Prevalence and assessment of clinical management of sexually transmitted infections among female sex workers in two cities of India

Facilitators and Barriers for Chlamydia and Gonorrhea Testing in Female Sex Workers: A Scoping Review

We conducted a scoping review to examine the barriers and facilitators accessing Chlamydia trachomatis and Neisseria gonorrhoeae testing among female sex workers. A literature search was conducted in Embase, Medline, and Web of Science for studies published from the date of creation of database to 17 March 2023, without restrictions for publication date. We used thematic synthesis to identify common affecting factors across included studies and then linked them into categories of the socioecological framework. Among the 14 articles included, 3 utilized qualitative methods, 7 utilized quantitative surveys, 2 were mixed methods, and 2 were randomized controlled trials. Several important affecting factors stood out during this review, including stigma and discrimination, as well as social support at the societal level, and financial costs at the service level. This review suggested that interventions on addressing societal- and service-level determinants are needed, which includes reducing stigma and discrimination toward sex work and cost for facility testing, as well as increasing social support and community engagement.

Using education based on the health belief model to modifications in performance of behaviors related to sexually transmitted infections in vulnerable women

BACKGROUND

Sexually transmitted infections (STIs) have always been considered as a health problem in the world. Also, vulnerable women (addicts, jail breakers, and prostitutes) are at the highest risk. According to the World Health Organization's (WHO) approach, the only effective way to prevent and control this disease is public health education, and high-risk and vulnerable groups should be prioritized in educational programs. The aim of the study was to investigate the effect of health belief model (HBM)-based education on changing the behaviors related to STIs in vulnerable women.

MATERIALS AND METHODS

The present study is an intervention (field trial) study in vulnerable women. Convenience sampling method was used in this study and the sample size was determined to be 84 subjects. Through tossing a coin, the social support center was selected as the intervention group and the drop-in center as the control group. Quantitative data analysis was performed, and descriptive and inferential statistical methods were used.

RESULTS

The mean scores of perceived threat, perceived benefits, perceived barriers, and perceived self-efficacy and changes in performance between the three measurement stages, as well as changes in the scores of perceived threat, perceived benefits, perceived barriers, and perceived self-efficacy over three measurement times were significantly different between the two groups (interaction) (P < 0.001). The mean score of performance 3 months after the intervention was significantly higher than before the intervention (P = 0.001).

CONCLUSIONS

The present study confirmed the effectiveness of the HBM in promoting behavioral modifiers that lead to STIs. Therefore, educational interventions with emphasis on understanding the threats, benefits, barriers, and self-efficacy and, ultimately, performance improvement in relation to STIs are recommended.

Prevalence of reproductive tract infections including sexually transmitted infections among married women in urban and peri-urban mid to low socioeconomic neighbourhoods of Delhi, North India: an observational study protocol

INTRODUCTION

The Global Health Sector Strategy on sexually transmitted infections (STIs), endorsed by the World Health Assembly in 2016 aims to end STIs as public health threat by 2030. WHO conducts global estimates of prevalence to monitor progress towards achieving the same. However, limited laboratory confirmed data exist of STIs and reproductive tract infections (RTIs) apart from few prevalence surveys among key populations and clinic-based reports, including in India. Syndromic approach is the cornerstone of RTI/STI management and to maximise the diagnostic accuracy, there is a need to determine the main aetiologies of vaginal discharge. This study aims to estimate the prevalence of common STIs and RTIs and their aetiological organisms in symptomatic and asymptomatic women living in the urban and peri-urban, mid to low socioeconomic neighbourhoods of Delhi, North India.

METHODS AND ANALYSIS

A cross-sectional study will be conducted among 440 married women who participated in the 'Women and Infants Integrated Interventions for Growth Study (WINGS)'. Information on sociodemographic profile, sexual and reproductive health will be collected, followed by examination and collection of vaginal swabs for nucleic acid amplification tests to diagnose Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis and microscopy to identify bacterial vaginosis and Candida albicans. Treatment will be as per the syndromic approach recommendations in the Indian National Guidelines. Data will be analysed to estimate prevalence, presence of symptoms and signs associated with laboratory confirmed RTIs/STIs using STATA V.16.0 (StataCorp).

ETHICS AND DISSEMINATION

This study protocol has been approved by the ethics review committees of the WHO and Society for Applied Studies (SAS/ERC/RHR-RTI/STI/2020). Approval has been obtained by the WINGS investigators from SAS ethics research committee to share the contact details of the participants with the investigators. The findings will be published in peer-reviewed journals and disseminated through scientific conferences.

