Search

The syndromic management of vaginal discharge syndrome (VDS) is challenging because of the prevalence of mixed infection with sexually transmitted infection (STI) pathogens and non-STI causes, such as bacterial vaginosis and candidiasis (CA). We aimed to determine the relative prevalence of VDS etiologies in women presenting to sentinel primary health care clinics in South Africa. Secondary objectives were to ascertain the predictive value of speculum findings for the presence of STI pathogens and the proportion of women presenting with clinical features of CA who had identifiable yeast on vaginal smear microscopy.Consecutive, consenting women with complaints of abnormal vaginal discharge were enrolled between January 1, 2019, and December 31, 2020. Genital discharge swab and blood specimens were collected and transported to a central STI reference laboratory in Johannesburg.A total of 364 women were enrolled at 3 sentinel sites. Bacterial vaginosis was the most common cause of VDS (163 of 361 [45.2%]; 95% confidence interval [CI], 40.1%-50.3%); however, a significant proportion had STI coinfection (71 of 163 [43.6%]; 95% CI, 35.8%-51.5%). The predominant STI etiology was Chlamydia trachomatis (73 [20.2%]; 95% CI, 16.4%-24.7%). An abnormal speculum finding had poor predictive value for STIs, and Gram stain microscopy showed yeast in only 37.2% of vaginal smears from women with CA symptoms.Bacterial vaginosis is the predominant cause of VDS in South Africa; however, STI coinfection is common. Clinical findings are poorly predictive of STI etiologies or candidiasis; therefore, a rapid and accurate STI point-of-care test would be useful in optimizing VDS management.

Almost 1 in 4 women being seen for prenatal care in our clinics in Porto Alegre Brazil were diagnosed with a sexually transmitted infection. Among women who tested positive, 59% did not have any symptoms. Supplemental digital content is available in the text., Background Porto Alegre, Brazil, has the highest rates of congenital syphilis and HIV in the country. Other treatable sexually transmitted infections (STIs) are associated with poor pregnancy and neonatal outcomes, but are only diagnosed by syndromic algorithms. Methods Between September 2018 and November 2019, we offered all pregnant women clinic-based STI testing for HIV antibody and treponemal antibody (via lateral flow assay rapid tests provided by the Brazilian Government) and for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis (via polymerase chain reaction–based testing provided by Gene Xpert, Sunnyvale, CA) in 10 public prenatal health clinics in Porto Alegre. Participating women answered a brief survey via audio computer-assisted survey instrument regarding demographics, partnerships, and sexual behaviors. All infected individuals received appropriate treatment and referrals. Results Of 400 pregnant women recruited, 94 (24%) were diagnosed with an STI, including 2% with HIV, 11% with syphilis, 9% with chlamydia, 1% with gonorrhea, 5% with trichomoniasis, and 3% with more than 1 STI. In our multivariate analysis, younger age (adjusted odds ratio [AOR], 1.1; 95% confidence interval [CI], 1–1.2), being non-White (AOR, 1.8; 95% CI, 1.1–3.1), having less education (AOR, 2; 95% CI, 1.2–3.4), and having a relationship

BACKGROUND We evaluated the clinical management and risk factors for Trichomonas vaginalis-positive adolescents in upstate South Carolina. METHODS An Epic electronic medical record report was generated to identify any physician-ordered T. vaginalis test from February 2016 to December 2017 for patients aged 12 to 18 years within the Prisma Health Upstate system. Utilizing a case-control study design of patients with a documented T. vaginalis diagnostic result, we reviewed records of patients with physician-ordered T. vaginalis tests for demographics, clinical disease course, sexually transmitted infection test results, treatment order and dosage, infection risk factors, comorbidities, pregnancy term, and neonatal birth outcomes. RESULTS Of 789 male and female adolescents with physician-ordered T. vaginalis tests, 44% had a documented result. Of those with a document test result, 13% were T. vaginalis positive. Cases (n = 45) and randomly selected negative controls (n = 45) were all girls. Cases were more likely to be African American, symptomatic, and present with vaginal discharge, pain, and vulvar itch. T. vaginalis patients were more likely to have documented histories of chlamydia (P < 0.0001) and gonorrhea (P = 0.0191), with 18% having concurrent triple infections (T. vaginalis, chlamydia, and gonorrhea). All 26 pregnant girls with T. vaginalis delivered full-term, healthy infants. CONCLUSIONS We identified a disproportionally high burden of T. vaginalis infection, with an alarmingly high rate of triple infections, among a population of suspected high-risk adolescents. Our results indicate the need to clarify infection prevalence, develop pediatrician-focused education campaigns, and elucidate potentially modifiable risk factors for these high-risk patients.

BACKGROUND: Syphilis prevalence in sub-Saharan Africa appears to be stable or declining but is still the highest globally. Ongoing sentinel surveillance in high-risk populations is necessary to inform management and detect changes in syphilis trends. We assessed serological syphilis markers among persons with sexually transmitted infections in Zimbabwe. METHODS: We studied a predominantly urban, regionally diverse group of women and men presenting with genital ulcer disease (GUD), women with vaginal discharge and men with urethral discharge at clinics in Zimbabwe. Syphilis tests included rapid plasma reagin and the Treponema pallidum hemagglutination assay. RESULTS: Among 436 evaluable study participants, 36 (8.3%) tested positive for both rapid plasma reagin and Treponema pallidum hemagglutination assay: women with GUD: 19.2%, men with GUD: 12.6%, women with vaginal discharge: 5.7% and men with urethral discharge: 1.5% (P < 0.0001). CONCLUSIONS: Syphilis rates in Zimbabwe are high in sentinel populations, especially men and women with GUD.

BACKGROUND: Prioritizing HIV prevention for adolescent girls and young women (AGYW) at high risk of HIV acquisition in sub-Saharan Africa (typically considered ≥3 per 100 person years [PYs]) is urgently needed, but identifying these AGYW is challenging. We sought to assess and, if needed, enhance a risk assessment tool from the VOICE trial for identifying AGYW at high risk for HIV in Lilongwe, Malawi. METHODS: A multisite prospective cohort study was conducted among sexually active AGYW 15–24 years old at four health centers in 2016–2017. The VOICE tool was first applied and then updated by excluding variables that were not predictive and adding variables that were. Incidence rates (IR), incidence rate ratios (IRR), ninety-five percent confidence intervals (CIs), area under the receiver-operator characteristic curve (AUC), sensitivity, and specificity were calculated. RESULTS: Seven-hundred ninety-five participants experienced 14 seroconversions over 672 person-years (IR: 2.08 per 100 PYs, CI: 1.23–3.52). The VOICE tool had moderate predictive ability (AUC: 0.64, CI: 0.52, 0.75). Maintaining two variables (genital ulcers and vaginal discharge), removing five socio-demographic variables, and adding two variables (ever pregnant and >5 year male-female age gap) enhanced performance (AUC=0.79, 95% CI: 0.69–0.89). Thirty-five percent had a score of 0, 41% had a score of 1–2, and 24% had a score ≥3. A score ≥1 resulted in 100% sensitivity, 35.9% specificity, and an IR of 3.25 per 100 PYs. A score ≥3 resulted in 64.3% sensitivity, 76.8% specificity, and an IR of 5.89 per 100 PYs. CONCLUSIONS: A simple risk assessment tool identified a subset of AGYW in Malawi at high risk of HIV acquisition who may benefit from biomedical HIV prevention.

