The Prevalence of Other Sexually Transmitted Infections in Confirmed HIV Cases at a Referral Clinic in Jamaica
Hutton-Rose, Nellian, Blythe, Charmaine, Ogbonna, Chinedu, McGrowder, Donovan, The Journal of the Royal Society for the Promotion of Health
Jamaica has the second highest number of acquired immunodeficiency syndrome (AIDS) cases and deaths in the Caribbean and a significant number of human immunodeficiency virus (HIV) infected individuals have a concomitant sexually transmitted infection (STI). The study determined the prevalence of non-ulcerative and ulcerative STIs and their association with sexual risky behaviour in a sample of HIV seropositive men and women. This study was conducted at the Comprehensive Health Centre in Jamaica, a sexually transmitted infection referral centre. The sample comprised 138 men and 132 women age 15-49 years, of average 29.5 years. The study was retrospective, from 2000 to 2002, and sample collection was randomized. The sexual behaviours of the subjects were assessed from the case records. In the 270 HIV diagnosed cases examined, the prevalence of STIs was 51.1% in men and 48.9% in women, with 85.4% having one or more STIs with an average of four STIs per patient. There was a total occurrence of 744 STIs with non-gonococcal urethritis (19.4%), gonorrhoea (17.2%), candidiasis (13.4%), trichomonas (12.4%), genital ulcer (10.4%) and syphilis (7.3%) the most common in HIV infected men and women. The presence of STI was associated with continued practice of risky sexual behaviour. The age group most implicated was the 30-34 year old, and 73.1 % of the HIV infected patients had multiple sexual partners with only 16.4% reporting frequent condom use. The study demonstrates that there is a high prevalence of non-ulcerative and to a lesser extent ulcerative STIs in HIV infected patients in Jamaica. There are significant associations between STIs and continued high risk sexual practices in HIV infected men and women. The findings support the need for implementation of effective diagnosis and treatment strategies coupled with education about safe-sex practices in HIV prevention and STI control programmes.
HIV; sexually transmitted infections; prevalence; condoms
HIV/AIDS is presently taking a heavy toll on the Caribbean, with prevalence rates that are second only to those of sub-Saharan Africa.1 In Jamaica, the rate of HIV infection is one to two per cent of the adult population.2 New HIV infections in adolescents have been increasing at an alarming rate since 1995 and adolescent females have a three times higher risk of HIV infection than males of the same age. At the end of 2000, there were 5099 cases of AIDS in Jamaica with a case fatality rate of 61.4% (3131 persons have died)3 and 60.7% of HIV/AIDS cases were attributed to heterosexual transmission.4 Similarly, there were an estimated 50,590 STI cases per 100,000 population in Jamaica (not including HIV infection) among sexually active adults in the year 2000.3 A quarter of these infected persons did not seek medical treatment and a large population of them had multiple sex partners using condoms inconsistently thus increasing the risk of STI and HIV.3
Sexually transmitted infections ranked fourth among the major cause of health centre visits for males and third for females in Jamaica. Infection with gonorrhoea accounted for 20.0% of the STI visits, syphilis 7.4% and herpes 1.7%.5 In a study of male STI clinic attendees, rates of genital ulcer disease had increased from 9.3% to 18.2%, in an eight year period and from 4.2% to 6.8% among females.6 In another Jamaican-based study of female STI clinic attendees, approximately onethird of the women aged 15-24 years tested positive for human papillomavirus (HPV) with increasing age being significantly associated with a lower prevalence of the virus.7 The risk factors reported by HIV infected Jamaicans include a history of STI (38.7%), multiple sex partners (31.8%) and sexual intercourse with a sex worker (23%).* Several STI epidemics are well documented in populations at risk for HIV9,10 suggesting that STIs may also be prevalent in HIV infected people who continue to practise risky sexual behaviours. In addition, previous research has shown prevalence of STIs in people living with HIV infection that varies from 15% to 25% depending on time intervals and inclusion criteria."'12 In a study by Osewe et al. investigating trends in the acquisition of STIs among HIV seropositive patients at sexually transmitted disease clinics, 26% of those tested positive for HIV returned with at least one STI within 5 years.13 While STIs are a serious health condition, they also act as co-factors amplifying HIV transmission dynamics between the HIV positive individual and their HIV negative partner.14
The Comprehensive Health Clinic (CHC) is a Type V Health Centre and a major referral centre for STIs and HIV/AIDS clinical care in the island of Jamaica. This is the only specialized STI clinic in West Kingston and is surrounded by the lowincome communities of Arnett Gardens, Jones Town, Craig Town and Torrington Park. These areas are noted for being vulnerable to increased violent activities, promiscuous sexual behaviour and sexual abuse including rape and incest. The aim of the present study was to estimate the point prevalence of STIs in HIV seropositive men and women attending the CHC, which can provide important information for screening people with HIV, and forecasting trends in HIV infections. We also examined demographic characteristics, condom use, illicit drug use and sexual practices among HIV positive men and women with clinically confirmed STIs.
