Screening for Sexually Transmitted Infections in Adolescent Girls and Young Women in Mombasa, Kenya: Feasibility, Prevalence, and Correlates

Abstract

Introduction:
As adolescents and young women become sexually active, they are at risk of adverse reproductive health outcomes including sexually transmitted infections (STIs). We assessed feasibility and acceptability of STI screening among 15- to 24-year-old women in Mombasa, Kenya.

Methods:
After sensitization activities, participants were recruited from 3 high schools and 1 university. Study staff conducted informational sessions. Students interested in participating were given consent forms to take home, and invited to visit our clinic for STI screening. During clinic visits, participants completed a self-administered questionnaire and provided a urine specimen for STI testing using a nucleic acid amplification test.

Results:
Between August 2014 and March 2015, 463 high school and 165 university students collected consent forms. Of these, 293 (63%) from high schools versus 158 (95%) from university attended clinic for STI screening (P < 0.001). Of the 150 (33%) who reported any history of insertive vaginal sex, 78 (52.0%) reported condom use at the last sex act, 31 (20.7%) reported using modern nonbarrier contraceptive methods, and 37 (24.7%) reported not using any contraception at the last sex act. Twenty-six (5.8%) participants were diagnosed with STIs (7 [1.6%] Neisseria gonorrhoeae, 16 [3.6%] Chlamydia trachomatis, 3 [0.7%] Trichomonas vaginalis). In multivariable analyses, reporting receptive vaginal sex without a condom was associated with having a laboratory confirmed STI (odds ratio, 6.21; 95% confidence interval, 1.72-22.28).

Conclusions:
These findings support the need for reproductive health interventions to reduce the risk of STIs in a population of adolescent girls and young women in East Africa.

Full text

Screening for Sexually Transmitted Infections in
Adolescent Girls and Young Women in Mombasa,
Kenya: Feasibility, Prevalence, and Correlates
Linnet N. Masese, MBChB, MPH, PhD,* George Wanje, BA, MPH,†Emmanuel Kabare, BSc,†
Valentine Budambula, PhD,‡Francis Mutuku, PhD,‡Grace Omoni, MSc, PhD,§
Anisa Baghazal, MBChB, MPH,¶
Barbra A. Richardson, PhD,||**†† and R. Scott McClelland, MD, MPH*†||‡‡
Introduction: As adolescents and young women become sexually active,
they are at risk of adverse reproductive health outcomes including sexually
transmitted infections (STIs). We assessed feasibility and acceptability of
STI screening among 15- to 24-year-old women in Mombasa, Kenya.
Methods: After sensitization activities, participants were recruited from
3 high schools and 1 university. Study staff conducted informational ses-
sions. Students interested in participating were given consent forms to take
home, and invited to visit our clinic for STI screening. During clinic visits,
participants completed a self-administered questionnaire and provided a
urine specimen for STI testing using a nucleic acid amplification test.
Results: Between August 2014 and March 2015, 463 high school and 165
university students collected consent forms. Of these, 293(63%) from high
schools versus 158 (95%) from university attendedclinic for STI screening
(P< 0.001). Of the 150 (33%) who reported any history of insertive vag-
inal sex, 78 (52.0%) reported condom use at the last sex act, 31 (20.7%)
reported using modern nonbarrier contraceptive methods, and 37 (24.7%)
reported not using any contraception at the last sex act. Twenty-six (5.8%)
participants were diagnosed with STIs (7 [1.6%] Neisseria gonorrhoeae,
16 [3.6%] Chlamydia trachomatis, 3 [0.7%] Trichomonas vaginalis). In
multivariable analyses, reporting receptive vaginal sex without a condom
was associated with having a laboratory confirmed STI (odds ratio, 6.21;
95% confidence interval, 1.72–22.28).
Conclusions: These findings support the need for reproductive health
interventions to reduce the risk of STIs in a population of adolescent girls
and young women in East Africa.
Adolescence and young adulthood represent unique life transi-
tions. As adolescents and young women become sexually ac-
tive, they are at risk for adverse reproductive health outcomes
including unwanted pregnancy and sexually transmitted infections
(STIs).
1,2
There is a need to develop and tailor existing reproduc-
tive health services to meet the needs of this important population.
Improving health at this crucial stage holds potential to impact the
health of adolescents, young adults, and their future children.
3
Chlamydia trachomatis, Neisseria gonorrhoeae, and Trich-
omonas vaginalis cause the majority of treatable STIs worldwide.
4
These STIs have been associated with pelvic inflammatory dis-
ease, infertility, ectopic pregnancy, chronic pelvic pain and adverse
pregnancy outcomes.
