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Biomedical subjects

H Grosskurth

Publications and source records attributed to H Grosskurth.

At least 19 recordsLinked to original sources
PubMed2006

Rationale and design of the MEMA kwa Vijana adolescent sexual and reproductive health intervention in Mwanza Region, Tanzania.

Large-scale innovative, integrated, multifaceted adolescent sexual and reproductive health (ASRH) interventions are urgently needed in sub-Saharan Africa. Implementation through schools and health facilities may maximize intervention coverage and sustainability, however the impact of the use of these structures on intervention content and delivery is not well documented. This paper describes the rationale and design of a large-scale multifaceted ASRH intervention, which was developed and evaluated over three years in rural communities in Mwanza Region, North West Tanzania. The intervention comprised community mobilization, participatory reproductive health education in primary schools, youth-friendly reproductive health services and community-based condom provision for youth. We examine the effect of socioeconomic, cultural and infrastructural factors on intervention content and implementation. This paper demonstrates the means by which such interventions can be feasibly and sustainably implemented to a high standard through existing government health and school structures. However, the use of these structures involves compromise on some key aspects of intervention design and requires the development of complementary strategies to access out-of-school youth and the wider community.

Adolescent↗
PubMed2006

Lack of effectiveness of syndromic management in targeting vaginal infections in pregnancy in Entebbe, Uganda.

OBJECTIVES: To measure the prevalence of reproductive tract infections (RTIs) during pregnancy in Entebbe, Uganda, and to evaluate the current syndromic diagnosis and management approach in effectively targeting infections, such as bacterial vaginosis (BV) and trichomoniasis, that are associated with low birth weight and prematurity among newborns. METHODS: We enrolled 250 antenatal clinic attenders. Vaginal swabs and diagnostic tests were performed for BV, Trichomonas vaginalis (TV), candida, Neisseria gonorrhoeae, Chlamydia trachomatis and for HIV-1 and active (TPHA+/RPR+) syphilis infection. Same day treatment was offered for symptoms according to syndromic management guidelines. The treatment actually provided by healthcare workers was documented. Sensitivity, specificity, positive and negative predictive values were used to assess the effectiveness of syndromic management guidelines and practice. RESULTS: The prevalence of infections were: BV 47.7%, TV 17.3%, candida 60.6%, gonorrhoea 4.3%, chlamydia 5.9%, syphilis 1.6%, and HIV 13.1%. In total, 39.7% of women with BV and 30.2% of those with TV were asymptomatic. The sensitivity of syndromic management as applied by health workers in targeting BV and TV was 50.0% and 66.7%, respectively. This would have increased to 60.3% (BV) and 69.8% (TV) had the algorithm been followed exactly. CONCLUSIONS: The prevalence of BV and TV seen in this and other African populations is high. High rates of asymptomatic infection and a tendency of healthcare workers to deviate from management guidelines by following their own personal clinical judgment imply that many vaginal infections remain untreated. Alternative strategies, such as presumptive treatment of BV and TV in pregnancy, should be considered.

Adolescent↗
PubMed2005

Determinants of the impact of sexually transmitted infection treatment on prevention of HIV infection: a synthesis of evidence from the Mwanza, Rakai, and Masaka intervention trials.

Community-randomized trials in Mwanza, Tanzania, and Rakai and Masaka, Uganda, suggested that population characteristics were an important determinant of the impact of sexually transmitted infection (STI) treatment interventions on incidence of human immunodeficiency virus (HIV) infection. We performed simulation modeling of HIV and STI transmission, which confirmed that the low trial impact in Rakai and Masaka could be explained by low prevalences of curable STI resulting from lower-risk sexual behavior in Uganda. The mature HIV epidemics in Uganda, with most HIV transmission occurring outside core groups with high STI rates, also contributed to the low impact on HIV incidence. Simulated impact on HIV was much greater in Mwanza, although the observed impact was larger than predicted from STI reductions, suggesting that random error also may have played some role. Of proposed alternative explanations, increasing herpetic ulceration due to HIV-related immunosuppression contributed little to the diminishing impact of antibiotic treatment during the Ugandan epidemics. The strategy of STI treatment also was unimportant, since syndromic treatment and annual mass treatment showed similar effectiveness in simulations of each trial population. In conclusion, lower-risk behavior and the mature HIV epidemic explain the limited impact of STI treatment on HIV incidence in Uganda in the 1990s. In populations with high-risk sexual behavior and high STI rates, STIs treatment interventions may contribute substantially to prevention of HIV infection.

