Prevention and control of sexually transmissible infections among hotel-based female sex workers in Dhaka, Bangladesh.

BACKGROUND: Hotel-based sex workers in Bangladesh have high rates of sexually transmissible infections (STIs), high client turnover and low condom use. Two monthly clinic-based strategies were compared: periodic presumptive treatment (PPT) and enhanced syndromic management (ESM) - one round of presumptive treatment followed by treatment based on assessment and laboratory tests. METHODS: A randomised controlled trial compared PPT and ESM by prevalence and incidence, behaviour, retention, cost and STI incidence and prevalence. Demographic, behavioural and clinical data were collected from women at two clinics in Dhaka. All women received presumptive treatment and were randomised to receive PPT or ESM at nine monthly visits. RESULTS: In total, 549 women (median age: <20 years) were enrolled. At baseline, the prevalence of chlamydia (Chlamydia trachomatis) and gonorrhoea (Neisseria gonorrhoeae) was 41% (ESM: 41%; PPT: 42%). After 9 months, chlamydia and gonorrhoea decreased to 7% overall, (ESM: 7.4%; PPT: 6.8%). At each visit, 98% of women receiving ESM met the therapy criteria and were treated. Retention was low (50%). Total costs were 50% lower per visit for each woman for PPT (ESM: $11.62 v. PPT: $5.80). The number of sex work sessions was reduced from 3.3 to 2.5 (P<0.001), but income did not change. Coercion was reduced but condom use at last sex did not change significantly. CONCLUSIONS: Monthly PPT and ESM were effective approaches for STI control. PPT offered a feasible, low-cost alternative to ESM. Educational aspects led to a reduction in coercion and fewer sessions. Implementation studies are needed to improve condom use and retention.

On-site rapid antenatal syphilis screening with an immunochromatographic strip improves case detection and treatment in rural South African clinics.

OBJECTIVES: Congenital syphilis is a significant cause of adverse pregnancy outcomes. In South Africa, rural clinics perform antenatal screening offsite, but unreliable transport and poor client follow up impede effective treatment. We compared 3 syphilis screening strategies at rural clinics: on-site rapid plasma reagin (RPR), on-site treponemal immunochromatographic strip (ICS) test, and the standard practice offsite RPR with Treponema pallidum hemagglutination assay (RPR/TPHA). METHODS: Eight rural clinics performed the on-site RPR and ICS tests and provided immediate treatment. Results were compared with RPR/TPHA at a reference laboratory. Chart reviews at 8 standard practice clinics established diagnosis and treatment rates for offsite RPR/TPHA. FINDINGS: Seventy-nine (6.3%) of 1,250 women screened on-site had active syphilis according to the reference laboratory. The on-site ICS resulted in the highest percentage of pregnant women correctly diagnosed and treated for syphilis (89.4% ICS, 63.9% on-site RPR, 60.8% offsite RPR/TPHA). The on-site RPR had low sensitivity (71.4% for high-titer syphilis). The offsite approach suffered from poor client return rates. One percent of women screened with the ICS may have received penicillin unnecessarily. There were no adverse treatment outcomes. CONCLUSIONS: The on-site ICS test can reduce syphilis-related adverse outcomes of pregnancy through accurate diagnosis and immediate treatment of pregnant women with syphilis.

Sexually transmitted infections among female sex workers in Kupang, Indonesia: searching for a screening algorithm to detect cervical gonococcal and chlamydial infections.

BACKGROUND AND GOAL: Notifications of HIV infection in Indonesia are increasing, but there are few data on other sexually transmitted infections (STIs), especially in the eastern islands of Indonesia. We aimed to measure the prevalence of STIs among female sex workers (FSWs) in Kupang, West Timor, and to develop screening algorithms to detect cervical infections with Neisseria gonorrhoeae and/or Chlamydia trachomatis (NG/CT). STUDY DESIGN: During 6 months in 1999, we recruited all the FSWs at Kupang's only brothel complex and a smaller number of independent FSWs. The women were examined at dedicated clinics and most laboratory tests were performed at provincial laboratories. Algorithms based on the strongest associations of variables with NG/CT were compared with the laboratory diagnoses. RESULTS: We recruited 288 women. The prevalence of N gonorrhoeae infection was 31%, that of C trachomatis infection was 24%, that of Trichomonas vaginalis infection was 5%, and that of syphilis was 13%. No case of HIV infection was detected. Few women had symptoms of STI. The only variables significantly associated with NG/CT after logistic regression analysis were the presence of cervical discharge (either yellow or clear) and a high count of polymorphonuclear leukocytes on gram-stained endocervical smear. Several algorithms to screen for NG/CT achieved high (>80%) sensitivity, but the highest specificity among these was only 50%. CONCLUSIONS: Although several of the generated algorithms may be useful in the absence of simple, accurate, affordable diagnostic tests, the high rates of STIs in this population could justify a more aggressive strategy incorporating periodic presumptive treatment to rapidly reduce prevalence.