Sexual behavior, sexually transmitted diseases, male circumcision and risk of HIV infection among women in Nairobi, Kenya.

OBJECTIVE: To study risk factors for HIV infection among women in Nairobi, Kenya, as the epidemic moves beyond high-risk groups. DESIGN: A cross-sectional case-control study among women attending two peri-urban family planning clinics. METHODS: A total of 4404 women were enrolled after giving written informed consent. Information on risk factors was obtained by interview using a structured questionnaire. Blood was taken for HIV and syphilis testing, and genital specimens for gonorrhea and trichomoniasis screening. RESULTS: Two hundred and sixteen women (4.9%; 95% confidence interval, 4.3-5.5) were HIV-1-positive. Although risk of HIV was significantly increased among unmarried women and among women with multiple sex partners, most seropositive women were married and reported only a single sex partner in the last year. Women with a history or current evidence of sexually transmitted disease were at significantly increased risk; however, the prevalence of these exposures was low. Women whose husband or usual sex partner was uncircumcised had a threefold increase in risk of HIV, and this risk was present in almost all strata of potential confounding factors. Only 5.2% of women reported ever having used a condom. CONCLUSIONS: These data suggest that, among women who are not in high-risk groups, risk of HIV infection is largely determined by their male partner's behavior and circumcision status. Interventions designed to change male sexual behavior are urgently needed.

The relationship between HIV infection and cervical intraepithelial neoplasia among women attending two family planning clinics in Nairobi, Kenya.

OBJECTIVE: To determine the relationship between HIV-1 infection and cervical intraepithelial neoplasia (IN) among women at relatively low risk for both conditions. DESIGN: A case-control study comparing women with cytological evidence of IN (cases) with those without IN (controls) and HIV-1 serostatus as the principal exposure of interest. METHODS: A total of 4058 women attending two family planning clinics in Nairobi, Kenya between October 1989 and May 1991 were enrolled following HIV pretest counseling and informed consent. Structured interviews by trained nurses and medical students were used to obtain data on social, demographic, contraceptive practice and sexual behavior variables. A Papanicolaou smear specimen for cervical cytology and an endocervical swab for gonorrhea culture were obtained. HIV-1 serostatus was determined by enzyme-linked immunosorbent assay and confirmed by Western blot; syphilis serostatus was determined by the rapid plasma reagin test. RESULTS: Eighty-two of the 4058 (2.02%) women had cytological evidence of IN. We observed a significant positive association between HIV-1 infection and IN that remained after controlling for sexual behavior, contraceptive practices and other potential confounding variables (odds ratio, 2.78; 95% confidence interval 1.32-5.85). clinical symptoms and signs were uncommon among the HIV-1-seropositive women, suggesting that they were still in the early stages of the infection. CONCLUSION: The risk of IN among women even in the early stages of HIV-1 infection is increased.

PIP: Women attending 2 family planning clinics in Nairobi, Kenya, were enrolled in a study of risk factors for HIV infection between October 1989 and May 1991. Data were obtained using a structured questionnaire on social, demographic, medical, and sexual behavior. During pelvic examination, were obtained specimens, for a Papanicolaou (PAP) smear and for sexually transmitted disease (STDs). 4058 women had an interpretable smear (with both squamous and endocervical cells present). 82 of the 4058 (women 2.0% had cytological evidence of cervical intraepithelial neoplasia (CIN): 58 had CIN-I, 23 had CIN 11, and 1 had CIN III. Single women were at a reduced ask for CIN (multivariate odds ratio = OR, 0.25; 95% confidence interval = CI, 0.07-0.86). There was no consistent association between number of pregnancies and CIN, although there was some evidence of a protective effect of later age at first pregnancy (P for linear trend = 0.07 and 0.35 in the crude and multivariate analyses, respectively). Age at first intercourse of at least 19 years compared with an age of 16 years of under was protective against CIN (OR, 0.45; 95% CI, 0.20-0.97). Having more than one lifetime sex partner increased the risk of CIN (OR, 1.60; 95% CI, 0.86-2.99). Positive syphilis serology was associated with a doubling of risk (OR, 2.28; 95% CI, 0.6%-7.63). Oral, intrauterine, or injectable contraception was not significantly associated with CIN. Ten (4.9%) of the 205 HIV-seropositive women had CIN, compared with 72 (1.9%) of the 3853 HIV-seronegative women (OR, 2.69; 95% CI, 1.29-5.49). This positive association remained after controlling for sexual behavior and other risk factors. On clinical examination, enlarged cervical, axillary, or inguinal lymph nodes were detected in 5.1% of the HIV-seropositive women compared with 1.7% of the HIV-seronegative women. CIN was more common among 204 HIV-seropositive women with symptoms or signs consistent with immunodeficiency (weight loss, fever, diarrhea); however, none of these associations reached statistical significance.

