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STI management and control in Latin America: Where do we stand and where do we go from here?

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Patricia J Garcia
Patricia J Garcia
Patricia J Garcia
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Adele S Benzaken
Adele S Benzaken
Adele S Benzaken
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Enrique Galban Garcia at National Institute of Gastroenterology
Enrique Galban Garcia
  • National Institute of Gastroenterology
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Control of sexually transmitted infection (STI) remains challenging in most regions; Latin America (LA) is no exception. The Latin American and Caribbean Association for the Control of Sexually Transmitted Infections (ALAC-ITS)1 implemented a survey to collect information on STI programmes in the region. This paper highlights some important sexual behavioural trends from recently published literature and presents key results of the survey of STI programmes, identifying weaknesses, strengths and opportunities for STI control in LA. ALAC-ITS developed a survey to assess reporting, epidemiology and organisational aspects of STI programmes. The survey was distributed in November 2007 by email to the directors of the national STI programmes in 20 ALAC-ITS member countries. The following 19 countries returned the survey: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Dominican Republic, Uruguay and Venezuela. Haiti did not respond. The data analysed were shared and validated at a meeting in March 2008, with representatives from 18 national STI programmes, ALAC-ITS, and international agencies. In addition, we have updated information on some countries with data from the national STI programmes and ALAC-ITS members. Data related to syphilis have been published.2 We have complemented the data presented with literature review. ### Sexual behaviour in LA A recent analysis of sexual behaviour around the world revealed that age at first sexual intercourse in LA varies from a median of 16.5 to 17.5 years for men and 15.5 to 17.5 years for women.3 …
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STI management and control in Latin America: where
do we stand and where do we go from here?
Patricia J Garcia,
1,2
Adele S Benzaken,
3
Enrique Galban,
4
the ALAC-ITS members
INTRODUCTION
Control of sexually transmitted infection (STI)
remains challenging in most regions; Latin America
(LA) is no exception. The Latin American and
Caribbean Association for the Control of Sexually
Transmitted Infections (ALAC-ITS)
1
implemented
a survey to collect information on STI programmes
in the region.
This paper highlights some important sexual
behavioural trends from recently published litera-
ture and presents key results of the survey of STI
programmes, identifying weaknesses, strengths and
opportunities for STI control in LA.
METHODS
ALAC-ITS developed a survey to assess reporting,
epidemiology and organisational aspects of STI
programmes. The survey was distributed in
November 2007 by email to the directors of the
national STI programmes in 20 ALAC-ITS member
countries. The following 19 countries returned the
survey: Argentina, Bolivia, Brazil, Chile, Colombia,
Costa Rica, Cuba, Ecuador, El Salvador, Guatemala,
Honduras, Mexico, Nicaragua, Panama, Paraguay,
Peru, Dominican Republic, Uruguay and Venezuela.
Haiti did not respond. The data analysed were
shared and validated at a meeting in March 2008,
with representatives from 18 national STI
programmes, ALAC-ITS, and international agencies.
In addition, we have updated information on some
countries with data from the national STI
programmes and ALAC-ITS members. Data related
to syphilis have been published.
2
We have comple-
mented the data presented with literature review.
RESULTS
Sexual behaviour in LA
A recent analysis of sexual behaviour around the
world revealed that age at first sexual intercourse in
LA varies from a median of 16.5 to 17.5 years for
men and 15.5 to 17.5 years for women.
3
From
analyses of demographic and health surveys from
eight countries (Bolivia, Brazil, Colombia, Domin-
ican Republic, Guatemala, Nicaragua, Paraguay and
Peru) conducted between 1990 and 2000,
researchers have found that premarital sexual
activity has been increasing.
4
There is a trend
towards increased uptake of contraception, which
varies from 6% for Guatemala to 27% in Colombia.
These results also show that condom use increased,
although the contribution of condom use to
contraceptive protection represents only 10e20%
of all contraceptive methods. However, the increase
in contraceptive use is not sufficient to decrease the
risk of pregnancy due to increased sexual activity,
nor other risks associated with unsafe sex (eg,
STIs). In 1990, a Brazilian study showed that 30%
of sexually active adolescent males from low-
income areas reported having had an STI at least
once.
5
In Peru, from a 2006 population-based survey
of asymptomatic men 18e29 years old, we found
28% reported having had urethral discharge, genital
ulcers or genital warts in the 12 months before the
survey (P J Garcia, personal communication, 2008).
Data on sexual partnerships in LA shows over-
reporting of partners by men and under-reporting
by women.
3
Estimates of proportions of men who
have sex with men vary from 6% to 20%.
6
Epidemiological situation of STIs
All countries have mandatory reporting of AIDS
and HIV infection, except Brazil and Uruguay,
which do not require reporting of HIV infection.
Mandatory reporting of other STIs, however, varies
greatly across countries (table 1).
It is not easy to characterise accurately the
epidemiological situation of STIs in the LA region
from the data collected by the national STI
programmes; in contrast with HIV/AIDS, the
surveillance and reporting systems differ consider-
ably from one country to another with regard to
definitionsdclinical versus syndromic versus labo-
ratory baseddand even those using laboratory-
based diagnosis differ with regard to the type of
tests available.
