Determinants of condom use in female sex workers in Surabaya, Indonesia.

In the developing world condom use among sex workers and their clients plays a dominant role in the transmission of HIV/STD. In Surabaya, Indonesia, data from the 1993 STD prevalence survey in female sex workers (brothels, street, massage parlours, barber shops, call-girl houses, and nightclubs) reveal that only 5% (33/692) of the brothel workers and 14% (25/177) of the street walkers had condoms in their possession at the time of the interview. During the last paid sexual intercourse, sex workers from the brothels, streets, and nightclubs used condoms infrequently (14%, 20%, and 25%, respectively). Sex workers from massage parlours, barber shops, and call girls were about 5 to 3 times more likely to use condoms than sex workers from nightclubs (adjusted odds ratio of 3.5, 4.9, and 4.2, respectively); thus condom promotion programmes should be targeted at sex workers at brothels, streets, and nightclubs. Programmes should include: (1) free distribution of condoms to sex establishments at the initial stage, and condom social marketing at later stages; (2) penalties, including legal sanctions, against any sex establishments that do not consistently use condoms; (3) participation of brothel owners and madams in encouraging sex workers to consistently have clients use condoms during sexual intercourse; and (4) establishment of sentinel surveillance to monitor STD/HIV and condom-use compliance.

Risk profile of female sex workers who participate in a routine penicillin prophylaxis programme in Surabaya, Indonesia.

We conducted a sexually transmitted disease (STD) prevalence survey of 1867 female sex workers in Surabaya, Indonesia, some of whom reported participation in a routine penicillin prophylaxis programme. In Surabaya, 34% of female sex workers had received a prophylactic penicillin injection programme from the government within 28 days. Sex workers who had received routine prophylaxis injection were more likely to be less educated, to work in brothel complexes, and to have more customers per week than other sex workers. The prevalence rates of syphilis, gonorrhoea, chlamydia, and trichomoniasis were higher among sex workers who received the routine penicillin treatment than among those who had not received antibiotic treatment in the last 28 days. However, after adjustment for age, education, fee per sex act, number of customers, and condom use in the previous 7 days, only trichomoniasis was still significantly different (adjusted odds ratio of 3.2). High-risk women were more likely to participate in the routine penicillin prophylaxis programme. The lack of a demonstrable individual-level protection from this prophylaxis treatment programme in this cross-sectional study appears due to differential uptake of penicillin prophylaxis by women at higher presumptive risk for STD. Randomized clinical trials and mathematical modelling, together with observational data such as presented here, all can contribute to optimal understanding of a complex intervention like mass chemoprophylaxis for STD among female sex workers.

PIP: In Surabaya, Indonesia, routine prophylaxis injection with long-acting penicillin to prevent syphilis has been conducted among female prostitutes since 1957, with the goal of severing the syphilis transmission chain by maintaining a treponemicidal level of penicillin of greater than 0.03 mg/ml of blood in the target population. The program currently provides an intramuscular injection of 1.2 million units of benzathine penicillin once every 2 weeks. Based upon sexually transmitted disease (STD) survey data for 1867 female prostitutes in the city, findings are presented from a study comparing the risk profiles of women who participate in the prophylaxis program with women who do not. 635 (34%) of the prostitutes reported having received a prophylactic penicillin injection from the program within the 28 days preceding the survey. Women who had received an injection were more likely to be less educated, to work in brothel complexes, and to have more customers per week than the other prostitutes. Prevalence rates of syphilis, gonorrhea, chlamydia, and trichomoniasis were higher among prostitutes who received the routine penicillin treatment than among those who had not received antibiotic treatment in the past 28 days. However, after adjusting for age, education, fee per sex act, number of customers, and condom use during the preceding 7 days, only trichomoniasis remained significantly different. High-risk women were more likely to participate in the routine penicillin prophylaxis program. The lack of any demonstrable individual-level protection from this prophylaxis treatment program seems due to the differential uptake of penicillin prophylaxis by women at higher presumptive risk for STD.

Patterns of sexually transmitted diseases in female sex workers in Surabaya, Indonesia.