Validity of contraceptive histories in a rural community in Kenya.

To determine the validity of self-reported contraceptive histories obtained from rural Kenyan women, we interviewed 122 women participants in a long-term study during which their contraceptive use had been recorded regularly at clinics. Interview information was compared with each woman's clinic record. In all 71 women (58%) reported ever use of oral contraceptives, while 76 (62%) of the clinic records documented ever use. The agreement between the records and interview was reasonable (Kappa = 0.54, P < 0.001). The sensitivity of self-report of use compared to clinic records was 79%, specificity was 76%, positive and negative predictive values were 85% and 69% respectively. Ever use of injectable contraceptives (Depo-Provera) was reported by 78 (63%) women while the records showed use by 80 (65%) women (Kappa = 0.87, P < 0.001). The sensitivity, specificity, positive and negative predictive values were 94%, 93%, 96%, and 89% respectively. For the intrauterine contraceptive device, ever use was reported by 18 (14.8%) women while the records showed 19 (15.6%) (Kappa = 0.90, P < 0.001). The associated sensitivity, specificity, positive and negative predictive values were 90%, 99%, 94% and 98% respectively. The validity of reported duration of use of each method showed a similar pattern to that of the history of ever use. The Spearman's rank correlations for the duration of use calculated from interview compared with the clinic records were for oral contraceptives r = 0.68 (P < 0.001), injectables r = 0.81 (P < 0.001) and intrauterine devices r = 0.82 (P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors for invasive cervical cancer in Kenyan women.

BACKGROUND: Few epidemiological investigations of invasive cervical cancer have been conducted in Sub-Saharan African populations. METHODS: Using information collected as part of the hospital-based World Health Organization (WHO) Collaborative Study of Neoplasia and Steroid Contraceptives, we examined potential risk factors for invasive cervical cancer among Kenyan women. In all 112 women with histologically confirmed invasive cervical cancer diagnosed at the Kenyatta National Hospital, Nairobi, Kenya, between June 1981 and September 1988 and 749 control subjects were included in the present analyses. All women were interviewed regarding their medical and reproductive history, methods of birth control, and history of sexual relationships and sexually transmitted infections. Multiple logistic regression procedures were used to derive maximum likelihood estimates of adjusted odds ratios (OR) and 95% confidence intervals (CI). RESULTS: After adjusting for age, several factors were found to be associated with invasive cervical cancer. These include multiple sexual partners, early age at first sexual intercourse (OR = 1.9 and 2.6 for women reporting first intercourse at age 16-17 years and < 15 years, respectively, compared to women with first intercourse > or = 18 years), history of abnormal vaginal discharge (OR = 13.8, 95% CI: 8.3-23.0), and history of gonorrhoeal infection (OR = 3.2, 95% CI: 1.6-6.2). Low educational attainment and multiparity were also associated with the risk of invasive cervical cancer. Although the Papanicolaou smear has been extensively used as a screening method for cervical cancer in many countries, only three cases and four controls reported ever having a Papanicolaou smear (2.6% cases and 0.5% of controls). CONCLUSIONS: As has been observed in other parts of the world, cervical neoplasia in Kenya appears to be a late consequence of venereally transmitted carcinogenic agents.

