contraceptive use all increased significantly among adolescents at the intervention school sites. In the out-of-school settings, there was no statistical difference between intervention and control groups. Overall, youth in both the intervention and control sites were exposed to non-project educational messages, so the direct effects of this project are difficult to quantify. Nonetheless, this project confirms that peer education is possible, and can improve the reproductive health knowledge, self-efficacy, and practices of youth in West Africa.

Eaton, L. et al. Unsafe sexual behavior in South African youth. Social Science & Medicine 56:149–165 (2003).
This article reviews research, both published and unpublished, dated 1990 to 2000 on the sexual behavior of South African youth ages 14 to 35 years. According to these 75 reports and papers, at least 50 percent of youth are sexually active by age 16. The majority of sexually active students reported at most one partner in the previous year, but a persistent minority of 1 to 5 percent of females and 10 to 25 percent of males reported having more than four partners per year. Between 50 and 60 percent of youth never use condoms. The studies indicate that poverty and social norms that perpetuate women’s subordination have a large impact on unsafe sexual behavior. Personal factors and the proximal (interpersonal relationships, physical and organizational environment) and distal (culture and structural factors) contexts interact to encourage unsafe sexual behaviors. For example, girls may be persuaded by their boyfriends that the advantages of unprotected sex outweigh the disadvantages. Poverty also has a significant impact on young people’s sexual behavior and risk for HIV and other STIs.

Fetters, T. et al. Investing in Youth: Testing Community Based Approaches for Improving Adolescent Sexual and Reproductive Health. New York: Population Council, Frontiers Project (1999).
The distribution of condoms by peer educators and small business loans offered to youth aged 14 to 19 led to safer sexual practices among adolescents in peri-urban communities in Zambia. From 1996 to 1998, CARE Zambia, with assistance from the Population Council, tested two community-based interventions to improve adolescent reproductive and sexual health. In one area, condoms were distributed by peer educators; in another area youth aged 14 to 19 received small loans and information on business skills and sexual and reproductive health; a third area received both of these interventions; and a fourth area was the control site. The 130 peer educators conducted more than 4,000 counseling sessions and distributed more than 65,600 condoms during the 20-month project period. They reached between 4 and 15 percent of the adolescents in their area. While the loan recipients learned new skills, lack of repayment made it impossible to establish a revolving loan fund. Both interventions did result in safer sexual behaviors, but combining the interventions did not yield a greater impact. Peer educator programs, while expensive and labor intensive, can lead to safer sexual behaviors among adolescents and peer educators alike.

Finger, W. and Pribila, M. Condoms and sexually active youth. Youthnet No. 5 (March 2003). Available at: www.fhi.org/.
This research brief summarizes the findings from several surveys on condom use among youth. Condom use among unmarried sexually active youth varies considerably: from more than 70 percent in Peru, South Africa, and Zambia, to fewer than 30 percent in Ecuador, Senegal, Togo, and even lower in Egypt and Nepal. Risk perception, social support, accessibility, acceptability, and gender all affect condom use. Youth often underestimate their health risk, especially for HIV, and risk perception is difficult to change. Increasing the accessibility and acceptability of condom use affects their use. Gender perceptions of condom use differ. The brief includes a summary of program recommendations and research needs.

Hawken, M. et al. Opportunity for prevention of HIV and sexually transmitted infections in Kenyan youth: results of a population-based survey. Journal of Acquired Immune Deficiency Syndromes 31(5):529–535 (December 15, 2002).
This population-based survey of 1497 adults ages 15 to 49 in a suburb of Mombasa, Kenya, found that sexual activity in the previous 12 months was largely limited to one partner for both men and women of all age groups. Among the 15 to 19 age group, 56 percent of boys and 48 percent of girls were sexually active. Condom use was low with all partners, but was highest among those ages 20 to 29. Knowledge of STI symptoms and HIV was incomplete. HIV prevalence was 10.8 percent, with higher rates among women (13.7%) than among men (8.0%). HIV seroprevalence among those ages 15 to 19 was 3.2 percent. Reported STI symptoms in the last year were high. STIs found included gonorrhea (.9%), chlamydia (1.5%), and syphilis (1.3%). This survey indicates the high vulnerability of young adults, especially young women, to HIV. The low use of condoms, incomplete knowledge of STIs, and high number of reported STI infections in the past year offer opportunities for intervention in this population.

