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 the multiplex polymerase chain reaction (M-PCR) analysis DNA from herpes simplex virus (HSV), Haemophilus ducreyi, and Treponema pallidum was detected in 158 (52.0 percent), 72 (23.7 percent), and 31 (10.2 percent) of 304 ulcer specimens. Of the 304 subjects, 67 (22 percent) were HIV-seropositive and 64 (21 percent) were T. pallidum-seroactive. Granuloma inguinale was clinically diagnosed in nine (13.4 percent) of 67 ulcers negative by M-PCR analysis and in 12 (5.1 percent) 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 percent, 53.8 percent, and 75 percent and 91.2 percent, 83.6 percent, and 75.4 percent, respectively. Reactive syphilis serology was 74 percent sensitive and 85 percent 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 pleads for syndromic management of genital ulcers in Jamaica. Prevention efforts should be intensified.(Au)

HDV 16 antibody prevalence in Jamaica and the United States reflects differences in cervical cancer rates

Human papillomavirus (HPV) is widely accepted as the primary etiologic agent in the development of cervical cancer. DNA of a particular HPV type, HPV 16, is found in about half of tumors tested. Inconsistent with this causal relationship, however, population-based studies of HPV DNA prevalence have often failed to find high rates of anogenital HPV infection in countries with high cervical cancer rates. To examine this issue, we used serology to compare HPV 16 exposure in healthy volunteer blood donors in the United States (n = 278) and similar subjects from a country with 3-fold higher cervical cancer rates, Jamaica (n = 257). Jamaican sexually transmitted disease (STD) patients (n = 831) were also studied to examine in detail the relation of HPV 16 antibodies with sexual history. Serology was conducted using an ELISA employing HPV 16 virus-like particles (VLPs). Age-adjusted seroprevalence rates were greatest among male (29 percent) and female (42 percent) STD patients, intermediate in male (19 percent) and female (24 percent) Jamaican blood donors and lowest among male (3 percent) and female (12 percent) U.S. blood donors. The higher seroprevalence in women was significant, and prevalence tended to increase with age. In multivariate logistic regression, controlling for age and gender, Jamaican blood donors were 4.2-fold (95 percent CI 2.4 - 7.2) and STD patients 8.1-fold (95 percent CI 5.0 - 13.2) more likely to have HPV 16 VLP antibodies than U.S. blood donors. Among STD patients, HPV 16 antibodies were associated with lifetime number of sex partners and years of sexual activity, as well as other factors. Our data suggest that HPV 16 VLP antibodies are strongly associated with sexual behavior. Moreover, exposure to HPV 16 appears to be much greater in Jamaica than in the United States, consistent with the high rate of cervical cancer in Jamaica (Au)

HIV/STD control in Jamaica

Reported AIDS case rates in the Caribbean, with the notable exception of Cuba, tend to be relatively high. While the pattern of HIV spread does vary among the different Caribbean countries, the HIV/AIDS epidemic in Jamaica appears to be less developed than that found in most other Caribbean territories, except Cuba. Jamaica has a comprehensive HIV/STD control programme which, since the late 1980s, pioneered the integration of HIV and STD, contact tracing of persons with HIV/AIDS, syndromic management of STDs, a variety of innovative behaviour change communications programmes, the promotion of condom use for all sexual encounters and a policy of dual method use, i.e., an effective family planning method and the condom. A unique National AIDS Committee was established in 1988 and research had been used widely to guide the development of the HIV/AIDs control programme and evaluate its progress. The annual AIDS case rate in Jamaica has increased only marginally in the past 3 years from 18.5 per 100 000 population in 1995 to 21.4 in 1997. HIV prevalence in the general population groups tested has been about 1 percent or less, 6.3 percent in STD clinic attenders, around 10 percent and 20 percent in female prostitutes in Kingston and Montego Bay, respectively, and approximately 30 percent among homosexuals. Syphilis rates have declined and condom use has increased considerably. HIV/AIDS control measures have apparently slowed the HIV/AIDS epidemic in Jamaica; however, a significant minority of persons continue to have unprotected sex in high risk situations.(AU)

