A research agenda to improve incidence and outcomes of assisted vaginal birth

Access to emergency obstetric care, including assisted vaginal birth and caesarean birth, is crucial for improving maternal and childbirth outcomes. However, although the proportion of births by caesarean section has increased during the last few decades, the use of assisted vaginal birth has declined. This is particularly the case in low- and middle-income countries, despite an assisted vaginal birth often being less risky than caesarean birth. We therefore conducted a three-step process to identify a research agenda necessary to increase the use of, or reintroduce, assisted vaginal birth: after conducting an evidence synthesis, which informed a consultation with technical experts who proposed an initial research agenda, we sought and incorporated the views of women's representatives of this agenda. This process has allowed us to identify a comprehensive research agenda, with topics categorized as: (i) the need to understand women's perceptions of assisted vaginal birth, and provide appropriate and reliable information; (ii) the importance of training health-care providers in clinical skills but also in respectful care, effective communication, shared decision-making and informed consent; and (iii) the barriers to and facilitators of implementation and sustainability. From women's feedback, we learned of the urgent need to recognize labour, childbirth and postpartum experiences as inherently physiological and dignified human processes, in which interventions should only be implemented if necessary. The promotion and/or reintroduction of assisted vaginal birth in low-resource settings requires governments, policy-makers and hospital administrators to support skilled health-care providers who can, in turn, respectfully support women in labour and childbirth.

It's not just about pads! Adolescent reproductive health views in Kenya: A qualitative secondary analysis

Many adolescents face barriers to accessing reproductive health care even though quality reproductive health care is a fundamental human right. The objective of this study is to understand the requests of quality reproductive health among high school girls in Kenya. We conducted a secondary analysis of qualitative data from a sub-sample of adolescent girls in Kenya who participated in the What Women Want global campaign and analyzed interview data from key informants involved in the survey. We used pre-existing codes and current literature to design the coding framework and thematic analysis to describe emerging themes. Atlas. ti 8 was used to organize and analyze codes. Over 4,500 high school girls, ages 12 and 19 years, were included in the analysis, with 61.6% from all-girls boarding schools and 13.8% from mixed-day schools. Data from nine key informants complemented findings from the survey. Emerging themes included: 1) The need for improved menstrual health and hygiene: Sanitary towels and cleaner toilets; 2) Prevention of adolescent pregnancy: Access to contraception; 3) Respect and dignity: Participants want privacy and confidentiality; and 4) The need to address social determinants of health: Economic stability and a safe physical environment. This study indicated that adolescent high school girls have varied requests for reproductive health care and services. While menstrual health and hygiene are key issues, reproductive needs are beyond just sanitary products. The results suggest a need for targeted reproductive health interventions using a multi-sectoral approach.

Transitioning to Digital Systems: The Role of World Health Organization's Digital Adaptation Kits in Operationalizing Recommendations and Interoperability Standards

INTRODUCTION

The transition from paper to digital systems requires quality assurance of the underlying content and application of data standards for interoperability. The World Health Organization (WHO) developed digital adaptation kits (DAKs) as an operational and software-neutral mechanism to translate WHO guidelines into a standardized format that can be more easily incorporated into digital systems.

METHODS

WHO convened health program area and digital leads, reviewed existing approaches for requirements gathering, mapped to established standards, and incorporated research findings to define DAK components.

RESULTS

For each health domain area, the DAKs distill WHO guidelines to specify the health interventions, personas, user scenarios, business process workflows, core data elements mapped to terminology codes, decision-support logic, program indicators, and functional and nonfunctional requirements.

DISCUSSION

DAKs aim to catalyze quality of care and facilitate data use and interoperability as part of WHO's vision of SMART (Standards-based, Machine-readable, Adaptive, Requirements-based, and Testable) guidelines. Efforts will be needed to strengthen a collaborative approach for the uptake of DAKs within the local digital ecosystem and national health policies.