TRIAL REGISTRATION NUMBER

CTRI/2020/03/023954.

Cluster analysis for symptomatic management of Neisseria gonorrhoea and Chlamydia trachomatis in sexually transmitted infections related clinics in China

OBJECTIVE

This study aimed to perform a cluster analysis of symptoms linked with Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) and to identify which cluster of symptoms was associated with a higher risk of NG and CT.

STUDY DESIGN

From 15 April to 16 May 2018, a cross-sectional study was conducted, and patients attending sexually transmitted infections (STI) related clinics were recruited from 22 medical institutions in six districts of Shenzhen city.

METHODS

A structured questionnaire was used to collect social-demographic information as well as STI symptoms, and urine samples were collected for nucleic acid detection. Cluster analysis and logistic regression were applied.

RESULTS

Among 8,207 participants, the prevalence of CT and NG infection was 9.04% (742/8,207) and 2.36% (194/8,207), respectively. Among male outpatients, four clusters with distinct symptomatic patterns were identified. Unmarried, having casual sexual partners in the past 6 months, cluster 2 (OR = 6.70, 95% CI = 3.36-13.35) and cluster 4 (OR = 24.53, 95% CI = 12.96-46.44) were risk factors associated with NG infection. Unmarried, cluster 2 (OR = 2.54, 95% CI = 1.83-3.53) and cluster 4 (OR = 3.31, 95% CI = 2.37-4.61) were risk factors associated with CT infection. Among female outpatients, five clusters with distinct symptomatic patterns were identified. Aged 24 years or below and cluster 3 (OR = 3.68, 95% CI = 1.61-8.39) were risk factors associated with NG infection. Aged 24 years or below, unmarried, having a high school/secondary technical school education, and having junior high school or below education were risk factors associated with CT infection.

CONCLUSION

The cluster of symptoms integrated into risk assessment for CT and NG infections suggests a new strategy of symptomatic management. Healthcare providers in STI clinics and resource-limited places may use this strategy to identify more potential patients and deliver adequate, acceptable, and equitable STI care for outpatients with a high risk of STI.

What Proportion of Female Sex Workers Practise anal Intercourse and How Frequently? A Systematic Review and Meta-analysis

HIV is more efficiently acquired during receptive anal intercourse (AI) compared to vaginal intercourse (VI) and may contribute substantially to female sex workers' (FSW) high HIV burden. We aim to determine how common and frequent AI is among FSW globally. We searched PubMed, Embase and PsycINFO for studies reporting the proportion of FSW practising AI (prevalence) and/or the number of AI acts (frequency) worldwide from 01/1980 to 10/2018. We assessed the influence of participant and study characteristics on AI prevalence (e.g. continent, study year and interview method) through sub-group analysis. Of 15,830 identified studies, 131 were included. Nearly all (N = 128) reported AI prevalence and few frequency (N = 13), over various recall periods. Most studies used face-to-face interviews (N = 111). Pooled prevalences varied little by recall period (lifetime: 15.7% 95%CI 12.2-19.3%, N = 30, I2 = 99%; past month: 16.2% 95%CI 10.8-21.6%, N = 18, I2 = 99%). The pooled proportion of FSW reporting < 100% condom use tended to be non-significantly higher during AI compared to during VI (e.g. any unprotected VI: 19.1% 95%CI 1.7-36.4, N = 5 and any unprotected AI: 46.4% 95%CI 9.1-83.6, N = 5 in the past week). Across all study participants, between 2.4 and 15.9% (N = 6) of all intercourse acts (AI and VI) were anal. Neither AI prevalence nor frequency varied substantially by any participant or study characteristics. Although varied, AI among FSW is generally common, inconsistently protected with condoms and practiced sufficiently frequently to contribute substantially to HIV acquisition in this risk group. Interventions to address barriers to condom use are needed.

Sex under Influence of Drugs: A Nationwide Survey among Iranian Female Sex Workers

Background

Due to the high level of sexual relationships, prostitute women are faced with many dangers, including acquired immune deficiency syndrome (AIDS), sexually transmitted infections (STIs), fertility problems, drug use, etc. In this regard, addict prostitute women are exposed to more risks because drug use is considered as an outstanding factor in those associated with transmission of AIDS and being in an insecure sexual relationship. The purpose of this study was to find out the variables influential on the level of drug use, before or during sexual relationship.

