Improvement of Clinical Algorithms for the Diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis by the Use of Gram-Stained Smears Among Female Sex Workers in Accra, Ghana

Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Шербрук, Quebec, Canada
Sex Transm Dis (Impact Factor: 2.84). 09/2000; 27(7):401-10. DOI: 10.1097/00007435-200008000-00005
Source: PubMed


Screening for cervical infection is difficult in developing countries. Screening strategies must be improved for high-risk women, such as female sex workers.
To evaluate the sensitivity and specificity of screening algorithms for cervical infection pathogens among female sex workers in Accra, Ghana.
A cross-sectional study among female sex workers was conducted. Each woman underwent an interview and a clinical examination. Biologic samples were obtained for the diagnosis of HIV, syphilis, bacterial vaginosis, yeast infection, Trichomonas vaginalis, Neisseria gonorrhoeae, and Chlamydia trachomatis infection. Signs and symptoms associated with cervicitis agents were identified. Algorithms for the diagnosis of cervical infection were tested by computer simulations.
The following prevalences were observed: HIV, 76.6%; N. gonorrhoeae, 33.7%; C. trachomatis, 10.1%; candidiasis, 24.4%; T. vaginalis, 31.4%; bacterial vaginosis, 2.3%; serologic syphilis, 4.6%; and genital ulcers on clinical examination, 10.6%. The best performance of algorithms were reached when using a combination of clinical signs and a search for gram-negative diplococci on cervical smears (sensitivity, 64.4%; specificity, 80.0%).
In the algorithms, examination of Gram-stained genital smears in female sex workers without clinical signs of cervicitis improved sensitivity without altering specificity for the diagnosis of cervical infection.

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    • "Clinical algorithms developed for female SWs in other countries do not distinguish first from follow-up visits (Vuylsteke et al. 1993; Germain et al. 1997; Deceuninck et al. 2000). Simple laboratory tests such as the detection of intra-cellular Gram-negative diplococci in cervical smear (Deceuninck et al. 2000) or >10 leucocytes/field in vaginal smears (Germain et al. 1997) have been included elsewhere in algorithms for SWs. The sensitivity of these algorithms ranged from 58% to 71% with specificities from 56% to 80%. "
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    ABSTRACT: Sex work is frequently one of the few options women in low-income countries have to generate income for themselves and their families. Treating and preventing sexually transmitted infections (STIs) among sex workers (SWs) is critical to protect the health of the women and their communities; it is also a cost-effective way to slow the spread of HIV. Outside occasional research settings however, SWs in low-income countries rarely have access to effective STI diagnosis. To develop adequate, affordable, and acceptable STI control strategies for SWs. In collaboration with SWs we evaluated STIs and associated demographic, behavioural, and clinical characteristics in SWs living in two cities in Madagascar. Two months post-treatment and counselling, incident STIs and associated factors were determined. Evidence-based STI management guidelines were developed with SW representatives. At baseline, two of 986 SWs were HIV+; 77.5% of the SWs in Antananarivo and 73.5% in Tamatave had at least one curable STI. Two months post-treatment, 64.9% of 458 SWs in Antananarivo and 57.4% of 481 women in Tamatave had at least one STI. The selected guidelines include speculum exams; syphilis treatment based on serologic screening; presumptive treatment for gonorrhoea, chlamydia, and trichomoniasis during initial visits, and individual risk-based treatment during 3-monthly follow-up visits. SWs were enthusiastic, productive partners. A major HIV epidemic can still be averted in Madagascar but effective STI control is needed nationwide. SWs and health professionals valued the participatory research and decision-making process. Similar approaches should be pursued in other resource-poor settings where sex work and STIs are common and appropriate STI diagnostics lacking.
    Preview · Article · Apr 2003 · Tropical Medicine & International Health
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    ABSTRACT: Description of the epidemiology of HIV infection among sex workers (SW) in Accra, Ghana. In all, 1013 SW working out of their homes ( seaters ) or finding customers in bars, hotels, brothels or on the street ( roamers ) were interviewed and tested for HIV. Overall, prevalence of HIV infection was nearly 50% (506 of 1013), varying from 26% (133 of 507) among the roamers to 74% (368 of 496) among the seaters. Profound differences were noted between these two categories of SW with regard to age, number of clients per day, price per instance of intercourse, condom use, and other characteristics. Respectively, 27% and 58% of roamers and seaters were infected with HIV within their first 6 months of sex work, despite a limited number of unprotected sex acts with seropositive clients. Independent risk factors for HIV infection varied between types of SW: age among the roamers; region of origin and duration of sex work among the seaters; number of clients per day, and presence of current or past genital ulcer and gonococcal cervicitis in both groups. In Accra, considerable heterogeneity exists in the population of SWs. In both categories of SW, new recruits become rapidly infected with HIV after entering the trade. The 25-fold higher prevalence of HIV among SWs than in the general adult population suggests that in Accra, as in many cities of West Africa, a high fraction of new cases of HIV infection continue to be acquired from SWs. Intervention programs targeting SW should be an essential component of national AIDS control strategies. Special efforts should be made to identify and offer preventive services to new sex workers.
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    ABSTRACT: Within an ongoing HIV/STD prevention project aimed at female sex workers (FSW) in Cotonou, Benin, we evaluated time trends in HIV and STD prevalences from 1993 to 1999. Three serial cross-sectional surveys were conducted in 1993 (n = 374), 1995-1996 (n = 365), and 1998-1999 (n = 591). A questionnaire was administered to the FSW and they were screened for HIV, syphilis, Neisseria gonorrhoeae, and Chlamydia trachomatis. The mean percentage of condom use with clients in the week preceding the interview increased from 62.2% in 1993 to 80.7% in 1998-1999 (P = 0.0001). The prevalence of all infections decreased significantly (all P < 0.02; chi-square for trend) over time: HIV from 53.3% in 1993 to 40.6% in 1998-1999; syphilis from 8.9 to 1.5%; gonorrhoea from 43.2 to 20.5%; and chlamydia from 9.4 to 5.1%. However, the mean age of FSW decreased from 31.0 to 28.4 years between 1993 and 1998-1999. Moreover, the country of origin of these women changed dramatically over time: the proportion of Ghanaian women decreased from 66.3% in 1993 to 21.6% in 1998-1999 when the predominant group became Nigerian (38.0%). When controlling for age and country of origin, HIV prevalence was stable over time (P = 0.71), whereas the downward trend remained significant for syphilis and gonorrhoea (both P < 0.001), and was present but not significant for chlamydia (P = 0.13). These data suggest that the time trends in HIV and STD prevalences are partly due to the changing sex work milieu, but that the intervention also had an impact. Prevention programmes aimed at FSW should be highly prioritized.
    Full-text · Article · Mar 2002 · AIDS
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