Sex workers and their clients as core groups of high frequency transmitters play a dominant role in the transmission of HIV and other sexually transmitted diseases (STDs). In Surabaya, Indonesia, little is known about the prevalence of STDs in various sex establishments. We conducted an STD prevalence survey of 1873 female sex workers in Surabaya, Indonesia. We did not find any sex workers with HIV infection. Prevalence rates of other STDs (chlamydia, gonorrhoea, serological test for syphilis positive, and/or trichomoniasis) in female sex workers were 48% in brothels (n = 696), 42% on the streets (n = 192), 16% in massage parlours (n = 344), 25% in barber shops (n = 150), 17% at call-girl houses (n = 73), and 10% in nightclubs (n = 418). Sex workers from the brothels had the highest prevalence rates of gonorrhoea (24%) and trichomoniasis (8%), while sex workers from the streets and the barber shop had the highest rates of serological test for syphilis (STS) positive (30%) and chlamydia (18%). STD rates decreased with an increase in age (except for STS positive), an increase in education, a decrease in the number of sex partners, and condom use in the previous week. Condom use in the previous week was universally low among sex workers, especially among sex workers from the brothels (14%). Sex workers from the brothels had STD rates about 4 times higher than sex workers from the nightclubs (adjusted odds ratio of 4.4). Although the HIV seroprevalence rate is currently low, widespread prostitution and high rates of STDs in sex workers warrant programmes to avert a potential explosion of HIV transmission. Because sex workers from the brothels in Surabaya have high rates of STDs and low use of condoms but good cooperation with local authorities, STD preventive measures should focus on this group.

PIP: A sexually transmitted disease (STD) prevalence survey of 1873 female sex workers recruited from six types of sex establishments in Surabaya, Indonesia, in 1992-93 failed to reveal any cases of HIV. The prevalence rates of the other STDs included in the study (chlamydia, gonorrhea, syphilis, and trichomoniasis), by setting, were as follows: brothels (n = 696), 48%; streets (n = 192), 42%; massage parlors (n = 344), 16%; barber shops (n = 150), 25%; call-girl houses (n = 73), 17%; and nightclubs (n = 418), 10%. Sex workers based in brothels and on the streets had the lowest socioeconomic status, while nightclub and call-girl house workers had the highest status. Brothel workers had the highest rates of gonorrhea (24%) and trichomoniasis (8%), while street and barber-shop based workers had the highest prevalences of syphilis (30%) and chlamydia (18%). Condom use in the week preceding the survey ranged from 14% among brothel workers to 67% among call girls. STD rates decreased with increases in age and education and with any condom use. The high rates of STDs documented in this survey, especially among sex workers in brothels, indicate the need for programs aimed at preventing an HIV epidemic. For example, the medical monitoring available from a private physician to workers in most massage parlors, barber shops, call-girl houses, and nightclubs should be made available to brothel-based prostitutes. Also urged are free distribution of condoms to sex establishments, sanctions against establishments where condoms are not used consistently, and a media campaign to encourage men to use condoms with sex workers.

Douching and sexually transmitted diseases in pregnant women in Surabaya, Indonesia.

OBJECTIVE: Our purpose was to investigate the association between douching (douching agents and timing) and sexually transmitted disease. STUDY DESIGN: A cross-sectional survey of sexually transmitted diseases and habits of vaginal douching was performed on 599 pregnant women who visited a prenatal clinic in Surabaya, Indonesia. RESULTS: Of the 599 pregnant women, 115 (19.2%) had at least one sexually transmitted disease (gonorrhea, chlamydia, syphilis, trichomoniasis, or herpes simplex virus-2). Most women had douched with water (19%) or water and soap (63%) at least once in the preceding month. Approximately 10% of the women had douched in the preceding month with a commercial agent (2%) or betel leaf (8%). Douching with water alone after sex was not associated with sexually transmitted disease. Douching with water and soap or with a betel leaf or commercial agent after sex was associated with sexually transmitted disease; adjusted odds ratios were 2.6 (95% confidence interval 1.0 to 7.1) and 2.7 (95% confidence interval 0.5 to 14.5), respectively. The association was enhanced if the women douched before sex or both before and after sex; adjusted odds ratio were 2.7 (95% confidence interval 1.0 to 7.3) for douching with water and soap and 5.2 (95% confidence interval 1.6 to 16.7) for douching with betel leaf or a commercial agent. Compared with women who never douched, women who always douched with betel leaf or a commercial agent had a substantially increased risk for sexually transmitted disease (adjusted odds ratio 9.4, 95% confidence interval 1.8 to 50.3). CONCLUSIONS: We found a significant association between sexually transmitted disease and douching habits (douching with betel leaf, commercial agents, or water and soap). However, further prospective investigations are needed to evaluate the temporal relationship between douching and sexually transmitted disease.