Methods

In 2010, 625 prostitute women were selected by multistage sampling from 21 centers out of 12 provinces. Then, we used a standard questionnaire for gathering data by a face-to-face interview. The multilevel ordinal logistic regression in survey model was used to find out the relationship between variables and the level of drug use before or during sexual relationship.

Findings

The number of monetary customers at the last working day [adjusted odds ratio (AOR): 1.87, 95% confidence interval (CI): 1.50-2.32] and having sexual relationship during the past month with monetary customers (AOR: 4.77, 95% CI: 2.61-8.70) were significantly related to the level of drug use before or during sexual relationship in the past month.

Conclusion

Since the level of drug use before or during sexual relationship was higher in women who had more daily sexual relationships, these women are exposed to the consequences of drug use; thus, identifying the status of this group of women is important to plan for future injuries.

A Study on the Prevalence of Genital Trichomoniasis among Female Outpatients Attending Sexually Transmitted Infection Clinic in a Tertiary Care Hospital

INTRODUCTION

Women with high-risk sexual behavior accounts for more than half of the sexually transmitted infection (STI) clinic attendees. The prevalence of trichomoniasis is as low as 5% in the general population to as high as 60% in high-risk population. This infection can pave the way to the acquisition of human immunodeficiency virus and other STIs, vice versa and is even associated with cancer.

OBJECTIVES

To identify, isolate and study the prevalence of Trichomonas vaginalis in genital specimens of female outpatients.

MATERIALS AND METHODS

Total number of subjects involved in the study was 130, among them 85 belonged to high-risk group and 45 belonged to low-risk group. Two high vaginal swabs were collected from each patient. Saline wet mount, Giemsa stain, and culture in modified cysteine peptone liver infusion maltose medium were performed. Results were tabulated and analyzed.

RESULTS

Saline wet mount was positive for trichomoniasis in seven individuals, Giemsa detected trichomoniasis in five patients, and culture was positive in eight patients. Of these eight culture positive cases, one was wet mount negative and four were Giemsa stain negative.

CONCLUSION

Culture is more sensitive than wet mount and Giemsa stain.

The Performance of the Vaginal Discharge Syndromic Management in Treating Vaginal and Cervical Infection: A Systematic Review and Meta-Analysis

Background

This review aimed to synthesize and analyze the diagnostic accuracy and the likelihood of providing correct treatment of the syndromic approach Vaginal Discharge Flowchart in managing cervical infections caused by Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT), and vaginal infections caused by Trichomonas vaginalis (TV) and Bacterial vaginosis (BV) and Candida albicans. This review will inform updating the WHO 2003 guidelines on Vaginal Discharge syndromic case management.

Methods

A systematic review was conducted on published studies from 01-01-2000 to 30-03-2015 in multiple databases. Studies evaluating the diagnostic accuracy and validation of the WHO Vaginal Discharge Flowchart were included. Validation parameters including sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) and the 95% confidence intervals for the different types of the flowchart were taken as outcomes, re-calculated, and analysed using a fixed model meta-analysis for data pooling. The level of agreement between the index and reference test were determined by the Cohen’s Kappa co-efficiency test. Each individual study was assessed on quality using the QUADAS-2 tool.

Findings

The search yielded 2,845 studies of which 16 met the eligibility criteria for final analysis. The diagnostic performance to identify cervical infections was low and resulted in a high proportion of over and missed treatment. The four flowcharts had a sensitivity between 27.37% in history and risk assessment and 90.13% with microscopy, with the inverse in specificity rates. The treatment performances between the flowcharts were inconsistent. The same applies to the use of vaginal discharge flowchart for treating vaginal infections. For vaginal infections the vaginal discharge flowchart had a good performance in flowchart 3 with 91.68% of sensitivity; 99.97% specificity; 99.93% PPV and 0.02% who missed their treatment and 8.32% of women who were over treated by the vaginal discharge flowchart

Conclusion

The vaginal discharge flowchart should focus on management of vaginal infection. It could be used as an intermediate approach for cervical infections for sex workers until a point of care test is available in resource poor settings.

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.