A total of 539 063 STI cases, including syndromic
notifications, were reported by the 19 countries for
2006 (table 2). Compared with 1999 WHO estimates
of 38 million new cases of five curable STIs in LA,
7
the numbers reported from the national STI
programmes represent a very small proportion of the
expected incident STI cases. Several STIs are not
reported because of difficulties with STI diagnosis
and recognition of cases. Studies in LA have shown
that private physicians provide a substantial
proportion of health delivery for STIs, and such cases
are not reported at the national level.
8e10
In addi-
tion, patients with STI often bypass formal health-
care systems and seek care in the informal sector (eg,
pharmacies), as has been documented for LA.
11
Members of the national STI programmes of 10 of
the 19 countries responding to our survey estimated
that 25e50% of STI cases are seen at pharmacies.
Organisational aspects of STI programmes in LA
All the countries surveyed reported that STI
management is integrated into primary care
services. In addition, they reported 241 ‘specialised’
STI clinics in the 19 LA countries. Syndromic
management of STIs is now universally accepted as
the standard of care throughout the region,
although acceptance of this policy took much longer
in countries such as Uruguay and Ecuador (2006)
1
Epidemiology, STD/AIDS Unit,
School of Public Health,
Universidad Peruana Cayetano
Heredia, Lima, Peru
2
Department of Global Health,
University of Washington,
Seattle USA
3
Fundacion Alfredo da Matta,
Manaus, Brazil
4
Instituto de Gastroenterologia,
Cuba
Correspondence to
Professor Patricia J Garcia,
Universidad Peruana Cayetano
Heredia, Av Honorio Delgado
430 SMP Lima 31, Lima, Peru;
patricia.garcia@upch.pe
Accepted 29 August 2011
This paper is freely available
online under the BMJ Journals
unlocked scheme, see http://sti.
bmj.com/site/about/unlocked.
xhtml
Sex Transm Infect 2011;87:ii7eii9. doi:10.1136/sextrans-2011-050177 ii7
Supplement
than in Brazil (1994). General practitioners, as well as specialists
in infectious diseases, gynaecology, urology and dermatology, are
responsible for treating STI cases in most of the countries,
although nurses and midwives also see and manage cases.
12
Most countries reported providing services to all individuals
seeking care for an STI through ministry of health clinics, where
consultations for STIs are free of charge for any patient (general
or high-risk population) in 14 of 19 countries and STI drugs are
offered free of charge in 17 of 19 countries (Colombia and
Uruguay do not offer free treatment for STIs). Paraguay and
Bolivia reported that condoms are not regularly offered as part of
STI management.
All countries except Colombia, El Salvador and Paraguay offer
partner notification services. Most of the countries (12 of 19)
have implemented partner notification solely by asking patients
to notify their partners; only four used a combined patient and
health provider notification strategy. National STI programme
staff estimated that notification reaches <25% of the partners in
STI cases.
STI screening and services for specific populations
As shown in table 3, STI screening is almost universal for female
sex workers (conducted in 16 of 19 countries) and mostly
includes HIV and syphilis testing, although five countries also
Table 1 Sexually transmitted infections for which mandatory reporting is required, LAC region, 2007
Total
Congenital
Pregnant women
Total
Pregnant Women
Newborn
Argentina
Bolivia
Brazil
Chile
Colombia
Costa Rica
Cuba
Ecuador
El Salvador
Guatemala
Honduras
México
Nicaragua
Panamá
Paraguay
Perú
Dominican R.
Uruguay
Venezuela
Hep B
Country
Syphilis
Gonorrhea
Chlamydia
Chancroid
LGV
Herpes
Genital Warts
Trichomonas
HIV infection
AIDS
Urethral discharge
Vaginal discharge
Genital Ulcers
Hep B, Hepatitis B; LGV, Lymphogranuloma venereum.
Table 2 Cases of sexually transmitted infection (STI) reported by national STI programmes, LAC region, 2006
Country Syphilis
Congenital
syphilis Gonorrhoea Chlamydia HSV Condyloma
Urethral
discharge
Vaginal
discharge
Genital
ulcers Other Total
Argentina 672 579 4046 eee 26 510 ee 676 32 483
Bolivia ee e e ee 3841 e7504 e11 345
Brazil e5789 e e ee eeee 5789
Chile 2993 53 1313 e ee eeee 4359
Colombia 3000 773 1624 5226 2190 e eee 8312 21 125
Costa Rica 1040 96 1287 e ee eeee 2423
Cuba 1970 0 5660 ee4155 2423 87 024 e81 342 182 574
Ecuador 1885 110 2962 e1393 e2330 e2073 177 10 930
El Salvador 443 9 1086 e971 1018 eee 7535 11 062
Guatemala 234 5 eee700 682 e394 42315 44 330
Honduras 626 46 4366 11 998 355 1176 2250 e100 e20 917
Me
´xico 2562 78 1256 e1982 24 131 35 649 ee 801 66 459
Nicaragua 662 5 1558 ee892 eeee 3117
Panama
`e16 e e ee eeee 16
Paraguay 1065 220 eeee 42 5281 32 174 6814
Peru
´4521 517 790 719 ee 6117 e4391 e17 055
Dominican
R
ee e e ee eeee 0
Uruguay 1415 125 7 654 e31 31 eee 2263
Venezuela 3000 2 10000 20 000 10000 15 000 20 000 e18 000 e96 002
Total 26 088 8423 35 955 38 567 16 891 47 103 99 875 92 305 32 494 141 332 539 063
ii8 Sex Transm Infect 2011;87:ii7eii9. doi:10.1136/sextrans-2011-050177
Supplement
report screening for gonorrhoea. STI screening of pregnant
women is also common and includes syphilis and HIV testing.