PATIENTS AND METHOD
The records of patients with STIs who attended the Comprehensive Health Clinic, during the period January 2000 to December 2002 were reviewed for HIV seropositivity and details of demographic data. In collecting the data, a random selection of 10 HIV positive patients per month over the three years was carried out over a period of four months, March to June 2004. The sample size was 40% (n = 675) of the entire population of the Clinic. A total of 138 men and 132 women were selected, within the age range 15-49 years. Data related to the use of illicit drugs, medical history, diagnosis, and sexual practices were obtained from patient records. The study was approved by the local board of the Comprehensive Health Clinic.
Diagnosis was based on history, clinical examination and laboratory investigation. In the diagnosis of HIV, serum was collected from each patient screened. The anti-bodies were detected by enzyme linked immunosorbent assay (ELISA) technique and positive results were confirmed by Western blot (WB). Syphilis was diagnosed by DGI microscopy followed by Venereal Disease Research Laboratory (VDRL) and reactive results confirmed by fluorescent treponemal antibody absorption (FTAABS)." Gonorrhoea was diagnosed clinico bacteriologically using gram stain and culture. In male patients with urethritis, the diagnosis was made by direct microscopy of stained smears of urethral discharge. Non-gonococcal urethritis (NGU) was a diagnosis of exclusion in cases of urethritis. Chancroid was diagnosed clinically, followed by gram staining and culture in doubtful cases. Lymphogranuloma venereum (LGV) was diagnosed and clinically supplemented by the identification of elementary and inclusion bodies from the bubo plus by Giemsa Romanowsky stain. The diagnosis of herpes genitalis was made on clinical grounds supplemented by the identification of multinucleated giant cells on Tzanck smear stained by Giemsa and ELISA/Complement.
The data was analyzed using SPSS 11.0 and values of each group were compared by either a paired student's t test or two-way analysis of variance (ANOVA) followed by Benferroni multiple comparison test. P values less than 0.05 were considered to be significant.
Of the 270 HIV diagnosed cases, the prevalence of HIV was 51.1 % in men and 48.9% in women. The highest number of HIV cases belonged to the 30-34 year age group and the lowest number of cases were observed in the 45-49 year age group. Analysis of the data showed that 14.8% (n = 40) of the HIV patients had no STI while 85.2% (n = 230) had one or more STI (Table 1). More women had STIs than men in the age groups ranging from 15-29, while more men had STIs than women in the 30-49 age group (Figure 1).
