A comprehensive response to the HIV/AIDS epidemic in Jamaica: a review of the past 20 years.

Jamaica has a well-established, comprehensive National Human Immunodeficiency Virus (HIV) programme that has slowed the HIV epidemic and mitigated its impact. Adult HIV prevalence has been stable at approximately 1.5% since 1996. HIV rates are high among those most at risk such as sex-workers (9%) and men who have sex with men [MSM] (31.8%). Risk behaviour among adults with AIDS includes multiple sexual partners (80%), a history of a sexually transmitted infection [STI] (51.1%), commercial sex (23.9%) and crack/cocaine (8.0%). Approximately 20% of all reported AIDS cases, mainly women, give no history of any of the usual risk factors for HIV infection. The national programme is based in the Ministry of Health. Since 1988, Jamaica has had a national plan to guide its HIV response. A National AIDS Committee was established in 1988 to lead the multi-sectoral response. Prevention approaches have included information, education and communication campaigns, condom promotion, sexually transmitted infections (STI) control, targeted interventions, cultural approaches, outreach and peer education, workplace programmes and HIV counselling and testing. Concerted efforts have been made to reduce HIV stigma and discrimination. Antiretroviral therapy (ARV) was introduced for prevention of mother-to-child transmission in 2001 and a public access treatment programme introduced in 2004. A national HIV/AIDS Policy was adopted unanimously in parliament in 2005. The National Strategic plan 2007-2012 commits Jamaica to achieving universal access to HIVprevention, treatment and care. Awareness of HIV and how to prevent it is near universal though belief in myths remains strong. The condom market has increased from approximately 2.5 million in 1985 to 12 million in 2006 while condom use has grown significantly with nearly 75% of men and 65% of women reporting condom use at last sex with a non-regular partner The proportion of women 15-24 years reporting ever having a HIV test increased from 29.8% in 2004 to 48.9% in 2008. HIV transmission from mother-to-child has declined from 25% prior to 2000 to less than 8% in 2007. As of September 2008, 4450 persons or an estimated 68.5% of persons with advanced HIV and AIDS have been placed on ARV treatment resulting in a significant decline in mortality and morbidity due to HIV

Seroprevalence of sexually transmitted infections among accepted and deferred blood donors in Jamaica.

Critical donor selection and testing increases the safety of blood transfusion by excluding donors at risk of transmitting infections. This study investigated the seroprevalence of and risk factors for sexually transmitted infections (STIs) among accepted and deferred blood donors in Jamaica. A total of 1015 blood donors consisting of 794 (78%) accepted donors and 221 (22%) deferred donors presenting at the Central Blood Bank, Jamaica, over a six-month period, were recruited for this study. A standardized questionnaire was administered to each participant and a sample of blood obtained for detection of hepatitis B surface antigen, antibodies to Treponema pallidum, human immunodeficiency virus (HIV) and human T-cell lymphotrophic virus type-1 (HTLV-1). Deferred donors were three times more likely to be seropositive for STI than accepted donors (16.3% vs 5.2%, OR 3.57, 95% CI 2.16 - 5.90, p < 0.0001). Males had significant association between STI seropositivity and having fathered children with two or more women (p = 0.0085), unprotected sexual intercourse with several persons (p = 0.0326), and history of genital herpes (p = 0.0121). Significant risk factors identified among females were unprotected sex with several partners (p = 0.0385); having more than ten lifetime partners (p = 0.0105); and use of depoprovera (p = 0.0028). This study confirms higher rates of STI among deferred blood donors and supports the donor deferral system in Jamaica.

Seroprevalence of sexually transmitted infections among accepted and deferred blood donors in Jamaica / Seroprevalencia de las infecciones transmitidas sexualmente entre los donantes de sangre aceptados y diferidos en Jamaica

Critical donor selection and testing increases the safety of blood transfusion by excluding donors at risk of transmitting infections. This study investigated the seroprevalence of and risk factors for sexually transmitted infections (STIs) among accepted and deferred blood donors in Jamaica. A total of 1015 blood donors consisting of 794 (78) accepted donors and 221 (22) deferred donors presenting at the Central Blood Bank, Jamaica, over a six-month period, were recruited for this study. A standardized questionnaire was administered to each participant and a sample of blood obtained for detection of hepatitis B surface antigen, antibodies to Treponema pallidum, human immunodeficiency virus (HIV) and human T-cell lymphotrophic virus type-1 (HTLV-1). Deferred donors were three times more likely to be seropositive for STI than accepted donors (16.3vs 5.2, OR 3.57, 95CI 2.16 - 5.90, p < 0.0001). Males had significant association between STI seropositivity and having fathered children with two or more women (p = 0.0085), unprotected sexual intercourse with several persons (p = 0.0326), and history of genital herpes (p = 0.0121). Significant risk factors identified among females were unprotected sex with several partners (p = 0.0385); having more than ten lifetime partners (p = 0.0105); and use of depoprovera (p = 0.0028). This study confirms higher rates of STI among deferred blood donors and supports the donor deferral system in Jamaica.

