Author's response to reviews Patterns of sexually transmitted infections in adolescents and youths in Dar es Salaam, Tanzania

Background: Syndromic management of STDs has been advocated as simplified and cheap approach. Youth have been reported to be at increased risk of acquiring STD which can facilitate HIV transmission. It is important to study the relationship between the syndromic management and specific aetiological diagnosis and the health seeking behaviour in youths. Methods: Between September 1998 and February 1999 among 1895 adolescent and youths below 25 years seen in the clinic 199 (10.5%) were randomly selected into the study. A standard questionnaire was administered. Blood and vaginal or urethral specimens were taken and investigated for STD causative agents. Results. Among a total of 199 studied youth 22.6 % were teenagers, with fewer females 17.8% than males, 27.5% (p<0.018). 20.8% of the females compared to 11.5% in males were HIV infected. Genital discharge was the most common complaint found which was found in 54.1% of male and in 63.4 % of female patients. All males with gonorrhoea and 4/5 with chlamydia were given appropriate treatment with syndromic management, while 28% women with gonorrhoea or chlamydia did not receive appropriate treatment by syndromic management. All patients with active syphilis had complained of genital ulcers and would have been assigned to syndromic treatment for syphilis. Conclusions: The burden of STD in this youth population is large indicating that youth are at increased risk of STD and will certainly require youth friendly clinics. There is a need to refine the current syndromic management guidelines. Introduction Sexually Transmitted Diseases (STDs) especially genital ulcer diseases are an epidemiologic and biologic risk factor for the transmission of HIV-1 infection 1, . Young people aged 15 to 24 years are at the epicentre of the HIV epidemic especially those living in sub Saharan Africa which accounts for about 64.5% of people living with HIV/AIDS globally . There are recent reports showing that adolescents in Africa engage in unsafe sexual behaviour which predisposes them to adverse outcome including sexually infected diseases . Consequently the youth in the continent have been reported to have high rates of various STDS . Enhancing and optimising the management of STDs remains one of the most feasible and cost effective interventions to control them including HIV. A study done in Tanzania has shown that treatment of STDs can reduce HIV transmission by more than 40-60% . The adoption of syndromic management has provided simplified and cheap method although its performance can be influenced by various factors including health seeking behaviour, cultural and economic factors, and the distribution of major aetiologies of STD syndromes . We have investigated the relationship between the syndromic management and specific aetiology diagnosis in this group and its relationship with HIV infection and health seeking behaviour. Patients and Methods The study was done between September 1998 and February 1999. The study population was adolescents and youths below 25 years of age attending the youth health clinic. Recruitment of subjects was done randomly irrespective of having symptoms by blind selection of cards at the reception on arrival. Those who picked yes cards were invited into the study. A standardised questionnaire was administered to the recruited subjects and was used to collect details of sociodemographic information, sexual history, and basic knowledge on STIs and its prevention and on possible sources of the current infection, history of present illness and its management. Answers were pre-coded with an exception of few which gave youths opportunity to answer open-ended questions. All clients were subjected to clinical examination including speculum examination for female youths. They were screened for syphilis, trichomoniasis and candidiasis by laboratory investigations. Of the 199 recruited youths 110, 108 and 197 were also tested for the presence of gonorrhoea, chlamydia and HIV infections respectively. Free treatment was given to all those found with STIs using syndromic approach according to Tanzania national treatment guidelines. Sexual partners were invited to attend the clinic. Condoms, health education and counselling were offered to all. All were offered post test HIV counselling. Those who were found to be HIV infected, were offered further follow up counselling, medical care and were referred to other institutions which provide different services for people living with HIV/AIDS (PLWHA). Laboratory methods: Syphilis antibodies were detected by the Venereal Disease Research Laboratory (VDRL Murex Biotech Ltd, U.K) test and by Treponema pallidum particle agglutination (TPPA Fujirebio Inc, Tokyo, Japan) Male youths had a urethral swab while females had both cervical and high vaginal swab taken and inserted into Stuart transport media for culture of N. gonorrhoeae and C. albicans. Swabs for detection of Chlamydia trachomatis antigen were collected using appropriate collection kits. Using wet mount saline preparation all swab specimens were examined for the presence of pus cells, budding yeast cells and motile T.vaginalis in the referral laboratory. Smears from the urethral and cervical specimens were Gram stained and examined for the presence of typical bean shaped Gram-negative diplococci, budding yeast cells and clue cells on Gram stains. Clinically significant Candida infection was suggested by budding yeast cells in wet smears. Clue cells found on Gram stains were taken as an indication of bacterial vaginosis. The swabs were plated onto modified Thayer Martin agar (Oxoid, Unipath Limited, Basingstoke, UK) supplemented with vancomycin, nystatin, colistin, and trimethoprim. Plates were incubated in a candle jar at 37C for 48 hours. After 48 hours of incubation presumptive identification of N.gonorrhoeae was done by Gram stain and oxidase test on suspected colonies. All isolates were confirmed to be N.gonorrhoeae by the Phadebact coagglutination test (Phadebact, Monoclonal GC test, Boule Diagnostics AB, Huddinge, Sweden).Specimens were also inoculated onto Saboraud’s Dextrose agar (Oxoid, Unipath Limited, Basingstoke, UK) and incubated at 37C for 48 hours. Isolates were identified as C. albicans by typical colonial morphology and germ tube test. Antigen detection of Chlamydia trachomatis: Chlamydia infection was diagnosed using Chlamydia EIA MicroTrak II (Behring Diagnostics Inc. Cupertino, CA 95014, USA) following package insert instructions. All patients entered into the study had their sera tested for antibodies for HIV following informed consent and pre-test counselling. The antibodies against HIV were determined by the use of Behring plus HIV-1 &2 ELISA (Behring Diagnostic GmbH, D-35041 Marburg, Germany) and those found positive were retested by the Wellcoenzyme HIV-1 ELISA (Murex Biotech Ltd., Central Road, Temple Hill, Dartford DAI 5LR, UK) in an alternative confirmatory strategy for diagnosis of HIV infection . Discordant samples were subjected to Western blot for confirmation. Statistical methods: Data were compiled and analysed by the SPSS 10.0 soft ware. Proportions were compared by chi-square (χ) values or Fisher’s exact test, and the level of significance used was 0.05 in two-tailed tests. Results Between September 1998 and February 1999, 1895 adolescents and youth (YH) below 25 years attended the youth health clinic at the Infectious Disease Centre (IDC). Among these, 199 participants consisting of 101 (50.8%) females and 98 (49.2%) males consented to participate in the study. Forty five (22.6%) were teenagers and 154 (77.4%) were youth aged 20 and 24 years. One third of females were already married compared to 9% of the males (Table 1).