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RHO archives : Topics : Reproductive Tract Infections

Annotated Bibliography

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Adeokun, L. et al. Promoting dual protection in family planning clinics In Ibadan, Nigeria. International Family Planning Perspectives 28(2):87-95 (June 2002).
To improve the delivery of integrated family planning and HIV/STI prevention services in the face of the escalating HIV epidemic in sub-Saharan Africa, dual protection services were introduced in six family planning clinics in Ibadan, Nigeria. Family planning providers received training in dual protection, and a dual-protection counseling protocol was introduced in the clinics. Clients were offered female condoms as part of routine clinical services. The project also introduced standardized management information systems in the clinics that documented dual-protection counseling, clients decision-making and clients acceptance of male and female condoms. Providers delivered dual-protection counseling to a majority of clients, and demonstrated the female condom to 80 percent of the new clients observed. Condom purchases increased from 2 percent of all family planning visits to 9 percent, mostly from increased acceptance of female condoms. Interviews with providers indicated that providers own internalization of the importance of STI/HIV infection prevention was key to their promotion of dual protection among clients.

Askew, I. and Maggwa, N.B. Integration of STI prevention and management with family planning and antenatal care in sub-Saharan Africa—what more do we need to know? International Family Planning Perspectives 28(2):77-86 (June 2002).
While STI prevention and treatment services have been integrated into existing antenatal and family planning programs in many low-resource settings, little is known about how they can best be configured and about their impact on health. This article summarizes what is known and not known about integrated services, and identifies priorities for further research. The authors found that most integrated programs do not include evaluation components, or are done on an experimental basis and the lessons learned have not been widely disseminated. There are no known prospective controlled studies to test specific service configurations of integrated STI and family planning services. This type of study could demonstrate whether such integration is feasible and if it meets the goals of STI and FP programs. There is need to test new strategies that reorient routine health consultations toward the dual goals of protecting against unwanted pregnancy and infection, with greater involvement of the client. There is also need to develop and test new strategies to reach male partners and facilitate adolescents access to services.

Becker J, Dabash R, McGrory E, et al. Paving the Path: Preparing for Microbicide Introduction. New York: EngenderHealth; 2004. Available at:
Results from focus group discussions and in-depth interviews (September 2002-2003) with individuals at the community, health services, and policy levels in Langa, Western Cape Province, South Africa, indicate great support for and interest in microbicides. The greatest perceived benefits include their use in preventing the spread of HIV, and the need for a female-controlled method in the face of the high level of sexual violence in South Africa. However, respondents also said that women’s lack of power, microbicides’ partial effectiveness against HIV, and the “wetness” or lubrication associated with use are potential barriers. These findings can help policy-makers, program managers, and health care providers prepare to address these challenges prior to the introduction of microbicides.

Brown, H. Women’s Lack of Control Over STI Risks Drives Microbicide Search. Washington, DC: Population Reference Bureau (April 2003). Available at:
Women are often limited in their ability to control the prevention of HIV and other STIs. An affordable, noncontraceptive method that women can use without male consent is urgently needed. Many microbicidal agents are being studied, but the soonest an effective, topical microbicide may be commercially available would be 2007. This article provides an overview of the status of current microbicides under development, and details the obstacles encountered by clinical trials. Commercial backing will depend on the proven existence of a market for the product. Although a microbicide will improve women’s ability to protect themselves from risk, there is also need to address the gender inequalities that put them at risk.

Cates, W. and Spieler, J. Contraception, unintended pregnancies, and sexually transmitted infections. Sexually Transmitted Diseases 28:552-554 (September 2001).
In this editorial, the authors outline the complexity of decision-making to achieve dual protection against pregnancy and sexually transmitted infections. These decisions operate at the individual, community, and policy levels. Biological and behavioral factors also influence the effects of contraception on pregnancy and infection. Hormonal contraception has been associated with increased detection of cervical infections such as chlamydia. IUDs are associated with increased risk of upper genital tract infections, primarily around the time of insertion. An "antisynergy" effect appears to affect behavioral factors: couples using one contraceptive method to protect against pregnancy are less likely to use condoms as a second method to protect against infection. In fact, the more effective the contraceptive method, the less likely are couples to use condoms consistently. To have the greatest public health impact, the authors urge that resources be focused on those at greatest risk for HIV infection and unplanned pregnancy (sex workers, men and women with multiple partners, and young adults). This can best be done by overcoming negative provider attitudes and condom promotion.

Cates, W. and Steiner, M. Dual protection against unintended pregnancy and sexually transmitted infections. Sexually Transmitted Diseases 29(3):168-174 (March 2002).
This commentary suggests that providers have a key role to play in helping clients obtain the most effective protection against pregnancy and sexually transmitted infections. While a contraceptive method that offers dual protection is ideal, the contraceptives that are most effective at preventing pregnancy (sterilization, hormonal methods, IUD) provide little if any protection against STIs. Condoms offer the best protection against STIs, but are associated with relatively higher pregnancy rates for most users. In the absence of evidence-based recommendations, the authors propose providers should assist clients in determining their likelihood of exposure to infection based on client risk factors or community prevalence levels. If exposure is likely, especially to HIV, use of condoms for dual protection should be suggested. Where unintended pregnancy is a greater concern, use of two methods for dual protection may be more appropriate. The authors propose hypotheses for testing the best approach to dual protection.

Celentano D. It’s all in the measurement: consistent condom use is effective in preventing sexually transmitted infections. Sexually Transmitted Diseases. 2004;31(3):161-162.
This editorial highlights the importance of high quality data and rigorous methodology to assess the effectiveness of condoms in preventing STIs. Large sample size, consistency of assays, and analysis of subsets of participants can yield valuable data. A study comparing consistent condom users with inconsistent users shows that condoms are an important strategy for reducing risks associated with acquiring STIs. There is still need for more use effectiveness studies, especially those using highly sensitive STI assays, in prospective or randomized controlled studies.

Coggins, C. et al. Preliminary safety and acceptability of a carrageenan gel for possible use as a vaginal microbicide. Sexually Transmitted Infections 76:480-483 (2000).
Seven women at each of five clinical sites were enrolled in a study of the safety and acceptability of a vaginal gel formulation microbicide, PC-503. The gel contained a two-percent pharmaceutical grade lambda carageenan. The participants applied 5 ml of the gel vaginally once a day for seven days while abstaining from sexual intercourse. Some participants reported "bladder fullness," "genital warmth," discomfort, or lower abdominal pain. Most found the gel to be pleasant or neutral in feel and smell, while one-third found it messy. This small study indicates the general acceptability of a carrageenan gel microbicide, but further larger studies with sexually active women are warranted.

Dallabetta, G.A., Laga, M., and Lamptey, P.R. (Eds). Control of Sexually Transmitted Diseases: A Handbook for the Design and Management of Programs. Family Health International, AIDS Control and Prevention (AIDSCAP) Project (1996).
This handbook is developed for use by people who design and/or manage STI programs in poor-resource settings. It provides a comprehensive account of STI management and prevention and addresses a wide range of issues (including training, communication approaches, surveillance, curative and preventive services, evaluation, and the like) that need to be addressed by STI managers when designing and implementing STI programs.

Donovan B. Sexually transmissible infections other than HIV. The Lancet. 2004;363(9408):545-556.
High levels of STIs are prevalent, especially among young people. According to this seminar article, this is due to the subtlety and lack of symptoms, and the disconnect between infection and related consequences such as infertility, ectopic pregnancy, cancer and psychosocial dysfunction. Improved test sensitivities (due to nucleic-acid amplification tests) make it both possible and more acceptable to accurately diagnose STIs. Unfortunately, many of these tests are not commercially available or are too expensive to be used by those who need them the most. Improvements in treatments (such as single dose oral azithromycin, and self-treatment of genital warts with podophyllotoxin or imiquimod) and the prospect of a vaccine against genital papillomavirus are important advances that will improve health. Ultimately, better control of STIs will require an adequately funded, broad health-sector response and a change in social and political attitudes.

Epstein, H. et al. HIV/AIDS Prevention Guidance for Reproductive Health Professionals in Developing-Country Settings. New York: The Population Council and United Nations Population Fund (2002).
This 60-page booklet summarizes the issues, challenges, and opportunities associated with integrating HIV/AIDS interventions into existing reproductive and sexual health services. One of its six chapters focuses on “HIV Prevention through Management of Reproductive Tract Infections.” This chapter provides some highlights of the challenges to STI prevention and treatment in developing countries, similar to the information included in this topic area of Reproductive Health Outlook.

Feldblum, P. J. et al. Female condom introduction and sexually transmitted infection prevalence: results of a community intervention trial in Kenya. AIDS 15(8):1037-1044 (2001).
This trial measured the impact of female condom introduction and a risk-reduction program on the prevalence of STIs among Kenyan agricultural workers. Six matched pairs of sites were selected from tea, coffee, and flower plantations. The six intervention sites received an informational/motivational program and free distribution of both male and female condoms. The control sites received only male condoms and related information. STI prevalence at the intervention site dropped from 22.1 percent at baseline to 18.2 percent after twelve months. Prevalence also dropped at the control site, from 25.6 percent to 18.4 percent. However, the female condom had no effect. It is not clear from the study which aspects of the intervention (STI education, condom promotion, or case management) were responsible for the drop in prevalence.

FHI. Family planning and STIs. Network 20(4) (2001). Available at:
This issue of Network focuses on the overlap between family planning and STIs. It covers topics of importance to family planning providers and their clients, including the need for dual protection, the needs of HIV-positive women, reaching men and youth, STI risk and circumcision, and the protection/risk associated with condoms, nonoxynol-9, and hormonal contraception. It includes a chart summarizing each contraceptive method and whether each offers protection against specific viral and bacterial infections.

FHI. Lessons from a female condom community intervention trial in rural Kenya. FHI Research Briefs on the Female Condom, No. 7 (October 9, 2001). Available at:
A community intervention trial compared distribution of and education regarding female and male condoms with that of male condoms alone. The participants, women from tea, coffee, and flower plantation in rural Kenya, were tested and treated for gonorrhea, chlamydia, and trichomoniasis at the beginning of the trial and at six and twelve months. At the start of the study, about 24 percent of women in both the control (male condom only) and intervention (male and female condoms) sites had one or more of the three STIs. After twelve months, this percentage declined to about 18 percent in both sites. The availability of the female condom did not reduce STI rates more than the availability of the male condom alone. While female condom users liked the product, provider preconceptions may have limited opportunities for women to use the female condom.

Fleming, D.T. and Wasserheit, J.N. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sexually Transmitted Infections 75(1):3-17 (February 1999).
This article reviews the scientific data on the role of STIs in sexual transmission of HIV infection. It reviews data from studies published since 1990. The article provides a wealth of evidence identifying the contribution of ulcerative and non-ulcerative inflammatory STIs to sexual transmission of HIV infection. The article then discusses the implications of these findings for HIV and STI prevention policy and practice by highlighting initial steps in activities such as community-based behavioral intervention, surveillance, and clinical services that would help build synergistic HIV and STI prevention programs.