La prueba y selección crítica del donante aumenta la seguridad de la transfusión de sangre, excluyendo a los donantes con riesgo de transmitir infecciones. Este estudio investigó la seroprevalencia de las infecciones transmitidas sexualmente (ITS) entre los donantes de sangre aceptados y diferidos en Jamaica. Un total de 1015 donantes de sangre consistente en 794 (78%) donantes aceptados, y 221 (22%) donantes diferidos que acudieron al Banco de Sangre Central en Jamaica por un periodo de seis meses, fueron reclutados para este estudio. A cada uno de los participantes se le aplicó una encuesta estandarizada, y se obtuvo una muestra de sangre para la detección del antígeno de superficie de la hepatitis B, los anticuerpos del Treponema pallidum, el virus de la inmunodeficiencia humana (VIH), y el virus linfotrópico humano de células T tipo 1 (HTLV-1). Los donantes diferidos presentaron una probabilidad tres veces mayor de ser seropositivos que los donantes aceptados (16.3% frente a 5.2%, OR 3.57, 95% CI 2.16 - 5.90, p <0.0001). En los varones se dio una asociación significativa entre la seropositividad de ITS y el haber engendrado hijos con dos o más mujeres (p = 0.0085), el intercambio sexual desprotegido con distintas personas (p = 0.0326), y una historia de herpes genitales (p = 0.0121). Los factores de riesgo significativos identificados entre las hembras fueron el sexo desprotegido con diferentes parejas (p = 0.0385), el haber tenido más de diez parejas a lo largo de su vida (p = 0.0105), y el uso de depoprovera (p = 0.0028). Este estudio confirma que las tasas de ITS entre los dotantes de sangre diferidos son más altas, y respalda el sistema de aplazamiento de donantes en Jamaica.

Marginal validity of syndromic management for reproductive tract infections among pregnant women in Jamaica.

We assessed the validity of a syndromic case management approach for reproductive tract infections (RTIs) among 371 pregnant women attending antenatal care facilities in Kingston, Jamaica, using an algorithm previously validated in high-risk Jamaican women. For our antenatal attenders, the algorithm had low sensitivities for all RTIs (66.7% for cervicitis, 35.4% for trichomoniasis, 11.1% for bacterial vaginosis (BV) and 24% for candidiasis). Specificities for BV (88.9%) and candidiasis (81.1%) were higher than for cervicitis (62.8%) and trichomoniasis (68.5%). The positive predictive values were lower than 36% for all diagnoses, especially BV (6.9%). Syndromic management of RTIs in pregnant women was problematic using a clinical algorithm that had worked well for high-risk women. Syndromic management for RTIs in Jamaican antenatal clinics is only a temporary solution until more simple and affordable diagnostic tests for RTIs are developed and/or until laboratory support and clinical care can be upgraded at antenatal clinics.

Genital ulcers: etiology, clinical diagnosis, and associated human immunodeficiency virus infection in Kingston, Jamaica.

Individuals presenting consecutively with genital ulcers in Kingston, Jamaica, underwent serological testing for human immunodeficiency virus (HIV) infection, chlamydial infection, and syphilis. Ulcer material was analyzed by multiplex polymerase chain reaction (M-PCR) analysis. DNA from herpes simplex virus (HSV), Haemophilus ducreyi, and Treponema pallidum was detected in 158 (52.0%), 72 (23.7%), and 31 (10.2%) of 304 ulcer specimens. Of the 304 subjects, 67 (22%) were HIV-seropositive and 64 (21%) were T. pallidum-seroreactive. Granuloma inguinale was clinically diagnosed in nine (13.4%) of 67 ulcers negative by M-PCR analysis and in 12 (5.1%) of 237 ulcers positive by M-PCR analysis (P = .03). Lymphogranuloma venereum was clinically diagnosed in eight patients. Compared with M-PCR analysis, the sensitivity and specificity of a clinical diagnosis of syphilis, herpes, and chancroid were 67.7%, 53.8%, and 75% and 91.2%, 83.6%, and 75.4%, respectively. Reactive syphilis serology was 74% sensitive and 85% specific compared with M-PCR analysis. Reported contact with a prostitute in the preceding 3 months was associated with chancroid (P = .009), reactive syphilis serology (P = .011), and HIV infection (P = .007). The relatively poor accuracy of clinical and locally available laboratory diagnoses pleads for syndromic management of genital ulcers in Jamaica. Prevention efforts should be intensified.

