Tina Hylton-Kong

Genital Ulcers: Etiology, Clinical Diagnosis, and Associated Human Immunodeficiency Virus Infection in Kingston, Jamaica

Individuals presenting consecutively with genital ulcers in Kingston, Jamaica, underwent serological testing for human immunodeficiency virus (HIV) infection, chlamydial infection, and syphilis. Ulcer material was analyzed by multiplex polymerase chain reaction (M-PCR) analysis. DNA from herpes simplex virus (HSV), Haemophilus ducreyi, and Treponema pallidum was detected in 158 (52.0%), 72 (23.7%), and 31 (10.2%) of 304 ulcer specimens. Of the 304 subjects, 67 (22%) were HIV-seropositive and 64 (21%) were T. pallidum-seroreactive. Granuloma inguinale was clinically diagnosed in nine (13.4%) of 67 ulcers negative by M-PCR analysis and in 12 (5.1%) of 237 ulcers positive by M-PCR analysis (P = .03). Lymphogranuloma venereum was clinically diagnosed in eight patients. Compared with M-PCR analysis, the sensitivity and specificity of a clinical diagnosis of syphilis, herpes, and chancroid were 67.7%, 53.8%, and 75% and 91.2%, 83.6%, and 75.4%, respectively. Reactive syphilis serology was 74% sensitive and 85% specific compared with M-PCR analysis. Reported contact with a prostitute in the preceding 3 months was associated with chancroid (P = .009), reactive syphilis serology (P = .011), and HIV infection (P = .007). The relatively poor accuracy of clinical and locally available laboratory diagnoses pleads for syndromic management of genital ulcers in Jamaica. Prevention efforts should be intensified.

Self-reported condom use is associated with reduced risk of Chlamydia, Gonorrhea, and Trichomoniasis

Objectives: To evaluate the association between self-reported condom use and prevalent and incident chlamydia, gonorrhea, and trichomoniasis. Study Design: Prospective study of 414 males attending a sexually transmitted infection (STI) clinic in Jamaica. Condom use and STI status were assessed at enrollment and at 4 follow-up visits. Results: The analyses on condom use and prevalent STI included data from 414 men, while those on incident STI were based on 1111 intervals from 355 men. We diagnosed prevalent STI (chlamydia, gonorrhea, and/or trichomoniasis) in 54.6% (n = 226) of the participants at enrollment. About 14% (n = 51) of participants had at least 1 of the study STIs during follow-up. Follow-up visits in which participants reported consistent condom use (100% of acts) for the past 7 days had less incident STI (adjusted OR, 0.4; 95% CI, 0.2–0.9) compared with visits where no condom use was reported. Self-reported condom use was more closely correlated with incident than prevalent STI. For example, the adjusted OR for prevalent infection for participants reporting consistent versus no condom use in past 7 days was 0.7 (95% CI, 0.4–1.2). Classifications based on the number of unprotected acts yielded findings similar to those based on the proportion of acts protected. Conclusions: Consistent condom use was associated with reduced risk of incident urethral STI. Research on condom effectiveness should focus on incident STI outcomes, where the temporal relationship between condom use and infection is clearer.

Hormonal contraception and the risks of STI acquisition: results of a feasibility study to plan a future randomized trial☆

BACKGROUND Because of limitations in observational studies, a randomized controlled trial (RCT) would help clarify whether hormonal contraception increases the risks of acquiring a sexually transmitted infection (STI). However, the feasibility of such a trial is uncertain. STUDY DESIGN We conducted a study to assess the feasibility of conducting a RCT that would compare the acquisition risk for Chlamydia trachomatis and Neisseria gonorrhoeae in women randomized to an intrauterine device (IUD) or depot medroxyprogesterone acetate (DMPA). In our cross-sectional survey conducted at three clinics, we gave information on a potential RCT to clients, asked them questions to assess comprehensibility and finally asked respondents whether they would consider enrolling in such a trial. In addition, the 190 participants provided urine or endocervical swab specimens so we could estimate the prevalence of STIs. RESULTS Overall, 70% of participants stated that they would take part in a future trial and accept randomization to either the IUD or DMPA. Participant understanding of the trial requirements was high. Twenty-nine percent of the participants were infected with either N. gonorrhoeae or C. trachomatis. CONCLUSION With a high prevalence of STI in this population and the apparent willingness of appropriate candidates to participate, an RCT to measure risks of incident STI infection from hormonal contraception appears feasible.