INTRODUCTION: Symptomatic vaginal discharge is a common gynecological condition managed syndromically in most developing countries. In Zimbabwe, women presenting with symptomatic vaginal discharge are treated with empirical regimens that commonly cover both sexually transmitted infections (STI) and reproductive tract infections, typically including a combination of an intramuscular injection of kanamycin, and oral doxycycline and metronidazole regimens. This study was conducted to determine the current etiology of symptomatic vaginal discharge and assess adequacy of current syndromic management guidelines. METHODS: We enrolled 200 women with symptomatic vaginal discharge presenting at 6 STI clinics in Zimbabwe. Microscopy was used to detect bacterial vaginosis and yeast infection. Nucleic acid amplifications tests were used to detect Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis and Mycoplasma genitalium. In addition, serologic testing was performed to detect HIV infection. RESULTS: Of the 200 women, 146 (73%) had an etiology detected, including bacterial vaginosis (24.7%); N. gonorrhoeae (24.0%); yeast infection (20.7%); T. vaginalis (19.0%); C. trachomatis (14.0%) and M. genitalium (7.0%). Among women with STIs (N=90), 62 (68.9%) had a single infection, 18 (20.0%) had a dual infection and 10 (11.1%) had three infections. Of 158 women who consented to HIV testing, 64 (40.5%) were HIV infected. The syndromic management regimen covered 115 (57.5%) of the women in the sample who had gonorrhea, chlamydia, M. genitalium, or bacterial vaginosis, while 85 (42.5%) of women were treated without such diagnosis. CONCLUSION: Among women presenting with symptomatic vaginal discharge, bacterial vaginosis was the most common etiology and gonorrhea was the most frequently detected STI. The current syndromic management algorithm is suboptimal for coverage of women presenting with symptomatic vaginal discharge; addition of point of care testing could compliment the effectiveness of the syndromic approach.

We investigated the antimicrobial resistance in gonococci 2009 to 2014 in Yaoundé, Cameroon, and recommend revisions of the Cameroonian treatment guideline. We observed a high resistance to ciprofloxacin (17.6%) but no ceftriaxone resistance. Ceftriaxone should replace ciprofloxacin as the recommended first-line treatment for urethral/vaginal discharge. Enhanced resistance surveillance in Africa is essential.

Background The burden of sexually transmitted infections (STIs) in areas of sub-Saharan Africa with poor access to health care services is not well documented. In remote areas of South Africa, we investigated the prevalence of STIs and approaches to providing STI services through a mobile clinic.Methods We recruited 251 adult women visiting a mobile clinic that normally provides general health education and screening services, but not STI care. Clinical and sexual history was obtained and vaginal specimens were tested for Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Mycoplasma genitalium infection and for Candida albicans and bacterial vaginosis.Results Laboratory test was positive for 133 (53%) of 251 women for at least 1 STI: C. trachomatis was observed in 52 (21%) women, N. gonorrhoeae in 39 (16%) women, T. vaginalis in 81 (32%) women and M. genitalium in 21 (8%) women. Eighty-one (32%) women met the criteria for vaginal discharge syndrome, of which 58% (47/81) would have been treated accurately. Among asymptomatic women 84 (49%) of 170 were diagnosed with an STI but untreated under the syndromic approach. We could not identify factors associated with asymptomatic STI infection.Conclusions There is a high unmet need for STI care in rural South African settings with poor access to health care services. Provision of STI services in a mobile clinic using the syndromic management approach provides a useful approach, but would have to be enhanced by targeted diagnostics to successfully address the burden of infection.

We report on the antimicrobial resistance profile of Neisseria gonorrhoeae isolates and the distribution of tetM genes in isolates with high-level tetracycline resistance in KwaZulu-Natal, South Africa.Male and female patients presenting with urethral and/or vaginal discharge were recruited into the study. Urethral and cervical secretions were cultured on New York City agar. Confirmatory tests for N. gonorrhoeae included Gram stain, catalase, oxidase, and carbohydrate utilization tests. Beta-lactamase was tested by means of the chromogenic cephalosporin test. Minimum inhibitory concentrations were determined using agar dilution with multipoint inoculation. Polymerase chain reaction with gel electrophoresis was used to detect the presence and type of the tetM gene.N. gonorrhoeae was isolated from the specimens of 319 (26%) of the 1220 recruited patients. Of these 319 isolates, 71% were resistant to 3 or more drugs. Resistance to azithromycin was found in 68% of the isolates. All isolates showed high-level tetracycline resistance with minimum inhibitory concentration values of 16 and 32 mg/mL. The tetM gene was present in 293 (92%). The American type was found in 264 (90%) and the Dutch type in 29 (10%). Twenty-six (8%) did not carry a tetM gene.The current syndromic management with dual ceftriaxone and azithromycin is due to the high level of azithromycin resistance factually single-drug therapy. High-level tetracycline resistance based on a resistance mechanism other than ribosome protection by the tetM gene product is present in N. gonorrhoeae infecting South African patients.

We examined quality of care across different clinical settings within a large safety-net hospital in Massachusetts for patients presenting with penile discharge/dysuria or vaginal discharge.Using a modified Delphi approach, a list of sex-specific sexually transmitted infection (STI) quality measures, covering 7 domains of clinical care (history, examination, laboratory testing, assessment, treatment, additional screening, counseling), was selected as standard of care by a panel of 5 STI experts representing emergency department (ED), obstetrics/gynecology (Ob/Gyn), family medicine (FM), primary care (PC), and infectious disease. Final measures were piloted with 50 charts per sex from the STI Clinic and age, sex, and visit date-matched charts from PC, FM, ED, and Ob/Gyn. Performance was scored as compliance among individual measures within 7 domains, standardized to add up to one to adjust for variable number of measures per domain, with an overall score of 7 indicating complete adherence to standards.Expert review process took 2 weeks and resulted in 24 and 34 final measures for male and female patients, respectively. Performance on 7 clinical domains ranged from 3.16 to 4.36 for male patients and 3.17 to 4.33 for female patients. Sexually transmitted infection clinic seemed to score higher on laboratory testing, additional screening, and counseling, but lower on examination and assessment, and ED seemed to score higher on examination and treatment, PC and FM on laboratory testing for male patients and on examination and treatment for female patients, and Ob/Gyn on treatment.An instrument to discern standard of care and identify strengths and weaknesses in specific domains of clinical documentation for patients presenting with STI complaints can be developed and implemented for quality evaluation across care settings. Further research is needed on whether these findings can be integrated into site-specific quality improvement processes and linked to cost analyses.