STI screening for other groups is less common.
Dedicated STI services for specific populations are also
common in the LA region, and were reported by all countries
except Colombiadwhich provides no differentiated caredand
Argentinadwhich did not respond to the question. Female sex
workers are the most common beneficiaries of differentiated
services, although there are also services for male sex workers,
prisoners and truck drivers in some countries.
Antibiotic resistance and Neisseria gonorrhoeae
Only nine of the countries surveyed (47%) have implemented
surveillance of resistance of Neisseria gonorrhoeae strains to
antibiotics currently used. In the region, strains resistant to
penicillin and tetracycline are widely disseminated, and strains
with intermediate resistance to ciprofloxacin are also circulating.
Four countries, Chile, Costa Rica, Mexico and Panama, no longer
recommend ciprofloxacin for gonococcal infections; instead, the
current recommendation is ceftriaxone, which is much more
costly and logistically more difficult because it requires paren-
teral administration.
DISCUSSION
Under-reporting of STIs is extremely common in national STI
programmes in LA, and there is no regional consensus on what
STIs to report and how to report the STI data. STI syndromic
management is being used in all the countries surveyed, and
there are specialised clinics for STIs across LA, with different
types of clinicians (medical doctors with and without appro-
priate specialties and other health providers such as nurses and
midwives) offering STI management. This diversity represents
an important strength. However, costs and availability of
condoms differed between countries, and there are major issues
about partner notification. Services for different populations
such as sex workers (female and male), prisoners and truck
drivers have been implemented in some, but not all, countries.
The current state of STI control in LA shows that advances
have been made and that new and continuing challenges lie
ahead. There is great potential for learning from each other in
the LA region, to share lessons learnt, improve information and
surveillance systems, and move towards the provision of better
STI prevention and care services in the region.
Competing interests None.
Contributors PJG wrote the manuscript and contributed to the development of the
initial survey instrument and the analysis of the data presented. ASB contributed to
the development of the survey instrument and the writing of the manuscript. EG
designed and analysed the initial survey. Members of ALAC-ITS contributed data. All
listed authors contributed to the preparation of the manuscript.
Provenance and peer review Commissioned; externally peer reviewed.
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Table 3 Sexually transmitted infection (STI) screening and services
available for specific populations, LAC region, 2007
Female sex workers
Pregnant women
Men having sex with men
Military personnel
Prisoners
Female sex workers
Male sex workers
Prisoners
Truck drivers
Argentina
Bolivia
Brazil
Chile
Colombia
Costa Rica
Cuba
Ecuador
El Salvador
Guatemala
Honduras
México
Nicaragua
Panamá
Paraguay
Perú
Dominican R.
Uruguay
Venezuela
Dedicated Services
Country
Regular STI screening
Key messages
<STI control remains challenging in the Latin American (LA)
region.
<The increase in contraceptive use in LA (including condoms) is
not sufficient to decrease the risk of pregnancy due to
increased sexual activity, nor other risks associated with
unsafe sex and STIs.
<Under-reporting of STIs is extremely common in national STI
programmes in LA, and there is no regional consensus on
what or how STIs are reported.
<HIV reporting is similar across the countries studied, but STI
reporting is highly variable.
<STI syndromic management is used in all countries surveyed,
partner notification is low, and condom availability differed by
country.
PAGE fraction trail=3
Sex Transm Infect 2011;87:ii7eii9. doi:10.1136/sextrans-2011-050177 ii9
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... There are several factors that could explain lower overall self-reported gonorrhea diagnosis rates in Eastern Europe and Latin America in our analysis: lower diagnosis rates could possibly be explained by higher underreporting of STI due to a higher social desirability bias among respondents from these regions, less extragenital testing (which might not have been sufficiently controlled for because we are only able to control for rectal swabbing, not for pharyngeal swabbing), the use of less sensitive tests, and the more common adoption of a syndromic treatment approach [42]. A systematic review on curable STIs in the Americas published in 2015 states that there is "limited availability of reliable and inexpensive STI tests" and "of 18 reporting countries, 16 pursue syndromic management as their national policy" which supports our explanation that syndromic treatment and the use of less sensitive tests may indeed play a role. ...
... Despite widespread implementation of screening for asymptomatic NG/CT infections in MSM and subsequent treatment, there is currently no evidence for individual or public health benefits of these measures [48,49]. In any case, it would be sensible to push for evidence of individual and/or public health benefit from gonorrhea and chlamydia screening programs among MSM before attempting to implement such screening, especially in resource-constrained settings Likewise, low levels of self-reported diagnosed chlamydia in Central East and Southeast Europe, Central America and in the Philippines are possibly explained by less chlamydia-specific (extragenital) testing and/or less sensitive chlamydia tests, and more syndromic treatment of symptomatic infections [42,50]. ...