Ikimalo, J. et al. Sexually transmitted infections among Nigerian adolescent schoolgirls. Sexually Transmitted Infections 75(2):121 (April 1999).
In this survey of schoolgirls aged 10 to 19 years, STIs were not diagnosed as frequently as expected. Of the 1,066 girls examined, laboratory tests determined that 13.8 percent had an STI and 11.1 percent had symptomatic candidosis. The prevalence of STIs included gonorrhea (2.1%), chlamydia (2.1%), syphilis (1.0%), and trichomoniasis (9.1%). Non-sexually experienced girls were almost as likely to report any discharge (43.4%) as the sexually experienced (53.6%). The study concludes that adolescent programs should not assume a high STI risk, and should use the WHO clinical management algorithms with caution, as they tend to over-diagnose certain infections.

James, N.J. et al. A collaborative approach to management of chlamydial infection among teenagers seeking contraceptive care in a community setting. Sexually Transmitted Infections 75:156–161 (1999).
The goal of this study was to develop and assess a coordinated model of care for effective management of genital chlamydial infection in young women identified through a selective screening program in a community-based teenage health clinic. Selective screening was undertaken among young women aged 13 to 19 years who were having a routine cervical smear test, being referred for termination of pregnancy, or who reported behavioral risk factors for and/or symptoms of genital infection. Collaboration among family planning, genitourinary medicine (GUM), and public-health staff was used to enhance management of infected women, with particular focus on partner notification. A total of 94 (11%) of the 857 young women tested had confirmed genital chlamydial infection. All 94 index patients received appropriate antibiotic therapy and follow up; 93 (99%) of these were counseled by a health adviser. Among the index patients, 62 (66%) provided sufficient details of their sexual partners for contact tracing, resulting in treatment of male partners associated with 51 (82%) of these young women. Younger age (less than or equal to 16 years) was significantly associated with delay in presenting for treatment. The authors note that the 11 percent positive test result may be an underestimate of infection among this population due to practical difficulties associated with selection of women for screening on the basis of behavioral factors. They conclude that there is an urgent need to implement the use of a non-invasive screening test for chlamydia (for example, use of PCR tests for urine samples or vaginal swabs) among young women. Furthermore, they state that effective management of genital chlamydial infection can be achieved in settings outside GUM clinics using a collaborative approach that incorporates cross referencing between community-based services and GUM clinics.

Karim, A.M. et al. Reproductive health risk and protective factors among unmarried youth in Ghana. International Family Planning Perspectives 29(1):14–24 (March 2003).
A nationally representative survey of 12–24 year olds in Ghana found that the sexual behavior of these youth is influenced by a number of individual, family, community and societal level factors. Thirty-six percent of the males and 41 percent of the females reported ever having had sex. Few had used a condom at first intercourse, and few use condoms consistently (24 percent of males and 20 percent of females). School attendance, peer behaviors and community connections appear to have a stronger influence on initiation of sex and number of partners than on condom use. The latter is more influenced by young people’s gender role perceptions, condom use self-efficacy, and communication with partners about pregnancy and STI risk.

Kiapi-Iwa L, Hart GJ. The sexual and reproductive health of young people in Adjumani district, Uganda: qualitative study of the role of formal, informal and traditional health providers. AIDS Care. 2004;16(3):339–347.
Young people in Adjumani district, Uganda are sexually active and at risk of STIs, according to this small qualitative study. Interviews with 11 young people (aged 10 to 21) and service providers revealed that STIs and unwanted pregnancy are significant problems for young people and health care providers in this area. Young people often visit informal and traditional health care providers. Young people may prefer the privacy and accessibility these numerous providers offer despite the need to pay for services. These providers clearly need training in sexual and reproductive health, and need to be better integrated into the service delivery system.

Lappa, S. et al. Managing sexually transmitted diseases in adolescents. Adolescent Medicine 25(1):71–111 (March 1998).
This paper discusses the unique role of primary care clinicians in the prevention of STIs among adolescents. Using tools such as sexual history and clinical examination, the clinician can determine an adolescent's risk for STIs and, based on this risk, perform the appropriate evaluations. The paper reviews the necessary steps a primary care clinician must take to perform an effective STI assessment, including eliciting risk factors and identifying syndromes. It discusses key components involved in an STI evaluation, including sexual history, physical examination, screening, diagnostic testing, and partner management. Strategies for managing STI syndromes, such as urethritis, cervicitis, epididymitis, vaginitis, genital ulcers, and pelvic inflammatory disease, among others, also are discussed.