A phase 3 randomized study of single-dose metronidazole vaginal gel 1.3% versus vehicle gel in participants with bacterial vaginosis demonstrated superior cure rates in the metronidazole treatment group., Background Bacterial vaginosis (BV), a prevalent infection in women of reproductive age, is associated with increased risk of upper genital tract and sexually transmitted infections, and complications in pregnancy. Currently approved treatments include metronidazole, which requires once or twice daily intravaginal administration for 5 days or twice daily oral administration for 7 days. This phase 3 study determined the safety and efficacy of single-dose metronidazole vaginal gel (MVG) 1.3%. Methods In this double-blind, vehicle-controlled study, 651 women with clinical diagnosis of BV were randomized 1:1 to receive MVG 1.3% or vehicle vaginal gel. Primary efficacy measure was clinical cure (normal discharge, negative “whiff test,” and

Trichomonas vaginalis (TV) and bacterial vaginosis (BV) are independently associated with increased risk of vaginal shedding in HIV-positive women. Because these 2 conditions commonly co-occur, this study was undertaken to examine the association between TV/BV co-occurrence and vaginal shedding of HIV-1 RNA.HIV-positive women attending outpatient HIV clinics in 3 urban US cities underwent a clinical examination; were screened for TV, BV, Neisseria gonorrhoeae, Chlamydia trachomatis, and vulvovaginal candidiasis; and completed a behavioral survey. Women shedding HIV-1 RNA vaginally (≥50 copies/mL) were compared with women who had an undetectable (50 copies/mL) vaginal viral load to determine if women who were TV positive and BV positive or had co-occurrence of TV/BV had higher odds of shedding vaginally when compared with women who did not have these conditions.In this sample of 373 HIV-positive women, 43.1% (n = 161) had co-occurrence of TV/BV and 33.2% (n = 124) were shedding HIV-1 RNA vaginally. The odds of shedding HIV vaginally in the presence of TV alone or BV alone and when TV/BV co-occurred were 4.07 (95% confidence interval [CI], 1.78-9.37), 5.65 (95% CI, 2.64-12.01), and 18.63 (95% CI, 6.71-51.72), respectively, when compared with women with no diagnosis of TV or BV, and after adjusting for age, antiretroviral therapy status, and plasma viral load.T. vaginalis and BV were independently and synergistically related to vaginal shedding of HIV-1 RNA. Screening and prompt treatment of these 2 conditions among HIV-positive women are important not only clinically but for HIV prevention, as well.

Trichomonas vaginalis is the most prevalent curable sexually transmitted infection in the world.1 In the United States, according to the 2000 to 2004 National Health and Nutrition Examination Survey, an estimated 3.1% of women of reproductive age are infected with T. vaginalis, making this parasitic infection more prevalent than either chlamydia or gonorrhea.2,3 A disproportionately high burden of disease has been observed among older women and non-Hispanic black women.2,4 Infection with T. vaginalis has been associated with serious adverse outcomes such as pelvic inflammatory disease5,6 and 1.5 to 2.7 times greater risks of HIV acquisition and transmission.7–10 An estimated 70% to 85% of infected women are asymptomatic.2,11 Symptoms of trichomoniasis range from mild to severe inflammation and genital pruritis and may also include cervicovaginal and/or urethral discharge. A single oral dose of a nitroimidazole antimicrobial (ie, 2 g of metronidazole or tinidazole) is generally sufficient treatment to cure infection.12 Although in vitro antimicrobial resistance has been documented in 4% of vaginal culture specimens collected from sexually transmitted disease (STD) clinics, in vivo antimicrobial resistance has remained infrequent to date.13,14 The Centers for Disease Control and Prevention (CDC) STD Treatment Guidelines recommend that all women seeking care for symptoms of vaginal discharge should be tested for T. vaginalis infection.12 As for screening asymptomatic persons, however, these guidelines recommend routine annual screening only among HIV-infected women and currently do not include specific recommendations for T. vaginalis screening among the general population or among other high-risk groups.12 Although approximately 71% of male sexual partners of women with trichomoniasis are also infected with T. vaginalis, clinical testing for this parasite is not commonly conducted for male patients.15 Traditional diagnostic testing is by wet mount microscopy, in which a specimen of genital (eg, cervicovaginal) fluid is collected by a clinician during a pelvic examination and interpreted at the point of care; the test is inexpensive but operator dependent, and sensitivity is generally poor at 51% to 65%.16,17 Additional testing options include culture, which does not provide immediate results and is less commonly performed; recently developed rapid antigen tests, which may be performed at the point of care; and nucleic acid amplification tests (NAATs), the first of which was cleared for use in symptomatic or asymptomatic women by the US Food and Drug Administration in 2011, with high sensitivity (95%–100%) and specificity (95%–100%) for detecting T. vaginalis in urine specimens, endocervical swabs, or vaginal swabs.16,18,19 Little is known about current diagnostic testing and screening practices for this very common STD among persons presumably at high risk for infection, such as patients presenting at STD clinics.20 The objective of this analysis was to assess T. vaginalis prevalence among symptomatic and asymptomatic women tested or screened at a diverse group of STD clinics in the United States.

Bacterial vaginosis (BV) is a frequent cause of vaginal discharge that may be more common among women reporting sex with women (WSW). The objective of this study was to determine the prevalence of BV and predictors of infection among a sample of African American WSW.African American WSW aged 18 years or older presenting to the Mississippi State Department of Health STD Clinic between 2009 and 2010 and reporting a history of sexual activity with a female partner during the preceding year were invited to participate. A survey on sexual history and sexual behavior characteristics was completed. Bacterial vaginosis was defined by Amsel criteria. Associations with participant characteristics were determined using logistic regression analysis.Bacterial vaginosis was diagnosed in 93 (47.4%) of 196 women. Bisexual identity (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.03-3.66; P = 0.04), douching within the past 30 days (OR, 1.93; 95% CI, 1.09-3.43; P = 0.02), age 18 years or less at first sexual encounter with a female partner (OR, 3.18; 95% CI, 1.16-8.71; P = 0.02), and report of more than 1 lifetime male sexual partners (OR, 1.94; 95% CI, 1.01-3.74; P = 0.04) were significant predictors of BV in bivariate analysis. Bacterial vaginosis was less common among women who reported more than 1 lifetime female sexual partner (OR, 0.26; 95% CI, 0.09-0.76; P = 0.01). In multivariable analysis, age 18 years or less at first sex with a female partner approached significance, while report of 1 lifetime female sexual partner remained strongly associated with BV.Bacterial vaginosis was common in this sample of African American WSW and significantly associated with report of 1 lifetime female sexual partner.

Positivity of microscopy and culture was greater (P < 0.0001) in men with urethral discharge syndrome (65.8%) than in women with vaginal/cervical discharge (0.5%), indicating that basic diagnostic tests may not be cost-effective for diagnosis of vaginal/cervical discharge syndrome. Microscopy when compared with culture showed sensitivity, specificity, positive predictive value and negative predictive value of 95.4%, 77.6%, 84.6%, and 95.3%, in men, whereas in women, it was 77.8%, 99.9%, 92.1%, and 99.9%, respectively.

BACKGROUND: Syndromic case management remains the cornerstone for STI (sexually transmitted infection) treatment in many countries. We undertook this study to better understand the etiology of STIs in adults in south India and to inform STI management guidelines. METHODS: Adult males and females presenting with genital complaints were recruited from clinics in Karnataka state south India. A questionnaire was administered physical examination performed and blood collected for herpes simplex virus-type 2 (HSV-2) and syphilis serology. Men with urethral discharge (UD) and women with vaginal discharge were tested for Neisseria gonorrhoeae (NG) Chlamydia trachomatis (CT) and Trichomonas vaginalis (TV). Vaginal swabs were also tested for bacterial vaginosis and yeast infection. Participants with genital ulcers were tested for Treponema pallidum (TP) Haemophilus ducreyi (HD) and HSV-2. human immunodeficiency virus (HIV) testing was offered to all individuals. RESULTS: There were 401 male and 412 female participants and rates of HIV infection were high (men 17%; women 15%). HSV-2 was significantly associated with HIV in men and women. Among men with the complaint of UD NG was identified in 35% CT in 10.5% and TV in 8.5%. Very little NG or CT was detected among women with vaginal discharge. However bacterial vaginosis was identified in approximately 40% of women with significant amounts of TV and Candida also detected. HSV-2 was the most commonly identified pathogen among participants with genital ulcer disease and the clinical distinction of herpetic versus nonherpetic lesions was not helpful. CONCLUSIONS: Current STI management guidelines should be reevaluated in south India. Consideration should be given to treating all persons with GUD for both HSV-2 and syphilis and to adding initial treatment for TV for men with UD in areas of high background prevalence of HSV-2 and TV respectively. This population is at high risk for HIV and should be counseled and tested appropriately.