Knowledge of AIDS and other sexually transmitted diseases among women attending a family planning clinic in Nairobi, Kenya.

We interviewed 1,716 women attending a family planning clinic in Nairobi between January 1990 and May 1991 about their knowledge of the acquired immunodeficiency syndrome (AIDS) and other sexually transmitted diseases (STDs). When participants in the study were asked to name spontaneously the STDs they knew, more than 90% of the women named gonorrhea and AIDS, and 75.0% named syphilis; 65.4% could name two or more signs of AIDS; and 96.9%, 66.5%, and 58.3% mentioned sexual transmission, transmission via blood transfusion, and perinatal transmission, respectively, as routes of transmission of AIDS. Knowledge of most symptoms and routes of transmission of AIDS, as well as knowledge of gonorrhea and syphilis, was significantly positively associated with level of education. Unmarried women were significantly less likely to know symptoms and routes of transmission of AIDS than were married women. Level of knowledge of gonorrhea and syphilis was significantly positively associated with number of lifetime sexual partners. Although awareness of AIDS was very high, detailed knowledge of signs of AIDS and routes of transmission was deficient, particularly among less educated women. This positive association of detailed AIDS knowledge with level of education suggests a need to design AIDS prevention activities that are more accessible to, and better understood by, women who have little education.

PIP: Between January 15, 1990 and May 6, 1991, in Kenya, family planning workers interviewed 1716 women who attended 2 peri urban family planning clinics in Nairobi to identify predictors of knowledge about AIDS and other sexually transmitted diseases (STDs). 16.3% of the women reported to have or have had an STD. The majority of the women had spontaneously mentioned gonorrhea, syphilis, and AIDS (95%, 75% and 94.2%, respectively). Reference to syphilis increased with education level (65.3% for none, 71.4% for upper primary, 85.8% for upper secondary; p .001). Few women mentioned herpes, chancroid, chlamydia, warts, and trichomoniasis (2% each) and candidiasis (11.7%). 65.4% of the women were able to correctly name at least 2 signs of AIDS. Knowledge of at least 2 signs of AIDS increased steadily with educational level (50.5% for none, 59.6% for lower primary, 71% for lower secondary; p .001) as it did for infection and diarrhea. The most well-known sign was weight loss regardless of education level (87.7%). Essentially everyone knew that AIDS was transmitted sexually (96.9%). Education level was positively associated with knowledge of its transmission perinatally and through a blood transfusion (p .001). Single women were less likely to be familiar with AIDS signs, perinatal transmission of AIDS, and transmission of AIDS by blood transfusions. The more lifetime sexual partners women had the more likely they were to know about gonorrhea and syphilis. These findings demonstrated the important role education plays in AIDS knowledge and the need to design accessible and easily understood AIDS prevention activities for women with limited education.

Pharmacodynamic effects of depot-medroxyprogesterone acetate (DMPA) administered to lactating women on their male infants.

Normal postpartum women, who had a spontaneous vaginal delivery of one full-term male infant, free of congenital abnormalities and other diseases, were recruited for this study. Thirteen women received 150 mg depot-medroxy-progesterone acetate (DMPA), intramuscularly on days 42 + 1 and 126 + 1 postpartum. Infants of nine mothers, who did not receive DMPA, served as controls. Blood samples were collected from treated mothers on days 44, 47, 74, 124, 128, and 130 postpartum for medroxyprogesterone acetate (MPA) measurements. Four-hour urine collections were obtained from all 22 infants in the morning on days 38, 40, 42, 44, 46, 53, 60, 67, 74, 88, 102, 116, 122, 124, 126, 128, 130, and 137. Urinary follicle stimulating hormone (FSH), luteinizing hormone (LH), unconjugated testosterone, and unconjugated cortisol were measured by radioimmunoassay, and serum MPA and urinary MPA metabolites were measured by gas chromatography-mass spectrometry (GC-MS). No MPA metabolites could be detected in the urine of the infants from the DMPA-receiving mothers. Hormonal profiles in the urine samples were not suppressed in comparison with those of the control infants. The present study demonstrates that DMPA, administered to the mother, does not influence the hormonal regulation of the breast-fed normal male infant.