Magnani, R. et al. Correlates of sexual activity and condom use among secondary-school students in urban Peru. Studies in Family Planning 32(1):53–63 (March 2001).
Survey data from interviews with 6,962 students aged 13 to 18 in nine large cities in Peru indicate that adolescent fertility is high, and that youth account for a disproportionate share of new HIV infections in the country. This study confirmed other studies showing adolescents at risk in Peru. However, this study showed that knowledge of pregnancy, the risk of acquiring STIs, and the means of avoiding both did not differentiate risk-takers from non-risk-takers. These findings suggest that adolescent programs need to broaden their focus beyond the immediate proximate determinants of behavior, such as sexual and reproductive health knowledge and access to contraceptives. Programs need to target some of the contextual factors that influence adolescent risk-taking behavior, and help create a safer and more supportive environment for youth.

Meekers, D. and Klein, M. Determinants of condom use among young people in urban Cameroon. Studies in Family Planning 33(4):335–346 (December 2002).
Data from the 2000 Cameroon Adolescent Reproductive Health Survey were analyzed to identify factors associated with condom use among 1,284 sexually experienced, unmarried youth in Yaoundé and Douala. Parental support for condom use, personal risk perception, and self-efficacy were associated with higher levels of condom use. Promoting parental support for condom use and educating young people about personal risk could increase the number of new condom users among youth. Communication programs should focus on building young people’s self-efficacy, especially their perceived ability to convince partners to use condoms and use them correctly. This information is being put into use through the 100% Jeunes social marketing program in Cameroon.

Merati, T.P. et al. Traditional Balinese youth groups as a venue for prevention of AIDS and other sexually transmitted diseases. AIDS 11 (Suppl. 1):511–519 (1997).
This study evaluated the feasibility of conducting peer-led educational interventions to prevent AIDS/STIs and surveyed sexual risk-taking and correlates among Balinese youth. Results from self-administered questionnaires of 375 youths aged 16 to 25 years revealed that sexual activity is prevalent in 25 percent of males and few females, that consistent condom use was reported by only 10 percent of sexually active males, and that there was a high correlation between the mean age of first sexual intercourse with that of first alcohol consumption. Data from the peer-led educational intervention showed an increase in knowledge about HIV/STIs and also in communication about sexual issues with peers and adults. The authors concluded that peer-led educational interventions, through traditional Balinese youth groups, may be an efficient way to deliver AIDS/STI education and to reach a wide range of pre-sexual youth.

Muyinda, H. et al. Harnessing the senga institution of adolescent sex education for the control of HIV and STDs in rural Uganda. AIDS Care 15(2):159–167 (2003).
In rural Uganda, the paternal aunt (father’s sister) or senga had the traditional role of communicating about sex and marriage with adolescent girls. This study assessed the impact of modifying this traditional role as an intervention for HIV and STI prevention in two pilot villages. Eleven adult women and three adolescent girls were trained to become sengas. The week-long training included information on perception of risk, HIV and AIDS, STIs, talking about sex, condom use, family planning, traditional and modern norms, and counseling and communication skills. Quantitative and qualitative data were collected during the longitudinal study, including surveys and in-depth interviews of adolescents in the two intervention and one control villages. After one year, the young girls who visited sengas had improved knowledge about HIV/AIDS, improved sexual communication skills, and increased consistent condom and family planning use compared to girls from the control village. Symptomatic STIs decreased among the intervention girls. The intervention was well accepted by the communities. This pilot study warrants larger study in other settings, but offers a potential way to improve communication with adolescents about STIs.

Ndubani, P. and Hojer, B. Sexual behavior and sexually transmitted diseases among young men in Zambia. Health Policy and Planning 16(1):107–112 (2001).
Interview and focus group discussions with 126 young men (aged 16 to 26) in rural Chiawa, Zambia, show that STIs, multiple sexual relationships, and unprotected sex are common among young men in this area. They are aware of STIs and the effectiveness of condoms, but traditional views of manhood have a negative effect on efforts to change unsafe sexual behaviors. While both urban and rural young men may be at risk of STIs, rural men are more influenced by the cultural norms of their elders. Urban young men are more exposed to and influenced by the mass media. Health messages in this rural setting must address the cultural context in which these young men live.