Is HIV/STD control in Jamaica making a difference?

OBJECTIVE: To assess the impact of the comprehensive HIV/STD Control Program established in Jamaica since the late 1980s on the HIV/AIDS epidemic. METHODS: AIDS case reports, HIV testing of blood donors, antenatal clinic attenders (ANC), food service workers, sexually transmitted disease (STD) clinic attenders, female prostitutes, homosexuals and other groups were used to monitor the HIV/AIDS epidemic. Primary and secondary syphilis and cases of congenital syphilis were also monitored. National knowledge, attitude and practice (KAP) surveys were conducted in 1988, 1989, 1992, 1994 and 1996. RESULTS: The annual AIDS incidence rate in Jamaica increased only marginally in the past three years from 18.5 per 100000 population to 21.4 in 1997. HIV prevalence in the general population groups tested has been about 1% or less. Among those at high risk, HIV prevalence rates have risen to 6.3% (95% confidence interval 5.0-8.0) in STD clinic attenders, around 10% and 21% in female prostitutes in Kingston and Montego Bay respectively and approximately 30% among homosexuals. Syphilis rates and congenital syphilis cases have declined. The proportion of men aged 15-49 years reporting sex with a non-regular partner declined from 35% in 1994 to 26% in 1996 (P< 0.001). Women ever having used condoms increased from 51% in 1988 to 62.5% in 1992 and 73% in 1994 and 1996 (P< 0.001), while condom use with a non-regular partner increased from 37% in 1992 to 73% in 1996 (P= 0.006). Condom use among men was high over the period: around 81% had ever used condoms and 77% used them with non-regular partners. Gay men, inner-city adults and adolescents aged 12-14 years all reported increases in condom use while condom sales and distribution increased from around 2 million in 1985 to 10 million in 1995. CONCLUSION: HIV/STD control measures appear to have slowed the HIV/AIDS epidemic in Jamaica, however a significant minority of persons continue to have unprotected sex in high risk situations.

A comparison of prevalence rates of genital ulcers among persons attending a sexually transmitted disease clinic in Jamaica.

Two cross-sectional surveys were undertaken, from December 1982 to August 1983 and from November 1990 to January 1991, to estimate the prevalence rates of genital ulcer disease (GUD) in all patients presenting with a new sexually transmitted disease (STD) complaint to the STD clinic at the Comprehensive Health Centre in Kingston, Jamaica. Diagnosis of syphilis and human immunodeficiency virus (HIV) infection was based on results of laboratory tests, but diagnosis of the other STDs was based on clinical features. Data from these two surveys were compared, and reported national annual incidence data for GUD reviewed. In 1982/83 6.8% of 23,050 patients had GUD, men (9.3%) more often than women (4.2%; p < 0.001). In 1990/91 the prevalence rate was 12.8%, with increased rates for both men (18.2%) and women (6.8%; p < 0.001). In patients with GUD, a clinical diagnosis of genital herpes was made, in 1982/83 and 1990/91, respectively, in 16.8% and 7.8% of the patients; syphilis, in 12.9% and 18.8%; chancroid, in 12.4% and 13.3%; viral warts, in 5.7% and 6.3%; lymphogranuloma venereum, in 4.1% and 3.9%; and granuloma inguinale, in 3.6% and 2.3%. In men the rate for syphilis was 19% in 1990/91 and 8% in 1982/83 (p = 0.001); and for genital herpes it was 7% in 1990/91 and 17% in 1982/83 (p = 0.025). These reversals were attributed to intense media coverage of herpes in 1982/83. There was no difference in prevalence rates between the two surveys for these diseases in women, or for lymphogranuloma venereum, granuloma inguinale and genital warts in men and women. A clinical diagnosis could not be made in 44.4% of cases in 1982/83 (particularly in men), and in 47.6% of cases in 1990/91. GUDs facilitate transmission and adversely affect the prognosis of HIV. The increase in their prevalence has implications for the evolution of the local HIV epidemic, and should be addressed effectively by strengthening the STD/HIV control programme.