There was a total occurrence of 744 STIs with women having 412 (55.4%) occurrences and men 332 (44.6%) occurrences. The mean number of STIs that was found in any of the HIV positive patients was four and this was seen in more females than males. Also the maximum number of STIs that could be found in any patient was eight and this was found in the female population. The prevalence of these STIs in HIV seropositive men and women (Table 2) were: non-gonococcal urethritis (19.4%), gonorrhoea (17.2%), candidiasis (13.4%), trichomoniasis (12.4%), genital ulcer disease (10.4%), syphilis (7.3%), bacterial vaginosis (5.8%), genital warts (3.9%), chancroid (3.2%), genital herpes (2.3%), pelvic inflammatory disease (1.6%), lymphogranuloma venerum (1.2%), hepatitis B (0.9%), granuloma inguinalie (0.8%) and human T cell lymphotrophic virus type 1 (HTLV-I) (0.3%).
Analyses of the data showed that 73.1% (n = 163) of the patients had multiple sex partners and 26.9% (n = 60) had a single partnership (Table 3). There was a progressive increase in multiple partners from 2000-2001 with a slight decrease in 2002. There were statistically significant differences between HIV positive individuals with single partners compared with those with multiple partners for the period 2000-2002 (p = 0.06). Information on condom use was reported for 220 cases: 48.4% used no condom, 35.6% seldom used, and 16.4% frequently used condoms. The prevalence of STIs among those who never used condoms was 48.4%, 35.2% among those who seldom used and 16.4% among those who frequently used condoms (Table 4). There were 46 individuals who were classified as high risk for contracting HIV and STIs and included: casual sex workers, homosexuals, drug users and prisoners.
Prevalence of HIV in male and female patients in different age groups
The Caribbean is the second most affected region in the world, and Jamaica after Haiti has the second-highest annual number of AIDS cases and deaths in the region.16 High HIV prevalence has been found among patients at sexually transmitted prevention clinics in 2002 with 8% of men attending these clinics being HIV-positive and almost 5% of the women.8 This study showed that 51.1% of the HIV infected patients were men while 48.9% were women. The age group with the highest prevalence of HIV was the 30-34 age group followed by the 25-29 age group. HIV/AIDS is the second leading cause of death in both men and women in the age group 30-39 years, and 34% of the 25,000 persons infected with HIV/AIDS Jamaica are in this age group while 20% lie in the age group 20-29 years.8
Jamaica's highest rate for HIV/AIDS occurs among those aged 15 to 24 years.17 In this study, the age groups 15-19 and 20-24 years had more women infected with HIV. Recently the Ministry of Health in Jamaica reported that adolescent females in the age group 15-19 years had three times higher risk of HIV infection than males of the same age group. In addition the rate of new HIV infection in women in the age group 20-24 years is increasing steadily more than men in the same age group.18 This is a result of social factors where young women are having sexual relations with HIV infected older men. On average 50% of young women reported that their sexual partner is 5-10 years older.18 There are studies which have reported that, due to the economic situation in developing countries, young women without a proper education and lacking employment opportunities often enter sexual relationships out of economic necessities. These women are sometimes ignorant of appropriate preventative measures and engage in unplanned or forced sexual intercourse where it may be difficult or impractical to negotiate safe sex.19,20
Ulcerative and non-ulcerative STIs in HIV seropositive patients
A report from the Ministry of Health in Jamaica stated that 39% of persons living with HIV/AIDS had a history of other sexually transmitted infections.8 In this study, 85.2% of the HIV-positive people had one or more STIs with the number of STIs greater in women than in men. There were similarities as well as differences in the prevalence of the major STIs in both HIV infected male and female patients. The most frequent diagnosis in HIV-positive men was non-gonococcal urethritis followed by gonorrhoea, genital ulcer, trichomonas, syphilis and genital warts. Women who are HIV-positive presented with nongonococcal urethritis followed by gonorrhoea, trichomonas, bacterial vaginosis, genital ulcer and syphilis. Infrequent diagnosis identified in both gender were herpes simplex virus, pelvic inflammatory disease, hepatitis B and HTLV-I. HTLV-I is endemic in Jamaica, the prevalence in the general population being 6.1%.21 The observed mixed STIs in HIV infected patients may be due to changing sexual practices with a large number of sexual contacts serving as a focus for multiple STIs.
