Reproductive-tract infections in women in low-income, low-prevalence situations: assessment of syndromic management in Matlab, Bangladesh

Understanding the factors affecting global political priority for controlling sexually transmitted infections: a qualitative policy analysis

INTRODUCTION

Sexually transmitted infections (STIs) are a significant public health challenge, but there is a perceived lack of political priority in addressing STIs as a global health issue. Our study aimed to understand the determinants of global political priority for STIs since the 1980s and to discern implications for future prioritisation.

METHODS

Through semistructured interviews from July 2021 to February 2022, we engaged 20 key stakeholders (8 women, 12 men) from academia, United Nations agencies, international non-governmental organisations, philanthropic organisations and national public health agencies. A published policy framework was employed for thematic analysis, and findings triangulated with relevant literature and policy documents. We examined issue characteristics, prevailing ideas, actor power dynamics and political contexts.

RESULTS

A contrast in perspectives before and after the year 2000 emerged. STI control was high on the global health agenda during the late 1980s and 1990s, as a means to control HIV. A strong policy community agreed on evidence about the high burden of STIs and that STI management could reduce the incidence of HIV. The level of importance decreased when further research evidence did not find an impact of STI control interventions on HIV incidence. Since 2000, cohesion in the STI community has decreased. New framing for broad STI control has not emerged. Interventions that have been funded, such as human papillomavirus vaccination and congenital syphilis elimination have been framed as cancer control or improving newborn survival, rather than as STI control.

CONCLUSION

Globally, the perceived decline in STI control priority might stem from discrepancies between investment choices and experts' views on STI priorities. Addressing STIs requires understanding the intertwined nature of politics and empirical evidence in resource allocation. The ascent of universal health coverage presents an opportunity for integrated STI strategies but high-quality care, sustainable funding and strategic coordination are essential.

Assessment of Symptoms and Risk Factors as a Screening Tool of Bacterial Vaginosis Among Reproductive Age-Group Females in West Bengal, India

Background Bacterial vaginosis (BV) is a ubiquitous vaginal discomfort and has overlapping symptoms with other reproductive tract infections. The World Health Organization suggested a symptomatic approach for diagnosing BV with insufficient laboratory setup. However, due to symptom overlap, BV is often misled and ends up with injudicious drug application. Objective The study aims to identify the most relevant symptoms and behavioral risk factors associated with BV in tertiary healthcare settings in West Bengal, India. It also seeks to develop a scoring system based on clinical symptoms to screen for BV, especially when laboratory facilities are limited. Methodology The study is a retrospective case-control study involving 95 women of reproductive age. It employs both univariate and multivariate binary logistic regression models to identify risk factors and symptoms associated with BV. The study also compares these clinical symptoms with laboratory tests (Amsel's test) and attempts to create a scoring system for BV diagnosis. Key Findings Good menstrual hygiene and condom use were identified as key behavioral practices reducing the risk of BV. Four clinical symptoms, like malodor (P = 0.007), lower abdominal pain (P = 0.015), abnormal vaginal discharge (P = 0.071), and painful intercourse (P = 0.08), were identified as notable predictors. Based on these four symptoms, the scoring system showed a sensitivity of 88.2%, a specificity of 67.25%, and an overall accuracy of 74.7%. An additional diagnosis of vulvovaginal candidiasis (VVC) revealed that the odds of malodor (P= 0.006) and burning sensation (P= 0.011) increased significantly during co-infection.

Impact of Point-of-Care Testing on the Management of Sexually Transmitted Infections in South Africa: Evidence from the HVTN702 Human Immunodeficiency Virus Vaccine Trial

BACKGROUND

Alternative approaches to syndromic management are needed to reduce rates of sexually transmitted infections (STIs) in resource-limited settings. We investigated the impact of point-of-care (POC) versus central laboratory-based testing on STI treatment initiation and STI adverse event (STI-AE) reporting.

METHODS

We used Kaplan-Meier and Cox regression models to compare times to treatment initiation and STI-AE reporting among HVTN702 trial participants in South Africa. Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) were diagnosed POC at eThekwini clinic and in a central laboratory at Verulam/Isipingo clinics. All clinics used POC assays for Trichomonas vaginalis (TV) testing.

RESULTS

Among 959 women (median age, 23 [interquartile range, 21-26] years), median days (95% confidence interval [95%CI]) to NG/CT treatment initiation and NG/CT-AE reporting were 0.20 (.16-.25) and 0.24 (.19-.27) at eThekwini versus 14.22 (14.12-15.09) and 15.12 (13.22-21.24) at Verulam/Isipingo (all P < .001). Median days (95%CI) to TV treatment initiation and TV-AE reporting were 0.17 (.12-.27) and 0.25 (.20-.99) at eThekwini versus 0.18 (.15-.2) and 0.24 (.15-.99) at Verulam/Isipingo (all P > .05). Cox regression analysis revealed that NG/CT treatment initiation (adjusted hazard ratio [aHR], 39.62 [95%CI, 15.13-103.74]) and NG/CT-AE reporting (aHR, 3.38 [95%CI, 2.23-5.13]) occurred faster at eThekwini versus Verulam/Isipingo, while times to TV treatment initiation (aHR, 0.93 [95%CI, .59-1.48]) and TV-AE reporting (aHR, 1.38 [95%CI, .86-2.21]) were similar.

CONCLUSIONS

POC testing led to prompt STI management with potential therapeutic and prevention benefits, highlighting its utility as a diagnostic tool in resource-limited settings.

HIV Prevention Tools Across the Pregnancy Continuum: What Works, What Does Not, and What Can We Do Differently?

PURPOSE OF REVIEW

Multiple tools exist to support the primary prevention of HIV in pregnant and postpartum women; however, there are opportunities to enhance their use and impact. This review summarizes the current status of HIV prevention tools and existing gaps and opportunities to improve their use along the pregnancy care continuum.

RECENT FINDINGS

HIV screening efforts have steadily improved with close to universal screening of pregnant women in several East and Southern African countries. Strategies to implement partner testing through the distribution of HIV self-test kits are promising though linkage to care remains challenging. Syphilis screening rates are increasing though detection of other sexually transmitted infections could benefit from improved diagnostic capacity. Male and female condoms are rarely used and are often not the optimal tool of choice during pregnancy. Oral pre-exposure prophylaxis (PrEP) is a promising tool, although barriers such as the need for daily adherence, side effects, and stigma may limit its use. There is a growing pipeline of PrEP agents with alternative delivery platforms that might suit women's preferences better and supports the notion that choice is vital to improving HIV prevention coverage during the pregnancy-postpartum continuum. Clear guidance on which tools to use and how to use them, safety data supporting their use, and surveillance data documenting the scale and effectiveness of the tools will be imperative in establishing a path to more impactful prevention efforts among pregnant and postpartum women.

Cost and cost-effectiveness of point-of-care testing and treatment for sexually transmitted and genital infections in pregnancy in low-income and middle-income countries: a systematic review protocol

INTRODUCTION

The economic and health burden of sexually transmitted and genital infections (henceforth, STIs) in low-income and middle-income countries (LMICs) is substantial. Left untreated, STIs during pregnancy may result in several adverse pregnancy and birth outcomes. Timely diagnosis and treatment at point-of-care (POC) can potentially improve these outcomes. Despite the availability and promotion of POC diagnostics for STIs as a key component of antenatal care in LMICs, their widespread use has been limited, owing to the high economic costs faced by individuals and health systems. To date, there have been no systematic reviews which explore the cost or cost-effectiveness of POC testing and treatment of STIs in pregnancy in LMICs. The objective of this protocol is to outline the methods that will compare, synthesise and appraise the existing literature in this domain.

