Prevalence of sexually transmitted infections and sexual risk behavior among female sex workers in nine provinces in Indonesia, 2005.

The objective of this study was to assess the sexually transmitted infection (STI) prevalence and sexual risk behavior among female sex workers (FSWs) in Indonesia. This cross-sectional 2005 study involved 2500 FSWs in nine provinces in Indonesia. Informed consent was obtained; behavioral and clinical data were collected. Specimens were collected for STI testing, endocervical swabs were tested for Chlamydia trachomatis and Neisseria gonorrhoeae (PCR), vaginal smears were cultured to detect Trichomonas vaginalis and sera were tested for syphilis (RPR and TPHA). The prevalence of chlamydial infection was 43.5%, gonorrhea 28.6%, trichomoniasis 15.1%, and syphilis 8.7%; the prevalence of any STI was 64.0%. Inconsistent condom use, younger age, and higher number of clients were independent risk factors for the presence of gonorrhea/chlamydia. Inconsistent condom use was common (73.2%); starting sex work at younger age, and higher number of clients were independent risk factors. Vaginal douching was reported by 89.6% of FSWs; no association with gonorrhea/chlamydial infection was found. This study identified a high STI prevalence and low consistent condom use among FSWs in Indonesia. This will need to be addressed to prevent further spread of infections, including HIV.

Addressing the high prevalence of gonorrhoea and chlamydia among female sex workers in Indonesia: results of an enhanced, comprehensive intervention.

OBJECTIVES: The authors developed a comprehensive STI-control programme to decrease gonorrhoea and chlamydia prevalence, and increase consistent condom use among brothel-based sex workers in Indonesia. METHODS: The STI-control programme for brothel-based sex workers in Bintan Island (Riau Islands) and Salatiga (Central Java) included (1) provision of adequate drugs for gonorrhoea and chlamydia as periodic presumptive treatment (PPT) followed by syndromic treatment; (2) condom-use promotion by involving the local community and ensuring sufficient condom supply. Endocervical samples were collected and tested for gonorrhoea and chlamydia by PCR. Cross-sectional assessments of gonorrhoea and chlamydia prevalence, and consistent condom use with clients in the last week were made at several time points for sex workers attending the STI clinic. RESULTS: 580 sex workers participated in the programme. A steady decrease in prevalence was observed for gonorrhoea (36.1-7.6%) and chlamydia (33.7-10.2%) (both p<0.01) among sex workers in Bintan from March 2008 until June 2009. Sex workers in Salatiga showed a sharp initial decrease in prevalence, followed by an increase after provision of the old drug regimen. Gonorrhoea and/or chlamydia prevalence among those who had received at least one PPT round was lower compared with that in newcomers (p<0.01). The proportion of sex workers reporting consistent condom use doubled to 40% in June 2009 compared with November 2007 (p<0.01). CONCLUSION: The STI-control programme was effective in reducing infection prevalence and increasing condom use among sex workers. This intervention has been scaled up and may decrease national STI levels and reduce HIV transmission.

No increase in cervicovaginal proinflammatory cytokines after Carraguard use in a placebo-controlled randomized clinical trial.

BACKGROUND: Assessment of cervicovaginal cytokine levels may be helpful to evaluate subclinical epithelial inflammation during safety evaluations of candidate microbicides. METHODS: Fifty-five HIV-seronegative Thai women were enrolled in a safety trial of the candidate microbicide Carraguard and were randomized to use Carraguard or placebo gel before vaginal sex. Cervicovaginal lavages were collected at baseline and after 1 month of gel use; levels of interleukin (IL)-1beta, IL-6, IL-8, and secretory leukocyte protease inhibitor (SLPI) were measured using microwell plate-based enzyme immunoassays. Median levels were compared between the baseline and 1-month follow-up visits using paired t tests; the median change between groups was compared using Wilcoxon rank sum tests. Women were examined for the presence of genital findings; the association between genital findings and cytokine levels was studied. RESULTS: No increase in levels of proinflammatory cytokines after use of Carraguard gel or placebo gel was observed during the study. The median change from the baseline to 1 month of follow-up was not significantly different between Carraguard and placebo groups (IL-1beta: -0.3 pg/mL vs. -3.93 pg/mL; P = 0.4, IL-6: -0.3 pg/mL vs. 0 pg/mL; P = 0.3, IL-8: -40.1 pg/mL vs. -53.2 pg/mL; P = 0.8, and SLPI: -26.5 pg/mL vs. 12.6 pg/mL; P = 0.07). Genital findings with intact epithelium were found in 16 (29%) women; these women tended to have somewhat higher IL-6 levels than those with normal epithelium (14.9 pg/mL vs. 8.8 pg/mL; P = 0.08). CONCLUSION: We found no increase in proinflammatory cytokines after Carraguard and placebo gel use, suggesting that neither gel causes inflammation. Further studies to assess the role of cytokines in microbicide safety studies are warranted.

Screening HIV-infected women for cervical cancer in Thailand: findings from a demonstration project.

