Prevalence and risk factors of sexually transmitted infections and cervical neoplasia in women from a rural area of southern mozambique

There is limited information on the prevalence of sexually transmitted infections and the prevalence of cervical neoplasia in rural sub-Saharan Africa. This study describes the prevalence and the etiology of STIs and the prevalence of cervical neoplasia among women in southern Mozambique. An age-stratified cross-sectional study was performed where 262 women aged 14 to 61 years were recruited at the antenatal clinic (59%), the family-planning clinic (7%), and from the community (34%). At least one active STI was diagnosed in 79% of women. Trichomonas vaginalis was present in 31% of all study participants. The prevalence of Neisseria gonorrhea and Chlamydia trachomatis were 14% and 8%, respectively, and Syphilis was diagnosed in 12% of women. HPV DNA was detected in 40% of women and cervical neoplasia was diagnosed in 12% of all women. Risk factors associated with the presence of some of the STIs were being divorced or widowed, having more than one sexual partner and having the partner living in another area. A higher prevalence was observed in the reproductive age group and some of the STIs were more frequently diagnosed in pregnant women. STI control programs are a priority to reduce the STIs burden, including HIV and cervical neoplasia.

Bacterial sexually transmitted infections among HIV-infected patients in the United States: estimates from the Medical Monitoring Project.

BACKGROUND: Bacterial sexually transmitted infections may facilitate HIV transmission. Bacterial sexually transmitted infection testing is recommended for sexually active HIV-infected patients annually and more frequently for those at elevated sexual risk. We estimated percentages of HIV-infected patients in the United States receiving at least one syphilis, gonorrhea, or chlamydia test, and repeat (≥2 tests, ≥3 months apart) tests for any of these sexually transmitted infections from mid-2008 through mid-2010. DESIGN: The Medical Monitoring Project collects behavioral and clinical characteristics of HIV-infected adults receiving medical care in the United States using nationally representative sampling. METHODS: Sexual activity included self-reported oral, vaginal, or anal sex in the past 12 months. Participants reporting more than 1 sexual partner or illicit drug use before/during sex in the past year were classified as having elevated sexual risk. Among participants with only 1 sex partner and no drug use before/during sex, those reporting consistent condom use were classified as low risk; those reporting sex without a condom (or for whom this was unknown) were classified as at elevated sexual risk only if they considered their sex partner to be a casual partner, or if their partner was HIV-negative or partner HIV status was unknown. Bacterial sexually transmitted infection testing was ascertained through medical record abstraction. RESULTS: Among sexually active patients, 55% were tested at least once in 12 months for syphilis, whereas 23% and 24% received at least one gonorrhea and chlamydia test, respectively. Syphilis testing did not vary by sex/sexual orientation. Receipt of at least 3 CD4+ T-lymphocyte cell counts and/or HIV viral load tests in 12 months was associated with syphilis testing in men who have sex with men (MSM), men who have sex with women only, and women. Chlamydia testing was significantly higher in sexually active women (30%) compared with men who have sex with women only (19%), but not compared with MSM (22%). Forty-six percent of MSM were at elevated sexual risk; 26% of these MSM received repeat syphilis testing, whereas repeat testing for gonorrhea and chlamydia was only 7% for each infection. CONCLUSIONS: Bacterial sexually transmitted infection testing among sexually active HIV-infected patients was low, particularly for those at elevated sexual risk. Patient encounters in which CD4+ T-lymphocyte cell counts and/or HIV viral load testing occurs present opportunities for increased bacterial sexually transmitted infection testing.

Sexual Behavior and Network Characteristics and Their Association with Bacterial Sexually Transmitted Infections among Black Men Who Have Sex with Men in the United States.

BACKGROUND: Black men who have sex with men (MSM) have a high prevalence of bacterial sexually transmitted infections (STIs), and individual risk behavior does not fully explain the higher prevalence when compared with other MSM. Using the social-ecological framework, we evaluated individual, social and sexual network, and structural factors and their association with prevalent STIs among Black MSM. METHODS: The HIV Prevention Trials Network 061 was a multi-site cohort study designed to determine the feasibility and acceptability of a multi-component intervention for Black MSM in six US cities. Baseline assessments included demographics, risk behavior, and social and sexual network questions collected information about the size, nature and connectedness of their sexual network. Logistic regression was used to estimate the odds of having any prevalent sexually transmitted infection (gonorrhea, chlamydia, or syphilis). RESULTS: A total of 1,553 Black MSM were enrolled in this study. In multivariate analysis, older age (aOR = 0.57; 95% CI 0.49-0.66, p<0.001) was associated with a lower odds of having a prevalent STI. Compared with reporting one male sexual partner, having 2-3 partners (aOR = 1.74; 95% CI 1.08-2.81, p<0.024) or more than 4 partners (aOR = 2.29; 95% CI 1.43-3.66, p<0.001) was associated with prevalent STIs. Having both Black and non-Black sexual partners (aOR = 0.67; 95% CI 0.45-0.99, p = 0.042) was the only sexual network factor associated with prevalent STIs. CONCLUSIONS: Age and the number and racial composition of sexual partners were associated with prevalent STIs among Black MSM, while other sexual network factors were not. Further studies are needed to evaluate the effects of the individual, network, and structural factors on prevalent STIs among Black MSM to inform combination interventions to reduce STIs among these men.

