The Bali STD/AIDS study: association between vaginal hygiene practices and STDs among sex workers.
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OBJECTIVES: To assess the association between genital cleansing practices and the prevalence of sexually transmitted diseases and of sexual health knowledge among female sex workers in Bali, Indonesia. METHODS: Low priced commercial sex workers (CSWs) participated in the Bali STD/AIDS Study, a 3 year educational project evaluating the effect of education on the subsequent use of condoms and the prevalence of STDs and AIDS. Structured interviews, genital evaluation, laboratory evaluation for STDs, and treatment were performed. Vaginal cleansing characteristics including frequency, type, and reasons for use, were evaluated. Associations between these characteristics and the presence of bacterial and viral genital infections were assessed. RESULTS: Of 625 female sex workers evaluated between May and July 1998, 99.1% used substances, such as soap and toothpaste, to clean the vagina at least daily, with 69.3% performing this after each intercourse. The women using such cleansers after each client did not differ from those using them once or less daily in education, AIDS and condom use knowledge, time working as a CSW, or number of clients in the previous day. However, they were younger than those using vaginal cleansers daily or less, and reported lower condom usage in the past week. Several genital symptoms, such as discoloured discharge and odour, were reported less by women with the highest frequency of vaginal cleanser use. Prevalence of genital infections in this population of women was substantial, with bacterial infections more prevalent than viral infections. Infections were not associated with the type of cleanser used, using a genital cleanser on the day of examination, or using a cleanser after each client versus daily or less, except for candida colonisation, which was more prevalent in women cleansing after each client (OR=1.87, 95% CI 1.21, 2.90). However, symptomatic candida vulvovaginitis (positive culture plus presence of symptoms) was not associated with the prevalence of genital cleansing. Women using genital cleansing in part for "infection avoidance" (39.7%) were more likely to have heard of STDs and AIDS, but were less knowledgeable about these infections, compared with women not citing this reason for genital cleansing. CONCLUSION: Commercial sex workers in low priced brothels in Bali have a high rate of genital infections, with lower rates of viral compared with bacterial infections. Genital cleansers, on a daily or after each intercourse schedule, are used routinely. Although genital cleansing after each intercourse was associated with fewer genital symptoms, the prevalence of STDs did not differ significantly based on this frequency, and the women's knowledge of STDs and AIDS was less than that of women cleansing less often. The effect of genital cleansing in general on STD and AIDS prevalence could not be assessed in this population owing to the lack of a non-cleansing cohort. Further study to elucidate the effect of vaginal cleansing practices on STD prevalence and resistance is needed. (+info)
Late seroconversion in HIV-resistant Nairobi prostitutes despite pre-existing HIV-specific CD8+ responses.
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Resistance to HIV infection in a small group of Kenyan sex workers is associated with CD8+-lymphocyte responses to HIV cytotoxic T-lymphocyte (CTL) epitopes. Eleven prostitutes meeting criteria for HIV resistance seroconverted between 1996 and 1999. The occurrence and specificity of preexisting HIV-1 epitope-specific responses were examined using the IFN-gamma enzyme-linked immunospot assay, and any epitopes recognized were cloned and sequenced from the infecting viral isolate. Immunologic and behavioral variables were compared between late seroconverters and persistently uninfected sex worker controls. HIV-1 CTL epitope responses were present in four of six cases, 5-18 months before seroconversion, and their presence was confirmed by bulk CTL culture. A possible viral escape mutation was found in one of six epitopes. The key epidemiologic correlate of late seroconversion was a reduction in sex work over the preceding year. In persistently uninfected controls, a break from sex work was associated with a loss of HIV-specific CD8+ responses. Late seroconversion may occur in HIV-1-resistant sex workers despite preceding HIV-specific CD8+ responses. Seroconversion generally occurs in the absence of detectable CTL escape mutations and may relate to the waning of HIV-specific CD8+ responses due to reduced antigenic exposure. (+info)
Prevalence of human papillomavirus, Chlamydia trachomatis, and Neisseria gonorrhoeae in commercial sex workers in Japan.
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OBJECTIVE: We used the hybrid capture assays to investigate the prevalence of human papillomavirus (HPV), Chlamydia trachomatis and Neisseria gonorrhoeae among commercial sex workers in Tokyo. METHODS: Five hundred forty-six consecutive commercial sex workers (CSW) who visited an STD clinic for STD checkup in 1998 and 1999 were studied. A control group consisted of 233 consecutive women who visited a general gynecological clinic for annual checkup. A cervical sample was obtained for hybrid capture assays for HPV-A (low-oncogenic-risk types), HPV-B (intermediate- and high-oncogenic-risk types), C. trachomatis, and N. gonorrhoeae. Fisher's exact test was used for statistical analyses. RESULTS: The positive rate for HPV-B among the CSW was 48.4%, significantly higher than the 6.0% among the control subjects. The positive rates for HPV-A, C. trachomatis, and N. gonorrhoeae were also significantly higher among the CSW than among the control subjects. Among the microorganisms tested, the positive rate for HPV-B was the highest in both the STD and control groups. CONCLUSIONS: The high prevalence of HPV, C. trachomatis, and N. gonorrhoeae infection in CSW poses a risk of further transmission of STD to the general public, suggesting the need for further education and screening for CSW and the general public. We found high- and intermediate-oncogenic-type HPV to be the most prevalent infection among both CSW and control subjects. Screening for HPV may be necessary in STD and general clinics to predict the risk of cervical malignancy. Hybrid capture assays, which permit simultaneous detection of HPV and other STD with high sensitivity, may be a useful diagnostic method. (+info)
STI prevention and the male sex industry in London: evaluating a pilot peer education programme.
