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1 MINISTRY OF EUDCATION AND TRAINING MINISTRY OF HEALTH NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY Nguyen Minh Quang PREVALENCE AND INFLUENCING FACTORS OF THE LOWER REPRODUCTIVE TRACT INFECTIONS AMONG FEMALE SEX WORKERS IN THE CENTRE FOR TREATMENT REHABILATION - EDUCATION - SOCIAL LABOUR II HANOI AND EVALUATION OF THE INTERVENTIONS Speciality: Social Hygiene and Health Administration Code: 62.72.01.64 THESIS SUMMARY SUPERVISORS: Associate Prof Ngo Van Toan, MD., PhD Do Hoa Binh, MD., PhD Ha Noi - 2013 THE THESIS WAS COMPLETED NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY SUPERVISORS: Associate Prof PhD NGO VAN TOAN DO HOA BINH, MD PhD Opponent 1: Opponent 2: Opponent 3: The thesis will be defended at the Assessment Commetee at Institute Level The defend at National Institute of Hygiene and Epidemiology Time: date month 2013 The thesis stored at: - National Library - National Institute of Hygiene and Epidemiology Library PUBLICATIONS Nguyen Minh Quang, Bui Van Nhon, Ngo Van Toan (2012), “Prevalence of lower genital tract infections among female sex workers in Hanoi Social Education Labor Centre in 2009-2011”, Journal of Medical Research, Volume 80, N03 Nguyen Minh Quang, Bui Van Nhon, Ngo Van Toan, Do Hoa Binh, Nguyen Thi Thuy Duong (2012), “Risk behaviors of the lower sexual tract infections among female sex workers in Hanoi Social Education Labor Centre in 2010”, Journal of Preventive Medicine, Volume XXII, N0 (133) Nguyen Minh Quang, Bui Van Nhon, Ngo Van Toan, Do Hoa Binh, Nguyen Thi Thuy Duong (2012), “Effectiveness of intervention measures to prevent the lower genital tract infections in female sex workers at Centre 02 in Hanoi city, 2010-2012”, Journal of Preventive Medicine, Volume XXII, N0 (133) INTRODUCTION Rationale of the thesis WHO defined that infections of lower reproductive tract (LRTI) are genitials infections including STDs and others LRTIs are common, dificult to determine exactly the the incident rates of the differente teritories, especial in sex workers (SW) The rate of LRTI is general high from 41-47% in the world In Vietnam, a study in 2005 reported 81.3% abnormal of reproductive tract, including 66.6% LRTI, closely related to HIV, sinificant hight in FSW Risks of LRTI in FSW are lack of knowledge and practising to prevent STD, including unsafty exual, less of condom using, many kinds of sex partners, unsatisfy contraception The stydy on efectiveness of LRTI preventive measures was carry out and it is pointed that the most effected solution is using condom for all sexual intercourses In Vietnam, there are some stydies in effectiveness of prevention HIV, however the systematic studies on LRTI are very rare This sudy aims to indicate the risk factors and efectiveness of interventions, in order to improve the knowledge and practising to prevent LRTI in FSWs , who are concentrated for treatment, rehabilation, education and social labor in the Center II, Ba Vi, Hanoi The subjects of study are: Describe the incidences and risk behaviors of LRTIs in female sex workers, who are concentrated in the Center for Treatment, Rehabilitation, Education and Social Labor II of Hanoi in 2011 Evaluate the effectiveness of interventions to prevent lower genital tract infection for female sex workers and improve the knowledge of sexually transmitted infections for medical staffs in the Center for Treatment, Rehabilitation, Education and Social Labor II of Hanoi, period 2011-2012 New contributions of the thesis This is the first systemetic study on LRTI with evaluations on incidences and efectiveness of interventions, in order to improve the knowledge and pratising for FSW, who were being in the Center II The thesis has proved the evidence on effectiveness of interventions by training, LRTI screening for FSW and performance on training to improve knowledge on managing LRTI for medical staffs of the center The thesis has identified the high incidence of LRTI in FSW and the role of condom using to prevent LRTI for all sexual intercoureses with all clients, it is also mentioned the effect of media education, advantage of initiative health care to reduce LRTI diseases in FSW The study results are used ful for the policy and planning programs in order to expand this intervention modul for the other centers over