PIP: The prevalence of genital ulcer disease (GUD) was investigated in two cross-sectional studies of patients presenting to the sexually transmitted disease (STD) clinic at the Comprehensive Health Center in Kingston, Jamaica, between December 1982 and August 1983 (n = 23,050) and between November 1990 and January 1991 (n = 1001). The median age of participants was 26 years for men and 25 years for women; most were low-income inner-city residents. The prevalence of GUD rose from 6.8% (9.3% in men and 4.2% in women) in the 1982-83 survey to 12.8% (18.2% in men and 6.8% in women) in 1990-91. In 1982-83 and 1990-91, respectively, genital herpes was diagnosed in 16.8% and 7.8% of patients, syphilis in 12.9% and 18.8%, chancroid in 12.4% and 13.3%, viral warts in 5.7% and 6.3%, lymphogranuloma venereum in 4.1% and 3.9%, and granuloma inguinale in 3.6% and 2.3%. A clinical diagnosis could not be made in 44.4% of cases in 1982-83 and in 47.6% in 1990-91. Since GUDs facilitate the transmission of HIV, HIV prevention efforts must include the strengthening of STD control programs. All cases of GUD should be screened for both syphilis and HIV, with prompt treatment to reduce the period of GUD transmissibility. Jamaica has revised its national STD case management guidelines to include simplified algorithms for GUD management and strengthened STD surveillance and contact tracing. Changes in GUD prevalence over time may be a useful indicator for evaluating the impact of STD/HIV interventions.

Incidence of HIV and HTLV-1 infection among sexually transmitted disease clinic attenders in Jamaica.

Of 970 sexually transmitted disease (STD) patients enrolled at the Comprehensive Health Centre, Kingston, Jamaica, between November 1990 and January 1991, 710 (73%, 333 men and 377 women) were reexamined between January 1992 and July 1993 to estimate the incidence of HIV and HTLV-I infection and to identify risk factors for infection. Of those reexamined, 20% were recruited passively when they returned to the clinic of their own accord, and 80% were recruited actively through field visits to their homes. Passively recruited persons were significantly more likely than active recruits to have had a sexually transmitted disease since enrollment or at their follow-up visit. Seven men and one woman became HIV positive during the period of follow-up. The overall HIV incidence rate was 0.7 per 100 person years (95% confidence interval [CI] = 0.3 to 1.4), 1.4 (CI = 0.6 to 2.8) for men and 0.2 (CI = 0.004 to 0.9) for women. Four of 270 men and 4 of 318 women were HTLV-I positive, an overall incidence of 0.9 per 100 person years (CI = 0.4 to 1.7), 1.0 for men and 0.8 for women. HTLV-I infection was associated with an age of 30 years or older (p < 0.01). The presumed lower transmission probability for HTLV-I may combine with a higher prevalence of HTLV-I in sexual partners to produce similar overall incidence rates for the two infections. The HIV and HTLV-I incidence rates may have been underestimated, because the study subjects who did not return to the clinic may have had a somewhat higher risk. On univariate analysis, there were significant associations between HIV infection in men and drinking alcohol before sex, cocaine use, total number of sex partners, sex with a prostitute since enrollment, ever accepting money for sex, the average number of sex partners per month, bruising during sex, and genital ulcers found on follow-up examination. This analysis needs to be interpreted with caution in view of the small number of seroconverters, which did not allow testing for independent effects in a logistic regression model.

Survey of patients with sexually transmitted diseases seen by private physicians in Jamaica.