Bacterial vaginosis (bv) is a common cause of abnormal or altered vaginal discharge in women of childbearing age. Its association with obstetric and gynecologic complications and HIV are increasingly recognized. Few population-based surveys of BV have been conducted in Africa. The objective of the study was to examine the role of genital infections including Herpes simplex virus type 2 (HSV-2) and demographic factors on the prevalence of BV among pregnant women in Burkina Faso.Consenting pregnant women from Burkina Faso answered a face-to-face interview on their demographic characteristics. Then, genital and blood swabs were collected and tested for BV and other genital infections. Univariable and multivariable models were used to investigate the risk factors of BV.Among the 2133 women included in the analyses (over 2284 enrolled), the prevalence of BV was 6.4% [95% confidence interval (CI), 5.5%-7.6%], ranging from 3% to 12% between regions. In multivariable analyses, HSV-2 [odds ratio (OR), 1.64; 95% CI 1.04-2.59) was the only genital infection that remained significantly associated with BV. Other factors related to BV were history of abortion (OR, 1.57; 95% CI, 1.01-2.43) and geographical origin. HIV infection (OR, 1.98; 95% CI, 0.90-5.20) and polygamy (OR, 1.48; 95% CI, 1.00-2.36) tended to be associated with BV without reaching statistical significance.The prevalence of BV among pregnant women was lower than expected, with large geographical disparities. Our data confirm the potential interaction between BV and HSV-2.

The objective of this study was to evaluate patterns in sexually transmitted disease (STD) syndromes after the introduction of an STD syndromic management program. We used the HIV sentinel surveillance in patients with STDs (1990 –2001) to compute the proportions of STD syndromes (as a proportion of all patients with STDs) before and after the introduction of the syndromic management program. A decline in the proportion of genital ulcer disease (GUD) urethral discharge (UD) and vaginal discharge (VD) was observed from the baseline (1990 –1994) to the year 2000 (P

BACKGROUND: Diagnosis of bacterial vaginosis (BV) in resource-poor primary health care settings is often overlooked; there is a need for a cheap, rapid, objective point-of-care diagnostic test. GOAL: The goal was to determine the prevalence of BV and to evaluate the performance of a new commercial diagnostic test kit in a developing country environment. STUDY DESIGN: Vaginal and cervical swabs were collected from 230 consecutive women attending a genitourinary medicine clinic with reported symptoms of vaginal discharge and/or itching. Etiological testing was carried out. BV was diagnosed on the basis of the Nugent score, the Amsel clinical criteria, and results of FemExam card tests. Card 1 is for pH and amines, and card 2 measures proline iminopeptidase (PIP) activity. RESULTS: BV prevalence was 47.9% according to the Nugent score. When compared with the Nugent score, the Amsel clinical criteria had a sensitivity of 77.9% and specificity of 58.4%, FemExam card 1 had a sensitivity of 71.4% and specificity of 72.8%, FemExam card 2 had a sensitivity of 70% and specificity of 81.0%, and FemExam cards 1 and 2 combined had a sensitivity of 91.0% and specificity of 61.5%. Cost per patient and cost per true case detected ranged from US $0.74 and US $1.54, respectively, for Gram stain diagnosis, to US $8.32 and US $18.49 for the FemExam two-card method. CONCLUSIONS: In a setting where BV was frequently associated with vaginal discharge, the FemExam test compared favorably with conventional clinical diagnosis, and it has the advantage of being rapid, less subjective, and easily performed. Cutting its cost would provide wider accessibility in developing countries.

Background Studies of the accuracy of syndromic management have demonstrated widely varying results depending upon gender, location of infection, risk group, organisms, among other factors. Goal To review current knowledge about syndromic management of sexually transmitted diseases (STDs) and to make recommendations about the strengths and weaknesses of different syndromic management algorithms. Study design The authors identified articles and abstracts about the syndromic management of STDs. Evaluation of the effectiveness of algorithms for urethral discharge, genital ulcer disease, and vaginal discharge was based primarily on published sensitivity and specificity data. Results Overall, algorithms for the diagnosis and treatment of urethral discharge and genital ulcer disease in men had high sensitivities or cure rates (urethral discharge, 87-99%; genital ulcer disease, 68-98%). The sensitivities for the algorithms for vaginal discharge ranged from 73% to 93% among women presenting with symptoms of vaginal discharge, and from 29% to 86% among women not presenting with symptoms. Vaginal discharge was not found to be an effective indicator of cervical infection and, therefore, is not an independently effective screening tool to detect women with cervical infection, especially in low-risk or asymptomatic populations. Incorporating risk scores can improve the accuracy of algorithms to detect cervical infection. Conclusions Algorithms for urethral discharge and genital ulcer disease can be effective in STDs. The current algorithms for vaginal discharge are not highly effective in detecting gonorrhea and chlamydia in women; risk scores can improve their efficacy, but must be tailored to reflect community risks. Without attention to the qualitative aspects of STD syndromic management, these methods will likely have even less accuracy than the studies reviewed above. There remains an urgent need for the development of an affordable, rapid, and effective diagnostic technique that will improve STD detection in resource-poor settings.

OBJECTIVE Although established in women as a common cause of vaginal discharge, the prevalence of Trichomonas vaginalis (TV) in men compared with other classic urethral pathogens has not been well characterized. To assess this issue, the authors compared the prevalence of Neisseria gonorrhoeae (GC), Chlamydia trachomatis (CT), and TV in consecutive men attending a sexually transmitted diseases (STD) clinic. METHODS From June 1, 1998 to July 27, 1998, 454 consecutive men presenting to the Denver Metro Health Clinic with a new problem were tested for GC by urethral swab culture, for CT by polymerase chain reaction of urine, and for TV by urine sediment culture. RESULTS GC, CT, and TV were detected in 23 (5.1%), 34 (7.5%), and 13 (2.8%) of men, respectively. There were significant differences by age for both CT (11.3% in men younger than 30 years versus 3.3% in men 30 years and older, P < 0.05) and TV (0.8% in men younger than 30 years versus 5.1% in men 30 years and older, P < 0.05). In 50 men 30 years or older with symptoms of urethral discharge, TV prevalence (12.0%) rivalled that of GC (12.0%) and CT (14.0%). In 45 men 30 years and older with nongonococcal urethritis, the prevalence of TV and CT were each 13.3%. Multivariate logistical regression analysis showed the presence of discharge and nongonococcal urethritis in men 30 years and older to be an independent predictor of TV. CONCLUSIONS TV is common in men attending sexually transmitted disease clinics, especially in those 30 years or older, in whom it may account for as much urethritis as GC or CT. These findings suggest that in older men with nongonococcal urethritis, diagnostic evaluation, empiric treatment, and partner management should include the possibility of TV infection.