the nation Scientific and practical meanings of the thesis Scientific meaning: The study uses community intervention design, meets to subjects of research , data collection and analysis are exactly , has proved remarkable effectiveness on interventions by media education, initiative health care for FSW, has improved knowledge of managing LRTI for medical staffs of the center Practical meaning: The results of the thesis has performed the effectiveness of the intervention model to help planners and policy makers as well as presventing LRT for FSW and improve knowledge and pratising STD managing for health workers, base on that to expand this intervention model for other centers over the nation The layout of the thesis The thesis is presented in 124 pages, excluding appendixes and is divided into: Introduction: pages Chapter 1: Overview: 35 pages Chapter 2: Subjects and Methods of study: 198 pages Chapter 3: Research Results: 36 pages Chapter 4: Discussion: 27 pages Conclusions: pages Recommendations: page There are 41 tables, 11 charts The appendix includes 151 references (57 Vietnamese, 94 English), Questionnaires sheet, List of FSW , List of staffs involved in the training Chapter OVERVIEW 1.1 Basic conceptions of LRTI: By WHO, infections of lower reproductive tract (LRTI) are infection disease caused by or not by sexual transmition disease (STD) including vulgaris, vaginalis and cervicitis 1.2 Prevalance of LRTI and risk behaviors 1.2.1 Prevalence of LRTI Gonorrhea: caused by Streptococcus Gonorrhea Studies in provinces showed the incidence is 3.2 % Nguyen Trong Thuc reported on his Sentinel surveillence Research in southest province, the Gonorrhea incidence in FSW was 4.64 % This ratio is higher in the North and Middle of Vietname, the research in North border provinces described with 11.9% Gonorrhea in FSW The Gonorrhea ratio in the neiboring contries are 5.7 % in Cambodia and 9.5 % in China Syphilis: caused by Treponema pallidum Research in border provinces of Vietnam showed the incidence rate is 10.7 % in general, highest is Quang ninh (24.8 %) and Lai Chau (20.2 %) and 03 remains provinces of Dong Thap , An Giang, Kien Giang have rates ranging 5.7 - 9.4 % Chlamydiasis: is one of STD cause by Chlamydia,a parasite stained Gram (-) color A research in Provinces of Mekong Delata indicated 3.5 % FSW has positive with Chlamydia Foreign researches on FSW reported incidence rate ranging 12% -2 7.0 % in Asia and Europe countries Trichomatis: caused by Trichomonas, a parasite of anaerobic protozoa, round shape with diameter 10-20 µm The incidence rate ranging 2-2.5 % in general and 50-70 % in FSW over the world In Vietnam LRT Trichomatis incidence rate 8.13 % in FSW and 0.84 % in pregnants are reported Fungal LRTI: cause by Candidas Albicans and some time by other strains Candidas Albicans is also causing fungal diseases in many organs such as the skin and mucosal infections, Septicaemia, endocarditis, meningitis The incidence in Haiphong province is 10.7%, highest among researched provinces Research in 2005 showed fungal LRTI incidence rate is 11.9 % of FSW in South provinces Reproductive papiloma: caused by Human Papiloma Virus (HPV) Typical sumptoms are red-brown soft warts, glomerate in vulva, vagina, cervix The lessions evoke itching, discomfort due to increasing secretion, easy to bleed by touch Dianosistic based on physical symptoms, cervix luminate, HPV determine by PCR technique HPV papiloma has high ratio in FSW, accounting for 9.2 % Reproductive Herpes: caused by Herpes Simplex Virus type I, II It 's leading to obstetric accidences such as miscarriage, premature give birth, premature placental detachment Research in Hai Phong province showed the incidence rate in FSW is 3.9 % in FSW, 32.8 times higher than the lower risk groups Complex microbial LRTI - vulgaris, vaginalis: the pathogens are nonspecific, diversity Clinic symptoms are homogeneous liquid discharge with white or gray color, stinking smell Some local and overseas studies reported the incidence rate of complex microbial vulgaris, vaginalis without symtoms are quite hight (50-70 %) 1.2.2 Factors and risk behaviors afects to LRTI in FSW Age is an important factor of LRTI in teenagers Studied in Central Institute of Dermatology of Vietnam 2003-2005 and other researches indicated the incidence rate tend to be higher in