Nzioka C. Unwanted pregnancy and sexually transmitted infection among young women in rural Kenya. Culture, Health & Sexuality. 2004;6(1):31–44.
Eight focus group discussions with 94 school girls aged 15 to 19 in Makueni District of Eastern Kenya in 2000, found these girls at high-risk of STIs and unwanted pregnancy despite knowledge of the protective value of condoms and other contraceptives. Use of these methods is hindered by the girls’ inability to access condoms, fear of side effects, and by their desire to remain faithful to their religion. Most girls turn instead to traditional methods, such as periodic abstinence, or the use of herbs, prayers or withdrawal. Girls also reported difficulty negotiating sex and condom use. There is a need to make condoms more accessible to girls in rural areas, and for education in effective use of traditional methods, and in how to be more assertive in sexual negotiations.

Obasi, A. et al. Prevalence of HIV and Chlamydia trachomatis infection in 15–19 year olds in rural Tanzania. Tropical Medicine and International Health 6(7):517–525 (July 2001).
This large study estimated the prevalence of HIV and Chlamydia trachomatis (CT) infection among adolescents aged 15 to 19 in rural Mwanza Region, Tanzania. A total of 9,455 adolescents were interviewed and their urine tested. HIV prevalence was 0.6 percent in males and 2.4 percent in females, increasing steeply with age. HIV infection was associated with female sex, never having been to primary school for males, and current symptoms of genital discharge or genital ulcer in females. The prevalence of CT was 1.0 percent in males and 2.4 percent in females. CT infection was associated with female sex, current symptoms of STI, and positive leucocyte esterase (LE) test. The majority of adolescents with CT were asymptomatic. The high rates of HIV and CT infection, and of asymptomatic infection, in this young population (especially females) indicate the need for effective interventions to improve adolescent reproductive health.

Obunge, O.K. et al. A flowchart for managing sexually transmitted infections among Nigerian adolescent females. Bulletin of the World Health Organization 79(4):301–305 (2001).
Although syndromic management of women with vaginal discharge has been recommended in areas with limited laboratory facilities, its effectiveness among adolescent women—who are often asymptomatic and inexperienced in distinguishing between normal and abnormal discharge—is limited. This study evaluated a flowchart for management of chlamydial infection, gonorrhea, and trichomoniasis among adolescents. Girls aged 14 to 19 from the Port Harcourt area of Nigeria were interviewed and screened for sexually transmitted infections. Stage 1 of the flowchart identified sexually active girls under age 20. Stage 2 involved leukocyte esterase (LE) testing of the sexually active girls, and at Stage 3, those with negative LE tests were assessed based on any vaginal discharge. According to the flowchart, 26.2 percent of all adolescents screened would receive treatment for cervicitis and vaginitis. Correct diagnoses were made in 37.5 percent of girls with chlamydia, 66.7 percent of those with gonorrhea, and in 50 percent of those with trichomoniasis. The flowchart used in this study may be more suitable for assessment of adolescents than the WHO algorithm, but it is a poor substitute for laboratory testing and needs adapting to local settings.

Okonofua, F. et al. Assessment of health services for treatment of sexually transmitted infections among Nigerian adolescents. Sexually Transmitted Diseases 26(3):184–190 (March 1999).
This study investigated the quality of services provided to adolescents by a variety of health practitioners for the treatment and prevention of STIs in Benin City, Nigeria. In-depth interviews were conducted with 48 practitioners from the formal and informal sector, and their facilities were inspected. The practitioners were selected based on information from key informants. Practitioners from the private and informal sector (private doctors, patent medicine dealers, traditional healers, and laboratory technologists) treated the most adolescents. Many traditional healers and patent medicine dealers provided inappropriate STI prevention and treatment services. While practitioners in the private and formal sector were more likely to provide appropriate treatment, they often lacked appropriate diagnostic tools, did not promote the use of condoms, and had no established system for referring patients. There is need for reproductive health education for adolescents, retraining of health providers, and consolidation of STI prevention and treatment services.

Palmer, A. Reaching Youth Worldwide, Johns Hopkins Center for Communication Programs, 1995–2000. Working Paper No. 6. Baltimore, Maryland: Johns Hopkins University, Bloomberg School of Public Health, Population Communication Services (April 2002). Available at: www.jhuccp.org/pubs/wp/6/6.pdf.
This working paper reviews JHUCCP-sponsored communication programs in Africa, Latin America, the Near East, Europe, and Eurasia that seek to inform young people about safe sexual behavior and to help them obtain high-quality reproductive health services. It presents country programs and lessons learned in communicating with young people about their reproductive health. The lessons apply to designing programs, establishing youth friendly centers and services, hotlines, entertain-to-educate efforts, and involving youth through technology.