Aetiology of genital ulcer disease in patients attending an STD clinic in Kingston, Jamaica

The purpose of this study was to determine the aetiology of genital ulcers (GUD) in STD clinic attenders, using state-of-the-art diagnostic tests, and to compare this with clinical diagnosis. Patients attending an STD clinic in Kingston, Jamaica for a new STD complaints were screened for GUD and clinically diagnosed. Swabs of ulcers were taken and tested for T. pallidum (TP), herpes simplex virus (HSV), and H. ducreyi (HD), using polymerase chain reaction (PCR). Sera were tested for syphilis and HIV infection. Of 4873 patients screened, 304 (6.2 percent) had GUD. In patients with ulcers, 158 (52 percent) were HSV (+), 73 (24 percent) were HD (+), and 31 (10 percent) were TP (+). Dual infections were identified in 20 (7 percent) ulcers. Clinically, herpes was diagnosed in 85/158 (54 percent) of HSV (+) ulcers, chancroid in 54/72 (75 percent) of HD (+) ulcers, and syphilis in 21/31 (68 percent) of TP (+) ulcers. Over three-quarters of GUD in Kingston had defined aetiology for herpes, chancroid or syphilis using PCR, with herpes being the commonest. Uniformly, clinical diagnosis performed poorly and Jamaican algorithms for the management of GUD will need to take into account the findings of this study, and should include counselling for herpes.(AU)

Is HIV/STD control in Jamaica making a difference?

A comprehensive HIV/STD control programme has been established in Jamaica since the late 1980s. AIDS case reports and HIV testing of blood donors, antenatal clinic attenders (ANC), food service workers, 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 1989, 1992, 1994 and 1996. The annual AIDS case rate in Jamaica has remained stable at around 20 per 100,000 population since 1995. HIV prevalence in the general population groups test has been about 1 percent or less. Among those at high risk, HIV infection rates have risen to 6.3 percent in STD clinic attenders, around 10 percent and 20 percent in female prostitutes in Kingston and Montego Bay, respectively, and approximately 30 percent among homosexuals. Syphilis rates and congenital syphilis cases have declined. Condom use had increased considerably: use on last sex with a non-regular partner was 77 percent for men and increased from 37 percent in 1992 to 73 percent in 1996 for women. Condom sales and distribution increased from 2 million in 1985 to 10 million in 1995. HIV/STD control measures appear to have slowed the HIV/AIDS epidemic in Jamaica, but a significant minority of the population continue to have unprotected sex in high risk situations.(AU)

Improving sexually transmitted disease management in the private sector: the Jamaica experience

OBJECTIVES: To improve the quality of sexually transmitted disease (STD) case management in Jamaica by providing comprehensive continuing medical education to private practitioners who manage 60 percent of all STDs on the island. METHODS: Six half-day STD seminars were presented at 3-4 month intervals and repeated in three separate geographic locations. All Jamaican practitioners received invitations. The subjects were as follows: urethritis, genital ulcer disease, HIV infection, vaginal discharge syndrome, STDs in children and adolescents, and a review seminar. The program effectiveness was evaluted with a written, self-reported pre-test and a telephone post-test that measured changes in clinical management. RESULTS: Six hundred and twenty eight practitioners attended at least one seminar. Comparing pre-versus post-test scores, there were practitioner improvement trends in all four of the general STD management categories: counseling/education (69.8-73.3 percent; P > 0.05); diagnostics/screening (57.2-71.0 percent; P = 0.042); treatment (68.3-74.5 percent; P > 0.05)l and knowledge (66.4-83.2 percent; P = 0.002). Obtaining syphilis serologies during pregnancy rose from 38.3 to 83.8 percent (P = 0.001), and providing effective treatment for gonorrhea rose form 57.8 to 81.1 percent (P = 0.002), but correct responses on treatment for mucopurulent cervicitis at the post-test was a low 32.4 percent. CONCLUSION: The introduction of contiuing medical education for improved STD care targetting private physicians in Jamaica was successful based on high attendance rates and self-reported STD management practices. However, efforts should continue to address the weaknesses found in STD management and counseling and to reach the providers who did not participate. In the global effort to reduce HIV transmission by improving STD care services. continuing education programs that target the private sector can be successful and should be included as standard activity to improve care and providee a public/private link to STD/HIV control.(Au)