Fletcher, M. Vaccine candidates in STD. International Journal of STD & AIDS 12:419-422 (2001).
While there are several vaccines in development against sexually transmitted infections, particular scientific problems are causing delays. Development of a successful vaccine depends on choice of the appropriate antigen and the feasibility of its preparation. Specific problems encountered include incomplete attenuation (in the case of herpes simplex 2), accentuated immunopathology (chlamydia), poor immunogenicity (trepenoma pallidum), and broad antigenic heterogeneity (gonorrhea). Based on an analysis of currently licensed vaccines, the author suggests that vaccines based on subunit protein antigens look promising in the use against both viral and bacterial STIs.

Fonck, K. et al. Health-seeking and sexual behaviors among primary healthcare patients in Nairobi, Kenya. Sexually Transmitted Diseases 29(2):106-111 (February 2002).
A survey of 555 patients (56 percent female) attending three primary healthcare clinics in a low-income area of Nairobi, Kenya, found major differences in the healthcare-seeking behavior of men and women for STI treatment. Women waited an average of 14 days, and men an average of 5 days, before coming to the clinic. Both men and women were more likely to use the private health care sector when they have an STI. Womens health knowledge, and specifically STI knowledge, was poor. More men than women reported a history of STIs (68% versus 47%), and more men reported extramarital affairs. Gonorrhea (3%) and chlamydia (6%) were common in both men and women, but a urine dipstick test was not effective at detecting these infections. Providers rarely recorded information related to STIs on clinic health cards. Better understanding of the behavioral factors affecting those seeking treatment for STIs is needed, as is improved health education and information.

Fonck, K. et al. Healthcare-seeking behavior and sexual behavior of patients with sexually transmitted diseases in Nairobi, Kenya. Sexually Transmitted Diseases 28(7):367-371 (July 2001).
Information about healthcare-seeking and sexual behavior was obtained from 471 patients attending an STI clinic in Nairobi, Kenya, in 1998. A large proportion of these patients had sought treatment in public and private clinics prior to attending this special STI clinic, and most had already spent considerable money on treatment. Most patients waited about one week after symptoms began before they sought treatment. Women were more likely than men to engage in sexual activity while symptomatic. Sixty-eight percent of the men admitted to extramarital affairs, and 30 percent paid for sex, but they blamed their wives for their infection. Health education messages in Kenya need to address delays in seeking treatment for STIs, and STI-treatment services should be made more widely available.

Ford, K. et al. The Bali STD/AIDS Study: human papillomavirus infection among female sex workers. International Journal of STD & AIDS 14:681-687 (October 2003).
Female sex workers from seven low-priced brothels in Denpasar, Indonesia, participated in this intervention study (1997-1999) designed to promote condom use and prevent STIs, including HIV/AIDS. The intervention included educational sessions, STI treatment, condom distribution, and media for clients. Some brothels received more intensive behavioral interventions than others. About 600 sex workers were evaluated at 6-month intervals during the 18-month study. Human papillomavirus infection was initially high (38.3 percent), but declined to 29.7 percent after 18 months. HPV prevalence declined with age, and was associated in the first period with reported symptoms of STIs. HPV infection was associated with gonorrhea infection in the first period. Prevalence of HPV infection declined more in the areas receiving more intensive behavioral interventions.

Foreit, K.G. et al. When does it make sense to consider integrating STI and HIV services with family planning services? International Family Planning Perspectives 28(2):105-107 (June 2002).
Despite the general acceptance of the advantages of integrated services, there is no consensus on what integration means, and whether integrated family planning/STI services should replace stand-alone STI/HIV services. This commentary offers three reasons why all services should not be integrated in all situations, and even where integrated services are possible, they should sometimes be offered separately. First, family planning clients may not be at greatest risk for STIs, and those at high risk (men and young people) are less likely to seek services at family planning clinics. Secondly, not all family planning services are operationally compatible with STI/HIV services. It is important to specify which services are to be integrated at which service delivery points. Third, the difficulty of diagnosing and testing asymptomatic women or those with vaginal discharge suggests the cost of adding clinical screening for STIs may not be justified by the number of cases detected and treated. In the face of health sector reform, it is important to define what services should be integrated and offered as part of essential services packages.

Francis-Chizororo M, Natshalaga NR. The female condom: acceptability and perception among rural women in Zimbabwe. African Journal of Reproductive Health. 2003;7(3):101-166.
Women attending primary health care centers in Zimbabwe were recruited for this study of the acceptability of the female condom. Qualitative and quantitative methods were used. Prior to the study, few women had used the female condom, but most women liked the method, especially younger women. Focus group discussions found that men and women liked the dual role of disease and pregnancy prevention offered by the female condom. Respondents thought introducing the female condom to married couples could be difficult given the negative stigma attached to condoms. Women did have difficulty inserting the condom and were concerned about lubrication, size, appearance, and how to dispose of it. The cost of the female condom could hinder its use (male condoms are offered free of charge at health centers). There is need for further information and education about use of the female condom.

French, P.P. et al. Use-effectiveness of the female versus male condom in preventing sexually transmitted disease in women. Sexually Transmitted Diseases 30(5):433-439 (May 2003).
This study compared STI rates between women given education and free supplies of either male or female condoms. Women attending a public STI clinic in Philadelphia, Pennsylvania, between May 1, 1995, and April 12, 1996, were randomly assigned to either the male condom (n=587) or female condom (n=855) intervention. The women were given instructions on how to use the condom, supplies of condoms, and were then compared for incidence of STIs over time based on their medical records. The odds ratio for an STI between the male and female condom groups was .75 (95% CI, 0.56-1.01). Incidence rates for an STI among women returning for screening were 6.8 per 100 woman-months of observation in the female condom group and 8.5 in the male condom group. Women in the female condom group appear to be at least as protected from STIs as those in the male condom group. Programs offering both types of condoms may confer an advantage, and the female condom should not be viewed as “second best.”

Germain, A. et al. (editors).Reproductive Tract Infections: Global Impact and Priorities for Women's Reproductive Health. New York: Plenum Press (1992)
This book includes the papers, conclusions, and recommendations of the multidisciplinary meeting on reproductive tract infections held in Bellagio, Italy, from April 29 to May 3, 1991. The book is intended for use as a reference by educators, health policy makers, and women's health activists and is specifically directed to individuals involved in establishing priorities in and implementing health programs. Its chapters are arranged in four parts: overview of RTIs, programmatic issues, actions for consideration, and country cases. It focuses on the risk of RTIs among women and reviews the implications of RTIs for prevention and control programs.

Green, G. et al. Female control of sexuality: illusion or reality? Use of vaginal products in south west Uganda. Social Science and Medicine 52:585-598 (2002).
In this trial, 131 women and 21 men were offered a range of vaginal products (female condom, contraceptive sponge, tablets, foam, and gel) and were asked to select two to use for five weeks. They were also asked to continue to use their favorite product for another three months. They were interviewed up to seven times during the five-month period. The women reported that the major benefit of the methods (other than the female condom) was their ability to be used secretly. Nonetheless, less than 40 percent of the women used a product without their partners knowledge in the first week, and only 22 percent used a product secretly after ten weeks. The women and men preferred these products to the male condom. According to the women, these products were empowering and gave the women greater control over their sexual health, even though in practice their use often required negotiation with a partner. These results indicate that should an effective vaginal microbicide be developed, it will play an important role in reducing STIs and in increasing womens sexual and reproductive health.

Grosskurth, H. et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomized controlled trial. Lancet 346:530-536 (August 26, 1995).
The goal of this randomized study was to evaluate the impact of improved STI case management at the primary health care level on the incidence of HIV infection in rural Tanzania. A total of 11,632 cases of STIs were treated at the study health units. Key components of the STI intervention program included establishing an STI reference clinic and laboratory, training health staff in STI syndromic management, supplying STI drugs, and providing health education about STIs. The results showed a 1.2 percent seroconversion rate in the intervention cohort compared to 1.9 percent in the control cohort over two years of follow-up. The largest impact was seen in women aged 15-24 and men aged 25-34. The authors concluded that the 42 percent reduction in HIV incidence over the two-year study period was most likely due to the shortened average duration of STI infection. This study is the first randomized trial to demonstrate the preventive effect of STI treatment on HIV incidence.

Haberland, N. et al. "Pitfalls and Possibilities: Managing RTIs in Family Planning and General Reproductive Health Services." In: Haberland, N. and Measham, D., eds. Responding to Cairo: Case Studies of Changing Practice in Reproductive Health and Family Planning. New York: Population Council (2002).
Using case studies from Zimbabwe and Vietnam, this chapter summarizes the benefits and inadequacies of integrated RTI and reproductive health services in low-resource settings. These experiences highlight a number of lessons about integration in lower-prevalence settings among lower-risk groups (such as antenatal care clients): (1) RTI management strategies must be based on local prevalence of specific RTIs, observed health-seeking behaviors, and clinical capacity; (2) there is no consensus on strategies to identify and manage chlamydia and gonorrhea among these groups; (3) it is possible to diagnose and treat endogenous infections; (4) it is possible to diagnose and treat trichomoniasis in settings with limited laboratory capacity; (5) there is urgent need for simple, accurate, low-cost diagnostic tools for use in peripheral sites; (6) partner notification is an essential part of RTI management; (7) all women benefit from information about risk as they seek to protect themselves from infection and pregnancy; (8) family planning and reproductive services can incorporate STI prevention activities into their services.

Holmes KK, Levine R, Weaver M. Effectiveness of condoms in preventing sexually transmitted infections. Bulletin of the World Health Organization. 2004;82(6):454-461. Available at:
This review of prospective studies published after June 2000 shows that condom use is associated with statistically significant protection of men and women against chlamydial infection, gonorrhea, herpes simplex virus type 2, and syphilis. Condoms may also protect women against trichomoniasis. Research published after the United States National Institutes of Health review of the scientific evidence on the effectiveness of condoms in preventing STIs provide considerably more evidence of condom effectiveness in reducing the spread of STIs within populations.

Holmes, K. et al., eds. Sexually Transmitted Diseases. 3rd ed. New York: McGraw-Hill (1999).
This is the third edition of a well-regarded text book on STIs. While oriented toward teaching clinicians how to diagnose and treat STIs in developed countries, it includes several chapters highlighting the differences and similarities between developed and less developed countries. These include prevention and treatment of STIs in developing countries; management of STIs in developing countries; laboratory diagnosis of STIs in resource-limited settings; and sexual behavior and behavioral interventions in developing areas.

Jivasak-Apimas, S. et al. Acceptability of the female condom among sex workers in Thailand. Sexually Transmitted Diseases 28(11):648-657 (November 2001).
While female condoms have been shown to protect against some sexually transmitted infections, their acceptability needs to be established in the context in which they will be used, since personal and cultural factors and individual circumstances all affect use. This prospective study assessed the acceptability of female-condom use among female sex workers in Thailand. Of the 148 women (of 276 originally enrolled) who continued through eight weeks of follow-up, two-thirds (68%) were satisfied with the female condom. However, a substantial portion of women also complained of difficulties in insertion (31%), pain while using the female condom (43%), excessive lubricants (56%), itching (22%), and excessive length (41%). Most women found the female condom easier to use with practice. The results are based solely on backup use of the female condom if clients refused use of a male condom. The sex workers in this study said their main reason for using a female condom in the future would be its perceived safety; while the primary reason for not using the method would be clients refusal.