METHODS AND ANALYSIS

We will conduct literature searches in MEDLINE, Embase and Web of Science. To find additional literature, we will search Google Scholar and hand search reference lists of included papers. Two reviewers will independently search databases, screen titles, abstracts and full texts; when necessary a third reviewer will resolve disputes. Only cost and cost-effectiveness studies of POC testing and treatment of STIs, including syphilis, chlamydia, trichomonas, gonorrhoea and bacterial vaginosis, in pregnancy in LMICs will be included. Published checklists will be used to assess quality of reporting practices and methodological approaches. We will also assess risk of publication bias. Interstudy heterogeneity will be assessed and depending on variation between studies, a meta-analysis or narrative synthesis will be conducted.

ETHICS AND DISSEMINATION

Ethical approval is not required as the review will use published literature. The results will be published in a peer-reviewed open source journal and presented at an international conference.

PROSPERO REGISTRATION NUMBER

CRD42018109072.

Diagnostic accuracy of the Xpert CT/NG and OSOM Trichomonas Rapid assays for point-of-care STI testing among young women in South Africa: a cross-sectional study

OBJECTIVES

Syndromic management of sexually transmitted infections (STIs) omits asymptomatic infections, particularly among women. Accurate point-of-care assays may improve STI care in low- and middle-income countries (LMICs). We aimed to evaluate the diagnostic performance of the Xpert Chlamydia trachomatis/Neisseria gonorrhoeae (CT/NG) and OSOM Trichomonas vaginalis (TV) Test as part of a STI care model for young women in South Africa.

DESIGN

Diagnostic evaluation conducted as part of a prospective cohort study (CAPRISA 083) between May 2016 and January 2017.

SETTING

One large public healthcare facility in central Durban, KwaZulu-Natal, South Africa PARTICIPANTS: 247 women, aged 18-40 years, attending for sexual and reproductive services to the clinic. Pregnant and HIV-positive women were excluded.

OUTCOMES

Diagnostic performance of the Xpert CT/NG and OSOM TV assays against the laboratory-based Anyplex II STI-7 Detection. All discordant results were further tested on the Fast Track Diagnostics (FTD) STD9 assay.

RESULTS

We obtained vaginal swabs from 247 women and found 96.8% (239/247) concordance between Xpert and Anyplex for CT and 100% (247/247) for NG. All eight discrepant CT results were positive on Xpert, but negative on Anyplex. FTD STD9 confirmed three positive and five negative results, giving a confirmed prevalence of CT 15.0% (95% CI 10.5 to 19.4), NG 4.9% (2.2-7.5) and TV 3.2% (1.0-5.4). Sensitivity and specificity of Xpert CT/NG were 100% (100-100) and 97.6% (95.6-99.7) for CT and 100% (100-100) and 100% (100-100) for NG. The sensitivity and specificity of OSOM TV were 75.0% (45.0-100) and 100% (100-100).

CONCLUSION

The Xpert CT/NG showed high accuracy among young South African women and combined with the OSOM TV proved a useful tool in this high HIV/STI burden setting. Further implementation and cost-effectiveness studies are needed to assess the potential role of this assay for diagnostic STI testing in LMICs.

TRIAL REGISTRATION NUMBER

NCT03407586; Pre-results.

Multiplex nested polymerase chain reaction targeting multiple genes for the detection of Neisseria gonorrhoeae and Chlamydia trachomatis in genitourinary specimens

Objectives:

The objective of this study was to design and evaluate a novel multiplex nested polymerase chain reaction (PCR) protocol for simultaneous detection of Neisseria gonorrhoeae and Chlamydia trachomatis in genitourinary specimens obtained from symptomatic patients clinically suspected of sexually transmitted infections (STIs), targeting two different genes each for these pathogens.

Materials and Methods:

A total of 116 genitourinary specimens were collected from men (n = 12) and women (n = 104). Direct microscopy, culture isolation, and antimicrobial susceptibility testing for N. gonorrhoeae were performed. Multiplex nested PCR was performed on clinical samples using novel designed primers targeting porA pseudogene and opa gene of N. gonorrhoeae and momp gene and cryptic plasmid of C. trachomatis simultaneously. DNA sequence analysis of nested PCR amplicons for each of four gene targets was carried out for the validation of in-house designed primers and PCR protocol.

Results:

A total of 51.72% (60/116) patients were detected to have either of the two STIs. About 35.35% (41/116) of patients were positive for C. trachomatis and 33.62% (39/116) for N. gonorrhoeae by employing multiplex nested PCR. Coinfection with N. gonorrhoeae and C. trachomatis was detected in 17.24% (20/116) patients. 31.5% endocervical swabs (n = 54), 64.4% speculum-assisted high vaginal swabs (n = 45), and 80% self-collected vaginal swabs (n = 5) were detected positive for either of two STIs.

Conclusions:

The multiplex nested PCR protocol designed and employed in the present study may be used in the diagnosis and management of both symptomatic as well as asymptomatic cases of N. gonorrhoeae and C. trachomatis, particularly among high-risk groups.

Beyond syndromic management: Opportunities for diagnosis-based treatment of sexually transmitted infections in low- and middle-income countries

Introduction

In light of the limited impact the syndromic management approach has had on the global sexually transmitted infection (STI) epidemic, we assessed a care model comprising point-of-care (POC) STI testing, immediate treatment, and expedited partner therapy (EPT) among a cohort of young women at high HIV risk in South Africa.

Methods and findings

HIV negative women presenting for STI care underwent POC testing for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV), and swabs were sent for NG culture and susceptibility testing. Results were available within 2 hours and women with STIs were immediately treated and offered EPT packs, including medication, condoms, and information for sexual partners. An EPT questionnaire was administered after one week, and women retested for STIs after 6 and 12 weeks. 267 women, median age 23 (IQR 21–26), were recruited and 88.4% (236/267) reported genital symptoms. STI prevalence was CT 18.4% (95%CI 13.7–23.0), NG 5.2% (95%CI 2.6–7.9) and TV 3.0% (95%CI 1.0–5.0). After 12 weeks, all but one NG and two CT infections were cleared. No cephalosporin-resistant NG was detected. Of 63/267 women (23.6%) diagnosed with STIs, 98.4% (62/63) were offered and 87.1% (54/62) accepted EPT. At one week 88.9% (48/54) stated that their partner had taken the medication. No allergic reactions or social harms were reported. Of 51 women completing 6-week follow up, detection rates were lower amongst women receiving EPT (2.2%, 1/46) compared to those who did not (40.0%, 2/5), p = 0.023. During focus group discussions women supported the care model, because they received a rapid, specific diagnosis, and could facilitate their partners’ treatment.

Conclusions

POC STI testing and EPT were acceptable to young South African women and their partners, and could play an important role in reducing STI reinfection rates and HIV risk. Larger studies should evaluate the feasibility and cost-effectiveness of implementing this strategy at population level.

Comparative analysis of syndromic case management and polymerase chain reaction based diagnostic assays for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis and genital mycoplasmas in patients of genitourinary discharge

To respond to the situation of high prevalence and need for effective treatment for sexually transmitted infections (STIs) in low-resource settings, syndromic diagnostic approach was recommended by the World Health Organization and was adopted by National AIDS Control Organization at the primary health centre level. A retrospective study was undertaken in symptomatic patients attending an STI clinic to validate the syndromic approach for genitourinary discharge syndrome. For aetiological diagnosis, culture and/or polymerase chain reaction was used. An infective aetiology could be established in only 20% (106 of 530) patients. The present data call for an early appraisal and review of the diagnostic policy by national authorities on syndromic case management.