A survey of physicians in private practice in Jamaica was conducted between March and September 1993 to provide a descriptive analysis of the occurrence of patients with sexually transmitted diseases (STDs) seen in their practices. Questionnaires were delivered to 371 physicians of whom 127 (34%) responded, completing 683 (men 353, women 330) individual patient questionnaires. Each physician collected data over a period of one week. The median ages of the men and women were 27 years and 26 years, respectively. 464 (68%) patients were being seen for the first time for symptomatic STDs, and the visit was a follow-up for 132 (19%) who had been previously diagnosed; 40 (6%) patients were asymptomatic contacts referred by a sex partner, and 12 (2%), who were asymptomatic, asked for a 'checkup'. A history of previous STD was given by 358 (52%) patients. 470 (69%) patients had a genital discharge (M, 65%; F, 73%; p = 0.017), 52 (8%) had anogenital lesions (M, 10%; F, 5%; p = 0.013) and 45 (7%), inguinal lymphadenopathy (M, 10%; F, 3%; p = 0.002). Among women, 131 (40%) had lower abdominal pain on examination and 105 (32%) had cervical excitation tenderness or pain suggesting pelvic inflammatory disease (PID). A working diagnosis of gonorrhoea was made in 273 (40%) patients, trichomoniasis in 121 (18%), nongonococcal infection in 114 (17%), syphilis in 60 (9%), herpes genitalis in 20 (3%) and chancroid in 11 (2%). PID was diagnosed in 121 (37%) women and nongonococcal urethritis in 98 (28%) men. The most frequently prescribed treatments were for chlamydia, gonorrhoea and trichomoniasis. In general, working diagnoses correlate well with clinical observations and treatment given, matched with diagnosis according to national guidelines. A comparison of the STD burden between the public and private sectors was not possible because of sample bias.

Genital Chlamydia trachomatis (serotypes D-K) infection in Jamaican commercial street sex workers.

OBJECTIVES: To determine the prevalence of genital Chlamydia trachomatis infections in commercial street sex workers (CSSW) in Jamaica. METHODS: The prevalence of C trachomatis infection was determined in 129 Jamaican CSSW using the direct fluorescent antibody (DFA) method and the isolation techniques which utilise fluorescent and iodine staining of endocervical cytobrush specimens cultured in McCoy cells. The seroprevalence of C trachomatis in the CSSW was also compared with that in blood donors (n = 435), using the microimmunofluorescence (MIF) test. RESULTS: The DFA detected C trachomatis in 16% (21/129) of the specimens. The prevalence as determined by the iodine and fluorescein stained cultures was 24% (31/129) and 25% (33/129) respectively. The overall prevalence of current chlamydial infection detected by the isolation techniques used was 25% (33/129). As determined by the MIF test, a statistically significantly higher seroprevalence rate of C trachomatis (95%, 61/64) was found in CSSW compared with blood donors (53%, 229/435; OR 22.6; chi 2 = 49.8; p < 0.001). The prevalence of current infection in CSSW as indicated by the isolation of C trachomatis was not influenced by history of previous pelvic inflammatory disease (PID), sexually transmitted disease, or condom use. N gonorrhoeae (9%) and Candida albicans (7%) were found in comparatively low frequencies, while Trichomonas vaginalis (0%) was not found in specimens from the CSSW. CONCLUSIONS: A high seroprevalence rate and a high rate of current infection with C trachomatis occur in Jamaican CSSW. In order to control the spread and prevent the severe clinical complications and sequelae of C trachomatis infection, the diagnosis and treatment in such high risk groups such as CSSW should be optimised.

PIP: The prevalence of Chlamydia trachomatis infection was investigated in 129 commercial sex workers (CSWs) recruited on the streets in Kingston, Jamaica. The direct fluorescent antibody method detected C. trachomatis in endocervical cytobrush specimens from 21 women (16%). When the specimens were cultured, current chlamydial infection was detected by iodine staining in 31 (24%) and by monoclonal antibodies in 33 (25%). The microimmunofluorescence test for chlamydial antibodies was performed on clotted blood samples obtained from 64 CSWs and, as controls, 435 blood bank donors. A significantly higher seroprevalence rate was found among CSWs (95%) than blood donors (53%) (p 0.001). Among CSWs, the most common clinical manifestation of C. trachomatis infection was vaginal discharge. The presence of C. trachomatis infection was not related to previous history of pelvic inflammatory disease, sexually transmitted disease (STD), or condom use. Neisseria gonorrhoeae was isolated from 11 (9%) endocervical swabs. This study confirms the predominance of C. trachomatis among the bacterial causes of STDs in high-risk groups in Jamaica, and suggests a need for screening and treatment to control the spread and prevent the severe clinical sequelae of chlamydial infection.

Is under-reporting of AIDS a problem in Jamaica?