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Background Men who have sex with men (MSM) are in general more vulnerable to sexually transmitted infections (STIs) than the heterosexual men population. However, surveillance data on STI diagnoses lack comparability across countries due to differential identification of MSM, diagnostic standards and methods, and screening guidelines for asymptomatic infections. Methods We compared self-reported overall diagnostic rates for syphilis, gonorrhea, and chlamydia infections, and diagnostic rates for infections that were classified to be symptomatic in the previous 12 months from two online surveys. They had a shared methodology, were conducted in 68 countries across four continents between October 2017 and May 2018 and had 202,013 participants. Results Using multivariable multilevel regression analysis, we identified age, settlement size, number of sexual partners, condom use for anal intercourse, testing frequency, sampling rectal mucosa for extragenital testing, HIV diagnosis, and pre-exposure prophylaxis use as individual-level explanatory variables. The national proportions of respondents screened and diagnosed who notified some or all of their sexual partners were used as country-level explanatory variables. Combined, these factors helped to explain differences in self-reported diagnosis rates between countries. The following differences were not explained by the above factors: self-reported syphilis diagnoses were higher in Latin America compared with Europe, Canada, Israel, Lebanon, and the Philippines (aORs 2.30 – 3.71 for symptomatic syphilis compared to Central-West Europe); self-reported gonorrhea diagnoses were lower in Eastern Europe and in Latin America compared with all other regions (aORs 0.17-0.55 and 0.34 - 0.62 for symptomatic gonorrhea compared to Central-West Europe); and self-reported chlamydia diagnoses were lower in Central East and Southeast Europe, South and Central America, and the Philippines (aORs 0.25 - 0.39 for symptomatic chlamydia for Latin American subregions compared to Central West Europe). Conclusions Possible reasons for differences in self-reported STI diagnosis prevalence likely include different background prevalence for syphilis and syndromic management without proper diagnosis, and different diagnostic approaches for gonorrhea and chlamydia.
View
... A survey conducted in 1998 -99 reported that PN at that time was not part of STI case management in France, Spain, and Italy [28], indicating large cultural differences regarding the practice of STI PN in Europe. Garcia et al. reported in an overview on STI management and control in Latin America that PN rates in Latin America are usually low [29]. Given historically determined differences across countries, it is important to update geo-cultural determinants as well. ...
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Background Partner notification (PN) after a sexually transmitted infection (STI) diagnosis is being promoted as a means to interrupt transmission chains. We investigated whether Internalised Homonegativity (IH) is associated with PN among men having sex with men (MSM). Methods PN, defined as notifying at least one partner after diagnosis of syphilis and gonorrhoea, was queried in two internet-based self-completion surveys conducted between Oct 2017 and May 2018 in 68 countries in Europe, Latin America, Canada, and the Philippines. IH is defined by a man’s level of agreement or disagreement with negative social beliefs about male homosexuality. Covariates included in a multivariate regression model with a random intercept at country level were age, HIV diagnosis, partnership status, sexual self-efficacy, HIV serostatus communication during last sex with a non-steady partner, place where this partner was met, and PN-related socio-historical background of the country of residence. We grouped countries in three areas: North- and Central-Western European countries plus Canada, former socialist countries, and Latin-American/Mediterranean countries plus the Philippines. In each of the three areas individuals were assigned to 4 subgroups based on IH quartiles and PN rates were determined for each subgroup. Results PN rates were calculated for 49 countries (excluding countries with less than 10 diagnoses). Mean proportions of MSM notifying their partners were 68.1% and 72.9% after syphilis and gonorrhoea diagnoses, respectively. PN rates were lower in Latin American countries and the Philippines compared to European countries. Within Europe, a North–South divide with lower PN rates in Mediterranean countries was observed. In each of the three regions we mostly observed a stepwise increase of PN rates with decreasing IH. Regression analysis showed lower IH scores associated with higher PN rates. Higher perceived self-efficacy, living in a partnership, and HIV status communication were positively associated with PN. Men who had met their last partner in a gay social venue were more likely to have notified their partners of a syphilis diagnosis compared to men who had met this partner online. Men with diagnosed HIV were less likely to report PN. Conclusions We could demonstrate that IH was associated with PN among MSM across all countries included in our analysis. Reducing cultural homophobia and ensuring inclusive policies may contribute to STI prevention and control.
View
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View
... O screening para a infecção gonocócia deve ser realizado para as mulheres de risco: idade inferior a 25 anos, história prévia de gonorréia, outras DST, múltiplos parceiros sexuais ou novo parceiro, parceiro com múltiplas parceiras ou que apresenta alguma DST, não uso de preservativo e usuárias de drogas 6,9 . 3) Cultura endocervical 7 dias após o tratamento (avaliar cura) 1 . Se for utilizado um métido de biologia molecular, repetir o exames após 30 dias. ...
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... Several studies have evaluated the association between the EOSI and STIs, early pregnancies, abortions, and long-term sexual consequences (40). However, to the best of our knowledge, no such studies have been conducted in Latin America, a region where the control of STIs is a persisting challenge (41). In this study, we determined that the EOSI increases the prevalence of STIs by 27% in women of childbearing age compared with those who report initiating sexual activities after the age of 15 years. ...