Adolescent↗
PubMed2004

Adolescent reproductive health and awareness of HIV among rural high school students, North Western Ethiopia.

Ethiopia is faced with an increasing problem from HIV infection, and the vulnerability of adolescents is a key concern. There is little information on the knowledge, attitudes and practices of this age group with respect to HIV, sexually transmitted diseases and preventive measures. We conducted a cross-sectional study among 260 students from two rural high schools in North Western Ethiopia. We found that although the general awareness of HIV was high, correct knowledge of the virus and its modes of transmission was shown in only 44% of adolescent boys and 41% of adolescent girls. Knowledge of HIV and condoms was lower among students whose parents were farmers, significant so among girls (p=0.02). Use of condoms among sexually active single male students (49%) was insufficient but was higher than among adolescents in many other African settings. Knowledge of STDs was generally low: 82% of adolescent males and 37% of adolescent females had some awareness of STDs. Almost 20% of sexually active males in the study had previously experienced an STD, almost all of whom had visited a commercial sex worker. Targeted interventions are warranted among adolescents and sex workers in Ethiopia complemented by STD treatment services.

Adolescent↗
PubMed2004

The sexual health of pupils in years 4 to 6 of primary schools in rural Tanzania.

BACKGROUND/OBJECTIVES: There is an urgent need for effective interventions to improve the sexual and reproductive health of adolescents. Reliable data on the sexual health of adolescents are needed to guide the development of such interventions. The aim was to describe the sexual health of pupils in years 4 to 6 of 121 rural primary schools in north western Tanzania, before the implementation of an innovative sexual health intervention in 58 of the schools. METHODS: A cross sectional survey of primary school pupils in rural Tanzania was carried out. The study population comprised pupils registered in years 4 to 6 of 121 primary schools in 20 rural communities in 1998. Basic demographic information was collected from all pupils seen. Those born before 1 January 1985 (aged approximately 14 years and over) were invited to participate in the survey, and asked about their knowledge and attitudes towards sexual health issues, and their sexual experience. A urine specimen was requested and tested for HIV, Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and, for females, pregnancy. RESULTS: 9283 pupils born before 1 January 1985 were enrolled and provided demographic information and a urine sample. Male pupils were significantly older than females (mean age 15.5 years v 14.8 years, p<0.001), but all other demographic characteristics were similar between the sexes. 14 (0.2%) of the enrolled pupils (four male and 10 female) were HIV positive, 83 (0.9%) were positive for CT, and 12 (0.1%) for NG. 32 female pupils (0.8%) were positive by pregnancy test. Sexual experience was reported by one fifth of primary school girls, and by almost half of boys. Only 45/114 (39%) girls with biological markers of sexual activity reported having had sex. CONCLUSIONS: HIV, CT, NG, and pregnancy were present though at relatively low levels among pupils in years 4 to 6 of primary school. A high proportion of pupils with a biological marker of sexual activity denied ever having had sex. Alternative ways of collecting sensitive data about the sexual behaviour of school pupils should be explored.

Adolescent↗
PubMed2003

Comparison of STD prevalences in the Mwanza, Rakai, and Masaka trial populations: the role of selection bias and diagnostic errors.