women over 20 years old than the women under 19 years old 10 The incidence rate of LRTI is usually higher in group has low education and and unstable careers This is also a difficult matter on education to improve practising of LRTI prevention In fact, the low education group has shown the poor knowledge of LRTI and unsafty sexual activities, unsafety injection that entrain to high incidence of HIV and LRTI Career is important factor related to LRTI and HIV infection, the incidence rate are 14.7 %; 13.1%; 13.1 % and 8.4 %, correlatively in the groups of workers, freelances, market sellers and students Having unsafty sex is risk to be infected HIV and LRTI, in countries with high prevalences of HIV & LRTI, were recognised the main cause of very low rate of condom using (condoms) In a study in the southern provinces showed that 65% of female sex workers not use condoms during sex courses, HIV prevalence in this group was 5.2% and the proportion accounted for LRTI is high (above 80%) Average number of customers / month is one of the high-risk factor to be infected HIV and STD in FSWs Research by Centre for Disease Prevention and Control showed up to 80% of cases LRTI does not use condoms regularly, compared with 2% of LRTI cases in FSWs often use of condoms in sexcourses with clients and partners The initiative to get the tests of LRTI is meaningful in preventing infection LRTI for their clients, husband / partner and also help the women be able to access the treatment in cases of LRTIs 1.3 The LRTI prevention models 1.3.1 Communication programs for behavior change The main purpose of communication programs for behavior change is to increase awareness, knowledge, understanding of transmission LRTI and prevention measures for all the people, forthe high risk groups, eapecial FSWs Communication programs for behavior change aims to access the high-risk groups, differentiate to the other media is for community This program also provide information of to prevent LRTIs and provide services, which support to change behaviors and maintain safety sex by using condoms, resist drug abuse and personal hygiene guide 1.3.2 The program of 100% condom using The program encourages FSWs to use condom for 100% sexual intercourses (says as program 100% condom) is not simply to provide condom, but it includes many activities to improve the awareness, knowlege about 21 Infection Non infection (n=134) (n=273) Understanding Condom use OR Right 226 67.7 108 32.3 Wrong 15 68.2 31.8 1.1 95%CI 0.36-3.84 Right understanding FSW group had LRTI rate lower than the wrong group (66% compared with 71%) However, this difference was not statistic meaning Percentage of LRTI in FSW who wellknowed of condom use for all sexcourses was lower than the misunderstading group (67.7% compared with 68.2%) However, this difference is not statistically meaningful Table 3.22 The relation between self-assessment of risks and LRTIs Infection Self-assessment Non-infection (n=273) (n=134) OR 95%CI Quantity % Quantity % High risk 29 75.2 11 27.5 Low rist 39 57.4 29 42.6 0.5 0.20-1.28 No risk 98 72.6 37 27.4 1.0 0.42-2.36 Did'nt know 107 66.2 57 34.8 0.7 0.71-1.62 22 Only 9.8% FSWs had self assessment for LRTI risks (for both FSWs with or without the disease), 16.7% selfassessment for low risk, 33.2% self-assessment in no risk and 40.3% did not know whether they were at risk of LRTI or not No relation was statistic significant between self-assessment and risk of LRTIs Table 3:25 Relation between personal characteristics, risk behaviors and LTRIs by multivariative regression model Personal characteristics and behavior risks OR 95% CI Age 1.2 0.78-1.79 Ethnic group 0.8 0.53-1.34 Teritory 0.6 0.60-1.51 Education 1.1 0.66-1.36 Age of 1st sexcourse 1.2 0.72-2.08 Number of clients / month 1.1 0.81-1.36 New clients / day 1.1 0.78-1.49 Regular clients / day 1.0 0.78-1.33 New clients used condom for all sexcouses 2.5 1.07-4.09 Regular clients used condom for all sexcouses 2.3 1.12-4.10 Initiative medical exam 0.9 0.43-2.05 Iniative medical test 1.5 0.69-3.31 Self-assessment LRTI risks 1.0 0.95-1.09 Study with multivariative regression model of the relation between personal characteristics and risk behaviors with LRTI showed that no condom use for all sexcourses lead to incease risks of LRTIs The other factors was not significantly influenceto the