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

OBJECTIVE: To determine in 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 microimmuofluorescence (MIF) test. RESULTS: The DFA detect C trachomatis in 16 percent (21/129) of the specimens. The prevalence as determined by the iodine and fluorescein stained cultures was 24 percent (31/129) and 25 percent (33/129) respectively. The overall prevalence of current chalmydial infection detected by the isolation techniques used was 25 percent (33/129). As determined by the MIF test, a statistically significantly higher seroprevalence rate of C trachomatis (95 percent, 61/64) was found in CSSW compared with blood donors (53 percent, 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 percent) and Candida albicans (7 percent) were found in comparatively low frequencies, while Trichomonas vaginalis (0 percent) 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 sequeles of C trachomatis infection, the diagnosis and treatment in such high risk groups such as CSSW should be optimised.(AU)

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 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 percent of 23,050 patients had GUD, men (9.3 percent) more often than women (4.2 percent; p < 0.001). In 1990/91 the prevalence rate was 12.8 percent with increased rates for both men (18.2 percent) and women (6.8 percent; 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 percent and 7.8 percent of the patients; syphilis, in 12.9 percent and 18.8 percent; chancroid, in 12.4 percent and 13.3 percent; viral warts, in 5.7 percent and 6.3 percent; lymphogranuloma venereum, in 4.1 percent and 3.9 percent; and granuloma inguinale, in 3.6 percent and 2.3 percent. In men the rate for syphilis was 19 percent in 1990/91 and 8 percent in 1982/83 (p=0.001); and for genital herpes it was 7 percent in 1990/91 and 17 percent 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 percent of cases in 1982/83 (particularly in men), and in 47.6 percent of cases in 1990/91. GUDs faciltate transmission and adversely affect the prognosis of HIV. The increase in their prevalence has implications for the evolution of the local HIV epidemic, and hould be addressed effectively by stregthening the STD/HIV control programme.

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 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 percent of 23,050 patients had GUD, men (9.3 percent) more often than women (4.2 percent; p < 0.001). In 1990/91 the prevalence rate was 12.8 percent with increased rates for both men (18.2 percent) and women (6.8 percent; 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 percent and 7.8 percent of the patients; syphilis, in 12.9 percent and 18.8 percent; chancroid, in 12.4 percent and 13.3 percent; viral warts, in 5.7 percent and 6.3 percent; lymphogranuloma venereum, in 4.1 percent and 3.9 percent; and granuloma inguinale, in 3.6 percent and 2.3 percent. In men the rate for syphilis was 19 percent in 1990/91 and 8 percent in 1982/83 (p=0.001); and for genital herpes it was 7 percent in 1990/91 and 17 percent 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 percent of cases in 1982/83 (particularly in men), and in 47.6 percent of cases in 1990/91. GUDs faciltate 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 stregthening the STD/HIV control programme.(AU)

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 percent, 333 men and 377 women) were reexamined between January 1992 and July 1993 to estimated the incidence of HIV and HTLV-1 infection and to identify risk factors for infection. Of those reexamined, 20 percent were recruited passively when they returned to the clinic of their own accord, and 80 percent 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 women became HIV positive during the period of follow-up. The overall HIV incidence rate was 0.7 per 100 person years (95 percent confidence interval [CI] = 0.3 to 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-1 positive, and 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-1 infection was associated with an age of 30 years or older (p < 0.01). The presumed lower transmission probability for HTV-1 may combine with a higher prevalence of HTLV-1 in sexual partners to produce similar overall incidence rates for the two infections. The HIV and HTLV-1 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 partner 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(AU)