Implementation of the new WHO antenatal care model for a positive pregnancy experience: a monitoring framework

Monitoring the implementation and impact of routine antenatal care (ANC), as described in the new World Health Organization (WHO) ANC model, requires indicators that go beyond the previously used global benchmark indicator of four or more ANC visits. To enable consistent monitoring of ANC content and care processes and to provide guidance to countries and health facilities, WHO developed an ANC monitoring framework. This framework builds on a conceptual framework for quality ANC and a scoping review of ANC indicators that mapped existing indicators related to recommendations in the new WHO ANC model. Based on the scoping review and following an iterative and consultative process, we developed a monitoring framework consisting of core indicators recommended for monitoring ANC recommendations in all settings, as well as a menu of additional measures. Finally, a research agenda highlights areas where ANC recommendations exist, but measures require further development. Nine core indicators can already be monitored globally and/or nationally, depending on the preferred data sources. Two core indicators (experience of care, ultrasound scan before 24 weeks) are included as placeholders requiring priority by the research agenda. Six context-specific indicators are appropriate for national and subnational monitoring in various settings based on specific guidance. Thirty-five additional indicators may be relevant and desirable for monitoring, depending on programme priorities. Monitoring implementation of the new WHO ANC model and the outcomes of routine ANC require greater attention to the measurement of ANC content and care processes as well as women’s experience of ANC.

A Landscape Analysis of Offering HIV Testing Services Within Family Planning Service Delivery

Introduction: Offering HIV testing services (HTS) within sexual and reproductive health (SRH) services is a priority, especially for women who have a substantial risk. To reach women with HIV who do not know their status and prevent mother-to-child HIV transmission, the World Health Organization (WHO) recommends routinely offering HTS as part of family planning (FP) service delivery in high HIV burden settings. We conducted a landscape analysis to assess HTS uptake and HIV positivity in the context of FP/SRH services.

Assessment of Research and Programs: We searched records from PubMed, four gray literature databases, and 13 organization websites, and emailed 24 organizations for data on HTS in FP/SRH services. We also obtained data from International Planned Parenthood Federation (IPPF) affiliates in Eswatini, Kenya, Lesotho, Malawi, Namibia, Uganda, Zambia, and Zimbabwe. Unique programs/studies from records were included if they provided data on, or barriers/facilitators to, offering HTS in FP/SRH. Overall, 2,197 records were screened and 12 unique programs/studies were eligible, including 10 from sub-Saharan Africa. Four reported on co-delivery of SRH services (including FP), with reported HTS uptake between 17 and 94%. Six reported data on HTS in FP services: four among general FP clients; one among couples; and one among female sex workers, adolescent girls, and young women. Two of the six reported HTS uptake >50% (51%, 419/814 Kenya; 63%, 5,930/9,439 Uganda), with positivity rates of 2% and 4.1%, respectively. Uptake was low (8%, 74/969 Kenya) in the one FP program offering pre-exposure prophylaxis. In the IPPF program, seven countries reported HTS uptake in FP services and ranged from 4% in Eswatini to 90% in Lesotho; between 0.6% (Uganda) and 8% (Eswatini) of those tested were HIV positive.

Implications: Data on providing HTS in FP/SRH service delivery were sparse and HTS uptake varied widely across programs.

Actionable Recommendations: As countries expand HTS in FP/SRH appropriate to epidemiology, they should ensure data are reported and monitored for progress and impact.

Towards achieving the family planning targets in the African region: a rapid review of task sharing policies

Background

Expanding access and use of effective contraception is important in achieving universal access to reproductive healthcare services, especially in low- and middle-income countries (LMICs), such as those in sub-Saharan Africa (SSA). Shortage of trained healthcare providers is an important contributor to increased unmet need for contraception in SSA. The World Health Organization (WHO) recommends task sharing as an important strategy to improve access to sexual and reproductive healthcare services by addressing shortage of healthcare providers. This study explores the status, successes, challenges and impacts of the implementation of task sharing for family planning in five SSA countries. This evidence is aimed at promoting the implementation and scale-up of task sharing programmes in SSA countries by WHO.

