Bridging the Gap: Conference Record [Abstract book, International Conference on AIDS (12th: 1998: Geneva, Switzerland)]

642 Abstracts 33247-33251

12th World AIDS Conference

33247 What role for routine curative health services in the
detection of asymptomatic sexually transmitted
infections?
Philippe Mayaud1, K. Mugeye1.4, B. West4, A. Gavyole3, J. Changalucha4,
D. Mabey1, A. Buve5. 1London Sch. of Hygiene and Tropical Medicine Keppel
Street London Wcie 7HT, England; 2 Municipal Health Office, Mwanza; 3AMREF,
Mwanza; 4NIMR, Mwanza, Tanzania; 5Institute for Tropical Medicine, Antwerp,
Belgium
Objectives: (i) to assess the prevalence of laboratory confirmed STI's among
patients attending the OPD of a district hospital; (ii) to assess the proportion
of patients with STI who were missed by the health workers, (iii) to assess the
performance of different strategies for the detection of asymptomatic infections;
(iv) to estimate the number of STI's that are detected by partner notification.
Methods: Consecutive men and women attending the outpatient department
of a rural hospital were approached after they were seen by regular hospital staff.
With informed consent they were interviewed about STD related complaints, and
underwent a full genital examination with laboratory testing. Their medical records
were then checked for the diagnosis and treatment made by health staff. Patients
with any indications of STI's were requested to inform their partners, who were
interviewed and underwent a full examination.
Results: 521 men and 562 women were enrolled, of whom respectively 13%
and 51% were suffering from a laboratory proven STI. In addition 3% were suffering from a genital ulceration (5% men and 1.4% women). Of the men 245
with urethritis were identified by the health workers; 50% with genital ulceration.
Research staff identified another 10% of men with symptoms, but 46% were
asymptomatic. Of the women 18% of STI's were detected by the health workers
(25% of genital ulcerations). Research staff detected another 14% with STD
related complaints and 35% were asymptomatic. Screening of urine of men with
LED and applying a risk score to women as a screening tool, would increase
the detection of STI's in this population but the positive predictive values were
generally low. 0.37 partners per index case were seen, in male partners 11% had
a laboratory confirmed STI; in female partners this percentage was 51%. The
detection rate of STI's was 0.19 infections per male index patient, 0.04 infections
per female index patient.
Conclusions: Under routine conditions, the performance of syndromic management can be low. Moreover, since over half of the infected population denies
having any STI symptom, alternative strategies are urgently warranted for STI
screening. In resource-poor settings, screening of male urethritis using an LED
could be an alternative. Careful questioning of women may help. Partner notification, even in the context of syndromic management, is a useful strategy to detect
and treat asymptomatic STI cases.
33248 Behavioral risk assessment and serology for syphilis,
hepatitis B and HIV among commercial sex workers in an
isolated brothel in Goalanda, Rajbari
Hasan Mahmud1, M.A. Kabir2, M.A.H. Mian2, E. Karim3. 1STD Project IEDCR,
Mohakhali, Dhaka 1212, Bangladesh 2Medical Officer STD Project IEDCR,
Dhaka; 3Senior Scientific Officer IEDCR, Dhaka, Bangladesh
Background: To study the risk taking sexual behavior of CSWs at Goalanda
Brothel which is a riverside isolated brothel beside Ferry, Ghat and Train Station
and to assess the prevalence of Syphilis, Hepatitis B Virus and HIV antibody.
Methods: Random selection of 205 Commercial Sex Workers (CSWs), indepth
interview in a predesigned hybrid questionnaire and focus group discussion
(FGD) to assess their sexual behaviors, knowledgeand practices with respect to
AIDS/STDs and blood samples were collected after pre-test counselling and informed consent of the respondents. The study took place in between September'
93-November' 93. Data were initially analyzed using EPIINFO software.
Results: The mean age of CSW was 23.13 years (SDV ~ 5.22 yrs) and 95%
were from 15-34 years age group, the most primetime of their reproductive life.
107 CSWs out of 205, were left by their husbands, 43 being separated, 25
coerced to sex trade, 17 due to breakdown of families due to multiple marriage
of their husbands and 11 were sexually abused and abandoned by their families
and the society which driven them to commercial sex business for their bread
and butler. Most of the clients were Truck Drivers, Students, mobile people and
businessmen. Most of them used to drink local wine, spirit, canabis and other
sedative and hypaotic drugs but none were intravenous drug shooter. On average,
they entertained 5-7 clients per day. They were well aware of STD/RTI and took
medicines on their own without consulting to physicians. But, they never heard
about AIDS nor they knew about HIV. 17.1% (35) were positive for VDRL, 15.1%
(31) positive for HBsAg and only one (0.5%) found positive for anti-HIV antibody.
Conclusion: Though HIV infection is very low compared to syphilis, but presence of risk-related sexual behaviours, low use of condoms and poor health care
seeking behaviour put them at risk of HIV infection. So there is an urgent need to
start STD care services along with preventive education, counselling and condom
promotion among the CSWs.

