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Pattern of Sexually Transmitted Diseases and Risk Factors Among Women Attending an STD Referral Clinic in Nairobi, Kenya

Fonck, Karoline MD, MPH*†; Kidula, Nancy MB, ChB MMed; Kirui, Patrick MD§; Ndinya-Achola, Jeconiah MB, ChB, MSc; Bwayo, Job MB, ChB, MSc, PhD; Claeys, Patricia MD, MPH*; Temmerman, Marleen MD, PhD*

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Sexually Transmitted Diseases: August 2000 - Volume 27 - Issue 7 - p 417-423
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Abstract

IT IS NOW well documented that the presence of ulcerative and nonulcerative sexually transmitted diseases (STD) facilitates the transmission and acquisition of HIV.1–7 Therefore, STD control has been recognized as a key strategy to reduce HIV infection.8,9 Furthermore, STD and their ensuing complications are a major burden of morbidity and mortality, particularly among women and neonates in developing countries.10–13 A related problem in southern and eastern African countries is cancer of the cervix, the most frequently detected cancer among African women.14 Cervical dysplasia rates of 2% to 12% have been reported in selected populations.15–17

In Kenya, STD treatment using syndromic management has been introduced in different primary healthcare centers. Healthcare providers were trained and first-line drug kits were distributed in the health sector. Patients requiring second-line treatment or patients with complicated reports of symptoms had to be referred to one of the STD referral clinics. The STD clinic in downtown Nairobi is well equipped with supplies, drugs, and a trained staff, and is well known among the local population. This study was undertaken to identify the burden and pattern of disease in the STD referral clinic in Nairobi. The specific objectives were to (1) determine the prevalence of sexually transmitted infections among women attending the main STD referral clinic in Nairobi, (2) determine the prevalence of cervical intraepithelial neoplasia (CIN) in this population, and (3) study risk markers for STD, HIV, and CIN in this population.

Methods

Population Examined and Clinical Assessment

The target study group included women attending the Special Treatment Clinic, the main STD referral clinic in Nairobi, Kenya. The Special Treatment Clinic clinic is well known in Nairobi, particularly among persons with a lower socioeconomic background. Many self-referred patients also frequent the clinic.

The average attendance in the clinic is approximately 150 patients per day, half of whom are women. After registration, patients are referred to the clinical officers in one of the consultation rooms. Study enrollment took place from June 1996 to April 1997. After registration by the clinic clerks, the patients were taken inside the clinic. The choice of the physician who would see the patient depended solely on the number of patients still queuing in front of the clinician's room. The selection of the patients was in that sense not entirely random, but the best alternative given the circumstances. The women who were willing to participate in the study were examined by the research physician. Informed consent was obtained from all participants. A nurse was responsible for administering a standardized questionnaire to each woman, and also offered pretest HIV counseling. Data collection included sociodemographic data, previous reproductive medical history, sexual behavior, and the presence of genital symptoms. The study physician performed a full gynecologic examination. Vaginal swabs were taken for wet mount, potassium hydroxide testing, and pH testing. Cervical samples were obtained for Gram staining and detection of Neisseria gonorrhoeae and Chlamydia trachomatis. A Papanicolaou smear was taken, and venous blood was drawn for rapid plasma reagin (RPR) and HIV testing. The patients were treated according to the national guidelines, following the syndromic approach. During a follow-up visit the treatment was adapted, when necessary, according to the laboratory findings.

Laboratory Techniques

Saline wet mounts were examined for the presence of motile Trichomonas vaginalis, of yeast cells indicative of Candida albicans, and of clue cells indicative of bacterial vaginosis. The analysis of other samples was performed at the laboratory of the Department of Medical Microbiology (University of Nairobi). Bacterial vaginosis was diagnosed, based on the following symptoms: vaginal fluid pH of more than 4.5, release of a fishy amine odor from vaginal fluid mixed with 10% potassium hydroxide, and presence of clue cells on wet mount. Swabs for N gonorrhoeae isolation were inoculated onto a Thayer-Martin medium and incubated in a candle extinction jar at 36 °C for 24 hours to 48 hours. Swabs for chlamydia were tested with enzyme-linked immunoassay (Syva, Dade-Behring, Brussels, Belgium). Blood samples were tested for syphilis using the RPR test (Becton Dickenson, Becton-Benelux, Erembodegem, Belgium) and for HIV-1 using ELISA Detect and Recombigent (Cambridge-Biotech Corp., Boston, MA). The Papanicolaou smear was read at the Department of Pathology (University of Nairobi) with quality control at the University of Ghent (Belgium).

Data Analysis

The data were entered using Epi-info version 6.0. SPSS version 7.0 (SPSS, Inc., Chicago, IL) for Windows was used for univariate and multivariate analyses.

Results

Demographic Data

A total of 520 women were recruited (Table 1). The mean age was 26 years (SD, 6.8; range, 14-49 years); 54% of the women were married or cohabiting, 31% were single, and 10% were either separated, divorced, or widowed. Before the current relationship, 15% of women had been separated or divorced and 1% had been widowed. Most women (59%) were Protestant, 39% were Catholic, and 1% were Muslim. Approximately half of clients (48%) had 5 years to 8 years of schooling, whereas 41% had 9 years to 13 years of schooling (i.e., secondary education). Approximately half of women had no income.