Pathfinder International. Youngpeople and STDs/HIV/AIDS. In Focus, Focus on Young Adults (December 1997). Available online at www.pathfind.org/IN%20 FOCUS/HIVI.html.
This article summarizes program experience and research on young adults and STIs, including HIV/AIDS. It includes current data on adolescents and STIs, why adolescents are vulnerable, the health and social consequences, the types of programs being implemented, and the lessons learned.

Speizer I, Magnani RJ, Colvin CE. The effectiveness of adolescent reproductive health interventions in developing countries: a review of the evidence. Journal of Adolescent Health. 2003;33:324–348.
This review of studies on adolescent reproductive health (ARH) synthesizes findings from 41 studies for which there were scientific bases for causality in the outcomes measured. Most of the interventions appear to have had a positive impact on knowledge and attitudes, but only a small proportion of ARH interventions have been rigorously evaluated. While no single intervention appears as the most effective, this review shows it is important for programs to provide adolescents with consistent, accurate messages; life-skills needed to protect health and well-being; social support; and access to contraceptives and appropriate health services. There is clear need for further rigorous evaluation of interventions, including large-scale studies and efforts to scale-up successful small programs.

Speizer, I. et al. An evaluation of the "Entre-Nous Jeunes" peer-educator program for adolescents in Cameroon. Studies in Family Planning 32(4):339–351 (December 2001).
Peer educators in Nkongsamba, Cameroon, improved the knowledge of contraceptives and sexually transmitted infections and the use of contraceptives, especially condoms, among youth they contacted. This quasi-experimental study evaluated the effectiveness of 42 peer educators through pre-test and post-test surveys. Following the 18-month intervention, 54 percent of youth interviewed from Nkongsamba knew of the program, and almost 40 percent had had an encounter with a peer educator. Among the sexually active, 55 percent reported contact with a peer educator. Multivariate analysis of the data show that exposure to the peer-educator program is significantly associated with greater spontaneous knowledge of modern contraceptives and STI symptoms. Models indicate that without the ENJ program, contraceptive use would have been lower. Future studies need to evaluate if these short-term impacts on behavior persist, and if this type of peer educator strategy can be replicated on a larger scale.

Taffa, N. et al. Prevalence of gonococcal and chlamydial infections and sexual risk behavior among youth in Addis Ababa, Ethiopia. Sexually Transmitted Diseases 29(12):828–833 (December 2002).
According to this community-based study in Addis Ababa, Ethiopia, out-of-school youths, especially females, take sexual risks and are very susceptible to STIs. Self-administered questionnaires and PCR urine testing for gonorrhea and chlamydia was undertaken among 561 youths ages 15–24 years old. STI infection was low in this survey: 9 youths (1.7%) tested positive for gonorrhea and chlamydia (five each and one double infection). All but one infection was in out-of-school youth, and none complained of any symptoms. Seven (13.5%) of the sexually active females had an STI, while only 2 (1.5%) of the males had an STI. Sexual activity was greatest for males age 20 or older, out of school, with reported consumption of khat and/or alcohol.

Taffa, N. et al. Psychosocial determinants of sexual activity and condom use intention among youth in Addis Ababa, Ethiopia. International Journal of STD & AIDS 13:714–719 (October 2002). This study of 561 in- and out-of-school youth (ages 15 to 24) in Ethiopia found that out-of-school males aged 20 to 24 years were most likely to be sexually active. Use of alcohol and khat were also associated with sexual activity. One-third of the youths interviewed reported sexual intercourse in the past, and about half of those sexually active reported using a condom during most recent sexual intercourse. Psychosocial constructs determining use of condoms included attitude, self-efficacy, skills, and barriers. The last three variables were significantly correlated. These findings emphasize the need for HIV and STI education programs to include social and cognitive components in addition to information about disease transmission.

Temin, M. et al. Perceptions of sexual behavior and knowledge about sexually transmitted diseases among adolescents in Benin City, Nigeria. International Family Planning Perspectives 25(4):186–195 (December 1999).
Twenty-four single-sex focus groups were conducted among young people aged 15 to 20 years in Benin City, Nigeria. The groups discussed adolescents perceptions of the sexual activity of their peers and knowledge of sexually transmitted infections (STIs) and their prevention. The participants said that sexual activity is common among their peers. Romantic relationships are motivated by physical attraction, while sexual relationships are motivated by material or monetary gain. Many had some knowledge of STIs, including HIV, but felt infections were inevitable. For treatment of an STI, many went to traditional healers because doctors and hospitals were perceived as costing more, offering slow service and lacking confidentiality. Media campaigns may be the best way to educate young people about risky behaviors, STIs, and condom use. Parents would benefit from education about reproductive health and communicating with adolescents. Training medical providers in low-cost diagnosis and treatment techniques and emphasizing confidentiality and sensitivity would also improve services.