Randomized Controlled Trial on the Effectiveness of Counseling Messages for Avoiding Unprotected Sexual Intercourse During Sexually Transmitted Infection and Reproductive Tract Infection Treatment Among Female Sexually Transmitted Infection Clinic Patients

Background The effectiveness of counseling messages to avoid unprotected sex during short-term treatment for curable sexually transmitted infections is unknown. Methods We randomized 300 female STI clinic patients 18 years or older with cervicitis and/or vaginal discharge in Kingston, Jamaica, in 2010 to 2011, to 1 of 2 counseling messages for their course of syndromic treatment: abstinence only or abstinence backed up by condom use. At a follow-up visit 6 days afterward, we collected vaginal swabs to test for prostate-specific antigen (PSA), a biological marker of recent semen exposure, and administered a questionnaire assessing sexual behavior. Results No differences were found in the proportions of women testing positive for PSA at follow-up in the abstinence-plus-condom group (11.9%) and abstinence-only group (8.4%) (risk difference, 3.5; 95% confidence interval, −3.5 to10.5). There also was no significant difference in reporting of unprotected sex between groups. Reporting a history of condom use before enrollment significantly modified the effect of counseling arm on PSA positivity (P = 0.03). Among those reporting recent condom use, 10.3% in the abstinence-only arm and 4.8% in the abstinence-plus-condom arm tested positive for PSA. Conversely, among those not reporting recent condom use, 6.5% in the abstinence-only arm and 17.3% in the abstinence-plus-condom arm had PSA detected. Conclusions We found no evidence to support the superiority of either counseling message. Post hoc analyses suggest that women with recent condom experience may benefit significantly more from abstinence-plus-condom messages, whereas women without such experience may benefit significantly more from abstinence-only messages. Providers should weigh individual condom use history when determining the most appropriate counseling message.

Does a choice of condoms impact sexually transmitted infection incidence? A randomized, controlled trial.

Objective: The objective of this study was to assess whether providing a choice of condoms would increase condom acceptability, increase self-reported use, and decrease incident sexually transmitted infection. Study: We randomized 414 men presenting with urethral discharge in Jamaica to receive either the “standard” clinic condom or a choice of 4 different types of condoms. Men were treated presumptively at enrollment and followed up at 1, 2, 4, and 6 months. Results: Participants in the choice group had a strong preference (P <0.01) for the most popular condom available in Jamaica. This preference did not translate into higher condom use (P = 0.16). The 6-month cumulative probability of first incidence of gonorrhea, chlamydia, or trichomoniasis was slightly higher in the choice group (21%; 95% confidence interval [CI], 15–28%) versus the control group (17%; 95% CI, 11–23%); the difference in the survival curves was not significant (P = 0.35). Conclusion: A choice of condoms may increase perceived acceptability but not lead to increased condom use and subsequently lower sexually transmitted infection rates.

Exploring Discordance Between Biologic and Self-Reported Measures of Semen Exposure: A Qualitative Study Among Female Patients Attending an STI Clinic in Jamaica

We explored the use of qualitative interviews to discuss discrepancies between two sources of information on unprotected sex: biomarker results and self-reported survey data. The study context was a randomized trial in Kingston, Jamaica examining the effect of STI counseling messages on recent sexual behavior using prostate-specific antigen (PSA) as the primary study outcome. Twenty women were interviewed. Eleven participants were selected because they tested positive for PSA indicating recent semen exposure, yet reported no unprotected sex in a quantitative survey (“discordant”): 5 reported abstinence and 6 reported condom use. Nine participants who also tested positive for PSA but reported unprotected sex in the survey were interviewed for comparison (“concordant”). Qualitative interviews with 6 of the 11 discordant participants provided possible explanations for their PSA test results, and 5 of those were prompted by direct discussion of those results. Rapid PSA testing combined with qualitative interviews provides a novel tool for investigating and complementing self-reported sexual behavior.

Association of Progestin Contraceptive Implant and Weight Gain.

OBJECTIVE: To evaluate initiation of a two-rod, 150-mg levonorgestrel contraceptive implant on womens perceived and observed body weight. METHODS: We conducted a secondary analysis of data from an open, randomized controlled trial of adult, nonpregnant, human immunodeficiency virus-negative women attending a public clinic in Kingston, Jamaica, who were assigned to initiate implant use either immediately or after a 3-month delay. The primary objective of the parent study was to assess the effect of initiation of the implant on the frequency of condom use. We compared study arms during follow-up using one-sided &khgr;2 tests for differences in perceived weight gain and loss, one-sided Wilcoxon-Mann-Whitney tests for median gain in measured weight, and logistic regression with generalized estimating equations for risk of gaining greater than 2 kg. RESULTS: From 2012 to 2014, women were assigned to the implant (n=208) or delay arm (n=206). At 3 months, more women in the implant arm (15.3%) reported perceived weight gain than in the control arm (4.3%) (P=.01). Despite differences in perception, the implant and control arms did not differ significantly in median weight gain at 1-month (0.0 kg and 0.0 kg, respectively; P=.44) and 3-month visits (0.5 kg and 0.0 kg, respectively; P=.27). Study arms did not differ in risk of gaining greater than 2 kg (odds ratio 0.9, 95% confidence interval 0.6–1.3). CONCLUSION: We found no evidence of weight gain from short-term implant use. Through the power of the nocebo effect, the practice of counseling women to expect possible weight gain from initiating implant use could lead them to perceive weight gain even in its absence and contribute to the early discontinuation of this highly effective contraceptive method.