Intravaginal clindamycin treatment for bacterial vaginosis: effects on preterm delivery and low birth weight.

OBJECTIVE: Our goal was to evaluate whether treatment of bacterial vaginosis during pregnancy with 2% clindamycin vaginal cream reduces the incidence of either preterm delivery or low birth weight or of both. STUDY DESIGN: A multicenter, double-blind, randomized, placebo-controlled trial in Indonesia compared a 2% clindamycin vaginal cream with a placebo cream. Women seeking prenatal care at 14 to 26 weeks of gestational age who had bacterial vaginosis (Gram stain score > 6 and pH of vaginal fluid > 4.5) were invited to participate. Of the 745 women enrolled, 681 (91.4%) women were followed up through delivery. RESULTS: Clindamycin vaginal cream was an effective treatment for bacterial vaginosis. Two weeks after completion of the treatment, 85.5% of the women were cured. The rate of preterm delivery (< 37 weeks) was 15.0% for clindamycin patients and 13.5% for placebo patients (odds ratio 1.1, 95% confidence interval 0.7 to 1.7). The rate of low birth weight was 9.0% for clindamycin patients and 6.8% for placebo patients (odds ratio 1.3, 95% confidence interval 0.8 to 2.4). CONCLUSIONS: Treatment of bacterial vaginosis with clindamycin vaginal cream did not reduce preterm delivery or low birth weight. Although clindamycin vaginal cream is an effective treatment for bacterial vaginosis, intravaginal treatment would not be effective against bacterial vaginosis-associated microorganisms harbored in the upper genital tract. Systemic treatment may be required to eradicate upper tract infection to reduce preterm delivery.

Antimicrobial susceptibilities of Neisseria gonorrhoeae strains isolated in Surabaya, Indonesia.

Until recently, the only common strains of antimicrobial agent-resistant Neisseria gonorrhoeae detected in Indonesia were penicillinase-producing N. gonorrhoeae (PPNG) strains. Despite the spread of resistance to other antimicrobial agents among N. gonorrhoeae in Southeast Asia, surveillance for such resistance in Indonesia has been limited. We evaluated the in vitro susceptibilities of 86 N. gonorrhoeae isolates from female sex workers in Surabaya, Indonesia, to 13 antimicrobial agents. Of the 86 isolates, 89% were resistant to penicillin (MIC, > or = 2.0 micrograms/ml), 98% were resistant to tetracycline (MIC, > or = 2.0 micrograms/ml), 18.1% were resistant to spectinomycin (MIC, > or = 128.0 micrograms/ml), and 97.7% showed decreased susceptibility to thiamphenicol (MIC, 1 to 2 micrograms/ml). Thus, thiamphenicol and spectinomycin may be approaching the end of their usefulness as the drugs of choice for the treatment of gonococcal infections in Surabaya. While the susceptibilities of N. gonorrhoeae to cephalosporins (ceftriaxone, cefixime, and cefoxitin) and fluoroquinolones (ciprofloxacin and ofloxacin) are universal, these drugs have not been used because they are more expensive in Indonesia than thiamphenicol. We conclude that Surabaya had the highest reported rate of penicillin and tetracycline resistance among the Southeast Asian countries and that cephalosporins or fluoroquinolones should be reasonable alternatives for the treatment of gonorrhea in this locale.

Penicillinase-producing Neisseria gonorrhoeae among prostitutes in Surabaya.

Thirty-six strains of penicillinase-producing Neisseria gonorrhoeae (PPNG) were detected among 794 prostitutes between October 1981 and May 1982 in Surabaya, Indonesia. The high prevalence of PPNG strains among the high-class prostitutes and a lower prevalence among the low-class suggest that regular mass treatment for syphilis did not play an important role in the emergence and spread of PPNG; the importation of PPNG strains from abroad is more likely to have been responsible.

Penicillinase-producing Neisseria gonorrhoeae isolated in Surabaya.

Although penicillinase-producing strains of Neisseria gonorrhoeae (PPNG) were discovered in 1976 in neighbouring countries, not until 1980 were such strains isolated and identified in Indonesia. In that year PPNG were detected in three male patients with gonococcal urethritis in Surabaya. The minimum inhibitory concentration of penicillin G for all three strains was 12 . 5 microgram/ml.