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Sexually transmitted infections (STIs) are prevalent in developing countries where diagnostic and treatment facilities are often poor. The World Health Organisation has advised an approach to prevalence assessment and management based on clinical features in areas where prevalence is high and facilities are poor. Researchers in India have shown the inaccuracies of such an approach.
Female sex workers in a red light area of the city of Surat were encouraged to attend a nearby health camp where a behavioural questionnaire was administered, clinical examination performed, and diagnostic samples collected. Testing for HIV was anonymous and unlinkable to the individual. Of an estimated 500 female sex workers in the area, 118 were studied. They reported a mean of five clients a day and 95% reported using condoms consistently. Almost 60% had no symptoms of STI when seen. The most frequently reported symptoms relevant to STI were lower abdominal pain (23 of 118), abnormal vaginal discharge (15), pain on intercourse (15), pain on micturition (13), genital itching (12), genital ulceration (7), and inguinal swelling (3). Four syndromic diagnoses were made; genital discharge syndrome (confirmed by speculum examination) 61 patients, genital ulcer syndrome (7), lower abdominal pain (23), and enlarged inguinal lymph nodes (14). Fifty one women (43%) were HIV positive. Laboratory tests were positive for syphilis (rapid papain resin (RPR) and Treponema pallidum haemagglutination assay (TPHA) test) in 27 women, gonorrhoea (gonococcal culture) in 20, genital chlamydia (Pace 2 CT assay on endocervical specimens) in 10, trichomonal infection (wet mount microscopy and culture in Whittington media) in 17. Vaginal discharge (by speculum) had a sensitivity of 88% for trichomonas infection, 70% for genital chlamydia, and 60% for gonorrhoea. The specificity of vaginal discharge for each of these infections was about 50%. Genital ulcer syndrome was 15% sensitive and 97% specific for syphilis.
STIs and HIV infection are highly prevalent among female sex workers in Surat. Diagnosis based on STI clinical syndromes misses asymptomatic cases and leads to treatment of non-infected women. STI services need to be improved for these women.
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