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Article
Full-text available
People who use crack cocaine (PWUCC) are a population severely impacted by a concentrated epidemic of HIV. Behavioral interventions to prevent and treat HIV among PWUCC have been implemented around the world including in low- and middle-income countries which have been disproportionately affected by HIV. However, few studies have validated and assessed psychometric properties of measures on PWUCC, especially in transnational populations. Our sample was comprised of 1324 PWUCC, Spanish mono-lingual speakers, residing in the metropolitan area of San Salvador, El Salvador. Exploratory factor analysis and subsequent confirmatory factor analysis using statistical softwares SPSS and Amos were conducted on three abbreviated and translated condom use attitude measures (i.e., Condom Use Attitudes Scale—Spanish Short Form, Condom Use Social Norm—Spanish Short Form [CUSN-SSF], Condom Use Self-Efficacy—Spanish Short Form). Convergent validity was examined by computing bivariate correlations between the scales and condom use and sexually transmitted disease diagnosis. Results indicated that a two-factor, 8-item correlated model for the CUAS-SSF scale had an excellent fit and adequate reliability (α = .76). The confirmatory factor analysis for the 5-item CUSN-SSF scale indicated a satisfactory fit with 3 of 6 fit indices indicating adequate fit. Analysis of the two-factor 5-item CUSE-SSF scale indicated satisfactory fit and adequate reliability (α = .84). There were significant correlations between all measures and with self-reported condom use. Results indicate that these brief measures are reliable and valid and can be utilized to assess the effectiveness of HIV risk reduction interventions among Spanish-speaking PWUCC.
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... However, scant information is available about the incidence of STIs among MSWs in Mexico City. This is partly due to underreporting of STIs in Latin American countries, including Mexico, because national STI programs lack consistency about which STIs are reportable by law, and definitions of these STIsclinical versus syndromic versus laboratory based [8]. Information is also limited because MSWs are a highly vulnerable and stigmatized population, leading few MSWs to openly disclose their occupation as sex workers [9,10]. ...
Incidence and time-varying predictors of HIV and sexually transmitted infections among male sex workers in Mexico City
Article
Full-text available
  • Dec 2021
Background Male sex workers are at high-risk for acquisition of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). We quantified incidence rates of STIs and identified their time-varying predictors among male sex workers in Mexico City. Methods From January 2012 to May 2014, male sex workers recruited from the largest HIV clinic and community sites in Mexico City were tested for chlamydia, gonorrhea, syphilis, hepatitis, and HIV at baseline, 6-months, and 12-months. Incidence rates with 95% bootstrapped confidence limits were calculated. We examined potential time-varying predictors using generalized estimating equations for a population averaged model. Results Among 227 male sex workers, median age was 24 and baseline HIV prevalence was 32%. Incidence rates (per 100 person-years) were as follows: HIV [5.23; 95% confidence interval ( CI ): 2.15–10.31], chlamydia (5.15; 95% CI : 2.58–9.34), gonorrhea (3.93; 95% CI : 1.88–7.83), syphilis (13.04; 95% CI : 8.24–19.94), hepatitis B (2.11; 95% CI : 0.53–4.89), hepatitis C (0.95; 95% CI : 0.00–3.16), any STI except HIV (30.99; 95% CI : 21.73–40.26), and any STI including HIV (50.08; 95% CI : 37.60–62.55). In the multivariable-adjusted model, incident STI (excluding HIV) were lower among those who reported consistently using condoms during anal and vaginal intercourse (odds ratio = 0.03, 95% CI : 0.00–0.68) compared to those who reported inconsistently using condoms during anal and vaginal intercourse. Conclusions Incidence of STIs is high among male sex workers in Mexico City. Consistent condom use is an important protective factor for STIs, and should be an important component of interventions to prevent incident infections.
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The association between non-viral sexually transmitted infections and pregnancy outcome in Latin America and the Caribbean: A systematic review
Article
  • Dec 2023
Introduction Non-viral sexually transmitted infections are known to be associated with adverse pregnancy outcomes. For these pathogens, standard antenatal screening is not broadly performed in Latin America and the Caribbean. The aim of this study was to comprehensively review the association of non-viral sexually transmitted infections and neonatal outcomes among pregnant women in the region. Methods Four databases (PubMed, Embase, SciELO and LILACS) were examined to identify eligible studies published up to September 2022. English or Spanish cross-sectional, case-control and cohort studies assessing the association of non-viral sexually transmitted infections and adverse pregnancy outcomes were evaluated. Articles were firstly screened by means of title and abstract. Potential articles were fully read and assessed for inclusion according to the eligibility criteria. Snowballing search was performed by screening of bibliographies of the chosen potentially relevant papers. Risk of bias within studies was assessed using the Joanna Briggs Institute reviewer's manual. Results A selection of 10 out of 9772 search records from five Latin America and the Caribbean countries were included. Six studies associated Treponema pallidum infection with preterm birth (1/6), history of previous spontaneous abortion (2/6), fetal and infant death (1/6), low birth weight (1/6) and funisitis of the umbilical cord (1/6). Three studies associated Chlamydia trachomatis infection with preterm birth (2/3), ectopic pregnancy (1/3) and respiratory symptoms on the newborn (1/3). One study associated Mycoplasma genitalium infection with preterm birth. Conclusion This review provides evidence on the association of non-viral sexually transmitted infections with adverse pregnancy outcomes. Further investigation is needed to establish more associations between non-viral sexually transmitted infections and pregnancy outcome, especially for Mycoplasma genitalium, Trichomonas vaginalis and Neisseria gonorrhoeae. Overall, this review calls for more research for public health interventions to promote screening of non-viral sexually transmitted infections during pregnancy, among high-risk population groups of pregnant women living in the region.