Methodology and findings

We employed a rapid programme review (RPR) methodology to generate evidence on task sharing for family planning programmes from five SSA countries namely, Burkina Faso, Cote d’Ivoire, Ethiopia, Ghana, and Nigeria. This involved a desk review of country task sharing policy documents, implementation plans and guidelines, annual sexual and reproductive health programme reports, WHO regional meeting reports on task sharing for family planning; and information from key informants on country background, intervention packages, impact, enablers, challenges and ways forward on task sharing for family planning. The findings indicate mainly the involvement of community health workers, midwives and nurses in the task sharing programmes with training in provision of contraceptive pills and long-acting reversible contraceptives (LARC). Results indicate an increase in family planning indicators during the task shifting implementation period. For instance, injectable contraceptive use increased more than threefold within six months in Burkina Faso; contraceptive prevalence rate doubled with declines in total fertility and unmet need for contraception in Ethiopia; and uptake of LARC increased in Ghana and Nigeria. Some barriers to successful implementation include poor retention of lower cadre providers, inadequate documentation, and poor data systems.

Conclusions

Task sharing plays a role in increasing contraceptive uptake and holds promise in promoting universal access to family planning in the SSA region. Evidence from this RPR is helpful in elaborating country policies and scale-up of task sharing for family planning programmes.

Development of the WHO Antenatal Care Recommendations Adaptation Toolkit: a standardised approach for countries

BACKGROUND

Increasingly, WHO recommendations are defined by context-specific factors and WHO is developing strategies to ensure that recommendations are successfully adapted and implemented at country level. This manuscript describes the development of a toolkit to support governments to adapt the WHO recommendations on antenatal care (ANC) for a positive pregnancy experience for their context in a systematic manner.

METHODS

The toolkit was developed in three steps. It was created with input from methodologists and regional implementation experts (Step 1) followed by a user-testing phase (Step 2), implemented during country stakeholder meetings. User testing consisted of stakeholder interviews that were transcribed, and data was categorised according to the content analysis method. Suggestions for toolkit improvement and issues identified during the interviews were assessed as serious, moderately serious or minor/cosmetic.

RESULTS

A total of 22 stakeholders - comprising five Ministry of Health (MoH) consultants, four MoH policy-makers, and 13 advisors/implementers - from Burkina Faso, India, Rwanda and Zambia participated in user-testing interviews during stakeholder meetings held in each country between August 2018 and February 2019. Most stakeholders had a medical or nursing background and half were women. Overall, responses to the toolkit were positive, with all stakeholders finding it useful and desirable. User testing interviews highlighted four serious, four moderately serious and five minor/cosmetic issues to be managed. These were addressed in the final step (Step 3), an updated version of the WHO ANC Recommendations Adaptation Toolkit, comprised of two main components - a baseline assessment tool with spreadsheets for data entry and a Slidedoc^®, a dual-purpose document for reading and presentation, outlining the qualitative data that shaped the women-centred perspective of the guidelines, accompanied by an instruction manual detailing the components' use.

CONCLUSIONS

The WHO ANC Recommendations Adaptation Toolkit was developed to support countries to systematically adapt the WHO ANC recommendations for country contexts. Using this approach, similar tools can be developed to support guideline implementation across different health domains and the continuum of care.

From Research to Policy: The WHO Experience With Developing Guidelines on the Potential Risk of HIV Acquisition and Progestogen-Only Contraception Use

To develop guidance for women at high risk of HIV, WHO carefully considered the risks of maternal morbidity and mortality from unintended pregnancy against possible increased risk of HIV acquisition with injectable use. Among the many challenges: (1) balancing timeliness of changing the guidance against the potential impact of it; (2) engaging a range of stakeholders; (3) translating complex research and policy messages to clients; (4) needing additional research; and (5) monitoring and evaluating successes and challenges with implementing new guidelines.

Shortages of benzathine penicillin for prevention of mother-to-child transmission of syphilis: An evaluation from multi-country surveys and stakeholder interviews

BACKGROUND

Benzathine penicillin G (BPG) is the only recommended treatment to prevent mother-to-child transmission of syphilis. Due to recent reports of country-level shortages of BPG, an evaluation was undertaken to quantify countries that have experienced shortages in the past 2 years and to describe factors contributing to these shortages.