Kaiser Family Foundation. Microbicides: Issue Update. (May 2001). Available at:
This newsletter summarizes the need for microbicides to combat STIs. It explains how potential microbicides work, which products are in development, and whether women in the U.S. are interested in using microbicides. While an effective product may not be available for several years, much depends on research funding and protocols established for testing new products.

Kamali A, Quigley M, Nakiyingi J, et al. Syndromic management of sexually-transmitted infections and behavior change interventions on transmission of HIV-1 in rural Uganda: a community randomised trial. The Lancet. 2003;361:645-652.
This trial assessed the effect of STI treatment and behavioral interventions on the incidence of HIV and other STIs in southwest Uganda. Adults in 18 rural communities were randomly allocated to receive behavioral interventions alone (group A), behavioral and STI interventions (group B), or routine government health services and community development services (group C). The communities were matched in triplets by type of passing road, distance from the district capital, and quality of the local government health facility. Behavioral and STI interventions (group B) were associated with an increase in condom use with the last casual partner, and with substantial reductions in syphilis and gonorrhea. In group A, there was a reduced incidence of HSV2, and in group B there was an increased recognition of STI symptoms. None of these changes had a measurable effect on the incidence of HIV-1 over median follow-up of three to six years. These results are consistent with those found in the Rakai trial, and suggest that characteristics of the study population are probably more important than the type of intervention. Efforts should continue to identify and promote effective interventions against STIs, both for their own effect and for their potential effect on HIV-1.

Kisubi, W., Farmer, F., and Sturgis, R. An African Response to the Challenge of Integrating STD/HIV-AIDS Services Into Family Planning Programs. Pathfinder International (July 1997).
This publication presents several key issues in the integration of STI/HIV services into family planning programs in Africa. Issues discussed include: defining integration and related topics; documenting the process of integration; and identifying and managing appropriate activities for integration based on the level of sophistication, capacity, and available resources of the program or service delivery site and on community needs. It discusses practical considerations for program managers thinking about how they might integrate services. Two case studies of integrating services in Uganda and Kenya are highlighted.

Kleinschmidt I, Maggwa BN, Smit J, et al. Dual protection in sexually active women. South African Medical Journal. 2003;93(11):854-857.
Secondary analysis of data from the South African Demographic and Health Survey (1998) indicate that few women are protected against STIs and unwanted pregnancy. The analysis sought to determine both the prevalence and co-factors associated with the practice of dual protection among this cross-sectional sample of South African women aged 15 to 49. Only 10.5 percent of all sexually active women used a condom at last sex, and 6.3 percent used a condom as well as another contraceptive method. Younger, more educated, more affluent, urban women and women who change partners more frequently were more likely to use a condom. Women’s reasons for not using condoms were more likely to be associated with personal attitudes (of themselves or their partners) than with poor knowledge or lack of access, except for a minority (six percent) of socially disadvantaged women who have difficulty obtaining condoms. Women who have no need or desire to prevent pregnancy are less likely to use condoms. This study highlights the need to promote dual protection with condoms, and indicates the subgroups of women who can benefit from special interventions.

Lande, R. Controlling sexually transmitted diseases. Population Reports L(9) (June 1993) Available at:
This issue reveals the devastating role of STIs worldwide. STIs may lead to pelvic inflammatory disease, lifelong pain, infertility, ectopic pregnancy among women and also have negative effects on children and men. Strategies are presented to reduce the toll of STIs, as well as practical approaches to diagnosing, treating and managing STIs.

MacLachlan, E.W. et al. The feasibility of integrated STI prevalence and behavior surveys in developing countries. Sexually Transmitted Infections 78:187-189.
This study assessed whether it is possible to conduct a national, combined STI prevalence and behavior survey among vulnerable populations. The survey was conducted using cluster sampling among five risk groups at four sites (taxi/bus stations, markets, households, brothels) in Mali. The study included a behavioral questionnaire, urine sample, and finger-stick blood sample. There were high participation rates for all components of the study (84%-100%), although rates were lower for biological samples. The cost of the entire survey was US$154,905. The cost of the biological component added US$30 per participant (including training, laboratory costs, and STI drugs and testing). This study demonstrates an effective methodology for collecting risk behavior and STI/HIV prevalence concurrently, and should be considered by countries expanding STI/HIV surveillance.

Mantell, J.E. et al. Family planning providers’ perspectives on dual protection. Perspectives on Sexual and Reproductive Health 35(2):71-78 (2003).
Semi-structured interviews with 22 healthcare providers at a large family planning/STI agency in New York City in 1998 indicate that STI prevention is seen as an integral part of family planning counseling. Most providers thought condom use along with another effective contraceptive (hormonal contraception) offered dual protection. Few advocated the use of a male or female condom alone. The female condom was seen as a method of last resort for women at high risk and those with no other options. Providers also lacked knowledge of how the female condom works, and how to counsel its use. However, they were interested in learning more. Training is needed to reduce providers’ negative views of the female condom, and to reinforce the need for individualized counseling addressing a client’s specific circumstances.

Marseille, E. et al. Cost-effectiveness of the female condom in preventing HIV and STDs in commercial sex workers in rural South Africa. Social Science and Medicine 52:135-148 (2001).
The health and economic outcome of current levels of male condom use among 1,000 commercial sex workers (averaging 25 partners per year) with an HIV prevalence of 50.3 percent was compared with the impact of providing female condoms to these sex workers. A simulation model was used assuming five years of HIV infectivity, one month of syphilis and gonorrhea infectivity, and female condom use in 12 percent of episodes of vaginal intercourse. In one year, the program would distribute 6,000 female condoms at a cost of US$4,002, and would avert 5.9 cases of HIV, 38 of syphilis, and 33 of gonorrhea. This would result in savings of US$12,090 in averted HIV/AIDS treatment costs, and US$1,074 in averted syphilis and gonorrhea treatment costs for a net savings of US$9,163. The model was used with varying key inputs (lower HIV prevalence, fewer partners per year, non-commercial sex workers, etc.) and the economic savings persisted. The authors conclude that distribution of female condoms to commercial sex workers and other women with casual partners would be cost-effective and save public sector health funds.

Mayaud P, Mabey D. Approaches to the control of sexually transmitted infections in developing countries: old problems and modern challenges. Sexually Transmitted Infections. 2004;80(3):174-182.
STIs represent a huge economic and health burden for developing countries. They contribute to the HIV/AIDS epidemic, and there is evidence that control of STIs can reduce transmission of HIV. Reducing the incidence and prevalence of STIs can be accomplished through primary prevention (information, education, and communication campaigns; condom promotion; use of safe microbicides; and vaccines), screening and case finding among vulnerable groups, comprehensive syndromic case management, targeted interventions for high risk groups, and in some circumstances, periodic mass treatment.

Mindel, A. et al. (editors). Syndromic approach to STD management. Sexually Transmitted Infections 74 (Suppl. 1) (June 1998). (Abstracts of all articles are available through
This issue of Sexually Transmitted Infections includes 25 articles related to the challenges of managing STIs in low resource settings through syndromic protocols. The prevalence of reproductive tract infections, even in "low-risk" populations is highlighted. The difficulty in diagnosing and managing cervical gonococcal and chlamydia infection is a particular area of emphasis; the feasibility of syndromic management of vaginal discharge in high- and low-risk populations, the value of adding risk assessment to syndromic protocols, and other many other issues are discussed. This is an excellent resource for those interested in state-of-the-art information on syndromic management of STI and other issues related to providing STI management in low resource settings, particularly developing country settings.

Morrison CS et al. Hormonal contraceptive use, cervical ectopy, and the acquisition of cervical infections. Sexually Transmitted Diseases. 2004;31(9):561-567.
Women attending two reproductive health centers in Baltimore, MD, United States, were prospectively enrolled in this study to measure the effect of oral contraceptive (OC) and depot-medroxyprogesterone acetate (DMPA) on the acquisition of chlamydia and gonorrhea. Forty-five of 819 women in the study acquired a chlamydial or gonococcal infection during the study. DMPA use, but not OC use, was associated with a three-fold increased risk of acquiring these two cervical infections. These findings reinforce the need to counsel all hormonal contraceptive users who are not in a mutually monogamous relationship about the need to use condoms consistently and correctly.

Morroni C et al. Dual protection against sexually transmitted infections and pregnancy in South Africa. African Journal of Reproductive Health. 2003;7(2):13-19.
This cross-sectional study of primary health care patients in South Africa found the prevalence of dual protection against pregnancy and STIs is low. Of the 929 sexually active women aged 15 to 49, interviewed at 89 primary health care clinics, only 12 percent were protected from pregnancy and STIs at last intercourse. Higher education, being unmarried, and having multiple sexual partners in the last year were predictors of dual method use. Young age, higher education, and awareness of the dual function of condoms were predictors of condom use alone. Given the high prevalence of non-barrier contraceptive use in South Africa (59%), adding a barrier method (male or female condom) to existing contraceptive use may be an important strategy for increasing dual protection. Among younger people, promotion of condom use alone may be an effective way to increase protection.

Moses, S. et al. Response of a sexually transmitted infection epidemic to a treatment and prevention programme in Nairobi, Kenya. Sexually Transmitted Infections 78 (Suppl. 1):i114-i120 (2002).
This article describes the public-sector STI-prevention and treatment program established in 1991 in Nairobi, Kenya. to address the widespread STI epidemic. Health care workers, supervisors and trainers were trained, a supervisory system established, STI drug supply assured, and a referral system was established. Patient education and counseling was strengthened, with an emphasis on condom promotion. Syphilis screening was decentralized to local clinics, and efforts made to improve partner notification. Community-level activities, aimed at high-risk groups, were also established. Between 1992 and 1999 several surveys were conducted to monitor STI and behavior change. The data show that the epidemic has moved from a hyperendemic (Phase II) to a decline phase (phase III). While it is impossible to attribute the decline to program activities, they doubtless had an effect. The article outlines the constraints confronted and overcome, as well as the lessons learned about program implementation. Going beyond Phase III, and making a significant impact on STIs will require expanding activities to the district, provincial, and national levels. This will require substantial political support and commitment, and external support from development assistance agencies.

National Institute of Allergy and Infectious Diseases (NIAID). Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention. July 20, 2001. Available at:
This report summarizes studies on the effectiveness of condoms in protecting against HIV/AIDS and other sexually transmitted infections. The review was conducted by a panel convened by the U.S. National Institutes of Health (NIH) and the U.S. Centers for Disease Control and Prevention (CDC) with the participation of the World Health Organization (WHO). The review concludes that condoms, when used correctly and consistently, are effective in preventing HIV infection in both women and men, and in preventing gonorrhea infection in men. For other STIs, the evidence is less complete. Laboratory studies have shown that male latex condoms are impervious to infectious agents in genital secretions, including the smallest viruses. However, male condoms may be less effective in protecting against STIs that are transmitted through skin-to-skin contact, as the condom may not cover the infected area. More research is needed to address the gaps in current knowledge.

