Protection against sexually transmitted diseases by granting sex workers in Thailand the choice of using the male or female condom: results from a randomized controlled trial.

BACKGROUND: The male condom is the most effective barrier method available for protection against sexually transmitted diseases (STDs), including HIV infection. There is an urgent need to develop and evaluate other prevention methods, such as the female condom. This study estimated the additional protection against STDs offered to sex workers by giving them the option of using the female condom when clients refused to use a male condom. METHODS: Sex establishments in four cities in Thailand were randomized into two study groups: one in which sex workers were instructed to use male condoms consistently (male condom group); and one in which sex workers had the option of using the female condom if clients refused or were not able to use male condoms (male/female condom group). Randomization was done by sex establishments, and not by individuals, to minimize sharing of female condoms across study groups. The proportion of unprotected sexual acts (defined as sexual acts in which condoms were not used, tore, or slipped in or out) and incidence rate of STDs (gonorrhoea, chlamydial infection, trichomoniasis and genital ulcer disease) were measured over a 24-week period and compared between the two study groups. FINDINGS: Results are available from 34 sex establishments (249 women) in the male/female condom group, and 37 sex establishments (255 women) in the male condom group. Condom use was very high in both groups (97.9 and 97.3 % of all sexual acts, respectively, P > 0.05). Male condom use was lower in the male/female condom group when compared with the male condom group (88.2 and 97.5%, respectively, P < 0.001). However, this reduction in male condom use was counterbalanced by the use of female condoms in 12.0% of all sexual acts in the male/female condom group, contributing to a 17% reduction in the proportion of unprotected sexual acts in this group when compared to the male condom group (5.9 versus 7.1%, respectively, P = 0.16). Female condom use was sustained over the entire study period. There was also a 24% reduction in the weighted geometric mean incidence rate of STDs in the sex establishments of the male/female condom group compared to the male condom group (2.81 versus 3.69 per 100 person-weeks, P = 0.18).

HIV prevalence, risk, and partner serodiscordance among pregnant women in Bangkok. Bangkok Collaborative Perinatal HIV Transmission Study Group.

CONTEXT: Most prior studies of the human immunodeficiency virus (HIV) epidemic in Thailand have focused on commercial sex encounters; however, because the epidemic increasingly concerns stable heterosexual relationships, determining risk factors for this form of transmission is warranted. OBJECTIVES: To determine temporal trends in HIV prevalence, risk factors for HIV seropositivity, and rates of partner serodiscordance for pregnant women in Bangkok, Thailand. DESIGN: Retrospective review of hospital antenatal clinic HIV test results from 1991 through 1996. Baseline demographic and behavioral risk factors for HIV were assessed for subjects enrolled from November 1992 through March 1994. SETTING: Two Bangkok hospitals with routine antenatal clinic HIV counseling and testing. PARTICIPANTS: The HIV-positive pregnant women enrolled in a perinatal HIV transmission study and their partners and HIV-negative pregnant controls. RESULTS: From 1991 through 1996, antenatal clinic HIV seroprevalence increased from 1.0% to 2.3%. On multivariate analysis of data from 342 HIV-positive and 344 HIV-negative pregnant women, more than 1 lifetime sex partner, history of a sexually transmitted disease, and a high-risk sex partner were the most important factors for seropositivity (all P<.001). Twenty-six percent of partners of HIV-positive women were HIV negative. Women reporting more than 1 lifetime sex partner were more likely to have an HIV-negative partner than women reporting only 1 (45% vs 8%; relative risk, 5.5; 95% confidence interval, 3.2-9.5; P<.001); women reporting no high-risk behaviors were less likely to have an HIV-negative partner (10% vs 44%; relative risk, 0.2; 95% confidence interval, 0.1-0.4; P<.001). CONCLUSIONS: Prevalence of HIV in pregnant women has increased steadily in Bangkok from 1991 through 1996. Sex with current partners was the only identified risk exposure for about half (52%) of the HIV-positive women. Although few HIV-positive pregnant women reported high-risk behaviors, more than 1 lifetime partner and a partner with high-risk behavior were strong risk factors for seropositivity. Together with the unexpected finding that one fourth of partners of seropositive pregnant women were seronegative, these data emphasize that women in the general population are at risk for HIV because of the risk behavior of both current and previous partners.

Carbon dioxide laser vaporization for genital wart.

The purpose of this study was to evaluate the effectiveness of carbon dioxide laser vaporization in the treatment of coalescent condyloma acuminata of the female lower genital tract. Between July 1990 and September 1992, 24 cases were enrolled in the study. There were 13 pregnant patients and 11 nonpregnant patients. We performed the procedure under colposcopic guidance on an out-patient basis. Carbon dioxide laser vaporization was carried out in continuity to an appropriate tissue depth with carbon dioxide brushing 1 cm around the lesion. Of these 24 cases, biopsy proven 2 residual lesions and 1 recurrence were documented at the 2nd week and the 2nd month postoperative, respectively. We found low rate of intraoperative and postoperative morbidity or complication, with mild to moderate vulvar pain in the patients and no gross scarring. It is concluded that carbon dioxide laser is effective for eradicating extensive condylomata in the female lower genital tract with low intraoperative and postoperative morbidity on an out-patient basis.

