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  • Title: Unrecognized sexually transmitted infections in rural South African women: a hidden epidemic.
    Author: Wilkinson D, Abdool Karim SS, Harrison A, Lurie M, Colvin M, Connolly C, Sturm AW.
    Journal: Bull World Health Organ; 1999; 77(1):22-8. PubMed ID: 10063657.
    Abstract:
    Sexually transmitted infections (STIs) are of major public health concern in developing countries, not least because they facilitate transmission of human immunodeficiency virus (HIV). The present article presents estimates of the prevalence, on any given day, of STIs among women in rural South Africa and the proportion who are asymptomatic, symptomatic but not seeking care, and symptomatic and seeking care. The following data sources from Hlabisa district were used: clinical surveillance for STI syndromes treated in health facilities, microbiological studies among women attending antenatal and family planning clinics, and a community survey. Population census provided denominator data. Adequacy of drug treatment was determined through quality of care surveys. Of 55,974 women aged 15-49 years, a total of 13,943 (24.9%) were infected on any given day with at least one of Trichomonas vaginalis, Neisseria gonorrhoeae, Chlamydia trachomatis, or Treponema pallidum. Of the women investigated, 6697 (48%) were asymptomatic, 6994 (50%) were symptomatic but not seeking care, 238 (1.7%) were symptomatic and would seek care, and 14 (0.3%) were seeking care on that day. Only 9 of the 14 women (65%) were adequately treated. STIs remained untreated because either women were asymptomatic or the symptoms were not recognized and acted upon. Improved case management alone is therefore unlikely to have a major public health impact. Improving partner treatment and women's awareness of symptoms is essential, while the potential of mass STI treatment needs to be explored. Estimates of the prevalence, on any given day, of sexually transmitted infections (STIs) among rural South African women and the proportion of these women who are asymptomatic, symptomatic but not seeking care, and symptomatic and seeking care were developed through reference to data from the Hlabisa health district (KwaZulu/Natal). The prevalence of HIV among women attending antenatal clinics in Hlabisa rose from 4.2% in 1992 to 22% in 1997. Data sources included clinical surveillance for STI syndromes treated in health facilities, microbiologic studies among women attending antenatal and family planning clinics, and a community survey. The 1991 population census provided denominator data. It was estimated that, on any given day, 13,943 district women 15-49 years of age were infected with at least one STI--a point prevalence of 24.9% of the resident female population in this age group. Of these women, 6697 (48%) were asymptomatic and 7246 (52%) were symptomatic. Only 252 symptomatic women (2%) sought care and, of these, just 164 (65%) received adequate treatment. The majority of women with an STI were in the 15-29 year age group. Pregnant women were significantly less likely than nonpregnant women to have an asymptomatic infection (1% vs. 59%). Among nonpregnant women, syphilis and Trichomonas vaginalis were more likely to be asymptomatic (67% and 58%, respectively) than infection with Neisseria gonorrhoeae (37%) or Chlamydia trachomatis (36%). These findings indicate that improved STI case management alone is unlikely to improve STI control. Improving women's recognition of and treatment-seeking behavior for abnormal urogenital symptoms should increase the numbers treated, but a large burden of asymptomatic infection will remain unless screening or mass treatment is considered.
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