Orroth KK, Korenromp EL, White RG, et al. Higher risk behaviour and rates of sexually transmitted diseases in Mwanza compared to Uganda may help explain HIV prevention trial outcomes. AIDS. 2003;17(18):2653-2660.
This study used data from three trials of the effect of STI interventions on HIV incidence to determine if baseline differences between the study populations could explain the different study outcomes. Data from the Mwanza, Tanzania, and Rakai and Masaka, Uganda studies were reanalyzed to determine if the results could be attributed to differences in demography, sexual risk behavior, and HIV/STI epidemiology. The HIV epidemic was at the mature stage in Rakai and Masaka, and at an earlier stage in Mwanza. Short duration, curable STIs were more prevalent and reported risky sexual behaviors were higher, especially for recent partners, in Mwanza than in Rakai or Masaka. Higher STI prevalences and higher risk sexual behaviors in Mwanza could help explain why STI reductions also reduced HIV incidence in Mwanza, but not in Rakai or Masaka. Theoretically, STI treatment and behavioral interventions would have a larger impact in populations where reductions in risky sexual behaviors have not yet occurred, and where curable STIs are still highly prevalent.

Panos Institute. The Silent Pandemic: Reproductive Tract Infections. Panos Media Briefing No. 21 (December 1996).
This comprehensive paper summarizes reproductive tract infections worldwide. It provides key facts, the costs associated with neglecting RTIs, the relationship between poverty and RTIs, possible solutions, and information about specific RTIs.

PATH (Program for Appropriate Technology in Health). Preventing HIV/AIDS in low-resource settings. Outlook 19(1):1-8 (May 2001). Available at:
This article focuses on selected issues related to preventing HIV/AIDS transmission, including strategies for strengthening women's ability to protect themselves and their infants. Topics include communication for behavior change, voluntary counseling and testing, counseling, contraception, reducing STIs, reaching hard-to-reach populations, reducing mother-to-child transmission, male circumcision, and additional prevention measures (vaccines and microbicides).

Population Council. Reproductive Tract Infections: An Introductory Overview [fact sheet series] (2001). Available at:
These thirteen RTI fact sheets, produced by Population Council staff, present up-to-date information related to RTIs in a clear and accessible manner. They are intended to be informational and are designed for health promoters, program managers, and service providers. Topics include basic information about RTIs; endogenous and iatrogenic infections of the reproductive tract; basic issues, treatment, and management of sexually transmitted infections; relationships between sexually transmitted infections and HIV/AIDS and between human papilloma virus and cervical cancer; and much more. An extensive annotated bibliography is included.

Population Council. Reproductive tract infection. Lessons learned from the field: where do we go from here? Proceedings from Population Council Seminar (February 6-7, 1995). The Robert H. Ebert Program on Critical Issues in Reproductive Health and Population (March 1996).
This publication presents lessons learned from field experience in trying to control RTIs. The topics covered include: an overview of the problem of RTIs; the utility of algorithms and risk screening; and building the coalitions needed to address RTIs.

Robinson, N.J. et al. Proportion of HIV infections attributable to other sexually transmitted diseases in a rural Ugandan population: simulation model estimates. International Journal of Epidemiology 26(1):180-189 (1997).
The goal of this study was to estimate the proportion of HIV infections attributable to STIs in rural Uganda. Using simulation modeling, the researchers analyzed the spread of HIV infection in a cohort study population of about 10,000 in south-west Uganda. Their first scenario assumed that the risk of HIV transmission would increase by a factor of ten during all episodes of ulcerative STIs and by a factor of two during episodes of non-ulcerative STIs. Their second scenario assumed risk factors of 100 and five, respectively. Results from simulation of data from 1980 to 1990 showed that over 90 percent of HIV infections were attributed to STIs and that ulcerative STIs accounted for the majority of these infections. In both simulation scenarios, STIs played a pivotal role in the rapid and extensive spread of HIV infection. With progression of the HIV epidemic, the role of STIs in HIV infection decreased. However, the authors concluded that implementation of STI control programs may help control the spread of HIV.

Roddy, R.E. et al. Effect of nonoxynol-9 gel on urogenital gonorrhea and chlamydial infection. Journal of the American Medical Association 287(9):1117-1122 (March 6, 2002).
This randomized, controlled study in Yaounde, Cameroon, compared use of nonoxynol-9 gel and condom use with condom use alone to prevent male-to-female transmission of gonococcal and chlamydial infection. High-risk women (1,241) having symptoms of or being treated for STIs at 10 community clinics and 10 pharmacies were randomly assigned to each group and followed for six months. The rate ratio of new urogenital infections in the gel/condom group was 1.2 when compared with the condom only group. The rate ratio for gonococcol infections was 1.5 and for chlamydial infections was 1.0 in the gel/condom group compared with the condom-only group. Nonoxynol-9 did not protect against urogenital gonoccocal and chlamydial infections.

Rowley, J. and Berkely, S. "Sexually Transmitted Diseases." In: Murray, J.L. and Lopez, A.D., eds. Health Dimensions of Sex and Reproduction. Boston, Massachusetts: Harvard University Press (1998).
This chapter focuses on the global burden of disease associated with sexually transmitted infections. It includes information on the natural history and epidemiology of STIs, focusing specifically on gonorrhea, chlamydia, and syphilis. The authors provide prevalence information from specific epidemiological surveys of STIs in various regions, and data linking STIs and HIV.

Roy, S. et al. Thermoreversible gel formulations containing sodium lauryl sulfate or n-lauroylsarconsine as potential topical microbicides against sexually transmitted diseases. Antimicrobial Agents and Chemotherapy 45(6):1671-1681 (June 2001).
A study of the microbicidal efficacy of sodium lauryl sufate and n-lauroylsarcosine in cells and in vitro found showed that both were powerful inhibitors of herpes simplex type-2 infection. No infectious virus could be found in the vaginal mucosa of mice after pre-treatment with the gel formulations. The gels did not cause significant genital irritation to the genital mucosa of rabbits. These results suggest that these two gel formulations could be effective and safe topical microbicides for prevention of herpes simplex 2 and possibly other sexually transmitted pathogens.

Sangani P, Rutherford G, Wilkinson D. Population-based interventions for reducing sexually transmitted infections, including HIV infection (Cochrane Review). In: The Cochrane Library, Issue 2. Chichester, UK: John Wiley & Sons, Ltd.; 2004.
This review updates a previous review (see Wilkinson et al., 2003) and includes five population-based, randomized, controlled trials of STI interventions and their effects on the frequency of HIV infection, frequency of STIs, and quality of STI management. The reviewers continue to find limited evidence for STI control as an effective way to prevent HIV infection. While improved STI treatment services can reduce HIV incidence in an emerging HIV epidemic environment where STI treatment services are poor (Mwanza trial), there is no substantial benefit from treating all community members. However, there is evidence that improving STI treatment services can improve the quality of services provided. The Kamali trial shows an increase in condom use, a marker of risk reduction, as a result of behavioral and STI interventions. There is need for community-based randomized controlled trials that test a range of STI control strategies and their effects on health seeking behavior, quality of treatment, and HIV and STI infection in a variety of settings.

Shlay J et al. Comparison of sexually transmitted disease prevalence by reported level of condom use among patients attending an urban sexually transmitted disease clinic. Sexually Transmitted Disease. 2004;31(3):154-160.
This large (126,220) cross-sectional study of female and heterosexual male visits to an urban STI center in Denver, Colorado, USA between 1990 and 2001 found that comparing the prevalence of STIs between condom users and nonusers is confounded by the greater sexual risk in users. Fifty percent more condom users reported new sex partners and 70 percent more reported multiple partners compared to nonusers. To more accurately assess the field effectiveness of condoms, this study measured various levels of use (inconsistent use, consistent use, any use, nonuse). STI infection rates among condom users were significantly lower in consistent than inconsistent users for both men and women for gonorrhea, and chlamydia, and for trichomonas in women, and for genital herpes in men. When all condom users were compared with nonusers, there was limited evidence of protection. While this study was unable to assess the correctness of condom use, which affects effectiveness, it does show that consistent use of condoms provides some protection for men and women against nonviral STIs, and against genital herpes for men.

Talwar, G.P. et al. Polyherbal formulations with wide spectrum antimicrobial activity against reproductive tract infections and sexually transmitted diseases. American Journal of Reproductive Immunology 43(3):144-151 (March 2000).
Although a variety of drugs and antibiotics are available to treat candidiasis and bacterial infections, no one wide-spectrum formula is available for intravaginal use to prevent and treat common disease organisms. This study tested the ability of two polyherbal formulations to inhibit growth of bacteria, candida, and viruses, including those resistant to drugs. Both formulations inhibited the growth in culture of several isolates of N. gonorrhea (including two resistant to penicillin), candida albicans, candida krusei, and candida tropicalis. They also inhibited urinary tract e. coli, and N. gonorrhea. They were virucidal against HIV-1, and prevented vaginal transmission of C. trachomatis in a mouse model. In vivo, the formulations prevented the development of herpes lesions.

Warren, M. and Philpott, A. Expanding safer sex options: introducting the female condom into national programmes. Reproductive Health Matters 11(21):130-139 (2003).
The successful introduction of the female condom in Brazil, Ghana, Zimbabwe, and South Africa is due to several key factors. These programs have focused on training providers and peer educators, face-to-face communication with potential users, an identified target audience, consistent supply, assessment of actual use post initial introduction, and using a mix of public- and private-sector distribution. In addition to these factors, successful introduction depends on the involvement of key decision-makers, program managers, service providers, community leaders, and women’s and youth groups.

Warner L, Newman DR, Austin HD, et al. Condom effectiveness for reducing transmission of gonorrhea and chlamydia: the importance of assessing partner infection status. American Journal of Epidemiology. 2004;159(3):242-251.
Data from a large cross-sectional study of STI/HIV counseling in five United States cities were used to examine the importance of differential exposure to infected partners in determining the effectiveness of latex condoms for prevention of STIs. Among 429 participants with known exposure to gonorrhea or chlamydia, consistent condom use was associated with a significant reduction in prevalence of gonorrhea and chlamydia (30 percent versus 43 percent). The number of unprotected sex acts was significantly associated with infection when exposure was known, but not when exposure was unknown). Among 4,314 participants with unknown exposure, consistent condom use was associated with a lower reduction in gonorrhea and chlamydia (24 percent versus 25 percent). Restricting analysis to known exposure to infected partners reduces confounding in condom effectiveness studies, and is critical to evaluating condom effectiveness for prevention of STIs.