Cervical cancer in Kenya: prospects for early detection at primary level.

OBJECTIVES: To assess the feasibility of cytologic screening services for rural women and to establish the prevalence of abnormal cytology in Kenya. METHOD: Women at four maternal and child health/family planning (MCH/FP) clinics were screened, and some screens were repeated. After Pap staining they were graded in classes I-IV, where abnormal smears referred to classes III and IV. RESULTS: The prevalence of abnormal cytology was 2.9% and 2.6% for the first and second screen, respectively. Enrolled community nurses took adequate smears and were able to diagnose overt lesions of the cervix. Training of technicians in cytologic techniques and setting up of a network of laboratories down to district level was considered feasible. CONCLUSIONS: Cytology services may be extended to rural populations through existing MCH/FP clinics. Enrolled nurses can take adequate cervical smears and diagnose overt cervical lesions, and could be used in a downstaging and screening program extending to rural areas.

Contraceptive use and the risk of HIV infection in Nairobi, Kenya.

OBJECTIVES: To determine: (a) the prevalence of human immunodeficiency virus-1 (HIV-1) infection among women attending family planning clinics in Nairobi; and (b) the associations between contraceptive use and HIV infection. METHODS: History, clinical examination and laboratory tests were used to obtain data from 4404 women attending family planning clinics in Nairobi. We conducted a case-control study comparing HIV seropositive and seronegative women with regard to previous and current use of contraception. RESULTS: The overall prevalence of HIV-1 infection was 4.9% (95% C.I. 4.3-5.5). Previous and current use of oral contraceptives (OC), injectable contraceptives and the intrauterine device were not associated with a significant increase in risk, while current users of condoms had a non-significant reduction in risk. OC use was significantly associated with cervical ectopy, but no significant association was evident between ectopy and HIV infection. CONCLUSION: The finding of no significant association between past or current OC use and risk of HIV infection suggests that any independent association that may exist between OC use and HIV risk is not large.

Focusing on maternal mortality and morbidity.

PIP: The rate of maternal mortality is a measure of the health care available in a society. Maternal mortality rates in most of Africa are estimated at between 3 and 12/1000 births, indicating an inadequate health care system. Morbidity levels are also high. There is a lack of knowledge regarding health care facilities. In addition, antenatal care is not regularly provided. Antenatal clinics should serve as a screen to identify high risk obstetric cases, especiallly those involving cephalopelvic disproportion. The shortage of trained personnel also contributes to the high rate of mortality and morbidity in Africa. The establishment of a medical program in East Africa will remedy this condition somewhat. However, medical personnel will still be providing delivery services for only 25% of the population in 1984. More reliance will have to be made on the traditional birth attendants. Therefore, they should receive proper training.^ieng

Birth interval and pregnancy outcome.

PIP: 615 Kenyan women who had experienced 2407 pregnancies and 1792 birth intervals were interviewed who had delivered at the Kenyatta National Hospital during the months of June and July, 1985. Birth intervals that were 25-36 months long were associated with the most favorable pregnancy outcome. Poor pregnancy outcome was followed by very short birth intervals with more than 75% of the birth intervals being 24 months long or less. When no contraceptives were used 58% of the birth intervals were 24 months long or less compared with only 25.5% when contraceptives were used. Breastfeeding alone is not very effective in prolonging the birth interval since 33.4% of women resumed regular menstruation by 4-6 months when they are still breastfeeding. Only 31% of married women were abstinent by 3 months postpartum and therefore in this group of women abstinence played no role in prolonging the birth interval. It is apparent that the use of effective modern contraceptive methods, good obstetrics and neonatal care and adequate breastfeeding are the key measures that can ensure the optimum birth interval and hence the most favorable pregnancy outcome.^ieng

Review of abortions at Kenyatta National Hospital, Nairobi.