TABLE 1
TABLE 1:
Demographic Characteristics, Reproductive History, and Sexual Behaviour*

Reproductive History and Sexual Behavior

Sixty-four percent of women reported first sexual intercourse between age 16 years and 19 years, and 11% had sex at the age of 15 years or younger. Seventy-five percent of women had only one sexual partner in the past 3 months and 11% had two or more partners; 12% had one new sexual partner in the last 3 months and 5% reported having two or more new partners in that period. Most of the partners were circumcised (87%).

The mean number of pregnancies in this population was 2.1 and the mean number of children born was 1.3. Twenty-three percent of women had experienced a miscarriage or abortion, whereas 9% had a history of stillbirth. At the time of the interview, 38% of women were pregnant and 26% were using contraception, of which only 1% used condoms. Almost half of women (47%) reported ever having used condoms.

One third of women (32%) reported a history of STDs. However, more women (44%) claimed having sought treatment for genital infections in the past, predominantly for vaginal discharge, followed by genital ulcers and genital warts.

Current Medical Problem

The main reasons for seeking medical care were lower abdominal pain (27%), vaginal itch (22%), and vaginal discharge (20%) (Table 2). However, after probing for reports of symptoms, the majority of women admitted having vaginal discharge (70%), followed by pruritus vulvae (61%), abdominal pain (48%), and dysuria (31%).

TABLE 2
TABLE 2:
Reason for Seeking Medical Care Spontanously Mentioned Compared With Probing*

The majority of the women were infected with C albicans (35%), followed by T vaginalis (25%), and bacterial vaginosis (19%) (wet mounts were performed for 324 women only). N gonorrhoeae was detected in 6% of women and C trachomatis was present in in 4% of women. Syphilis serology was positive in 6% of women and was associated with history of stillbirth (P = 0.02). Genital warts and ulcers were observed in 6% and 12% of women, respectively. The overall HIV prevalence was 29%. Among women less than 20 years, 28% were HIV positive, whereas this rate was 27% in the 20 years to 29 years age group, 38% in the 30 years to 39 years age group, and 26% in the 40 years to 49 years age group. The HIV prevalence was significantly higher in the age group of 30 years to 39 years compared with other age groups (P = 0.04). The prevalence of STDs among pregnant and nonpregnant women is shown in Table 3. The HIV prevalence among nonpregnant women was 34% compared with 23% among pregnant women (P = 0.01). Pregnant women also had significantly more candidiasis (P = 0.02) and significantly less genital ulcers (P = 0.03) than pregnant women. In 22% of the patients, none of the STI pathogens could be identified. CIN was found in 13% of women (95% CI, 9.8-15.8), of whom 8.4% had CIN I, 3.2% had CIN II, and 1.2% had CIN III carcinoma in situ.

TABLE 3
TABLE 3:
Prevalence of Reproductive Tract Infections per Pregnancy Status and Number of Sex Partners*

Risk Factors for Sexually Transmitted Diseases

The relation between risk factors and the major STDs is shown in Table 4. The behavioral risk factors significantly associated with HIV in univariate analysis were first sexual intercourse on or before the age of 15 years, more than one partner in the last 3 months, being single, ever having been treated for an STD, pregnancy, a uncircumcised partner, and ever having used a condom. After multivariate analysis including all these variables, only the number of partners in the previous 3 months (P = 0.02) and an uncircumcised partner (P = 0.01) remained statistically significant.

TABLE 4
TABLE 4:
Odds Ratios and 95% CI for Risk Factors and Sexually Transmitted Infections*

The only risk factors for gonococcal infection was the number of sex partners in the last 3 months (P = 0.001). Women with chlamydial infection had significantly less history of first sexual intercourse when younger than 16 years (P = 0.04). RPR seroreactivity was associated in univariate analysis with the number of sex partners, having had a new sex partner, and ever having been treated for STD. After multivariate analysis including those variables, only having a new partner in the last 3 months remained statistically significant. The only factor associated with CIN was history of an STD (P = 0.03). Bacterial vaginosis, trichomonas infection, candidiasis, and genital ulcers were not associated with any of the risk factors. Young age was strongly associated with presence of genital warts in multivariate analysis (P = 0.007).

The association between HIV and the STD was examined (Table 5). Gonorrhea, bacterial vaginosis, RPR seroreactivity, CIN, and genital warts and ulcers were significantly associated with HIV infection. After multivariate analysis, all factors except syphilis seroreactivity remained significantly associated with HIV infection. The presence of genital ulcers was significantly associated with RPR seroreactivity (P < 0.00).