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High prevalence of rectal chlamydia among pregnant adolescents in La Romana, Dominican Republic warrants extragenital STI testing
Article
  • Sep 2021
To our knowledge, there are no studies estimating the prevalence of extragenital sexually transmitted infections (STIs) among pregnant adolescents in the Caribbean. This study sought to fill this gap by assessing the prevalence and correlates of oral, genital, and rectal chlamydia (CT) among a sample of pregnant adolescents in La Romana, Dominican Republic. Two hundred pregnant youths, aged 15–24 years, were recruited by systematic sampling during their first prenatal visit to a maternal care unit. A sociodemographic and behavioral questionnaire was administered and urine and oral/anal swabs were collected and tested for CT. Descriptive analyses and Fisher’s exact tests were performed. The prevalence of oral, genital, and rectal CT was 6%, 15%, and 23%, respectively, although less than 5% of participants reported ever engaging in receptive anal intercourse. This discrepancy could be explained by autoinoculation, concurrent transmission during sex, undertreatment of rectal CT, or underreporting of anal sex. Almost half of CT infections would have been missed if only genital samples were collected, as current protocol dictates. More research is needed to understand sexual behaviors and rectal STI risk factors among heterosexual adolescent women. STI screening procedures for pregnant and sexually active adolescents should include routine testing of extragenital sites.
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Incidence and Time-Varying Predictors of HIV and Sexually Transmitted Infections Among Male Sex Workers in Mexico City
Preprint
Full-text available
  • Aug 2020
Background: Male sex workers are at high-risk for acquisition of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). We quantified incidence rates of STIs and identified their time-varying predictors among male sex workers in Mexico City. Methods: From January 2012 to May 2014, Male sex workers recruited from the largest HIV clinic and community sites in Mexico City were tested for chlamydia, gonorrhea, syphilis, hepatitis, and HIV at baseline, 6-months, and 12-months. Incidence rates with 95% bootstrapped confidence limits were calculated. We examined potential time-varying predictors using generalized estimating equations for a population averaged model. Results: Among 227 male sex workers, median age was 24 and baseline HIV prevalence was 32%. Incidence rates (per 100 person-years) were as follows: HIV [5.23; 95% confidence interval (CI): 2.15–10.31], chlamydia (5.15; 95% CI: 2.58–9.34), gonorrhea (3.93; 95% CI: 1.88–7.83), syphilis (13.04; 95% CI: 8.24–19.94), hepatitis B (2.11; 95% CI: 0.53–4.89), hepatitis C (0.95; 95% CI: 0.00–3.16), any STI except HIV (30.99; 95% CI: 21.73–40.26), and any STI including HIV (50.08; 95% CI: 37.60–62.55). In the multivariable-adjusted model, incident STI (excluding HIV) were lower among those who reported consistently using condoms during anal and vaginal intercourse (odds ratio = 0.03, 95% CI: 0.00–0.68) compared to those who reported inconsistently using condoms during anal and vaginal intercourse. Conclusions: Incidence of STIs is high among male sex workers in Mexico City. Consistent condom use is an important protective factor for STIs, and should be an important component of interventions to prevent incident infections.
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Situación de la sífilis en 20 países de Latinoamérica y el Caribe: Año 2006
Article
Full-text available
  • Jan 2007
Introducción: Las infecciones de transmisión sexual, en especial a sífilis, se encuentran entre las principales causas de enfermedad en el mundo y en la mayoría de los países de la América Latina. Objetivo: realizar una exploración de la situación de la sífilis y la sífilis congénita en los países de la región y disponer de una aproximación a la situación epidemiológica actual y sus tendencias. Métodos: se realizó un estudio de corte transversal y para la obtención de los datos se diseño una encuesta que fue validada en el mes de diciembre del 2007 y enviada posteriormente a los coordinadores de programas nacionales de 20 países de la región. El periodo de ejecución y llenado de la información transcurrió entre enero y febrero del 2008 y se solicitó información de los últimos cuatro años (periodo 2003 - 2007). Resultados: todos los países poseen servicios de Vigilancia Epidemiológica y en la mayoría de ellos la sífilis total y congénita son enfermedades de notificación obligatoria. Existen, al menos, 10 países cuyas tasas de incidencia de sífilis congénita están por encima de 0,5 X 1.000 Nacidos vivos a pesar de que la subnotificación de casos en la región es grande. Latinoamérica y Caribe notifican en el 2006 un pequeño porcentaje del total de los casos de sífilis y sífilis congénita que la OMS/OPS estima ocurren en el área y según la opinión de los jefes de programas y expertos nacionales la tendencia de estas infecciones en la mitad de los países de la región es al aumento o desconocida. Conclusión: La sífilis congénita continúa siendo un serio problema de salud en la región. La información disponible sobre sífilis en términos de incidencia, prevalencia, tendencias, prioridades de intervención, coberturas de atención a grupos vulnerables, disponibilidad de recursos humanos y materiales es insuficiente en muchos países. Se observa en la región la existencia de oportunidades para el desarrollo de trabajo colaborativo conjunto entre los países miembros.-
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Estimating the number of men who have sex with men in low and middle income countries
Article
Full-text available
  • Jul 2006
To collect and analyse published and unpublished surveillance and research data on the prevalence of same sex sexual activity among male adults (including male-to-female transgenders and sex workers) in low and middle income countries. Key indicators were operationalised (ever sex with a man, sex with a man last year, high risk sex last year (as defined by unprotected anal sex or commercial sex)) and a database was designed for data collection. Searches were conducted (PubMed, databases (US Census Bureau, World Bank, conferences)) and regional informants helped. Reference reports were used to assess the methodology and quality of information in each record. The best data available per region were identified and indicator estimates were used to propose regional range estimates. Of 561 studies on male sexual behaviour and/or MSM population characteristics, 67 addressed prevalence of sex between men, with diverse numbers per region and virtual unavailability in sub-Saharan Africa, Middle East/North Africa, and the English speaking Caribbean. Overall, data on lifetime prevalence of sex with men (among males) yielded figures of 3-5% for East Asia, 6-12% for South and South East Asia, 6-15% for Eastern Europe, and 6-20% for Latin America. Last year figures were approximately half of lifetime figures, and prevalence of high risk sex among MSM last year was approximately 40-60% in all regions except South Asia, where it is 70-90%. Data available on the prevalence of male same sex sexual activity across regions are scarce (non-existent in some areas), with validity and comparability problems. In South and South East Asia, Eastern Europe, and Latin America, a lifetime prevalence of 6-20% was estimated, with smaller figures in East Asia. A cross cultural analysis of terminology and practices is needed, as is continued work on epidemiological and social analysis of male-male sexual practices in societies across regions.
