Abstracts Vol. 1 [International Conference on AIDS (11th: 1996: Vancouver, Canada)]

Monday, July 8, 1996

Mo.C.343 - Mo.C.441

Results: Preliminary analysis of the model shows that strategy co' i'p nrd veiwhelmingly
on drug prices. In our model, strategy (I) shows the highest effec vore.,s, but is times
more expensive than strategy (2). Strategy (3) is twice as expensive.s rtrtegy (2). but
saves drugs. However, effectiveness is markedly affected by poor lab:-rormrrance. Strategy
(2) effectiveness is dependent on control visit rates, drug compliancr,. rcd gori ociroccal resistance to antibiotics. Maximizing compliance shows the greatest iml,;t- on efct(iveness.
Conclusion: Alternative strategies are acceptable and even preferabl, ic terns of cost-effectiveness, only if the cheaper antibiotic is 80 % effective and compliare irs. Ir,. cr if lab conditions for Gram stain are optimal.
Francois Crabbe, Institute of Tropical Medicine, Nationalestraat I.'Ci, 2i)"" Antwerpen,
Belgium.Tel. [phone]; Fax [phone]
Mo.C.343
STD/HIV/AIDS: CHEMISTS AND THE COMMUNITY
Pradhan, Mahesh P*, Srestha O*, Basnyat A**, Murgrditchian D** ' " Nepal Chemists and
Druggists Association, Kathmandu, Nepal; **AIDSCAP/Nepal, Kathr,;andu, Nepal;
***AIDSCAP/Asia Regional Office, BangkokThailand.
Issue: Up to 90% of Nepal's population does not have access to cormrnprehe;ive health care
services. Local chemists (pharmacists) are often the first point of enconte for men and
women seeking treatment for sexually transmitted diseases (STDs).
Project: To reach chemists serving large numbers of men and women who are at risk for
STDs working and living in areas adjacent to Nepal's major transport I ghways, a tailored
training curriculum was developed to strengthen chemists skills as STD/HIV/AIDS educators and to strengthen chemists' knowledge of proper STD drug dipensing practices in
accordance with the STD syndromic approach.
Results: Men and women working as full- and part-time chemists in Nepal's Central Region
actively sought the opportunity to participate in 2-day prevention eduation workshops
sponsored by the Nepal Chemists and Druggists Association.The trairing introduced the
STD syndromic approach for the treatment of STDs and the inter 'elation between STD
and HIV infections, discouraged the misuse of antibiotics, and promoted the 4 basic health
messages: the 4 C's. In addition to the training package, each participant received reference
(on condoms), IEC materials, educational brochures for distribution to customers, and a
brochure holder with simple reminders for the chemists. A pre- and post-mystery shopper
survey of chemists was conducted by an independent research agency to evaluate the
impact of this new type of training in Nepal.
Lessons Learned: Following training, chemists felt a greater responsibility to slow the spread
of HIV and other STDs in their communities.
Mahesh P Pradhan, c/o Alfred Nimocks, AIDSCAR 2101 Wilson Blvd. #700 Arlingotn,VA,
USA, 22201; tel. [phone]; fax. 703.516.978 I
Mo.C.344
SURVEY OF STDS SEEN AMONG PRIVATE PHYSICIANS IN JAMAICA
Brathwaite, Alfred R, Figueroa JP Epidemiology Unit, Ministry of Heaith
Objective: A survey of physicians in private practice in Jamaica was conducted between
March and September of 1993. It attempted to provide a descriptive analysis of the occurrence of conventional STDs seen in their practices.
Methods: Questionnaires were delivered by field officers to a convenient sample of 371
private physicians.The list of physicians used contained an estimated 450 private physicians.
Each physician collected data over a period of one week. Completed questionnaires were
collected or mailed-in to the Epidemiology unit.
Results: 127/371 I(34%) of physicians responded, completing a total of 683 (men 353,
women 330) individual patient questionnaires. Each physician collected data over a oneweek period but 23% did so at periods other than requested.The mean age of the 683
patients seen was 28 years. Of these: 464 (68%) were first visits for a symptomatic STD
condition, 132 (19%) were follow-up for the same condition, 40 (h.%) were asymptomatic
contacts referred by a sex partner, and I 2 (2%) were asymptomatic i st visits for a 'checkup'. A history of past STD was given by 358 (52%) of patients. A total of 52 (8%) patients
had anogenital lesions, 45 (7%) inguinal lymphadenopathy and 470 (69%) a genital discharge
(men 65%, women 73%). Among women, I 3 I (40%) had lower abdominal pain on examination and 105 (32%) evidence of PID on moving the cervix. A working diagnosis of gonorrhoea was made in 273 (40%), trichomoniasis in 121 (18%), syphils in 60 (9%), herpes genitalis in 20 (3%) and chancroid in II (2%) of STD patients. PID was diagnosed in 121 (17%)
of women and nongonococcal urethritis in 98 (62%) of men.The most fiequently prescribed treatments were for chlamydia, gonorrhea and trichomoniasis.
Conclusions: In general, working diagnoses correlated well with clinical observations and
treatment matched diagnosis according to national guidelines; important findings for
STD/HIV control in Jamaica.
Alfired Brathwaite, c/o Alfred Nimocks, AIDSCARP 210 I Wilson BIva. 9700. Arlington,VA,
USA. 22201; tel. 703.5 I 6.9779; fax. 733.5 16.978 I
Mo.C.345
VALIDATION OF THE WHO DIAGNOSTIC ALGORITHM AND DEVELOPMENT OF
AN ALTERNATIVE SCORING SYSTEM FOR THE MANAGEMENT OF VAGINAL
DISCHARGE IN MALAWI
Dallabetta G,** o alrC* Wangel A-M,* Hoffman,5* Canner j.' Iule h.' 'i Lema
V,* * Liomba N:.*** *John Snow, Inc.: **AIDSCAP/FHI; *''Li b. Chrpel Hill,
****College of Medicine, Malawi; *****NACP Malawi.
Objective: To evaluate the performance of the World Health O rsniz,.rtion (WHO) algorithm for the detection of cervical infection in women presenting,vitI. vag v,pl discharge and
modify the risk assessment score for optimum effectiveness in IMolawi.
Methods: 550 women presenting with nonulcerative genitourinaro rr:p.,rts were interviewed and examined. Cervical infection was defined as preserce of isvs.-i 'onorrhoeae
on culture and/or Chlamydio trrchomotis by enzyme immunoas --s O.,ie laboratory investigations included serology for syphilis and HIV and wet mount rnic scopy LeuKocyte
esterase dipstick testing of cervical and vaginal secretions and pH sting of vaginal fluid
were evaluated. All women were treated according to WHO algorithmns with modification
according to laboratory results. Sensitivity, specificity, and positive pr'dirctve values (PPVs) of
different algorithms were determined in the analysis.

