HIV infection among sex workers in Accra: need to target new recruits entering the trade.

OBJECTIVE: Description of the epidemiology of HIV infection among sex workers (SW) in Accra, Ghana. METHODS: In all, 1013 SW working out of their homes ( seaters ) or finding customers in bars, hotels, brothels or on the street ( roamers ) were interviewed and tested for HIV. RESULTS: Overall, prevalence of HIV infection was nearly 50% (506 of 1013), varying from 26% (133 of 507) among the roamers to 74% (368 of 496) among the seaters. Profound differences were noted between these two categories of SW with regard to age, number of clients per day, price per instance of intercourse, condom use, and other characteristics. Respectively, 27% and 58% of roamers and seaters were infected with HIV within their first 6 months of sex work, despite a limited number of unprotected sex acts with seropositive clients. Independent risk factors for HIV infection varied between types of SW: age among the roamers; region of origin and duration of sex work among the seaters; number of clients per day, and presence of current or past genital ulcer and gonococcal cervicitis in both groups. CONCLUSION: In Accra, considerable heterogeneity exists in the population of SWs. In both categories of SW, new recruits become rapidly infected with HIV after entering the trade. The 25-fold higher prevalence of HIV among SWs than in the general adult population suggests that in Accra, as in many cities of West Africa, a high fraction of new cases of HIV infection continue to be acquired from SWs. Intervention programs targeting SW should be an essential component of national AIDS control strategies. Special efforts should be made to identify and offer preventive services to new sex workers.

Improvement of clinical algorithms for the diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis by the use of Gram-stained smears among female sex workers in Accra, Ghana.

BACKGROUND: Screening for cervical infection is difficult in developing countries. Screening strategies must be improved for high-risk women, such as female sex workers. GOAL: To evaluate the sensitivity and specificity of screening algorithms for cervical infection pathogens among female sex workers in Accra, Ghana. STUDY DESIGN: A cross-sectional study among female sex workers was conducted. Each woman underwent an interview and a clinical examination. Biologic samples were obtained for the diagnosis of HIV, syphilis, bacterial vaginosis, yeast infection, Trichomonas vaginalis, Neisseria gonorrhoeae, and Chlamydia trachomatis infection. Signs and symptoms associated with cervicitis agents were identified. Algorithms for the diagnosis of cervical infection were tested by computer simulations. RESULTS: The following prevalences were observed: HIV, 76.6%; N. gonorrhoeae, 33.7%; C. trachomatis, 10.1%; candidiasis, 24.4%; T. vaginalis, 31.4%; bacterial vaginosis, 2.3%; serologic syphilis, 4.6%; and genital ulcers on clinical examination, 10.6%. The best performance of algorithms were reached when using a combination of clinical signs and a search for gram-negative diplococci on cervical smears (sensitivity, 64.4%; specificity, 80.0%). CONCLUSIONS: In the algorithms, examination of Gram-stained genital smears in female sex workers without clinical signs of cervicitis improved sensitivity without altering specificity for the diagnosis of cervical infection.

Evaluation of a targeted AIDS prevention intervention to increase condom use among prostitutes in Ghana.

OBJECTIVE: To assess the short- and long-term impact of a 6-month pilot intervention program on condom use among prostitutes in Accra, Ghana. DESIGN: The 4-year prospective study follows-up cohorts enrolled in the intervention in 1987 and 1988, comparing condom use in 1991 with that among a comparison group not enrolled in the intervention. SETTING: The community-based intervention was initiated in Accra, Ghana in 1987. PARTICIPANTS: Self-identified female prostitutes who volunteered participation. INTERVENTION: The educational intervention used local health workers to train and support selected prostitutes to be health educators and condom distributors to their peers. OUTCOME MEASURES: Self-reported condom use with clients. RESULTS: Reported condom use increased dramatically between 1987 and 1988 during the first 6 months of the intervention. In 1991, after 3 years of program relapse, 107 (43%) of the 248 women who had enrolled in 1987 or 1988 were still in prostitution and located for interview. Their level of condom use in 1991 was higher than pre-enrollment but similar to use among prostitutes never enrolled. Sixty-four per cent of those followed-up reported always using condoms with clients in 1991. These 'always users' were more likely to have maintained informal contact with project staff, know that HIV can be transmitted by healthy clients, and report that clients frequently initiate condom use. CONCLUSIONS: Findings support the development of long-range educational strategies that recognize the career longevity of prostitutes, available channels for informal program diffusion, individual changes in condom use over time, and the role of clients in condom negotiation.

PIP: Findings of a prospective study of condom use among prostitutes in Ghana provided support for acquired immunodeficiency syndrome (AIDS) prevention educational interventions with this high risk populating and evidence of informal program diffusion. 382 self-identified prostitutes voluntarily entered the study in three waves (a pilot group of 72 recruited in June 1987, another 176 prostitutes who were admitted at their request in January 1988, and 106 who entered in September 1991). From this group, selected prostitutes were trained to educate their peers about AIDS risk factors through meetings and printed materials and to distribute free condoms. Self-reported condom use in 1991 was correlated with contact with these peer educators. During the 6-month pilot study, the proportion of prostitutes who always used condom increased from 6% at baseline to 71%. 48% of prostitutes entering the study in January 1988 were already always using condoms, suggesting a diffusion effect. In 1991, consistent condom use was reported by 56% of women from the pilot group available for follow-up and 66% of those interviewed from the 1988 wave; however, these rates were not appreciably higher than the 55% rate reported at baseline by the 1991 wave of recruits. (This convergence is assumed to reflect both suspension of the educational program in 1988-91 and increased social acceptance of condom use given the spread of AIDS.) Of the 107 women from the pilot and expanded groups available for interview in 1991, 24% identified peer outreach workers as their source of AIDS information. Women who had contact with staff were 2.63 times more likely than non-exposed women to report consistent condom use. The interaction model revealed that women who maintained contact with project staff were 3.17 times more likely to be consistent users, those who knew that healthy appearing men could transmit AIDS were 2.68 times more likely to fall into this use category, and prostitutes who had clients who initiated condom use more than half the time were 4.49 times more likely than other women to be consistent users, even when staff contact and AIDS knowledge were controlled. Given the career longevity of some prostitutes, sustained program activity is encouraged.

HIV seropositive cases presenting as urological patients at the Korle-Bu Teaching Hospital, Accra--a preliminary report.

Thirty-six patients (33 males, 3 females) were screened for HIV antibodies at the Urological clinics, at the Korle Bu Teaching Hospital, Accra because of chronic diarrhoea, unexplained weight loss, multiple sexual partners, recurrent sexually transmitted diseases, non resolution of symptoms or history of possible exposure to HIV. Ten patients (27.8%) were found to be HIV seropositive; 6 were confirmed as HIV-1, one as HIV-2 and 3 as both HIV-1 and HIV-2. The HIV seropositive patients presented as follows: recurrent cystitis and offensive vaginal discharge in 2 females, non-resolution or recurrence of urological symptoms and signs such as warts (genital, meatal and or urethral) in 4 males and recurrent penile ulcers in 4 males. This report indicates that physicians should be alert and screen high risk patients for both HIV-1 and HIV-2 antibodies.