5–9
In addition, these STIs have been shown
to increase the risk of HIV acquisition.
10–12
Sub-Saharan Africa bears 80% to 90% of the global STI
burden.
13
Although STIs are a growing concern in the region, rel-
atively few studies have characterized their epidemiology, owing
to limited laboratory infrastructure and diagnostic capacity. We
sought to explore the feasibility of school-based recruitment for
STI screening in female adolescents (age, 15–17 years) and young
women (age, 18–24 years), and to characterize the prevalence and
correlates of STIs in this population.
METHODS
We conducted a cross-sectional study among 15 to 24 year
olds recruited from 3 high schools and 1 university in Mombasa
County, Kenya. Ethical approval was obtained from the ethics
committees at the University of Nairobi/Kenyatta National Hospi-
tal and University of Washington.
Procedures for this study were developed after a formative
qualitative phase that included adolescent girls, young women,
parents, and teachers.
14
At the beginning of the STI screening
phase, study staff visited the institutions to introduce the study
and answer questions from students. After these information ses-
sions, interested students were given the informed assent/consent
forms to take home. Adolescents younger than 18 years were
encouraged to discuss the study with their parents or guardians.
Students were invited to visit the research clinic for STI
From the *Department of Medicine, University of Washington, Seattle,
WA; †University of Nairobi Institute of Tropical & Infectious Disease
(UNITID), Nairobi; ‡Department of Environment and Health Sciences,
Technical University of Mombasa, Mombasa; §School of Nursing
Sciences, University of Nairobi, Nairobi; ¶Mombasa County Depart-
ment of Health, Mombasa, Kenya; ||Department of Global Health,
**Biostatistics, University of Washington; ††Vaccine and Infectious
Disease Division, Fred Hutchinson Cancer Research Center; and ‡‡De-
partment of Epidemiology, University of Washington, Seattle, WA
Acknowledgements: The authors would like to thank Mombasa County for
working with us on this project. The authors appreciate the support that
they received from the 4 institutions that allowed us to work with their
students and staff. In particular, the authors thank the teachers and in-
structors who facilitated the study and the students who enthusiastically
volunteered to participate.
Funding:This research was funded by a 2011 developmental grant from
the University of Wa shington Global Center for Integrated Heal th of
Women, Adolescents, and Children (Global WACh). One of the authors
received training support from the Fogarty International Center (NIH
5D43-TW000007 to LM). Infrastructure and logistical support for the
Mombasa Field Site were received from the University of Washington
& Fred Hutchinson Cancer Research Center’s Center for AIDS
Research (grant number P30-AI-27757). The funders had no role in
study design, data collection and analysis, decision to publish, or
preparation of the manuscript.
This work was presented in part at the World STI & HIV Congress 13-16th
September, 2015, Brisbane, Australia. Poster P03.19.
Competing Interests: RSM receives research funding from Hologic
Corporation, which is paid as a grant to the University of Washington.
Correspondence: Linnet Masese, MBChB, MPH, PhD, University of
Washington, HMC Box 359909, 325 9th Avenue, Seattle, WA
98104-2499. E‐mail: linnet@uw.edu.
Received for publication February 13, 2017, and accepted June 3, 2017.
DOI: 10.1097/OLQ.0000000000000674
Copyright © 2017 American Sexually Transmitted Diseases Association
All rights reserved.
ORIGINAL STUDY
Sexually Transmitted Diseases •Volume 00, Number 00, Month 2017 1
Copyright © 2017 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.

screening. For minors (<18 years old), written parental consent
was required in addition to participant assent.
At the clinic visit, a brief self-administered questionnaire
was administered to ascertain demographic data, obstetrical and
gynecological history, and sexual risk behavior. Participants were
asked to provide a 20- to 30-mL first-catch urine specimen. Two
milliliters of urine were transferred into a specimen tube (Hologic,
San Diego, CA), and transported to the laboratory. Results were
provided to participants after 1 week. In the event of a positive test
result, treatment was provided to participants and sexual partners
at no charge, following Kenyan National Guidelines for treatment
of STIs.
Laboratory Methods
Urine samples were tested for C. trachomatis, N. gonorrhoeae,
and T. vaginalis by transcription mediated amplification using the
Hologic Aptima Detection System (Hologic). Testing was performed
at the University of Washington/University of Nairobi HIV &
STD Research Laboratory in Mombasa.
