Sexually
transmitted
bacterial
infections
among
young
women
in
Central
Western
Brazil
Yanna
Andressa
Ramos
de
Lima
a,*
,
Marı´lia
Dalva
Turchi
a,
Zulmirene
Cardoso
Fonseca
a,
Fernanda
Lopes
Brito
Garcia
a,
Fernanda
Alves
de
Brito
e
Cardoso
a,
Moˆnica
Nogueira
da
Guarda
Reis
a,
Eleuse
Machado
de
Britto
Guimara˜es
b,
Rosane
Ribeiro
Figueiredo
Alves
b,
Nı´gela
Rodrigues
Carvalho
a,
Maria
de
Fa´tima
Costa
Alves
aa
InstituteofTropicalPathologyandPublicHealth,FederalUniversityofGoia´s,Rua235,s/n,SetorUniversita´rio,CEP74605050,Goiaˆnia,Goia´s,Brazil
b
FacultyofMedicine,FederalUniversityofGoia´s,Goiaˆnia,Brazil
1. Introduction
Chlamydia trachomatis, Neisseriagonorrhoeae, and Treponema pallidumarethemostcommonpathogensresponsibleforbacterial sexually transmitted infections (STI) worldwide, disproportion-atelyaffectingwomenunder25 yearsofage.1According tothe
World Health Organization (WHO), approximately 126 million newcasesof curable STIsoccur each year in theregion of the Americas.1
C.trachomatisisanobligateintracellularpathogenthatinfects epithelial cells of the genital tract. The infection resolve
spontaneouslyinmostinfectedwomen,butpersistentinfection mayoccurandleadtothespread ofthepathogentotheupper genitaltract.N.gonorrhoeaeistheetiologicalagentofgonorrhea, aninfectiononthesurfaceoftheurethra,endocervix,andfallopian tubes. Clinically it is indistinguishable from genital chlamydial infection. Asymptomatic infection is frequent among women, increasing the risk of persistent undiagnosed chlamydial and gonococcalinfections,which mayleadtocomplicationssuchas pelvicinflammatorydisease(PID),infertility,ectopicpregnancy, andchronicabdominalpain.2T.pallidumisthecausativeorganism ofsyphilis,achronicinfectionthatmaypersistforyears,leadingto cardiovascular and neurological damage. Syphilis is especially relatedtoadverseoutcomesinpregnancy,suchaslateabortion, prematurity, low birth weight, neonatal death, and congenital infection.3BacterialSTIcomplicationsareanimportant
prevent-ARTICLE INFO Articlehistory:
Received24November2013 Receivedinrevisedform23March2014 Accepted27March2014
CorrespondingEditor:EskildPetersen, Aarhus,Denmark
Keywords:
Bacterialsexuallytransmittedinfections Prevalence
Riskfactor Epidemiology Youngwomen
SUMMARY
Background:StudiesonsexuallytransmittedinfectionsinBrazilaredonemainlyinlargemetropolises andscreeningisavailableforpregnantwomenonly.Weaimedtoestimatetheprevalenceandrisk factorsforChlamydiatrachomatis,Neisseriagonorrhoeae,andTreponemapalliduminfectionamongyoung non-pregnantwomeninnon-clinicalsettingsinmiddle-sizedcitiesofCentralBrazil.
Methods:Across-sectionalcommunity-basedsampleof1072participantswasincluded.Sexuallyactive women(64.9%)providedfirst-catchurinesamplesforPCRinvestigationofchlamydialandgonococcal infection.Syphiliswastestedinserum.Univariateanalysisinvestigated riskfactorsforchlamydial infection.Multivariatelogisticregressionincludedassociationswithap-value<0.20.
Results:Themeanageofparticipantswas18years;73.2%reportedunprotectedintercourse,37.6%were married/cohabiting,and5%reportedapreviousSTI.PrevalenceratesofC.trachomatis,N.gonorrhoeae, andT.pallidumwere9.6%(95%confidenceinterval(CI)7.4–12.4%),0.7%(95%CI0.2–1.9%),and0.15% (95%CI0.0–0.7%),respectively.Afteradjustments,being<20yearsold(adjustedoddsratio(aOR)1.90, 95%CI1.07–3.37)andhavingthreeormorelifetimesexualpartners(aOR2.57,95%CI1.46–4.53)were associatedwiththeriskforchlamydialinfection.