Itraconazole in the treatment of acute vaginal candidosis.

An open non-comparative multicenter study of Itraconazole (Sporal) 400 mg as a single day therapy for vaginal candidosis was carried out at Siriraj Hospital and Chulalongkorn Hospital from 1st November 1988 to 31st August, 1989. Fifty-nine female out patients with vaginal candidosis were included in the study after excluding pregnancy, lactation, mixed vaginal infection and prior antimycotic therapy. Two capsules of 100 mg Itraconazole were given b.i.d. as a single day 400 mg dose. The patients were evaluated at the beginning prior to treatment for physical signs and symptoms, direct microscopic examination, and culture of vaginal fluid. The first and second follow-up were arranged at the end of one week and one month after therapy. The evaluations were the same as in the first visit. The clinical cure rate was 89 and 90 per cent at first and second follow-up respectively. The mycological cure rates were 83.3 and 69.57 per cent at the first and second follow-up respectively. There was one case of Torulopsis glabarta at the second follow-up.

Risk factors in puerperal infection.

Puerperal infection is one of the most common obstetric complications which leads to certain serious sequelas for those parturients. The study of 92 postpartum women at Siriraj Hospital from April 1, 1980 to March 1, 1983 was conducted to investigate the risk factors of puerperal infection. All 92 cases were diagnosed for puerperal infection according to the criteria of the Joint Committee on Maternal Welfare. Irregular antenatal care or no antenatal care, sexual intercourse during the last week before delivery and pelvic examination during pregnancy were found to be important predisposing factors in the antepartum period. Pelvic examination during labor accounted for 78 per cent of the patients and played an important role, while operative obstetrics (30%) and concomitant diseases during pregnancy (27%) were the next significant factors.

Treatment of puerperal infection.

Ninety-two patients with puerperal infection admitted to Siriraj Hospital from April 1, 1980 to March 1, 1983 were studied. The treatment in this study was both medical and surgical, blood transfusion was given in some cases with low hematocrit level. The medical treatment alone was based on the causative organisms which were detected by cervical & intrauterine swab, smear & gram stain and cultures. PGS & Kanamycin were the most frequently used antibiotics which were intended to treat both gram-positive and gram-negative bacteria and adjunctive chloramphenicol for anaerobes. The surgical procedures which were performed in combination with medical treatment included total abdominal hysterectomy, uterine curettage, appendectomy and drainage of subdiaphragmatic abscess. The result of the treatment was satisfactory, 96.7 per cent improved after therapy with slight morbidity in some patients.

Rapid eradication of trichomonads by single-dosed nimorazole.

Previous in vitro studies demonstrated the rapidity of trichomonacidal action of nimorazole (Naxogin 500) which was twice that of metronidazole and many times that of tinidazole. Since rapid eradication of parasites can lead to a significant decrease in transmission rate, and hence, a lower prevalence of this sexually transmitted disease, a pilot study was designed to investigate the in vivo speed of action of nimorazole. Twenty females with positive wet smears for trichomonas vaginalis were treated with a single 2 gram-dose of nimorazole orally. Without any antiseptics, specimens of vaginal discharge were collected at 0 hour (before treatment), 3, 24 and 72 hours for parasite count and culture. After a single treatment with 2 g of nimorazole the cure rate was 65 per cent at 3 hours and 100 per cent at all points thereafter. The result of this pilot study supports previous in vitro findings that nimorazole rapidly eradicates vaginal parasites.

Experience with the Copper-7 and Copper-T intrauterine devices at Siriraj Hospital in Bangkok, Thailand.

