Intravaginal cleansing among women attending a sexually transmitted infection clinic in Kingston, Jamaica.

OBJECTIVES: Although common worldwide, intravaginal cleansing is associated with poor health outcomes. We sought to describe intravaginal cleansing among women attending a sexually transmitted infection (STI) clinic in Jamaica. METHODS: We examined intravaginal cleansing ("washing up inside the vagina", douching, and products or materials used) among 293 participants in a randomized trial of counselling messages at an STI clinic in Kingston. We focussed on information on intravaginal cleansing performed in the 30 days and three days preceding their baseline study visit. We describe reported cleansing behaviours and used logistic regression to identify correlates of intravaginal cleansing. RESULTS: Fifty-eight per cent of participants reported intravaginal cleansing in the previous 30 days, and 46% did so in the three days before baseline. Among those who cleansed in the previous 30 days, 88% reported doing so for hygiene unrelated to sex, and three-fourths reported generally doing so more than once per day. Soap (usually with water) and water alone were the most common products used for washing; commercial douches or detergents were reported infrequently. Intravaginal cleansing in the three days before the baseline visit was positively associated with having more than one sex partner in the previous three months (adjusted odds ratio [AOR], 1.9; 95% CI, 1.1, 3.2), and negatively associated with experiencing itching in the genital area at baseline (AOR, 0.6; 95% CI, 0.4, 1.0). CONCLUSIONS: A large proportion of women attending STI clinics in Jamaica engage in frequent intravaginal cleansing, indicating a need for clinicians to discuss this topic with them accordingly.

Intravaginal cleansing among women attending a sexually transmitted infection clinic in Kingston, Jamaica / Limpieza intravaginal entre mujeres que asisten a una clínica de infecciones de transmisión sexual en Kingston, Jamaica

OBJECTIVES: Although common worldwide, intravaginal cleansing is associated with poor health outcomes. We sought to describe intravaginal cleansing among women attending a sexually transmitted infection (STI) clinic in Jamaica. METHODS: We examined intravaginal cleansing ("washing up inside the vagina", douching, and products or materials used) among 293 participants in a randomized trial of counselling messages at an STI clinic in Kingston. We focussed on information on intravaginal cleansing performed in the 30 days and three days preceding their baseline study visit. We describe reported cleansing behaviours and used logistic regression to identify correlates of intravaginal cleansing RESULTS: Fifty-eight per cent of participants reported intravaginal cleansing in the previous 30 days, and 46% did so in the three days before baseline. Among those who cleansed in the previous 30 days, 88% reported doing so for hygiene unrelated to sex, and three-fourths reported generally doing so more than once per day. Soap (usually with water) and water alone were the most common products used for washing; commercial douches or detergents were reported infrequently. Intravaginal cleansing in the three days before the baseline visit was positively associated with having more than one sex partner in the previous three months (adjusted odds ratio [AOR], 1.9; 95% CI, 1.1, 3.2), and negatively associated with experiencing itching in the genital area at baseline (AOR, 0.6; 95% CI, 0.4, 1.0). CONCLUSIONS: A large proportion of women attending STI clinics in Jamaica engage in frequent intravaginal cleansing, indicating a need for clinicians to discuss this topic with them accordingly.