While treatment of symptomatic sexually transmitted diseases (STDs) has been shown to reduce the incidence of HIV infection, there are few published reports describing the delivery of high quality STD care in Africa.To test the feasibility of providing comprehensive, affordable STD services through the existing primary care infrastructure.STD treatment services using a syndromic' approach were established in two semi-urban hospital outpatient departments (OPD) in Central African Republic (CAR). A dedicated paramedical provider took a clinical history, performed an examination, explained the diagnosis and the importance of referring partners, dispensed drugs, and offered partner referral vouchers. A fee-for-service system was used to resupply drugs initially purchased with project funds.Of 9,552 visits by index patients and partners over a 28-month period starting in October 1993, 60% were made by women; of these women, 90% were symptomatic, 77% had "vaginal discharge," 70% "lower abdominal pain," and 7% "genital ulcer." Among men, 64 % were symptomatic, 38 % had "urethral discharge," and 14% "genital ulcer." Half of all symptomatic patients presented within 1 week of the onset of symptoms; 44% of men compared to 18% of women had sought care elsewhere before the clinic visit. The average cost per STD treated with recommended drugs was $3.90. Etiologic data from subpopulations in both sites suggest that a high proportion of patients was infected with an STD.Comprehensive yet affordable care for STDs in persons (and their partners) who recognize symptoms is feasible and should be widely implemented in primary care systems to prevent the spread and complications of STDs and HIV in Africa.This study examines the feasibility of providing comprehensive, low-cost sexually transmitted disease (STD) services through the existing primary care infrastructure in two semi-urban health centers in the Central African Republic. The results showed that out of the 9552 visits made by index patients and partners over a 28-month period, 60% were made by women. Among these women, 90% were symptomatic, 77% had vaginal discharge, 70% had lower abdominal pain, and 7% had genital ulcer. In addition, 44% of men, as compared to 18% of women, had looked for treatment elsewhere prior to the clinic visit. The average cost per STD treated with the recommended drugs was $3.90. Furthermore, condom use was low in both areas and etiologic data suggest that a large proportion of patients was infected with an STD. The findings suggest that a comprehensive and affordable model for STD control can be implemented in primary care systems to prevent the spread of STDs in Africa.

To design, introduce, and evaluate "STD syndrome packets" containing recommended drugs for each syndrome, four condoms, a partner treatment card, and a patient information leaflet, with the goal of improving sexually transmitted disease (STD) case management.Packet design evolved around available packaging technology, informed by pilot testing with nurses working in primary care clinics, doctors in private medical practices, and patients with an STD, in Hlabisa, South Africa. Evaluation 1 year later included analysis of distribution records and interviews with 16 nurses and 64 patients.A cheap packet (2 U. S. cents each, excluding contents) compatible with current legislation was designed and introduced to six public sector clinics and as a short pilot to five private medical practices. Four thousand eighty-five packets were distributed to the clinics, equivalent to approximately 115% of the STDs reported over that period. All 16 nurses reported using the packets, but only 63% did so all the time because of occasional supply problems. All believed the packets improved treatment by saving time (75%), improving supply of condoms and partner cards (44%), and making treatment easier (56%). Patients also responded positively, and most said they would buy a packet (up to $5) at a pharmacy (84%) or store (63%) if available.The STD syndrome packets have the potential to improve STD syndromic management by standardizing therapy and improving the supply of condoms, partner cards, and information leaflets. Packets are popular with practitioners and patients, but consistent supply is essential for maximal impact. There may be scope for social marketing of the packets, which could further increase use.As part of an intervention to improve the syndromic management of sexually transmitted diseases (STDs), the acceptability of STD syndrome packets was tested in Hlabisa, South Africa. The packets contained drugs recommended for each syndrome, four condoms, a partner treatment card, and a patient information sheet. 4085 such packets were distributed, at a cost of US$0.02 each, to six public sector clinics during the 1-year study period. These clinics treated a total of 3535 STD patients in that time period. Interviews conducted with 16 clinic nurses 1 year after project implementation indicated that they thought the packets made treatment easier and saved staff time. 10 nurses indicated they used the packets all the time; the remaining 6 used them most of the time, with gaps attributed to supply shortages. Also interviewed were 64 STD patients who received the packets. 84% indicated they would be willing to buy the packet from a pharmacy and 63% would buy it from a general store. 67% of STD patients were prepared to spend up to US$5 on the packet. These findings suggest that STD packets have an important role to play in increasing access to STD treatment in developing countries. Use could be increased even further by social marketing of the packets.

Although chlamydia is a well-studied disease, little is known about the rates of genital chlamydial disease among female Hispanics in urban family planning clinics.To determine the prevalence of women with chlamydia in two clinic populations during 1994. We also sought to describe previously identified and novel risk factors for chlamydial disease in this unique population.We conducted a retrospective case-control analysis in two community clinics in the Washington Heights section of New York City.In 1994, 4,190 screening tests were done for Chlamydia trachomatis in these clinics, and the prevalence of positive tests was 5.4% (227/4,190). The mean age of the women screened was 19.2 years and most were of Hispanic origin (76%), students (51%), and received Medicaid (61%). Risk factors found to be associated with C. trachomatis infection included young age; earlier age at first coitus; pregnancy at the time of chlamydia screening; concurrent gonorrheal infection; and the clinical findings of cervical abnormalities, vaginal discharge, and adnexal tenderness. Hormonal contraception appeared to be protective against chlamydial infection (odds ratio, 0.36%; confidence interval, 0.17-0.77).Sexually transmitted diseases were common in our population because 5.4% of the women screened had chlamydial infection and 1.5% had concurrent gonorrheal infection. Our study confirmed risk factors established in other populations. These data support the need for enhanced screening efforts for chlamydia to decrease the prevalence of disease in our population.The prevalence of and risk factors associated with chlamydia infection were investigated retrospectively among 4190 US women under 30 years (mean age, 19.2 years) who were patients at two young adult family planning clinics in New York City, New York. Immigrants from the Dominican Republic comprise the largest segment of the population served by these clinics. 76% of study participants were Hispanic, 61% were Medicaid recipients, and 51% were students. 227 women (5.4%) were positive for Chlamydia trachomatis. 7 women (3.5%) with chlamydia had concurrent gonorrhea. Compared with their counterparts with a negative chlamydia test, women with chlamydia were younger (mean age, 19.4 vs. 18.8 years) and had a lower mean age at first coitus (16 vs. 15 years). Use of barrier methods of contraception alone conferred no more protection against chlamydia than contraceptive nonuse, presumably because of inconsistent or improper use. However, women who used both a barrier and hormonal method were less than half as likely to be infected with chlamydia than those using no protection. 39% of women diagnosed with chlamydia had no cervical or vaginal abnormalities, while 20% of women with a negative chlamydia test had physical examination findings suggestive of genital infection. Regression analysis identified three factors significantly associated with chlamydia infection: positive pregnancy test at the time of the first clinic visit, vaginal discharge on pelvic examination, and self-reported drug use. The positive predictive value of diagnosing an infection increased from 50% using the clinical impressions of the providers to 61% with this model.