A survey of physicians in Jamaica was conducted between March and September, 1993 in order to estimate the level of reporting of HIV and AIDS. A questionnaire was delivered to nearly all of approximately 1,200 physicians practising in Jamaica. Completed questionnaires were received from 418, a response rate of 35%. Of the physicians responding, 46% were in private practice only, 22% in the public sector only and 32% in both. Two-thirds (66%) of the physicians in private practice had not diagnosed a case of AIDS and 65% had not had a patient with a positive HIV test result. Half (54%) of the private physicians had reported all their AIDS cases, 8% had reported some and 38% (45 doctors) had reported none. The main reasons for not reporting were: "thought someone else had reported" (15 doctors), concern for confidentiality (11) and not knowing where to report (8). Only 9% of private practitioners were currently seeing an AIDS patient and 12% were seeing an HIV-infected person. Of physicians with current AIDS patients 16% preferred not to report, 21% intended to report and 63% had reported. Nearly one-third (29%) of private practitioners expressed reservations about treating persons with HIV/AIDS. Most (75%) public sector physicians had seen one or more AIDS patients. Sixty-four per cent of these physicians said that all of their AIDS cases were reported, 4% said some, 4% said none and 28% didn't know. Reporting of AIDS cases is better in the public sector than among private physicians.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: Almost all of the approximately 1200 physicians practicing in Jamaica were surveyed between March and September 1993 in a study to estimate the level of reporting of HIV and AIDS. Completed questionnaires were received from 418. Of these, 46% were in private practice only, 22% in the public sector only, and 32% in both. 66% of physicians in private practice had not diagnosed a case of AIDS and 65% had not had a patient with a positive HIV test result. 54% of the private physicians had reported all their AIDS cases, 8% had reported some, and 38% had reported none. The main reasons for not reporting were the belief among 15 doctors that someone else had reported, concern for confidentiality among 11 doctors, and not knowing where to report among eight. 9% of private practitioners were currently seeing an AIDS patient and 12% were seeing an HIV-infected person. Of physicians with current AIDS patients, 16% preferred not to report, 21% intended to report, and 63% had reported. 75% of public sector physicians had seen one or more AIDS patients. 64% of these physicians said that all of their AIDS cases were reported, 4% said some, 4% said none, and 28% did not know. The reporting of AIDS cases is therefore better in the public sector than among private practitioners. The authors believe that it is likely that some, if not many, of the AIDS cases not reported by private physicians are reported when admitted to hospital. They further note their inability to estimate the exact level of underreporting of AIDS in Jamaica on the basis of their survey. 29% of private practitioners expressed reservations about treating persons with HIV/AIDS. Efforts need to be undertaken to address these reservations and convince health practitioners of the need to report HIV/AIDS cases in a timely manner.

Plasmid-mediated antimicrobial resistance in Neisseria gonorrhoeae in Kingston, Jamaica: 1990-1991.

BACKGROUND AND OBJECTIVES: Gonococcal infections caused by antimicrobial-resistant strains of Neisseria gonorrhoeae have spread into many geographic areas and have increased in prevalence since the mid 1970s. Surveillance of antimicrobial-resistant gonococcal strains of Jamaica from 1981 to 1983 indicated that fewer than 3% of strains of produced beta-lactamase (penicillinase-producing Neisseria gonorrhoeae); approximately 4% of strains were resistant to penicillin, and 12% were resistant to tetracycline. GOAL OF THIS STUDY: To measure the frequency and nature of antimicrobial resistance in Neisseria gonorrhoeae isolates in Kingston, Jamaica, from 1990 to 1991 and to assess the effectiveness of prescribed treatment regimens. STUDY DESIGN: Urethral isolates of Neisseria gonorrhoeae from 116 heterosexual men with uncomplicated gonorrhea, representing 7.1% (116/1633) men attending the STD Comprehensive Health Centre from October 1990 through March 1991 who had positive Gram-stained smears, were characterized by auxotype, serovar, presence of the TetM determinant, and plasmid content. Antimicrobial susceptibilities to penicillin, cefoxitin, ceftriaxone, ciprofloxacin, tetracycline, and spectinomycin were determined by an agar dilution method. RESULTS: A total of 80.2% (93/116) of the isolates exhibited plasmid-mediated resistance to penicillin, tetracycline, or both: penicillinase-producing Neisseria gonorrhoeae (13/116; 11.2%), tetracycline-resistant Neisseria gonorrhoeae (25/116; 21.6%), and penicillinase-producing/tetracycline-resistant Neisseria gonorrhoeae, (55/116;47.4%). Isolates with chromosomally mediated resistance to penicillin, tetracycline, or both, accounted for 5.2% (6/116) of the isolates. Penicillinase-producing Neisseria gonorrhoeae, tetracycline-resistant Neisseria gonorrhoeae, and penicillinase-producing/tetracycline-resistant Neisseria gonorrhoeae belonging to multiple auxotype/serovar classes were isolated repeatedly through the study period. CONCLUSIONS: Infections caused by Neisseria gonorrhoeae exhibiting plasmid-mediated resistance to penicillin, tetracycline, or both, have become prevalent and endemic in Kingston, Jamaica. Therefore, all gonococcal infections should be treated with antimicrobial therapies known to be active against penicillin-resistant and tetracycline-resistant organisms to reduce gonorrhea transmission.