Syndromic Diagnosis in Evaluation of Women with Symptoms of Vaginitis

PURPOSE OF REVIEW

This review aims to determine the effectiveness of the use of syndrome diagnosis in the evaluation of vaginitis and to make suggestions based on the review findings.

RECENT FINDINGS

Vaginal discharge as the main symptom of vaginitis is unspecific. A randomized study of symptom-based diagnosis and treatment of vaginitis in the USA favored symptoms used for treatment; however, this was only a pilot study. Hence, a population-based study is necessary to validate these findings. Most of the study that assessed treatment of vaginitis in pregnancy reported low diagnostic sensitivity and specificity for bacterial vaginosis and vaginal candidiasis and a wide range for trichomonas vaginalis reflecting ineffectiveness of syndrome-based treatment in pregnancy. A systematic review of the web for relevant literature was made, and appropriate articles were extracted and reviewed. Sensitivity, specificity, and positive values were used, where applicable to determine effectiveness. Forty-three full articles and abstracts were reviewed. Studies that validated or applied WHO algorithm for treatment of vaginitis reported high sensitivity (91.5-100%) but moderate to low specificity (0-27.5%) among women with vaginal symptoms. Studies that focused on symptoms for diagnosis of the three main etiologic agents of vaginitis reported low sensitivity and specificity, while such studies in pregnancy reported sensitivity and specificity ranging from 35.4 to 54% for TV, 11 to 100% for BV, and 0 to 56.2% for trichomonas vaginalis, bacterial vaginosis, and vaginal candidiasis, respectively. Studies that added point of care test reported higher sensitivity and specificity and positive predictive value. The use of WHO syndrome-based algorithm or its modification for treatment of vaginitis though moderately effective has the potential for overtreatment and physician error. Point of care testing and laboratory investigation are essential for productive intervention especially in pregnancy.

Do female patients with nonpathological vaginal discharge need the same evaluation as for Dhat syndrome in males?

AIM

The aim of this study was to evaluate the concept of female Dhat syndrome characterized by the complaint of nonpathological vaginal discharge in association with somatic, anxiety, and depressive symptoms.

MATERIALS AND METHODS

A total of 26 female subjects with nonpathological vaginal discharge along with depressive and somatic complaints were assessed on a self-rated questionnaire modified from Comprehensive Questionnaire for Assessment of Dhat Syndrome designed for males. They were also assessed for psychiatric comorbidity as per ICD-10.

RESULTS

All female subjects received an ICD-10 psychiatric diagnosis, with somatoform/dissociative disorder (57.7%) being the most common. The mean age of onset of vaginal discharge was 24.6 (standard deviation - 7.0) years, noted every day or for 2-3 times per week by more than two-third of the participants. Two-fifth (61.5%) of the women described it as a milky discharge. The most common reason reported for passage of vaginal discharge was that of urinary infection or problems of urinary tract infections (42.3%) followed by vaginal infection/disease (34.6%). More than half (53.8%) of the subjects considered vaginal discharge to be responsible for weakness in the body, weakness in stamina and thinness of physique, while slightly more than two-third (69.2%) of them reported bodily weakness and sleep disturbances. Overall the clinical picture in females was similar to male patients with Dhat syndrome on most of the account.

CONCLUSIONS

Subgroup of patients with vaginal discharge attribute their somatic and mental symptoms to the passage of whitish vaginal discharge and are distressed due to the same. The clinical picture is similar to Dhat syndrome in males. There is a need to recognize female variant of Dhat syndrome as a culture-bound syndrome. Identification of the same may help in managing this subgroup of patients seeking help from the gynecologists for their nonpathological vaginal discharge or from mental health professionals for their symptoms of common mental disorders.

Logic regression-derived algorithms for syndromic management of vaginal infections

Background

Syndromic management of vaginal infections is known to have poor diagnostic accuracy. Logic regression is a machine-learning procedure which allows for the identification of combinations of variables to predict an outcome, such as the presence of a vaginal infection.

Methods

We used logic regression to develop predictive models for syndromic management of vaginal infection among symptomatic, reproductive-age women in south India. We assessed the positive predictive values, negative predictive values, sensitivities and specificities of the logic regression procedure and a standard WHO algorithm against laboratory-confirmed diagnoses of two conditions: metronidazole-sensitive vaginitis [bacterial vaginosis or trichomoniasis (BV/TV)], and vulvovaginal candidiasis (VVC).

Results

The logic regression procedure created algorithms which had a mean positive predictive value of 61 % and negative predictive value of 80 % for management of BV/TV, and a mean positive predictive value of 26 % and negative predictive value of 98 % for management of VVC. The results using the WHO algorithm were similarly mixed.

Conclusions

The logic regression procedure identified the most predictive measures for management of vaginal infections from the candidate clinical and laboratory measures. However, the procedure provided further evidence as to the limits of syndromic management for vaginal infections using currently available clinical measures.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-015-0228-5) contains supplementary material, which is available to authorized users.

Medicine Sellers for Prevention and Control of Sexually Transmitted Infections: Effect of a Quasi-Experimental Training Intervention in Bangladesh

This study used a quasi-experimental pre-post design to test whether short training can improve medicine sellers' (MSs) practices and skills for prevention and control of sexually transmitted infections (STIs) in Bangladesh. The training included lectures, printed materials, and identification of referral sites. Difference-in-differences estimation was used to determine the effects of intervention on key primary and secondary outcomes. Advice given by the MSs in intervention group for partner treatment and condoms use increased significantly by 11% and 9%, respectively, after adjusting for baseline differences in education, religion, age, duration of training, and study site. Referral of clients to qualified service providers increased by 5% in the intervention group compared to the comparison group, but this change was not found to be statistically significant. Significantly higher proportion of MSs in the intervention group recognized the recommended medications as per the national syndromic management guidelines in Bangladesh for treatment of urethral discharge and genital ulcer symptoms. Short training intervention was found to be effective in improving MSs' practice of promoting condom use and partner treatment to the clients. We anticipate the need for broad based training programs of MSs to improve their skills for the prevention and control of STI/HIV in Bangladesh.

Utility of microbiological profile of symptomatic vaginal discharge in rural women of reproductive age group

INTRODUCTION

Symptomatic vaginal discharge is the most frequent symptom in women of reproductive age group. Owing to social stigma majority of affected women hesitate to seek medical consultation. Therefore the actual incidence of vaginal discharge is much more than what is reported. The aim of the study is to determine the microbiological profile of symptomatic vaginal discharge in rural area and its utility in the management of genital tract infection.

MATERIALS AND METHODS

This was a descriptive type of observational study, conducted in sexually active women of reproductive age group (18-45 years) attending the OPD/IPD of Obstetrics and Gynaecology Department of National Institute of Medical Sciences, Shobhanagar, Jaipur (Rajasthan), over a period of 18 months from June 2012 to December 2013. Hundred sexually active non pregnant women of reproductive age group (18-45 years) were included in the study. After taking consent general physical examination along with pelvic examination was performed. Two high vaginal swabs and blood sample were collected for various tests. Hanging drop preparation was immediately made. This was followed by gram staining and culture. Chlamydia trachomatis IgM antibody was detected by ELISA method.

RESULTS

Out of 100 women with symptomatic vaginal discharge, specific diagnosis was obtained in 89% of cases whereas no specific aetiology was found in 11% cases. Mean age was 32.60 years. Fifty-three percent patient had Bacterial vaginosis, candidiasis was found in 14% cases, 16% had Chlamydia trachomatis infection while Trichomonas vaginalis infection was detected in 6% cases. Homogenous discharge was most prevalent (52%), followed by mucopurulant discharge in 23% of women.