Wilkinson, D. et al. Nonoxynol-9 for preventing vaginal acquisition of HIV infection by women from men (Cochrane Review). In: The Cochrane Library, Issue 2. Oxford: Update Software (2003).
This meta-analysis of the safety and effectiveness of nonoxynol-9 (N-9) in preventing vaginal acquisition of HIV infection by women from men evaluated five trials, four of which were analyzed. The risk of HIV infection was not statistically significantly different among women receiving N-9 (RR 1.12, 95% CI 0.88-1.42; P = 0.4). However, the risk of genital lesions, which do increase the risk of HIV acquisition, was significantly greater among women receiving N-9 (RR 1.18, 95% CI 1.02-1.36; P = 0.02).

Wilkinson, D. et al. Nonoxynol-9 for preventing vaginal acquisition of sexually transmitted infections by women from men (Cochrane Review). In: The Cochrane Library, Issue 2. Oxford: Update Software (2003).
Ten of twelve randomized controlled studies were included in this meta-analysis of the effectiveness of nonoxynol-9 (N-9) on preventing vaginal acquisition of STIs. The risks of gonorrhea (RR 0.91, 95% CI 0.67-1.24), cervical infection (RR 1.02, 0.84-1.22), trichomoniasis (RR 0.84, 0.69-1.02), bacterial vaginosis (RR 0.88, 0.74-1.04), chlamydia (RR 0.88, 0.77-1.01) and candidiasis (RR 0.97, 0.84-1.12) were not statistically different in women receiving N-9 compared with placebo. Genital lesions were more common in N-9 users (RR 1.17, 1.02-1.35). Evidence indicates that N-9 does not protect against STIs, and, because it may increase genital ulceration, N-9 cannot be recommended for STI protection. While most of the studies involved commercial sex workers, multiple sexual partners and sexual acts, and high risk for STIs, the findings may not be the same for women in low-risk situations.

Wilkinson, D., and Rutherford, G. Population-based interventions for reducing sexually transmitted infections, including HIV infection (Cochrane Review). In: The Cochrane Library, Issue 3. Oxford: Update Software (2002).
This review identified four population-based, randomized, controlled trials of STI interventions and their effects on the frequency of HIV infection, frequency of STIs, and quality of STI management. The reviewers found limited evidence for STI control as an effective way to prevent HIV infection. While improved STI treatment services can reduce HIV incidence in an emerging HIV epidemic environment where STI treatment services are poor (Mwanza trial), there is no substantial benefit from treating all community members. However, there is evidence that improving STI treatment services can improve the quality of services provided. There is need for community based randomized controlled trials that test a range of STI control strategies and their effects on health seeking behavior, quality of treatment, and HIV and STI infection in a variety of settings.

World Health Organization (WHO). Entry Points to Antiretroviral Treatment. Geneva: WHO; 2003. WHO/HIV/2003.16. Available in English, French, and Spanish at:
As part of its program to treat three million people living with HIV/AIDS by 2005 (The 3 by 5 Initiative), the World Health Organization advocates including HIV testing and counseling as part of all STI services. This requires scaling-up testing and counseling services, training providers, emphasizing youth-friendly services, and use of simple clinical protocols.

WHO. Global Prevalence and Incidence of Selected Curable Sexually Transmitted Infections: Overview and Estimates. Geneva: WHO (2001). Available at:
This booklet provides basic information about chlamydia, gonorrhea, syphilis, and trichomoniasis. It includes data on global and regional prevalence and incidence, and the effects of infections on certain vulnerable groups, such as pregnant women.

Yimin, C. et al. Use of the female condom among sex workers in China. International Journal of Gynecology and Obstetrics 81:233-239 (2003).
This study of acceptance of the female condom among sex workers in China found that understanding and use of the female condom can be greatly improved through the active promotion of the method by medical workers. Of the 315 participants, 155 were randomly assigned to an intervention group, and 160 were controls. The proportion of sex workers reporting liking the female condom increased from 60 percent pre-intervention to 93.5 percent post-intervention. Those indicating they thought their clients could accept the female condom also increased from 27.1 percent to 92.3 percent.

Zachariah R, Harries AD, Buhendwa L, Spielman MP, Chantulo A, Bakali E. Acceptability and technical problems of the female condom amongst commercial sex workers in a rural district of Malawi. Tropical Doctor. 2003;33(4):220-224.
Eighty-eight sex workers in rural southern Malawi participated in this study to assess the acceptability of the female condom. Ninety-eight percent of the women were satisfied with the female condom, 80 percent preferred it to the male condom, and 92 percent said they were ready to use it routinely. The most common problem was reuse of the device with consecutive clients. The most common complaints were too much lubrication (32%), device too large (16%) and noise during sex (11%).

Zaneveld, L. et al. Properties of a new, long-lasting vaginal delivery system (LASRS) for contraceptive and antimicrobial agents. Journal of Andrology 22(3):481-490 (May/June 2001).
To address the need for improved vaginal formulations that prevent pregnancy and/or transmission of sexually transmitted infections, a new delivery system was developed. This base formulation (Long Acting Sustained Release of Spermicide, LASRS) contains bioadhesive ingredients and was designed to provide long-lasting vaginal retention and minimize vaginal irritation caused by other ingredients (e.g., spermicides). This multi-series study showed the LASRS formed a persistent, bioadhesive layer that was non-irritating in primates. The LASRS with nonoxynol-9 was highly spermicidal even 12 hours after placement. Another cytotoxic spermicide, menfegol, produced the same results as nonoxynol-9. The LASRS suppository is a good vehicle for delivery of active ingredients to the vagina.

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Country-specific studies of prevalence and incidence of RTIs

Behets, F. et al. Sexually transmitted infections and associated socio-demographic and behavioral factors in women seeking primary care suggest Madagascars vulnerability to rapid HIV spread. Journal of Tropical Medicine and International Health 6(3):202-211 (March 2001).
Women seeking care for genital discharge (1,066 women) at a clinic in Antananarivo, Madagascar, were examined and interviewed to identify socio-demographic and behavioral risk factors for STIs. The prevalence of STIs found among sex workers in this group was: bacterial vaginosis (BV), 85 percent; trichomoniasis (TV), 16 percent; cervical infection (CI, from gonorrhea or chlamydia), 49 percent; and syphilis seroreactivity, 16 percent. Among occasional sex workers the prevalences were: BV, 70 percent; TV, 18 percent; CI, 30 percent; and syphilis reactivity, 13 percent. Among general women, the infection rates were: BV, 53 percent; TV, 24 percent; CI, 17 percent; and syphilis reactivity, 4 percent. CI was associated with a symptomatic partner in the last three months, unfaithful partner, joblessness, and being younger than age 25. Syphilis was associated with low schooling, young age at first intercourse, sex work, and more than one partner in the previous three months. These high rates of STIs suggest local vulnerability to the spread of HIV, and show the need for prevention efforts aimed at youth, sex workers, occasional sex workers, sex clients, and men with concurrent sexual partnerships.

Bogaerts, J. et al. Sexually transmitted infections among married women in Dhaka, Bangladesh: unexpected high prevalence of herpes simplex type 2 infection. Sexually Transmitted Infections 77:114-119 (April 2001).
This study documents the prevalence and incidence of reproductive tract infections among women attending a basic healthcare clinic in Dhaka, Bangladesh, and identifies associated risk factors. From 1996 to 1998, 2,335 consecutive women were examined and interviewed. One year after ending the study, a sample was examined for selected RTIs. Overall prevalences for gonorrhea (.5%), chlamydia (1.9%), trichomonas (2%), and syphilis (2.9%) were low in this population. Risk factors for gonorrhea and chlamydia were the husband not living at home or suspected of being unfaithful. The prevalence of herpes simplex virus (HSV-2) was 23 percent.

Claeys, P. et al. Sexually transmitted infections and reproductive health in Azerbaijan. Sexually Transmitted Diseases 28(7):372-378 (July 2001).
Data on STI prevalence in the former Soviet Republic of Azerbaijan is limited. This 1999 study of pregnant women, female gynecology patients, and male STI patients attempted to provide baseline information for the development of national guidelines on the management of STIs. Although limited in scope, the study found that women have poor reproductive and sexual health, and men practice high-risk behaviors. The 407 pregnant women had a mean of 1.47 abortions and 1.4 births. Syphilis was found in 1.7 percent. The 326 gynecology patients had a mean of 2.54 abortions and 2.63 births per woman. Eleven percent reported contraceptive use, and 63 percent had previously had symptoms of an STI. Current STIs found were syphilis (2.2%), chlamydia (3.1%), gonorrhea (2.8%), T. vaginalis (7.1%), candida (33.1%), and bacterial vaginosis (32.5%). Of the 197 male patients, 62 percent had paid for sex, 37 percent had ever used a condom, and 40 percent had previously had symptoms of an STI. Current STI infections in men included syphilis (9.5%), chlamydia (5.9%), gonorrhea (17%), and T. vaginalis (4.4%). The authors conclude that official national STI statistics are underreported, but the new data will help improve overall STI management.

Clift, S. et al. Variations of HIV and STI prevalences within communities neighbouring new goldmines in Tanzania: importance for intervention design. Sexually Transmitted Infections 79:307-312 (2003).
Cross-sectional surveys were conducted to measure the prevalence of HIV and other STIs in communities neighboring new large-scale goldmines in northern Tanzania. Male mine workers (n=207), men (n=202), women (n=205), and female food and recreational facility workers (FRFW, n=206) were randomly selected for interviews and HIV/STI testing. Of these groups, the FRFW workers had the highest prevalence of HIV (42 percent), followed by women (18 percent), men (16 percent), male mine workers (6 percent). Among the FRFW, 24 percent had active syphilis, 9 percent chlamydia, and 4 percent gonorrhea. Half of the FRFW and half of the community men never use condoms. Compensated sex is common among the mineworkers and male community members. Although HIV and STI infection is still low among the mineworkers, high-risk sex is common. Interventions targeting FRFW will be extremely important at preventing infections in this area.

Connolly, C.A. et al. Incidence of sexually transmitted infections among HIV-positive sex workers in KwaZulu-Natal, South Africa. Sexually Transmitted Diseases 29(11):721-724 (November 2002).
This longitudinal study evaluated the incidence of STIs among HIV-positive sex workers at truck stops in KwaZulu-Natal province. Among 472 sex workers screened for participation in another trial, 263 qualified for this study, and 77 were included in the final analysis. These 77 women were followed for a total of 58.1 women years. The incidence rate per 100 women-years was 150 for trachomatis, 66 for gonorrhea, 30 for chlamydia, and 244 for any STI. Despite their participation in a monthly STI diagnosis, counseling and treatment program, the incidence of STIs is high in this group of HIV-positive sex workers.