33249 STD intervention among SWs in a red light area
Debasis Bose1, S. Jana1, M. Singh2, S. Ghosh2, M. Mukherjee1. 18/2 Bhawani
Dutta Lane, STD/HIV Intervention Programme, Calcutta; 2Durbar Mahila
Samanwaya Committee, Calcutta, India
Issue: STD intervention in red light areas (RLAs) requires motivation, compliance

development & intensive follow-up through efficient peer education. Opportunistic
Screening & periodic re-assessment become subsequently mandatory.
Project: Given the high prevalence of STDs & scanty condom use in Sonagachi
RLA of Calcutta, an intervention using clinical service, condom promotion and
IEC was launched. Local SWs, trained for peer education, motivated their fellows
to attend the clinic, utilise the medicines properly, report for follow-up & use
condoms. The doctors subjected high-risk attenders to meticulous genital examination and regular VDRL testing, irrespective of symptoms. Follow-up registers
were maintained for the daily fetching of the patients & to assess compliance &
health-seeking behaviour.
Results: The programme being welcomed by the SWs, Sonagachi clinic was
attended by 9782 patients in 1996. Opportunistic screening uncovered a massive quantum of asymptomatic STDs. A baseline survey (1992) was followed by
two evaluative repeat surveys (1993 & 1995). VDRL positivity, in 1:8 or higher
dilutions, fell from 25.42 to 14.10%, Gonorrhoea from 13.24 to 11.81%, Trichomoniasis from 11.11 to 9.47% & Candidiasis from 23.24 to 4.21%. Condom use
increased from 2.7 to 81.7%.
STD intervention programme in RLAs are potentially successful if they are
backed by a well-trained peer educator group. Parallel enforcement of strict
opportunistic screening and intensive follow-up are essential.
S33250 HIV/AIDS awareness and intervention among women in
prostitution and allied groups in Salem, Tamil Nadu, India
Arulraj Louis, Lalitha Kumaramangalam, V.N. Sabapathy, S. Velan. Prakriti,
Chennai TN, India
Issue: In the rural town of Salem in South India, the commercial sex workers
lead a subsistence existence. Due to stigma, taboo and repression, continuing
dependence on sex work, low condom usage and high rates of STD (Sexually
Transmitted Diseases) they are at risk to HIV/AIDS infection.
Project: The project targeted WIP (Women in Prostitution) in this area in a
wholistic approach to decrease the vulnerability of these women to STDs including HIV/AIDS. The project also targeted the affiliated target groups that had
power or influence over the WIP and used them as agents of change. It aimed
at, whereever possible, to raise the economic status of WIP by decreasing their
economic dependence on sex trade. Contraception was also promoted to encourage WIP to protect themselves from repeated unwanted pregnancies and thus
improve their general health. The project improved the access of WIP to social
and health services, especially reproductive health and STD services, child care,
functional literacy etc.
Results: In 18 months increase in STD treatment was achieved, while reproductive health problems decreased by 23%. Condom usage increased to nearly
36% among WIPs.
Lessons Learned: Prevention activities for women in prostitution should be
carried out with empathetic non-judgmental attitudes and after building good
rapport. Gender considerations must be considered to improve lifestyles of WIP.
33251 Development of national guidelines of STD case
management and integration with the primary health care
services in Bangladesh
M.D. Ahsanul Kabir4, H. Mahmud1, M.A.H. Mian2, E. Karim4, M.N. Islam5.
1Team Leader; 2 Medical Officer; 3Senior Scientific Officer - 4STD Project
IEDCR, Mohakhali, Dhaka; 5Project Director, BAPCP, Dhaka, Bangladesh
Issues: To develop a standardized protocol and flow-charts for management of
STD cases in Bangladesh. In the absence of a standard management guidelines,
there is a varied range of irrational use of drugs leading to antimicrobial resistance
to microorganism.
Project: In Bangladesh, prevention and control of STDs were non-existent
inspire of Skin and VD Department in different Medical Colleges and Districts
Hospitals. In April 1993, the prevention and control of STD projects came into
being as a pilot project in the Fourth Five Year (FFY). In October, 1993, the STD
project developed STD case Management guidelines and Flow-Charts on the
basis of WHO flow charts. Since then, a series of workshop involving eminent Virologists, Epidemiologist, Microbiologists and expert from NGO sectors to review
and finalize the treatment guidelines and comprehensive STD case management
training package. The STD Service Delivery Package (SSDP) had a TOT Manual,
Flow-Charts with Treatment Schedule and reporting format for reporting of STD
cases. The major emphasis was given on Syndromic Management of STD cases,
counselling, Health education and communication skills, ensure compliance of
drugs, proper and correct use of condom. Treatment of the partner and partner
notification was also included and given due priority. All these were done keeping
in line with the National Policy Document of HIV/AIDS and STD related issues.
Results: The training package (SSDP) became the tools for training of Medical
Officer (MO), Health Assistant (HA) and the General Practitioners (GPs). Following the development of the package, two TOTs and one training workshop for the
General Practitioners were held. The SSDP was also used by the NGOs working
in the field of STI/RTI/HIV/AIDS prevention and control. Besides, This guideline,

flow-charts were integrated with the essential service package (ESP) of 5 HAPP
and would be used at all levels of health care service delivery.
Lessons Learned: National guidelines for the Management of STD/RTI were
proved very effective in providing RTI/STI services and the felt need both by
GO/NGO and Family Physicians. Treatment regimens would be reviewed on the
basis of time to time follow-up and sensitivity of drugs to different microorganism