Statistical Methods
The outcome of this study was laboratory confirmed STI
(composite variable of the 3 tested STIs). Potential correlates in-
cluded age, marital status (single or married), religion (Muslim vs
Christian), parity, reporting receptive vaginal sex (none, receptive
sex with condom, receptive sex without a condom), anal sex
(yes, no), nonpenetrative sex (yes, no), reported substance use
(alcohol, tobacco, Catha edulis [khat], Cannabis sativa [marijuana],
polysubstance use), prior STI diagnosis, and sexual reproductive
health education (ever taught about STIs in school, ever taught about
HIV/AIDS in school, and sexual health discussion with parents/
guardians). Nonpenetrative sex was defined as sexual activity that
does not involve penetration of the vagina or anus. Polysubstance
use was defined as reporting the use of more than 1 drug. For com-
parability to earlier work, we used questions from the US Centers
for Disease Control and Prevention youth risk behavior surveil-
lance system. The main explanatory sex risk variable, "Receptive
Vaginal Intercourse”was an independent variable in response to
the question, "The last time you had vaginal sexual intercourse,
did you or your partner use a condom?”Possible responses in-
cluded: (a) I have never had vaginal intercourse, (b) Yes [we used
a condom], and (c) No [we did not use a condom]. We used this
variable to identify women who had never had vaginal intercourse
(response “a”to this question).
We used logistic regression to determine correlates of
having any STI. First, potential predictors of STIs were assessed
in bivariable analyses. Variables associated with any STI (α≤0.10)
in the bivariable analysis were included in the final multivariable
model, which was assessed for collinearity. Because condomless
sex could be in the causal pathway linking substance use to STI,
adjusting for condomless sex could mask a true association between
substance use and STI. Therefore, we explored the association be-
tween substance use and STI in a model that excluded condomless
sex but retained other potential confounding factors. In addition,
we conducted sensitivity analyses limited to participants who re-
ported being sexually active. In these analyses, we included sexual
risk behavior predictors that were only collected among those who
reported being sexually active: age at sexual debut, numberof life-
time sex partners, number of sex partners in the last 3 months, al-
cohol or drugs before last sex act, and condom use at last sex act.
Analyses were performed using IBM SPSS 19.0 (IBM, Kirkland,
WA) and STATA 12 (StataCorp, College Station, TX).
RESULTS
Between August 2014 and March 2015, 463 high school
and 165 university students collected consents during the informa-
tional sessions as illustrated in the flow diagram (Fig. 1). Of these,
293 (63.3%) from high schools versus 158 (95.8%) from universi-
ties attended the clinic for STI screening (P<0.001).
Median age of the 451 participants was 18 years (interquar-
tile range, 17–19 years), with 195 (43.2%) being below 18 years
(Table 1). One hundred fifty (33.3%) reported ever having
receptive vaginal sex. Most reported being 17 years older at first
sex (N = 120, 80.0%). About half reported only 1 lifetime sexual
partner (N = 76, 50.7%). Anal intercourse was rarely reported
(10 students, 2.2%). Nonpenetrative sex was reported by 107
(23.7%) students. Of the 150 students reporting vaginal sex, 78
(52.0%) reported condom use, 31 (20.7%) reported using
modern nonbarrier contraception, and 37 (24.7%) reported no
contraception at last sex. Only 7 (4.7%) reported dual protection,
defined as using condoms to prevent both STIs and pregnancy
plus an additional modern contraceptive method, at last sex act.
Figure 1. The flow diagram is based on high school versus college numbers rather than by age group, because this is how the sensitization
meetings were conducted. Consent documents were collected at the sensitization meetings.
Masese et al.
2Sexually Transmitted Diseases •Volume 00, Number 00, Month 2017
Copyright © 2017 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.

