Sexually Transmitted Infections and other Reproductive Tract Infections in rural Vietnam : Current situation, management and implications for control

Sammanfattning: Background: Sexually transmitted infections (STI) and other reproductive tract infections (RTI) constitute a huge health and economic burden in low-income countries. The infections may result in severe sequelae, particularly in women, and facilitate HIV acquisition and transmission. In Vietnam, women from rural or remote areas delay before seeking care for STI. Little is known about the situation regarding STI/RTI in the community. Aims: To explore perceptions and attitudes towards STI/RTI among people in the community; to assess the knowledge of STI and possible associations between socioeconomic determinants and STI knowledge among women aged 15 to 49; to investigate the prevalence of STI/RTI and related factors among married women aged 18 to 49; and to assess healthcare providers (HCPs ) knowledge and reported practices regarding STI. Methods: Ten focus group discussions (FGDs) were conducted with a total of 73 participants aged 15 to 49 (46 women and 27 men) in Bavi district (Study I). Face-to-face interviews using a structured questionnaire about STI knowledge were carried out among 1805 women aged 15 to 49 randomly selected from 17 clusters of an epidemiological field laboratory in Bavi district (FilaBavi) (Studies II, III). In total, 1,012 married women, in addition to being interviewed, underwent a gynaecological examination. Specimens were collected for laboratory diagnostics of chlamydia, gonorrhoea, trichomonas, bacterial vaginosis (BV), candidiasis, hepatitis B, HIV, and syphilis (Study III). HCPs working in Bavi district, including 390 medical personnel and 75 pharmacy personnel participated in a self-completion questionnaire survey on STI knowledge and case scenarios (Study IV). Results: In the FGDs, RTI, gonorrhoea and syphilis was described as three stages of an STI. Health-seeking patterns for STI/RTI were reported to differ between men and women: self-medication was a common practice among women, while men were more likely to seek healthcare from private HCPs. Complaints were voiced about clinicians negative attitudes towards STI/RTI patients (Paper I). Among 1,805 women, 78% did not know of any symptom of any STI. Of 40 possible correct answers, the mean knowledge score was 6.5. Young and/or unmarried women demonstrated very low levels of STI knowledge. Experience of an induced abortion predicted a higher level of knowledge (Paper II). Of the 1,012 married women, 39% were aetiologically confirmed as having an STI/RTI. Endogenous infections were most prevalent (candidiasis 26%, BV 11%) followed by hepatitis B 8.3%, Chlamydia trachomatis 4.3%, Trichomonas vaginalis 1%, Neisseria gonorrhoeae 0.7%, genital warts 0.2%, HIV and syphilis 0%. Prevalence of any STI was 6.0%. Age under 30 years or using an intrauterine device were significantly associated with increased risk of BV. Determinants of candidiasis were vaginal douching, high education level and low economic status, whereas a determinant of chlamydia was high economic status. Out migration of the husband was associated with an increased risk of hepatitis B surface antigen seroposivity among women. Compared with the laboratory diagnostics, both self-reported symptoms and clinical diagnosis had very low sensitivity and positive predictive values (Paper III). Of 465 HCPs, 70% acknowledged the necessity for partner treatment for BV or candidiasis cases (which is often not the case). Sharing clothes/food or kissing were commonly mentioned as transmission routes of STI (60%). Mean score of knowledge and reported practice were 28.2 (minimum 0, maximum 50, median 26) and 4.7 (minimum 0, maximum 20, median 2), respectively. Of the HCPs, 34% and 78% had suboptimal knowledge and practice score (below 50% of the total score). Being a medical doctor, assistant medical doctor, midwife or serving STI patients predicted a higher level of knowledge. Additionally, serving STI patients, being a midwife, female provider, and having participated in STI/RTI training courses predicted higher level of practice (Paper IV). Recommendations: Health education interventions to improve knowledge of STI/RTI for community members as well as HCPs are urgently needed. Further, communication between STI/RTI patients and clinicians needs to be improved. Syndromic algorithms should be supplemented by risk assessment in order to reduce under and over treatment. Microscopic diagnosis could be applied in primary care settings to achieve more accurate diagnoses. Vaccination to prevent hepatitis B for migrants should be considered.