Survey of patients with sexually transmitted diseases seen by private physicans 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 percent) 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 percent) patients were being seen for the first time for symptomatic STDs, and the visit was a follow-up for 132 (19 percent) who had been previously diagnosed; 40 (6 percent) patients were asymptomatic contacts referred by a sex partner, and 12 (2 percent), who were asymptomatic, asked for a "check up". A history of previous STD was given by 358 (52 percent) patients. 470 (69 percent) patients had a genital discharge (M, 65 percent; F, 73 percent; p = 0.017), 52 (8 percent) had anogenital lesions (M, 10 percent; F, 5 percent; p = 0.013) and 45 (7 percent), inguinal lymphadenopathy (M, 10 percent; F, 3 percent; p = 0.002). Among women, 131 (40 percent) had lower abdominal pain on examination and 105 (32 percent) had cervical excitation tenderness or pain suggesting pelvic inflammatory disease (PID). A working diagnosis of gonorrhoea was made in 273 (40 percent) patients, trichomoniasis in 121 (18 percent), nongonococcal infection in 114 (17 percent), syphilis in 60 (9 percent), herpes genitalis in 20 (3 percent) and chancroid in 11 (2 percent). PID was diagnosed in 121 (37 percent) women and nongonococcal urethritis in 98 (28 percent) men. The most frequently prescribed treatments were for chlamydia, gonorrhoea and trichomoniasis. In general, working diagnoses correlated 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.

The decentralization of syphilis screening for improved care in Jamaican public clinics: Collaborative Working Group on Decentralization Syphilis Screening

OBJECTIVES: This study examined the decentralization of syphilis screening for improved care in Jamaican public clinics. METHODS: One of every five serum samples tested at the six peripheral sites was frozen and retested at the central laboratory in Kingston. Patient files and laboratory logbooks were compared over a 3-month period. RESULTS: Between May 1993 and December 1994, 15.5 percent of 32913 patients with sexually transmitted disease and 8.3 percent of 8914 women seeking prenatal care were found syphilis seroreactive. Of 2001 samples evaluated, 1933 (96.6 percent) had been correctly reported at the peripheral sites. Of 129 syphilis seroreactors detected at the peripheral sites, 88 (68 percent) were treated the same day and 21 (16 percent) more within 3 days after testing. CONCLUSIONS: Syphilis seroreactors were accurately detected and quickly treated at the peripheral sites. If these efforts can be sustained, Jamaican syphilis rates should decrease.(AU)

Survey of patients with sexually transmitted diseases seen by private physicans 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 percent) 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 percent) patients were being seen for the first time for symptomatic STDs, and the visit was a follow-up for 132 (19 percent) who had been previously diagnosed; 40 (6 percent) patients were asymptomatic contacts referred by a sex partner, and 12 (2 percent), who were asymptomatic, asked for a "check up". A history of previous STD was given by 358 (52 percent) patients. 470 (69 percent) patients had a genital discharge (M, 65 percent; F, 73 percent; p = 0.017), 52 (8 percent) had anogenital lesions (M, 10 percent; F, 5 percent; p = 0.013) and 45 (7 percent), inguinal lymphadenopathy (M, 10 percent; F, 3 percent; p = 0.002). Among women, 131 (40 percent) had lower abdominal pain on examination and 105 (32 percent) had cervical excitation tenderness or pain suggesting pelvic inflammatory disease (PID). A working diagnosis of gonorrhoea was made in 273 (40 percent) patients, trichomoniasis in 121 (18 percent), nongonococcal infection in 114 (17 percent), syphilis in 60 (9 percent), herpes genitalis in 20 (3 percent) and chancroid in 11 (2 percent). PID was diagnosed in 121 (37 percent) women and nongonococcal urethritis in 98 (28 percent) men. The most frequently prescribed treatments were for chlamydia, gonorrhoea and trichomoniasis. In general, working diagnoses correlated 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. (AU)