OBJETIVOS: Aunque común mundialmente, la limpieza intravaginal se halla asociada con pobres resultados de salud. Buscamos describir la limpieza intravaginal entre mujeres que asisten a una clínica de infecciones de transmisión sexual (ITS) en Jamaica. MÉTODOS: Examinamos la limpieza intravaginal ("lavado del interior de la vagina", ducha, y productos o materiales usados) entre 293 participantes en una prueba aleatoria de mensajes de counseling en una clínica de ITS en Kingston. Las participantes proporcionaron la información sobre la limpieza intravaginal realizada en los 30 y tres días que precedieron a su visita para el estudio inicial. Describimos las conductas de limpieza reportadas y la regresión logística usada para identificar los correlatos de la limpieza intravaginal. RESULTADOS: Cincuenta y ocho por ciento de las participantes reportaron la limpieza intravaginal en los 30 días anteriores, y el 46% lo hicieron en los tres días antes del inicio del estudio. Entre aquéllas que realizaron la limpieza en los 30 días anteriores, el 88% reportó haberlo hecho por razones de higiene independientes de la vida sexual, y tres cuartos reportaron hacerlo de manera general más de una vez al día. Jabón (normalmente con agua) y agua solamente fueron los productos más comunes usados para el lavado. Las duchas comerciales o detergentes no fueron reportadas muy frecuentemente. La limpieza intravaginal en los tres días antes de la visita del estudio inicial estuvo positivamente asociada con tener más de una pareja sexual en los tres meses anteriores (odds ratio ajustado [AOR], 1.9; 95% CI, 1.1, 3.2), y negativamente asociado con experimentar comezón en el área genital al inicio del estudio (AOR, 0.6; 95% CI, 0.4, 1.0). CONCLUSIONES: Un gran número de mujeres que asisten a las clínicas de ITS en Jamaica practican frecuentemente la limpieza intravaginal, lo cual indica la necesidad de que los médicos clínicos discutan este asunto con ellas.

Poverty, folate deficiency, human immunodeficiency virus and ulcerated vulval sexually transmitted diseases in Jamaica.

Sexually transmitted genital ulcerative conditions are declining in Jamaica. The rates at present are far lower than that seen in the 1950s-1960s. Review of the records of the national Comprehensive Clinic has revealed that all of the major sexually transmitted conditions (Syphilis, Lymphogranuloma Venereum (LGV), Chancroid, Granuloma Inguinale and Herpes Simplex) have declined but have had three peaks between 1958 and 2000. Closer review seems to suggest that the peaks were associated firstly with poverty in the 1960s and 1970s and to the HIV epidemic in the 1980s and early 1990s. There are also smaller spikes which appear to be associated with periods of environmental disasters, with a possible association with folate deficiency. This is apparent for the bacterial and chlamydial conditions as well as viral conditions such as Herpes simplex.

Poverty, folate deficiency, human immunodeficiency virus and ulcerated vulval sexually transmitted diseases in Jamaica / Pobreza, deficiencia de ácido fólico, virus de la inmunodeficiencia humana, y la ulceratión de la vulva por enfermedades de transmisión sexual, en Jamaica

Sexually transmitted genital ulcerative conditions are declining in Jamaica. The rates at present are far lower than that seen in the 1950s -1960s. Review of the records of the national Comprehensive Clinic has revealed that all of the major sexually transmitted conditions (Syphilis, Lymphogranuloma Venereum (LGV), Chancroid, Granuloma Inguinale and Herpes Simplex) have declined but have had three peaks between 1958 and 2000. Closer review seems to suggest that the peaks were associated firstly with poverty in the 1960s and 1970s and to the HIV epidemic in the 1980s and early 1990s. There are also smaller spikes which appear to be associated with periods of environmental disasters, with a possible association with folate deficiency. This is apparent for the bacterial and chlamydial conditions as well as viral conditions such as Herpes simplex.

Las condiciones ulcerativas genitales transmitidas sexualmente están disminuyendo en Jamaica. En el presente, los índices son muchos más bajos que los observados en la década de 1950 y 1960 respectivamente. La revisión de los archivos de la llamada Nacional Comprehensive Clinic ha revelado que todas las condiciones principales (sífilis, linfogranuloma venéreo, chancroide, granuloma inguinal, y el herpes simple) han disminuido. No obstante, ha habido tres puntos críticos entre 1958 y 2000. Un examen detallado sugiere que estos picos estaban asociados primeramente con la pobreza en los años 60 y 70, y la epidemia de VIH en la década de los 80 ochenta y principios de los 90. Hay también pequeñas alzas que parecen estar asociados con periodos de desastres medioambientales, así como con una posible asociación con la deficiencia de folato. Esto es evidente en el caso de las condiciones bacterianas y clamidiales, así como las condiciones virales tales como la que representa el herpes simple.

