This paper outlines three important issues in the clinical management of sexually transmitted diseases (STDs) in Papua New Guinea which have, until now, gone unrecognized or been neglected. Suggestions for possible solutions are made. The high prevalence of both chlamydial and trichomonal infections in women cannot be ignored. Both of these infections have been shown to increase the transmission of HIV. The current algorithm for the treatment of vaginal discharges does not include treatment for trichomonal infection in the first instance, yet trichomoniasis has been shown to be the most common STD in community studies both here and elsewhere. Trichomoniasis is usually asymptomatic in men, but still increases the risk of HIV transmission; furthermore, it causes illness in their female partners and thus needs to be treated. The current recommended regimens for the treatment of gonococcal and chlamydial infection are complex due to the number of drugs recommended for gonorrhoea to combat the problem of drug resistance, and the length of therapy for chlamydia. Compliance with such a regimen is likely to be poor, particularly in asymptomatic partners. We need to consider the relative advantages provided by a drug which could be given as a single oral dose for chlamydia, and perhaps for both infections. Azithromycin is one possibility, as it has been shown to be effective for chlamydial infection in numerous studies, and has been found satisfactory for gonorrhoea where local isolates were susceptible. Testing of a small number of isolates from Papua New Guinea has shown that azithromycin may be suitable for use here, but further susceptibility testing needs to be performed. Utilization of services for STDs, particularly by women, is extremely low. This is due to a combination of factors involving limited knowledge of symptomatology and its significance, the asymptomatic nature of many infections, the structure of the services, health worker behaviour, and social attitudes. To address these issues we must make modifications to STD service provision, as well as provide widespread information about the potentially serious consequences of contracting STDs, including both infertility and AIDS. Possible modifications to the services are discussed, and include making routine screening available for women through currently existing services such as family planning and antenatal clinics and considering the possibility of establishing Women's Health Clinics which would provide all primary reproductive health services in an integrated manner. PIP: This paper summarizes three relevant issues in the clinical management of STDs in Papua New Guinea which have gone unrecognized or been neglected until now. First, the issue of chlamydial and trichomonal infections, which have been shown to increase HIV transmission, is discussed. Although trichomonal infections generally display less pathology than chlamydial infections, they are nonetheless a serious problem. Both types of infections are also more prevalent in Asaro Valley as compared with gonorrhoea and syphilis. The second discussion focuses on the treatment regimen for gonococcal and chlamydial infections. The current treatment, which involves the intake of different tablets and extends for a week, seems to be unappealing and unrealistic for most patients. Thus, a more cost-effective drug has been introduced: azithromycin, which has been proven effective against chlamydial infection and has also been found satisfactory for gonorrhea treatment where local isolates were susceptible. The final topic is that of the barriers to the use of STD treatment services. This study revealed that the low utilization of these services, particularly by women, is due to 1) the limited knowledge of symptomatology and its significance, 2) to the asymptomatic nature of some infections, 3) to factors concerning the structure of services, 4) to health worker behavior, and 5) to social attitudes. Additionally, potential modifications to the existing services are discussed, including the possibility of establishing women's health clinics, which would provide all primary reproductive health services in an integrated manner.

This paper reports on women's understanding of diseases believed to be sexually transmitted in the Asaro Valley of the Eastern Highlands Province. Sexually transmitted diseases (STDs) seemed to be a new category of disease as there were no local language terms for them. Women did not associate STDs with infertility. Although some symptoms were recognized and known to be sexually transmitted, STDs sometimes went untreated for years. STDs were thought of as milder than AIDS because they could be treated. Those informants who had good knowledge of AIDS claimed to have known an AIDS patient. It was interesting that those who knew an AIDS patient reported a change in sexual behaviour among people who saw the deteriorating state of their relative who was dying of AIDS. PIP: Women's perception of STDs in the Asaro Valley of the Eastern Highlands Province of Papua New Guinea was studied along with the local language terms for reproductive tract infections. Considering that there are no known specific local language terms for diseases that are sexually transmitted, women tend to view STDs as a new category of disease. The study emphasizes the women's understanding of the risk factors, as well as signs and symptoms, causes and measures taken, behavior towards treatment, and suggestions concerning treatment and protection. Interviews were conducted with 30 women aged 17-50 years. 14 of those participated in the clinical side of a community- based STD study, while the rest provided information independently. Particular emphasis was given to sources of information on STDs, understanding of risk factors, signs and symptoms, causes and measures taken, attitude towards treatment, and suggestions for treatment and protection. Since the local language does not have a term to refer to any diseases thought to be passed on through sexual intercourse, three terms were used: "sik nogut" (bad sickness), gonorrhea, and syphilis; additionally, signs and symptoms were described rather than named. It was found that rumors and educated relatives were the primary sources of information about "sik nogut." One of the major findings was that women did not link infertility with STDs, even if symptoms were felt in and around the reproductive tract. The paper concludes that sexual intercourse, as identified by women, is the dominant mode of disease transmission in the Valley. Condoms are becoming acceptable but are not used because of their unavailability. An interesting finding in this study is the reported change in sexual behavior among people who have seen their relatives die of AIDS.
Acquired Immunodeficiency Syndrome - ethnology ; Disease Transmission, Infectious - prevention & ; control ; Educational Status ; HIV Infections - transmission ; Health Knowledge, Attitudes, Practice ; Infectious Disease Transmission, Vertical - prevention & ; control