A systematic review on the prevalence and utilization of health care services for reproductive tract infections/sexually transmitted infections: Evidence from India

Several studies have reported prevalence rate of reproductive tract infections (RTIs) but very few studies have described health seeking behavior of patients. This paper critically looks at and summarizes the available evidence, systematically. A structured search strategy was used to identify relevant articles, published during years 2000-2012. Forty-one full-text papers discussing prevalence and treatment utilization pattern were included as per PRISMA guidelines. Papers examining prevalence of sexually transmitted diseases used biochemical methods and standard protocol for diagnosis while studies on RTIs used different methods for diagnosis. The prevalence of RTIs has not changed much over the years and found to vary from 11% to 72% in the community-based studies. Stigma, embarrassment, illiteracy, lack of privacy, cost of care found to limit the use of services, but discussion on pathways of nonutilization remains unclear. Lack of methodological rigor, statistical power, specificity in case definitions as well as too little discussion on the limitation of selected method of diagnosis and reliance on observational evidence hampered the quality of studies on RTIs. Raising awareness among women regarding symptoms of RTIs and sexually transmitted infections and also about appropriate treatment has remained largely a neglected area and, therefore, we observed absence of health system studies in this area.

Drug Use and High-Risk Sexual Behaviors of Women at a Drop-In Center in Mazandaran Province, Iran, 2014

BACKGROUND

Female drug users are more likely to transmit human immunodeficiency virus (HIV) to their sexual partners. Little is known about HIV, sexually transmitted diseases (STDs), cervicitis, and drug abuse among female sex workers in Iran.

OBJECTIVES

Therefore, this study was conducted at a drop-in center (DIC) in Iran to investigate the prevalence of HIV associated risk factors, the prevalence of drug use, high-risk sexual behaviors, and the relationship between the associated factors in women.

PATIENTS AND METHODS

This quantitative cross-sectional study was conducted on 190 female sex workers (SW) in a DIC in Sari, Mazandaran, Northern Iran, in January and February 2014. The study sample was selected through census sampling. In the end, 190 female SWs referring to the DIC participated in our study. There was no limitation in sampling. The self-administered questionnaire was completed via an interview.

RESULTS

The results showed that 39% of the female SWs were less than 30 years old and 64% had elementary school education. In addition, 59% of the participants took some type of illegal drugs and 1.1% of them were reportedly injecting drug users. Moreover, 43% of them had substance dependent husbands, and 39% were reportedly regular condom users. They had 1 - 10 sexual partners on average per week. The overall prevalence of HIV infection was 4%. A significant relationship was found between the type of drugs used and factors such as having a substance dependent husband, use of condom during the last sexual contact, regular condom use, and the number of sexual acts per week. A significant correlation exists between using psychiatric drugs and factors like regular condom use, education, cervicitis, and the number of sexual conducts per week.

CONCLUSIONS

Female sex workers often engage in sex for financial reasons and are at high risk of drug abuse, HIV, and cervicitis. In addition, the rate of cervicitis among females with high-risk sexual behavior is considerable in Mazandaran, Iran. Therefore, the state authorities should provide sex workers with health care services and help them acquire a good job to support their life.

A systematic review on the prevalence and utilization of health care services for reproductive tract infections/sexually transmitted infections: Evidence from India

Several studies have reported prevalence rate of reproductive tract infections (RTIs) but very few studies have described health seeking behavior of patients. This paper critically looks at and summarizes the available evidence, systematically. A structured search strategy was used to identify relevant articles, published during years 2000-2012. Forty-one full-text papers discussing prevalence and treatment utilization pattern were included as per PRISMA guidelines. Papers examining prevalence of sexually transmitted diseases used biochemical methods and standard protocol for diagnosis while studies on RTIs used different methods for diagnosis. The prevalence of RTIs has not changed much over the years and found to vary from 11% to 72% in the community-based studies. Stigma, embarrassment, illiteracy, lack of privacy, cost of care found to limit the use of services, but discussion on pathways of nonutilization remains unclear. Lack of methodological rigor, statistical power, specificity in case definitions as well as too little discussion on the limitation of selected method of diagnosis and reliance on observational evidence hampered the quality of studies on RTIs. Raising awareness among women regarding symptoms of RTIs and sexually transmitted infections and also about appropriate treatment has remained largely a neglected area and, therefore, we observed absence of health system studies in this area.

Correlates of chlamydia and gonorrhea infection among female sex workers: the untold story of Jiangsu, China

Objective(s)

To estimate the prevalence of sexually transmitted infections (STIs) among female sex workers (FSWs) in the Jiangsu Province, China and measure the association of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections with their potential correlates.