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Sexually transmitted and reproductive tract infections in symptomatic clients of pharmacies in Lima, Peru
Article
Full-text available
  • Apr 2007
To determine prevalences and predictors of sexually transmitted and reproductive tract infections among men and women seeking care at pharmacies. Men and women with urethral discharge or dysuria and vaginal discharge were enrolled at 12 central and 52 smaller pharmacies in Lima, Peru. All participants answered a questionnaire. Men provided urine for polymerase chain reaction (PCR) testing for Neisseria gonorrhoeae and Chlamydia trachomatis, and for leucocyte esterase testing. Women provided self-obtained vaginal swabs for PCR testing for N gonorrhoeae and C trachomatis, Trichomonas vaginalis culture and bacterial vaginosis and Candida. Among 106 symptomatic men, N gonorrhoeae and C trachomatis were detected in 34% and were associated with urethral discharge compared with dysuria only (odds ratio (OR) 4.3, p = 0.003), positive urine leucocyte esterase testing (OR 7.4, p = 0.009), less education (OR 5.5, p = 0.03), and with symptoms for <5 days (OR 2.5, p = 0.03). Among 121 symptomatic women, 39% had bacterial vaginosis or T vaginalis, and 7.7% had candidiasis. N gonorrhoeae and C trachomatis were detected in 12.4% of the women. Overall, 48.8% had one or more of these infections. No factors were associated with vaginal infection, and only symptoms of vaginal discharge for <5 days were associated with N gonorrhoeae and C trachomatis (OR 4.0, p = 0.02). The main reason reported for seeking advice at pharmacies by both men and women was trust in pharmacy workers. Among men and women presenting to pharmacies with urethral and vaginal symptoms, rates of urethral and vaginal infections were comparable to those found in other clinical settings. Pharmacies can contribute to the care and prevention of sexually transmitted infection in developing countries.
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Review article. Private health care provision in developing countries: a preliminary analysis of levels and composition
Article
  • Sep 1998
  • HEALTH POLICY PLANN
While the importance of the private sector in providing health services in developing countries is now widely acknowledged, the paucity of data on numbers and types of providers has prevented systematic cross-country comparisons. Using available published and unpublished sources, we have assembled data on the number of public and private health care providers for approximately 40 countries. This paper presents some results of the analysis of this database, looking particularly at the determinants of the size and structure of the private health sector. We consider two different types of dependent variable: the absolute number of private providers (measured here as physicians and hospital beds), and the public-private composition of provision. We examine the relationship between these variables and income and other socioeconomic characteristics, at the national level. We find that while income level is related to the absolute size of the private sector, the public-private mix does not seem to be related to income. After controlling for income, certain socioeconomic characteristics, such as education, population density, and health status are associated with the size of the private sector, though no causal relationship is posited. Further analysis will require more complete data about the size of the private sector, including the extent of dual practice by government-employed physicians. A richer story of the determinants of private sector growth would incorporate more information about the institutional structure of health systems, including provider payment mechanisms, the level and quality of public services, the regulatory structure, and labour and capital market characteristics. Finally, a normative analysis of the size and growth of the private sector will require a better understanding of its impact on key social welfare outcomes.
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Summary of proceedings of the IUSTI Global Challenges Symposium (ISSTDR 2007/10th IUSTI World Congress)
Article
  • Mar 2009
Working in our own geographical areas it can be easy to take a parochial view of sexually transmitted infection (STI) management and control. But although the problems and challenges faced by STI physicians vary enormously around the world there are also common themes which can benefit from a common approach. By understanding how health services in different regions identify and address STI control we can contribute and improve our local services and contribute to the development of global STI care. At the 17th conference of the International Society for Sexually Transmitted Disease Research (ISSTDR) in Seattle a symposium on Global Challenges was organized by the International Union against STIs (IUSTI) to provide feedback from physicians around the world on what they consider to be their greatest challenges. Moderated by Angelika Stary and Kit Fairley the symposium included contributions from North and South America Africa Europe and Asia-Pacific regions. In this article the speakers have summarized their talks and provide an insight into the many challenges facing global STI control today. (excerpt)
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Male midwives: Preferred managers of sexually transmitted infections in men in developing countries?