Results: Cervical infection was identified in 19.5% of women (17.1% gonorrhoea, 3.7%
chlamydia).The sensitivity/specificity/PPV of the WHO risk assessment were 43%/73%/28%,
respectively, by history alone and 62%/61%/27% with the addition of speculum examination.
Using Malawi results to modify the risk assessment improved the performance to
61%/68%/3 I% respectively by history alone, which increased to 73%/64%/33% with the
addition of bimanual examination and 72%/56%/29% with speculum examination.
Conclusion: The sensitivity of the WHO risk assessment is low for the detection of cervical
infection in Malawi. Although the Malawi risk assessment performed somewhat better on
history alone, this study identified external and bimanual examination as variables that
improved the diagnostic performance of the algorithm in settings where speculum examination was not possible. Although the PPVs of the algorithms are low, country-specific risk
assessments can provide a framework for the management of women with nonulcerative
STDs until simple, affordable diagnostic tests for the definitive diagnosis of cervical infection
are available.
C. Daly, c/o Alfr-ed Nimocks, AIDSCARP 2101 Wilson Blvd., #700 Arlington,VA, USA, 2220 I;
Tel. [phone]: Fax. 703.5 I 6.978 I
Mo.C.440
DECLINING PREVALENCE OF GONORRHOEA (GC) AND CHLAMYDIA (CT) IN
FEMALE SEX WORKERS (FSW), CHIANG RAI,THAILAND, 1991-94
Kilmarx, Peter H*, Limpakarnjanarat K**, Uthaivoravit W***, St. Louis ME*,Young N***,
Korattana S**, Kaewkungwal J**, MastroTD***. *CDC, Atlanta, GA, USA; **HIV/AIDS
Collaboration, Nonthaburi,Thailand; ***Chiang Rai Hospital,Thailand
Objective: To assess the Thai government condom-promotion HIV-prevention campaign, we
investigated risk factors for and temporal trends in prevalent GC and CT in a defined
cohort of FSW in Thailand using accurate laboratory methods.
Methods: From 1991I to 1994, FSW were enrolled and evaluated with interview, physical
exam, and GC and CT Gen-probeTM of cervical secretions. Prevalence in women enrolling
in 199 1-93 was compared to that in women enrolling in 1994.
Results: GC infection was present in 15.4% of FSW at enrollment; 73 (17.5%) of 416
enrolled 199 I-93, and 3 (3.8%) of 79 in 1994 (odds ratio [OR] 0. 19 [for enrollment in
1994 vs. 199 I -93]; 95% confidence interval [CI] 0.06-0.53). CT was present in 20.2%: 93
(22.4%) of 416 enrolled 199 I -93, and 7 (8.9%) of 79 in 1994 (OR 0.33; 95% CI 0.16-0.7 I).
FSW enrolling in 1994 were less likely to be higher-risk brothel-based FSW and were more
likely to report 100% condom use and to have <2 customers per working day In stratified
analysis, GC and CT prevalence declined significantly (p<0.05) in 1994 in both high and
lower risk groups. In multivariable analysis, GC was less prevalent in FSW reporting use of
depo-medroxyprogesterone (DMPA) (adjusted OR [AOR] 0.28; 95% ClI 0.09-0.87), <2 customers per working day (AOR 0.30; 95% CI 0. 12-0.77), or 100% condom use (AOR 0.59:
95% CI 0.33-1.0), or enrolling in 1994 (AOR 0.34; 95% CI 0. 10 I0-.2). CT was associated with