METHODS AND FINDINGS

Country-level data about BPG shortages were collected using 3 survey approaches. First, a survey designed by the WHO Department of Reproductive Health and Research was distributed to 41 countries and territories in the Americas and 41 more in Africa. Second, WHO conducted an email survey of 28 US Centers for Disease Control and Prevention country directors. An additional 13 countries were in contact with WHO for related congenital syphilis prevention activities and also reported on BPG shortages. Third, the Clinton Health Access Initiative (CHAI) collected data from 14 countries (where it has active operations) to understand the extent of stock-outs, in-country purchasing, usage behavior, and breadth of available purchasing options to identify stock-outs worldwide. CHAI also conducted in-person interviews in the same 14 countries to understand the extent of stock-outs, in-country purchasing and usage behavior, and available purchasing options. CHAI also completed a desk review of 10 additional high-income countries, which were also included. BPG shortages were attributable to shortfalls in supply, demand, and procurement in the countries assessed. This assessment should not be considered globally representative as countries not surveyed may also have experienced BPG shortages. Country contacts may not have been aware of BPG shortages when surveyed or may have underreported medication substitutions due to desirability bias. Funding for the purchase of BPG by countries was not evaluated. In all, 114 countries and territories were approached to provide information on BPG shortages occurring during 2014-2016. Of unique countries and territories, 95 (83%) responded or had information evaluable from public records. Of these 95 countries and territories, 39 (41%) reported a BPG shortage, and 56 (59%) reported no BPG shortage; 10 (12%) countries with and without BPG shortages reported use of antibiotic alternatives to BPG for treatment of maternal syphilis. Market exits, inflexible production cycles, and minimum order quantities affect BPG supply. On the demand side, inaccurate forecasts and sole sourcing lead to under-procurement. Clinicians may also incorrectly prescribe BPG substitutes due to misperceptions of quality or of the likelihood of adverse outcomes.

CONCLUSIONS

Targets for improvement include drug forecasting and procurement, and addressing provider reluctance to use BPG. Opportunities to improve global supply, demand, and use of BPG should be prioritized alongside congenital syphilis elimination efforts.

HIV/STD: the women to blame? Knowledge and attitudes among STD clinic attendees in the second decade of HIV/AIDS

We aimed to determine the knowledge and attitudes towards HIV/STDs among women attending an STD clinic by interviewing 520 randomly selected women. Nearly all had heard of HIV/AIDS/STDs, with posters, pamphlets and the radio being the main source of their information. The years of schooling was the only predictive factor of knowing a preventive measure of HIV. Two-thirds thought they were at risk of contracting HIV from their regular partner. Knowledge of the sexual habits of their male partners was low with 260 (50%) of the women distrusting their partner. Only 52 (10%) of respondents admitted to sex in exchange for gifts or money. In the event of a positive HIV test result, the perceived partner response would be to blame the woman for introducing the infection into the relationship. After a positive HIV test result, only 3.5% would resort to using condoms while another 3.7% would try to pass on the disease to other people. The quality of their knowledge of the transmission of HIV was low in spite of the fact that most respondents have heard of HIV/AIDS/STDs. Violence against women was expected in relation to a positive test result. There is a need for better educative effort on the modes of transmission and prevention of HIV, also in ‘low risk’ populations.

The Botswana Medical Eligibility Criteria Wheel: Adapting a Tool to Meet the Needs of Botswana's Family Planning Program

In efforts to strive for family planning repositioning in Botswana, the Ministry of Health convened a meeting to undertake an adaptation of the Medical eligibility criteria for contraceptive use (MEC) wheel. The main objectives of this process were to present technical updates of the various contraceptive methods, to update the current medical conditions prevalent to Botswana and to adapt the MEC wheel to meet the needs of the Botswanian people. This commentary focuses on the adaptation process that occurred during the week-long stakeholder workshop. It concludes with the key elements learned from this process that can potentially inform countries who are interested in undergoing a similar exercise to strengthen their family planning needs.