There was a greater prevalence of nonulcerative STIs (gonorrhoea, nongonococcal urethritis or trichomonas) than ulcerative STIs (syphilis, herpes, or chancroid) in HIV infected patients. A synergistic relationship exists between HIV infection and other STIs.'4 HIV infection increases susceptibility to STIs and may have contributed to some extent to STI increases, especially of viral agents such as herpes simplex virus (responsible for genital herpes) or HPV.19 There is evidence of a potential interaction between HIV and HPV. HIV could indirectly upregulate HPV replication through decreased generalized CD4 cell function22 and decreased Langerhans cell density in the cervix.23 STIs affect factors potentially related to accelerated rates of HIV disease progression.24 Acute gonococcal cervicitis and pelvic inflammatory disease increase HIV plasma viremia through increased inflammatory cytokines such as IL-4, IL-6, IL-10 and TNF-a or through the modulation of immune responses that control HIV viremia.25
The presence of certain STIs increases HIV transmission by up to five times in developing countries.26 Non-ulcerative STIs increases HIV shedding in the genital tract, which promotes HIV infectivity and is associated with a greater HIV viral load in the semen of infected men.27 Increased viral load is associated with increased chance of infecting one's partner,28 implying that untreated STIs may increase not only the chance of any individual contracting HIV, but also the chance of infecting someone else. STIs also appear to increase susceptibility to HIV, by recruiting HIV susceptible inflammatory cells to the genital tract and by disrupting mucosal barriers to infection.29 A current or past history of genital ulcer, active syphilis and bruising during sexual intercourse are significantly associated with HIV prevalence in Jamaica.30 Gonorrhoea has been shown to be a significant risk factor for HIV infection in women, but not men.30 These data support the possibility of interrelation between HIV infection and genital ulcer infections and, perhaps, non-ulcerative STIs in Jamaica.6
Condom use and number of sexual partners among HIV seropositive patients
The presence of a STI in HIV infected patients increases the risk of acquiring other STIs, as observed in this study, where the mean number of STIs in HIV infected patients was four, with more cases of STIs in women than in men. Many HIV positive individuals who are engaging in risky sexual behaviours, such as unprotected sexual intercourse and multiple sex partners, are at elevated risk of STI acquisition, exposure to other more virulent drug resistant HIV and infecting HIV seronegative partners. The study shows that in most cases there was multiple partner involvement. One primary factor that may contribute to high-risk sexual behaviour in Jamaica is that young men are expected to initiate sexual activity very early in life and have both frequent sex and multiple sex partners.31
In this study 48% of HIV-positive patients with STIs used condoms. The importance of condom use to reduce STI and HIV was revealed in the study as the comparison of condom use over three years showed that non use and seldom use of condoms were higher in the years when the number of STIs was greatest. Studies have revealed that correct and consistent use of latex condoms can reduce the risk of STI and HIV infection. A retrospective study of HIV transmission within heterosexual couples suggested that compared to infrequent users, regular condom use reduced transmission from an HIV infected partner by 69%. In addition it was revealed that HIV infection was rare among women who reported always using a condom.32
The fact that the study population was confined to a single urban STI clinic was a limitation of this study. A retrospective study is always limited by the variability of documentation in the case record. However, by concentrating on key data such as sexual history and diagnoses we have minimized this potential bias. The study did not include actual interviews with patients where more information could have been obtained as it relates to their sexual behaviours.
The study demonstrates that there is a high prevalence of non-ulcerative and to a lesser extent ulcerative STIs in HIV infected patients in Jamaica. Condom use is quite low despite increased awareness of HIV/AIDS prevention. Our results endorse the urgent need for early diagnosis and effective treatment of STIs, especially non-gonococcal urethritis and gonorrhoea in patients with HIV infection as key components of HIV prevention and STI control programmes. Such measures, coupled with increasing public campaigns and implementation of innovative strategies to educate the adult population on risky sexual behaviour and safe sex-practices could potentially reduce the prevalence rate of STIs in HIV infected patients in Jamaica.