Factors associated with asymptomatic non-chlamydial non-gonococcal urethritis in heterosexual men: findings from a case-control study.

The significance of asymptomatic non-chlamydial non-gonococcal urethritis (NCNGU) is unclear. Organisms associated with NCNGU, e.g. Mycoplasma genitalium, for which there is no widely available test, are linked to reproductive sequelae in women but UK guidance no longer recommends urethral smear microscopy to screen for asymptomatic NCNGU. This case-control study of heterosexual male genitourinary (GU) medicine clinic attenders aimed to identify clinical, demographic and sexual behaviour factors associated with asymptomatic NCNGU so that we could determine whether the presence or absence of symptoms provides a rational basis for deciding to whom we should offer microscopy and whom we should treat. Men with asymptomatic NCNGU were very similar to men with symptomatic NCNGU, except for more consistent condom use. Asymptomatic and symptomatic NCNGU could be different ends of the same clinical syndrome. Until the microbiological basis of NCNGU is understood, we recommend treatment of men with NCNGU irrespective of symptoms.

The determinants of sexually transmitted infections among reproductive age women in St. Petersburg, Estonia and Finland.

OBJECTIVES: Sexually transmitted infections' (STIs) rate vary in St. Petersburg, Estonia and Finland; the aim was to compare the determinants of self-reported sexually transmitted infections in these areas. METHODS: Data from four population-based questionnaire surveys were used (Finland in 1992 and 1999; St. Petersburg in 2003; Estonia in 2004). With the exception of the 1992 Finnish survey (interview) all were postal surveys, with 1,070 respondents in Finland (78 and 52% response rates), 1,147 (68%) in St. Petersburg, and 5,190 (54%) in Estonia. RESULTS: Risky sexual behaviours were equally common in the three areas and the determinants were the same. Women with an STIs history more often had had their first sexual intercourse when aged under 18, had not used condom during first intercourse, had a high number of lifetime or previous year sexual partners. However, marital status and education were not similar determinants. Cohabiting and well-educated women in Finland were more likely to have STIs while in other areas the associations found were not statistically significant. CONCLUSIONS: Risky behaviour predicts STIs, but does not explain the varying rates of STIs between areas.

A survey of knowledge of sexually transmitted infections among patients at a public hospital in Pulau Pinang, Malaysia.

OBJECTIVE: The aim of this study was to assess the patients' knowledge and awareness of sexually transmitted infections (STIs). SUBJECTS AND METHODS: A face-to-face interview was conducted among the patients visiting the Venereal Diseases Outpatient Department of the General Hospital of Pulau Pinang (Malaysia). A 19-item questionnaire was used. A total of 116 patients participated in the study and 107 patients had valid responses. The reliability and internal consistency of the questionnaire tool was estimated on the basis of Cronbach's alpha (= 0.81). The Statistical Package for Social Sciences (SPSS 13.0(R)) was used for data analysis. Student's t test and analysis of variance were used to analyse the knowledge differences among the groups. RESULTS: Of the 107 patients, 82 (76.6%) were diagnosed with syphilis; AIDS was the most commonly known STI among the patients. Of the 107 patients, 35 were sexually active and of these 23 (65.7%) had more than 1 sexual partner. The most popular source of knowledge was newspapers (51 patients, 47.7%), with hospitals (3 patients, 2.8%) being the least popular one. Overall mean score on knowledge questions was 12.21 out of the maximum of 33 points. Knowledge about causative organisms, risk groups, transmission, symptoms, prevention and treatment of STIs was inadequate. The knowledge level was significantly related to gender (p = 0.03), religion (p = 0.005), educational level (p = 0.000), marital status (p = 0.000) and income level (p = 0.036). CONCLUSION: This study demonstrated evidence of poor knowledge of STIs amongst the patients attending an STI service in the General Hospital of Pulau Pinang (Malaysia). Hence there is an immediate need for efforts towards improving patient knowledge of STIs.