Prevalence of human papillomavirus among STD clinic attenders in Jamaica: association of younger age and increased sexual activity.

BACKGROUND AND OBJECTIVES: Human papillomavirus is the major etiologic agent of cervical cancer. Although the incidence of cancer of the cervix is high in Jamaica, the prevalence of human papillomavirus among Jamaican women has not been defined. GOAL OF THE STUDY: To estimate the prevalence of human papillomavirus infection and associated risk factors in women attending an STD clinic in Kingston, Jamaica. STUDY DESIGN: A cross-sectional survey was done of 202 women attending an STD clinic in Kingston in 1990. Cervical and vaginal cells were collected by lavage, and human papillomavirus genomes were detected in extracted DNA using low-stringency Southern blot hybridization. RESULTS: Fifty-eight (28.7%) women were identified as HPV positive. Prevalence of HPV by age group was 39% in women 15-19 years old, 33% of women 20-24 years old, 31% in women 25-29 years old, and 17% in those 30 years or older. Increasing age was significantly associated with a lower prevalence of human papillomavirus infection (test for trend, P = 0.025). The effect of age was independent of years of sexual activity. Women reporting more than one sexual partner per month on average were found to have a significantly higher HPV prevalence (odds ratio 2.87, 95% confidence Interval 1.29-6.38), as were women who reported more frequent sex (test for trend, P = 0.006). CONCLUSIONS: Sexual behavior is associated with risk of human papillomavirus infection. The decrease of human papillomavirus prevalence in older women agrees with other studies that argue in favor of a biological effect, such as increased immunity to human papillomavirus with age. A better understanding of why immunity to human papillomavirus may develop in older women may provide the basis for developing an effective vaccine to prevent cancer of the cervix.

PIP: During November 1990-January 1991, DNA was extracted from cervicovaginal cells from 202 women attending the Comprehensive Health Centre, a sexually transmitted disease (STD) clinic, in Kingston, Jamaica, to determine the prevalence of human papilloma virus (HPV). Health workers interviewed these women so researchers could identify risk factors for HPV. 58 women (28.7%) tested positive for HPV. 62% had uncharacterized HPV DNA types. 16% had more than one type of HPV. HPV prevalence fell with age (39% for 15-19 year olds, 33% for 20-24 year olds, 31% for 25-29 year olds and 17% for 30+ year olds; odds ratio [OR] for oldest group = 0.34; p = 0.025), suggesting that older women have developed an immunity to HPV infection. The higher the number of years of sexual activity, the lower the HPV prevalence (40% for 1-4 years, 32% for 5-9 years, and 23% for 10+ years; OR for 10+ years was 0.44; p = 0.03). Women with at least two sexual partners over the last 12 months had a higher HPV prevalence than those with fewer sexual partners (OR = 2.87; p = 0.01). The greater the average number of times women claimed to have had vaginal intercourse per month in the last year, the greater the HPV prevalence (OR for 3-4 times = 2.07, OR for 5+ times = 3.22; p = 0.006). A multiple logistic regression analysis revealed that age confounded the inverse association between HPV prevalence and years of sexual activity. 3% of Pap smears exhibited cervical dysplasia. Further studies are needed to obtain a better understanding of why immunity to HPV may occur in older women. This information could form the basis for developing an effective vaccine against cervical cancer.

Quality of sexually transmitted disease services in Jamaica: evaluation of a clinic-based approach. Collaborative Working Group on Indicators of STD Case Management.