The authors would like to thank the staff of the Comprehensive Health Clinic and Mrs Collette Guthrie, Senior Lecturer at the University of Technology, Kingston, Jamaica. The authors would also like to thank Professor Norma McFarlaneAnderson (Department of Basic Medical Sciences) and Professor Monica Smikle (Department of Microbiology), University of the West Indies for critically reading the manuscript.
1 Henry F. Health and wealth in paradise. Perspectives in Health 2004; 9: 11-14
2 Figueroa IP. An overview of HIV/AIDS in Jamaica: strengthening the response. West Indian Medical Journal 2004; 53: 277-282
3 Ministry of Health - National Action on AIDS (NACA) report on facts and figures of STI clinic data. Kingston, Jamaica: Ministry of Health, 2001
4 Ministry of Health - Surveillance Report, 2000: 10-14. Kingston, Jamaica: Ministry of Health, 2000
5 Ministry of Health - Annual Report 1998. Kingston, Jamaica: Ministry of Health, 1999
6 Brathwaite AR, Figueroa JP, Ward E. A comparison of prevalence rates of genital ulcers among persons attending a sexually transmitted disease clinic in Jamaica. West Indian Medical Journal 1997; 46: 67-71
7 Figueroa JP, Ward E, Luthi TE, Vermund SH, Brathwaite AR, Burk RD. Prevalence of human papilloma virus STD clinic attenders in Jamaica: association of younger age and increased sexual activity. Sexual Transmitted Diseases 1995; 19: 61-77
8 Ministry of Health - National HIV/STI Programme - Fact Sheet. Jamaica AIDS Report Jan - June. Kingston: Jamaica: Ministry of Health, 2003
9 Aral SO. Heterosexual transmission of HIV: the role of other sexually transmitted infections and behaviour in its epidemiology, prevention and control. Annual Review of Public Health 1993; 14: 451 - 457
10 Aral SO, Peterman TA. Measuring outcomes of behavioural interventions for STD/HIV prevention. International Journal of STD AIDS 1996; 7 (Suppl 2): 30-38
11 Bersoff-Matcha SJ, Morgan MM, Fraser VJ, Mundy LM, Stoner BP. Sexually transmitted disease acquisition among women infected with human immunodeficiency virus type 1. The Journal of Infectious Diseases 1998; 178: 1174-1177
12 Lewis DA, Foster GE, Goh B. Gonorrhoea in HIV seropositive homosexual men attending an East London genitourinary medicine clinic. Genitourinary Medicine 1996; 72:74.
13 Osewe PL, Peterman TA, Ransom RL, Zaidi AA, Wroten JE. Trends in the acquisition of sexually transmitted diseases among HIV-positive patients at STD clinics, Miami 1988-1992. Sexual Transmitted Diseases 1996; 23:230-233
14 Wasserheit JN. Epidemiology synergy: interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sexual Transmitted Diseases 1992; 19: 61-77
15 Manual of Tests for Syphilis. U.S. Department of Health Education and Welfare, Public Health Service, Washington D.C. 1969
16 United Nations Programme on HIV/AIDS (UNAIDS). AIDS Epidemic Update, December 2003
17 United States Agency for International Development, Jamaica. Washington, D.C: USAID, 2000
18 Ministry of Health - National HIV/STD Prevention and Control Program Facts and Figures - HIV/AIDS Epidemic Update, Jamaica, January to December, 2004
19 Mayaud P, Mabey D. Approaches to the control of sexually transmitted infections in developing countries: old problems and modern challenges. Sexual Transmitted Infections 2004; 80: 174-182
