THE BURDEN OF ILLNESS from sexually transmitted disease (STD) is high, particularly in developing countries, where resources for their management are limited. Harare, the capital city of Zimbabwe, has an estimated population of 1,408,091; 64% of this population is in the 15- to 64-year-old age group.1
In the Harare City Health Department, health services for sexually transmitted diseases have been decentralized and integrated into primary health care since 1984.2 The only specialist STD clinic is the genitourinary center, which is a referral center for all the primary care clinics.
The City Health Department offers preventive and curative services in 33 rimary care clinics. These clinics provide services for the population within that catchment area. Services offered in the clinics, for all age groups, are curative (acute and chronic), maternity, child spacing, and mental health.
In the primary care clinics, the diagnosis of an STD is based on the syndromic approach.3 In these clinics, STDs are the most common presenting complaint among people aged 18 years and older and contribute approximately 25% to the total case load seen.4,5 Since 1990, genital ulcer disease (GUD) has been the most prevalent STD, with urethritis ranked second. Sixty-nine percent of all GUD cases are in the 20- to 34-year-old age group, and 3% in those older than 45 years.
The prevention of STD transmission is a priority in the Harare City Health Department, particularly because recent evidence suggests STDs may facilitate the transmission of the human immunodeficiency virus.6 The health education section of the City Health department, as part of the program on STD prevention, has focused on promoting the use of condoms and seeking early, prompt treatment.
Previous studies have shown that the risk of acquiring an STD increases with the number and type of sexual contacts, never having used a condom, and a past history of an STD.7,8 Hook et al., in a study carried out in an STD clinic in Baltimore, reported differences in the risk behaviors associated with gonorrheal and chlamydial infections.9 No studies were available that compared the risk factors for GUD and other STDs. It is not known whether men with GUD have the same risk factors as men with any other STD. A very limited number of studies have addressed the issue of health-seeking behavior for STDs.
This study was therefore carried out to see if there were differences in risk factors for GUD and other STDs and to document the health-seeking behavior of men with any STD.
Materials and Methods
Design and Subject Selection
An unmatched case-control study was conducted in Mabvuku and Glenview primary care clinics from August, 1992 to March, 1993. These clinics were selected because they were in the study site for a larger project on GUD control and human immunodeficiency virus transmission. Before commencement of the study, four nurses and two social workers were trained for 3 weeks in the diagnosis and management of all STDs.
Genital ulcer disease cases were defined as any man presenting to the clinic with a genital ulcer. Other STD cases were defined as any man presenting with either urethral discharge, dysuria, or genital warts. Men presenting with dual STDs were excluded from the study.
The two groups of cases (256 per group) were recruited by consecutive enrollment of all men aged 15 years and older presenting to each clinic with (1) GUD or (2) other STDs. Control subjects (N = 256) were recruited by selecting every third man attending the same clinic, aged 15 years and older, without a complaint of STD and reporting headache or any minor respiratory illness. All other complaints were excluded. All consenting subjects were interviewed by a social worker using a standardized, prepiloted interview protocol. The interviewer was not blinded to the diagnosis of the subjects.
Demographic data on age, marital status, level of education, and employment status were obtained. A detailed sexual history of the number and types of partners in the preceding 3 months, condom use with the same partners, and history of previous STD symptoms was recorded. The previous STD was based on reporting using the syndromic approach.
A sex partner was classified as a steady girlfriend when a relationship of 6 months or more was maintained and a “recent new sexual contact” when the relationship was less than 6 months' duration and no money was exchanged for sex.
Treatment-seeking behavior was assessed by asking the number of days before seeking treatment for the current complaint and the health facility where treatment was first sought.
On completion of the interview, all subjects underwent a physical examination by the nurse and were treated according to the diagnosis. A genital examination was performed only on cases.
For the statistical analysis, odds ratios (OR) with 95% confidence intervals (CI) were computed independently for GUD versus controls and STD versus controls. Chi-square was used to test differences in delay before seeking treatment and facility where treatment was sought.
A total of 768 subjects were recruited: 256 with GUD, 256 with other STDs, and 256 control subjects.
The mean age was the same for the three groups: GUD cases, 26.8 ± 6.8 years (±SD); other STD cases, 26.1 ± 5.2 years; and control subjects 26.3 ± 7.5 years. There were significantly more cases aged 25 to 30 years compared with control subjects. No significant differences were noted in marital status, level of education, and employment status between the cases and control subjects (Table 1).
History of Sexually Transmitted Disease in the Previous 12 Months
Compared with control subjects, both GUD cases and other STD cases were more likely to report a past history of STD symptoms in the previous 12 months (Table 2). Reporting symptoms of dysuria was not a predictor of risk for GUD, but only for other STDs (other STD vs. control subjects OR = 2.4). Proportionally more GUD cases reported symptoms of painful and irritating sores on the genitals in the previous year compared with other STD cases. Conversely, other STD cases reported a higher proportion of urethral discharge and dysuria compared with GUD cases.
