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.

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.