Background and Objectives: It has been suggested that bacterial vaginosis may play a role in the etiology of cervical neoplasia. The authors analyzed the prevalence, risk factors, and impact on histologic changes of bacterial vaginosis in women with cytological abnormalities of the uterine cervix. Methods: Two-hundred-eighty women with dyskaryotic smears were surveyed. Using a questionnaire, data were obtained on smoking habits and sexual history. Bacterial vaginosis was the diagnosis if the vaginal discharge produced a fishy odor upon alkalinization and if due cells were seen in the wet smear. Cervical scrapes were analyzed for the presence of human papillomavirus DNA, and cervical tissue specimens were analyzed for the presence and severity of (intraepithelial) neoplasia acid the proliferation rate (mitotic index) of the lesion. Chlamydia trachomatis was identified by culture of an endocervical swab. Results: Bacterial vaginosis was found in 56 (20%) out of the 280 women. The presence of bacterial vaginosis was significantly associated with the number of cigarettes smoked per day, age at first sexual intercourse, the lifetime number of sexual partners, and current Chlamydia trachomatis infection. The number of cigarettes currently smoked per day and the lifetime number of sexual partners were independent significant risk factors for the presence of bacterial vaginosis. There was no relation between the presence of bacterial vaginosis and the human papillomavirus infection. Bacterial vaginosis did not influence the severity of the (intraepithelial) neoplasia or the mitotic index. Conclusion: In women with dyskaryotic cervical smears, the prevalence of bacterial vaginosis did not seem to be increased, and bacterial vaginosis did not influence the histologic changes. Therefore, bacterial vaginosis is unlikely to be important in the etiology of cervical neoplasia, despite the similarity between its epidemiologic features and those of cervical human papa lomavirus infection and cervical neoplasia.

BACKGROUND: This study was undertaken to establish the etiology of the male urethral discharge (MUDS) and vaginal discharge (VDS) syndromes to determine the prevalence of other sexually transmitted infections (STI) and human immunodeficiency virus (HIV) coinfections and to examine associations between STIs and HIV serostatus among STI patients in South Africa. METHODS: A total of 507 MUDS and 300 VDS patients were recruited in Cape Town (CPT) and Johannesburg (JHB). A multiplex polymerase chain reaction assay detected Neisseria gonorrhoeae Chlamydia trachomatis Trichomonas vaginalis and Mycoplasma genitalium infections. Bacterial vaginosis and candidiasis were detected by microscopy. Sera were screened for syphilis HSV-2 and HIV antibodies. RESULTS: Etiological diagnoses were made for 92% of MUDS patients and 85% of VDS patients. Gonorrhoea accounted for 85% (CPT) and 71% (JHB) of MUDS presentations. Chlamydia was the second most frequently detected MUDS pathogen (CPT 13%; JHB 24%). Among VDS patients bacterial vaginosis was the most common cause (CPT 46%; JHB 36%) and trichomoniasis the most frequently detected STI pathogen (CPT 19%; JHB 34%). Few patients (4%) had serological evidence of syphilis. The HSV-2 and HIV seroprevalence were higher in Johannesburg compared to Cape Town and among women compared to men. HIV infection was statistically significantly associated with HSV-2 seropositivity at both sites and with the presence of N. gonorrhoeae and absence of C. trachomatis in Cape Town MUDS patients. CONCLUSIONS: Gonorrhoea and bacterial vaginosis were confirmed as the most frequent causes of MUDS and VDS. The high HIV seroprevalence in STI patients emphasizes the need to address HIV testing among this population.

Bacterial vaginosis (BV) is traditionally described as a condition in which the usual Lactobacillus-dominant vaginal bacteria are replaced by overgrowth of Gardnerella vaginalis and mixed, predominantly anaerobic organisms.1 BV is the most common cause of symptomatic vaginal discharge in reproductive-age women, and has been associated with serious health consequences such as preterm birth,2 postoperative gynecologic infection,3 and acquisition of HIV4 and other sexually transmitted organisms.5 The etiology of BV is unknown, and whether it is a sexually transmitted infection is controversial.6 Personal hygiene behaviors, particularly douching, have also been associated with BV.7,8 African-American women consistently have been found to be at doubled or greater risk of having prevalent BV compared to white women,9,10 although the reason is not known. Demographic factors such as less education, and behavioral factors such as douching, although more common among African-American women, do not explain the difference.11 Recently, the race of the male sex partner has been associated with prevalent BV in the first trimester of pregnancy.12 Among white women, when the father of the pregnancy was African-American, the prevalence of BV was 45.7%, compared with 20.9% when the father was white.12 The association of BV with a characteristic of the male might provide support for sexual transmission of BV, and it also suggests that difference in social networks13 between white and African-American women might account for the strong racial differences in this condition. We conducted this analysis to study the association between the race of the male sex partner and incident BV in a longitudinal cohort of non-pregnant women.

The objective was to investigate Chlamydia trachomatis (Ct) epidemiology among 5829 women 18 to 25 years old in Costa Rica. Data are from a community-based human papillomavirus 16/18 vaccine trial. Before randomization eligible women who reported previous sexual activity were interviewed and tested for Ct DNA by Hybrid Capture 2 and polymerase chain reaction-based genotyping. Multivariate models were developed. Overall prevalence was 14.2% (95% confidence interval 13.3-15.1). Among Ct genotypes serovar E was the most common (4.3%) followed by serovar F (3.0%) serovar D/Da (2.9%) and serovar I/Ia (2.1%). Ct increased with lifetime sexual partners of the women and among women with 1 lifetime partner with sexual partners of the partner. Current intrauterine device users had an increase in Ct detection [odds ratio (OR) 1.6 1.1-2.5] but hormonal contraceptives or condom users did not. Miscarriages were associated with a reduction in Ct detection (OR 0.7 0.5-1.0) while current regular smokingincreased it (OR 1.7 1.2-2.5). Vaginal discharge reactive changes ASCUS or LSIL and moderate to severe inflammation in the cytology were significantly more common among Ct positive women (P less than 0.001). Gonorrhea prevalence was 0.8% and it was as other STIs highly correlated with Ct detection. This is a high-prevalence population where we confirmed the strong link between Ct and sexual behavior of women and their partners. The establishment of a screening program in the age group included in this study should be considered. More studies are needed in developing countries to further investigate the role of intrauterine devices and the lack of protection by condoms in addition to the interplay between Ct and other STIs ectopy inflammation and epithelial abnormalities. (authors)

Despite the fact that bacterial vaginosis (BV) is the most prevalent cause of symptomatic vaginal discharge in the United States1,2 and is a risk factor for preterm birth3 and acquisition of HIV,4 its cause remains unknown and its treatment suboptimal. Not only are initial cure rates of BV poor, but recurrence rates are high.5 Debate exists as to whether recurrences are due to relapse or reinfection. However, 1 hypothesis is that relapse may occur secondary to inadequate treatment of BV-associated organisms, either due to resistance of BV-associated organisms to metronidazole or to inadequate penetration of a biofilm community.6,7 Anecdotally it is more difficult to eradicate BV in some women compared with others. Recent data substantiates this by the finding that women with more complicated vaginal flora reflected by higher Nugent scores (predominantly because of morphotypes consistent with Mobiluncus), are more likely to fail therapy than those with lower scores.8 The presence of Mobiluncus spp. (M. curtisii and M. mulieris) in the vagina is highly specific although not sensitive for the diagnosis of BV.9,10 Of the two, M. curtisii appears to predominate and in vitro is resistant to metronidazole, the most commonly used therapy for BV.11 Therefore, recurrence of BV could be related to failure to clear this organism. Using specimens obtained from a prospective study of the treatment of BV, we determined if there was an association between persistence of M. curtisii and recurrence of BV at 65 to 70 days after completion of initial therapy. Vaginal swabs were collected during a prospective treatment study of BV. Women attending the Jefferson County Health Department STD Clinic with symptomatic BV were enrolled and treated for BV as previously described.8 All women received metronidazole for 7 or 14 days plus or minus azithromycin. Subjects were reevaluated at 21, 35 to 40, and 65 to 70 days after beginning the study. Subjects were discontinued from the study upon recurrence of symptomatic BV but were followed if the BV was asymptomatic. Vaginal swabs for Gram stain and polymerase chain reaction (PCR) were collected at baseline and each follow-up visit. For this substudy we included only those women who had M. curtisii present at baseline as detected by PCR and who completed 3 follow-up visits for the main study. Recurrence of BV at 65 to 70 days was defined as a Nugent score of 7 to 10 at that follow-up visit regardless of symptoms. Persistence of M. curtisii was defined as the organism being present at baseline and at least one of the follow-up visits. Baseline characteristics of the subsample and larger cohort were compared by the chi-square test for categorical variables and the t test for continuous variables. The relationship between the persistence of M. curtisii the development of recurrence was examined by the chi-square test. A stratified analysis was used to examine the relationship between M. curtisii and recurrence controlling for treatment and the Breslow-Day statistic was used to test homogeneity of the strata. All analyses were conducted with SAS Ver. 9.1 and a P value of