Sexual Contact in the Previous 3 Months
There was no difference between GUD and other STD cases in the proportion who admitted to having sexual contact in the preceding 3 months. However, both cases were more likely than control subjects to have had sexual contact: for GUD, 240 (93%), and for other STD, 246 (96%), compared with 154 (60%) for control subjects. Compared with control subjects, both GUD and other STD cases reported more frequent sexual contact with a commercial sex worker (CSW) and with recent new sexual contacts (Table 3). Having sexual contact with a CSW increased the risk of acquiring GUD (OR = 1.46; CI = 1.0–2.1).
Condom Use in the Previous 3 Months
There were no statistically significant differences in condom use between the groups. Over 70% of all men reported never using a condom with recent new sexual contacts, CSWs, and their wives.
Health Facilities Where Treatment Was Sought for Current Complaint
No significant differences were noted between groups with respect to the proportion who sought treatment initially at a primary care clinic. Over 80% attended the primary care clinics as their first contact. However, significantly more cases with GUD (9%) sought treatment at a traditional healer before coming to the clinic, compared with none of the control subjects.
Delay Before Seeking Treatment for Current Complaint
Control subjects with minor respiratory illness and headache sought treatment earlier than cases with any STD (Table 4).
Of the 210 GUD cases who did not seek treatment elsewhere, 29% waited more than 8 days before attending the clinic. Similarly, for other STD cases, of the 223 who did not seek treatment elsewhere, 29% delayed more than 8 days before presenting to the clinic.
The risk factors for acquiring either GUD or any other STD were similar. However, men with GUD, compared with other STDs, were at an increased risk for acquiring GUD on having sexual intercourse with a CSW.
The risk factors identified were history of STD symptoms in the past 12 months and history of sexual contact with a CSW and a recent new sexual contact. This is consistent with other studies in developing and developed countries.10,11 Infrequent use of a condom was not a risk factor for this population. However, other studies have shown the effectiveness of condoms in reducing the risk of STD transmission.
Most of the men with an STD sought treatment at a health facility. This finding is consistent with one other study in Tanzania.12
As part of the health education program for STD/acquired immunodeficiency syndrome, the frequent use of condoms has been promoted to decrease the transmission of STDs. The effectiveness of condoms in decreasing transmission of STDs has been reported by Ngugi et al.13 It is apparent, however, that in these two communities men continue to engage in risky sexual practices by having unprotected sex with CSWs, recent new sexual contacts, and, ultimately, their wives.
Condom use was reported less frequently with CSWs and wives. This contrasts with a study reported by Mbizvo et al. in which men used condoms more frequently with partners considered risky, such as CSWs.14 This study also reported less frequent condom use with wives.
The proportion of men who lived in town with their wives was not established in this study. However, a study by Mbizo et al. in Harare reported 60% of wives living in rural homes, with the husbands commuting.15 This may explain why some of the men had not had any sexual contact in the 3 months preceding the study. Da Costa et al., in Nairobi, cited CSWs as reservoirs for STDs.8 Men would in effect predispose their wives to these STDs and the transmission would continue.
The treatment-seeking behavior in this population of men with STD is of great concern. One third of married men with GUD and reporting sexual intercourse with a CSW would delay more than 3 days before seeking treatment at any facility. The implications for married women are that there is an increased risk of contracting an STD because a cohort study in this same community showed that men continued to have unprotected sexual intercourse while still infected.
Upchurch et al. reported similarly behaviors in their study in Baltimore, with over 33% of subjects continuing to have sexual contact with their partners despite experiencing urogenital symptoms or being told of STD exposure.11 This behavior has serious implications for the STD control program because the mainstay of the program is to interrupt the transmission of STD.
This study has not addressed the issue of why men delay in seeking treatment. Further research is needed to address this very important issue and to work out possible strategies to change this risky behavior. The factors may be socioeconomic in nature, including inability to pay for treatment, failure to perceive that they have an illness that requires treatment, and inability to take time off from work to attend for treatment. Ross, in an STD clinic in Australia, reported that the subjects' perceptions of illness for an STD differed depending on whether they were first or repeat attenders.16 First attenders, without a previous history of STD, saw STD as an illness less frequently than those with a previous infection. Previous STD attenders practiced risky behavior by not seeking prompt treatment and continuing to have unprotected sexual intercourse before resolution of all signs and symptoms. This is similar to the situation in Harare, where men tend to delay in seeking treatment.
Health education continuously needs to reinforce monogamous relationships, the use of condoms to reduce the risk of STD transmission, and the need to seek early and prompt treatment for STD.
Although the prevalence of STDs in Harare has shown a declining trend, it is still unacceptably high. The declining STD prevalence may partly be due to a change in behavior. That fact, however, is not substantiated by this study.
Limitations of the Study
The results for reporting past symptoms (Table 2) may have been influenced by recall bias. Patients coming to the clinic with GUD may be more likely to recall a previous genital sore, just as likely as those with urethral discharge may be more likely to recall a similar episode within the last year. Because of the study design, it was not possible to differentiate between infection from chancroid and herpes simplex. As a result, when analyzing the associations between GUD and sexual contact with a CSW, the herpes cases may have biased the results. It is, however, not possible to ascertain whether the herpes cases diluted or strengthened the statistical associations.
Both cases and control subjects were interviewed by a social worker who was not blinded to the diagnosis. This may have introduced interviewer bias despite the use of a standardized questionnaire. Control subjects were not examined for the presence of any STD and may have been harboring an STD.
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