Detels R, Wu Z, Rotheram J, et al. Sexually transmitted disease prevalence and characteristics of market vendors in eastern China. Sexually Transmitted Diseases. 2003;30(11):803-808.
Prevalence of STIs has been increasing in China, and this study of market vendors in eastern China indicates that rates among subgroups are even higher. Among 1,536 randomly selected market stall vendors, prevalence of any STI was 20.1 percent in those reporting having had sexual intercourse. Chlamydia (9.4 percent) and herpes (9.3 percent) were most common. Among those reporting never having had intercourse, 5.5 percent had an STI, and 4.5 percent had herpes. STIs were more common among females, vendors with low education, and those with multiple partners. Pharmacies are the most frequent source of health care (48.8 percent). These results indicate that targeting only STI clinic patients and individuals reporting multiple partners will exclude a large proportion of people with infection. Broader STI control efforts are needed, including diffusion of less stigmatizing treatment services.

Esquivel, C.A. et al. Prevalence of Chlamydia trachomatis infection in registered female sex workers in northern Mexico. Sexually Transmitted Diseases 30(3):195-198 (March 2003).
Using an enzyme immunoassay, 354 female sex workers (FSW) from northern Mexico were tested for chlamydia trachomatis infection during 1999-2001. Overall prevalence of chlamydia was 12.4 percent in FSW tested from three cities (Durango, Zacatecas, Torreón). Rates of infection were greater among women younger than age 25 and among those with low socioeconomic status. In Durango, chlamydia infection was associated with non-use of condoms, and in Torreón, chlamydia was more frequent in FSW who worked in more than one state. Prevention programs should emphasize condom use, and should pay special attention to younger women and those of low socioeconomic status.

García PJ, Chavez S, Feringa B, et al. Reproductive tract infections in rural women from the highlands, jungle and coastal regions of Peru. Bulletin of the World Health Organization. 2004;82(7):483-492. Available at:
During 1997-1998, researchers visited 18 rural districts in Peru to assess prevalences of RTIs among women members of community-based organizations. Of the 754 participants, 77 percent had symptoms of RTIs and 70 percent had objective evidence of one or more infection. The infections found were bacterial vaginosis (43.7%), trichomoniasis (16.5%), vulvovaginal candidiasis (4.5%), chlamydia (6.8%), gonorrhea (1.2%), syphilis seroposivity (1.7%), cervical HPV infection (4.9%), and genital warts or ulcers (2.8%). The sensitivity and predictive value of the existing Peruvian algorithm for syndromic management of vaginal discharge were low for cervical infection. The results of this study were used to modify the algorithm to recommend treatment of vaginal infections with metronidazole.

Garg, S. et al. Reproductive morbidity in an Indian urban slum: need for health action. Sexually Transmitted Infections 78:68-69 (2002).
This study measured the prevalence of RTIs among married women living in a slum area of New Delhi, India. Of the 380 participants, 332 gave blood samples and 301 had internal examinations. Eighty-eight percent of the women had symptoms of gynecological morbidity. The prevalence of RTIs identified was bacterial vaginosis (41%), chlamydia (29%), candidiasis (19%), trichomoniasis (4%), syphilis (4%), hepatitis B (6%), hepatitis C (2%), HPV 16 (12%), and HPV 18 (3%). In the absence of cost-effective tests for RTIs, health workers in peripheral settings need to be trained to elicit an accurate risk history, symptoms, and use standardized clinical criteria for diagnosis. Routine inclusion of RTI/STI screening in antenatal care and other gynecological clinics, and improved diagnostic tests are needed.

Jansen, H. et al. Geographical variations in the prevalence of HIV and other sexually transmitted infections in rural Tanzania. International Journal of STD & AIDS 14:274-280 (April 2003).
Data from a large, community-randomized trial conducted between 1991 and 1995 in Mwanza, Tanzania were analyzed to compare levels of infection with HIV and other STIs between communities. Two communities are located in Lake Victoria, and eight others on the mainland. The prevalence and incidence of HIV and syphilis were lower on the islands, but this was not true for herpes simplex 2, gonorrhea, chlamydia, male urethritis or antenatal prevalence of trichomonas. Island men were more likely to be circumcised and had fewer sexual partners than mainland men. Island women were less mobile. The lower prevalences of HIV and syphilis in the island communities may be due to geographical isolation, more core-group sexual contact on the mainland, higher levels of male circumcision on the islands, and differences in marital status.

Joyee AG, Thyagarajan SP, Rajendran P, et al. Chlamydia trachomatis genital infection in apparently healthy adult population of Tamil Nadu, India: a population-based study. International Journal of STD & AIDS. 2004;15:51-55.
This population-based study in Tamil Nadu, India assessed the prevalence of genital chlamydial infections in the community. A representative sample was taken from three randomly selected districts, and adults aged 15 to 45 were enrolled and blood and urine samples collected. Prevalence of antibodies to C. trachomatis was 2.4 percent, and the prevalence of genital chlamydial infection was 1.1 percent. Most infections were asymptomatic. This study provides baseline data for tracking chlamydial infection in this population, and suggests a substantial burden of asymptomatic infection in the general population.

Klavs I, Rodrigues LC, Wellings K, et al. Prevalence of genital Chlamydia trachomatis infection in the general population of Slovenia: serious gaps in control. Sexually Transmitted Infections. 2004;80:121-123.
In this stratified sample of 18 to 49 year olds in Slovenia, C. trachomatis infection was diagnosed in 3.0 percent of men and 1.6 percent of women. Prevalence was highest (4.1 percent for men and women) among those aged 18-24 years. This level is higher than in corresponding estimates in Britain (2.7 percent among men and 3.0 percent among women) where reported levels of high-risk behaviors are higher. These results suggest gaps in the diagnosis and treatment of chlamydia in Slovenia, and offer support for the introduction of chlamydia screening.

Leutscher, P. et al. Sexual behavior and sexually transmitted infections in men living in rural Madagascar. Sexually Transmitted Diseases 30(3):262-265 (March 2003).
This cross-sectional study of STIs and sexual behavior among men in two coastal villages and one highland village in Madagascar found young men are at high risk for STIs, including HIV. Data were collected from urogenital morbidity and schistosomiasis studies in 1998. Among the 401 men studied, 45.6 percent reported having multiple partners in the previous three months, and only 6.5 percent had used a condom during previous three months. About 32 percent of all men reported symptoms of urethritis in the previous week, with a higher proportion among those ages 15-19 (40.7%) and those living in the coastal villages (38.9 and 40%). Prevalence of schistosoma hematobium was 31.0 and 55.0 percent in these villages, but none of the men in the highland village were infected. Young men are especially at risk of STIs in the villages studied. Treatment of urogenital schistosomiasis should be included in the syndromic algorithm for STI treatment among those seeking care for urethritis in endemic areas.

Lien, P.T. et al. The prevalence of reproductive tract infections in Hue, Vietnam. Studies in Family Planning 33(3):217-226 (September 2002).
The prevalence of RTIs is moderate among women attending the Hue Maternal and Child Health/Family Planning center according to this study. Of the 600 women in the study, 21 percent had an RTI, including 4.7 percent (28 cases) with an STI. More than half of the women with an RTI had endogenous infections (candidiasis, bacterial vaginosis). Most vaginal infections could be identified through simple, clinic-based diagnostic tests (microscopy). Current clinical practice results in overdiagnosis and overtreatment of RTIS, especially cervical infections. Adaptation of the WHO syndromic flow chart for vaginal discharge based on local epidemiological data could improve the current diagnostic accuracy for vaginal and cervical infections.

Ma, S. et al. Decreasing STD incidence and increasing condom use among Chinese sex workers following a short term intervention: a prospective cohort study. Sexually Transmitted Infections 78:110-114 (2002).
This prospective cohort study of 966 commercial sex workers in Guangzhou, China, evaluated the impact of repeated preventive education and the provision of STI testing and treatment services to female sex workers. At each visit, information was collected on sexual behavior, condom use, and knowledge about HIV transmission and condom use. The women were also given education, and STI diagnosis and treatment at each visit. As only 75 of 966 women returned for more than three visits, the study analyzed trends from intake through the third visit. The proportion of women consistently using condoms increased from 30 to 81 percent; knowledge of HIV transmission increased from 4.3 percent to 98.6 percent, and knowledge of good condom use increased from 23.6 percent to 79.3 percent. The incidence of STIs also decreased from the first follow-up visit to the third: gonorrhea (from 17.5 per 100 person years to 5.1); trichomoniasis (22.4 to 3.0), and chlamydia (65.9 to 16.1). This type of repeated STI education, prevention, and treatment is likely to reduce unprotected sexual behavior and STI incidence among this high risk group of women.

Machungo, F. Syphilis, gonorrhoea and chlamydial infection among women undergoing legal or illegal abortion in Maputo. International Journal of STD & AIDS 13:326-330 (May 2002).
This study compared the prevalence of syphilis, gonorrhea, and chlamydia among women undergoing legal (103 women) and illegal abortions (101 women) in Maputo, Mozambique. Syphilis seropositivity was found in 10.9 percent of women undergoing illegal abortion (IA) and 4.9 percent of women undergoing legal abortion (LA). Gonorrhea exposure in the two groups was similar: 34.7 percent in the IA group and 31.1 percent in the LA group. Chlamydia was also similar in the two groups: 44.4 percent in the IA group and 40.6 in the LA group. STIs are highly prevalent in these two groups and interventions are urgently needed to reduce their prevalence and health consequences.

Maitra, K. et al. Prevalence of self-reported symptoms of reproductive tract infections among recently pregnant women in Uttar Pradesh, India. Journal of Biosocial Science 33:585-601 (2001).
Reproductive tract infections are common among married, recently pregnant women in Uttar Pradesh. This study reviewed data from a population survey of 18, 506 women who had a pregnancy within three years of the interview. Nearly one in four women reported having at least one RTI symptom, mostly vaginal discharge or pain on urination. Less than one-third of women reporting a symptom sought treatment. Logistic regression analyses of sociodemographic characteristics found a woman was more likely to report having a symptom if the last pregnancy did not end in live birth or if she has low economic status. Reporting of symptoms also increased with age and decreased with parity. While this study relied on self-reporting of RTI symptoms, and thus likely underestimates RTI prevalence, it offers a low-cost method for measuring RTI symptoms and for identifying associated sociodemographics. The findings suggest the need for improved RTI screening and treatment in Uttar Pradesh.

Miranda AE, Szwarcwald CL, Peres RL, Page-Shafer K. Prevalence and risk behaviors for chlamydial infection in a population-based study of female adolescents in Brazil. Sexually Transmitted Diseases. 2004;31(9):542-546.
Adolescent girls (aged 15 to 19) were surveyed in this cross-sectional population-based study to measure the prevalence of chlamydia in Vitória, Brazil. Of the 465 adolescents surveyed, 8.9 percent had chlamydia. Among sexually active women, 12.2 percent had chlamydia and 1.9 percent had gonorrhea. Women reporting regular condom use and having condoms at home were significantly less likely to have chlamydia. These findings highlight the need for ongoing STI prevention and treatment, including risk reduction through condom use.