Risk factors associated with STD/HIV seropositivity among female commercial sex workers (FCSWs)-implications for an integrated intervention strategy - abstract

HIV seropositivity is still relatively low in the general population in Jamaica. An initial study in Kingston identified an HIV prevalence of 12 percentage among female commercial sex workers (FCSWs). This study among Montego Bay FCSWs was to determine the prevalence of HIV/STD and identify risk factors associated with HIV seropositivity at initial presentation to a screening service [Women Health Interventions (WHI), ACOSTRAD project]. From August 1994 to October 1995, a detailed sexual history, a full physical examination, voluntary laboratory examination for syphilis and HIV infection were conducted on 143 FCSWs and a questionnaire administered. 25 percent of the FCSWs were seropositive for HIV infection (CI=17.6, 33.0) and 34 percent had a positive serological test for syphilis (CI=26.1, 42.3). Significant associations were found between HIV seropositivity and duration of time in prostitution greater than or equal to 5 years (OR=2.60 CI=1.10, 6.15); living alone with no regular partner (OR=3.90 CI=1.36, 11.21); number of different sex partners (paying and nonpaying) during this last week > two (OR=2.86 CI=1.25, 6.54), number of paying customers this last week> five (OR=2.57 CI=1.10, 5.99). Partners' cocaine use (p=0.003), "ever had syphilis" (p=0.009),"ever had sores on genitals" (0.013), were also significantly correlated with HIV seropositivity. No significant associations were noted with condom use during last sex act, sexual practices, self reported drug use and past history of other common STDs. The seroprevalence of HIV among FCSWs in Montego Bay is high. Strategies to decrease the prevalence of prostitution and create other opportunities for FCSWs are urgently needed (AU)

Genital ulcer audit, Jamaica: patient profile - abstract

Between March and August 1996, 4873 patients (2,181 men and 2,682 women) attending the Comprehensive Health Centre, Kingston, for a new STD complaint were screened for genital ulcer disease (GUD). Prevalence of GUD was 7.3 percent (356/4,873; men 13.4 percent women 2.4 percent). This represented a two-fold decrease in six years. 304 (men 252, women 52) ulcer patients were questioned for demographic and behavioural factors related to STD, clinically assessed for GUD, and tested for HIV infection, syphilis and other GUDs. The employment rate among GUD patients was 77 percent (M 83 percent, F50 percent), 79 percent were single or had a steady visiting partner and 55 percent had completed secondary education. Condoms were reportedly used more than half of the time by 34 percent. Of 280 patients, 17 percent reported no contacts, 53 percent one, and 47 percent two or more in the past month. Of 274 subjects who admitted having sex in the previous three months, 55 percent were with steady partners, 43 percent with casual partners, 27 percent with new partners and 13 percent with prostitutes. A history of bruising was obtained from 50 percent of patients. It was significantly associated with the presence of more than 1 ulcer ( p=0.005), but not with clinical assessment of herpes. 24 percent of patients continued to have sex despite their ulcers and despite the fact that 58 percent of the ulcers were painful. One-third of patients had one ulcer, the rest, two or more. Prevalence of HIV-1 infection was 22 percent (M23 percent, F 19 percent), three times the rate in the general STD population. HIV infection was significantly higher (p<0.002) in patients clinically assessed as having granuloma inguinale, and in those with reactive tests for syphilis (p<0.002). Prevalence of syphilis serology [TRUST + MHA - TP(+)] was 24 percent (M 22 percent, F 33 percent). GUDs continue to be important in the transmission of HIV infection. Creative clinical and community approaches are required for its effective control. (AU)