A comprehensive response to the HIV/AIDS epidemic in Jamaica: a review of the past 20 years / Una respuesta integral a la epidemia de VIH/SIDA en 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 HIV prevention, 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.

Jamaica tiene un Programa Integral Nacional del Virus de la Inmunodeficiencia Humana bien establecido, gracias al cual se ha disminuido la epidemia de VIH y mitigado su impacto. La prevalencia del VIH en los adultos se ha mantenido estable en aproximadamente 1.5% desde 1996. Las tasas de VIH son altas entre aquellos que presentan un mayor riesgo, tales como las trabajadoras sexuales (9%) y los hombres que tienen sexo con otros hombres (31.8%). El comportamiento de riesgo entre los adultos con SIDA incluye parejas sexuales múltiples (80%), historia de infección por transmisión sexual (ITS) (51.1%), sexo comercial (23.9%) y crack/cocaína (8.0%). Aproximadamente el 20% de todos los casos de SIDA reportados, principalmente las mujeres, no reportaron historia ninguna de los factores de riesgo usualmente asociados con la infección de VIH. El Programa Nacional tiene su base en el Ministerio de Salud. Desde 1988, Jamaica ha tenido un plan nacional para guiar su respuesta al VIH. En 1988, se creó un Comité Nacional de SIDA con el propósito de dirigir la respuesta multi-sectorial. Los enfoques en relación con la prevención han incluido campañas de información, educación y comunicación, promoción del uso del condón, control de las infecciones por transmisión sexual (ITS), intervenciones dirigidas, enfoques culturales, actividades de vinculo con las comunidades (outreach) y educación entre iguales, programas en el centro de trabajo, así como aconsejamiento y pruebas de VIH. Se han concertado esfuerzos a fin de reducir el estigma y la discriminación por VIH. En 2001, se introdujo la terapia antiretroviral (ARV) para la prevención de la transmisión de madre a hijo en 2001, y un programa de tratamiento de acceso al público fue introducido en 2004. Una Política Nacional en relación con el VIH/SIDA fue adoptada unánimemente por el Parlamento en 2005. Con el Plan Estratégico Nacional 2007-2012, Jamaica se compromete a lograr el acceso universal a la prevención, tratamiento y cuidado del VIH. La conciencia con respecto al VIH y cómo prevenirlo es casi universal, si bien la creencia en mitos relacionados con la enfermedad sigue siendo fuerte. El mercado del condón ha aumentado, de aproximadamente 2.5 millones en 1985 a 12 millones en 2006, mientras que el uso del condón ha crecido significativamente. Así, casi el 75% de los hombres y el 65% de las mujeres reportan haber hecho uso del condón la última vez que tuvieron sexo co su pareja habitual. La proporción de mujeres de 15-24 años que reportan haber tenido prueba de VIH alguna vez, aumentó de 29.8% en 2004 a 48.9% en 2008. La transmisión de VIH de madre a hijo ha disminuido de un 25% antes del año 2000 a menos de un 8% en el 2007. A partir de septiembre de 2008, una cifra de 4450 personas o un estimado de 68.5% de personas con VIH y SIDA avanzados, se han puesto bajo tratamiento ARV, con el resultado de un descenso significativo en la mortalidad y morbilidad por VIH.

Paediatric and perinatal HIV/AIDS in Jamaica: an international leadership initiative, 2002-2007 / VIH/SIDA pediátrico y perinatal en Jamaica: iniciativa de liderazgo internacional, 2002-2007