Article
  • Nov 2008
  • REV PANAM SALUD PUBL
To describe demographic and practice characteristics of male and female midwives in private practice (MIPPs) in 10 cities of Peru, and their role in the delivery of reproductive health care, specifically management of sexually transmitted infections (STIs). As part of an intervention trial in 10 cities in the provinces of Peru designed to improve STI management, detailed information was collected regarding the number of midwives in each city working in various types of practices. A door-to-door survey of all medical offices and institutions in each city was conducted. Each MIPP encountered was asked to answer a questionnaire regarding demographics, training, practice type(s), number of STI cases seen per month, and average earnings per consultation. Of the 905 midwives surveyed, 442 reported having a private practice, either exclusively or concurrently with other clinical positions; 99.3% of these MIPPs reported managing STI cases. Andean cities had the highest density of MIPPs, followed by jungle and coastal cities, respectively. Jungle cities had the largest proportion of male MIPPs (35.5%). While both male and female MIPPs reported seeing male patients, male MIPPs saw a significantly greater number than their female counterparts. In areas of Peru where physicians are scarce, MIPPs provide needed reproductive health services, including STI management. Male MIPPs in particular appear to serve as health care providers for male patients with STIs. This trend, which may exist in other developing countries with similar healthcare workforce demographics, highlights the need for new areas of training and health services research.
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Private health care provision in developing countries: a preliminary analysis of levels and composition
Article
  • Oct 1998
While the importance of the private sector in providing health services in developing countries is now widely acknowledged, the paucity of data on numbers and types of providers has prevented systematic cross-country comparisons. Using available published and unpublished sources, we have assembled data on the number of public and private health care providers for approximately 40 countries. This paper presents some results of the analysis of this database, looking particularly at the determinants of the size and structure of the private health sector. We consider two different types of dependent variable: the absolute number of private providers (measured here as physicians and hospital beds), and the public-private composition of provision. We examine the relationship between these variables and income and other socioeconomic characteristics, at the national level. We find that while income level is related to the absolute size of the private sector, the public-private mix does not seem to be related to income. After controlling for income, certain socioeconomic characteristics, such as education, population density, and health status are associated with the size of the private sector, though no causal relationship is posited. Further analysis will require more complete data about the size of the private sector, including the extent of dual practice by government-employed physicians. A richer story of the determinants of private sector growth would incorporate more information about the institutional structure of health systems, including provider payment mechanisms, the level and quality of public services, the regulatory structure, and labour and capital market characteristics. Finally, a normative analysis of the size and growth of the private sector will require a better understanding of its impact on key social welfare outcomes.
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STD trends and patterns of treatment for STD by physicians in private practice in Peru
Article
  • Nov 2003
To describe trends in STD visits to physicians in private practice in Peru over a 15 year period and in the patterns of treatments used for STD. IMS Health conducts for pharmaceutical marketing purposes surveys of a random cluster sample of 1.63% of practising physicians in Peru, stratified by region and specialty. Physicians record details of diagnoses and treatments for all patients seen during a 7 day period every 6 months. Data collected on selected STD syndromes were retrospectively reviewed over a 15 year period. The number of first visits for pelvic inflammatory disease (PID) and trichomoniasis, and total visits for genital herpes increased from 1983-5 to 1996-7; while first visits for gonorrhoea and total visits for syphilis have changed little in recent years. Treatment for gonorrhoea usually involved the use of spectinomycin or an aminoglycoside only. Treatments offered for PID were remarkably inadequate and for trichomoniasis often involved products not known to be effective for trichomoniasis or other causes of vaginal discharge. This form of active surveillance provides information potentially useful to guide policies for prevention and management of STDs and HIV infections in developing countries.
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Sexual and reproductive behaviour among single women aged 15-24 in eight Latin American countries: A comparative analysis
Article
  • Apr 2005
A comparative analysis of exposure to sexual activity, contraceptive use, conceptions, and pregnancy resolutions among single women aged 15-24 in eight Latin American countries is presented. Using data from Demographic and Health Surveys complete contraceptive and reproductive histories are constructed for single women aged 15-24 during the 5 year period preceding each survey. Pre-marital conception rates and overall and cause-specific life-table probabilities of contraceptive discontinuation are estimated. Pregnancy outcome and intention status of births are summarized. Trends in virginity, contraceptive protection, and conception rates for five sites are documented. In all eight countries, virginity accounts for over half of all single woman-years of exposure between age 15 and 24. The percentage of sexually active time protected by contraception is less than 20% in five countries, is about 30% in Peru and 50% in Brazil and Colombia. The contribution of condoms to contraceptive protection ranges from one-tenth to one-fifth. Pre-marital conception rates among sexually active single women range from 14.1 per 100 woman-years in Nicaragua to 25.8 in Bolivia. Most pre-marital conceptions ended in live birth, and births that are legitimized by marriage or cohabitation are more likely to be wanted. In five settings, virginity has fallen over time, especially in Northeast Brazil and Colombia, and uptake of condoms has increased faster than use of other methods. Because of pervasive declines in the protective effect of virginity, conception rates among single women in Latin America are rising. Contraceptive uptake, particularly of condoms, is increasing but not sufficiently to offset the decline in virginity.
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