RESUMO
This study aims to evaluate condom use, sexually transmitted infection (STI) screening, and knowledge of STI symptoms among female sex workers in Peru associated with sex work venues and a community randomised trial of STI control. One component of the Peru PREVEN intervention conducted mobile-team outreach to female sex workers to reduce STIs and increase condom use and access to government clinics for STI screening and evaluation. Prevalence ratios were calculated using multivariate Poisson regression models with robust standard errors, clustering by city. As-treated analyses were conducted to assess outcomes associated with reported exposure to the intervention. Care-seeking was more frequent in intervention communities, but differences were not statistically significant. Female sex workers reporting exposure to the intervention had a significantly higher likelihood of condom use, STI screening at public health clinics, and symptom recognition compared to those not exposed. Compared with street- or bar-based female sex workers, brothel-based female sex workers reported significantly higher rates of condom use with last client, recent screening exams for STIs, and HIV testing. Brothel-based female sex workers also more often reported knowledge of STIs and recognition of STI symptoms in women and in men. Interventions to promote STI detection and prevention among female sex workers in Peru should consider structural or regulatory factors related to sex work venues.
Assuntos
Preservativos/estatística & dados numéricos , Conhecimentos, Atitudes e Prática em Saúde , Programas de Rastreamento/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Profissionais do Sexo/psicologia , Infecções Sexualmente Transmissíveis/diagnóstico , Adolescente , Adulto , Feminino , Infecções por HIV/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Peru/epidemiologia , Prevalência , Trabalho Sexual , Profissionais do Sexo/estatística & dados numéricos , Infecções Sexualmente Transmissíveis/epidemiologia , Infecções Sexualmente Transmissíveis/prevenção & controleRESUMO
BACKGROUND: As part of a community-randomized trial of a multicomponent intervention to prevent sexually transmitted infections, we created Mobile Teams (MTs) in ten intervention cities across Peru to improve outreach to female sex workers (FSW) for strengthened STI prevention services. METHODS: Throughout 20 two-month cycles, MTs provided counseling; condoms; screening and specific treatment for Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), and vaginal Trichomonas vaginalis (TV) infections; and periodic presumptive metronidazole treatment for vaginal infections. RESULTS: MTs had 48,207 separate encounters with 24,814 FSW; numbers of sex work venues and of FSW reached increased steadily over several cycles. Approximately 50% of FSW reached per cycle were new. Reported condom use with last client increased from 73% to 93%. Presumptive metronidazole treatment was accepted 83% of times offered. Over 38 months, CT prevalence declined from 15.4% to 8.2%, and TV prevalence from 7.3% to 2.6%. Among participants in ≥ 9 cycles, CT prevalence decreased from 12.9% to 6.0% (p <0.001); TV from 4.6% to 1.5% (p <0.001); and NG from 0.8% to 0.4% (p = 0.07). CONCLUSIONS: Mobile outreach to FSW reached many FSW not utilizing government clinics. Self-reported condom use substantially increased; CT and TV prevalences declined significantly. The community-randomized trial, reported separately, demonstrated significantly greater reductions in composite prevalence of CT, NG, TV, or high-titer syphilis serology in FSW in these ten intervention cities than in ten matched control cities.
Assuntos
Relações Comunidade-Instituição , Equipe de Assistência ao Paciente , Trabalho Sexual , Infecções Sexualmente Transmissíveis/prevenção & controle , Feminino , Humanos , Peru/epidemiologia , Prevalência , Infecções Sexualmente Transmissíveis/classificação , Infecções Sexualmente Transmissíveis/epidemiologiaRESUMO
BACKGROUND: HIV pre-exposure prophylaxis (PrEP), the use of antiretroviral drugs by uninfected individuals to prevent HIV infection, has demonstrated effectiveness in preventing acquisition in a high-risk population of men who have sex with men (MSM). Consequently, there is a need to understand if and how PrEP can be used cost-effectively to prevent HIV infection in such populations. METHODS AND FINDINGS: We developed a mathematical model representing the HIV epidemic among MSM and transwomen (male-to-female transgender individuals) in Lima, Peru, as a test case. PrEP effectiveness in the model is assumed to result from the combination of a "conditional efficacy" parameter and an adherence parameter. Annual operating costs from a health provider perspective were based on the US Centers for Disease Control and Prevention interim guidelines for PrEP use. The model was used to investigate the population-level impact, cost, and cost-effectiveness of PrEP under a range of implementation scenarios. The epidemiological impact of PrEP is largely driven by programme characteristics. For a modest PrEP coverage of 5%, over 8% of infections could be averted in a programme prioritising those at higher risk and attaining the adherence levels of the Pre-Exposure Prophylaxis Initiative study. Across all scenarios, the highest estimated cost per disability-adjusted life year averted (uniform strategy for a coverage level of 20%, US$1,036-US$4,254) is below the World Health Organization recommended threshold for cost-effective interventions, while only certain optimistic scenarios (low coverage of 5% and some or high prioritisation) are likely to be cost-effective using the World Bank threshold. The impact of PrEP is reduced if those on PrEP decrease condom use, but only extreme behaviour changes among non-adherers (over 80% reduction in condom use) and a low PrEP conditional efficacy (40%) would adversely impact the epidemic. However, PrEP will not arrest HIV transmission in isolation because of its incomplete effectiveness and dependence on adherence, and because the high cost of programmes limits the coverage levels that could potentially be attained. CONCLUSIONS: A strategic PrEP intervention could be a cost-effective addition to existing HIV prevention strategies for MSM populations. However, despite being cost-effective, a substantial expenditure would be required to generate significant reductions in incidence. Please see later in the article for the Editors' Summary.
Assuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/prevenção & controle , Modelos Teóricos , Sexo sem Proteção/estatística & dados numéricos , Fármacos Anti-HIV/economia , Análise Custo-Benefício , Humanos , Masculino , PeruRESUMO
BACKGROUND: Sexually Transmitted diseases (STD) syndrome management has been one cornerstone of STD treatment. Persons with STD symptoms in many countries, especially those with limited resources, often initially seek care in pharmacies. The objective of the study was to develop and evaluate an integrated network of physicians, midwives and pharmacy workers trained in STD syndromic management (The PREVEN Network) as part of a national urban community-randomized trial of sexually transmitted infection prevention in Peru. METHODS AND FINDINGS: After a comprehensive census of physicians, midwives, and pharmacies in ten intervention and ten control cities, we introduced seminars and workshops for pharmacy workers, and continuing education for physicians and midwives in intervention cities and invited graduates to join the PREVEN Network. "Prevention Salespersons" visited pharmacies, boticas and clinicians regularly for educational support and collection of information on numbers of cases of STD syndromes seen at pharmacies and by clinicians in intervention cities. Simulated patients evaluated outcomes of training of pharmacy workers with respect to adequate STD syndrome management, recommendations for condom use and for treatment of partners. In intervention cities we trained, certified, and incorporated into the PREVEN Network the workers at 623 (80.6%) of 773 pharmacies and 701 (69.6%) of 1007 physicians and midwives in private practice. Extremely high clinician and pharmacy worker turnover, 13.4% and 44% respectively in the first year, dictated continued training of new pharmacy workers and clinicians. By the end of the intervention the Network included 792 pharmacies and 597 clinicians. Pharmacies reported more cases of STDs than did clinicians. Evaluations by simulated patients showed significant and substantial improvements in the management of STD syndromes at pharmacies in intervention cities but not in control cities. CONCLUSIONS: Training pharmacy workers linked to a referral network of clinicians proved feasible and acceptable. High turn-over was challenging but over come.
Assuntos
Educação em Farmácia , Farmacêuticos , Médicos , Infecções Sexualmente Transmissíveis/terapia , Certificação , Seguimentos , Humanos , Tocologia/estatística & dados numéricos , Peru/epidemiologia , Farmacêuticos/estatística & dados numéricos , Médicos/estatística & dados numéricos , Infecções Sexualmente Transmissíveis/epidemiologiaRESUMO
BACKGROUND: We assessed prevalences of seven sexually transmitted infections (STIs) in Peru, stratified by risk behaviours, to help to define care and prevention priorities. METHODS: In a 2002 household-based survey of the general population, we enrolled randomly selected 18-29-year-old residents of 24 cities with populations greater than 50 000 people. We then surveyed female sex workers (FSWs) in these cities. We gathered data for sexual behaviour; vaginal specimens or urine for nucleic acid amplification tests for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; and blood for serological tests for syphilis, HIV, and (in subsamples) herpes simplex virus 2 (HSV2) and human T-lymphotropic virus. This study is a registered component of the PREVEN trial, number ISRCTN43722548. FINDINGS: 15 261 individuals from the general population and 4485 FSWs agreed to participate in our survey. Overall prevalence of infection with HSV2, weighted for city size, was 13·5% in men, 13·6% in women, and 60·6% in FSWs (all values in FSWs standardised to age composition of women in the general population). The prevalence of C trachomatis infection was 4·2% in men, 6·5% in women, and 16·4% in FSWs; of T vaginalis infection was 0·3% in men, 4·9% in women, and 7·9% in FSWs; and of syphilis was 0·5% in men, 0·4% in women, and 0·8% in FSWs. N gonorrhoeae infection had a prevalence of 0·1% in men and women, and of 1·6% in FSWs. Prevalence of HIV infection was 0·5% in men and FSWs, and 0·1% in women. Four (0·3%) of 1535 specimens were positive for human T-lymphotropic virus 1. In men, 65·0% of infections with HIV, 71·5% of N gonorrhoeae, and 41·4% of HSV2 and 60·9% of cases of syphilis were in the 13·3% who had sex with men or unprotected sex with FSWs in the past year. In women from the general population, 66·7% of infections with HIV and 16·7% of cases of syphilis were accounted for by the 4·4% who had been paid for sex by any of their past three partners. INTERPRETATION: Defining of high-risk groups could guide targeting of interventions for communicable diseases-including STIs-in the general Peruvian population. FUNDING: Wellcome Trust-Burroughs Wellcome Fund Infectious Disease Initiative and US National Institutes of Health.