Increased risk of HIV in women experiencing physical partner violence in Nairobi, Kenya

As part of a study on etiology of sexually transmitted infections (STI) among 520 women presenting at the STI clinic in Nairobi, data on partner violence and its correlates were analyzed. Prevalence of lifetime physical violence was 26%, mainly by an intimate partner (74%). HIV seropositive women had an almost twofold increase in lifetime partner violence. Women with more risky sexual behavior such as early sexual debut, number of sex partners, history of condom use and of STI, experienced more partner violence. Parity and miscarriage were associated with a history of lifetime violence. We found an inverse association between schooling and level of violence. Six percent of the women had been raped. Gender-based violence screening and services should be integrated into voluntary counseling and testing programs as well as in reproductive health programs. Multi-sector approaches are needed to change prevailing attitudes towards violence against women.

Screening and management of precancerous lesions to prevent cervical cancer in low-resource settings

Cervical cancer is a leading cause of cancer death among women in low-resource settings, but it is completely preventable by screening for and treating precancerous lesions. In this article, the current approaches to screening, confirmation, and treatment of precancerous lesions of the cervix are reviewed from the perspective of low-resource settings. Cervical cytology is compared to visual inspection with acetic acid (VIA) for screening women to detect precancerous lesions. The use of colposcopy to confirm findings in women with positive screening test results and various treatment methods are discussed. With one examination, cytology appears to detect fewer precancerous lesions than VIA, but VIA has a lower specificity and labels proportionately more women falsely positive. When available, colposcopy may be used to obtain directed biopsies from abnormal areas of the cervix to pathologically confirm the findings in women with positive screening tests. Treatment with cryotherapy appears to be a safe, acceptable, and effective procedure for the majority of precancerous lesions. Lesions that are not suitable for cryotherapy because of endocervical canal involvement or large size are amenable to outpatient treatment by loop electrical excision procedure (LEEP). HIV/AIDS and immune system suppression are associated with more rapid CIN progression and HIV-positive women generally have high recurrence rates of CIN after treatment. Women tempora may more readily transmit the virus after cryotherapy and, therefore, they require counseling regarding abstinence and condom use. Highly active antiretroviral therapy (HAART) may cause CIN to regress and may decrease the risk of cervical cancer in HIV-infected women. Cost-effectiveness modeling using South African data shows that use of a single lifetime VIA test and immediate cryotherapy saves costs compared to cytology or to no screening. VIA and cryotherapy are appropriate services for low-resource settings. Colposcopy and LEEP services should be available on a referral basis.

Pattern of sexually transmitted diseases and risk factors among women attending an STD referral clinic in Nairobi, Kenya

BACKGROUND

In Kenya, sexually transmitted disease (STD) clinics care for large numbers of patients with STD-related signs and symptoms. Yet, the etiologic fraction of the different STD pathogens remains to be determined, particularly in women.

GOAL

The aim of the study was to determine the prevalence of STDs and of cervical dysplasia and their risk markers among women attending the STD clinic in Nairobi.

STUDY DESIGN

A cross-section of women were interviewed and examined; samples were taken.

RESULTS

The mean age of 520 women was 26 years, 54% had a stable relationship, 38% were pregnant, 47% had ever used condoms (1% as a method of contraception), 11% reported multiple partners in the previous 3 months, and 32% had a history of STDs. The prevalence of STDs was 29% for HIV type 1, 35% for candidiasis, 25% for trichomoniasis, 16% for bacterial vaginosis, 6% for gonorrhea, 4% for chlamydia, 6% for a positive syphilis serology, 6% for genital warts, 12% for genital ulcers, and 13% for cervical dysplasia. Factors related to sexual behavior, especially the number of sex partners, were associated with several STDs. Gonorrhea, bacterial vaginosis, cervical dysplasia, and genital warts or ulcers were independently associated with HIV infection. Partners of circumcised men had less-prevalent HIV infection.

CONCLUSION

Most women reported low-risk sexual behavior and were likely to be infected by their regular partner. HIV and STD prevention campaigns will not have a significant impact if the transmission between partners is not addressed.