TABLE 1. Characteristics of 451 Adolescent Girls and Young Women
Adolescent Girls (15–17 Years) Young Women (18–24 Years) All
Characteristics
Median (Range) or Number
(Percent), n = 195
Median (Range) or Number
(Percent), n = 256
Median (Range) or Number
(Percent), n = 451
Age, y 17 (15–17) 19 (18–24) 18 (15–24)
Single 195 (100) 252 (98.4) 447 (99.1)
Religion
Christian 78 (40.0) 180 (70.3) 258 (57.2)
Muslim 117 (60.0) 74 (28.9) 191 (42.4)
Other 0 2 (0.8) 2 (0.4)
Parity 0 (0–2) 0 (0–4) 0 (0–4)
Sexual history
Ever had vaginal intercourse 21 (10.8) 129 (50.4) 150 (33.3)
Receptive vaginal intercourse
None 174 (89.2) 127 (49.6) 301 (66.7)
With a condom 9 (4.6) 69 (27.0) 78 (17.3)
Without a condom 12 (6.2) 60 (23.4) 72 (16.0)
Age at first vaginal sex act*
11 y or younger 1 (4.8) 2 (1.6) 3 (2.0)
12–14 y 1 (4.8) 5 (3.9) 6 (4.0)
15–16y 12(57.2) 9(7.0) 21(14.0)
17 y or older 7 (33.3) 113 (87.6) 120 (80.0)
Lifetime vaginal sex partners*
1 partner 16 (76.2) 60 (46.5) 76 (50.7)
2–3 partners 4 (19.1) 47 (36.4) 51 (34.0)
4–5 partners 1 (4.8) 12 (9.3) 13 (8.7)
6 or more partners 0 10 (7.8) 10 (6.7)
Vaginal sex partners in the last 3 mo*
No sex in the last 3 mo 8 (38.1) 28 (21.9) 40 (26.7)
1 partner 13 (61.9) 78 (60.9) 93 (62.0)
2–3 partners 0 13 (10.2) 13 (8.7)
4 or more partners 0 5 (3.9) 4 (2.7)
Alcohol or drugs before last sex act* 2 (9.5) 7 (5.4) 9 (6.0)
Condom use at last sex act* 9 (42.9) 69 (53.5) 78 (52.0)
Contraception at last sex act*
None 4 (19.1) 33 (25.6) 37 (24.7)
Oral contraceptive pills 4 (19.1) 23 (17.8) 27 (18.0)
Condoms 9 (42.9) 58 (45.0) 67 (44.7)
IUD/implant/injection 0 4 (3.1) 4 (2.7)
Withdrawal 3 (14.29) 9 (7.0) 12 (8.0)
Not sure 1 (4.8) 2 (1.6) 3 (2.0)
Anal intercourse 5 (2.6) 5 (2.0) 10 (2.2)
Nonpenetrative sex 21 (10.8) 86 (33.6) 107 (23.7)
Reported alcohol and drug use
Alcohol (≥1 drink per day) 5 (2.6) 34 (13.3) 39 (8.7)
Tob ac co
< 1 cigarette per day 2 (1.0) 6 (2.3) 8 (1.8)
≥1 cigarette per day 1 (0.5) 0 (0.4) 1 (0.2)
Khat (ever used) 16 (18.2) 38 (14.8) 54 (12.0)
Marijuana (ever used ≥1 times) 2 (1.0) 11 (4.3) 13 (2.9)
Cocaine (ever used ≥1times) 0 0 0
Glue or aerosolized drugs (ever used ≥1 times) 1 (0.5) 4 (1.6) 5 (1.1)
Intravenous drug use 1(0.5) 0 1 (0.2)
Any drug use 21 (10.8) 64 (25.0) 85 (18.8)
Monodrug use 16 (8.2) 43 (16.8) 59 (13.1)
Polydrug use 5 (2.6) 21 (8.2) 26 (5.8)
Reported presence of STI symptoms
Genital itching 75 (38.5) 124 (48.4) 199 (44.1)
Abnormal vaginal discharge 24 (12.3) 63 (24.6) 87 (19.3)
Dysuria 21 (10.8) 46 (18.0) 67 (14.9)
Ever diagnosed with STI?
Yes 8 (4.1) 15 (5.9) 23 (5.1)
Not sure 7 (3.6) 16 (6.3) 23 (5.1)
Sexual reproductive health education
Ever taught about STIs in school 192 (98.5) 248 (96.9) 440 (97.6)
Ever taught about HIV/AIDS in school 194 (99.5) 255 (99.6) 449 (99.6)
Continued next page
STI Screening Among Adolescent Girls and Young Women
Sexually Transmitted Diseases •Volume 00, Number 00, Month 2017 3
Copyright © 2017 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.

Of the 451 participants, 54 (12.0%) reported use of khat,
and 39 (8.7%) reported having 1 or more alcoholic drinks per
day. Compared with students younger than 18 years, more stu-
dents 18 years or older reported substance use (21 [10.8%] vs 64
[25.0%]; odds ratio [OR], 2.76; 95% confidence interval [CI],
1.62–4.71, P< 0.001). Twenty-six students (5.8%) reported
polysubstance use. Of these, 12 (46.2%) reported using a combi-
nation of alcohol and khat.