incidence statistics of LRTIs 3.3 The effectiveness of the intervention measures to prevent LRTIs 3.3.1 Knowledge: 23 FSW understanding rate of the clinical symptoms of LRTI was much higher compared with the it's figure when FSW entered the center (51.4% to 98%) This difference was significantly meaningful for statistic with p 40 years old had highest incidence of Phylitus accounting 5% while the lowest belongs to aged 30-39 year old Research of Nguyen Van Thuc in Ho Chi Minh city showed the highest rate of Gonorrhea were FSWs aged 21-30 The results of this study also figured that FSW group living in rural areas had a higher proportion of LRTI than the FSW group in urban areas (67.6% compared with 59.3%) FSW group widowed had highest rate of LRTI (80%), followed by the FSW groups of married and unmarried (70.7% and 68.8%), lowest FSW groups had separated or divorced (62.5% and 56.9%) Group of illiteracy FSW was highest at LRTI rate (70.2%), followed by the FSW groups had secondary or high school education (67.6% and 66.7%), the lowest was primary education FSW group (64.9%) The results of this study was quite consistent with the results of the other previous researches in Vietnam The incidence of Phylitu in free-job group was higher (1.7%) than the other job groups (0.7%) The results of this study complied with some research results on indentified study on relation between lower genital infection were sex and whored locations The study indicated that the FSW whored in gardens, parks, motels, massage places with no conditions and difficult to apply hygiene measures for safety sexual compare with the FSW 32 whored in the hotels The results of a study of HIV / STI in Vinh Long province reported FSW group had whored time of month or more with a higher rate of LRTI than the FSW group had whored time less than month (72.8 % compared with 58.9%) The study also said that the age of sexual behavior was also a risk of lower genital tract infections and HIV A number of domestic and international research showed that the young FSWs had sexcourse early, before the age to be able to fully understand the risk of lower genital tract infections were very susceptible to the disease The findings of Nguyen Manh Cuong 2008 on FSW in provinces of An Giang, Kien Giang and Dong Thap in the Mekong Delta showed the age of first sexual intercourse is 19.2 years old and there was no statistic meaning to differentiate between female sex workers in streets and restaurants (19.3 years old and 19.2 years old) This result was reasonable, because in fact in Vietnam, the FSW in streets were older than FSW in restaurants, no longer able to attract clients and have to relocate their whored place In Thailand, India, Indonesia and some African countries as well as in Vietnam in Ha Noi and neighboring provinces, high rates of lower genital tract infection in high-risk populations One of the characteristics of FSW is the nature mobility, due to the inferiority of their career, they not want to live in a place fixed for a long time On the other hand they also have to move from one province to another, one district to another depending on the number of clients and income for themselves Especial as of the current globalization, tourism development, travel conditions should ease the prostitution abroad is not difficult for female sex workers Some local studies have shown the average number of clients / month is one of the risk behaviors of lower genital tract infection for female sex workers and and reverse For female sex workers use condoms for all sexcourses, the average number of clients more or less is not very important, but for female sex workers without using condoms for all sexcourses with clients, this is a very important issue The research results showed that at Vinh Long in the past month, the proportion of women to sell sex from 1-9 clients is 15%, 10-19 clients accounted for 52.6%, from 20 clients and more accounted for 32,5% Average number of clients /months was 18.8 ± 13.5 The research results of the other topics in the Mekong Delta province showed the average number of sexual partners of FSW is 18.9 clients / month The authors also said there is a difference in the rate of HIV / STI and the average number of sexual partners, as many clients as much of risk of infection, however the affectivness of condom using or