Background: Nucleic acid amplification tests (NAATs) allow chlamydia screening in asymptomatic women who otherwise may not have pelvic examinations. How often these women have examination findings that may prompt empiric therapy is unclear. Objective: The objective of this study was to assess the relationship of chlamydia with pelvic examination findings in asymptomatic women screened by NAAT. Methods: The authors conducted a retrospective analysis of clinical data from 577 young asymptomatic women screened by chlamydial transcription-mediated amplification (TMA). Results: TMA was positive in 68 (11.8%). The most common examination finding was vaginal discharge (5.9%) followed by cervical ectopy (3.6%), endocervical mucopus (2.3%) or easily induced bleeding (2.3%), and cervical motion (1.4%) or adnexal (0.7%) tenderness. On multivariate analysis, only easily induced bleeding or mucopus predicted chlamydia (adjusted odds ratio [AOR] 4.7; P 0.010 and AOR 4.4; P 0.015, respectively). Conclusions: Abnormal pelvic examination findings were infrequent in asymptomatic young women screened by a chlamydial NAAT. However, endocervical bleeding or mucopus, when present, predicted chlamydia. MOST GENITAL CHLAMYDIAL INFECTIONS IN females are asymptomatic, 1 and therefore detection of infection often relies on diagnostic testing. Nucleic acid amplification tests (NAATs) are useful for chlamydial screening in asymptomatic females because they are highly sensitive and specific and can be performed on less invasive specimens (e.g., urine or self-obtained vaginal swabs), which provides an opportunity to screen for chlamydial infection in nontraditional settings (e.g., schools, correctional facilities, and so on) without performing a pelvic examination. A concern has been that screening in the absence of a pelvic examination will

To determine the prevalence of sexually transmitted infections (STIs) among women attending an antenatal clinic in urban China and to show whether reported symptoms and findings on clinical examination predicted STIs in this population.Cross-sectional descriptive study was conducted among 504 pregnant women attending an antenatal clinic in Fuzhou, China. Structured questionnaires were used to collect demographic and behavioral information, and clinical and gynecologic examinations were performed to detect clinical signs of STIs. Blood samples, vaginal swabs, and cervical swabs were collected, respectively, to test for antibodies to syphilis, culture Trichomonas vaginalis (T. vaginalis), and perform PCR to detect Chlamydia trachomatis (C. trachomatis) and Neisseria gonorrhoeae (N. gonorrhoeae).C trachomatis was detected in 51 (10.1%), N gonorrhoeae in 4 (0.8%), T vaginalis in 16 (3.2%), and syphilis in 1 (0.2%) of the 504 pregnant women. Fifty-two (73%) of 71 women with any STI were asymptomatic. Multiple logistic regression analysis indicated that ageor=25 years (OR=2.72) and monthly incomeRMB 2000 yuan (OR=3.57) were significant independent risk factors for chlamydial infection (P0.05). The reported symptom of vaginal discharge or the clinical sign of either vaginal or cervical discharge poorly predicted infection with C trachomatis, N gonorrhoeae, or T vaginalis, with a positive predictive value25% for each STI.A substantial prevalence of STIs, including a large proportion of asymptomatic infections, was found among pregnant women in the study area. These results support a strategy of screening pregnant women for bacterial STIs (followed by treatment of infections), which could be integrated into routine pregnancy care in China.

OBJECTIVE: The authors conducted an assessment of the role of beer halls in the HIV epidemic of rural Zimbabwe as part of the ongoing identification of risky places for the targeting of prevention activities. STUDY: A population-based survey of 9480 adults collected data on number of visits to beer halls in the last month, together with sociodemographics, sexual behavior, and HIV infection from 1998-2000. RESULTS: Fifty percent of men, but only 4% of women, had been to a beer hall in the last month. They reported higher levels of sexual behavior and stronger associations with commercial sex than those who had not been to a beer hall. A recent visit to a beer hall was also associated with HIV infection (men: odds ratio [OR] = 1.9, P

Cambodia has reported the highest prevalence of HIV in the general population in Asia. Sex work and high sexually transmitted infection (STI) prevalences are thought to be major contributory factors. The goal of this study was to assess standards of STI care through a survey of public sector health facilities in 4 border provinces of Cambodia. Healthcare facilities providing STI care were identified. Interviews were held with healthcare providers and STI patients and a manual check made of the STI register and standard medical history forms for female sex workers (SWs) registered with the 100% condom use program. Clinical management was assessed for SWs women with vaginal discharge and men with urethral discharge. Advice about condom use partner notification STI and HIV education and availability of STI drugs were reviewed. Seven percent of all patients seeking health care at health centers (HCs) had STI-related problems. Coverage of sex workers was high in 3 provinces. Drug stock outs particularly cefixime occurred at all levels of assessment. In STI clinics almost all (99–100%) cervicitis and urethritis cases were diagnosed and treated correctly. In HCs with integrated STI services according to national guidelines cervicitis was diagnosed in 65% of women with vaginal discharge of whom 47% were diagnosed correctly and in these 88% were treated correctly. Sixty-six percent of SWs seen at STI clinics were diagnosed with cervicitis and 54% at follow up. STI services should be expanded further to health centers not currently offering STI care. Overtreatment for cervicitis in both SWs at reattendance and low-risk women with vaginal discharge are continuing problems. The WHO/UNAIDS STI service indicator criteria had limited application for the assessment of SW services but were adapted for local needs. Attendance of SWs in designated STI clinics appears to be a useful indicator for the acceptability and efficiency of the current national STI program. (authors)

Interventions for upgrading sexually transmitted disease (STD) management in sub-Saharan Africa have focused on the public sector, and to a much lower extent on private medical practitioners and pharmacies. However, in most African cities there is a large informal sector that provides care to many patients with STD symptoms.To compare the quality of treatments offered to patients with major STD syndromes in the public sector, pharmacies, and the informal sector of the same city.Healthcare providers in health centers, pharmacies, private laboratories, and market drug peddlers in Bangui, Central African Republic, were asked to complete a short form for every patient consulting them with genital complaints. The treatments they ordered were evaluated for their potential efficacy against the major etiologic agents of the syndrome for which the patient consulted.The majority of male patients with STDs preferred to seek care in pharmacies and in the informal sector. The STD treatments offered to patients with urethral discharge or genital ulcers in pharmacies and in the informal sector tended to focus on a single etiologic agent. The quality of STD treatments offered by drug peddlers and private laboratories was poor, apart from adequate coverage of syphilis in patients with genital ulcers and of candidiasis in women with vaginal discharge. For instance, 41% and 34% of patients with urethral discharge managed by drug peddlers and private laboratories did not receive a drug active against either Neisseria gonorrhoeae or Chlamydia trachomatis, whereas this proportion was 22% in pharmacies and 14% in health centers. For patients with genital ulcers, the proportion offered a drug active against Haemophilus ducreyi was 2% if seen by drug peddlers, 0% in laboratories, 10% in pharmacies, and 25% in health centers. For each syndrome and each category of provider, between one fourth and two thirds of patients had already received another ineffective treatment elsewhere.National STD and HIV control programs will have to improve STD management in pharmacies and in the informal sector if they are to have any impact on the dynamics of HIV infection in urban centers.