Twenty-six students (5.8%; 95% CI, 3.6%–7.9%) were di-
agnosed with STIs (7 [1.6%] with N. gonorrhoeae, 16 [3.6%] with
C. trachomatis, and 3 [0.7%] with T. vaginalis). There was no stu-
dent with concurrent infections. The prevalence of STIs was 19
(12.7%) of 150 in those who reported receptive vaginal sex versus
7 (2.3%) of 301 in those who did not (OR 6.09; 95% CI
2.50–14.00, P= <0.001). Almost all students reported having re-
ceived reproductive health education about STIs (N = 440,
97.6%) and HIV (N = 449, 99.6%)in school, and 317 (70.3%) stu-
dents reported that their parents or guardians had discussed sexual
health with them.
In bivariable analyses, each additional year of age (OR, 1.28;
95% CI, 1.07–1.53), religion (Christian vs Muslim/other: OR, 2.11;
95% CI, 0.87–5.13), reporting receptive vaginal sex with a condom
(OR, 3.50; 95% CI, 1.14–10.73), and without a condom (OR, 9.25;
95% CI, 3.54–24.18), reporting nonpenetrative sex (OR, 3.52; 95%
CI, 1.58–7.85), alcohol use (OR, 3.81; 95% CI, 1.42–10.19),
smoking (OR, 5.82; 95% CI, 1.12–30.37), chewing khat (OR,
2.96; 95% CI, 1.18–7.42), and reporting polysubstance use (OR,
5.21; 95% CI, 1.74–15.59) were associated with STIs (Table 2).
TABLE 1. (Continued)
Adolescent Girls (15–17 Years) Young Women (18–24 Years) All
Characteristics
Median (Range) or Number
(Percent), n = 195
Median (Range) or Number
(Percent), n = 256
Median (Range) or Number
(Percent), n = 451
Do parents/guardians talk about sexual health
Yes 144 (73.9) 176 (68.8) 317 (70.3)
No 47 (24.1) 76 (29.7) 125 (27.7)
Not sure 4 (2.1) 4 (1.6) 9 (2.0)
Laboratory diagnosis of STIs
Any STI 7 (3.6) 19 (7.4) 26 (5.8)
Trichomonas vaginalis 0 3 (1.2) 3 (0.7)
Chlamydia trachomatis 2 (1.0) 14 (5.5) 16 (3.6)
Neisseria gonorrhoeae 5 (2.6) 2 (0.8) 7 (1.6)
Site
High school 194 (99.5) 99 (38.7) 293 (65.0)
University 1 (0.5) 157 (61.3) 158 (35.0)
*Analyzed among 21 adolescent girls and 129 young women who reported ever having vaginal sexual intercourse.
IUD indicates intrauterine device.
TABLE 2. Bivariable and Multivariable Analyses of Covariates Associated With STI Diagnosis Among All 451 Participants
Bivariable Analyses Multivariable Analyses
Characteristics
STI (N = 26)
N (%) or median (IQR)
No STI (N = 425)
N (%) or median (IQR) OR (95% CI) POR (95% CI) P
Age (continuous) 19 (17–21) 18 (17–19) 1.28 (1.07–1.53) 0.006 1.04 (0.82–1.31) 0.74
Married/cohabiting 1 (3.9) 3 (0.7) 5.63 (0.56–56.06) 0.14
Religion* (Christian vs Muslim) 19 (73.1) 239 (56.5) 2.11 (0.87–5.13) 0.10 1.30 (0.44–3.89) 0.64
Parity (ever pregnant) 1 (3.9) 5 (1.2) 3.36 (0.38–29.9) 0.28
Receptive vaginal intercourse
None 7 (26.9) 294 (69.2) 1.00 1.00
With a condom 6 (23.1) 72 (16.9) 3.50 (1.14–10.73) 0.03 1.96 (0.49–7.86) 0.34
Without a condom 13 (50.0) 59 (13.9) 9.25 (3.54–24.18) <0.001 6.21 (1.73–22.28) 0.005
Anal intercourse 1 (3.9) 9 (2.1) 1.85 (0.23–15.17) 0.57
Nonpenetrative sex 13 (50.0) 94 (22.1) 3.52 (1.58–7.85) 0.002 1.33 (0.50–3.52) 0.57
Reported drug use
Alcohol (≥1 drink per day) 6 (23.1) 31 (7.3) 3.81 (1.43–10.19) 0.01 2.03 (0.37–11.30) 0.28
Tobacco (ever smoked) 2 (7.7) 6 (1.4) 5.82 (1.12–30.37) 0.04 1.29 (0.13–12.40) 0.83
Khat (ever used) 7 (26.9) 47 (11.1) 2.96 (1.18–7.42) 0.02 1.90 (0.95–3.80) 0.07
Marijuana (ever used ≥1 times) 1 (3.9) 12 (2.8) 1.38 (0.17–11.01) 0.76
Drug use pattern
No drug use 16 (61.5) 350 (82.4) 1.00 1.00
Monodrug use 5 (19.2) 54 (12.7) 2.03 (0.71–5.75) 0.19 0.47 (0.09–2.36) 0.36
Polydrug use 5 (19.2) 21 (4.9) 5.21 (1.74–15.59) 0.003 0.50 (0.05–4.63) 0.54
Ever diagnosed with STI 3 (11.5) 20 (4.7) 2.64 (0.73–9.54) 0.14
No sexual health discussions with
parent/guardian
10 (38.5) 124 (29.2) 1.52 (0.67–3.44) 0.32
*N = 449. Analysis excludes 2 participants who reported religion as “other.”