BACKGROUND: Paediatric and Perinatal HIV/AIDS remain significant health challenges in the Caribbean where the HIV seroprevalence is second only to Sub-Saharan Africa. METHOD: We describe a collaborative approach to the prevention, treatment and care of HIV in pregnant women, infants and children in Jamaica. A team of academic and government healthcare personnel collaborated to address the paediatric and perinatal HIV epidemic in Greater Kingston as a model for Jamaica (population 2.6 million, HIV seroprevalence 1.5%). A five-point plan was utilized and included leadership and training, preventing mother-to-child transmission (pMTCT), treatment and care of women, infants and children, outcomes-based research and local, regional and international outreach. RESULTS: A core group of paediatric/perinatal HIV professionals were trained, including paediatricians, obstetricians, public health practitioners, nurses, microbiologists, data managers, information technology personnel and students to serve Greater Kingston (birth cohort 20 000). During September 2002 to August 2007, over 69 793 pregnant women presented for antenatal care. During these five years, significant improvements occurred in uptake of voluntary counselling (40% to 91%) and HIV-testing (53% to 102%). Eight hundred and eighty-three women tested HIV-positive with seroprevalence rates of 1-2% each year. The use of modified short course zidovudine or nevirapine in the first three years significantly reduced mother-to-child transmission (MTCT) of HIV from 29% to 6% (RR 0.27; 95% CI - 0.10, 0.68). During 2005 to 2007 using maternal highly active antiretroviral therapy (HAART) with zidovudine and lamivudine with either nevirapine, nelfinavir or lopinavir/ritonavir and infant zidovudine and nevirapine, MTCT was further reduced to an estimated 1.6% in Greater Kingston and 4.75% islandwide. In five years, we evaluated 1570 children in four-weekly paediatric infectious diseases clinics in Kingston, St Andrew and St Catherine and in six rural outreach sites throughout Jamaica; 24% (377) had HIV/AIDS and 76% (1193) were HIV-exposed. Among the infected children, 79% (299 of 377) initiated HAART, resulting in reduced HIV-attributable childhood morbidity and mortality islandwide. An outcomes-based research programme was successfully implemented. CONCLUSION: Working collaboratively, our mission of pMTCT of HIV and improving the quality of life for families living and affected by HIV/AIDS in Jamaica is being achieved.

ANTECEDENTES: El VIH/SIDA pediátrico y el perinatal continúan siendo retos significativos para la salud en el Caribe, donde la seroprevalencia de VIH ocupa el segundo lugar tras el África Subsahariana. MÉTODO: Se describe un enfoque colaborativo para tratamiento, prevención y cuidado de embarazadas, bebés y niños en Jamaica. Un equipo de personal académico y gubernamental vinculados a la salud, colaboraron para abordar la epidemia de VIH pediátrico y perinatal en Greater Kingston, como modelo para Jamaica (población de 2.6 millones, 1.5% seroprevalencia VIH). Se utilizó un plan de cinco puntos que incluyó liderazgo y entrenamiento, prevención de la transmisión madre a hijo (PTMAH), tratamiento y cuidado de mujeres, bebés y niños, investigaciones basadas en resultados, y outreach local, regional e internacional. RESULTADOS: Un grupo básico de profesionales del VIH pediátrico/perinatal, que incluía pediatras, obstetras, trabajadores de la salud, enfermeras, microbiólogos, administradores de datos, así como personal y estudiantes de la tecnología de la información, fue entrenado para servir en Greater Kingston (cohorte de nacimiento 20 000). De septiembre de 2002 hasta Agosto de 2007, más de 69 793 embarazadas se presentaron para recibir atención prenatal. Durante estos cinco años, tuvieron lugar mejoras significativos en cuanto a la recepción de asesoramiento (40% to 91%) y pruebas (53% to 102%) de VIH voluntarios. Ochocientos ochenta y tres mujeres resultaron VIH positivas en las pruebas, con tasas de seroprevalencia de 1-2% cada año. El uso de un ciclo corto modificado de zidovudina o nevirapina en los primeros tres años, redujo la transmisión madre a hijo (TMAH) de VIH significativamente de 29% a 6% (RR 0.27; 95% CI - 0.10, 0.68). Durante el 2005 hasta 2007, usando terapia antiretroviral altamente activa (TARAA) materna, con zidovudina y lamivudina con nevirapina, nelfinavir o lopinavir/ritonavir y nevirapina y zidovudina para niños, la TMAH se redujo a un estimado de 1.6 % en Greater Kingston y a .75% a lo largo de la isla. En cinco años, evaluamos 1570 niños en cuatro clínicas infecciosas pediátricas semanales en Kingston, Saint Andrew y Saint Catherine, así como en seis otros lugares destinados al servicio comunitario (outreach) por toda Jamaica; 24% (377) tenían VIH/SIDA y 76% (1193) estaba expuestos al VIH. Entre los niños infectados, 79% (299 de 377) iniciaron el TARAA, lo que trajo como resultado una reducción de la mortalidad y la morbilidad infantil atribuible al VIH, en todo el país. Se implementó exitosamente un programa de investigación basado en resultados. CONCLUSIÓN: Trabajando en colaboración, estamos logrando nuestra misión de prevenir la TMAH del VIH, y mejorar la calidad de vida de las familias que viven afectadas por el VIH/SIDA en Jamaica.