OBJECTIVES: To assess bias in estimates of STD prevalence in population based surveys resulting from diagnostic error and selection bias. To evaluate the effects of such biases on STD prevalence estimates from three community randomised trials of STD treatment for HIV prevention in Masaka and Rakai, Uganda and Mwanza, Tanzania. METHODS: Age and sex stratified prevalences of gonorrhoea, chlamydia, syphilis, HSV-2 infection, and trichomoniasis observed at baseline in the three trials were adjusted for sensitivity and specificity of diagnostic tests and for sample selection criteria. RESULTS: STD prevalences were underestimated in all three populations because of diagnostic errors and selection bias. After adjustment, gonorrhoea prevalence was higher in men and women in Mwanza (2.8% and 2.3%) compared to Rakai (1.1% and 1.9%) and Masaka (0.9% and 1.8%). Chlamydia prevalence was higher in women in Mwanza (13.0%) compared to Rakai (3.2%) and Masaka (1.6%) but similar in men (2.3% in Mwanza, 2.7% in Rakai, and 2.2% in Masaka). Prevalence of trichomoniasis was higher in women in Mwanza compared to women in Rakai (41.9% versus 30.8%). Herpes simplex virus type 2 (HSV-2) seroprevalence and prevalence of serological syphilis (TPHA+/RPR+) were similar in the three populations but the prevalence of high titre syphilis (TPHA+/RPR >/=1:8) in men and women was higher in Mwanza (5.6% and 6.3%) than in Rakai (2.3% and 1.4%) and Masaka (1.2% and 0.7%). CONCLUSIONS: Limited sensitivity of diagnostic and screening tests led to underestimation of STD prevalence in all three trials but especially in Mwanza. Adjusted prevalences of curable STD were higher in Mwanza than in Rakai and Masaka.

Diagnostic Errors↗
PubMed2003

Baseline survey of sexually transmitted infections in a cohort of female bar workers in Mbeya Region, Tanzania.

OBJECTIVES: To determine baseline prevalence of sexually transmitted infections (STI) and other reproductive tract infections (RTI) and their association with HIV as well as sociodemographic and behavioural characteristics in a newly recruited cohort of female bar workers in Mbeya Region, Tanzania. METHODS: 600 female bar workers were recruited from 17 different communities during September to November 2000 and underwent gynaecological examination, laboratory testing for HIV/STI, and interviews using structured questionnaires. RESULTS: HIV-1 seroprevalence was 68%. Prevalences of STI/RTI were high titre syphilis (TPPA/RPR >/=1/8), 9%; herpes simplex virus 2 antibodies, 87%; chlamydia, 12%; gonorrhoea, 22%; trichomoniasis, 24%; and bacterial vaginosis, 40%. HIV infection was associated with TPPA and HSV-2 seropositivity, bacterial vaginosis and clinically diagnosed genital ulcers, blisters, and warts. Reported high risk sexual behaviour during the past year (having multiple casual partners) was associated with prevalent STI. CONCLUSION: Female bar workers in Mbeya are at high risk of STI and HIV infection. Targeted STI/HIV prevention interventions for these women and their sexual partners need to be reinforced. Methods should be sought to improve healthcare seeking and to provide easily accessible and affordable STI care services.

Adult↗
PubMed2002

STD/HIV intervention and research programme Mwanza Region, NW Tanzania.

The social determinants and epidemiology of sexually transmitted disease (STD) were studied in rural communities in Mwanza Region, Tanzania, in the context of the phase specific model of STD transmission. The prevalence of HIV and syphilis was higher in communities close to main roads, and lower in communities living on islands in Lake Victoria, probably reflecting the proportion of high risk individuals in the population. The prevalence of Herpes simplex virus type 2 infection, gonorrhoea, chlamydial infection, and trichomoniasis was similar in all types of community, reflecting the fact that these infections remain in the hyperendemic phase. The transmission of STDs is fuelled by high population mobility and by the presence of high risk individuals in rural as well as roadside communities.

Developing Countries↗
PubMed2001

Prevalence of HIV and Chlamydia trachomatis infection in 15--19-year olds in rural Tanzania.