Masese et al.
4Sexually Transmitted Diseases •Volume 00, Number 00, Month 2017
Copyright © 2017 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.

In multivariable analyses, reporting receptive vaginal sex without a
condom remained significantly associated with STI diagnosis (OR,
6.21; 95% CI, 1.73–22.28).
We also assessed the association between substance use and
STIs in a multivariable model that did not adjust for condomless
sex. In this model, neither the use of individual substances (data
not shown) nor the combined drug use variable (OR, 0.89; 95%
CI, 0.10–8.18) was associated with STIs. We also explored
correlates of STIs in the subset of participants who reported
any history of receptive vaginal sex (N = 150). In bivariable
analyses, reporting receptive vaginal sex with 1 (OR, 3.65; 95%
CI, 0.79–16.79), and with 2 or more partners (OR, 2.53; 95%
CI, 0.33–19.66) in the past 3 months were associated with in-
creased likelihood of STIs. Condom use at last sex was associated
with lower odds of any STI (OR, 0.38; 95% CI, 0.14–1.06;
P= 0.06) (Table 3). However, none of these associations were
statistically significant.
DISCUSSION
A substantial number of adolescent girls and young women
at secondary schools and universities in Mombasa, Kenya were
willing to undergo clinic-based urine STI screening. Of students
who collected a consent form during informational meetings, a
larger proportion of students from the university visited the clinic
for STI testing comparedwith high school students. The additional
step of parental consent for minors may have been a barrier to
participation for younger girls. The overall STI prevalence
was 5.8%, with the highest prevalence being for C. trachomatis
(3.6%). Participants who reported receptive vaginal sex without
using condoms had a 6-fold higher likelihood of being diagnosed
with an STI. Prevalence of STIs among students aged 15 to
17 years was 3.6% compared with 7.4% among those aged 18 to
24 years. The proportion of students with gonorrhea was higher
in the younger age group compared with the older age group
(5/195 [2.6%] vs. 2/256 [0.8%]). In contrast, the proportion
of students with chlamydia was lower in the younger age group
compared with the older age group (2/195 [1%] vs 14/256 [5.5%]).
The prevalences for chlamydia and gonorrhea in this popu-
lation were similar to those reported in other studies of adolescent
girls and young women in the African region. A recent survey
of adolescent girls in rural Kenya reported C. trachomatis,
N. gonorrhoeae, and T. vaginalis prevalence at 2.5%, 0.6%, and
2.5%, respectively.
15
The girls in this study were younger at enroll-
ment, and it is likely that the majority were non-Muslim, unlike
our population. A cross-sectional study of female adolescents in
Uganda found a C. trachomatis prevalence of 4.5%.
16
In Addis
Ababa, Ethiopia, the combined prevalence of C. trachomatis and
N. gonorrhoeae among sexually active youth aged 15 to 24 years
was 4.8% (2.7% for each pathogen).
17
Significantly higher preva-
lences of chlamydia and gonorrhea, ranging from 13.5% to 16.0%
have been reported among out-of-school youth in the region.
17,18
Although T. vaginalis accounts for more than half of all curable
STIs worldwide,
4
the prevalence in our study was very low. This
finding is not entirely unexpected, because the prevalence of
trichomoniasis generally increases with age.