An updated review of of evidence to discourage douching.

PURPOSE: To review current studies on vaginal douching. DATA SOURCES: MEDLINE PubMed, CINAHL, and Cochrane databases from 2002 to 2008 using MeSh terms "vaginal AND irrigation or vaginal and douching" from 2002 to 2003 and "vaginal douching" and "vaginal douching and adverse effects" from 2004 to 2008. STUDY SELECTION: MEDLINE PubMed included 156 records, CINAHL 15, and Cochrane 10. Articles in English were reviewed, and those pertaining to vaginal douching and reproductive and gynecologic outcomes were included. References from these articles were reviewed and included when appropriate. 2008 Web sites of the Centers for Disease Control and Prevention were also included. DATA EXTRACTION: Articles were reviewed and summarized. RESULTS: Vaginal douching is a common practice for almost one-third of women in the United States. Douching is associated with adverse pregnancy outcomes including ectopic pregnancy, low birth weight, preterm labor, preterm birth, and chorioamnionitis. Douching is more prevalent among non-Hispanic black women than among white women or Hispanic women. Douching alters the vaginal flora and predisposes women to develop bacterial vaginosis (BV), which is also more prevalent among women who douche and among black women. Douching is also associated with serious gynecologic outcomes, including increased risk of cervical cancer, pelvic imflammatory disease, endometritis, and increased risk for sexually transmitted infections, including HIV. Many factors influence women's douching behaviors, including social, cultural, and educational factors. Healthcare providers can influence women to stop douching. CLINICAL IMPLICATIONS: Healthcare providers may not be aware of the mounting evidence of negative health outcomes associated with the practice of douching. At every opportunity, healthcare providers should ask women whether they douche and inquire about vaginal douching practices and beliefs associated with the practice. Douching should be discouraged because it places women at risk for multiple health problems.

Hormonal contraception and the risks of STI acquisition: results of a feasibility study to plan a future randomized trial.

BACKGROUND: Because of limitations in observational studies, a randomized controlled trial (RCT) would help clarify whether hormonal contraception increases the risks of acquiring a sexually transmitted infection (STI). However, the feasibility of such a trial is uncertain. STUDY DESIGN: We conducted a study to assess the feasibility of conducting a RCT that would compare the acquisition risk for Chlamydia trachomatis and Neisseria gonorrhoeae in women randomized to an intrauterine device (IUD) or depot medroxyprogesterone acetate (DMPA). In our cross-sectional survey conducted at three clinics, we gave information on a potential RCT to clients, asked them questions to assess comprehensibility and finally asked respondents whether they would consider enrolling in such a trial. In addition, the 190 participants provided urine or endocervical swab specimens so we could estimate the prevalence of STIs. RESULTS: Overall, 70% of participants stated that they would take part in a future trial and accept randomization to either the IUD or DMPA. Participant understanding of the trial requirements was high. Twenty-nine percent of the participants were infected with either N. gonorrhoeae or C. trachomatis. CONCLUSION: With a high prevalence of STI in this population and the apparent willingness of appropriate candidates to participate, an RCT to measure risks of incident STI infection from hormonal contraception appears feasible.

Cervicitis and genitourinary symptoms in women culture positive for Mycoplasma genitalium.

PROBLEM: Mycoplasma genitalium has been associated with male urethritis. We sought to relate M. genitalium to genitourinary signs and symptoms in women. METHOD OF STUDY: We compared 26 culture-positive women (group 1), 257 additional polymerase chain reaction-positive women (group 2), and 107 negative control women. We used logistic regression to evaluate signs and symptoms, controlling for co-infections, pregnancy, age, and intervention group assignment. RESULTS: Comparing group 1 with controls, we found significantly elevated odds ratios (ORs) for intermediate vaginal discharge (OR = 5.4; 95% confidence interval 1.01, 29.2) and action in response to discharge [3.9 (1.1, 13.5)]. Non-significant increases were observed for pathologic vaginal discharge [3.8 (0.78, 18.2)], pathologic dyspareunia [1.5 (0.25, 9.0)], vaginal odor [2.1 (0.75, 5.7)], and cervical mucopus [4.1 (0.74, 22.4)]. Group 2 results were similar, but showed no increase in cervical mucopus relative to controls. CONCLUSION: Infection with M. genitalium in women is independently related to increased genitourinary symptomatology.

A case-control study on the association between female genital mutilation and sexually transmitted infections in Sudan.

