Risk assessment and other screening options for gonorrhoea and chlamydial infections in women attending rural Tanzanian antenatal clinics.

Sexually transmitted diseases (STDs) are a major cause of morbidity and mortality in developing countries and may play a key role in enhancing the heterosexual transmission of human immunodeficiency virus (HIV). Treatment of STDs is one of the most cost-effective of all health interventions in developing countries; however, STDs among women in rural populations have received little attention. In this study, we report that prevalences of STDs among 964 women attending antenatal clinics in a rural area of the United Republic of Tanzania. A total of 378 (39%) of these women were infected with at least one STD pathogen, 97 (10%) had syphilis, and 81 (8%) has Neisseria gonorrhoeae (NG) and/or Chlamydia trachomatis (CT) infection. The recommended syndromic approach to screening for NG/CT infection, based on reported genital symptoms, had a low sensitivity (43%) and failed to discriminate between infected and uninfected women. A risk score approach that we developed, based on sociodemographic and other factors associated with NG/CT infection, had a higher sensitivity and lower cost per true case treated than other approaches, although its positive predictive value was only about 20%.

PIP: During 1992-1993 in 12 rural health centers in Mwanza region, Tanzania, a baseline survey was conducted of 964 women attending a prenatal clinic to determine the prevalence of sexually transmitted diseases (STDs) and to evaluate various screening methods to identify those infected with Neisseria gonorrhoeae and Chlamydia trachomatis. Only 2.7% had ever used condoms. 66% had symptoms (vaginal discharge, genital itching, lower abdominal pain, painful or difficult urination, difficult or painful intercourse) associated with genital tract infection. 37% had abnormal vaginal discharge. 39% had a laboratory-confirmed STD. 49% had a reproductive tract infection. 10.1% had syphilis. 8.4% had gonorrhea and/or chlamydia. Sociodemographic factors associated with gonorrhea/chlamydia included age less than 25 (odds ratio [OR] = 2.2), unmarried status (OR = 3.2;), polygamous marriage (OR = 2.3), last child born more than 5 years earlier (OR = 3.2), and more than 1 sexual partner during the last year (OR = 1.7). When the researchers adjusted for these factors, the only signs or symptoms associated with gonorrhea/chlamydia were painful intercourse (OR = 2.1; p 0.02) and cervical discharge (OR = 3.2; p 0.06). The syndromic approach (based on vaginal discharge and/or genital itching and other symptoms related to the genital tract but not necessarily indicative of gonorrhea/chlamydia in pregnancy) had a higher sensitivity than the recommended syndromic approach based only on vaginal discharge and/or genital itching (72% vs. 43%). The risk score approach based on sociodemographic and other factors associated with gonorrhea/chlamydia infection had a higher sensitivity and lower cost/true case treated than other approaches. Yet, its positive predictive value was no greater than about 20%. A combination of case management using the World Health Organization syndromic approach for women with self-recognized genital infections together with screening for gonorrhea/chlamydia using a score-driven approach may be the most cost-effective approach to diagnosing and treating STDs.

Sexual partner change and condom use among urban factory workers in northwest Tanzania.

OBJECTIVE: To describe sexual partner change and condom use at the intake of a cohort study of urban factory workers in Tanzania. METHODS: From October 1991 to March 1992, 926 male and 170 female factory workers were interviewed using a structured, pre-coded questionnaire. Questionnaire reliability was assessed by pre-testing and comparison with results of unstructured interviews and carrying out repeat questionnaires on a sub-sample. RESULTS: Almost half of both men and women had had sexual intercourse by their 17th birthday. The period of premarital sex had an interquartile range of 2 to 10 years in men and 0 to 2.5 years in women. Having had sexual intercourse in the past month with more than one partner was reported by 22% of the men and 5% of the women. Factors associated with multiple partners in men were being born in or near Mwanza Region, having low education and low income, and being married. Condoms had been used in the past month by 3% only, mainly with casual partners. Condom use in men was associated with being young, living in town, being born in Kagera Region, high education and high income, being circumcised, and having causal or steady (non- martial) partners. CONCLUSION: Information, education and communication (IEC) on sexual relationships and condom use should start at an early age, and include education at primary schools. Much sexual partner change appears to occur through steady (non-marital) partnerships, indicating the need for IEC to be expanded beyond groups such as commercial sex workers and their clients.

PIP: A cohort study of urban workers was initiated in a factory in Mwanza Municipality, Tanzania, October 1991 to March 1992, in order to identify risk factors for HIV-1 seroconversion and for contracting other STDs. All respondents were interviewed for 30-45 minutes in Kiswahili using a structured and pre-coded questionnaire that was slightly different for men and women. In the first 19 weeks 1096 workers (926 male, 170 female) were enrolled. Participants were more likely to be under 25 years old. By the 15th birthday 16% of male and 6% of female respondents reported having had sexual intercourse; by the 17th birthday these percentages were 44% and 33%, respectively. In those who had ever married, the median period of having had premarital sexual intercourse was 5 years (interquartile range 2-10 years) in men and 1 year (interquartile range 0-2.5 years) in women. Marriage survival was slightly longer for men than for women (0.05 p 0.1). 724/926 (78%) of male and 76/170 (45%) of the female factory workers were married and living together with their spouse. Of the 724 married men 45 (6%) had 2 wives, the others had 1 wife only. Among the married respondents 607/717 (85%) of the men and 71/76 (93%) of the women reported having had sex with their spouse in the past 4 weeks (men: median 4 times, women: median 5 times). Having had more than one sexual partner in the past month was reported by 205/926 (22%) of men and 8/170 (5%) of women. Factors associated with having had multiple sexual partners in the past month were: being born in Mwanza or the neighboring Mara or Shinyanga Regions, having had less education or having a low income, and being married. Having had more than one sexual partner in the past month was also associated with having ever had a genital discharge. Overall, 141/924 (15%) of men and 30/170 (18%) of women had ever used a condom. Only 28/924 (3%) of men and 5/170 (3%) of women had used a condom in the past month.