19
Compared with university students, a smaller proportion of
high school students visited the clinic for the urine STI test, despite
picking up a consent form after our informational meetings. This
may be due to the mandatory parental consent required in our
TABLE 3. Bivariable and Multivariable Analyses of Covariates of STI Diagnosis—Restricted to Those Who Report ReceptiveVaginal Sex (N = 150)
Bivariable Analyses Multivariable Analyses
Characteristics
STI (N = 19) N (%)
or Median (IQR)
No STI (N = 131) N (%)
or Median (IQR) OR (95% CI) POR (95% CI) P
Age (continuous) 20 (19–21) 20 (18–21) 0.99 (0.77–1.27) 0.92
Married/cohabiting 0 2 (1.5) Did not converge
Religion* (Christian vs Muslim) 3 (15.8) 18 (13.1) 0.80 (0.21–3.05) 0.81
Parity (ever pregnant) 1 (5.3) 3 (2.2) 2.37 (0.23–24.03) 0.47
Age at first vaginal sex act
(≥17 vs <17 y)
16 (84.2) 104 (79.4) 1.38 (0.38–5.10) 0.63
Life time sex partners
(≥2 vs 1 partner)
11 (57.9) 63 (48.1) 1.48 (0.56–3.93) 0.43
Sex partners in the last 3 mo
No sex in the last 3 mo 2 (10.5) 38 (29.0) 1.00 1.00
1 partner 15 (79.0) 78 (59.5) 3.65 (0.79–16.79) 0.10 3.30 (0.71–15.36) 0.13
≥2 partners 2 (10.5) 15 (11.5) 2.53 (0.33–19.66) 0.37 2.69 (0.34–21.23) 0.35
Condom use at last sex act 6 (31.6) 72 (55.0) 0.38 (0.14–1.06) 0.06 0.41 (0.14–1.16) 0.09
Anal intercourse 1 (5.3) 7 (5.2) 0.98 (0.11–8.47) 0.99
Nonpenetrative sex 13 (68.4) 65 (49.6) 2.20 (0.79–6.14) 0.13
Reported drug use
Alcohol (≥1 drink per day) 6 (31.6) 27 (20.2) 1.78 (0.62–5.11) 0.29
Tobacco (ever smoked) 2 (10.5) 4 (3.0) 3.74 (0.64–21.96) 0.15
Khat (ever used) 6 (31.6) 24 (17.9) 2.06 (0.71–5.96) 0.18
Marijuana (ever used ≥1 times) 1 (5.3) 9 (6.7) 0.67 (0.08–5.57) 0.71
Alcohol or drugs before last sex act 2 (10.5) 12 (9.0) 2.08 (0.40–10.86) 0.38
Drug use pattern
No drug use 10 (52.6) 85 (64.9) 1.00
Monodrug use 5 (26.3) 29 (22.1) 1.17 (0.34–4.03) 0.80
Polydrug use 4 (21.1) 17 (13.0) 2.50 (0.76–8.24) 0.13
Ever diagnosed with STI? 3 (15.8) 15 (11.2) 1.45 (0.38–5.57) 0.59
No sexual health discussions
with parent/guardian
7 (36.8) 40 (29.9) 1.15 (0.42–3.14) 0.78
*N = 149. Analysis excludes 1 participant who reported religion as “other.”
STI Screening Among Adolescent Girls and Young Women
Sexually Transmitted Diseases •Volume 00, Number 00, Month 2017 5
Copyright © 2017 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.

study. This finding highlights the ongoing regulatory and ethical
challenges surrounding adolescent clinical research. Such chal-
lenges may contribute to the fact that adolescents continue to be
an understudied population.
20
In addition, in most universities,
undergraduate students have flexible schedules with free time
between classes on weekdays (Monday to Friday). In contrast,
high school students have a fixed schedule with free time only
during the weekends. Recognizing this, we held Saturday
clinics. University students were, therefore, able to attend clinic
on weekdays or Saturdays, whereas the high school girls could
only attend clinic on Saturdays. This may also have contributed
to the differences in the proportions of college versus high
school students attending the clinic. Previous studies have reported
that extending hours of operation to include evening and weekend
would be ideal for youth, due to conflicting school schedules.
21,22
During the formative work for this study, which included in-depth
interviews and focus group discussions with students, we explored
the possibility of making services available at schools. However,
due to confidentiality concerns, girls participating in this formative
work felt strongly that they would prefer to receive services at
the clinic.
14
Use of male condoms was associated with a substantially
lower likelihood of STIs in our population, reaffirming the effec-
tiveness of condoms in preventing STI transmission.
23
Among
students who reported vaginal sex, only half reported condom
use at the last sexual encounter. About 20% reported using
modern nonbarrier contraceptive methods. Only 5% reported
dual protection with barrier and nonbarrier methods. Low rates
of contraceptive use among those who report beingsexually active
highlights the risk for pregnancy and STIs. We did not inquire
about fertility desire. However, we anticipate that the rate of fertil-
ity intent would be low in this population of girls and young
women continuing school.