OBJECTIVE: To assess whether the extent of female genital mutilation (FGM) influences the risk of acquiring sexually transmitted infections (STIs). DESIGN: Hospital-based case-control study. SETTING: Two obstetric/gynaecological outpatient clinics in Khartoum, Sudan, 2003-2004. POPULATION: A total of 222 women aged 17-35 years coming to antenatal and gynaecological clinics. METHODS: Women recruited for the study were divided into cases with seropositivity for Neisseria gonorrhoeae (gonococcal antibody test), Chlamydia trachomatis (enzyme immunoassay) or Treponema pallidum (Treponema pallidum haemagglutination assay) (n= 26) and controls without antibodies to these species (n= 196). Socio-demographic data were obtained and physical examination including genital examination was performed in order to classify the form of FGM. Cases and controls were compared using logistic regression to adjust for covariates. MAIN OUTCOME MEASURES: Extent of FGM and seropositivity for C. trachomatis, N. gonorrhoeae or T. pallidum. RESULTS: Of the cases, 85% had undergone the most severe form of FGM involving labia majora compared with 78% of controls (n.s.). Thus, there was no association between serological evidence of STIs and extent of FGM. The only factor that differed significantly between the groups was the education level, cases with STIs having significantly shorter education (P= 0.03) than controls. CONCLUSIONS: There is a little difference between cases and controls in regard to FGM. Having in mind the relatively small sample size, the results still indicate that FGM seems neither to be a risk factor for nor protective against acquiring STIs. This is important as argument against traditional beliefs that FGM protects against pre/extramarital sex.

Prevalence of chlamydial genital infection and associated risk factors in adolescent females at an urban reproductive health care center in Croatia.

The study was undertaken to determine the prevalence of chlamydial genital infection in sexually active, urban adolescent females 15-19 years; to identify behavioral, demographic, and clinical factors associated with chlamydial infections; and to develop criteria for potential screening strategies. 500 adolescent women, median age 17.7 years, who visited gynecological outpatient clinic in Children's Hospital Zagreb for different reasons were enrolled in this study. Gynecological exam, colposcopy, detection of chlamydial infection by the rapid direct immunoassay of endocervical swab (Clearview Chlamydia-Unipath), endocervical cytological examination--Papanicolaou smear, and questionnaire to obtain demographic, social, behavioral and presence of symptoms data were performed. Positive Chlamydia trachomatis test were found in 16.4% of participants, cytologic cervical abnormalities--cervical intraepithelial neoplasia (CIN I-CIN III) were found in 25.2% and cytological signs of Human papilloma virus were found in 11.4%. Stepwise multivariate logistic regression analysis identified five factors associated with infection: the age of menarche < or =13 years, > or =4 lifetime sexual partners, non-use of contraception (rare or never), cervical friability, and abnormal Papanicolaou test. Urban adolescent sexually active women are at high risk for chlamydial infection and other sexually transmitted diseases including HIV infection. Association between chlamydial genital infection and risk-taking sexual and contraceptive behavior was found. Routine Chlamydia trachomatis testing for this population is recommended as well as implementation of school based sexual health education because of their risk-taking sexual behavior.

Aetiology of sexually transmitted infections and response to syndromic treatment in southwest Uganda.

OBJECTIVE: To determine the aetiology of genital ulcers and discharges in rural south western Uganda and to assess response to syndromic treatment. METHOD: A longitudinal, prospective study using laboratory testing and questionnaires to evaluate 561 adult men and women presenting with clinically verified genital ulcers, urethral, or vaginal discharge at a general outpatient clinic and two health centres between December 1999 and July 2001. RESULTS: One third of patients had genital ulcers and two thirds discharges. There was good response to treatment in 461/508 patients (90.7%). Herpes simplex virus type 2 was found in 95/217 (43.8%) genital ulcers. In 24.1% of ulcer cases there was also a genital discharge. HIV seropositivity was high in ulcer cases (63.2%), with significantly more HSV2 and secondary bacterial infection than in seronegative cases. Neisseria gonorrhoeae was found in 135/204 (66.2%) male genital discharges. Female genital discharges were mostly associated with bacterial vaginosis (36.1%), Trichomonas vaginalis (18.9%), and candidiasis (18.6%). CONCLUSIONS: The aetiological pattern of STI syndromes reported will help inform revision of national STI guidelines. The importance of herpes simplex virus type 2, the variation in causes of genital ulcers according to HIV serostatus, the high frequency of multiple infections and secondary bacterial contamination of genital ulcers are notable. These results help explain the lack of effect of an STI intervention on HIV incidence in a recent trial in this area.

Incidence determinants of gonorrhea, chlamydial genital infection, syphilis and chancroid in attendees at a sexually transmitted disease clinic in Athens, Greece.