Todd, J. et al. Risk factors for active syphilis and TPHA seroconversion in a rural African population. Sexually Transmitted Infections 77:37–45 (February 2001).
Syphilis is a significant cause of disease in sub-Saharan Africa. To develop effective interventions to prevent syphilis infection, this study determined the prevalence and incidence of syphilis and potential risk factors for disease among residents of Mwanza, Tanzania. Active syphilis was found in 7.5 percent of men and in 9.1 percent of women. Among young people aged 15 to 19, the prevalence was much higher among women (6.6%) than among men (2%). The incidence of seroconversion was highest in women aged 15 to 19 (3.4 percent per year). The high incidence of syphilis among young women in this rural population indicates a need for sexual health interventions aimed at adolescents.

UNICEF, UNAIDS, and WHO. Young People and HIV/AIDS: Opportunity in Crisis. New York: UNICEF (July 2002). Available at: www.unicef.org/publications/index_4446.html.
This joint publication of the United Nations Childrens Fund (UNICEF), the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the World Health Organization (WHO) emphasizes the need to focus on young people to stop the spread of HIV/AIDS and other STIs. More than 11 million young people aged 15 to 24 are living with HIV/AIDS, and more than half of those newly infected with HIV every day are young people (nearly 6,000 young people). The report includes data from 60 new national surveys and provides two statistical tables with HIV/AIDS-related data on young people worldwide. Young people are at risk of HIV and other STIs because they are sexually active, yet lack necessary information. Girls are especially at risk, as are young people who inject drugs, those subject to sexual violence, street youth, those in armed conflict, and those orphaned by AIDS. The report summarizes what has been learned about helping youth: providing information, equipping young people with life skills to put knowledge into practice, providing youth-friendly health services, promoting confidential and voluntary counseling and testing, promoting young peoples participation, creating safe and supportive environments, and reaching out to those most at risk.

Voeten H, Egesah O, Habbema J. Sexual behavior is more risky in rural than in urban areas among young women in Nyanza Province, Kenya. Sexually Transmitted Diseases. 2004;31(8):481–487.
This cross-sectional study of 584 household members aged 15 to 29 in Nyanza province investigated the sexual risk behavior of young adults. Young women practiced riskier sexual behaviors in rural than in urban areas. Rural women were less likely to be virgins at marriage, have a higher number of lifetime partners, and less consistently use condoms with nonspousal partners than urban women. Risky sexual behaviors were similar between rural and urban men. The potential for spread of HIV and other STIs is great in Nyanza, and prevention and treatment efforts need to be expanded from the urban Kisumu area to the rural districts.

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Improving client-provider interaction

Chikamata, D.M. et al. Dual needs: contraceptive and sexually transmitted infection protection in Lusaka, Zambia. International Family Planning Perspectives 28(2):96–104 (June 2002).
Data from a 1998 situation analysis of eight public-sector family planning clinics in Lusaka, Zambia, were reviewed to evaluate the readiness of the clinics to provide STI prevention and diagnostic services. Interviews with 42 providers and 3,201 clients, and observations of 2,452 client-provider interactions were used to look at the exchange of information on the ability of non-barrier methods to protect against infection. The sites have the infrastructure necessary to offer integrated services, and providers have the training to give information about STI prevention, but are less prepared to offer STI diagnosis and treatment. Supplies of male and female condoms are unreliable, and providers minimum age requirements are obstacles. Multivariate analysis showed that clients who did not use condoms, but who had been told their method offered no protection against STIs were three times more likely to know this at an exit interview than were women who were not told this fact. Women with higher education levels, those whose provider had fewer years of schooling, and those attending smaller clinics were all more likely than other women to have correctly received the STI message given by providers. These results indicate that the educational levels of both providers and their clients can be barriers to the successful transfer of STI prevention information.