<2 years as a FSW (AOR 2.4: 95% CI 1.4-4.0) and age 2 I (AOR 1.8; 95% CI 1.0-3.0);
enrolling in 1994 was protective (AOR 0.42: 95% CI 0. 17- I.0).
Conclusions: The prevalence of GC and CT in FSW was lower in 1994 than in 199 t -93.
While this decrease was associated with less high-risk behaviour, the decrease remained in
analyses controlling for behaviour, suggesting a decline in community prevalence.This supports Thai government STD surveillance data suggesting that the national HIV-control program has been effective.
Peter H. Kilmarx, MS E-02, CDC, I 600 Clifton Road, N.E., Atlanta, GA, 30333, USA
Tel: [phone] Fax: [phone] e-mail: pbk4@cpsstd I.em.cdc.gov
Mo.C.44 I
RAPID DECLINE IN SEXUALLY TRANSMITTED DISEASE PREVALENCE AMONG
BROTHEL-BASED SEX WORKERS IN LA PAZ, BOLIVIA:THE EXPERIENCE OF
PROYECTO CONTRA SIDA, 1992-1995
Lvine William C, Higueras G, Revollo R,Vega J, Aliaga A,Tinajeros F, Garnica M, Lewis J
Ugarteche J, KauneV, Estenssoro M, Wright-Deaguero L, Pareja R, Negron E, Posner J,
Ransom R, Melgar M, Kuritsky J. Proyecto Contra SIDA, La Paz Health Dept, National
Secretariat of Health, and CIES, La Paz, Bolivia; Johns Hopkins Univ/CCR Baltimore; and
CDC, Atlanta, USA.
Objective: Efforts to decrease sexually transmitted diseases (STDs) among female sex
workers (FSWs) have been most successful in countries responding to massive HIV epidemics (e.g.,Thailand), and in intensive research settings (Projet SIDA, Zaire). Proyecto
Contra SIDA/Bolivia was designed to avert an HIV epidemic by rapidly reducing STD
prevalence among FSWs in a resource-poor setting with low HIV prevalence and no effective public STD services.
Methods: STD clinical and lab training and STD care, based in public facilities, and clinic and
community-level behavioural assessments began in 1992. In collaboration with a local NGO,
intensive community-level behavioural interventions began in 1993.As the project expanded, an increasing proportion of the 100- I 50 brothel FSWs seen at the clinic weekly
received lab tests and on-site treatment. In 1994, project and health department clinical services were integrated under a common protocol.Trends in gonorrhoea, syphilis (RPR titer
>1:8), genital ulcers, and condom use were assessed with the x2 test for trend.
Results: From 2/92- 8/95, the number of brothel FSWs tested increased from about 15 to
50 per month (once every 3 months per FSW).The median number of sex partners of
women tested did not change significantly over time (about 32 per month). STD prevalence
declined and self-reported condom use ("always" or "almost always" use) increased:

cO0
V
c3)
a)
0
U
0
o
L
a)
C
x
38

Gonorn-hoea, %
Syphilis. %
Genital ulcer disease, %
Condom use, %

1992
21.2
15.0
3.9
35.5

1993
26.4
11.7
5.2
35.6

1994
18.2
4.5
3.3
61.6

1995
9.5
7.4
1.5
73.5

p-value
<0.001
0.003
0.03
<0.001

HIV seroprevalence remained <I% throughout this period.
Conclusions: This HIV/STD prevention model is now being replicated in other cities in
Bolivia. Proyecto Contra SIDA/Bolivia is an example of how a program of intensive clinical