Contact investigation in the prevention of mother-to-child transmission of HIV comparing urban and rural outcomes in Jamaica / Investigación de contactos en la prevención de la transmisión del VIH de madre a hijo comparando los resultados urbanos y rurales en Jamaica

BACKGROUND AND PURPOSE: The contact investigators played a significant role in the decline of infectious syphilis in Jamaica and are likely important players in the prevention of mother-to-child transmission (PMTCT) in the HIV programme. A brief evaluation was done comparing the outcomes of contact investigation in Kingston and St Andrew (KSA) with that of the contact investigation in two rural parishes? METHODS: The interview and field records for the seropositive antenatal clinic attendees for the period October 2004 to September 2005, in urban KSA, were compared with those for rural Clarendon and Portland. RESULTS: HIV seropositive pregnant women (n = 88) were notified and/or referred to the parish contact investigators: 36 in KSA, 9 in Portland and 43 in Clarendon. The time from test date to interview date was almost twice as long for KSA (mean 27 days) than Portland (mean 15.7 days) and thrice that of Clarendon (mean 9 days). Mean disposition (case closure) times were for KSA: 19 days; Portland: 28 days and Clarendon: 15 days. Only 40% of the contacts were located for KSA and 48% of these tested positive for HIV. For Portland, 73% were located and 8% tested positive. For Clarendon, 45% were located and 35% of these tested positive. CONCLUSIONES: On site same day HIV rapid testing is not always available so the contact investigator is an essential member of the pMTCT team in Jamaica. One of the programme outcomes (time to interview) was longer in the urban than the rural parishes while others (time to resolution of the case and percentage of contacts located and tested) had no consistent urban-rural differences.

ANTECEDENTES Y PROPÓSITO: Los investigadores de contactos desempeñaron un papel significativo en el disminución de la sífilis infecciosa en Jamaica, y son probablemente agentes importantes en la prevención de la transmisión del VIH de madre a hijo dentro del programa de VIH. Se realizó una breve evaluación comparando los resultados de las investigaciones de contactos en Kingston y Saint Andrew (KSA) con los de la investigación de contactos en dos provincias rurales. MÉTODOS: Los datos de entrevistas y de campo de los asistentes seropositivas a la clínica de atención prenatal para el período comprendido desde octubre de 2004 a septiembre de 2005 en el perímetro urbano KSA, fueron comparados con los de las rurales Clarendon y Pórtland. RESULTADOS: Las mujeres embarazadas VIH seropositivas (n = 88) fueron notificadas y/o referidas a los investigadores de contactos de las provincias: 36 en KSA, 9 en Portland y 43 en Clarendon. El tiempo de la fecha de prueba a la fecha de la entrevista fue casi el doble para KSA (promedio 27 días) en comparación con Pórtland (promedio 15.7 días) y tres veces mayor que el de Clarendon (promedio 9 días). Los tiempos de disposición promedio (cierre de caso) fueron como sigue: KSA, 19 días; Port-land, 28 días; y Clarendon, 15 días. Sólo el 40% de los contactos fueron localizados para KSA y el 48% de estos resultaron VIH positivos a las pruebas. Para Pórtland, 73% fueron localizados y 8% resultaron positivos. Para Clarendon, 45% fueron localizados y 35% de estos resultaron positivos. CONCLUSIONES: No siempre hay pruebas de VIH rápidas disponibles para su realización en el mismo lugar el mismo día, de manera que el investigador de contactos es un miembro esencial del team PMTCT en Jamaica. Uno de los resultados del programa (tiempo de entrevista) tuvo mayor duración en las provincias urbanas que en las rurales, en tanto que otros (tiempo de solución del caso y porcentaje de contactos localizados y sometidos a prueba) no mostraron diferencias consistentes urbano-rurales.