not have to be considered Normally, very little FSW had initiative medical check and test by for sexually transmitted infections as of guilt, partly due to not knowing the benefits and did not know where tests should be done Research results in Vinh Long province said only a low percentage of FSW (20%) answered that had been tested for HIV and sexually transmitted 33 infections, while up to 80% of FSWs have no tested for STD Among FSWs have been tested for HIV, there were 77.5% initiatived and 22.5% forced Our study shows that the rate of FSW of correct understanding of condom use for all sexual intercourse was lower than misundersting group (67.7% compared with 68.2%) On multivariable regression model of the relation between the risk behaviors and LRTI, only FSW did not used condom for all sexcourses (both newregular clients) lead to increase incidence of LRTI (from 2.1 to 2.2 times) The other factors were not statistic significant influence to the incidence of LRTI in FSW The results of this study have confirmed effectiveness of using condoms for all sexcourses are very good for preventing LRTI in female sex workers The researches in Vietnam and around the world have also confirmed the role of condoms in preventing HIV and sexually transmitted infections 4.3 Effectiveness of intervention to change knowledge and attitudes of preventing transmission of lower genital tract disease 4.3.1 Knowledge and attitudes In education and communication interventions, the health knowledge indicators was the fastest growing, then to the attitude indicator and the practising indicator were slowly increased The results of this study on the improvement of knowledge on preventing sexually transmitted infections is quite in line with the results of the study by Nguyen Khac Hien and Nguyen Manh Cuong with such research of intervention by HIV education and communication Mekong Delta provinces Our report is also complied to the results of several intervention studies have been done in the early years of twenty-first century, which collaborated between the health sector and international organizations on the role of communication in reproductive health care 4.3.2 Reduce symptoms and NTDSDD After a period of training at the Centre, the rate of vaginal infection reduced from 8.8% to 3.9% Vaginalis dropped from 21.9% to 1.2% The vulvo-vaginalis decreased from 49.9% to 21.2% Cervititis reduced from 12% to 8.3% Exposed cervicitis decreased from 7.9% to 0.5% These differences are of statistical significance with p ranging from less than 0.01 to 0.001 and EF ranged from 30.8% to 94.5% The lower genital tract infections were not only in reducing in clinical but also in the incidence through the test results Tested results showed the pathogens in FSWs were marked decreased compared to entering center timepoint Holmes and colleagues studied the effect of Gonorrhea prevention programs in Africa, including treatment for FSW in the community, also concluded that intervention effectiveness by counseling, screening and treatment for FSW is feasible effective Nguyen Manh 34 Cuong conducted the intervention study of HIV prevention in Mekong Delta provinces also concluded that the rate of new HIV infections in FSW decreased over time of intervention 4.4 Effectiveness of intervention to improve clinical knowledge of medical staffs In parallel with the study, medical staffs have been training on examination, detection testing and treatment regimens at the center, the other activities as providing support materials "International Standard of reproductive health "of the Ministry of Health and other specialized documents, monitored and supported activities to medical exam, tests, treatment were implented regularly This is to ensure the effectiveness of interventions to improve the quality of clinical management of lower genital tract infection in center Through the process of training the medical staffs at the Center, I realize that the training activities, provide documentation to guide medical care and monitoring support was very helpful for them, because the Centre under the Department of Labor War Invalids and Social Affairs in Hanoi, so they are less of updated well-trained and re-trained for theit practising daily After intervention the rate of medical staffs who have knowledge of syphilis rised higher than before