Nessa K, Waris S-A, Sultan A, et al. Epidemiology and etiology of sexually transmitted infection among hotel-based sex workers in Dhaka, Bangladesh. Journal of Clinical Microbiology. 2004;42(2):618-621.
Four hundred hotel-based sex workers (HBSW) in Dhaka, Bangladesh, were enrolled in this study to evaluate prevalences of STIs. Forty of 100 hotels were randomly selected, and all sex workers in each selected hotel were invited to participate. Among the HBSWs, 228 women (57%) were symptomatic and 172 (43%) were asymptomatic. Of the 228 women, 86.8 percent tested positive for at least one RTI or STI: 35.8 percent tested positive for gonorrhea, 43.5 percent positive for chlamydia, 4.3 percent positive for trachomatis, 8.5 percent for syphilis, and 34.5 percent for HSV2. The data indicate high levels of STIs among these HBSWs.

Parish, W.L. et al. Population-based study of chlamydial infection in China: a hidden epidemic. JAMA 289(10):1265-1273 (March 12, 2003).
This study estimates prevalence of chlamydia and gonorrhea infections and identifies risk factors associated with infection. A nationally stratified sample of 3,426 Chinese individuals (1,738 women and 1,688 men) aged 20 to 64 were interviewed between August 1999 and August 2000, completed a computer survey, and provided a urine specimen. Chlamydia infection was 2.6 per 100 women, and 2.1 per 100 men. Prevalence of gonorrhea was .08 per 100 women and .02 per 100 men. These results suggest China is experiencing an epidemic of chlamydia infection, largely hidden because most infections are asymptomatic. Infection transmission appears to lead from commercial sex worker to husband/steady partner to wife/steady partner. Those most at risk are aged 25 to 44. Men who earn a high income, and women linked to them were more likely to be infected. However, more educated men and women were less likely to be infected. Targeted campaigns to reduce STIs among commercial sex workers and increase condom use and AIDS awareness is needed.

Patten, J.H. and Susanti, I. Reproductive health and STDs among clients of a womens health mobile clinic in rural Bali, Indonesia. International Journal of STD & AIDS 12:47-49 (January 2001).
While rural women in Indonesia have been considered "low risk" for sexually transmitted infections (STI), recent studies contradict this assumption. This study utilized a mobile clinic to assess the prevalence of reproductive tract infections (RTI) among 312 women in rural Bali. Overall 55.1 percent had at least one RTI, and 19.2 percent had at least one STI. Results showed candidiasis (5.8%), bacterial vaginosis (37.2%), trichomoniasis (15.1%), gonorrhea (.7%), chlamydia (5.6%), and syphilis (0%). Of those women with a confirmed RTI, about half were asymptomatic. Up to half of the women seen in this study are at direct risk of STI/HIV infection due to confirmed or suspected spousal non-monogamy. There is a clear need for preventive and curative STI services in rural Bali for both men and women. There is urgent need for a rapid, accurate, and affordable test for cervical infection.

Rodriquez AC, Castle PE, Smith JS, et al. A population based study of herpes simplex virus 2 seroprevalence in rural Costa Rica. Sexually Transmitted Infections. 2003;79:460-465.
A random sample of a cohort-based population of 10,049 women in Guanacase, Costa Rica were tested in this study to determine prevalence of herpes simplex virus 2 (HSV2) infection. An age-stratified random sample of 1,100 women were tested using HSV2 ELISA assay. Prevalence of HSV2 was 38.5 percent, and was strongly associated with increasing age among both monogamous women and women with multiple partners. A greater number of lifetime sexual partners was associated with higher seroprevalence, and barrier contraceptive use was negatively associated with prevalence. HSV2 infection is endemic in this population. High prevalence even among monogamous women suggests men play a significant role in transmission. In the absence of an effective vaccine, education to prevent high risk sexual behaviors and promotion of condom use are needed.

Soares, V. et al. Sexually transmitted infections in a female population in rural north-east Brazil: prevalence, morbidity and risk factors. Tropical Medicine and International Health 8(7):595-603 (July 2003).
This cross-sectional survey assessed STIs among rural women living in the Alagoas state of Brazil. Of the target population, 341 women (84 percent) volunteered to participate. At least one STI was diagnosed in 51 percent of the women. These included human papillomavirus (26 percent), bacterial vaginosis (15 percent), trichomoniasis (10 percent), gonorrhea and chlamydia (each 6 percent), and syphilis (3 percent). Being unmarried and age less than 20 years were significant risk factors for having an STI. Despite the self-selection of participants, this study indicates a high level of STI infection among women in Alagoas. There is need to provide STI-related health care and education to women in this area, especially for adolescents.

Sullivan, E.A. et al. Prevalence of sexually transmitted infections among antenatal women in Vanuatu, 1999-2000. Sexually Transmitted Diseases 30(4):362-366 (April 2003).
This cross-sectional survey of 547 pregnant women attending an antenatal hospital clinic in Vila, Vanuatu found high rates of chlamydia and trichomoniasis. Polymerase chain testing (PCR) on tampons found trichomoniasis, 27.5 percent; chlamydia, 21.5 percent; and gonorrhea, 5.9 percent. Rapid plasma reagin testing for syphilis identified 2.4 percent of women infected. No HIV cases were found. Young age and being unmarried were associated with infection. The maternal and perinatal risks associated with trichomoniasis and chlamydia, and the lack of accurate field diagnostics to identify infections make the high prevalences found in this study especially challenging.

Vuylsteke, B. et al. High prevalence of sexually transmitted diseases in a rural area in Mozambique. Genitourinary Medicine 69(6):427-430 (December 1993).
The goal of this cross-sectional study was to assess the extent of STIs in a rural area of Mozambique. Study participants were drawn from a primary health care setting in Vilanculos, Inhambane province, and included 201 pregnant women, 85 female patients and 77 male patients. Laboratory confirmation was performed for the following STIs: gonorrhea, chlamydial infection, active syphilis, trichomoniasis and HIV infection. The study findings revealed that over 50 percent of pregnant women and female patients and 62 percent of male patients presented with one or more of the above STIs. Sixteen percent of pregnant women, 23 percent of female patients and 28 percent of male patients were found to have gonorrhea or chlamydia. Genital ulcer disease was present in 6 percent, 28 percent and 36 percent, of pregnant women, female patients, and male patients, respectively. Active syphilis was present in about 15 percent of all three groups of study subjects. HIV infection was found in only 4 percent of male patients and none of the two female groups. The authors concluded that STIs are a major public health concern and that the high prevalence of STIs in this rural area in Mozambique has the potential for an explosive spread of the HIV/AIDS epidemic.

Walraven, G et al. The burden of reproductive-organ disease in rural women in The Gambia, West Africa. Lancet 357:1161-1167 (April 14, 2001).
Reproductive organ disease has a great impact on womens lives. This study used field workers to administer a questionnaire to 1,348 women in a rural area of The Gambia. In addition, a female gynecologist examined the women and took samples for RTI testing. The women were more likely to report reproductive-organ symptoms to the gynecologist (52.7 percent) than to the field workers (26.5 percent). The most commonly reported problems were menstrual problems, abnormal vaginal discharge, and vaginal itching. Few women had sought treatment for their problems. Seventy percent of women had at least one reproductive-organ disorder: menstrual dysfunction (34.1 percent), reproductive tract infection (47.3 percent), pelvic tenderness (9.8 percent), cervical dysplasia (6.7 percent), masses (15.9 percent), and childbirth-related damage to pelvic structures (46.1 percent). These women have little education and limited access to health care, but their reproductive health needs are great. For most of these women, their lives depend on their reproductive function, but this study shows the majority does not have reproductive health and well-being.

Wilkinson, D. et al. Unrecognized sexually transmitted infections in rural South African women: a hidden epidemic. Bulletin of the World Health Organization 77 (1):1-22 (January 1999).
This article presents estimates of STI prevalence among women in rural South Africa. Using a range of data sources (clinical surveillance data from patients treated in clinics, microbiological studies among women attending antenatal and family planning clinics, and a community survey) from the Hlabisa District, the study found that 24.9 percent of women on any given day were infected with an STI. Of the women investigated, 48 percent were asymptomatic, 50 percent were symptomatic but not seeking care, 1.7 percent were symptomatic and would seek care, and 14 percent were seeking care that day. A significant proportion of STIs remains untreated because women are asymptomatic or are symptomatic and do not seek care. Thus, improving case management will have no effect on STI prevalence. Improving partner treatment, increasing womens awareness of symptoms, and possible mass STI treatment would have a public health impact.

Zachariah, R. et al. Sexually transmitted infections and sexual behavior among commercial sex workers in a rural district of Malawi. International Journal of STD & AIDS 14:185-188 (March 2003).
This study of 1817 commercial sex workers presenting to mobile clinics in Thyolo District, Malawi, found high levels of STIs, and frequent unprotected sex. Twenty-five percent (448/1817) had an STI: 53 percent had abnormal vaginal discharge, 24 percent had pelvic inflammatory disease, and 21 percent had genital ulcer disease. The majority (87%) had sex while symptomatic, and 17 percent did so without using condoms. Unprotected sex was associated with being married, being involved with commercial sex outside a known rest house or bar, having genital ulcer disease, having fewer than two clients per day, alcohol intake, and having had no prior medication for an STI.

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Assessing syndromic management

Behets, F.M.-T., et al. Genital ulcers: etiology, clinical diagnosis, and associated immunodeficiency virus infection in Kingston, Jamaica. Clinical Infectious Diseases 28:1086-1090 (May 1999).
This study determined the causal agents for genital ulcers among STI patients at a large clinic in Kingston, Jamaica. For each patient, providers performed a physical examination, recorded a clinical diagnosis, and collected a specimen for laboratory analysis. The clinical diagnoses did not accurately reflect the laboratory diagnoses, which also had limitations. Of the 304 patients (252 men, 52 women) with genital ulcers, the most common causes identified by laboratory tests were herpes simplex virus (45%), chancroid (18%), and syphilis (7%). Twenty-two percent were HIV-positive. The major clinical diagnoses were chancroid (36%), herpes simplex virus (36%), and syphilis (15%). This study reaffirmed that clinical diagnosis of genital ulcer disease often is inaccurate, and supported the national guidelines used in Jamaica, which stipulate that genital ulcers should be managed syndromically because of the limitations of clinical and local laboratory diagnoses.

Bogaerts, J. et al. Simple algorithms for the management of genital ulcers: evaluation in a primary health care centre in Kigali, Rwanda. Bulletin of the World Health Organization 73(6):761-767 (1995).
The goals of this cross-sectional study were twofold: (1) to assess the proportion of genital herpes, syphilis, and chancroid in patients with and without HIV infection who presented with genital ulcer disease (GUD) and (2) to compare the effectiveness of three simple methods for managing GUD. The 395 study participants were patients with genital ulcers attending a primary health care center in Kigali, Rwanda. The researchers simulated the diagnostic outcome of two simple WHO flowcharts for the management of genital ulcers using both clinical data and the results of a rapid plasma reagin (RPR) test. The results were then compared with the laboratory diagnosis based on culture for genital herpes and Haemophilus ducreyi and serology for syphilis. The results indicated a high prevalence (73%) of HIV infection among the study participants: 67 percent of men and 83 percent of women. However, there was no difference between patients with and without HIV infection in the clinical presentation and etiology of GUD. The proportion of patients with a proven infection of chancroid and/or syphilis that received the correct treatment was 99 percent for the syndromic approach; 82 percent for a hierarchical algorithm including an RPR test ; and 38 percent for a clinical diagnosis. The authors concluded that in settings where laboratory support is not available, a simple syndromic approach is preferable to the clinical approach for the management of genital ulcer and should result in more cases being cured.