TABLE 5
TABLE 5:
Association Between STD and HIV Type 1 among 520 female patients, Nairobi, Kenya

Discussion

Twenty-nine percent of women were infected with HIV. A cross-sectional study of the female population attending this clinic has not been done before; hence, we cannot compare with earlier prevalence rates. Studies in family planning clinics in Nairobi show much lower HIV rates.17 However, among women with STD-related reports in public health facilities frequented by the same population as the one attending the STD clinic, similarly high HIV prevalence rates have been found.18,19 An alarming finding in our study was that by the age of 20 years, 28% of women were HIV infected. This is similar to findings of other studies performed in east Africa.20 Women in the younger age groups are infected with HIV at high rates because of a complex sociocultural and economic background. Specific interventions for HIV prevention among the youth are therefore urgently needed.

The prevalence of gonococcal or chlamydial infection in this study was rather low (6% and 4%, respectively) and corresponds to prevalence rates among asymptomatic persons.21 The prevalence of genital ulcers was 12%, but we did not study the etiologic diagnosis of the genital ulcers. However, other studies performed in the same Nairobi clinic show that there has been a decrease over time in the relative proportion of Haemophilus ducreyi while the importance of herpes simplex virus as the cause of genital ulcers is increasing. In 1991, 68% of ulcers were culture positive for H ducreyi,22 whereas this value was reduced to 31% in 1997.23 In the last study, 23% of cases were caused by syphilis infection, 16% by HSV, 15% by mixed infections, and 15% were of unknown origin. The prevalence of CIN in this population of STD patients was 13%, which is similar to the prevalence found in a family planning clinic in Nairobi; however, family planning clients are often perceived as a low-risk population.17

We failed to demonstrate an association between trichomoniasis and HIV infection, which has been reported by others.24 Although the wet mounts were done in the clinic by the study physician, this was made impossible during several months because of power interruptions in Nairobi. The association between chlamydia and HIV did not reach statistical significance but showed a trend toward protection, which has been shown by others.25 There is no definite explanation of this finding, but one possibility might be that we used enzyme-linked immunosorbent assay for the detection of C trachomatis. The more sensitive polymerase chain reaction technique was not yet available; hence, chlamydia prevalence is probably underreported and might have contributed to the lack of a significant association with HIV. Also, selection bias may explain this finding. Minkoff et al25 explain the negative association by suggesting that HIV-positive women have an increased condom use and, hence, have lower STD prevalence rates. This explanation might be true in the United States, but is certainly not the case in the setting where we worked, in which people seldom know their HIV status.

Few women claimed to have had more than one sexual partner in the last 3 months. A 3-month period was used in this study as to minimize the recall bias. We think that most of these women did have only one sexual partner and, hence, must have been infected by their spouse or regular partner, as stipulated in other studies.26 If HIV and STD prevention campaigns aim for a significant impact, the transmission between regular partners will have to be addressed. This, will be challenging, as women find it difficult to negotiate safe sex with their spouse. More gender-sensitive prevention campaigns and women-empowerment strategies will be needed. However, without strong commitment from the government, enforcing laws to protect women against rape, sexual abuse, and violence in their home, this aim will be difficult to achieve.

Few of the classic risk factors studied were significantly associated with genital infections. This might be explained by the low occurrence of these risk factors in this population and, hence, the relative lack of power to prove an association. Some trends did emerge for all STDs, such as positive associations with factors relating to sexual behavior. This study confirms that having multiple partners simultaneously heightens the risk for STDs more than the number of new sex partners.27

Almost all women in this study reported that their partner was circumcised. Male circumcision was associated with a reduced prevalence of HIV infection in the female partner, and this association remained after multivariate analysis. The association between HIV infection and circumcision in males has been demonstrated,28 and a reduction in risk among the female partners of circumcised men has been reported by Kapiga et al.29 There is a possibility of reporting bias of circumcision status, as shown in other studies.30 However, in a recent study in Tanzania, misreporting was found mostly in men who reported themselves as circumcised but who where found to be not circumcised on examination.31 This may reflect a change in norms in that society that favor male circumcision. Because the society in northwestern Tanzania is closely related to the society in Kenya, the same might be true in this study. The women from the only tribe in Kenya that does not traditionally practice circumcision reported their husbands to be circumcised 18%, whereas for the other tribes the proportion was more than 90%. If there has been overreporting of circumcision status in our study, the association between HIV and circumcision might have been even stronger.

We found a low rate of regular condom use, which is consistent with findings in other African settings. Some studies have been able to report a protective effect of reported condom use for STD.32 However, women who reported a history of condom use were more likely to be infected with HIV. A possibly explanation of this finding might be that reported use of condoms may be a surrogate marker for risky sexual behavior or extramarital sex. Women engaging in such high-risk behavior may use condoms more often than other women.

Women attending this clinic came from lower socioeconomic groups that usually have less access to preventive information from mass media or written materials. Few women reported the practice of safe sex, but also reported few high-risk behaviors. Attendance to the clinic provides a good opportunity for health education on a group and an individual basis, and this opportunity should be seized for information, education, and counseling activities (especially regarding safe-sex methods). Techniques to negotiate safe sex with regular partners could be an important protective tool in this population. Program addressing the empowerment of women in relation to their sexual behavior, especially with their regular partner, should be strengthened to achieve more effect on prevention and control activities in the field of STD and HIV.

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