intervention, including syphilis diseas, syphilis classification, clinical signs, its complications (narrow foreskin, swelling foreskin) and treatment regimen Proportion of health workers have knowledge of genital herpes increased after intervention than before the intervention After intervention knowledge of understanding of genital herpes (100%), diagnostic tests for genital herpes (100%), diagnostic criteria for genital herpes (93.3%), topical treatment (100 %) and systemic treatment (93.3%), increased significantly compared with before intervention After intervention rate of medical staffs have knowledge of chancroid disease was higher than before the intervention Post-intervention the knowledge of clinical symptoms (100%), diagnostic tests (73.3%), diagnosis (93.3%), the principle of treatment (100%) and systemic treatment (86.7%) were significantly increased compared to pre-intervention CONCLUSIONS The prevalence and risk behaviors of LRTI 1.1 LRTI prevalence in FSW The prevalence of at least one of the lower genital tract infection in FSW when entering the Center was high in clinical, accounted for 67.1% The most common infections were vulvo-vaginalis (49.9%), vaginalis (21.9%), cervicitis (8.8%), especial with 7.9% of FSW had exposed cervicitis When entering the center, FSWs inffected 35 complex bacterial at highest rate, accounted for 44.7%, followed by fungal infections, accounted for 10.1%, trichomonas 4.4%, syphilis 2.5% and the lowest was gonorrhea accounted for 0.5% 1.2 Affected factors and pathogens with lower genital tract infections in FSW According to monovariative analysis, FSW group in parks, gardens and streets have the highest LRTI rate compare with the group at motels (100% compared with 62%) The FSWs with no initiative health screening had higher incidence rate of LRTI than the initiative group In multivariaive regression models, FSW without behaviour of used condom for all sexcourse (both new and regular clients) lead to LRTI (increased from 2.1 to 2.2 times ) Effectiveness of interventions to change knowledge and attitudes for preventing transmission of lower genital tract disease 2.1 Changing knowledge and attitudes about sexually transmitted infections Effectiveness of interventios to change knowledge and attitudes were expressed very clearly Rate of FSW understanding of the clinical LRTI symptoms is higher when they entering center (51.4% to 98%) FSW attitude of control LRTI was also significantly higher after the intervention FSWs, who had self-assessment of high risk of LRTI havd rates increased from 9.8% to 31.9% after intervention 2.2 Effectiveness of reducing symptoms and LRTI The typical clinical symptoms of LRTI are including flow discharge / pus, painful urination, genital burning pain, ulcers, pappilome/sarchome and genital itching were significantly decreased after the intervention The genital tract infections as well as markedly and rapidlly decreased after the intervention, the rate of vulgaris reduced from 8.8% to 3.9%, vaginalis decreased from 21.9% to 1.2%, vulvo-vaginalis decreased from 49.9% to 21.2%, cervicitis reduced from 12% to 8.3%, cervical/exposed cervicitis decreased from , 9% to 0.5% The LRTI pathogen was markable decreased after the intervention Trichomonas, gonorrhea and syphilis decreased from 4.4%, 0.5% and 2.5%, respectively to abcense of LRTI; complex microbial reducted from 44.7% to 17.7%, fungal decresed from 10.1% to 3.9% Effectiveness of interventions to improve initiative health care capacity of health workers Effectiveness to improve ability of STD screening on clinical was significantly improved after the intervention Proportion of health workers with knowledge of direct exam tests to diagnosis LRTI was significantly higher after ... in FSW and 0.84 % in pregnants are reported Fungal LRTI: cause by Candidas Albicans and some time by other strains Candidas Albicans is also causing fungal diseases in many organs such as the skin... The pathogens of LRTIs on FSWs decreased very significantly compared to this figure when FSWs entering the center These differences were significant statistics with p less than 0.01 and EF ranged... screening on clinical was significantly improved after the intervention Proportion of health workers with knowledge of direct exam tests to diagnosis LRTI was significantly higher after 36 the intervention