Chowdhury, S.N.M. et al. Are providers missing opportunities to address reproductive tract infections? Experience from Bangladesh. International Family Planning Perspectives 25(2):92–97 (June 1999).
The goals of this study were to (1) examine the family planning service delivery process in Bangladesh, with particular attention to the management of RTIs during reproductive health service delivery at public and private clinics, and (2) identify areas where these services could be improved. A total of 172 clients in 46 previously selected family planning service facilities were interviewed, and their interaction with health care providers was observed during a one-month period in 1996. In addition, 112 doctors and family welfare service providers were interviewed at the end of the observation period. Seventy-seven percent of clients reported at least one symptom associated with RTIs at the time of the intake interview, but service providers only followed up on these complaints or obtained a comprehensive reproductive history in 22 percent of the cases. Of 18 women receiving an new IUD, only six were screened for RTIs. Providers explored the symptoms of only half of all women using injectable contraceptives who reported problems typical of RTIs. Twenty-one percent of symptomatic women were diagnosed with a RTI, and one-third of these women received specific, as opposed to symptomatic, treatment. Pelvic examinations were performed on 40 out of 60 new family planning clients and on 21 out of 50 family planning clients making follow-up visits. The study findings pointed to several missed opportunities and gaps in the knowledge and practice of service providers: providers failed to elicit necessary reproductive health information from clients; the client-provider interaction remained focused on the initial reason for the woman's visit and rarely looked beyond fertility regulation or pregnancy care. The gaps in provider knowledge, attitudes, and practices suggest a need for further training on issues related to reproductive health, including RTIs. The authors suggest that service delivery protocols should be revised so that each medical appointment is seen as an opportunity for interaction between the client and the provider. Furthermore, providers' skills need to be improved to elicit information from their clients and create a physical environment that enhances effective client-provider interaction.

Ghee, A. et al. Behavior change in the clinic setting. In: Control of Sexually Transmitted Diseases: A Handbook for the Design and Management of Programs. Dallabetta et al., eds. AIDSCAP (1996).
This chapter of the Handbook is intended to provide clinic managers and staff involved in providing STI services with information to help them design, implement and evaluate STI patient education at the clinic level. The chapter highlights the important role of the clinic manager in effective patient education and presents the rationale for education within the clinic setting. It addresses the main principles of and provides indicators for effective patient education. Also highlighted are case examples, caveats and an approach that maximizes the effect of patient education by using multiple channels and complementary community-based efforts.

Go, V. F. et al. Barriers to reproductive tract infection (RTI) care among Vietnamese women: implications for RTI control programs. Sexually Transmitted Diseases 29(4):201–206 (April 2002).
A population-based survey of 1,163 Vietnamese women aged 18 to 49 years found that 43.6 percent had symptoms of an RTI in the previous six months (abnormal discharge, 78.3 percent; lower abdominal pain, 46.7 percent; genital ulcers, 3.6%). Sixty-four percent of these women sought treatment at a medical facility (government health station, 24.7 percent; hospital, 15.8 percent; pharmacy, 15.2 percent; private doctor, 8.1%). Eleven percent of the women self-treated, and 24.8 percent ignored their symptoms. Women who ignored their symptoms were more likely to feel there is a stigma associated with STIs, be less likely to seek informal advice, have mild symptoms, and not perceive themselves to be ill than women who did seek care. The substantial number of women in this study who did not seek care for their symptoms of an RTI suggest efforts are needed to raise awareness of RTIs and combat negative stereotypes.

Kim, Y.M. et al. "Haki yako:" A client provider information, education, and communication project in Kenya. IEC Field Report Number 8. Johns Hopkins Center for Communication Programs (December 1996) Available at: www.jhuccp.org/pubs/fr/8/index.shtml.
This field report presents an overview of the Kenya client-provider IEC project and its major findings. The project's goal was to increase new and continued use of modern contraceptive methods among Kenyan couples by increasing couples' knowledge of modern methods, encouraging spousal communication, improving providers' communication skills, and promoting providers as well-trained, caring, and trustworthy sources of family planning information and services. The project resulted in improved counseling and interpersonal communication between providers and clients, increased availability and use of educational materials at the service delivery points, and widespread exposure to campaign materials among the general population. The lessons learned in this project can help program planners design further interventions that will continue strengthening the quality of service provided by Kenyan family planning organizations, raise public awareness, and increase discussion of family planning.

Lafort, Y. et al. Should family planning clinics provide clinical services for sexually transmitted infections? A case study from Côte d’Ivoire. Tropical Medicine and International Health 8(6): 552–560 (June 2003).
This evaluation of the usefulness of integrated STI care at nongovernmental family planning clinics in Côte d’Ivoire provides evidence for the benefits of integrated care in this population. The study included a survey measuring prevalence of STIs and the validity of treatment algorithms, exit interviews of clients, direct observations of client-provider contacts, monitoring of clinic workload and equipment and supplies, and interviews of providers and program managers. The prevalence of cervical infections was low, and the algorithm used to treat women with vaginal discharge needs to be modified to reduce overtreatment of cervicitis. Continued STI management is recommended because there exists an easily identifiable group of higher-risk women who need STI services, there is a large demand for these services, the prevalence of vaginal infections is high, and the costs to the family planning program are minimal.