Conclusions: Weobservedahighprevalenceofchlamydialinfectionandsexualriskbehaviorsinthis population.ThesefindingsareimportanttoguidescreeningstrategiesinBrazil.
ß2014TheAuthors.PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases. ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(
http://creativecommons.org/licenses/by-nc-nd/3.0/).
* Correspondingauthor.Tel.:+556232096111;Fax:+556235211839. E-mailaddress:yanna.and@gmail.com(Y.A.R.deLima).
ContentslistsavailableatScienceDirect
International
Journal
of
Infectious
Diseases
j o urn a l hom e pa ge : ww w. e l s e v i e r. c om/ l o ca t e / i j i d
http://dx.doi.org/10.1016/j.ijid.2014.03.1389
1201-9712/ß2014TheAuthors.PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/3.0/).
able cause of reproductive sequelae, infertility, and adverse pregnancyoutcomesinwomen.4
Screeningstrategiesareusefultoidentifyandtreat asymptom-atic infected people, preventing complications and avoiding dissemination among sexual contacts.5 C. trachomatis and N. gonorrhoeaescreeninghasbeencarriedoutincountriessuchasthe USA,theUK,andSweden.6–9Chlamydialandgonococcalinfections
shouldbeinvestigatedinsexuallyactiveindividualsundertheage of 25 years, especially women.6 Syphilis testing should be
performed in all pregnant women and individuals at elevated risk.10InBrazil,STIscreeningisroutineonlyforpregnantwomen
andincludesonlyhepatitisB,HIV,andsyphilistesting.11
According to previous studies, the prevalence rate of C. trachomatisinfectioninBrazilrangesfrom7.3%to17.6%among youngnon-pregnantwomenin non-clinicalsettings.12–15These studieswereperformedinlargecitiesandthereiscurrentlyalack ofdatafromoutsidemetropolises.Brazilisacountryofcontinental proportions.Thus,middle-sizedcitiesmayrepresentanimportant missingsetting fortheevaluationofSTI prevalenceandfor the collection of important information for the implementation of screening strategies. The present study aimed to estimate the prevalence of C. trachomatis, N. gonorrhoeae, and T. pallidum infections and to investigate behavior and social variables potentially associated withSTIsin asymptomatic non-pregnant youngwomeninmiddle-sizedcitiesofCentralWesternBrazil.
2. Methods
2.1. Studydesign,setting,andsampling
This study was a community-based, cross-sectional survey performedinthreecities(Ceres,Catala˜o,andInhumas)inthestate of Goia´s, Central Western Brazil, between 2007 and 2009.The overallpopulationofthesecitieswas141046inhabitants,withan estimated4500 women under25 years of agemonitored by a publichealthprogramknownastheFamilyHealthProgram(FHP). TheFHPisanassistancepublichealthservicecoveringallBrazilian cities and is responsible for promotingprimary health care by implementinginterventionsaccordingtocommunityriskfactors. The FHP consists of health units with multidisciplinary teams responsibleformonitoringadefinednumberoffamilies.16
Ceres is a city in the north of Goia´s State, with 18 637 inhabitantsandsixfamilyhealthunits.Catala˜oislocatedinthe southeast,with75623inhabitantsandthreefamilyhealthunits. Inhumasissituatedinthecentralregionofthestate,atadistance of54kmfromthecapitalGoiaˆnia,andhasapopulationof46786 inhabitants with 13 family health units. These cities were randomly selected to represent the urban population outside thecapitalinCentralWesternBrazil.
Allwomen aged 15–24 years monitored by the FHPin the selectedcitieswerepotentiallyeligible.Censusinformationwas provided by thelocal health department.The sample size was calculatedusingOpenSourceEpidemiologic StatisticsforPublic Health software (OpenEpi version 2.3.1). The sample size was basedon thestudydesign(prevalencestudywithoutclustering, i.e.,effectdesign=1).Thenumberofparticipantsrequiredwas646 sexuallyactivenon-pregnantwomenaged15–24years,basedona minimumexpectedSTIprevalenceof2.0%,witha1.0%precision andaconfidenceintervalof95%.Syphiliswasexpectedtobethe STIwiththelowestprevalence.Takingintoconsiderationthat20% of young women would not beliving at the recorded address (couldnotbecontacted),that approximately40%oftheinvited youngwomenwouldnotbesexuallyexperienced(wouldnotbe eligible),that10%ofthesexuallyexperiencedwouldbepregnant orwouldhaveusedantimicrobialsintheprevious15days(would
not beeligible), andanticipatingarefusalrateof25%, thefinal estimatedsamplesizewas1250women.