PIP: The case notes of patients admitted with abortions to Kenyatta National Hospital between January 1, 1978, and June 30, 1978, were analyzed. A retrospective study of 1424 patients was undertaken. Attempt was made to determine whether the abortion was spontaneous or had been induced. 16% of the cases were found to be septic and were suspected of having been induced illegally. Septic patients were largely single adolescent girls having a 1st pregnancy. Of the nonseptic patients, 65% were married and 55% were in the 21-30 age group. Mean hospital stay was 39 hours for the nonseptic and 91 hours for the septic group. There occurred an average of 2 maternal mortalities/1000 abortion admissions, due to complications of septic abortion. All this data is tabulated. Prevention of unwanted pregnancies through increased provision of sex education and contraceptive supplies is recommended.^ieng

Knowledge of and attitudes towards sexually transmitted diseases among secondary school students in Fako District Cameroon.

This study examines the level of knowledge, attitude and practice in matters concerning sexually transmitted diseases (STDs) among secondary school students in Fako-District, Cameroon. A substantial proportion of the respondents are sexually active and doing so with multiple sexual partners. Although 70% of respondents claimed they knew about STDs, not more than 16.1% of them could name any one common STD and give its signs or symptoms. Knowledge about prevention and complications of STDs was equally poor. The school teacher was the principal source of information followed by magazines/books. Among the respondents who had had an STD, only 8% had consulted in an STD clinic, 13.6 and 15.4% respectively to a Doctor and in Hospital, 43% received no treatment and another 19% had gone to chemist shops. The implication of these results together with the needs of the students are discussed.

PIP: In Fako district, Cameroon, a self-administered questionnaire was given to 1693 randomly selected students from 10 schools. The findings indicate that although 70.2% knew that disease can be transmitted sexually and 84% were aware that an STDs except AIDS could be cured, only barely 50% in the highest education group could define symptoms. Furthermore, of the 32% having an STD, 43% received no treatment, and 19.2% had gone to a chemist, where untrained medical staff without proper laboratory facilities provided treatment. The reason for this alarming situation is the lack of correct information on STDs, the lack of facilities and staff where adolescents can receive compassion and understanding, and maybe victimization by staff and parents. Since the school teacher was identified as the primary source of information, it is suggested that sex education or family life education be addressed in schools with an emphasis on the nature of infection, transmission, symptoms, and available treatment facilities for STDs.

The effect of low-oestrogen combined pill, progestogen-only pill and medroxyprogesterone acetate on oral glucose tolerance test.

The effect of a low-oestrogen combined pill, progestogen-only pill and medroxyprogesterone acetate on oral glucose tolerance test was studied in 29, 30 and 9 indigenous Kenyan women respectively. Glucose tolerance test was performed before treatment was started and then after 1,3 and 6 months in microgynon users. The mean areas under the glucose curves were also significantly elevated. Significant increase in blood glucose values were noted only at 30 minutes after 6 months of use of the progestogen-only oral contraceptive but the mean blood glucose values were higher than in the control after 1,3 and 6 months of use. However, the mean values of the areas under the glucose curves were significantly elevated after 1,3, and 6 months of use. Medroxyprogesterone acetate users showed significantly lower fasting blood glucose values at 60 and 90 minutes after 1 month of use, after which the blood glucose values returned to the pre-treatment values. The mean values of the glucose curve areas showed no significant change. It is concluded that both microgynon and minipill cause relative impairment of glucose tolerance test as early as after 1 month of use. Medroxyprogesterone acetate does not impair oral glucose tolerance for at least the first 6 months of use. The implications of these findings are discussed.