OBJECTIVE: To estimate the prevalence of HIV and Chlamydia trachomatis (CT) infections amongst adolescents in rural Mwanza Region, Tanzania and their association with demographic variables. DESIGN: Population-based cross-sectional survey. METHODS: All 15--19-year olds living in households selected by random cluster sampling were invited to participate. After interview, urine was tested for HIV and CT. RESULTS: 9445 15--19-year olds were enrolled. HIV prevalence was 0.6% (95% CI: 0.4--0.8%) in males and 2.4% (95% CI: 2.0--2.8%) in females, and increased steeply with age (trend: P < 0.006 and P < 0.001, respectively). After adjustment for age, risk of HIV infection was significantly associated with female sex (OR=4.3), never having been to primary school in males (OR=2.7), and current symptoms of genital discharge (OR=2.3) or genital ulcer (OR=5.3) in females. The prevalence of CT was 1.0% (95% CI: 0.8--1.4%) in males and 2.4% (95% CI: 2.0-2.9%) in females. After adjustment for age, CT infection was associated with female sex (OR=2.4), reported current symptoms of STD (males OR=2.5, females OR=1.9) and positive leucocyte esterase (LE) test (males OR=3.1, females OR=2.6). Eighty-two percent of males and 79% of females with CT were asymptomatic. There was no association between CT and HIV infection in either sex. CONCLUSIONS: There is a high prevalence of HIV and CT amongst adolescents, especially young women, in this rural population, highlighting the need for effective interventions to improve adolescent reproductive health. The high rates of asymptomatic infection imply that innovative strategies are needed to reach and treat young people with STD.

Adolescent↗
PubMed2001

How many patients with a sexually transmitted infection are cured by health services? A study from Mwanza region, Tanzania.

OBJECTIVES: To estimate the proportion of symptomatic patients with a bacterial sexually transmitted infection (STI) cured by primary health care services in Mwanza Region, Tanzania, and to compare the cure rate achieved by health centres before and after the introduction of improved STI treatment services. METHODS: A model was used that describes the different hurdles patients with an STI take before they can be considered cured by the health services. The values for the input parameters for the model were taken from different studies. Data from an intervention trial as well as from a population-based study on male urethritis were used to estimate the proportion of symptomatic patients with an STI who seek care from a health centre. An observational study in four health centres where improved STI treatment services had been introduced provided estimates of the proportions of patients with an STI correctly diagnosed and treated. Patients who returned to the health centres after 1 week were interviewed about compliance. An estimate of the efficacy of treatments prescribed for STIs in health centres before the introduction of improved STI services was obtained from a study on prescription patterns for genital discharge syndrome (GDS) and genital ulcer disease (GUD). RESULTS: It was estimated that in the catchment area of health centres offering improved STI services, 51-72% of patients with STI symptoms sought care from those health centres. About 76-85% of cases were correctly diagnosed, and of these 69-80% received efficacious treatment. Compliance with full treatment was estimated at 84%. The estimated overall cure rate achieved by the health centres offering improved STI services ranged between 23 and 41%. The proportion of symptomatic STI patients who attended a health centre before improved STI services were introduced was estimated at 39%. The estimated efficacy of the treatments prescribed was 28%. The overall cure rate achieved by these health centres was less than 10%. CONCLUSIONS: When assessing the performance of STI case detection and management all steps have to be taken into account that are taken by patients with an STI before they can be considered cured by the health services. The intervention to improve STI services in Mwanza Region has resulted in an improvement of the cure rate of STIs achieved by primary health care centres.

Adolescent↗
PubMed2001

Risk factors for active syphilis and TPHA seroconversion in a rural African population.

OBJECTIVES: Syphilis is an important cause of morbidity in sub-Saharan Africa, and a cofactor for the sexual transmission of HIV. A better understanding of the prevalence and risk factors of syphilis in African populations would help to formulate effective interventions for its prevention and treatment. METHODS: The prevalence and incidence of syphilis were obtained from a cohort recruited in Mwanza, Tanzania. Two unmatched case-control studies nested within the cohort provide information on potential risk factors. RESULTS: The prevalence of active syphilis (TPHA positive and RPR positive any titre) was 7.5% in men and 9.1% in women, but in youths (aged 15-19 years) the prevalence was higher in women (6.6%) than in men (2.0%). The incidence of TPHA seroconversion was highest in women aged 15-19 at 3.4% per year, and around 2% per year at all ages among men. A higher prevalence of syphilis was found in those currently divorced or widowed (men: OR=1.61, women: OR=2.78), and those previously divorced or widowed (men: OR=1.51, women: OR=1.85). Among men, prevalence was associated with lack of circumcision (OR=1.89), traditional religion (OR=1.55), and reporting five or more partners during the past year (OR=1.81) while incidence was associated with no primary education (OR=2.17), farming (OR=3.85), and a self perceived high risk of STD (OR=3.56). In women, prevalence was associated with no primary education (OR=2.13), early sexual debut (OR=1.59), and a self perceived high risk of STD (OR=3.57), while incidence was associated with living away from the community (OR=2.72). CONCLUSION: The prevalence and incidence of syphilis remain high in this rural African population. More effort is needed to promote safer sexual behaviour, and to provide effective, accessible treatment. The high incidence of syphilis in young women calls for sexual health interventions targeted at adolescents.