Therecruitmentprocesswasdoneintwophases.Thesampling processwasdoneinthefirstphaseofrecruitment.Thelocalhealth departments provided a list of households with potential participants (women aged 15–24 years registered at a family healthunit).Anumberwasassignedtoeachpotentialparticipant, andasimplesamplingwasdoneusingacomputer-generatedlist ofrandomnumbers(EpiInfosoftware3.4.version).Fromafinite population of approximately 4500 young women, 1250 were invitedbylettertopresenttothenearestfamilyhealthunit.Inthe secondphase,allwomenwhoacceptedtheinvitationandmetthe inclusioncriteriawereincludedinthestudy.
Volunteerswhopresentedtothelocalfamilyhealthunitwere firstinformedaboutthestudyandtheninterviewedbyatrained nurse or physician using a structured questionnaire to collect information on socio-demographic variables, including level of education, mother’s schooling, and family income, which was measuredinminimumBrazilianwages(US$213atthetimeofthe study). Participants were questioned on their previous sexual experience and issues relatedto generalhealth knowledge and health concerns.Women who reportedprevious sexualactivity were then invited for further procedures, including a second interviewusingamorespecificquestionnairecontainingquestions aboutsexualpracticesandreproductivelife,suchastheonsetof sexual life, number of partners, condom use, and STI history. Womenwhoreferredtoantimicrobialusewithintheprevious15 days or who were pregnant were excluded. All eligible young womenwererequestedtosignawritteninformedconsentform andwerereferredforfirst-catchurineandbloodsamplecollection forthediagnosisofC.trachomatis,N.gonorrhoeae,andT.pallidum. 2.2. Laboratoryprocedures
ForC.trachomatisandN.gonorrhoeaediagnostics,participants were instructed to collect an approximately 20-ml first-catch urinespecimenafter at least2hwithouturinating.PCR for C. trachomatisandN.gonorrhoeaewasperformedusingtheAmplicor CT/NG Kit (Roche MolecularSystems, Branchburg,NJ, USA)in accordancewiththemanufacturer’sinstructions,attheInfectious DiseasesImmunologyandMolecularBiologyLaboratory ofthe InstituteofTropicalPathologyandPublicHealthoftheFederal University of Goia´s, Brazil. In brief, a 208-bp nucleotide sequenceofC.trachomatisanda 201-bpnucleotidesequence ofN.gonorrhoeaeDNAwereamplifiedwithbiotinylatedprimers. A hybridizationchainreactionwasthen performedtoidentify targetsequences.Internalcontrolswereusedinallamplification assays.
Forsyphilisdiagnostics,a10-mlsampleofvenousbloodwas collectedfromanarmvein,and5mlofserumwasobtainedand storedat 708Cuntilanalysis.Allbasicbiosafetystandardswere assured during blood collection. The non-treponemal VDRL (Venereal Disease Research Laboratory)test was performed on allserumsamples.Confirmationofpositiveresultswasdonewith anFTA-Abstest(fluorescenttreponemalantibodyabsorptiontest). 2.3. Dataanalysis
Adescriptiveanalysiswasperformedforthe socio-demograph-ic and sexual behavior variables. Continuous variables were describedasthemedianwithinterquartilerange(IQR).Categorical variables werepresented asthefrequency andpercentage. The Chi-square test or Fisher’s exact test was used to analyze the differencesamongcategoricalvariables,withasignificancelevelof 5%.TheprevalenceofC.trachomatis,N.gonorrhoeae,andT.pallidum infectionsandtheirrespective95%confidenceintervals(95%CI)
wereestimatedasthenumberofpositivetestsdividedbythetotal numberofwomentested.
Univariate analysis was performed to investigate possible associations between C. trachomatis-positive tests and socio-demographicand behaviorvariables. Allassociations witha p-value <0.20 were then included in a multivariate logistic regressionanalysis.Inthefinalanalysis,ap-valueof0.05was considered statistically significant. Risk factors for gonococcal infectionand syphiliswerenotassesseddue toa low expected prevalenceraterequiringalargersamplesize.Dataanalyseswere conductedusingEpiInfoversion3.5.1andSPSSversion13.0.