Manhart, L.E. et al. Sexually transmitted diseases in Morocco: gender influences on prevention and health care seeking behavior. Social Science & Medicine 50: 1369–1383 (2000).
In 1996, the Ministry of Health in Morocco conducted a qualitative study to improve their IEC strategies. Seventy semi-structured interviews were conducted with men and women to understand their knowledge of STIs, and sources of information and treatment. The common name for STI is "berd," which means "the cold." Berd is caused by cold striking the genital area or through sexual intercourse. These two explanations provide an honorable excuse for individuals who become infected, while also warning against unsanctioned sexual behaviors. These interviews also showed that STIs are perceived as women's illnesses in Morocco; women are the cause of these infections and men are often the victims. Men have more access to treatment and to informal sources of information about STIs than do women. The physical and psychosocial consequences of STIs are more severe for women than for men in Morocco. This information is being incorporated into national training programs for health care providers.

Ndulo, J. et al. "Shopping" for sexually transmitted disease treatment. Sexually Transmitted Diseases 27(9):496–503 (October 2000).
Six focus group discussions were held in one rural and one urban area of Zambia to gain a better understanding of clients' choices of treatment for STIs. Participants (57 men and 44 women) said they combined traditional and modern forms of treatment. Even when biomedical treatment was received, many participants said it also was necessary to be cleansed with traditional herbs to achieve a complete cure. While modern medical treatment offered the benefits of effective treatment, laboratory tests, a complete examination and medical history, and treatment with injections, there also were many negative factors. Some of the obstacles mentioned were requests by providers to bring in sexual partners for treatment, long waiting times, lack of drugs, little privacy, high cost, and negative attitudes of the staff. Traditional healers were praised for their openness, respect for elders, and for their welcoming behaviors. However, participants also said these healers lacked diagnostic skills and provided inappropriate prescriptions. Improved cooperation between biomedical and traditional healthcare providers might improve service coverage and STI control in Zambia.

PATH. Improving interactions with clients: a key to high-quality services. Outlook. 1999;17(2):1–8. Available at: www.path.org/files/eol17_2.pdf.
This article focuses on the interactions of service providers with their clients, and describes why improving client-provider interaction is an important component of improving the overall quality of reproductive health services. It presents key points to consider when seeking to strengthen the quality of client-provider interaction, and identifies common challenges. The article contains useful messages for providers, guidelines for meeting the needs of special groups (including adolescents, refugees, older women, postpartum women, and male and female homosexuals), and counseling tips for providers with limited time.

Wotton, K. et al. Training in STD management. In: Control of Sexually Transmitted Diseases: A Handbook for the Design and Management of Programs ; Dallabetta et al., eds. AIDSCAP (1996).
This chapter of the Handbook is intended to provide STI clinic managers with information about training resources, design tips, and principles to develop and sustain STI training programs for health care providers. It highlights training objectives and the characteristics of effective training efforts, discusses key steps in developing a plan for health worker training, and addresses key issues for successful training. The chapter also examines public and private partnerships for STI prevention and control.

Wright, J.M. et al. Evaluation of the use of calendar blister packaging on patient compliance with STD syndromic treatment regimens. Sexually Transmitted Diseases 26(10):556–563 (November 1999).
Some STIs require multidose treatment therapy. Patient compliance with multiple-day, several-times-a-day therapy often is poor and can lead to inadequate STI treatment, complications, and antibiotic resistance. This study in South Africa evaluated two types of drug packaging to assess patient compliance and test the acceptability of calendar blister packages among men being treated for acute urethritis and/or genital ulcer disease at two STI clinics. The Primary Pill Pak (PPP) included prepackaged medications and daily instructions, along with health education messages about clinic attendance, condom use, and partner notification. Use of the PPP resulted in significantly better patient compliance with treatment than use of a standard pill package (SP), and the majority of patients were satisfied with their treatment and the pill package. Providers thought that the package was too large, and could stigmatize the patient, although patients did not report this as a problem. Patients who were unable to read reported difficulty understanding the package information. Patients were motivated to complete their treatment by their desire to be cured, and providers should emphasize the need to continue with medication even after symptoms decline. Drug packaging can improve communication and compliance.

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