Facility based assessment study, 1996 - abstract

The 1991 Facility Based Study Assessing STD case management identified the need to improve provider performance in the areas of history taking, treatment of syphilis, provision of education and counselling as well as distribution of condoms. The repeat Facility Based Study in 1996 showed much improvement. Adequate history taking increased from 34.2 percent to 86 percent at the Comprehensive Clinic (which has the greatest STD case load) and from 26.9 percent to 63.6 percent at the level 3 clinics with Contact Investigators (CIs). Treatment of syphilis was appropriate in 100 percent of cases in 1996 as compared with 74 percent in 1991. In level 3 clinics without CIs, providers discussed condom use with clients 25 percent of times in 1991 compared with 63 percent in 1996. Distribution of condoms at the clinics increased from 8 percent to 34 percent. The Facility Based Assessment is a useful method to guide improvements in STD case management and should be used every two or three years. (AU)

The incidence of HIV & HTLV-I infection among STD clinic attenders in Jamaica

Of 970 sexually transmitted disease (STD) patients enrolled at the Comprehensive Health Centre, Kingston, in January 1991, 710 (73 percent, 333 men and 377 women) were re-examined between January 1992 and July 1993 in order to estimate the incidence of HIV and HTLV-I infection and to identify risk factors for transmission. Of those re-examined, 20 percent were recruited passively when they returned to the clinic of their own accord, and 80 percent were recruited actively through field visits to their homes. Passively recruited persons were significantly more likely than active recruits to have had a STD since enrolment 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 (CI 0.3-1.4); or for men 1.4 (CI 0.5-2.8) and for women 0.2 (CI0.004-0.9). Four of 270 men and four of 318 women were HTLV-I-positive, an overall incidence of 0.9 per 100 person years (CI 0.4-1.7); 1.0 for men and 0.8 for women. 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 some of the study subjects who were not included may have had a somewhat higher risk. On univariate analysis there were significant associations between HIV transmission in men and drinking alcohol before sex, cocaine use, total number of sex partners and sex with a prostitute since enrollment and ever accepting money for sex, the average number of sex partners per month, bruising during sex and genital ulcers on follow-up examination. This analysis needs to be intepreted with caution in view of the small number of seroconverters which did not allow testing for independent effects in a logistic regression model (AU)

Surveys of STDs seen by private physicians in Jamaica

A survey of physicians in private practice in Jamaica was conducted between March and September of 1993. It attempted to provide a descriptive analysis of the occurrence of conventional STDs seen in their practices. Questionnaires were delivered to a sample of 371 physicians of whom 127 (34 percent) responded, completing a total of 683 individual patient questionnaires (men 353, women 330). Each physician collected data over a period of one week. The mean age of the 683 patients seen was 28 years. Of these: 464 (68 percent) were first visits for asymptomatic STD condition, 132 (19 percent) were follow-ups for the same condition, 40 (6 percent) were asymptomatic contacts referred by a sex partner, and 12 (2 percent) were symptomatic first visits for a 'check-up'. A history of previous STD was given by 358 (52 percent) patients. A total of 52 (8 percent) patients had anogenital lesions, 45 (7 percent) inguinal lymphadenopathy, and 470 (69 percent) a genital discharge (men 65 percent, women 73 percent). Among women, 131 (40 percent) had lower abdominal pain on examination and 105 (32 percent) evidence of PID on moving the cervix. A working diagnosis of gonorrhoea was made in 273 (40 percent), trichomoniasis in 121 (18 percent), syphilis in 60 (9 percent), herpes genitalis in 20 (3 percent) and chancroid in 11 (2 percent) STD patients. PID was diagnosed in 121 (17 percent) women and nongonococcal urethritis in 98 (62 percent) men. The most frequently prescribed treatments were for chlamydia, gonorrhoea and trichomoniasis. In general, working diagnoses correlated well with clinical observations and treatment given matched with diagnosis according to national guidelines (AU)