Providing low-cost sexually transmitted diseases services in two semi-urban health centers in Central African Republic (CAR): characteristics of patients and patterns of health care-seeking behavior.

BACKGROUND: While treatment of symptomatic sexually transmitted diseases (STDs) has been shown to reduce the incidence of HIV infection, there are few published reports describing the delivery of high quality STD care in Africa. GOAL: To test the feasibility of providing comprehensive, affordable STD services through the existing primary care infrastructure. DESIGN: STD treatment services using a syndromic' approach were established in two semi-urban hospital outpatient departments (OPD) in Central African Republic (CAR). A dedicated paramedical provider took a clinical history, performed an examination, explained the diagnosis and the importance of referring partners, dispensed drugs, and offered partner referral vouchers. A fee-for-service system was used to resupply drugs initially purchased with project funds. RESULTS: Of 9,552 visits by index patients and partners over a 28-month period starting in October 1993, 60% were made by women; of these women, 90% were symptomatic, 77% had "vaginal discharge," 70% "lower abdominal pain," and 7% "genital ulcer." Among men, 64 % were symptomatic, 38 % had "urethral discharge," and 14% "genital ulcer." Half of all symptomatic patients presented within 1 week of the onset of symptoms; 44% of men compared to 18% of women had sought care elsewhere before the clinic visit. The average cost per STD treated with recommended drugs was $3.90. Etiologic data from subpopulations in both sites suggest that a high proportion of patients was infected with an STD. CONCLUSIONS: Comprehensive yet affordable care for STDs in persons (and their partners) who recognize symptoms is feasible and should be widely implemented in primary care systems to prevent the spread and complications of STDs and HIV in Africa.

PIP: This study examines the feasibility of providing comprehensive, low-cost sexually transmitted disease (STD) services through the existing primary care infrastructure in two semi-urban health centers in the Central African Republic. The results showed that out of the 9552 visits made by index patients and partners over a 28-month period, 60% were made by women. Among these women, 90% were symptomatic, 77% had vaginal discharge, 70% had lower abdominal pain, and 7% had genital ulcer. In addition, 44% of men, as compared to 18% of women, had looked for treatment elsewhere prior to the clinic visit. The average cost per STD treated with the recommended drugs was $3.90. Furthermore, condom use was low in both areas and etiologic data suggest that a large proportion of patients was infected with an STD. The findings suggest that a comprehensive and affordable model for STD control can be implemented in primary care systems to prevent the spread of STDs in Africa.

Patient-led partner referral enhances sexually transmitted disease service delivery in two towns in the Central African Republic.

In Bambari and Bria, 2 towns in the Central African Republic (CAR), we analysed a patient-led partner referral programme within enhanced sexually transmitted disease (STD) services. New (index) patients received syndromic management, counselling about notifying and treating contacts, and vouchers for distribution. From October 1993 to February 1996, 5232 and 4320 patient visits, of which 1814 (35%) and 4320 (30%) were contact referral visits, were logged in Bambari and Bria, respectively. Vouchers were distributed for at least 90% of contacts. Index and contact patients had similar age and sex distributions. In both towns, having a spouse (Bambari: odds ratio [OR] 1.5, 95% confidence interval [CI] 1.4-1.7; Bria: OR 1.9, 95% CI 1.5-2.3) was a factor associated with successful referral of a partner. Successful referral was accomplished by both male and female patients. Appropriate counselling techniques and vouchers facilitated partner referral. Further research on how to reach casual partners would enhance STD control efforts using patient-led partner referral.

Predictors of rape in the Central African Republic.

This is a study of women in the Central African Republic (CAR) whose first sexual encounter was the result of rape. The analyses presented here are based on a national HIV/AIDS survey conducted in 1989. Respondents were selected through multistage cluster sampling, where census districts and households within districts were randomly selected. A total of 1307 females responded to the question regarding the circumstances of their first intercourse. Nearly 22% of female respondents reported that their first experience with intercourse was rape. Bivariate analyses found that rape during first intercourse was significantly related to the following respondent characteristics at the time of the survey: age, marital status, having a child, education, occupation, urban versus rural living, ethnic group, age at first date, and consumption of alcohol. Rape was not significantly related to ability to read, religion, and years in current village or town. Rape during first intercourse was found in a stepwise logistic regression to be related to age, marital status, occupation, and ethnic group. These data indicate that the incidence of rape is higher than previously reported in Africa, there are specific risk factors, and there are serious negative consequences.

Association between HIV1 infection and sexually transmitted disease among men in Central Africa.

In Africa, heterosexual contact is the major route of transmission of the human immunodeficiency virus (HIV). Previous studies have strongly suggested that other sexually transmitted diseases (STD) may facilitate HIV transmission. However, the association of HIV infection with other STD may simply be a marker of sexual promiscuity. Thus, we compared the association of different STD, HIV status, and sexual behaviour of 160 STD patients and 95 STD-free control individuals. Results showed that STD patients differed from controls in most of the sociological and behavioural parameters, as well as in HIV serological status. Within the STD group, people with genital ulcer disease (GUD) (n = 62) were more likely to be HIV-seropositive (21%) than people with urethritis (n = 98, 11.2%). Meanwhile, there was almost no difference in the sociological and behavioural parameters between the GUD and the urethritis group. Thus, our results reinforce the specific role of mucosal breakage (i.e. genital ulcers) in the transmission of HIV.

[Quantitative and qualitative anomalies of sperm in African individuals infected with HIV]. / Anomalies quantitatives et qualitatives du sperme chez des individus africains infectés par le VIH1.

Semen from 16 HIV1-infected african individuals (12 at stage II/CDC; 4 with pre-AIDS) has been analyzed both quantitatively (volume; number of spermatozoa) and qualitatively (motility). 12 healthy HIV1-seronegative individuals were recruited as controls. The HIV1-infected patients showed generally abnormalities of the semen: oligospermia (7 cases), azoospermia (3 cases), or asthenospermia (10 cases). These abnormalities were more marked in patients at advanced stages of the HIV infection. In comparison with the control group, the HIV1-infected individuals had more frequently a past history of sexually transmitted diseases. These abnormalities in the composition of the semen in HIV1-infected african individuals could affect the fertility of these men; that could indirectly restrict the risk of congenitally HIV contaminated child.

Evaluation of a method for rapid detection of penicillinase-producing Neisseria gonorrhoeae in urethral exudates.

A substrate, pyridine-2-azo-p-dimethylaniline cephalosporin (PADAC; Diagnostic Pasteur, Marnes-La-Coquette, France), for detection of penicillinase-producing Neisseria gonorrhoeae (PPNG) on isolated colonies grown on agar was compared with the nitrocefin reference test (Cefinase; Biomerieux, Marcy l'Etoile, France). The PADAC test was also used to detect PPNG directly on urethral exudates. All 38 PPNG-containing and 29 of 30 PPNG-negative urethral pus isolates gave results in agreement with those obtained on cultured isolates. We conclude that direct detection of PPNG in urethral exudates from males is simple, rapid, reliable, and sensitive.