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OBJECTIVE: To evaluate the effectiveness of a pilot peer education STI prevention programme with male sex workers. DESIGN: A process and outcome evaluation of the pilot programme undertaken in three London male escort agencies, using a quasi-experimental design. SUBJECTS: Workers in three London escort agencies, including 88 who completed a questionnaire, five peer educators, and a further 16 men (including management) working in two of these agencies. METHODS: A peer education STI prevention programme run by the Working Men Project (WMP), a specialist sexual health service for male sex workers, was piloted in two London escort agencies. Five male sex workers participated in a 2 day peer education training programme. They then returned to their respective agencies to disseminate information and condoms, in an attempt to influence norms of behaviour. An outcome evaluation aimed to assess changes in STI related knowledge, high risk sexual behaviour, and attendance at a sexual health service. A pre-intervention questionnaire assessing variables such as STI related knowledge, sexual behaviour, and demographic information was administered in both agency A and agency B and a third agency, C, which acted as a control. Ten weeks after the peer educators returned to their agencies, the same questionnaire was administered in the same agencies. Peer educator referrals to the WMP were also recorded over this time period. The process evaluation involved interviews and focus groups with peer educators, and the completion of diaries about their experiences in the role. A further 16 men working in the agencies (including managers and an owner) were interviewed about their experience of the programme. Participant observation was also undertaken through regular outreach work to the agencies. RESULTS: 57 men completed the questionnaire at time 1 and 44 at time 2. Unfortunately, only 13 of these were matched, precluding any meaningful analysis of change in STI related knowledge and sexual behaviour. The questionnaire provided a profile of the men working in the agencies. Of the 88 men who completed the questionnaire at least once, the majority were homosexual, and in their late teens/early 20s. Most were of a "white" ethnic group, though there was some range within these categories. Most preferred to speak English and education levels were high. Relative STI knowledge revealed a high understanding of HIV and hepatitis B, moderate understanding of gonorrhoea, syphilis, genital warts and herpes, and little knowledge of non-specific urethritis (NSU) or chlamydia. Sexual behaviour suggested a highly sexually active population with both male and female paying and non-paying partners. Condom use was highest for paying partners, particularly for anal sex. Condom use for oral sex with all partners was less consistent, and condom use for all types of sex with regular partners was lower than with other partners. The small number of men engaging in vaginal sex with paying and regular partners were less likely to use condoms. 26 new patients registered at the WMP as a result of peer educator referrals, representing 65% of all new contacts over the study period. The process evaluation revealed that while the training programme was considered adequate and while peer educators felt the programme and their roles to be a success, their experience of the role was difficult. The role of management support was crucial in supporting the programme. The assumption that "peers" are particularly effective educators was not borne out by the results. While peers were considered suitable to discuss some aspects of the industry, many preferred to consult "professionals" about health related matters. The concept of "peers" was problematic with most of the men drawing "peers" from subgroups within the agencies. Other constraints on behaviour such as a lack of power, particularly with regard to a lack of management support, or poverty, had a substantial impact on behaviour which were not influenced by the peer educators. CONCLUSIONS: The study illustrated the difficulties of utilising quasi-experimental evaluation methodology with this client group. It also demonstrated the limitations of peer education based on information provision health education models which focus on individual behaviour change. Suggestions are given for future interventions. (+info)
The association between abuse in childhood and STD/HIV risk behaviours in female genitourinary (GU) clinic attendees.