3. Results
A totalof 1072 asymptomatic youngwomen (15–24 years) were recruited; 696 (64.9%) of them declared being sexually experiencedandnotpregnant,andwerethereforeeligibleforthe study.Nosignificantdifferencesregardingsocio-demographicand behavioralcharacteristicswereobservedamongvolunteersfrom eachcity.Themedianageofthe696sexuallyactiveparticipants was20years(IQR17–22years)and37.8%ofthemwerealready married or cohabiting. Most of the eligible participants had completedmore than 8 years of schooling(72.8%), had poorly educatedmothers(70%),andalowfamilyincome(<4minimum wages/month,85.1%).
Concerning sexual behavior, more than 20% of participants wereyoungerthan15yearsatfirstintercourse(medianageatfirst intercourse16years,IQR15–17years).Halfofthemreportedtwo or morelifetime sexualpartners. Nevertheless, more than 80% reportedonlyonesexualpartnerinthelast3months. Approxi-mately70%ofsubjectsreportedinconsistentuseofcondomsand 5%reportedapreviousSTIdiagnostic.Regularuseofcondomswas morefrequentlyreported bysinglewomen thanby marriedor cohabitingwomen (p<0.001). Almost 40% of participants had beenpregnantat least onceand more than 25% of them were youngerthan15yearsatfirstpregnancy.
Fivehundredseventy-four(82.5%)subjectsprovidedafirst-catch urinesampleforC.trachomatisandN.gonorrhoeaetesting.Thosewho did not provide a urine sample were in menses or were taking antimicrobialtherapyatthattimeorhadtakensuchtherapyinthe prior 15days, andfailed to attendfora second visit.No specific information was gathered about non-compliers. Six hundred and eighty-five(98.4%)bloodsampleswereavailableforsyphilisdiagnosis. Elevenbloodsamples(1.6%)wereexcludedduetohemolysis. 3.1. PrevalenceofbacterialSTIs
TheoverallprevalenceofC.trachomatisinfectionwas9.6%(95% CI 7.4–12.4%), while the prevalences of N. gonorrhoeae and T. palliduminfectionwere0.7%(95%CI0.2–1.9%)and0.15%(95%CI 0.0–0.7%),respectively.Noneof theparticipantswithapositive testpresentedaco-infection.Therewasnosignificantdifferencein prevalenceofC.trachomatisinfectionamongparticipantsfromthe threecities(Table1).
3.2. Socio-demographicandsexualbehaviorvariablesassociatedwith theriskforSTI
UnivariateanalysisdemonstratedthatC.trachomatispositivity wasassociatedwithyoungerage(15–19yearsold),earlyonsetof sexuallife(<15years),andhavingthreeormorelifetimesexual
Table1
Prevalenceofbacterialsexuallytransmittedinfectionsinasymptomaticsexually activeyoungwomeninCentralWesternBrazil
Positives Tested Prevalence%(95%CI) Chlamydiatrachomatis 55 574 9.6(7.4–12.4) Ceres 13 106 10.9(5.9–18.0) Catala˜o 12 99 12.1(6.4–20.2) Inhumas 30 356 8.4(5.8–11.9) Neisseriagonorrhoeae 4 574 0.7(0.2–1.9) Treponemapallidum 1 685 0.1(0.0–0.9) CI,confidenceinterval.
Table2
Univariateanalysisofsocio-demographicvariablespotentiallyassociatedwiththeriskforChlamydiatrachomatisinfectioninsexuallyactiveyoungwomeninCentral WesternBrazil
Variables Numberofpatients(%) (n=696) C.trachomatis-positive (n=574) OR(95%CI) p-Value Origin Ceres 145(62.2) 13 1.01(0.41–2.53) 0.855 Catala˜o 123(65.4) 12 1.50(0.69–3.20) 0.353 Inhumas 428(65.7) 30 1.52(0.72–3.17) 0.315 Age,years 15–19 346(49.7) 35 1.90(1.07–3.37) 0.039a 20–24 350(50.3) 20 Maritalstatus Single 431(61.9) 37 1.45(0.78–2.73) 0.213 Married/cohabiting 262(37.6) 18 NA 3(0.4) Schooling,years 8 189(27.2) 15 1.05(0.53–2.03) 0.883 >8 506(72.7) 40 NA 1(0.1)
Mother’sschooling,years
8 486(70.0) 35 0.61(0.33–1.12) 0.147
>8 160(23.1) 18
NA 48(6.9)
Familyincome,minimumwageb
4 592(85.1) 45 0.69(0.31–1.54) 0.496
>4 79(11.4) 8
NA 25(3.6)
OR,oddsratio;CI,confidenceinterval;NA,notavailable.