Community health education played a major role in a study of sexually transmitted diseases (STDs) and other reproductive tract infections which we conducted in rural and periurban communities of the Asaro Valley near Goroka in the Eastern Highlands Province of Papua New Guinea. We found that most women had little knowledge about STDs, which they often did not realize were sexually transmitted. Even major signs and symptoms were thought to be normal and many women had not sought treatment until irreversible damage was done. Knowledge of the complications of STDs, such as infertility and stillbirth, was also slight in these women. It is apparent that there is a desperate need for more reproductive health education at the community level. In developing our health education methods, we found that simple line drawings of male and female reproductive organs and of people with different signs of STDs proved useful. These were quick and easy to produce from readily available materials. It was important to separate men and women into different groups with educators of the same sex, and to create a very informal atmosphere, encouraging free-ranging discussion. Following health education and sensitive interviewing, almost all the women selected for the community-based study of the prevalence of reproductive tract infections consented to vaginal examination, even if they were asymptomatic. Additionally, many nonselected women requested examination. PIP: This paper discusses the health education program carried out in the rural and periurban communities of the Asaro Valley in Papua, New Guinea, where knowledge of STDs is low and risky sexual behaviors are extremely common. The educational program seeks to ensure that the participants understand the reasons for the study and to raise their awareness of the transmission, treatment, and prevention of STDs. All members of the village were encouraged to participate in the educational workshop, which included lectures, group discussions, one-on-one health education, demonstrations, and interviews. After training workshops, practice sessions were also organized to assess the effectiveness of the different teaching methods and visual aids used. It was found that simple line drawings of male and female reproductive organs and of people with different signs of various STDs were useful. It was necessary to divide men and women into two groups with educators of the same sex, which created a more relaxed and free-flowing discussion. Considering that a majority of the women had no experience in using condoms, a demonstration of their use and how to put them on using bananas as models was performed. The questions asked by the women during discussions and private interviews proved that their level of biomedical knowledge about STDs and reproductive health was low, as was their knowledge of the anatomy and physiology of the reproductive system. A high frequency of risky behaviors was also observed, including involvement with multiple sexual partners, commonly in men and young women, with condoms virtually never used. Apparently there is a need for widespread community-based sexual and reproductive health education that is responsive to the needs of people living in rural areas.
Health Education - methods ; Health Education - organization & ; administration ; Health Knowledge, Attitudes, Practice ; Papua New Guinea ; Program Evaluation ; Sexually Transmitted Diseases - prevention & ; control

We conducted a community-based study of the prevalence of sexually transmitted diseases in rural and periurban communities in Eastern Highlands Province. We interviewed a stratified random sample of women and men, examined the women for evidence of sexually transmitted diseases (STDs) and collected specimens for diagnosis of syphilis, by serology and dark-field microscopy, gonorrhoea, by Gram stain and culture, chlamydial infection, by polymerase chain reaction (PCR) and direct immunofluorescence (DIF), trichomoniasis, by wet mount, and bacterial vaginosis, by wet mount and Gram stain. The men were tested for chlamydial infection only (first void urine tested by PCR and DIF). 201 women and 169 men were tested. Additionally, adults in the same communities who had not been randomly selected were offered the same services. An extra 243 women and 85 men were tested in this way. The laboratory results confirmed the clinical impression of an extremely high prevalence of STDs in this population. Among those randomly selected, 46% of the women had trichomonal vaginal infections and 26% had Chlamydia trachomatis infections detected by PCR, while 25% of the men had chlamydial infections. Other infections were much less common. 58% had one or more STDs. The prevalence of infection in self-selected adults was similar to that found in those randomly selected.
Chlamydia Infections - diagnosis ; Chlamydia Infections - epidemiology ; Data Collection ; Papua New Guinea - epidemiology ; Prevalence ; Rural Population ; Sexually Transmitted Diseases - epidemiology ; Trichomonas Vaginitis - diagnosis

We have used nested polymerase chain reaction (PCR) and the PCR-based endonuclease digestion method to genotype Chlamydia trachomatis serovars in 460 infected individuals from the Eastern Highlands Province of Papua New Guinea. Our study groups comprised women who presented in labour to the Goroka Base Hospital, their newborn infants, symptomatic children who presented to the hospital's Outpatients Department and men and women from 15 randomly selected villages in the Asaro Valley. In this analysis, the major outer membrane protein (MOMP) gene, omp1, of C. trachomatis was amplified using DNA obtained from the endocervix of women, urine from men, and both the eye and nasopharynx of children. Amplified DNAs were digested concurrently using Alul and a combination of EcoRI, Hinl and Hpall restriction enzymes. The mixtures were separated on electrophoretic gels and the respective serovars designated on the basis of resolved digested DNA patterns. Our results, which were confirmed also by omp1 sequence data, show serovars D, E, F, G, H and L3 to be present in the studied communities. The overall relative frequencies of these serovars were 30%, 21%, 25%, 1%, 20% and 2% respectively, with serovars D, E, F and H accounting for 97% of these infections. Double infections among these principal serovars were also detected in all our study groups but at a low overall frequency of 3%. Serovar D was the major agent involved in the aetiology of chlamydial infection in both children and adults though serovar F was the most frequent in newborn infants. Serovar H was relatively less frequent in symptomatic children. No trachoma-related serovars were detected, confirming the rarity of this disease in Papua New Guinea. In contrast, although clinical cases of lymphogranuloma venereum have not been described in the country, the detection of serovar L3 in this study suggests that it may occur. However, the association of L3 also with childhood infection indicates that it may be causing the same pathology as the serovars D-K that are associated with non-ulcerative sexually transmitted infections.
Upper case dee ; Papua New Guinea ; Child ; upper case aitch ; Upper case eff