Differences in misreporting of sexual behavior over time: implications for HIV trials

We used data from a prospective study of 300 women attending a sexually transmitted infection clinic in Kingston, Jamaica, to compare participant self-report of recent semen exposure to actual semen exposure measured by prostate-specific antigen in vaginal swabs. Underreporting of semen exposure was significantly more frequent at follow-up than baseline, suggesting that the accuracy of reports of sexual behavior may vary over time.

Assessing prevalence of missed laboratory-confirmed sexually transmitted infections among women in Kingston, Jamaica: results from a secondary analysis of the Sino-Implant clinical trial

Objectives To assess potentially missed sexually transmitted infections (STIs), we compared clinically diagnosed STIs to laboratory-confirmed diagnoses of gonorrhoea (GC), chlamydia (CT) and trichomonas (Tvag). Design Secondary analysis of a randomised controlled trial. Setting We used data and specimens previously collected for the Sino-Implant Study in Kingston, Jamaica. Participants The Sino-Implant Study randomised 414 women to receive a levonorgestrel implant at either baseline or 3 months post-enrolment to evaluate unprotected sex after implant initiation. This analysis used 254 available vaginal swab samples. Outcome measures Clinically diagnosed STIs were determined from medical records by assessing clinical impressions and prescriptions. Laboratory-confirmed STIs included GC, CT and Tvag tested by Aptima Combo 2 for CT/GC and Aptima Tvag assays (Hologic, San Diego, California, USA). Log-binomial regression models fit with generalised estimating equations were used to estimate associations of clinically diagnosed STIs with laboratory-confirmed diagnoses and demographic and behavioural characteristics. Results Overall, 195 (76.8%) women had laboratory-confirmed STI (CT, GC or Tvag) while only 65 (25.6%) women had clinically diagnosed cervicitis and/or vaginitis during the study period. Clinical diagnosis missed 79.7% of laboratory-confirmed STIs: 85% of GC (n=17/20), 78.8% of CT (n=141/179) and 80.0% of Tvag (n=180/225). Hormonal contraceptive use in the month prior to the study visit was significantly associated with clinical diagnosis at any time point (prevalence ratio (PR): 1.65, 95% CI 1.07 to 2.54). As age increased, clinically missed infections significantly decreased (PR: 0.98 per year increase, 95% CI 0.97 to 1.00). Conclusions The prevalence of laboratory-confirmed STIs was much higher than what was captured by clinical diagnosis. GC, CT and Tvag were not accurately detected without lab confirmation. Missed diagnoses decreased with older age. Increased laboratory capacity and refinement of the syndromic approach are needed to protect the health of sexually active Jamaican women. Trial registration number NCT01684358.

P3-S1.17 Syndromic management of cervicitis and vaginal discharge at a STI clinic in Jamaica: low cure rates for Chlamydial infection and trichomoniasis

Background Management of cervicitis and abnormal vaginal discharge in Jamaica is based on the syndromic approach recommended by the WHO. To evaluate current algorithms for treatment of gonorrhoea, chlamydial infection and trichomoniasis, we conducted laboratory testing with vaginal specimens from women presenting with cervicitis or vaginitis syndromes at a sexually transmitted infections clinic in Kingston and at follow-up to assess cure rates for these infections. Methods From August, 2010 through January, 2011, vaginal swab specimens were obtained from 258 women >18 years old during a routine clinical examination prior to syndromic treatment according to local guidelines. Treatment for gonorrhoea, chlamydial infection and trichomoniasis was prescribed for women with cervicitis. Treatment for trichomoniasis, bacterial vaginosis and candidiasis was prescribed for women with abnormal vaginal discharge. Women returned the next week for follow-up assessment and specimen collection. Specimens were tested for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) using APTIMA Combo2 and for Trichomonas vaginalis (TV) using APTIMA analyte-specific reagents. All baseline specimens were tested. Follow-up specimens from women with a positive baseline test or who remained symptomatic were also tested. Patients with a positive follow-up test were contacted and instructed to return to the clinic for additional treatment. Cure was defined as a positive baseline test and a negative follow-up test. Results Baseline prevalence of infection with NG was 11.7%, CT was 20.7%, TV was 25.6%. At least one of these STIs was detected by laboratory testing in 40.7% of women. Co-infections were common. Women with TV were more likely to have NG or CT than women without TV (OR: 2.6, 95% CI 1.4 to 4.8). STI testing at follow-up indicated cure rates of 77.3% for NG, 43.5% for CT and 47.1% for TV infections. CT incidence at follow-up was 5.9%; no incident NG or TV infections were detected. Conclusions With syndromic management, just over half of the STIs in women that were detected by laboratory testing at baseline were cured at follow-up. Reinfection, incorrect or inadequate treatment, failure to comply with treatment instructions or treatment failure could potentially explain prevalent STIs that were detected at follow-up. The low cure rates for chlamydial infection and trichomoniasis are cause for concern.