a
Statisticallysignificant,p-value<0.05;Fisher’sexacttestwasusedforfrequencies<5.
b
partners. Participants who reported a previous pregnancy or inconsistent condom use did not present a higher risk for chlamydialinfection.Socio-demographic andbehavior variables potentiallyassociatedwiththeriskforC.trachomatispositivityare showninTables2and3.
Tofurtherexploretheseassociations,a multivariateanalysis wasperformed.Thefollowingexposurevariableswereincludedin thelogisticregressionmodel:age(<20vs.20years),ageatfirst intercourse(<15vs.15 years),andnumber oflifetimesexual partners(<3vs.3).Agerangingfrom15and19years(oddsratio (OR)2.16, 95% CI 1.18–3.97) and having three or more sexual partnersin life (OR2.56, 95%CI 1.38–4.74) remained
indepen-dentlyassociatedwiththerisk forC.trachomatisinfectioneven afteradjustmentsforpossibleconfoundingfactors(Table4).
RiskfactorsforN.gonorrhoeaeandT.palliduminfectionwere notassessedduetothelowprevalenceobserved.Therewerefour positivecasesofN.gonorrhoeaeinfectionandonepositivecaseof syphilis.Thewomenwithgonococcalinfectionwerebetween18 and 22years old;two ofthefourreportedless than8years of schooling,twoweresingle,andthreewereaged15yearsatfirst intercourse.Theseparticipantsreportedonetosixlifetimesexual partnersandonlyonesexualpartnerinthelast3months.Twoof themreportedapreviouspregnancyandonlyonereportedregular useofcondoms.Theonlycasepositiveforsyphiliswasa
24-year-Table3
UnivariateanalysisofbehavioralvariablespotentiallyassociatedwithChlamydiatrachomatisinfectioninsexuallyactiveyoungwomeninCentralWesternBrazil Variables Numberofpatients(%)
(n=696)
C.trachomatis-positive (n=574)
OR(95%CI) p-Value
Ageatfirstintercourse,years
<15 165(23.7) 20 2.14(1.18–3.86) 0.013a
15 527(75.7) 34
NA 4(0.6)
Numberoflifetimesexualpartners
3 213(31.1) 27 2.57(1.46–4.53) 0.001a
<3 471(68.9) 27
NA 12(1.7)
Numberofsexualpartnersinthelast3months
3 9(1.3) 1 1.61(0.19–13.60) 0.503 <3 683(98.1) 53 NA 4(0.6) Regularpartner No 101(14.5) 9 1.31(0.61–2.80) 0.622 Yes 585(84.1) 45 NA 10(1.4) Condomuse Never 98(14.1) 8 1.05(0.38–2.88) 0.915 Sometimes/rarely 408(58.6) 33 1.05(0.50–2.24) 0.935 Always 185(26.6) 13 NA 5(0.7) Previouspregnancy Yes 271(38.9) 18 0.76(0.42–1.38) 0.449 No 416(59.8) 35 NA 9(1.3)
Ageatfirstpregnancy,years
<15 33(12.2) 5 2.90(0.95–8.85) 0.115 15 234(86.3) 13 NA 4(1.5) STIhistory Yes 33(4.7) 2 0.73(0.17–3.18) 1.000 No 638(91.7) 50 NA 25(3.6)
Sexualintercoursewithasymptomaticpartner
Yes 36(5.2) 3 1.15(0.34–3.95) 0.742
No 623(89.5) 47
NA 37(5.3)
OR,oddsratio;CI,confidenceinterval;NA,notavailable;STI,sexuallytransmittedinfection.
a
Statisticallysignificant,p-value<0.05;Fisher’sexacttestwasusedforfrequencies<5.