BACKGROUND AND OBJECTIVES: Lactoferrin has served as a marker for leukocytes (polymorphonuclear neutrophils [PMN]) in clinical specimens. GOAL: To investigate the potential of a lactoferrin latex agglutination test in the differential diagnosis of female genital infection. STUDY DESIGN: Lactoferrin was quantified in the vaginal discharge of women with genital infections. Polymorphonuclear neutrophils were added to vaginal discharge and observed over 8 hours. RESULTS: Vaginal lactoferrin titers were significantly elevated in women with trichomoniasis, candidiasis, and bacterial vaginosis (BV). Using a lactoferrin titer of > or = 1:40, the assay has a sensitivity of 79.3% and a specificity of 83.3% for the presence of trichomoniasis or bacterial vaginosis. Vaginal discharge from women with BV significantly destroyed added PMN. CONCLUSIONS: Vaginal lactoferrin determinations may provide a useful screen for inflammatory genital infections and identify individuals who require additional diagnostic evaluation. The observed absence of PMN in bacterial vaginosis may result from the destruction of PMN in vaginal discharge rather than the absence of a primary inflammatory response.

Background and Objectives: The prevalence of sexually transmitted diseases in Hispanic prenatal patients has not been well documented. Studies of disease prevalence in Hispanic patients often are complicated by multiple countries of origin and the combining of foreign-born and U.S.-born Hispanics into a single category. Goal of the Study: The purpose of this study was to document the prevalences of sexually transmitted diseases in low-income, pregnant Mexican-American women and to compare the prevalences of those born in the United States with those born in Mexico. We also compared the prevalence of those who recently arrived from Mexico with those who had been in the United States a longer time. Study Design: Three-hundred-forty-seven pregnant women attending a clinic for low-income populations were screened for syphilis, gonorrhea, chlamydia, and hepatitis B virus on their first perinatal visit. Results: Thirty-five women (10.1%) were positive for chlamydia, four (1.2%) for gonorrhea, one (0.3%) for syphilis, and none for hepatitis B virus. Women born in Mexico reported fewer past chlamydia and total sexually transmitted disease infections than Mexican-Americans and non-Hispanic whites born in the United States However, the prevalence of chlamydia and total sexually transmitted diseases did not differ by ethnicity, country of birth, or length of time in the United States The only variable correlated with chlamydia infection was the presence of vaginal discharge, but the sensitivity of this symptom was too low to be clinically useful as a means of selective screening. Conclusion: Low-income women of Mexican ancestry should be routinely screened for syphilis, gonorrhea, and chlamydia as part of their prenatal care in the United States. The value of hepatitis B virus screening in this population was neither supported nor refuted by this study

In Zimbabwe, sexually transmitted diseases are highly prevalent and represent a significant amount of the workload for physicians.To estimate the prevalence of sexually transmitted diseases and human immunodeficiency virus as well as symptoms related to sexually transmitted diseases.This was a cross-sectional study of 500 volunteers (285 women and 215 men) attending an sexually transmitted disease clinic in the Murewa District, 100 km northeast of the capital, Harare. Information on background characteristics and symptoms were obtained with a standardized questionnaire, and samples were collected and immediately transported to the laboratory for examination.The majority of the patients were 20-29 years old. Half of the men and 12% of the women had never been married, and 7.9% of the men and 12% of the women were divorced. Genital ulcers and dysuria were the most prevalent symptoms in men (64% and 62%, respectively). In women, the most prevalent symptoms were lower vaginal discharge and lower abdominal pain (91% and 79%, respectively). Almost 50% of the men and women were positive for human immunodeficiency virus-1 antibodies. The prevalence of Treponema pallidum and Neisseria gonorrhoeae was 15% and 18%, respectively, in men and 19% and 10%, respectively, in women. Chlamydia trachomatis showed the lowest prevalence (8%) in both sexes. No relationship was found between human immunodeficiency virus and other sexually transmitted diseases.Women who enter a sexually transmitted disease clinic with vaginal discharge or lower abdominal pain should be tested for several sexually transmitted diseases and human immunodeficiency virus. Men with dysuria or urethral discharge who enter such clinics should at least be tested for Neisseria gonorrhoeae.

Background Diabetes mellitus is reported to predispose women to vaginal candidiasis and hence patients attending busy diabetic clinics are often treated empirically with antifungal agents for genital symptoms. Goal of this study To investigate the etiology of vaginal infections in diabetic women and to determine appropriateness of empiric antifungal therapy for symptomatic women. Design Prospective study performed on consecutive patients attending two diabetic clinics. Setting Diabetic clinics serving developing communities belonging to two ethnic groups. Study population Two hundred and one women (101 African and 100 Indian) comprising 90 women with symptoms of pruritus vulvae and/or vaginal discharge and 111 asymptomatic women. Results Candidiasis (50% vs. 24%; P = 0.012) and bacterial vaginosis (28% vs. 8%; P = 0.017) occurred significantly more frequently in symptomatic African women compared to asymptomatic African women. Among Indian women bacterial vaginosis (28% vs. 5%; P = 0.026) occurred more frequently in symptomatic women. The prevalence of trichomoniasis was similar in symptomatic and asymptomatic women of both ethnic groups. Mixed vaginal infections were detected significantly more often in African compared to Indian women (24% vs. 5%; P = 0.03). Conclusion In diabetic women with genital symptoms, an attempt at diagnosis should be made prior to commencement of therapy. However, in busy clinics with overstressed facilities where investigations cannot be performed, the use of empiric antifungal therapy alone is not appropriate and consideration should be given to the use of an antifungal plus a nitroimidazole agent which would be effective for both trichomoniasis and bacterial vaginosis.

The symptoms, signs, and laboratory findings for 69 women who were seen at a sexually transmitted disease (STD) clinic and who had acute urinary tract infection (UTI) were compared with those for women who had vaginitis, gonorrhea, or chlamydial infection. Escherichia coli and Staphylococcus saprophyticus were the two most common causes of acute cystitis in this population and accounted for 62 (90%) of 69 infections. Forty-three percent of the women had positive tests for antibody-coated bacteria (ACB), an observation implying renal infection although symptoms of upper tract infection were infrequent. Frequency, urgency, dysuria, and suprapubic tenderness were significantly associated with cystitis, whereas vaginal discharge and vulvar itching were associated with vaginitis. There was, however, considerable overlap in symptoms among the four groups of women, and their accurate differentiation required objective information based upon pelvic examination, examination of vaginal fluid, and urinalysis. In the absence of vaginitis on wet mount and mucopurulent cervicitis on examination, pyuria, as determined by examination of centrifuged urine, had an 88% sensitivity, 76% specificity, 61% positive predictive value, and 93% negative predictive value for acute UTI. Because of the high prevalence of positive ACB tests and the possibility that infection with Chlamydia trachomatis and/or Neisseria gonorrhoeae may be mistaken for cystitis, we prefer a five- to seven-day course of antibiotics over single-dose therapy for treatment of patients with possible UTI in the setting of an STD clinic.