OBJECTIVES: Although cervical cancer is an AIDS-defining illness, few HIV-infected women are routinely screened for cervical cancer in Thailand. We screened HIV-infected women for cervical cancer as a component of HIV care and assessed high-risk human papillomavirus (HPV) and cervical cancer prevalence. METHODS: From July 2003 through February 2004, HIV-infected women attending either an infectious disease clinic or a sexually transmitted infection (STI) clinic in Bangkok were tested for high-risk HPV types by Hybrid Capture 2 and screened for cervical cancer by Pap test; those with abnormal cervical cytology were referred for diagnosis and treatment. RESULTS: Two hundred ten HIV-infected women at an infectious disease clinic (n = 150) and an STI clinic (n = 60) received cervical cancer screening. The high-risk HPV prevalence was 38.6% and the prevalence of abnormal cervical cytology was 20.4%. Abnormal cervical cytology and high-risk HPV detection were associated (P < 0.001). We received pathology reports for 23 (53.5%) of 43 women, including all those with a Pap test showing high-grade squamous intraepithelial lesions; the cervical cancer prevalence was 1.9% (4 of 210; 95% confidence interval, 0.5-4.8%). CONCLUSION: The estimated prevalence of high-risk HPV and cervical cancer among HIV-infected women in Thailand was high. This emphasizes the need to integrate cervical cancer screening into HIV care.

Sexually transmitted infection services as a component of HIV care: findings of a demonstration project among HIV-infected women in Thailand.

OBJECTIVES: As Thailand scales up its antiretroviral treatment program, the role of sexually transmitted infection (STI) services to prevent HIV transmission has not been addressed. We provided STI services for HIV-infected women as a component of HIV care and assessed STI prevalence and risk behaviors. METHODS: HIV-infected women attending an infectious disease clinic and an STI clinic in Bangkok were screened for the presence of genital ulcers by visual inspection, for gonorrhea and chlamydial infection by polymerase chain reaction, for trichomoniasis by wet mount, and for syphilis by serology. Women were asked about sexual risk behavior and use of antiretroviral treatment. Risk-reduction counseling, condoms, and STI treatment were provided. RESULTS: Two-hundred ten HIV-infected women at an infectious disease clinic (n = 150) and an STI clinic (n = 60) received STI services from July 2003 through February 2004. The prevalence for any STI was 8.0% at the infectious disease clinic and 30.0% at the STI clinic (P < 0.01). Of the 116 (55.2%) sexually active women, 42 (36.2%) reported sex without a condom during the last 3 months. Women receiving antiretroviral treatment reported condom use during last sex more often compared with those not receiving antiretroviral treatment (82.2% vs. 58.8%; P = 0.03). CONCLUSION: STIs and sexual risk behavior were common among these HIV-infected women, and STI services for HIV-infected persons have been expanded to more clinics in Thailand. Further analysis of HIV transmission risk is necessary for developing a national strategy for prevention of HIV transmission among HIV-infected persons.

Human papillomavirus (HPV) detection among human immunodeficiency virus-infected pregnant Thai women: implications for future HPV immunization.

BACKGROUND: Human immunodeficiency virus (HIV)-infected women are at increased risk for developing cervical cancer and for infection with human papillomavirus (HPV). Prophylactic vaccines targeting HPV types 16 and 18 are being evaluated for efficacy among young women. GOAL: The goal was to assess the prevalence of HPV among HIV-infected pregnant women in Bangkok and to evaluate the need for prophylactic HPV vaccines studies in this population. STUDY DESIGN: The study population consisted of 256 HIV-infected pregnant women who participated in a mother-to-child HIV transmission trial. Stored cervicovaginal lavage samples were tested for the presence of HPV DNA by polymerase chain reaction with PGMY09/11 primers and reverse line-blot hybridization for determination of anogenital HPV types. RESULTS: HPV prevalence was 35.5% (91/256); high-risk HPV prevalence was 23.4% (60/256). HPV type 16 or 18 was present in 8.2% (21/256). Almost half of all infections were multiple. Furthermore, overall HPV detection was associated with abnormal cervical cytology (P<0.001) and higher HIV-plasma viral load (P=0.007). CONCLUSIONS: Only one-quarter of HIV-infected pregnant women in Bangkok had high-risk HPV types; less than 10% had HPV types 16 or 18. As the HPV prevalence is expected to increase during HIV disease, prophylactic vaccines targeting HPV types 16 and 18 should be studied among HIV-infected women not yet infected with these HPV types and not previously exposed.

Interpretation of genital findings in microbicide safety trials: review of the 'Photo Atlas for Microbicide Evaluation'.

The Photo Atlas for Microbicide Evaluation was published in May 2002 for distribution among researchers to be used as a training or reference document during microbicide clinical trials. We have reviewed the contents of the Photo Atlas, including the interpretation and documentation of genital findings. The rationale for the categorization of genital lesions into different lesion types is also discussed. Efforts will continue to standardize colposcopy until more accurate and objective methods become available to assess the safety of candidate microbicides.