CONCLUSION

Patient with symptomatic vaginal discharge need to be actively managed with appropriate antimicrobial agents. Judicious management may be helpful in prevention of HIV, HPV, CIN and post infection sequelae.

Sexually transmitted infections in women: A correlation of clinical and laboratory diagnosis in cases of vaginal discharge syndrome

Aims:

This study compares the clinical and laboratory diagnosis of vaginal discharge syndrome.

Settings and Design:

This cross-sectional study was carried out at the gynaecology outpatient department of a tertiary care hospital in Gujarat, India.

Material and Methods:

Total of 180 females diagnosed as vaginal discharge or cervicitis based on syndromic approach and were recruited for the study. Their clinical profile was noted and they were investigated for bacterial vaginosis, trichomoniasis, candidiasis, gonorrhoea and chlamydia infection.

Results:

Lower abdominal pain (35%) followed by burning micturition (23.9%) were the common associated complaints. Bacterial vaginosis was the most common clinical diagnosis, while trichomoniasis was least common. Upon laboratory investigation, 35.6% of cases of vaginal discharge and 12% of cases of cervicitis tested positive. Percentage of cases confirmed by laboratory investigation was 50, 27.8 and 41.7 for bacterial vaginosis, trichomoniasis and candidiasis respectively.

Conclusion:

Among all the females diagnosed as vaginal discharge syndrome, a very small percentage actually turned out to be positive upon laboratory testing.

Gender variations in access, choice to use and cleaning of shared latrines; experiences from Kampala Slums, Uganda

Background

Sanitation is one of the most intimate issues that affect women, especially in slums of developing countries. There are few studies that have paid attention to the gender variations in access, choice to use and cleaning of shared latrines in slums.

Methods

This paper draws on qualitative data from a cross sectional study conducted between 2012 and 2013 in six slums of Kampala City, Uganda. The study involved both women and men. Data were collected from 12 Focus Group Discussions (FGDs), 15 Key informant interviews; community transects and photographs of shared latrines.

Results

Location of a shared latrine facility, distance, filthy, narrow and irregular paths; the time when a facility is visited (day or night), privacy and steep inclines were gender ‘filters’ to accessing shared latrines. A full latrine pit was more likely to inhibit access to and choice of a facility for women than men. Results indicate that the available coping mechanisms turned out to be gendered, with fewer options available for women than men. On the whole, women sought for privacy, easy reach, self-respect and esteem, cleanliness and privacy than men. While men like women also wanted clean facilities for use; they (men) were not keen on cleaning these facilities. The cleaning of shared latrines was seen by both women and men as a role for women.

Conclusion

The presence of sanitation facilities as the first step in the access, choice, use, and cleaning by both women and men has distinct motivations and limitations along gender lines. The study confirms that the use and cleaning of latrines is regulated by gender in daily living. Using a latrine for women was much more than relieving oneself: it involved security, intimacy and health concerns.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1180) contains supplementary material, which is available to authorized users.

Reproductive Tract Infections in Rural Vietnam, Women's Knowledge, and Health-Seeking Behavior: A Cross-Sectional Study

We interviewed 1,805 women in a rural setting in Vietnam with the aim of investigating women's knowledge regarding reproductive tract infections (RTIs) and their health-seeking behavior. We found that women's overall knowledge was poor. Furthermore, only one-third of the symptomatic women sought health care. RTIs affect millions of women globally each year. Most vulnerable are women in low- and middle-income countries where poverty and gender inequities affect their access to health care services. Findings from our study can be used in similar rural settings worldwide to understand and manage the widespread problem of RTIs.

Sexually transmitted infections: progress and challenges since the 1994 International Conference on Population and Development (ICPD)

BACKGROUND

Despite being recognized as an important challenge at the 1994 International Conference on Population and Development (ICPD), sexually transmitted ınfections (STIs) other than HIV are one of the most neglected dimensions of sexual and reproductive health. STIs, often undiagnosed and untreated, have especially harmful consequences for women and their neonates.

PROGRESS SINCE ICPD

During the last two decades, substantial knowledge and experience have accumulated in behavior change programming during the global response to the HIV epidemic which can also be used for prevention of STIs. There has been progress in development and implementation of vaccines against certain STIs such as hepatitis B and the human papilloma virus. Development of a rapid, point-of-care test for syphilis has opened the door to control this infection.

CHALLENGES

The estimated annual incidence of non-HIV STIs has increased by nearly 50% during the period 1995-2008. The growth in STIs has been aggrevated by a combination of factors: lack of accurate, inexpensive diagnostic tests, particularly for chlamydia and gonorrhea; lack of investment to strengthen health systems that can deliver services for diagnosis and management of STIs; absence of surveillance and reporting systems in the majority of countries; political, socioeconomic and cultural barriers that limit recognition of STIs as an important public health problem; and failure to implement policies that are known to work.

RECOMMENDATIONS

Governments, donors and the international community should give higher priority to preventing STIs and HIV; fully implementing behavior change interventions that are known to work; ensuring access of young people to information and services; investing in development of inexpensive technologies for STI diagnosis,treatment and vaccines; and strengthening STI surveillance, including of microbial resistance.

Engagement with HIV prevention treatment and care among female sex workers in Zimbabwe: a respondent driven sampling survey

Objective(S)

To determine the HIV prevalence and extent of engagement with HIV prevention and care among a representative sample of Zimbabwean sex workers working in Victoria Falls, Hwange and Mutare.

Design

Respondent driven sampling (RDS) surveys conducted at each site.

Methods

Sex workers were recruited using respondent driven sampling with each respondent limited to recruiting 2 peers. Participants completed an interviewer-administered questionnaire and provided a finger prick blood sample for HIV antibody testing. Statistical analysis took account of sampling method.

Results

870 women were recruited from the three sites. HIV prevalence was between 50 and 70%. Around half of those confirmed HIV positive were aware of their HIV status and of those 50-70% reported being enrolled in HIV care programmes. Overall only 25-35% of those with laboratory-confirmed HIV were accessing antiretroviral therapy. Among those reporting they were HIV negative, 21-28% reported having an HIV test in the last 6 months. Of those tested HIV negative, most (65-82%) were unaware of their status. Around two-thirds of sex workers reported consistent condom use with their clients. As in other settings, sex workers reported high rates of gender based violence and police harassment.

Conclusions

This survey suggests that prevalence of HIV is high among sex workers in Zimbabwe and that their engagement with prevention, treatment and care is sub-optimal. Intensifying prevention and care interventions for sex workers has the potential to markedly reduce HIV and social risks for sex workers, their clients and the general population in Zimbabwe and elsewhere in the region.

Influence of gender equity awareness on women's reproductive healthcare in rural areas of midwest China

OBJECTIVE

To investigate the impact of married women's gender equity awareness on use of reproductive healthcare services in rural China.

METHODS

The questionnaire-based study recruited 1500 married women who were aged 15-49years, had at least 1 pregnancy, and were living in rural Gansu, Qinghai, Shanxi, or Xinjiang, China, between October and December 2010. "Gender equity awareness" was quantified by responses to 7 statements, graded in accordance with a system scoring the strength of overall belief (≥19, strong; 15-18, moderate; and ≤14, weak).