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

Paediatric and perinatal HIV/AIDS in Jamaica an international leadership initiative, 2002-2007.

BACKGROUND: Paediatric and Perinatal HIV/AIDS remain significant health challenges in the Caribbean where the HIV seroprevalence is second only to Sub-Saharan Africa. METHOD: We describe a collaborative approach to the prevention, treatment and care ofHIVin pregnant women, infants and children in Jamaica. A team of academic and government healthcare personnel collaborated to address the paediatric and perinatal HIV epidemic in Greater Kingston as a model for Jamaica (population 2.6 million, HIV seroprevalence 1.5%). A five-point plan was utilized and included leadership and training, preventing mother-to-child transmission (pMTCT), treatment and care of women, infants and children, outcomes-based research and local, regional and international outreach. RESULTS: A core group of paediatric/perinatal HIV professionals were trained, including paediatricians, obstetricians, public health practitioners, nurses, microbiologists, data managers, information technology personnel and students to serve Greater Kingston (birth cohort 20,000). During September 2002 to August 2007, over 69 793 pregnant women presented for antenatal care. During these five years, significant improvements occurred in uptake of voluntary counselling (40% to 91%) and HIV-testing (53% to 102%). Eight hundred and eighty-three women tested HIV-positive with seroprevalence rates of 1-2% each year The use of modified short course zidovudine or nevirapine in the first three years significantly reduced mother-to-child transmission (MTCT) of HIV from 29% to 6% (RR 0.27; 95%0 CI--0.10, 0.68). During 2005 to 2007 using maternal highly active antiretroviral therapy (HAART) with zidovudine and lamivudine with either nevirapine, nelfinavir or lopinavir/ritonavir and infant zidovudine and nevirapine, MTCT was further reduced to an estimated 1.6% in Greater Kingston and 4.75% islandwide. In five years, we evaluated 1570 children in four-weekly paediatric infectious diseases clinics in Kingston, St Andrew and St Catherine and in six rural outreach sites throughout Jamaica; 24% (377) had HIV/AIDS and 76% (1193) were HIV-exposed. Among the infected children, 79% (299 of 377) initiated HAART resulting in reduced HIV-attributable childhood morbidity and mortality islandwide. An outcomes-based research programme was successfully implemented. CONCLUSION: Working collaboratively, our mission of pMTCT of HIV and improving the quality of life for families living and affected by HIV/AIDS in Jamaica is being achieved.

Contact investigation in the prevention of mother-to-child transmission of HIV comparing urban and rural outcomes in Jamaica.

BACKGROUND AND PURPOSE: The contact investigators played a significant role in the decline of infectious syphilis in Jamaica and are likely important players in the prevention of mother-to-child transmission (PMTCT) in the HIV programme. A brief evaluation was done comparing the outcomes of contact investigation in Kingston and St. Andrew (KSA) with that of the contact investigation in two rural parishes. METHODS: The interview and field records for the seropositive antenatal clinic attendees for the period October 2004 to September 2005, in urban KSA, were compared with those for rural Clarendon and Portland. RESULTS: HIV seropositive pregnant women (n=88) were notified and/or referred to the parish contact investigators: 36 in KSA, 9 in Portland and 43 in Clarendon. The time from test date to interview date was almost twice as long for KSA (mean 27 days) than Portland (mean 15.7 days) and thrice that of Clarendon (mean 9 days). Mean disposition (case closure) times were for KSA: 19 days; Portland: 28 days and Clarendon: 15 days. Only 40% of the contacts were located for KSA and 48% of these tested positive for HIV For Portland, 73% were located and 8% tested positive. For Clarendon, 45% were located and 35% of these tested positive. CONCLUSIONS: On site same day HIV rapid testing is not always available so the contact investigator is an essential member of the pMTCT team in Jamaica. One of the programme outcomes (time to interview) was longer in the urban than the rural parishes while others (time to resolution of the case and percentage of contacts located and tested) had no consistent urban-rural differences.