Design

A cross-sectional study on a representative sample of FSWs in Yangzhou and Changzhou cities of Jiangsu was conducted.

Methods

185 sex-work venues in Yangzhou and 174 in Changzhou were selected by stratified random sampling. 2972 FSWs (1108 in Yangzhou and 1864 in Changzhou), aged 15 years or more, who agreed to participate and provided blood sample for HIV and syphilis testing were interviewed in these venues. Cervical specimens from 849 randomly chosen participants were then tested for CT and NG.

Results

Proportions of young, school-educated, currently married FSWs who were living alone, migrated from other provinces and engaged in unprotected vaginal intercourse in past 3 months (UVI) were relatively high. Prevalence of HIV, syphilis, CT and NG were 0.20%, 4.88%, 14.61% and 5.42% respectively. Younger age, living alone or with persons other than partners/family members, engaging in UVI and having other STIs seemed to be associated with higher risk of CT or NG infection. Being divorced/widowed and working in middle/low-level venues were identified as additional risk factors for NG.

Conclusions

Based on a representative sample, this initial effort to identify the correlates of CT/NG infections among FSWs of Jiangsu revealed that focused interventions targeting high-risk FSWs are urgently required for controlling STI epidemics in Yangzhou and Changzhou where substantial number of STI cases were identified.

High rates of reinfection and incidence of bacterial sexually transmitted infections in a cohort of female sex workers from two Indian cities: need for different STI control strategies?

Background

Female sex workers (FSWs) in India are provided a standardised package of clinical interventions for management of sexually transmitted infections (STIs). A study was conducted among FSWs at known high STI prevalence sites to determine the effectiveness of the service package.

Methods

A cohort of FSW clinic attendees in two cities, Hyderabad and Mumbai, were enrolled and followed up from October 2008 to November 2009. At each visit, behavioural and clinical data were obtained and vaginal swabs collected for laboratory testing of cervical infections (gonorrhoea and chlamydia).

Results

417 participants were enrolled, of whom 360 attended at least a follow-up visit. Prevalence of cervical infections did not change between the baseline and final visits (27.7% and 21.3% respectively, p=0.08) in spite of presumptive treatment at baseline and syndromic management at all visits. The proportion of asymptomatic cervical infections increased from 36% at baseline to 77% at the final visit. Incidence rate of cervical infections was high (85.6/100 person years) and associated with a prevalent cervical infection at baseline (HR=2.7, p<0.001) and inconsistent condom use with non-commercial partners (HR=2.5, p=0.014).

Conclusions

High rates of STIs persisted despite the interventions due to poor condom use, minimal partner treatment, and high prevalence and incidence of STIs with a large proportion of asymptomatic infections. High-prevalence FSW sites in India need to design more effective partner treatment strategies and consider increasing the frequency of presumptive treatment as a temporary measure for quickly reducing STI prevalence, with renewed emphasis on consistent condom use with all partners.

HIV and other sexually transmitted infections in women with illegal social behavior in Isfahan, Iran

BACKGROUND

Little is known about sexually transmitted infections (STIs) among females who engage in illegal sexual behavior in Iran .So, this study was conducted to obtain knowledge about the prevalence and associated risk factors in this population.

MATERIALS AND METHODS

In a cross-sectional study, a total of 100 women who had exchange of sex for money in previous 3 months according to self report were recruited during 2009-2010 by simple non probable sampling method in Isfahan, Iran. HIV-Ab, Chlamydia trachomatis-IgG and syphilis infection were measured. A questionnaire on demographics and prostitution-associated risk data was collected as well. Chi-square and multivariate logistic regression models were used for data analysis.

RESULTS

Of 100 participants, the samples of 91 ones could be tested for STI markers (nine samples were hemolysis or insufficient). The overall prevalence of C. trachomatis was 19.8%. There was no case with syphilis or HIV infection. Multiple logistic regression analysis demonstrated that participants who reported temporarily marriage were less likely to be infected with C. trachomatis (AOR=0.003, 95%CI=0.001-0.58). The other risk factors for the tested STIs were not statistically significant in multiple logistic regressions.

CONCLUSION

The results of our study indicated that seroprevalence and associated risk factors of HIV and other STIs among female with illegal social behaviors is not considerable in Isfahan, Iran.