RESULTS

Only 383 women (26.3%) demonstrated high gender equity awareness. The percentage of women who received consistent prenatal care was highest in the group scoring 15 points or more (P<0.001); the percentage of women with hospital delivery and gynecologic examination (P<0.001) was highest in the group scoring 19 points or more; and the percentage of women with reproductive tract infections was highest in the group with the lowest scores (P<0.001).

CONCLUSION

Women's gender equity awareness is not strong in rural midwest China. There was a positive correlation between gender equity awareness and use of reproductive healthcare services. There should be an emphasis on various activities to educate women so that they can fully access reproductive healthcare.

Comparison of syndromic diagnosis of reproductive tract infections with laboratory diagnosis among rural married women in Medak district, Andhra Pradesh

INTRODUCTION

In developing countries, reproductive tract infections (RTI) commonly affect the quality of life. Many reproductive tract infections including sexually transmitted infections (STI) and cervical cancers remain asymptomatic for long periods. Syndromic case management (SCM) is the mainstay in the control of RTI/STI, especially at primary level, where laboratory diagnosis is not possible. However, lab diagnosis should be used when it is available.

OBJECTIVE

To assess the consistency of syndromic diagnosis with laboratory diagnosis.

MATERIALS AND METHODS

A total of 407 women were screened. Women were categorized according to Syndromic Diagnosis of RTI/STI based on history and clinical examination. Microbiological tests and Pap smears were done to confirm the diagnosis and compared with Syndromic Diagnosis.

RESULTS

Microbiologically, 33.14% were positive for at least one organism. Bacterial vaginosis was the most common finding (14%). Pap smear showed 32.9% inflammatory changes and 0.25% low-grade squamous intraepithelial lesion. Sensitivity and specificity of syndromic diagnosis with laboratory findings: Vaginal discharge syndrome with microbiological tests- (Se 58.9; Sp55.1%) Lower abdominal pain syndrome with microbiological tests-(Se 14.4%; Sp76.6%)

CONCLUSION

The findings of this study highlight the wide variation of syndromic and laboratory diagnosis.

The Relaxation Exercise and Social Support Trial (RESST): a community-based randomized controlled trial to alleviate medically unexplained vaginal discharge symptoms

BACKGROUND

Symptoms such as medically unexplained vaginal discharge (MUVD) are common and bothersome, leading to potentially unnecessary use of resources.

METHODS

A community-based individually randomized controlled trial to assess the effectiveness of a relatively simple, culturally appropriate multi-component intervention on reducing reported MUVD, among women suffering from low-moderate levels of common mental distress. The setting was a socio-economically deprived, informal settlement in the southern suburbs of Beirut, Lebanon. The intervention comprised up to 12 group sessions implemented over a six-week period, each divided into a psychosocial and a relaxation exercise component. The primary outcome was self-reported MUVD, which was defined as a complaint of vaginal discharge upon ruling out reproductive tract infections (RTIs), through lab analysis. Anxiety and/or depression symptoms were the secondary outcomes for this trial. These were assessed using an Arabic validated version of the Hopkins Symptoms Checklist-25 (HSCL-25). Assessments were done at baseline and six months using face-to face interviews, pelvic examinations and laboratory tests. Women were randomized into either intervention or control group. Blinding on the intervention status was not possible for both logistic and ethical reasons, especially as knowledge of involvement in the intervention was integral to its delivery. Intent to treat analysis was used.

RESULTS

Of 75 women randomized to the intervention, 48% reported MUVD at 6 months compared with 63% of 73 in the control group (difference of -15%, 95% confidence interval (CI) -31%, 0%, p=0.067). Adjustments for baseline imbalances and any factors relating to consent had no appreciable effect on these results. The risk of MUVD was reduced in absolute terms by 2.4% for each intervention session attended (95% CI -4.9%, 0.0%, p=0.049). While there was also marginal evidence of a beneficial effect on anxiety, there was no evidence of mediation of the effect on MUVD through measures of common mental disorders.

CONCLUSION

This study confirms that MUVD is an important public health problem. While the benefits of this intervention may appear modest, the intervention offers an opportunity for women to enhance their problem-solving skills as well as use physical relaxation techniques that can help them deal with stressful in their lives. Further research is needed in a variety of contexts, for different populations and preferably involving larger randomized trials of such an intervention.

TRIAL REGISTRATION

* Title of trial: The Relaxation Exercise and Social Support Trial ISRCTN assigned: ISRCTN98441241 Date of assignation: 10/09/2010 Link: http://www.controlled-trials.com/ISRCTN98441241* Also registered at the Wellcome Trust register:http://www.controlled-trials.com/mrct/trial/469943/98441241.

Epidemiologic features of Vulvovaginal Candidiasis among reproductive-age women in India

Background. Vulvovaginal candidiasis is characterized by curd-like vaginal discharge and itching, and is associated with considerable health and economic costs. Materials and Methods. We examined the incidence, prevalence, and risk factors for vulvovaginal candidiasis among a cohort of 898 women in south India. Participants completed three study visits over six months, comprised of a structured interview and a pelvic examination. Results. The positive predictive values for diagnosis of vulvovaginal candidiasis using individual signs or symptoms were low (<19%). We did not find strong evidence for associations between sociodemographic characteristics and the prevalence of vulvovaginal candidiasis. Women clinically diagnosed with bacterial vaginosis had a higher prevalence of vulvovaginal candidiasis (Prevalence 12%, 95% CI 8.2, 15.8) compared to women assessed to be negative for bacterial vaginosis (Prevalence 6.5%, 95% 5.3, 7.6); however, differences in the prevalence of vulvovaginal candidiasis were not observed by the presence or absence of laboratory-confirmed bacterial vaginosis. Conclusions. For correct diagnosis of vulvovaginal candidiasis, laboratory confirmation of infection with Candida is necessary as well as assessment of whether the discharge has been caused by bacterial vaginosis. Studies are needed of women infected with Candida yeast species to determine the risk factors for yeast's overgrowth.

Acceptance of self-testing for increased vaginal pH in different subsets of Ugandan women

We assessed the acceptance of self-testing for vaginal pH in 344 Ugandan women in different clinical settings. Women tested themselves by insertion of a gloved finger into the vagina to test vaginal pH and provide a smear on a glass slide. None of the tested women found the test very difficult: 8% found it somewhat difficult, 16% rather easy and 76% very easy to do. Of the 20% who found it difficult to read the test result, more women were attending a family planning clinic or had a higher diploma ( P = 0.001). Pregnant women were least likely to understand of the meaning of the test, while those visiting family planning clinics had the opposite experience. HIV-infected women were most motivated to accept: 95% would be happy to use the test more often if requested, and another 3.5% felt they might be better motivated to do repeat testing after extra explanation. Self-sampling of vaginal pH is well accepted by Ugandan women. Our new method also allows diagnostic work-up by formal microscopy. Before commencing large-scale population screening, unexpected reactions of different subpopulations should be taken into account.

Prevalence and risk of violence and the physical, mental, and sexual health problems associated with human trafficking: systematic review

BACKGROUND

There is very limited evidence on the health consequences of human trafficking. This systematic review reports on studies investigating the prevalence and risk of violence while trafficked and the prevalence and risk of physical, mental, and sexual health problems, including HIV, among trafficked people.