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.

Hepatitis B and C viruses and sexually transmitted disease patients in Jamaica.

OBJECTIVES: To determine the prevalence of hepatitis C virus (HCV), hepatitis B virus (HBV), human immunodeficiency virus (HIV) infections, and risk factors for HCV and HBV infections in sexually transmitted disease (STD) clinics in Jamaica. METHODS: A prospective observational cohort study was carried out. Blood was collected from 485 consecutive patients attending the comprehensive health centre in Kingston, Jamaica. Serum was tested using commercially prepared reagents and standard procedures for antibodies to HCV (anti-HCV), hepatitis B core antigen (anti-HBc), hepatitis B surface antigen (HBsAg), HIV-1 infection, and syphilitic infection. Sociodemographic and sexual characteristics of the patients were recorded for assessment as risk factors for HCV and HBV infections. RESULTS: None of the patients had anti-HCV, 21.0% had anti-HBc, 3.2% HBsAg, 2.5% tested positive for HIV-1, and 5.2% had reactive serological test for syphilis. Age was the only independent risk factor identified for anti-HBc positivity. CONCLUSIONS: The data obtained in this study were not in support of sexual transmission of HCV or HBV infections in Jamaica. Carefully designed multicentre studies could provide more consistent information on the transmission of these viruses by sexual routes.

Risky behaviour in Jamaican adolescent patients attending a sexually transmitted disease clinic

The prevalence of sexually transmitted diseases (STD) and risky behaviour patterns were studied in 165 adolescents attending a STD clinic in Jamaica. A standardised structured questionnaire, clinical algorithms for STD and serological tests for HIV and syphilitic infection were applied. High prevalences of risky behaviour including young age at onset of sexual activity, especially in boys, (mean age 12.5 ñ 2.5 years); unprotected sexual intercourse (only 4 percent used condoms consistently); multiple sexual partners (mean 3.8 ñ 2.4 and 1.8 ñ 1.2 for boys and girls, respectively were found. Marijuana, used by 60 percent of the boys, was an independent risk factor for dysuria (adjusted Odds Ratio (OR), 2.0; 95 prcent CI, 1.6 - 3.4). Repeated episodes of STD (33 percent), coinfection with HIV (1.2 percent), syphilis (1.2 percent) and teenage pregnancy (13 percent) were prominent findings. Educational strategies which promote behaviour intervention at an early age, frequent and consistent use of condoms, abstinence or delayed onset of sexual activity are essential to reducing the HIV/AIDS and STD risk in adolescents in Jamaica.(Au)

Risky behaviour in Jamaican adolescent patients attending a sexually transmitted disease clinic

The prevalence of sexually transmitted diseases (STD) and risky behaviour patterns were studied in 165 adolescents attending a STD clinic in Jamaica. A standardised structured questionnaire, clinical algorithms for STD and serological tests for HIV and syphilitic infection were applied. High prevalences of risky behaviour including young age at onset of sexual activity, especially in boys, (mean age 12.5 +/- 2.5 years); unprotected sexual intercourse (only 4 used condoms consistently); multiple sexual partners (mean 3.8 +/- 2.4 and 1.8 +/- 1.2 for boys and girls, respectively) were found. Marijuana, used by 60 of the boys, was an independent risk factor for dysuria (adjusted Odds Ratio (OR), 2.0; 95 CI, 1.6-3.4). Repeated episodes of STD (33), coinfection with HIV (1.2), syphilis (1.2) and teenage pregnancy (13) were prominent findings. Educational strategies which promote behaviour intervention at an early age, frequent and consistent use of condoms, abstinence or delayed onset of sexual activity are essential to reducing the HIV/AIDS and STD risk in adolescents in Jamaica.