Adolescent↗
PubMed2001

The interrelation of HIV, cervical human papillomavirus, and neoplasia among antenatal clinic attenders in Tanzania.

OBJECTIVES: To determine the prevalence and interrelation of cervical human papillomavirus (HPV) genotypes, squamous intraepithelial lesions (SIL), HIV, and other reproductive tract infections (RTIs) among urban antenatal clinic attenders in Mwanza, Tanzania. METHODS: Genital swabs were collected from 660 pregnant women and tested for a range of RTIs and for cervical cytology. Cervical HPV-DNA was detected by PCR and genotyped. HIV and syphilis serologies were performed. RESULTS: HPV prevalence was 34% (209/612 women). Of the 144 typeable samples, 83% were high risk (HR-HPV) oncogenic strains (56% HPV 16 related types). SIL was detected in 43 women (7%), with high grade SIL in 3%. There was a high prevalence of HIV (15%), and of any RTI (83%). Genital warts were detected in 20 women (3%). HPV infection was associated with some behavioural factors (short duration of relationship, single status, not using condoms) and gonorrhoea. There was no overall association between HPV and HIV (OR=1.02, 95% CI 0.6-1.6), but a non-significant trend towards a stronger association with HR-HPV in women aged 15-19 (OR=2.79, 95% CI 0.8-9.5) and women aged > or =30 (OR=3.20, 95% CI 0.7-15). SIL was associated with HPV (OR=3.66, 95% CI 1.9-7.0), but not significantly with HIV (OR=1.54, 95% CI 0.7-3.4). Prevalence of SIL was higher among women dually positive for HPV/HIV compared to HPV infection only (21% v 12%), although this difference was not statistically significant (p=0.17). CONCLUSIONS: HPV infection was highly prevalent in this young antenatal population. The association of HIV with HR-HPV types in older women may suggest that the principal HIV/HPV interaction in this population is for HIV to upregulate HPV persistence, leading to subsequent development of SIL.

Adolescent↗
PubMed2000

Syndromic treatment of sexually transmitted diseases reduces the proportion of incident HIV infections attributable to these diseases in rural Tanzania.

OBJECTIVES: To compare the proportion of HIV seroconversions attributable to other sexually transmitted diseases in the intervention and comparison arms of the Mwanza sexually transmitted diseases (STD) intervention trial. DESIGN: Case-control study of 96 cases of HIV seroconversion and 974 HIV-negative controls, nested within the Mwanza trial cohort. METHODS: Data on reported STD symptoms during 2 years of follow-up, and serological evidence of recent syphilis, were used to obtain odds ratios (ORs) for HIV seroconversion, adjusted for community, age, marital status, sex partners and travel. Population-attributable fractions (PAF) of HIV seroconversions associated with these STD exposures were calculated separately for the intervention and comparison arms, and for men and women. RESULTS: In men in the comparison arm, adjusted ORs for ulcers (14.8), discharge (3.3), any symptom (4.1) and any STD (4.0) were highly significant. There were no significant associations between HIV incidence and STD exposures in the intervention arm. The PAF were consistently higher in the comparison arm than the intervention arm. In men, the PAF for any STD was 39.6% [95% confidence interval (CI), 12.4-58.3)] in the comparison arm but only 12.0% (CI, 0.0-35.9) in the intervention arm. The PAF for women were lower than for men. CONCLUSIONS: These are minimal PAF estimates and they do not account for STD effects on HIV infectiousness. Nevertheless, a substantial proportion of new HIV infections in men in the comparison arm were attributable to STD. Lower PAF in the intervention arm than in the comparison arm for men provide further evidence of the role of STD cofactors in HIV transmission, supporting the hypothesis that the Mwanza intervention reduced the duration of symptomatic STD, thus reducing the HIV risk associated with such STD.