METHODS AND FINDINGS

We conducted a systematic review comprising a search of Medline, PubMed, PsycINFO, EMBASE, and Web of Science, hand searches of reference lists of included articles, citation tracking, and expert recommendations. We included peer-reviewed papers reporting on the prevalence or risk of violence while trafficked and/or on the prevalence or risk of any measure of physical, mental, or sexual health among trafficked people. Two reviewers independently screened papers for eligibility and appraised the quality of included studies. The search identified 19 eligible studies, all of which reported on trafficked women and girls only and focused primarily on trafficking for sexual exploitation. The review suggests a high prevalence of violence and of mental distress among women and girls trafficked for sexual exploitation. The random effects pooled prevalence of diagnosed HIV was 31.9% (95% CI 21.3%-42.4%) in studies of women accessing post-trafficking support in India and Nepal, but the estimate was associated with high heterogeneity (I² = 83.7%). Infection prevalence may be related as much to prevalence rates in women's areas of origin or exploitation as to the characteristics of their experience. Findings are limited by the methodological weaknesses of primary studies and their poor comparability and generalisability.

CONCLUSIONS

Although limited, existing evidence suggests that trafficking for sexual exploitation is associated with violence and a range of serious health problems. Further research is needed on the health of trafficked men, individuals trafficked for other forms of exploitation, and effective health intervention approaches.

Marital violence and women's reproductive health care in Uttar Pradesh, India

OBJECTIVE

Although the impact of marital violence on women's reproductive health is recognized globally, there is little research on how women's experience of and justification of marital violence in developing country settings is linked to sexually transmitted infection (STI) symptom reporting, and seeking care for the symptoms.

METHOD

This study analyzes data on 9,639 currently married women from India's 2006-2007 National Family Health Survey-3 from the Central/Northern Indian state of Uttar Pradesh. The likelihood of currently married women's reporting STIs or symptoms, and the likelihood of seeking care for these, are analyzed using multivariate logistic regression techniques.

RESULTS

Currently married women's experience of physical, sexual, and emotional marital violence in the last 12 months was significantly associated with greater likelihood of reporting a STI or symptom (odds ratio [OR], 1.364 [95% confidence interval (CI), 1.171-1.588] for physical violence; OR, 1.649 [95% CI, 1.323-2.054] for sexual violence; OR, 1.273 [95% CI, 1.117-1.450] for emotional violence). Experience of physical violence (OR, 0.728; 95% CI, 0.533-0.994) and acceptance of any justification for physical violence (OR, 0.590; 95% CI, 0.458-0.760) were significantly associated with decreased chance of seeking care, controlling for other factors.

CONCLUSION

This study suggests that experiencing marital violence may have a negative impact on multiple aspects of women's reproductive health, including increased self-report of STI symptoms. Moreover, marital physical violence and accepting justification for such violence are associated with decreased chance of seeking care. Thus, policies and programs to promote reproductive health should incorporate decreasing gender-based violence, and overcoming underlying societal gender inequality.

Seroprevalence of Treponema Pallidum antibody among pregnant population of Bangladesh

AIM

The aim of this study was to investigate the seroprevalence of antibody to Treponema pallidum among pregnant women and its association with age, sexual behavior and socioeconomic status.

MATERIALS AND METHODS

In this cross-sectional study, 1266 sera were collected from pregnant women attending Bangabandhu Sheikh Mujib Medical University and Rajshahi, Khulna and Chittagong Medical College Hospitals between February 2007 and April 2008. From each hospital, samples were collected from about a quarter of the total recruited pregnant women. Sera were tested to identify the antibody to T. pallidum using Treponema pallidum hemagglutination at the Virology Department of Bangabandhu Sheikh Mujib Medical University. Logistic regression was used to explore potential risk factors for syphilis.

RESULTS

Among 1250 sera tested (16 sera were discarded due to hemolysis), 37 (2.96%) were positive for T. pallidum antibody. Higher seropositivity was associated with couples with no formal education, low socioeconomic status (P = 0.006), marriage at or before 18 years of age (P = 0.002), multiple marriages of the husband (P = 0.031) and sexual activity for more than 10 years (P = 0.007). Among these factors, low education level of women, early age of marriage and multiple marriages of the husband showed individual effects on high seropositivity to T. pallidum.

CONCLUSIONS

The high seroprevalence of syphilis among pregnant women attending the antenatal clinics of these hospitals indicates the need for the incorporation of screening for syphilis in routine antenatal screening in Bangladesh. Improvement of education level in the female population, prevention of early marriage and preventing polygamy of husbands may play an important role in prevention of syphilis among women.

Contraception use and associations with intimate partner violence among women in Bangladesh

This study examines the association between contraception use and intimate partner violence (IPV) among women of reproductive age in Bangladesh. The observational study of 10,996 women used the chi-squared test and logistic regressions to assess the associations. Almost 80% of all respondents had used contraceptives at some point in their lives. About half of the respondents (48%) were victims of physical violence, while 11% experienced sexual abuse from their husbands. Urban residents, higher educated women and women aged 20-44 were more likely to use contraceptives than their peers in rural areas, those with lower education and those in their late forties (45-49 years). Women exposed to physical violence were almost two times (OR 1.93, CI 1.55-2.41) more likely to use contraceptives compared with their non-abused peers. Sexual abuse had no significant association with contraceptive use. Physical violence is a predictor for higher levels of contraceptive use among women in Bangladesh. The findings emphasize the importance of screening for IPV at health care centres. The differences in urban and rural contraceptive use and IPV exposure identified by the study have policy implications for service delivery and planning.

Treatment seeking, vaginal discharge and psychosocial distress among women in urban Mumbai

Vaginal discharge (safed pani in Hindi, meaning "white water") is one of the leading symptoms for which women in India seek care. Treatment-seeking for safed pani is disproportionately high among poor women, representing a physical, emotional and financial burden for low-income families. Safed pani is only rarely indicative of a reproductive tract or sexually transmitted infection. The discrepancy between symptom reports and observed pathology has led some researchers to characterize safed pani as a culturally based expression of more generalized negative life situation. Data are drawn from two prevention intervention studies (2002-2006 and 2007-2012) conducted in economically marginal communities in Mumbai. Results show that husbands as problem generators and spousal abusers and women's greater perceived empowerment and reported tension are significantly associated with safed pani. These results provide the basis for identifying women at greater risk for psychosocial distress and providing supports at the locations at which they seek treatment.

Etiology and determinants of sexually transmitted infections in Karnataka state, south India

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.

Socioeconomic disparity in healthcare-seeking behavior among Chinese Women with genitourinary symptoms

BACKGROUND

Sexually transmitted infections (STIs) are of growing concern in China. Understanding the relationship between socioeconomic status (SES) and healthcare-seeking (HCS) behavior will help design effective policies to contain the epidemic of STIs across SES.

METHODS

We used the Chinese Health and Family Life Survey, a nationally representative survey of 3813 adults from 48 Chinese cities and counties during 1999-2000. We studied the 730 women with at least one genitourinary (GU) symptom. HCS was measured by whether respondents visited a hospital or an unrecognized clinic, self-treatment, or doing nothing. Formal treatment was defined as visiting a hospital. SES was measured by income (tertile group) and education (< or =primary school, junior high school, senior high school, college or above). Bivariate tests and logistic regressions were applied.

RESULTS

There was a significantly positive relationship among income, education, and treatment. Odds ratios (ORs) of medium and high income were 2.01 (p = 0.04) and 1.39 (p = 0.46), respectively, after controlling demographics. ORs of middle school, high school, and college or above were 1.81 (p = 0.05), 2.27 (p = 0.03), and 1.27 (p = 0.64), respectively. The relationship between income and formal treatment was also positive, and the relationship between education and formal treatment was negative. Additional adjustment for STI knowledge and experience reduced the HCS disparity across education.

CONCLUSIONS

Income and education have different effects on HCS behavior among Chinese women with GU symptoms. Income may affect HCS via affordability, and education is a complicated proxy for sex education, STI knowledge, and experience that will affect the socioeconomic disparity in HCS.