PIP: Researchers followed 68 women who attended the Family Welfare Clinic at the Kenyatta National Hospital in Nairobi, Kenya to determine if the low estrogen combined oral contraceptive (OC) Microgynon, a progestogen only OC, and Depo-Provera induce changes in the oral glucose test. These women did not take any steroidal contraceptives before entry into the study. Blood glucose levels were significantly higher after 60, 90 and 120 minutes than the control levels for women taking Microgynon. In addition, the mean areas under the glucose curves were substantially elevated after 1, 3, and 6 months above the control (p.002, .005, and .01 respectively). The only significant change in blood glucose levels in women taking the progestogen only OC occurred at 30 minutes after 6 months. Yet the mean areas under the curve were significantly higher than the control after ,1 2, and 3 months (p.005, .05 and .002 respectively). As for Depo-Provera, significantly lowered blood glucose levels only occurred after 1 month at 30, 50, and 90 minutes although no significant changes occurred after 1, 3, and 6 months in the mean areas under the glucose curves. Metabolic change occurred earlier and more often in Microgynon users than progestogen only OC users. This could be due to the progestogen levonorgestrel which has been shown to interrupt glucose metabolism. These changes could possible adversely effect women who are predisposed to developing diabetes, since 1 woman did develop a diabetic curve after 1 month of using Microgynon. Nevertheless no pattern towards abnormal glucose tolerance existed. Standard deviations of areas under the curves indicated that the number of women who develop glucose intolerance may increase with duration of use.

Changes in plasma HDL-cholesterol in women using oral contraceptives in Kenya.

PIP: 125 black Kenyan women attending the Kenyatta National Family Welfare Clinic were randomly allocated to combined and fixed dose oral contraceptives (Eugynon: 500 mcg dl-norgestrel + 50 mcg ethinyl estradiol or Microgynon: 150 mcg levonorgestel + 30 mcg ethinyl estradiol). They were between 18-33 years of age with a mean of 25 +or- 7 years. The mean parity of this group was 3 and they had a mean education standard of 8 years. Fasting blood sampled were taken on recruitment (control cycle) and thereafter once for cycles 1, 3, 6, 9, and 12 during OC use. HDL-cholesterol was estimated in the sear. The 2 OCs elicited a significant decrease in levels of HDL-cholesterol (p0.01).^ieng

A second look into the problem of primary infertility in Kenya.

PIP: Laparoscopic investigation of primary infertility was performed in 104 women at Kenyatta National Hospital in Nairobi. Time of admission was during the 2nd half of the cycle in order to determine whether ovulation had occurred. The endometrial curettings were divided into 2: 1 was sent for histology and the other for culture and guinea pig innoculation for tuberculosis. Before laparoscopy, an effort was made to study the husband. Criteria for normality were either satisfactory seminal analysis or presence of children by another woman, the last born being younger than the duration of infertility. 24% had a history of disorders of menstruation. Only about 66% of the husbands were investigated, and abnormality was detected in 5%. The total patency rate was 22.6% with half of these having only 1 patent tube. Of the cases with blocked tubes (73.1%), nearly 25% had tuboovarian masses as a complication, and this excludes the possibility of surgical treatment. In the 26 cases with 1 or both tubes patent, the 2 most important factors were disorders of menstruation and anovulation on the 1 hand and faulty or uninvestigated husbands on the other. These 2 factors explained the cause of infertility in about 50%. In selecting cases that might benefit from tubal surgery, criteria were minimal involvement of the tubes with no masses, few peritubal adhesions causing kinking of the tubes, and fimbrial occlusion as demonstrated by the dye swelling up the tube. The finding of 76% tubal occlusion rate far exceeded the figure of 56% given by Chatfield, Suter, Bremner, Edwards, and McAdam, indicating that the problem is greater than previously thought. In only 25% of the cases could one help either through reassurance or treatment of disorders of menstruation and anovulation. The scope of surgical repair of blocked tubes is limited to a possible 12%. It appears necessary to reconsider the priorities at overtaxed clinics and hospitals. Possibly the best service that can be offered to patients is the treatment of disorders of menstruation. Due to the fact that there was evidence of past pelvic inflammatory disease in over 80% of all cases, the importance of gonorrhea cannot be underestimated.^ieng