(45/850)
OBJECTIVES: To compare and contrast women with a history of child abuse with those who have no history of child abuse on STI/HIV risk behaviours and safer sex beliefs in an inner city UK sample. DESIGN: Cross sectional sample survey. METHODS: Routine female clinic attendees were invited to complete an anonymous self report questionnaire which included background information, sexual and drug risk behaviour, self reported sexually transmitted infections (STIs), psychological distress (Hospital and Anxiety Depression Scale; HADS), Sexual Risk Cognitions Questionnaire (SRCQ), and history of child sexual, physical, and emotional abuse. RESULTS: 137 (45%) of 303 women reported a history of child abuse; all three forms of child abuse--sexual (26%), physical (20%), and emotional (27%) abuse--overlapped. The majority of women reported one sexual partner in the past month, and the majority did not use condoms. Women reporting a history of child abuse were more likely to have had previous STIs (p = 0.007) and to have had more than one STI (p = 0.04) compared with women who had not experienced child abuse. Injecting drug use and commercial sex work were of low prevalence across the whole sample and no group differences were found. Women reporting a history of child abuse had higher HADS anxiety (p = 0.03) compared with women with no history of child abuse. Confidence in using condoms with a sexual partner was not related to child abuse. Women with a history of child abuse reported significantly higher frequency of thoughts reflecting anticipated negative reactions from partners to suggesting condom use (p = 0.02) and judging a partner's risk by their appearance (p = 0.05) compared with women with no history of child abuse. CONCLUSIONS: Comparable rates of child sexual abuse with US studies were found in this UK inner city population of women attending sexual health services. Women who had experienced child abuse were more likely to report ever having had an STI and having had more than one STI. Complex psychological and social factors contribute to difficulties for women in negotiating safer sex including emotional distress, abuse histories, and anticipating a negative reaction from partners. Multifaceted prevention models are needed. (+info)
Assessment of risk for pelvic inflammatory disease in an urban sexual health population.
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OBJECTIVES: To determine the sexual and demographic risk factors for the acquisition of presumptive pelvic inflammatory disease (PID). METHODS: A retrospective, case-control study in women, who attended the Sydney Sexual Health Centre (SSHC), between April 1991 and December 1997. Logistic regression analysis was used to adjust for confounding variables. RESULTS: 741 women with PID and an equal number of controls were included. Cases were significantly younger than controls (p < 0.001). 42% of cases were born in north or South East Asia, compared with 12% of the controls (p < 0.001). The adjusted odds ratio for being born in north or South East Asia was 2.8 (95% CI 1.70-4.46), for not speaking English at home was 1.6 (95% CI 1.02-2.55), for having had previous PID was 5.9 (95% CI 3.59-9.73), and for being employed in the commercial sex industry and being born in north or South East Asia was 2.8 (95% CI 1.22-6.22). Women aged 15-19 were at considerable risk of developing PID (OR 5.3 (95% CI 2.76-10.11)). Women with previous human papillomavirus infection were significantly less likely to develop PID (OR 0.6 (95% CI 0.42-0.79)). The use of IUCDs (OR 4.5 (95% CI 2.14-9.39)), condoms (OR 1.4 (95% CI 1.03-1.87)), and not using contraception (OR 1.8 (95% CI 1.20-2.76)) was each associated with an increased risk. CONCLUSIONS: Several measures may help to reduce the burden of PID. Women should be encouraged to delay the onset of sexual activity and IUCDs should not be used in young women. Sexual health services for women whose home language is not English, and for commercial sex workers born in north or South East Asia should be improved. (+info)
Validation of a modified commercial enzyme-linked immunoassay for detection of human immunodeficiency virus type 1 immunoglobulin G antibodies in saliva.
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This study was performed to evaluate the performance of a saliva collection device (OmniSal) and an enzyme-linked immunoassay (EIA) designed for use on serum samples (Detect HIV1/2) to detect human immunodeficiency virus type 1 (HIV-1) antibodies in the saliva of high-risk women in Mombasa, Kenya. The results of the saliva assay were compared to a "gold standard" of a double-EIA testing algorithm performed on serum. Individuals were considered HIV-1 seropositive if their serum tested positive for antibodies to HIV-1 by two different EIAs. The commercial serum-based EIA was modified to test the saliva samples by altering the dilution and lowering the cutoff point of the assay. Using the saliva sample, the EIA correctly identified 102 of the 103 seropositive individuals, yielding a sensitivity of 99% (95% confidence interval [CI], 94 to 100%), and 96 of the 96 seronegative individuals, yielding a specificity of 100% (95% CI, 95 to 100%). In this high-risk population, the positive predictive value of the assay was 100% and the negative predictive value was 99%. We conclude that HIV-1 antibody testing of saliva samples collected with this device and tested by this EIA is of sufficient sensitivity and specificity to make this protocol useful in epidemiological studies. (+info)
Treatment failure with the use of ciprofloxacin for gonorrhea correlates with the prevalence of fluoroquinolone-resistant Neisseria gonorrhoeae strains in Bangladesh.
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Although ciprofloxacin is one of the recommended drugs of choice for the treatment of gonorrhea, in vitro resistance to this drug has been observed in surveillance studies and case reports from many parts of the world, including Bangladesh. However, to our knowledge, there have been no prospective studies of the correlation between in vitro response to the drug and treatment outcome. Therefore, a prospective study of 217 female sex workers in Dhaka, Bangladesh, was conducted to examine the correlation between the in vitro response of Neisseria gonorrhoeae and the outcome of ciprofloxacin treatment. Overall, 37.8% of the gonococcal isolates recovered from female sex workers were resistant to ciprofloxacin, and there was a good correlation between in vitro resistance and treatment failure. These findings suggest that in vitro resistance to ciprofloxacin is predictive of clinical treatment failure in patients with gonorrhea. (+info)