RESUMO
We conducted a sexually transmitted disease (STD) prevalence survey of 1867 female sex workers in Surabaya, Indonesia, some of whom reported participation in a routine penicillin prophylaxis programme. In Surabaya, 34% of female sex workers had received a prophylactic penicillin injection programme from the government within 28 days. Sex workers who had received routine prophylaxis injection were more likely to be less educated, to work in brothel complexes, and to have more customers per week than other sex workers. The prevalence rates of syphilis, gonorrhoea, chlamydia, and trichomoniasis were higher among sex workers who received the routine penicillin treatment than among those who had not received antibiotic treatment in the last 28 days. However, after adjustment for age, education, fee per sex act, number of customers, and condom use in the previous 7 days, only trichomoniasis was still significantly different (adjusted odds ratio of 3.2). High-risk women were more likely to participate in the routine penicillin prophylaxis programme. The lack of a demonstrable individual-level protection from this prophylaxis treatment programme in this cross-sectional study appears due to differential uptake of penicillin prophylaxis by women at higher presumptive risk for STD. Randomized clinical trials and mathematical modelling, together with observational data such as presented here, all can contribute to optimal understanding of a complex intervention like mass chemoprophylaxis for STD among female sex workers.
PIP: In Surabaya, Indonesia, routine prophylaxis injection with long-acting penicillin to prevent syphilis has been conducted among female prostitutes since 1957, with the goal of severing the syphilis transmission chain by maintaining a treponemicidal level of penicillin of greater than 0.03 mg/ml of blood in the target population. The program currently provides an intramuscular injection of 1.2 million units of benzathine penicillin once every 2 weeks. Based upon sexually transmitted disease (STD) survey data for 1867 female prostitutes in the city, findings are presented from a study comparing the risk profiles of women who participate in the prophylaxis program with women who do not. 635 (34%) of the prostitutes reported having received a prophylactic penicillin injection from the program within the 28 days preceding the survey. Women who had received an injection were more likely to be less educated, to work in brothel complexes, and to have more customers per week than the other prostitutes. Prevalence rates of syphilis, gonorrhea, chlamydia, and trichomoniasis were higher among prostitutes who received the routine penicillin treatment than among those who had not received antibiotic treatment in the past 28 days. However, after adjusting for age, education, fee per sex act, number of customers, and condom use during the preceding 7 days, only trichomoniasis remained significantly different. High-risk women were more likely to participate in the routine penicillin prophylaxis program. The lack of any demonstrable individual-level protection from this prophylaxis treatment program seems due to the differential uptake of penicillin prophylaxis by women at higher presumptive risk for STD.
Assuntos
Penicilinas/uso terapêutico , Trabalho Sexual , Infecções Sexualmente Transmissíveis/prevenção & controle , Adulto , Infecções por Chlamydia/prevenção & controle , Feminino , Gonorreia/prevenção & controle , Humanos , Indonésia , Fatores de Risco , Sífilis/prevenção & controle , Tricomoníase/prevenção & controleRESUMO
This paper outlines three important issues in the clinical management of sexually transmitted diseases (STDs) in Papua New Guinea which have, until now, gone unrecognized or been neglected. Suggestions for possible solutions are made. The high prevalence of both chlamydial and trichomonal infections in women cannot be ignored. Both of these infections have been shown to increase the transmission of HIV. The current algorithm for the treatment of vaginal discharges does not include treatment for trichomonal infection in the first instance, yet trichomoniasis has been shown to be the most common STD in community studies both here and elsewhere. Trichomoniasis is usually asymptomatic in men, but still increases the risk of HIV transmission; furthermore, it causes illness in their female partners and thus needs to be treated. The current recommended regimens for the treatment of gonococcal and chlamydial infection are complex due to the number of drugs recommended for gonorrhoea to combat the problem of drug resistance, and the length of therapy for chlamydia. Compliance with such a regimen is likely to be poor, particularly in asymptomatic partners. We need to consider the relative advantages provided by a drug which could be given as a single oral dose for chlamydia, and perhaps for both infections. Azithromycin is one possibility, as it has been shown to be effective for chlamydial infection in numerous studies, and has been found satisfactory for gonorrhoea where local isolates were susceptible. Testing of a small number of isolates from Papua New Guinea has shown that azithromycin may be suitable for use here, but further susceptibility testing needs to be performed. Utilization of services for STDs, particularly by women, is extremely low. This is due to a combination of factors involving limited knowledge of symptomatology and its significance, the asymptomatic nature of many infections, the structure of the services, health worker behaviour, and social attitudes. To address these issues we must make modifications to STD service provision, as well as provide widespread information about the potentially serious consequences of contracting STDs, including both infertility and AIDS. Possible modifications to the services are discussed, and include making routine screening available for women through currently existing services such as family planning and antenatal clinics and considering the possibility of establishing Women's Health Clinics which would provide all primary reproductive health services in an integrated manner.
PIP: This paper summarizes three relevant issues in the clinical management of STDs in Papua New Guinea which have gone unrecognized or been neglected until now. First, the issue of chlamydial and trichomonal infections, which have been shown to increase HIV transmission, is discussed. Although trichomonal infections generally display less pathology than chlamydial infections, they are nonetheless a serious problem. Both types of infections are also more prevalent in Asaro Valley as compared with gonorrhoea and syphilis. The second discussion focuses on the treatment regimen for gonococcal and chlamydial infections. The current treatment, which involves the intake of different tablets and extends for a week, seems to be unappealing and unrealistic for most patients. Thus, a more cost-effective drug has been introduced: azithromycin, which has been proven effective against chlamydial infection and has also been found satisfactory for gonorrhea treatment where local isolates were susceptible. The final topic is that of the barriers to the use of STD treatment services. This study revealed that the low utilization of these services, particularly by women, is due to 1) the limited knowledge of symptomatology and its significance, 2) to the asymptomatic nature of some infections, 3) to factors concerning the structure of services, 4) to health worker behavior, and 5) to social attitudes. Additionally, potential modifications to the existing services are discussed, including the possibility of establishing women's health clinics, which would provide all primary reproductive health services in an integrated manner.