PIP: A report of 2 studies focusing on the 2 year performance of Copper-7 (Cu-7) and Copper-T (Cu-T) IUDs is presented with particular reference to the characteristics of the users. 198 women had the Cu-7 IUD inserted and 200 women had the Cu-T inserted while menstruating or immediately after menstruation. In both devices, the copper wire had the same surface area. Of the sociodemographic and reproductive characteristics of the study groups, only the age and parity distributions were significantly different. The median age for the Cu-7 users was 26.8 years compared to 31.5 years for the Cu-T group. A median of 2.2 live births for the Cu-7 group is lower than for the Cu-T users (3.2 live births). Performance of the 2 devices did not differ significantly, over the study period. The net cumulative continuation rates were 68.6/100 Cu-7 users and 78.2/100 Cu-T users. At the end of 1 year, the gross cumulative pregnancy rate with the device in place was the same for both groups, .6/100 women. After 2 years, 2 additional Cu-7 users became pregnant, and the gross cumulative pregnancy rate was 2.3/100 women; the Cu-T rate remained the same. The pregnant women in the Cu-7 group were under 30 years of age. The gross cumulative expulsion rates at the end of 1 year were 5.0/100 Cu-7 users and 1.8/100 Cu-T users; after 2 years, the rates were 5.7/100 Cu-7 users and 2.5/100 Cu-T users. The majority in both groups were under 30 years old. For both groups, discontinuation of the IUDs because of pain was more frequent than for bleeding. The gross cumulative discontinuation rates of removals for bleeding/pain were 4.1/100 Cu-7 users and 2.4/100 Cu-T users at 1 year and 7.1/100 Cu-7 users and 5.7/100 Cu-T users after 2 years. 81.3% of these discontinuations occurred in women under 30 years old for the Cu-7 group compared to only 45.5% of the women discontinuing the Cu-Ts. The age-parity effect is difficult to specify due to the infrequency of events. However, younger less parous women, which was a higher proportion of the Cu-7 group, did have a higher incidence of expulsions and Cu-7 removals for pain/bleeding. The Cu-T group had a much higher proportion of women with previous IUD experience. The results suggest that the Cu-7 is as effective as the Cu-T device in minimizing the incidence of pregnancy, expulsion, and bleeding/pain removal.^ieng

Comparison of culdoscopic and laparoscopic tubal sterilization.

The growing number of women requesting interval sterilization (apart from term delivery or abortion procedures) necessitates the re-evaluation of traditional surgical procedures. A total of 800 women--the first 400 women undergoing culdoscopic and laparoscopic tubal sterilization procedures at Siriraj Hospital in Bangkok, Thailand--evaluate the appropriateness of the two sterilization procedures for use in interval sterilization programs. No serious operative complications occurred in either group. However, the rate of postoperative complications was considerably higher for the culdoscopic group than for the laparoscopic group. Hospitalization was required for only a small percentage of the patients and most had resumed their normal activities within two days of the operation. This study indicates that both procedures are effective and may be safely performed on an outpatient basis without general anesthetics and with minimal discomfort for the patients.

A comparison of laparoscopy and culdoscopy for internal sterilization.

In recent years, the increased demand for sterilization by women who have achieved their desired family size has emphasized the need to improve both existing methods of tubal occlusion and the means of access to the Fallopian tubes. Utilization of diagnostic instruments such as the laparoscope and culdoscope to perform sterilization minimizes the trauma associated with standard laparotomy and colpotomy and promises to reduce morbidity occurring as a result of sterilization. In order to evaluate and compare the improved techniques of laparoscopy and culdoscopy for elective interval sterilization, 722 women were studied between January and August of 1973 at the Siriraj Hospital in Bangkok. For 279 patients (Group I), sterilization was performed by culdoscopic tubal ligation using a modified Pomeroy technique; for 443 patients (Group II), the procedure used was laparoscopic tubal cauterization and cutting. All procedures were performed using local anesthesia on an outpatient basis. Complication rates and required surgical time were similar for both procedures and compared favorably with rates reported by other investigators. Because of a low incidence of complications and the elimination of the need for general anesthesia and hospitalization, both endoscopic procedures appear to be of particular value in developing countries where hospital facilities and physician time are in short supply.

Use of a low-dose oral contraceptive preparation: report of a study.

PIP: A study was carried out among 100 healthy married women using the low-dose oral contraceptive (OC) Ovostat E, also known as Ovostat 28, comprised of 1.0 mg lynestrenol and 0.05 mg ethinylestradiol, and confined to the 1st 12 cycles. Patients were divided into 2 groups: 1) 35 who had never taken OCs or had discontinued 3 months prior to the study, and 2) 59 who were taking OCs prior to the study. All were seen 1 month after the initial visit and thereafter once every 3 months, and were told to record their bleeding patterns. Average age of group 1 was 24 and of group 2 was 26. All had at least 1 living child. No pregnancies occurred, bleeding patterns were not unusual although there was a high incidence (4.9%) of light breakthrough bleeding or spotting in the 1st (21.9%) and 2nd (14.6%) cycle of group 1. No significant differences in the side effects between the 2 groups was noted except for nausea (10% higher in group 1 during the 1st 4 cycles). Incidence of headache increased in group 1 but markedly decreased in group 2. Weight and blood pressure showed no significant change. At the end of the year 78 women were still on medication (others had dropped out for personal or medical reasons). In general, side effects were no different from those with normal dose OCs. Although breakthrough bleeding existed in group 1, it was mild and well tolerated and could be avoided by starting the patient on a high dose preparation a few months before starting the low dose OC. Ovostat E is found to offer increased safety resulting from the low dose of active constituents.^ieng