OBJECTIVE: To determine the specific impact on the incidence rate of some demographic and behavioral characteristics in outpatients with four bacterial sexually transmitted diseases (STDs). STUDY DESIGN: A cross-sectional hospital outpatient-based study was conducted from 1990 to 1996 on 1064 consecutive symptomatic STD cases (Chlamydia trachomatis, n = 375; gonorrhea, n = 369; early symptomatic syphilis, n = 288, and chancroid, n = 32) using a standardized questionnaire. RESULTS: In a reference STD population of 5831 symptomatic outpatients, the relative incidence of gonorrhea, syphilis and chancroid was found to be increased among immigrants. Low educational/socioeconomic level was also a significant incidence predictor. Older age characterized homo/bisexuals. The chlamydial infection detection rate was not affected by nationality, injecting drug use history or sexual orientation in males. CONCLUSION: Innovative preventive and control strategies are needed among immigrants, older men having sex with men and injecting drug users, apart from those targeting the general population.

Prevalence of STD and HIV infections among attenders of the Erasmus MC STD clinic, Rotterdam, The Netherlands, during the years 1996 to 2000.

The purpose of the study was to investigate possible changes in the prevalence of STD and HIV collected at a Dutch STD clinic in the period 1996 to 2000. Age, gender, ethnic background, sexual preference, intravenous drug use and STD or HIV infection in persons attending an STD outpatient clinic were analysed and compared. The prevalence of HIV infection among the clinic visitors remained stable. The prevalence of Neisseria gonorrhoeae and Chlamydia trachomatis infections increased significantly among heterosexual men and heterosexual women. Among homo- and bisexual men a significant increase was seen in chlamydial infections only. Because of the increasing prevalence of gonococcal and chlamydial infections among STD clinic visitors in Rotterdam, more attention should be paid to coordinated preventive activities, such as health education and contact tracing. Further subgroup analyses should be done in order to get more information on risk behaviour in the different groups.

Vaginal douching.

OBJECTIVE: To review current literature on vaginal douching. DATA SOURCES: MEDLINE, CINAHL, and Cochrane databases from 1997 to 2001, using keywords douche or douching; 2001 Web sites of the Centers for Disease Control and Prevention; and Internet search engines for information about current retail sales of douches. STUDY SELECTION: MEDUNE included 67 records, CINAHL 18, and Cochrane 2. Abstracts of articles in English were reviewed, and those pertaining to vaginal douching practices were included. MEDLINE had 44 pertinent articles, CINAHL 11, and Cochrane 1. References from these articles were reviewed and included when appropriate. DATA EXTRACTION: Articles were reviewed and summarized. DATA SYNTHESIS: Vaginal douching is a common practice for women in the United States. Douching is associated with adverse reproductive and gynecologic outcomes including bacterial vaginosis, preterm birth, low-birth-weight infants, pelvic inflammatory disease, chlamydial infection, tubal pregnancy, higher rates of HIV transmission, and cervical cancer. Cultural beliefs and educational factors strongly influence douching practices. CONCLUSIONS: Nursing assessment of women should include information on vaginal douching practices and beliefs. Nurses should use culturally appropriate educational strategies to discourage women of all ages from using vaginal douches as part of routine feminine hygiene because of the associated risks. Further research is needed on factors that influence women's beliefs and douching practices.

[Genital infections in prepubertal girls]. / Genitalinfektionen bei präpuberalen Mädchen.

Vulvitis and vulvovaginitis are the most common gynecologic complaint in prepubertal girls. The frequently observed therapeutic failures are due mainly to lack of knowledge of the characteristics of this age group, of age and development in appropriate diagnostic procedures and of therapeutic measures similar to those in the adult female patient. Prepubertal girls are anatomically, physiologically and behaviorally at relative risk for vulvovaginitis. Symptoms include pruritus, genital pain, "vulvar dysuria" and discharge. History taking and a general pediatric examination are mandatory, thereafter an age appropriate careful anogenital examination should follow. It requires time, patience and knowledge of the different non traumatizing examination techniques. The findings in girls with vulvovaginitis are variable and erythema, excoriations and discharge can be found. The genital inspection and the use of microscopy and microbiologic studies are helpful in planning an appropriate therapy. The majority of vulvovaginal infections in children are nonspecific but they can also be caused by specific organisms and are mostly bacterial. Yeast infections are not found in otherwise healthy prepubertal girls. The therapeutic approach consists of improved anogenital hygiene, sitz/tub baths and use of non irritating soaps. However if an abnormal population of bacteria is present antimicrobial therapy should be considered. Reassurance and a review of preventive methods are crucial in the management of girls with vulvovaginitis.