Assuntos
Trabalho Sexual/estatística & dados numéricos , Comportamento Sexual/estatística & dados numéricos , Infecções Sexualmente Transmissíveis/epidemiologia , População Urbana/estatística & dados numéricos , Adolescente , Adulto , Anticorpos Antivirais/sangue , Infecções por Chlamydia/epidemiologia , Infecções por Chlamydia/urina , Feminino , Gonorreia/epidemiologia , Gonorreia/urina , Infecções por HIV/sangue , Infecções por HIV/epidemiologia , Infecções por HTLV-I/sangue , Infecções por HTLV-I/epidemiologia , Inquéritos Epidemiológicos , Herpes Simples/sangue , Herpes Simples/epidemiologia , Herpes Simples/virologia , Herpesvirus Humano 2 , Humanos , Masculino , Peru/epidemiologia , Prevalência , Infecções Sexualmente Transmissíveis/sangue , Infecções Sexualmente Transmissíveis/urina , Inquéritos e Questionários , Sífilis/sangue , Sífilis/epidemiologia , Vaginite por Trichomonas/epidemiologia , Vagina/microbiologia , Vagina/parasitologia , Adulto JovemRESUMO
BACKGROUND: Previous community-randomised trials of interventions to control sexually transmitted infections (STIs) have involved rural settings, were rarely multicomponent, and had varying results. We aimed to assess the effect of a multicomponent intervention on curable STIs in urban young adults and female sex workers (FSWs). METHODS: In this community-randomised trial, baseline STI screening was done between August, and November, 2002, in random household samples of young adults (aged 18-29 years) and in FSWs in Peruvian cities with more than 50,000 inhabitants. Geographically separate cities were selected, matched into pairs, and randomly allocated to intervention or control groups with an S-PLUS program. Follow-up surveys of random samples were done after 2 years and 3 years. The intervention comprised four modalities: strengthened STI syndromic management by pharmacy workers and clinicians; mobile-team outreach to FSWs for STI screening and pathogen-specific treatment; periodic presumptive treatment of FSWs for trichomoniasis; and condom promotion for FSWs and the general population. Individuals in control cities received standard care. The composite primary endpoint was infection of young adults with Chlamydia trachomatis, Trichomonas vaginalis, or Neisseria gonorrhoeae, or syphilis seroreactivity. Laboratory workers and the data analyst were masked, but fieldworkers, the Peruvian study team, and participants in the outcome surveys were not. All analyses were done by intention to treat. This trial is registered, ISRCTN43722548. FINDINGS: We did baseline surveys of 15,261 young adults in 24 Peruvian cities. Of those, 20 geographically separate cities were matched into pairs, in each of which one city was assigned to intervention and the other to standard of care. In the 2006 follow-up survey, data for the composite primary outcome were available for 12,930 young adults. We report a non-significant reduction in prevalence of STIs in young adults, adjusted for baseline prevalence, in intervention cities compared with control cities (relative risk 0·84, 95% CI 0·69-1·02; p=0·096). In subgroup analyses, significant reductions were noted in intervention cities in young adult women and FSWs. INTERPRETATION: Syndromic management of STIs, mobile-team outreach to FSWs, presumptive treatment for trichomoniasis in FSWs, and condom promotion might reduce the composite prevalence of any of the four curable STIs investigated in this trial. FUNDING: Wellcome Trust and Burroughs Wellcome Fund, National Institutes of Health, Center for AIDS Research, CIPRA, and USAID-Peru.