Diagnostic challenges of sexually transmitted infections in resource-limited settings

The global burden of sexually transmitted infections (STIs) is highest in the developing world where access to laboratory services is limited. Sophisticated laboratory diagnostic tests using noninvasive specimens have enabled developed countries to screen and diagnose curable STIs in a variety of settings, but control programs in resource-limited settings continue to struggle to find simple rapid tests that can provide adequate performance in the absence of laboratory services. While recent technological advances and investments in research and development may soon yield improved STI tests that can make an impact, these tests will need to be deployed within a health system that includes: regulatory oversight, quality assurance, good supply-chain management, effective training, information systems and a sound surveillance system to monitor disease trends, inform policy decisions and assess the impact of interventions.

Comparative study of syndromic and etiological diagnosis of reproductive tract infections/sexually transmitted infections in women in Delhi

BACKGROUND

The adequacy of the World Health Organization's syndromic approach for the diagnosis and management of sexually transmitted diseases (STDs), especially at primary health centers (PHCs) and at other levels, is still debatable in different settings in India and requires validation.

OBJECTIVES

A cross-sectional study was carried out in women attending the peripheral government clinics of Delhi in order to (1) enumerate their self-reported reproductive tract infection (RTI)/sexually transmitted infection (STI) symptoms; (2) assess their clinical status; (3) determine the syndromic diagnosis of RTI/STI in symptomatic women and etiological diagnosis in both symptomatic and asymptomatic women; and (4) compare the level of agreement between self-reporting of morbidity and syndromic and etiological diagnosis.

MATERIALS AND METHODS

The study was conducted over 26 months in 4090 women attending peripheral government healthcare centers, both rural and urban, in four zones of Delhi. They were recruited into four different study groups: group I, non-pregnant, reporting with symptoms of RTI/STI; group II, with a bad obstetric history or infertility; group III, pregnant women in any trimester attending the antenatal clinic; and group IV, the control group. Gynecological examination, followed by the collection of genital specimens and blood, were performed after informed and written consent was obtained. Every symptomatic patient was managed on the basis of algorithms of the syndromic approach as recommended by the National AIDS Control Organisation (NACO), India. All specimens were transported to the STD Reference Laboratory, Safdarjung Hospital, New Delhi and processed by standard methods to diagnose the various STDs. Laboratory reports were sent to the clinicians and appropriate treatment was instituted. Data were analyzed by applying statistical methods.

RESULTS

Overall, self-reporting of morbidity was 65.0%. However, the percentage of women with some STD-related syndrome was 71.4%. The rural women were observed to have significantly more STD syndromes than their urban counterparts. The etiological diagnosis could be established in only 32.2% of cases.

CONCLUSIONS

This study highlights the wide variation between self-reporting of morbidity and syndromic- and etiology-based diagnosis in women from both rural and urban settings. This has implications for the syndromic approach to STI case management. These observations call for a review of the diagnostic policy for RTIs/STIs by national authorities in order to avoid the overuse of antimicrobials. The study also highlights the need for the introduction and/or strengthening of facilities for simple diagnostic tests for RTIs/STIs, especially at the peripheral healthcare level.

Thresholds of morbidity among women in a peri-urban community of Maharashtra, India: conceptual and methodological issues

While data on perceived morbidity often correlate poorly with clinical morbidity, they can provide an indicator for how women's concepts of health change in the context of larger transitions in gender and health systems. Drawing on multiple sources of data on perceived morbidity among women in a peri-urban settlement of Maharashtra, India, this article examines variations in women's thresholds for articulating illness conditions. Data on women's health were collected from married women aged 15-49, using four different instruments: focus group discussion guides; general illness narrative guidelines; individual open-ended questions about morbidity; and a highly structured checklist. Comparing the data and the assumptions underlying these instruments, the article identifies four different thresholds relating to situational, agency, prototypical and dimensional aspects of women's experience and subsequent reporting of morbidity.

Prevalence of Mycoplasma genitalium in health clinic attendees complaining of vaginal discharge in Bangladesh

The objective of the study was to determine the prevalence of Mycoplasma genitalium in a sample of health clinic attendees complaining of vaginal discharge. A subsample of 399 vaginal and cervical swabs was randomly selected from 2579 samples collected during a study to determine the causes of vaginal discharge in women attending primary health-care clinics in Dhaka, Bangladesh. Cervical samples were tested for M. genitalium by polymerase chain reaction. In addition, the samples were tested for Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, bacterial vaginosis and candida. M. genitalium was detected in three samples (0.8%; 95% confidence interval: 0.00–1.6). The prevalence of C. trachomatis, N. gonorrhoeae T. vaginalis, bacterial vaginosis and candida was 1.3, 3.8, 8, 23.25 and 32.5%, respectively. Two women with M. genitalium were co-infected with T. vaginalis or candida. This is the first study to document the existence of M. genitalium in Bangladesh. Although the prevalence of this infection is low in the population tested, further research into this pathogen in other Bangladeshi populations is justified.

Reliability of self-collected versus provider-collected vaginal swabs for the diagnosis of bacterial vaginosis

Women reluctant to undergo a per-speculum examination consider self-sampling more acceptable. The aim of this study was to compare self-collected vaginal swabs for detection of bacterial vaginosis (BV), candidiasis and trichomoniasis, with vaginal specimens obtained by the gynaecologist at per-speculum examination. Self-collected and provider-collected vaginal swabs were obtained from 50 women attending the gynaecological outpatients department. The Gram-stained smears and saline wet mounts prepared from the provider-collected vaginal swabs were examined by a microbiologist and a gynaecologist. We determined the validity and the inter-rater reliability of the overall BV score and the morphotype specific score using Kappa statistics. When compared with the provider-collected smear, the ability of the self-collected smear to diagnose BV had a sensitivity of 70% and a specificity of 97%. With specific instructions to help assure the depth of sampling, self-collected swabs can reasonably approximate specimens obtained by clinicians during speculum examination for the diagnosis of BV.

Epidemiology of male same-sex behaviour and associated sexual health indicators in low- and middle-income countries: 2003-2007 estimates

OBJECTIVES

To conduct a systematic review of published and unpublished data from research and public health information systems on the prevalence of male-to-male sex in the total male population; as well as among men who have sex with men (MSM), data on prevalence of heterosexual activity and heterosexual unions; prevalence of condom use with male and female partners; and prevalence of HIV infection and other sexually transmitted infections (STIs).

METHODS

Key indicators were defined (a) among men in the general population: prevalence of sex with a man ever and last year; (b) among MSM: prevalence of heterosexual experiences ever and last year; proportion of male-female transgenders; proportion of sex workers; prevalence of HIV and other STIs, condom use in last sexual encounter; consistent condom use with men last year; never used a condom with a man. With help from key informants, study searches were conducted in Pubmed, LILLACS, institutional databases, conference records and other sources. Methodology and quality of information were assessed, and the best data available for 2003-7 were selected. Indicator estimates from each study were used to propose regional estimate ranges.

RESULTS

A total of 83 new entries were entered into the database in addition to the previous 561, totalling 644. Of these, 107 showing 2003-7 data were selected. Many new studies came from sub-Saharan Africa, portraying hidden HIV epidemics among MSM. The most frequently reported estimate was HIV infection, with high estimate ranges in most of the regions, except for Middle East and North Africa and Eastern Europe. The next most frequently reported was lifetime frequency of heterosexual sex, showing that roughly 50% of MSM ever had sex with a woman. The small number of newer studies reporting prevalence of "sex with a man in last 12 months" between 2003 and 2007, did not warrant enough new evidence to revise our 2005 size estimates for MSM populations.