Adolescent↗
PubMed2000

Control of sexually transmitted diseases for HIV-1 prevention: understanding the implications of the Mwanza and Rakai trials.

Two randomised controlled trials of sexually transmitted disease (STD) treatment for the prevention of HIV-1 Infection, in Mwanza, Tanzania, and Rakai, Uganda, unexpectedly produced contrasting results. A decrease in population HIV-1 incidence was associated with improved STD case management in Mwanza, but was not associated with STD mass treatment in Rakai. Some reductions in curable STDs were seen in both studies. These trials tested different interventions in different HIV-1 epidemic settings and used different evaluation methods; the divergent results may be complementary rather than contradictory. Possible explanations include: differences in stage of the HIV-1 epidemic, which can influence exposure to HIV-1 and the distribution of viral load in the infected population; potential differences in the prevalence of Incurable STDs (such as genital herpes); perhaps greater Importance of symptomatic than symptomless STDs for HIV-1 transmission; and possibly greater effectiveness of continuously available services than of intermittent mass treatment to control rapid STD reinfection. Implications of the trials for policy and future research agenda are discussed.

Adolescent↗
PubMed2000

Model-based evaluation of single-round mass treatment of sexually transmitted diseases for HIV control in a rural African population.

OBJECTIVES: To compare the impact of single-round mass treatment of sexually transmitted diseases (STD), sustained syndromic treatment and their combination on the incidence of HIV in rural Africa. METHODS: We studied the effects of STD interventions by stochastic simulation using the model STDSIM. Parameters were fitted using data from a trial of improved STD treatment services in Mwanza, Tanzania. Effectiveness was assessed by comparing the prevalences of gonorrhoea, chlamydia, syphilis and chancroid, and the incidence of HIV, in the general adult population in simulations with and without intervention. RESULTS: Single-round mass treatment was projected to achieve an immediate, substantial reduction in STD prevalences, which would return to baseline levels over 5-10 years. The effect on syphilis was somewhat larger if participants cured of latent syphilis were not immediately susceptible to re-infection. At 80% coverage, the model projected a reduction in cumulative HIV incidence over 2 years of 36%. A similar impact was achieved if treatment of syphilis was excluded from the intervention or confined to those in the infectious stages. In comparison with sustained syndromic treatment, single-round mass treatment had a greater short-term impact on HIV (36 versus 30% over 2 years), but a smaller long-term impact (24 versus 62% over 10 years). Mass treatment combined with improved treatment services led to a rapid and sustained fall in HIV incidence (57% over 2 years; 70% over 10 years). CONCLUSIONS: In populations in which STD control can reduce HIV incidence, mass treatment may, in the short run, have an impact comparable to sustained syndromic treatment. Mass treatment combined with sustained syndromic treatment may be particularly effective.

Adolescent↗
PubMed2000

High prevalence of trichomoniasis in rural men in Mwanza, Tanzania: results from a population based study.