Table4
Multivariateanalysisofsocio-demographicandsexualbehaviorassociatedriskfactorsforChlamydiatrachomatisinfectioninyoungwomeninCentralWesternBrazil Variable C.trachomatis-positive
(n=574)
OR(95%CI) p-Value aOR(95%CI) p-Value
Age,years
15–19 35 1.90(1.07–3.37) 0.039a
2.16(1.18–3.97) 0.0128a
20–24 20 Ageatfirstintercourse,yearsb
<15 20 2.14(1.18–3.86) 0.013a
1.40(0.73–2.66) 0.3069
15 34
Numberoflifetimesexualpartnersb
3 27 2.57(1.45–4.53) <0.001a
2.56(1.38–4.74) 0.0028a
<3 27
OR,oddsratio;CI,confidenceinterval;aOR,adjustedoddsratio.
a
Statisticallysignificant,p-value<0.05;Fisher’sexacttestwasusedforfrequencies<5.
b
old married woman with less than 8 years of schooling who reportedanonsetofsexuallifeat15yearsofageandwhohadonly hadonesexualpartnerinlife.Shereferredtoneverhavinguseda condominherlifeandapreviouspregnancyattheageof18years. 4. Discussion
The prevalence rate observed for chlamydial infection is in accordancewiththosefoundinstudiesinvolvingsexuallyactive youngBrazilian women in the northeast region (6–17.1%) and southeast region of the country (7.4–12.2%).17–20 A similar
prevalencerate (9.8%) wasalsoobserved in a national popula-tion-based study conducted in parturient women aged 15–24 years.21However, previous studiesperformed inyoungwomen
recruitedinthecapitalGoiaˆnia,Goia´s(CentralWesternRegion) presentedhigherprevalencerates(14.5–17.6%).12,13Ourfindingsare
alsoinaccordancewithestimatedprevalenceratesfoundinother studiesperformedinasymptomaticyoungwomenoutsideSTIclinics inothercountries:USA(8%),Norway(7.2%),andCanada(9.3%).22–24
Regarding N. gonorrhoeae infection, previous studies in asymptomaticBrazilian women recruited in non-clinicsettings demonstratedsimilarprevalenceratestothatfoundinthepresent study, ranging from 0.8% to 2.1%.13,17,18,21 Otherwise, a higher
prevalencerateofgonococcalinfection(3.2%)wasobservedina population recruited in 2000 at family health units in three BrazilianslumsofSalvador,Bahia.18Ahigherrateofgonococcal
prevalence(4.0%)wasobservedinwomenatpublichealthservices recruitedin2011inlargecitiesofthesoutheastofBrazil.25The lowerprevalenceratefoundinourstudycouldbeexplainedbythe type of specimen used for diagnosis. Although nucleic acid amplification tests are highly appropriate for the detection of genitalgonococcalinfection,26alowsensitivityofPCRhasbeen
demonstratedforN.gonorrhoeaedetectioninurinesamples.27
Thesyphilisprevalencerateobservedinthispopulation was consistent with data from a large urbanized area of Brazil.28
Meanwhile,asignificantlyhigherrateofsyphiliswasidentifiedin femalepublichealthattendeesinthenortheastregionofBrazil (5.1%, 95% CI 2.4–9.6%).18 Regardless of the low prevalence
observedfor T. pallidum infection in this study, this is a cause forconcern,sincethisisapopulationofchild-bearingage.Teenage pregnancy represents a higher vulnerability for STIs and their associatedcomplications,includinganincreasedsusceptibilityto HIV-1 acquisition.29 In this young population, a previous
pregnancywas reported frequently and a high percentage had becomepregnantatlessthan15yearsofage,reflectingapublic healthissue.
C.trachomatispositivitywassignificantlyassociatedwithbeing agedlessthan20yearsandhavingthreeormorelifetimesexual partners, corroborating the results of a prior studyin a similar population.21 Inconsistentcondom use was not associated with
positivityforchlamydialinfection.Thislackofassociationmaybe relatedtothe definitionof ‘inconsistentuse’,inwhichonemay answer‘always’fortheuseofcondomsinmostsexualencountersor justfortheuseofcondomswiththe currentpartner.Asagreat proportionofparticipantsreportedhavingasteadypartner,thelack ofassociationmayalsoberelatedtothefactthatthosewomenina regularrelationshipweremorelikelytousecondomsinconsistently. Thestudypresentssomelimitations,afewoftheminherentto cross-sectionalstudies.Surveystudiesarevaluableforestimating theburdenofaneventandforgeneratinghypotheses,buttheydo notprovidestrongevidenceforriskfactors.Itshouldbepointed outthatthelowprevalenceofgonococcalinfectionandsyphilis foundinthepresentstudypreventedusfromevaluatingtherisk factorsassociatedwiththeseinfections.Theinvestigationofrisk factorsforchlamydialinfectionmayalsohavebeenhampereddue tothelowprevalenceofexposurefactorsamongtheparticipants,
suchasahistoryofexchangingsexformoneyorillegaldruguse. ThelowreportofinconsistentcondomuseorpreviousSTIcouldbe duetoconstraintissuesrelatedtoface-to-faceinterviews,leading toincorrectreporting.Therateofrefusaltoparticipate,although withinthepredeterminedlimits,mayhaveledtoan underesti-mationoftheSTIprevalenceduetoself-exclusionprocedures.