Assuntos
Profissionais do Sexo/estatística & dados numéricos , Infecções Sexualmente Transmissíveis/prevenção & controle , População Urbana/estatística & dados numéricos , Adolescente , Adulto , Infecções por Chlamydia/epidemiologia , Infecções por Chlamydia/prevenção & controle , Chlamydia trachomatis , Preservativos/estatística & dados numéricos , Feminino , Gonorreia/epidemiologia , Gonorreia/prevenção & controle , Humanos , Análise de Intenção de Tratamento , Masculino , Peru/epidemiologia , Prevalência , Infecções Sexualmente Transmissíveis/epidemiologia , Tricomoníase/epidemiologia , Tricomoníase/prevenção & controle , Trichomonas vaginalis , Adulto JovemRESUMO
BACKGROUND: Clandestine induced abortions are a public health problem in many developing countries where access to abortion services is legally restricted. We estimated the prevalence and incidence of, and risk factors for, clandestine induced abortions in a Latin American country. METHODS: We conducted a large population-based survey of women aged 18-29 years in 20 cities in Peru. We asked questions about their history of spontaneous and induced abortions, using techniques to encourage disclosure. RESULTS: Of 8242 eligible women, 7992 (97.0%) agreed to participate. The prevalence of reported induced abortions was 11.6% (95% confidence interval [CI] 10.9%-12.4%) among the 7962 women who participated in the survey. It was 13.6% (95% CI 12.8%-14.5%) among the 6559 women who reported having been sexually active. The annual incidence of induced abortion was 3.1% (95% CI 2.9%-3.3%) among the women who had ever been sexually active. In the multivariable analysis, risk factors for induced abortion were higher age at the time of the survey (odds ratio [OR] 1.11, 95% CI 1.07-1.15), lower age at first sexual intercourse (OR 0.87, 95% CI 0.84-0.91), geographic region (highlands: OR 1.56, 95% CI 1.23-1.97; jungle: OR 1.81, 95% CI 1.41-2.31 [v. coastal region]), having children (OR 0.82, 95% CI 0.68-0.98), having more than 1 sexual partner in lifetime (2 partners: OR 1.61, 95% CI 1.23-2.09; > or = 3 partners: OR 2.79, 95% CI 2.12-3.67), and having 1 or more sexual partners in the year before the survey (1 partner: OR 1.36, 95% CI 1.01-1.72; > or = 2 partners: OR 1.54, 95% CI 1.14-2.02). Overall, 49.0% (95% CI 47.6%-50.3%) of the women who reported being currently sexually active were not using contraception. INTERPRETATION: The incidence of clandestine, potentially unsafe induced abortion in Peru is as high as or higher than the rates in many countries where induced abortion is legal and safe. The provision of contraception and safer-sex education to those who require it needs to be greatly improved and could potentially reduce the rate of induced abortion.
Assuntos
Aborto Criminoso/estatística & dados numéricos , Aborto Induzido/estatística & dados numéricos , Aborto Criminoso/legislação & jurisprudência , Aborto Induzido/legislação & jurisprudência , Aborto Espontâneo , Adolescente , Adulto , Fatores Etários , Coito , Comportamento Contraceptivo , Feminino , Humanos , Incidência , Análise Multivariada , Peru/epidemiologia , Gravidez , Prevalência , Fatores de Risco , Parceiros Sexuais , Inquéritos e Questionários , Adulto JovemRESUMO
BACKGROUND: Cervical cancer, although usually preventable by Pap smear screening, remains the leading cause of cancer-related deaths among women in Peru. The percentages and characteristics of women in Peru who have or have not had a Pap smear have not been defined. METHODS: In an urban community randomized trial of sexually transmitted infection (STI)/HIV prevention in Peru, 6712 randomly selected women between the ages of 18 and 29 from 20 cities were interviewed regarding having had cervical Pap smears. RESULTS: Among women sampled, only 30.9% had had a Pap smear. By multivariate analysis, the main predictors of having a Pap smear were having had sex, having had children, completion of secondary education and increasing age. Regional variations were also found: women from the highlands and rainforest were less likely to have had Pap smears than women from the coast. CONCLUSION: A norm of seeking and receiving Pap smears has not been established among sexually active young Peruvian women. To improve Pap smear coverage in Peru, promotion efforts should target underserved women and regions with less coverage.