Validity of the vaginal discharge algorithm among pregnant and non-pregnant women in Nairobi, Kenya

OBJECTIVE

To evaluate the validity of different algorithms for the diagnosis of gonococcal and chlamydial infections among pregnant and non-pregnant women consulting health services for vaginal discharge in Nairobi, Kenya.

METHODS

Cross sectional study among 621 women with complaints of vaginal discharge in three city council clinics between April and August 1997. Women were interviewed and examined for symptoms and signs of sexually transmitted infections (STIs). Specimens were obtained for laboratory diagnosis of genital infections, HIV, and syphilis. The data were used to evaluate the Kenyan flow chart as well as several other generated algorithms.

RESULTS

The mean age was 24 years and 334 (54%) were pregnant. The overall prevalence rates were: 50% candidiasis, 23% trichomoniasis, 9% bacterial vaginosis, 7% gonorrhoea, 9% chlamydia, 7% syphilis, and 22% HIV. In non-pregnant women, gonococcal and chlamydial infection was significantly associated with (1) demographic and behavioural risk markers such as being single, younger than 20 years, multiple sex partners in the previous 3 months; (2) symptom fever; and (3) signs including presence of yellow or bloody vaginal discharge, cervical mucopus, cervical erythema, and friability. Among pregnant women only young age, dysuria, and fever were significantly associated with cervical infection. However, none of these variables was either sensitive or specific enough for the diagnosis of cervical infection. Several algorithms were generated and applied to the study data. The algorithm including risk markers performed slightly better than the current Kenyan algorithm.

CONCLUSION

STIs form a major problem in the Nairobi area and should be addressed accordingly. None of the tested algorithms for the treatment of vaginal discharge would constitute a marked improvement of the existing flow chart. Hence, better detection tools for the specific aetiology of vaginal discharge are urgently needed.

Predicting Neisseria gonorrhoeae and Chlamydia trachomatis infection using risk scores, physical examination, microscopy, and leukocyte esterase urine dipsticks among asymptomatic women attending a family planning clinic in Kenya

BACKGROUND

Sexually transmitted infections (STIs) continue to exert a tremendous health burden on women in developing countries. Poor socioeconomic status, inadequate knowledge, lack of diagnostic facilities, and shortages of effective treatment all contribute to the high incidence of STIs. The use of clinical algorithms for the detection and management of STIs has gained widespread acceptance in settings where there are limited resources. Evaluation of these algorithms have been few, especially in women who are not recognized as members of high-risk groups.

OBJECTIVES

To develop a simple scoring system based on historical and demographic data, physical findings, microscopy, and leukocyte esterase (LE) urine dipsticks to predict cervical gonococcal and chlamydial infection among asymptomatic women.

METHODS

One thousand and forty-eight women attending an urban family planning clinic in Nairobi were randomly selected to participate. After the identification of factors that were associated with infection, we assigned one point each for: age 25 or younger, single status, two or more sex partners in the past year, cervical discharge, cervical swab leukocytes, and a positive LE urine dipstick. Identification of any one of these six factors gave a sensitivity of 85% and a specificity of 30% for the detection of cervical infections. A positive LE urine dipstick had a sensitivity of 63 % and a specificity of 47% when used alone and did not contribute to the identification of infection if a physical examination was performed. The application of existing clinical algorithms to this population performed poorly.

CONCLUSIONS

The use of risk scores, physical examination, microscopy, and the urine LE dipstick, used alone or in combination, as predictors of gonococcal or chlamydial cervical infection was of limited utility in low-risk, asymptomatic women. Accurate diagnostic testing is necessary to optimize treatment.