Boonstra, E. et al. Syndromic management of sexually transmitted diseases in Botswana’s primary health care: quality of care aspects. Tropical Medicine and International Health 8(7):604-614 (July 2003).
Using participative observations based on a checklist, this study assessed the quality of care of the syndromic management of STIs in Botswana’s primary health care system. Thirty randomly selected primary healthcare facilities in three administrative districts participated in the study. Observations were done by a team of two nurse-midwives and one pharmacy technician on 224 consecutive consultations of patients with STIs (135 females and 89 males). Twenty-one consultations were excluded for lack of an STI checklist. The quality of history taking and physical examinations were acceptable for 25 and 23 percent of women, respectively, and for 54 percent and 57 percent of men. Approximately 65 percent of women and 81 percent of men received appropriate treatment. Advice on partner notification was provided to 66 percent of women and to 86 percent of men. Counseling on condom use was provided to 75 percent of women and 89 percent of men. Lack of a fixed light source was a major constraint in doing vaginal speculum exams. Despite excellent availability of antibiotics and condoms, one-third of women and one-fifth of men did not receive appropriate treatment. There is considerable room for improvement of the quality of medical history and physical examinations, especially of women. Training in clinical exams is needed, along with improved supervision and in-service training.

Bosu, W.K. Syndromic management of sexually transmitted diseases: is it rational or scientific? Tropical Medicine and International Health 4(2):114-119 (February 1999).
Relying on syndromic management for STI care in resource-poor countries is a simple, rational, and effective approach. Clinical diagnosis often is incorrect, and laboratory-confirmed diagnoses are expensive. The syndromic approach is generic and can be adapted to local conditions. Despite being less effective for diagnosing cervical infections, syndromic management generally is simple, rapid, and cost-effective, and it has high cure rates. Although simplistic in design, effective syndromic management requires regular monitoring and evaluation of protocols, including their cost-effectiveness. Clinicians also need regular supervision and training.

Cheluget B, Joesoef MR, Marum LH, et al. Changing patterns in sexually transmitted disease syndromes in Kenya after the introduction of a syndromic management program. Sexually Transmitted Diseases. 2004;31(9):522-525.
Syndromic management of STIs was introduced in Kenya in 1995. Analysis of HIV sentinel surveillance data to track STI syndromes shows that the proportion of patients with specific STI syndromes (genital ulcer disease, urethral and vaginal discharge, and pelvic inflammatory disease) declined from 1994 to 2000, and increased again in 2001. These changes are consistent with the introduction of the STI syndromic management program in 1995, and the termination of free STI medicines in 2001. Whether these changes in patterns of syndromes is due to changes in incidences of diseases or just coincidence can not be determined by this study. Further study is needed to determine causes.

Daly, C. et al. A cost comparison of approaches to sexually transmitted disease treatment in Malawi. Health Policy and Planning 13(1):87-93 (1998).
The goal of this study was to compare the cost-effectiveness of syndromic management to standard national practice for the management of STIs in Malawi. Cost of antibiotic treatment for 144 patients receiving standard care for urethral discharge and genital ulcers was determined using prices from the Malawi government supply catalogue. This cost was compared to the calculated cost of treatment assuming the same patients were managed syndromically according to national guidelines. The results showed that the drug costs of standard treatment and of syndromic management were nearly the same. Yet standard practice resulted in nearly 33 percent of patients receiving ineffective treatment for the likely cause of their STI syndrome and drug wastage accounted for over 50 percent of total observed drug cost. The authors concluded that the adoption of syndromic management in Malawi would result in more effective treatment of STIs at no additional cost.

Desai, V.K. et al. Prevalence of sexually transmitted infections and performance of STI syndromes against aetiological diagnosis, in female sex workers of red light area in Surat, India. Sexually Transmitted Infections 79:111-115 (2003).
The performance of STI syndromic guidelines was evaluated among a cross-sectional group of sex workers in an area of Surat, India. Results from a behavioral questionnaire, clinical examination and specimen testing were analyzed for 118 sex workers. Sex workers reported a mean of five sexual partners per day, and 94.9 percent reported consistent condom use. About half (58.5%) reported no symptoms of STI. According to syndromic diagnosis, 51.7 percent had vaginal discharge, 19.5 percent had pain in lower abdomen, 11.9 percent had enlarged inguinal lymph nodes, and 5.9 percent had genital ulcers. STIs confirmed by laboratory testing included: syphilis (22.7%), gonorrhea (16.9%), chlamydia (8.5%), and trichomoniasis (14.4%). The performance of Indian recommended treatment guidelines for syndromic diagnoses of vaginal discharge and genital ulcer versus laboratory diagnosis was poor. Alternative strategies for the diagnosis and control of STIs among this group of sex workers is needed.

George R, Thomas K, Thyagarajan SP, et al. Genital syndromes and syndromic management of vaginal discharge in a community setting. International Journal of STD & AIDS. 2004;15(6):367-370.
Syndromic treatment of vaginal discharge in a community sample of Tamilnadu, India, would result in the over-treatment of 90 percent of the women with vaginal discharge. Vaginal discharge was found to be a poor indicator of vaginal infections among the 1,157 women participating in this community-based STI prevalence study. Forty-five of 421 women with genital discharge tested positive for disease (gonorrhea, trichomoniasis, chlamydia), and 59 of 663 women without discharge tested positive. Treating all women with vaginal discharge would be a waste of resources. Investing in private- and public-sector laboratory services would improve diagnosis and treatment.

Gisselquist, D. and Potterat, J. Confound it: latent lessons from the Mwanza trial of STD treatment to reduce HIV transmission. International Journal of STD & AIDS 14:179-184 (2003).
In this analysis, the authors propose that factors other than the trial intervention of syndromic management of STIs might have contributed to the 38 percent reduction of HIV observed in Mwanza, Tanzania in 1995. While the trial results have been used to promote syndromic management in the management of STIs, including HIV, confounding factors such as the provision of syringes and benzathine, along with a concurrent safe injection initiative could have impacted transmission of HIV.

Gray, R. et al. Relative risks and population attributable fraction of incident HIV associated with symptoms of sexually transmitted diseases and treatable symptomatic sexually transmitted diseases in Rakai District, Uganda. AIDS 13(15):2113-2123 (1999).
This observational study reviewed data from the randomized trial of STD control for HIV prevention in Rakai, Uganda. It found no link between symptoms of STIs and treatable STIs and the incidence of HIV. The study population has a high HIV prevalence (16%). Most seroconversion appears to occur in the absence of a treatable STI detected by screening and without recognized STI symptoms. Therefore, syndromic management of STIs is unlikely to reduce the incidence of HIV in this high-prevalence population. However, the study confirms that STIs are associated with significant HIV risk at the individual level.

Grosskurth, H. et al. Control of sexually transmitted diseases for HIV-1 prevention: understanding the implications of the Mwanza and Rakai trials. Lancet 355(9219):1981-1987 (June 3, 2000).
Two randomized controlled trials of sexually transmitted infection treatment for the prevention of HIV-1 (the Mwanza and Rakai trials) showed apparent contradictory results. In Mwanza, a decrease in HIV-1 infection in the population was associated with improved STI case management. In Rakai, mass treatment of STIs was not associated with a decrease in HIV-1 infection. The authors of this article point out that these trials tested different interventions using different evaluation methodologies in different HIV-1 epidemic situations, thus the findings may be complementary, not contradictory. The divergent results may be explained by: (1) differences in stages of the HIV-1 epidemic; (2) differences in prevalence of incurable STIs (e.g., genital herpes); (3) relative importance of symptomatic versus asymptomatic STI infections and HIV; and (4) effectiveness of intermittent mass treatment of STIs versus continuously available treatment to control rapid STI reinfection. The authors propose areas of further research including how to improve treatment-seeking behavior of STI patients, determining the role of incurable STI infections on HIV infection, evaluation of intervention strategies, and further trials of STI control and the impact on HIV prevention.

Hawkes, S. et al. Reproductive-tract infections in women in low-income, low-prevalence situations: assessment of syndromic management in Matlab, Bangladesh. Lancet 354:1776-1781 (November 20, 1999).
The goal of this study was to investigate the clinical effectiveness and cost of the syndromic management approach among a group of women with a low prevalence of infection. A total of 465 women seeking care at maternal and child health or family-planning centers with symptoms related to the genital tract agreed to take part in the study. Syndromic diagnoses made by trained health care workers were compared with laboratory diagnosis of infection (gold standard). The costs of treating women by the recommended WHO algorithm and an adapted algorithm incorporating use of a speculum and simple diagnostic tests were then calculated. The study results showed that the prevalence of endogenous infections among 320 women with all laboratory results available was 30 percent. Cervical infections (gonorrhea and chlamydia) were found in only three women. The WHO algorithm had a high sensitivity (100%) but a low specificity (zero for bacterial vaginosis, candida, and trichomoniasis). The speculum-based algorithm had a low sensitivity (between 0% and 59%), but a higher specificity (between 79% and 97%). Cost analysis showed that under the WHO algorithm, all cases of STIs, cervical infections, and endogenous infections were treated at a cost of US$1.22 per woman with symptoms seen, or US$3.61 per true case (any infection) treated. However, 87 percent of the expenditure was "wasted" on over-treatment. The speculum-based algorithm, by contrast, resulted in the treatment of 22 percent of the cases of STIs, none of the women with cervical infections, and 42 percent of those with endogenous infections, at a lower overall cost per woman with symptoms of US$0.38 or US$2.75 per true case treated. Although only 36 percent of expenditure was wasted on over treatment, most STIs (and all cervical infections) were not detected or treated. The authors conclude that the high rate of over-treatment carries both financial and social costs. They also make recommendations for management programs in areas of low STI prevalence and low income.

Hoffman, I. and Vuylsteke, B. STD syndromic management. HIV/AIDS Prevention and Control SYNOPSIS Series, Family Health International, AIDS Control and Prevention Project, Latin America and Caribbean Regional Office (November 1997).
This report is part of the HIV/AIDS Prevention and Control SYNOPSIS Series, compiled by the Latin America and Caribbean Regional Office of the AIDS Control and Prevention (AIDSCAP) Project and Family Health International. The SYNOPSIS Series synthesizes project experiences in 14 countries within the region. This report discusses the importance of syndromic management of STIs in STI/HIV control. It highlights some advantages and limitations of the syndromic approach and presents key issues involved in the design and adaptation of clinical flowcharts for use in resource-poor settings.

Hudson, C.P. Syndromic management for sexually transmitted diseases: back to the drawing board. International Journal of STD & AIDS 10:423-434 (July 1999).
This review article examines two trials: one conducted in