Vaginal infections in pregnant women in Jamaica: prevalence and risk factors.

Trichomoniasis, bacterial vaginosis (BV) and candidiasis are reproductive tract infections (RTIs) of the vagina. We conducted a cross-sectional study in 4 prenatal clinics in Kingston, Jamaica, to estimate the prevalence of these infections and the risk factors that may facilitate their transmission among pregnant women. Of the 269 women studied, 18.0% had culture-positive trichomoniasis, 44.1% had BV (Nugent score > or = 7) and 30.7% were positive for candidiasis by wet mount. A multiple logistic regression analysis showed that having a malodorous discharge was associated with trichomoniasis (odd ratios [OR]=3.9, confidence intervals [CI]=1.04-14.7) and BV (OR=3.4, CI=1.3-8.7). Women who took action to prevent HIV infection had lower BV prevalence (OR=0.34, CI=0.12-0.98). Women who were employed were less likely to have any of the infections (OR=0.61, CI=0.36-1.03). The strong association of a symptomatic presentation with trichomoniasis and BV suggests the merit of considering syndromic management of vaginitis in this population.

Risky behaviour in Jamaican adolescent patients attending a sexually transmitted disease clinic.

The prevalence of sexually transmitted diseases (STD) and risky behaviour patterns were studied in 165 adolescents attending a STD clinic in Jamaica. A standardised structured questionnaire, clinical algorithms for STD and serological tests for HIV and syphilitic infection were applied. High prevalences of risky behaviour including young age at onset of sexual activity, especially in boys, (mean age 12.5 +/- 2.5 years); unprotected sexual intercourse (only 4% used condoms consistently); multiple sexual partners (mean 3.8 +/- 2.4 and 1.8 +/- 1.2 for boys and girls, respectively) were found. Marijuana, used by 60% of the boys, was an independent risk factor for dysuria (adjusted Odds Ratio (OR), 2.0; 95% CI, 1.6-3.4). Repeated episodes of STD (33%), coinfection with HIV (1.2%), syphilis (1.2%) and teenage pregnancy (13%) were prominent findings. Educational strategies which promote behaviour intervention at an early age, frequent and consistent use of condoms, abstinence or delayed onset of sexual activity are essential to reducing the HIV/AIDS and STD risk in adolescents in Jamaica.

High prevalence of genital Chlamydia trachomatis infection in women presenting in different clinical settings in Jamaica: implications for control strategies

OBJECTIVE: To determine the prevalence of genital Chlamydia trachomatis infection and risk factors in women attending family planning, gynaecology, and sexually transmitted disease (STD) clinics in Jamaica. METHODS: Endocervical specimens from 645 women including 238 family planning, 170 gynaecology, and 237 STD clinic attendees were examined for C trachomatis using a direct fluorescence assay (DFA) and culture. Investigations were carried out for the presence of other STD pathogens and demographic, behavioural, historical, and clinical data recorded for each participant. RESULTS: The prevalence of C trachomatis infection was 35 percent, 47 percent, and 55 percent in family planning, gynaecology, and STD clinic clients, respectively. The performance of the DFA was comparable to that of culture in screening for C trachomatis. Logistic regression analysis revealed that the independent risk factors for C trachomatis were non-barrier contraceptive methods in family planning clients (OR = 2.1; 95 percent confidence interval (CI) = 1.2 - 3.9; p= 0.0110), cervical ectopy in gynaecology clients (OR = 3.9; 95 percent CI = 1.4 - 10.6; p= 0.0076) and concomitant Trichomonas vaginalis infection in STD clients (OR = 3.5; 95 percent CI = 1.8 - 6.8; p = 0.003). Age, number of sex partners, and reason for visit were not identified as risk factors for C trachomatis infection. CONCLUSIONS: Consistently high prevalence if C trachomatis infection occurs in Jamaican women. Universal screening or presumptive treatment should be evaluated as prevention and control measures for C trachomatis infection in this population where all women appear to be at risk. (AU)

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.