HIV/STD: the women to blame? Knowledge and attitudes among STD clinic attendees in the second decade of HIV/AIDS

We aimed to determine the knowledge and attitudes towards HIV/STDs among women attending an STD clinic by interviewing 520 randomly selected women. Nearly all had heard of HIV/AIDS/STDs, with posters, pamphlets and the radio being the main source of their information. The years of schooling was the only predictive factor of knowing a preventive measure of HIV. Two-thirds thought they were at risk of contracting HIV from their regular partner. Knowledge of the sexual habits of their male partners was low with 260 (50%) of the women distrusting their partner. Only 52 (10%) of respondents admitted to sex in exchange for gifts or money. In the event of a positive HIV test result, the perceived partner response would be to blame the woman for introducing the infection into the relationship. After a positive HIV test result, only 3.5% would resort to using condoms while another 3.7% would try to pass on the disease to other people. The quality of their knowledge of the transmission of HIV was low in spite of the fact that most respondents have heard of HIV/AIDS/STDs. Violence against women was expected in relation to a positive test result. There is a need for better educative effort on the modes of transmission and prevention of HIV, also in 'low risk' populations.

Risk factors for human papillomavirus and cervical precancerous lesions, and the role of concurrent HIV-1 infection

OBJECTIVES

To identify risk factors for human papillomavirus (HPV) infection and squamous intraepithelial lesions (SIL) of the cervix, and to measure the impact of concurrent HIV-1 infection.

METHODS

Women were studied at a family planning clinic in Nairobi, Kenya. Demographic and historical information was obtained using a semi-structured questionnaire and specimens were collected for sexually transmitted diseases (STDs), HPV, cervical cytology, and HIV-1 testing.

RESULTS

HPV was detected in 87 of 513 women (17%), including 81 (93%) oncogenic types (16, 18, 31, 33 and others) and six (7%) non-oncogenic types (6 and 11). HIV-1 prevalence was 10%. HPV detection was associated with HIV-1 infection [adjusted odds ratio (aOR) 3.9, 95% confidence interval (CI), 2.0-7.7], sexual behavior indicators including the number of sex partners and inflammatory STDs, as well as the number of pregnancies (0 or 1 vs. > or = 3, aOR 0.4; 95% CI, 0.2-0.9). SIL was detected in 61 women (11.9%), including 28 (46%) with low-grade lesions (LSIL) and 33 (54%) with high-grade lesions (HSIL). HPV infection was strongly associated with HSIL (OR 14.9; 95% CI, 6.8-32.8). In a multivariate model predictors of HSIL included HIV-1 serpositivity (aOR 4.8; 95% CI, 1.8-12.4), the number of lifetime sex partners (0-1 vs. > or = 4; aOR 3.8; 95% CI, 1.1-13.5), and older age (< 26 vs. > 30; OR 3.9; 95% CI, 1.1-13.6). An analysis stratified by HIV-1 showed a stronger association between HPV and HSIL in HIV-1 negative women (OR 17.0; 95% CI, 6.4-46.3) then in HIV-1 positive women (OR 4.5; 95% CI, 0.8-27.4).

CONCLUSION

Our results indicate that HSIL and even invasive cancer are highly prevalent in this setting of women on reproductive age considered to be at low risk for STDs, suggesting that routine Pap smear screening may save lives.

The supermarket for women's reproductive health: the burden of genital infections in a family planning clinic in Nairobi, Kenya

OBJECTIVES

To study the burden of disease of reproductive tract infections (RTIs) and cervical dysplasia in women attending a family planning clinic in Nairobi, Kenya, and to assess the acceptability of integrating reproductive healthcare services into existing family planning facilities.

METHODS

In a family planning clinic in Nairobi, Kenya, 520 women were enrolled in a study on RTI and cervical dysplasia.

RESULTS

RTI pathogens were detected in over 20% of women, the majority being asymptomatic. HIV-1 testing was positive in 10.2%. The diagnosis of cervical dysplasia was made on 12% of the cytology smears (mild in 5.8%, moderate in 3.5%, severe in 1.2%), and 1.5% had invasive cervical cancer. The intervention of case detection of RTI and Papanicolaou smear taking was well received by clients and considered feasible by the staff.

CONCLUSIONS

Early detection and treatment of potentially curable cervical lesions and RTI provide a unique opportunity to improve women's health. In Kenya, where the current contraceptive prevalence rate is 33%, family planning clinics are excellent sites to introduce health interventions.