This study was a community-based survey of bacterial STI prevalenceinyoungwomenattendingapublichealthservicein CentralWesternBrazil.Althoughthereissubstantialinformation aboutSTIepidemiologyindevelopedcountries,limiteddataare available in developing settings. In Brazil,most STI prevalence studieshavebeencarriedoutinlargeurbancenters.Weobserveda high prevalence of C. trachomatis infection in young Brazilian womenlivinginmiddle-sizedcitiesinthecentralregionofBrazil. Nevertheless,N.gonorrhoeaeandT.palliduminfectionsexhibited lowprevalencerates.
Although most of thevolunteers reportedan adequate level of educationandhadfreeaccesstocondomsinhealthunits,theystill engagedin sexual behaviorsassociated withthe riskfor STIs.This emphasizestheneedforpoliciesdirectedatsexualeducationandSTI prevention. Furthermore, awareness of the magnitude of these infections outsidehighriskgroupsisimportanttodeterminethenecessityfor screeningstrategiesdirectedatasymptomaticyoungwomen.
Inconclusion,ahighprevalenceofC.trachomatisinfectionwas observedamongsexuallyactiveyoungwomeninthree middle-sizedcitiesofCentralWesternBrazil.TheFamilyHealthProgramis afeasiblesettingforadolescentrecruitment,screening,andearly treatment of these infections in Brazil. Asymptomatic young womenrepresentatargetpopulationforSTIcontrolintervention strategies.
Acknowledgements
ThisstudywassupportedbygrantsfromProgramaNacionalde DST/Aids–Ministe´riodaSau´de(PN-DST/Aids)andfrom Coorde-nac¸a˜odeAperfeic¸oamentodePessoaldeNı´velSuperior(CAPES).Dr Turchihas a researchscholarship fromthe NationalCouncil of TechnologicalandScientificDevelopment(CNPq)andisamember oftheInstituteforHealthTechnologyAssessment–Brazil(IATS). Studysponsorshad no involvementin thestudydesign,in the collection,analysis,andinterpretationofthedata,inthewritingof themanuscript, orin thedecisiontosubmitthemanuscriptfor publication.
Ethicsstatement:ThisstudywasapprovedbytheEthicsReview Board of the University Hospital, Federal University of Goia´s. Potentialparticipantswhowerenotsexuallyexperiencedreceived counselingconcerninggeneralhealthissuesorwerereferredfora medicalappointmentand/orvaccinationwhennecessary.Testsfor chlamydia,syphilis,andgonorrheainfectionswereoffered free-of-chargeforthoseparticipantswhoreportedbeingsexuallyactive. After being informed and providing a written agreement, the participantswerereferredforbloodsamplecollectionandurine self-collection. Samples were kept until the end of the study. Biological samples and questionnaires were labeled with code identificationnumbersinordertopreserveparticipantanonymity. Thecodeidentificationwasheldinreservewiththeresearchteam. Attheendofthestudy,remainingsampleswerediscardedand questionnaireswerestoredinasafeplaceattheFederalUniversity of Goia´s.Participants witha positive resultfor any ofthe STIs investigated, received counseling and treatment in accordance withtheBrazilian GuidelinesforSexually TransmittedDiseases Treatment (Manual de Controle das Doenc¸as Sexualmente Transmissı´veis (DST). Brası´lia, DF: Ministry of Health; 2006). Participantswitha positiveresultwereadvisedtoinformtheir sexualpartnersandtoencouragethemtomakeanappointmentat aFamilyHealthUnitforcounselingandtreatment.
Conflict of interest: The authors declare that there are no conflictsofinterest.
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