20 Fawzi MC, Lambert W, Singler JM, Koenig SP, Leandre F, Nevil P, et al. Prevalence and risk factors of STD in rural Haiti: implications for policy and programming in resource-poor settings. International Journal of STD and AIDS 2003; 14: 848-853
21 Murphy EL, Figuerora JP, Gibbs WN, et al. Human T-lymphotrophic virus type-1 (HTLV-I) seropositive in Jamaica. Epidemiology 1991; 133: 1114-1124
22 Laurence J, Friedman SM, Chartash EK, Crow MK, Posnett DN. Human immunodeficiency virus infection of helper T cell clones. Early proliferative defects despite intact antigen-specific recognition and interleukin 4 secretion. The Journal of Clinical Investigation 1989; 83: 1843-1848
23 Spinillo A, Tenti P, Zappatore R, De Seta F, Silini E, Guaschino S. Langerhans cell counts and cervical intraepithelial neoplasia in women with human immunodeficiency virus infection. Gynecologic Oncology 1993: 48: 210-213
24 Levy JA. Pathogenesis of human immunodeficiency virus infection. Microbiological Reviews 1993; 57: 183-189
25 Anzala AO, Simonsen JN, Kimani J, Ball TB, Bagelkerke NJ, Rutherford J et al. Acute sexually transmitted infections increase human immunodeficiency virus type 1 plasma viremia, increase plasma type 2 cytokines, decrease CD4 cell counts. The Journal of Infectious Diseases 2000; 182: 459-466
26 Laga M, Manoka A, Kivuvu M, et al. Non-ulcerative sexually transmitted diseases as risk factors for HIV-I transmission in women: results from a cohort study. AIDS 1993; 7: 95-102
27 Cohen MS, Hoffman IF, Royce RA, et al. Reduction of concentration of HIV-1 in semen after treatment of urethritis: implications for prevention of sexual transmission of HIV-I. Lancet 1997; 349: 1868-1873
28 Gray R, Wawer M, Brookmeyer R, et al. Probability of HIV-1 transmission per coital act in monogamous heterosexuals, HIV-I discordant couples in Rakai, Uganda. Lancet 2001:357: 1149-1153
29 Spinola SM, Orazi A, Arno JN, et al. Haemophilus ducreyi elicits a cutaneous infiltrate of CD4 cells during experimental human infection. The Journal of Infect Disease 1996; 173:394-402
30 Figueroa JP, Brathwaite AR, Ward E, et al. The HIV/AIDS epidemic in Jamaica. AIDS 1995; 9: 761-768
31 Eggleston E, Jackson J, Hardee K. Sexual attitudes and behaviour among young adolescents in Jamaica. International Family Planning Perspectives 1999; 25: 78-84
32 Weller, SC. A meta-analysis of condom effectiveness in reducing sexually transmitted HIV. Social Science and Medicine 1994; 38: 1169-1170
BSc, Medical Technologist,
Department of Pathology,
University of the West
Indies, Kingston 7,
BSc, Faculty of Health and
Applied Sciences, University
of Technology, Kingston 7,
BMIS, MSc, Lecturer,
Faculty of Health and
University of Technology,
Kingston 7, Jamaica W.I.
BSc, MSc, PhD, FIBMS,
Lecturer, Department of
Pathology, University of the
West Indies, Kingston 7,
E-mail: dmcgrowd@yahoo. com
Donovan McGrowder, as above…
Questia, a part of Gale, Cengage Learning. www.questia.com
Publication information: Article title: The Prevalence of Other Sexually Transmitted Infections in Confirmed HIV Cases at a Referral Clinic in Jamaica. Contributors: Hutton-Rose, Nellian - Author, Blythe, Charmaine - Author, Ogbonna, Chinedu - Author, McGrowder, Donovan - Author. Journal title: The Journal of the Royal Society for the Promotion of Health. Volume: 128. Issue: 5 Publication date: September 2008. Page number: 242+. © SAGE PUBLICATIONS, INC. Nov 2008. Provided by ProQuest LLC. All Rights Reserved.
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