As part of a larger strategy to develop global indicators of HIV (human immunodeficiency virus) infection prevention programmes, a clinic-based method for the assessment of sexually transmitted disease (STD) service quality was developed and field tested by trained observers who visited a random sample of public-sector clinics in Jamaica in October 1991. The assessment included an inventory of equipment and drugs, interviews with clinic staff, and observations of 27 health workers in 15 clinics as they provided services to 115 patients presenting for STD care. This observation-based method provided Jamaican programme managers with descriptive data on STD case management in public clinics within a one-month study period at an approximate local cost of US+ 5000. Based on weighted estimates, 91% of public-sector STD patients in Jamaica were seen in clinics whose staff had received some training in STD case management during the preceding 12 months. The correct treatment rate was estimated to be 82% for those diagnosed with gonorrhoea, and 70% for those diagnosed with syphilis. Based on 98 observed encounters for first-time-for-episode patients, counselling included sex partner referral (57%), partner reduction (48%), and condom use (59%). Although 61% of STD patients were seen in clinics with condoms in stock on the day of the assessment, only 23% were offered condoms during their visit. The clinic-based assessment method can be adapted to the programme management and reporting needs of countries at all stages of STD service development, and can provide data needed to improve programme operations and meet international reporting standards.

Chlamydial infections in selected populations in Jamaica.

The importance of Chlamydia trachomatis as a cause of genital tract infection in Caribbean countries is largely unknown. Two hundred and sixteen cervical and urethral specimens were collected from patients with cervicitis and urethritis attending a Sexually Transmitted Diseases (STD) Clinic, a Gynaecology Clinic and a Family Planning Clinic in Kingston. Specimens were tested for chlamydiae by direct immunofluorescence and cell culture methods. They were also investigated for N. gonorrhoeae infections. Seventy-two of 138 patients (52.2%) at the STD Clinic were positive for chlamydiae; 28 of 50 (56.0%) from the Gynaecology Clinic and 11 of 28 (39.3%) from the Family Planning Clinic were positive. The prevalence of C. trachomatis (52.3%) was higher than that of N. gonorrhoeae (11.1%) in all groups. The results indicate that C. trachomatis is a common cause of genital tract infections in Jamaica.

Treatment of gonorrhoea and susceptibility to antimicrobials of PPNG and non-PPNG strains in Jamaica.

Of 1400 patients in Jamaica screened for uncomplicated gonorrhoea, 54% (753 patients) were culture positive. Of the 459 patients who complied with the terms of the study, 97% (211/218) of those treated with aqueous procaine penicillin G were cured compared with 94% (227/241) of those treated with ampicillin. Penicillinase producing Neisseria gonorrhoeae (PPNG) strains were identified for the first time during the study, and 10 patients infected with PPNG strains (two treated with penicillin, eight with ampicillin) contributed to the 21 treatment failures. The in vitro susceptibility of eight antimicrobial agents for 629 non-PPNG and 20 PPNG strains was estimated. Of the non-PPNG isolates, 8% had an MIC of 1 mg/l or more of penicillin, 11% were resistant to this concentration of ampicillin, 32% to tetracycline, and under 1% to the same concentration of cefuroxime and erythromycin. Fewer than 2% of the isolates were resistant to 2 mg/l or more thiamphenicol, and all isolates were susceptible to spectinomycin and trimethoprimsulphamethoxazole (at a ratio of 1:19). Significantly more strains from the 21 treatment failures were resistant to penicillin (52%) or ampicillin (62%) compared with 7% strains resistant to penicillin and 4% to ampicillin from the successfully treated group.

Auxotypes, plasmid contents, and serovars of gonococcal strains (PPNG and non-PPNG) from Jamaica.

The analysis of the auxotypes and plasmid profiles of 459 non-PPNG strains from Jamaica suggests that strains have been imported to the island. Unlike in many developing countries where strains are differentiated by only a few auxotypes, 13 different auxotypes were identified in the non-PPNG strains. In Jamaica over 10% of the strains were plasmid free and required proline, citrulline, and uracil (PCU-) for growth. These isolates predominate in Canada and are increasingly reported from areas of the United States of America and Europe. The serological analysis of 168 of the non-PPNG strains indicated that most (76%, 128) were from serogroup WII/III. Serogroup WII/III strains comprised 17 serovar combinations with GS and Ph reagents, whereas serogroup WI strains included only four serovars. Unusually, most WI Aedgkih non-PPNG strains were wild type or proline requiring. Strains of serovar Aedg were especially noted (in 93%, 13/14) for carriage of the transfer plasmid. The first 20 PPNG strains isolated in Jamaica proved to have multiple origins as they had eight variations of auxotype, serovar, and plasmid content. Most (60%, 12/20) of those isolated were typed as serogroup WI, and 10 of these isolates were serovar Aedgkih. Although most (70%, 14/20) PPNG strains harboured African type plasmids with or without transfer plasmids, six also carried Asian type plasmids (with the transfer plasmid).