CONCLUSIONS

A considerable number of new studies with estimates of relevance to understanding sexual behaviour and HIV among MSM were identified, with an encouraging amount of new data coming from sub-Saharan Africa. However, limitations in the quality, utility and comparability of available information persist. At least three measures could be promoted for use in surveillance and academic studies: standardised indicators for MSM studies; standardised operational definitions of, and instructions to describe, variables; and standardised research designs and data gathering strategies. A prerequisite for this all is intense advocacy to ensure a social climate in which research into such matters is prioritised, resources are made available as needed and the human rights of MSM are respected.

Field Evaluation of Simple Rapid Tests in the Diagnosis of Syphilis

The aim of this study was to detect the sensitivity and specificity of rapid syphilis diagnostic tests (immunochromatographic strip [ICS] test and rapid test device [RTD]) performed by low-skilled paramedics in field clinics and by highly-skilled technologists in laboratories and compare them with the gold standard (rapid plasma reagin [RPR] and Treponema pallidum haemagglutination [TPHA]) tests for diagnosis of syphilis. A cross-sectional study was conducted among female sex workers (FSWs) in Dhaka, Bangladesh, from August 2004 to July 2005. Blood specimens were tested for syphilis using (i) ICS, (ii) RTD, (iii) RPR tests performed by low-skilled paramedics; and (i) ICS, (ii) RTD, (iii) RPR and (iv) TPHA tests by highly-skilled technologists. The sensitivity and specificity of the ICS and RTD test performed by low- and highly-skilled personnel were compared with the gold standard. A total of 684 FSWs were enrolled and the prevalence of syphilis among FSWs was 20.8% as determined by the gold standard. There was no significant difference in the performance of ICS test done by paramedics in the field when compared with the gold standard performed by highly-skilled technologists in the laboratory (sensitivity, 94.45%; specificity, 92.6%). The ICS test could fulfil the need for a non-invasive, rapid screening test for syphilis.

Reproductive Health Awareness Among Adolescent Girls in Rural Bangladesh

This article presents the status of rural Bangladeshi adolescent girls' awareness about reproductive health. Analysis of data revealed that a sizable proportion of adolescent girls had incorrect knowledge or misconceptions about the fertile period, reproduction, sexually transmitted diseases, and HIV/AIDS. Age, education either of adolescents or their mothers, residence, and exposure to mass media were the significant predictors of adolescent girls' knowledge about reproductive health. Strong efforts are needed to improve awareness and to clarify misconceptions about reproductive health. Improved access to mass media and education could improve rural Bangladeshi adolescent girls' awareness about reproductive health.

The psychological and social contexts of complaints of abnormal vaginal discharge: a study of illness narratives in India

OBJECTIVE

Epidemiological studies have reported strong associations between psychosocial adversity and complaints of abnormal vaginal discharge (AVD) in South Asia. We aimed to explore the mechanism of these associations through qualitative research.

METHOD

We carried out serial in-depth interviews with 42 married women with the complaint of AVD who were purposively selected from a sample of 2494 women recruited into a population-based cohort study in Goa, India. The interviews elicited illness narratives of their complaint, focusing on causal attributions and help-seeking behaviors.

RESULTS

Women explicitly link their personal experiences of social adversity and stress (such as marital problems and heavy workloads) with their complaints of AVD. The complaint of tiredness, a core feature of depressive and somatoform disorders, and complaint of "tension" were commonly associated with AVD through bidirectional causal interpretations. Reproductive events, particularly related to the menstrual cycle and contraception, comprise another set of causal attributions. Many women hold multiple causal attributions. Most women sought health care, both biomedical and traditional, and their narratives indicate reinforcement of their causal attributions by health care providers. However, treatments were often discontinued or changed due to lack of symptomatic relief, side effects, or costs.

CONCLUSIONS

Reproductive health policy and practice must explicitly acknowledge and integrate research findings on psychosocial associations of AVD to promote a holistic and evidence-based approach for this common complaint in women in South Asia.

Violence against women, symptom reporting, and treatment for reproductive tract infections in Kerala state, Southern India

In this article we examine factors associated with women's self-reports of reproductive ill health symptoms and factors associated with seeking and receiving treatment for the symptoms. We focus on indicators of women's societal position, especially empowerment (indicated by experience of and attitudes toward violence against women), autonomy, and education. We used data from the National Family Health Survey-2 from Kerala state in Southern India. Based on our results we suggest that violence against women, whether actually experienced or internalized as acceptance of its justification, is associated with increased ill health symptoms, and the acceptance of violence is associated with decreased chance of treatment. Women's higher formal education appeared to reduce treatment seeking for reproductive ill health, perhaps due to the stigma associated with sexually transmitted disease (STD) in this cultural setting. Women's work participation had no significant impact, nor did indicators of women's economic and personal autonomy.

Durbolota (weakness), chinta rog (worry illness), and poverty: explanations of white discharge among married adolescent women in an urban slum in Dhaka, Bangladesh

I carried out ethnographic fieldwork among 153 married adolescent girls, aged 15-19, in a Dhaka slum from December 2001 to January 2003, including 50 in-depth interviews and eight case studies. I also held discussions with family and community members. In this article, I focus on popular understandings of vaginal discharge being caused by durbolota (weakness) and chinta rog (worry illness), as mentioned by young women. Eighty-eight young women reported that they had experienced white discharge, blaming it on a number of factors such as stress and financial hardships, tensions in the household, marital instability, hunger anxiety, and reproductive burdens. For married adolescent women in the urban slum, white discharge has many levels of meaning linked to the broader social, political, and material inequalities in their everyday lives.

Evaluation of a rapid point-of-care test for the detection of gonococcal infection among female sex workers in Benin

OBJECTIVES

To assess the validity of the PATH (Seattle, Washington, USA) GC-Check rapid test, a point-of-care immunochromatographic strip test, in the detection of gonococcal infection among female sex workers (FSWs) in Benin.

METHODS

Women consulting consecutively at two FSW-dedicated clinics in Cotonou and Porto Novo (Benin) were recruited over three, 1-month periods between October 2003 and July 2004. After written informed consent, participants were administered a short interview and underwent a speculum examination where two cervical swabs were collected (in a subset of women, a vaginal swab was also collected). One cervical swab and the vaginal swab were immediately tested with the rapid test. The other cervical swab was frozen at -20 degrees C for at most four weeks and then transported to Québec (Canada), where it was tested with the Roche Amplicor CT/NG PCR assay. Samples positive for gonococcal infection were confirmed using a 16SrRNA PCR assay.

RESULTS

1084 FSWs (median age 29 years) participated in the study, of whom 50 (4.6%) had a confirmed gonococcal infection. The sensitivity, specificity, positive and negative predictive values of the rapid test on cervical samples were 70.0% (95% confidence interval (CI) 55.4% to 82.1%), 97.2% (95% CI 96.0% to 98.1%), 54.7% and 98.5%, respectively. The sensitivity of the rapid test on vaginal swabs among 759 women (37 positives for gonococcal infection) was significantly lower than with the cervical swab (54.1%, p = 0.008), whereas the specificity was comparable (98.2%, p = 0.13).

CONCLUSIONS

The PATH GC-Check test may be as efficient as a gold standard polymerase chain reaction (PCR) test for treating gonococcal infection when taking into account the proportion of women who do not return for their test results. In clinics serving populations with moderate prevalence of this infection, it could significantly reduce over-treatment compared to the syndromic approach.