Over a quarter of STIs identified in this study (7 of 26) were
in girls who did not report being sexually active. This finding un-
derscores the potential importance of offering STI screening and
other reproductive health services to this population, regardless
of whether they acknowledge sexual activity.
In bivariable analyses, students who reported substance use
were more likely to be diagnosed with an STI compared with those
who reported no use. Previous studies have shown that poly-
substance users are at a higher risk of acquiring STIs.
24,25
Use of
substances may be a marker for risk-taking, which may in turn
lead to exposure to STIs. In addition, substance users are likely
to be involved in high-risk sexual networks, where they are more
likely to be exposed to STIs.
26
In future studies, it will be impor-
tant to explore the relationship between substance use and sexual
networks among adolescent girls and young women in Africa.
Sexually transmitted infection prevalences in this study
were relatively low. Attending school and receiving a basic educa-
tion has been shown to be effective in delaying sexual debut and
reducing the risk of STIs.
27
The benef its of being in school include
having stronger decision-making and negotiation skills and higher
self-esteem. Adolescent girls and young women in school may
also have higher earning potential, making them less likely to en-
gage in transactional sex.
28
In addition, almost all students in our
study reported having received some reproductive health educa-
tion in school as part of the education curriculum in Kenya. This
knowledge may have contributed to informed choices regarding
sexual relationships and use of condoms.
One strength of this study was the use of nucleic acid am-
plification based testing for STIs, which has excellent sensitiv-
ity (91.3–95.2%) and specificity (98.9–99.3%) for detection
of C. trachomatis,N. gonorrhoeae and T. vaginalis on first-
catch urine samples.
29,30
In addition, this study adds to the limited
literature on STIs in adolescents in Africa. In particular, this study
highlights the strengths and weaknesses of using school-based
sensitization as an approach to prompt adolescents and young
women to seek diagnosis and care at health clinics. The main
strength of this approach is being able to target large groups
of students for sensitization education. The challenges include
obtaining parental consent for the minors, and providing flexible
hours for clinic visits due to school attendance. The latter was
addressed by holding clinics on Saturdays.
There were also limitations to this study. We documented
the number of students collecting consents and the proportion
who eventually visited the clinic for STI testing. However, we did
not document the number of students attending the sensitization
sessions. Therefore, selection bias is possible, because students
who collected a consent form may differ from those who did not.
Despite this limitation, we believe these data are useful in identify-
ing some of the important bottlenecks to STI testing among adoles-
cents and young women in resource-limited settings. In addition,
we were unable to collect data on those who did not visit the clinic.
As a result, we could not compare the characteristics of those who
attended clinic versus those who did not. Information on partici-
pants who did not attend clinic would be valuable in informing in-
terventions targeted toward STI screening in these populations.
Our sample size was calculated based on the proportion accepting
STI testing in the 2 age groups (18–24 vs 15–17) rather than the
estimated STI prevalence. This could have resulted in an under-
powered analysis of risk factors for STIs. In addition, our sensitivity
analyses restricted to participants reporting vaginal sex excluded
more than half of the participants and as such this analysis also
had less power. Despite these limitations, these data highlight
modifiable predictors of STI diagnosis among adolescent girls
and young women in sub-Saharan Africa. Sexual risk behavior
was self-reported, introducing the possibility of recall and social de-
sirability bias. To mitigate these effects, we used self-administered
questionnaires and explained to the participants that their data were
anonymous. Another limitation was the lack of event-level data that
would allow a more detailed understanding of how exposures such
as alcohol use influence outcomes like unprotected sex at the time of
specific events. However, because untreated STIs persist for months
to years, we may gain valuable insights from examination of the
interval-level data collected in this study. Finally, this was a cross-
sectional study, limiting our ability to prove causal associations.
In conclusion, uptake of STI testing in this study provides
evidence that school-based recruitment linked to facility-based
testing is feasible and acceptable when conducted in collaboration
with students, parents, and teachers. Although uptake through
school-based sensitization was lower than for university, there still
appeared to be substantial demand in this population. Uptake of
STI screening might be higher if the requirement for parental con-
sent was waived. The STI prevalence in girls who reported recep-
tive vaginal intercourse was high (12.7%) compared with those
who did not report vaginal intercourse (2.3%). Tiered services,
providing risk reduction education to all adolescent girls and
young women, plus a more aggressive STI screening approach
for those who report vaginal intercourse, might provide an effi-
cient way of addressing STIs in this population. Adaptable inter-
ventions, such as a behavioral risk assessment survey during the
sensitization sessions, would be useful in identifying adolescents
and young women with the greatest need for STI testing.
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