OBJECTIVES: To measure the prevalence of urethral infections including trichomoniasis in rural Tanzanian men, to assess the prevalence of symptoms and signs among men with Trichomonas vaginalis, and to analyse the risk factors for trichomoniasis. DESIGN: A cross sectional study of 1004 men aged 15-54 years in a rural community in north west Tanzania. METHODS: Participants were interviewed about sexual behaviour and symptoms of sexually transmitted diseases. First fraction urine samples and urethral swabs were collected and used to test for T vaginalis by wet preparation and culture, Neisseria gonorrhoeae by culture, Chlamydia trachomatis by ligase chain reaction and non-specific urethritis by Gram stain. Urine was also tested for the presence of leucocytes using a leucocyte esterase dipstick. Men were re-interviewed 2 weeks later to document new symptoms and signs of urethritis. RESULTS: Complete laboratory results were available on 980 men. One in four men had laboratory evidence of urethritis. T vaginalis was found in 109 individuals (11%), gonorrhoea in eight (0.8%), and chlamydial infection in 15 (1.5%). Over 50% of men with urethritis were asymptomatic. The prevalence of signs and symptoms was similar among men with T vaginalis alone compared with men with other urethral infections. The sensitivity and specificity of the leucocyte esterase dipstick (LED) test for detecting T vaginalis were 80% and 48% respectively in symptomatic men and 60% and 68% in asymptomatic men. Factors associated with trichomoniasis included religion, type of employment, and marital status. CONCLUSIONS: A high prevalence of urethritis was found in men in this community based study. More than half of the urethral infections detected were asymptomatic. The most prevalent pathogen was T vaginalis. Studies are needed on the prevalence of trichomoniasis in men presenting to health services with complaints suggestive of urethritis since treatment for T vaginalis is not included in the syndromic management of urethritis in most countries. The performance of the LED test as a screening test for trichomoniasis was unsatisfactory in both symptomatic and asymptomatic men. Improved screening tests are urgently needed to identify urethral infections that are asymptomatic and which are not covered by current syndromic management algorithms.

Adolescent↗
PubMed2000

Operational performance of an STD control programme in Mwanza Region, Tanzania.

OBJECTIVES: To describe important details of the design and operational features of the Mwanza sexually transmitted diseases (STD) control programme. To assess the feasibility of the intervention, the distribution of STD syndromes observed, the clinical effectiveness of syndromic STD case management, the utilisation of STD services by the population, and the quality of syndromic STD services delivered at rural health units. METHODS: The intervention was integrated into rural primary healthcare (PHC) units. It comprised improved STD case management using the syndromic approach, facilitated by a regional programme office which ensured the training of health workers, a reliable supply of effective drugs, and regular support supervision. Five studies were performed to evaluate operational performance: (i) a survey of register books to collect data on patients presenting with STDs and reproductive tract infections (RTIs) to rural health units with improved STD services, (ii) a survey of register books from health units in communities without improved services, (iii) a survey of register books from referral clinics, (iv) a home based cross sectional study of STD patients who did not return to the intervention health units for follow up, (v) a cross sectional survey of reported STD treatment seeking behaviour in a random cohort of 8845 adults served by rural health units. RESULTS: During the 2 years of the Mwanza trial, 12,895 STD syndromes were treated at the 25 intervention health units. The most common syndromes were urethral discharge (67%) and genital ulcers (26%) in men and vaginal discharge (50%), lower abdominal tenderness (33%), and genital ulcers (13%) in women. Clinical treatment effectiveness was high in patients from whom complete follow up data were available, reaching between 81% and 98% after first line treatment and 97%-99% after first, second, and third line treatment. Only 26% of patients referred to higher levels of health care had presented to their referral institutions. During the trial period, data from the cohort showed that 12.8% of men and 8.6% of women in the intervention communities experienced at least one STD syndrome. Based on various approaches, utilisation of the improved health units by symptomatic STD patients in these communities was estimated at between 50% and 75%. During the first 6 months of intervention attendance at intervention units increased by 53%. Thereafter, the average attendance rate was about 25% higher than in comparison communities. Home visits to 367 non-returners revealed that 89% had been free of symptoms after treatment, but 28% became symptomatic again within 3 months of treatment. 100% of these patients reported that they had received treatment, but only 74% had been examined, only 57% had been given health education, and only 30% were offered condoms. Patients did not fully recall which treatment they had been given, but possibly only 63% had been treated exactly according to guidelines. CONCLUSIONS: This study demonstrated that it is feasible to integrate effective STD services into the existing PHC structure of a developing country. Improved services attract more patients, but additional educational efforts are needed to further improve treatment seeking behaviour. Furthermore, clear treatment guidelines, a reliable drug supply system, and regular supervision are critical. All efforts should be made to treat patients on the spot, without delay, as referral to higher levels of care led to a high number of dropouts. The syndromic approach to STD control should be supported by at least one reference clinic and laboratory per country to ensure monitoring of prevalent aetiologies, of the development of bacterial resistance, and of the effectiveness of the syndromic algorithms in use.

Adolescent↗