Evidence-based treatment guidelines for sexually transmitted infections developed with and for female sex workers


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     Amida, Texina Barivelo, Gillian Burkhardt, Rick Homan, Natalie Kruse, Onja Rahamefy, Leonardine Raharimalala, Zo Raharimanana, Jacqueline Rakotoarisoa, Dimisoa Rakotondramarina, Andriamahenina Ramamonjisoa, Jean René Randriasamimanana, Norbert Ratsimbazafy, Perle Rasanjimanana, Andry Rasamindrakotroka, Marie Clara Chantal Rasoamanarivo, Andry Rasoloarimanana, Solofoson Rakotonandrasana, Benjamin Ravelojaona, Marie Madeleine Razafinoro, Saholinirina Ranivoarimanana Fleur de Line, Cherif Soliman, Richard Steen.


background  Sex work is frequently one of the few options women in low-income countries have to generate income for themselves and their families. Treating and preventing sexually transmitted infections (STIs) among sex workers (SWs) is critical to protect the health of the women and their communities; it is also a cost-effective way to slow the spread of HIV. Outside occasional research settings however, SWs in low-income countries rarely have access to effective STI diagnosis.

objectives  To develop adequate, affordable, and acceptable STI control strategies for SWs.

methods  In collaboration with SWs we evaluated STIs and associated demographic, behavioural, and clinical characteristics in SWs living in two cities in Madagascar. Two months post-treatment and counselling, incident STIs and associated factors were determined. Evidence-based STI management guidelines were developed with SW representatives.

results  At baseline, two of 986 SWs were HIV(+); 77.5% of the SWs in Antananarivo and 73.5% in Tamatave had at least one curable STI. Two months post-treatment, 64.9% of 458 SWs in Antananarivo and 57.4% of 481 women in Tamatave had at least one STI. The selected guidelines include speculum exams; syphilis treatment based on serologic screening; presumptive treatment for gonorrhoea, chlamydia, and trichomoniasis during initial visits, and individual risk-based treatment during 3-monthly follow-up visits. SWs were enthusiastic, productive partners.

conclusions  A major HIV epidemic can still be averted in Madagascar but effective STI control is needed nationwide. SWs and health professionals valued the participatory research and decision-making process. Similar approaches should be pursued in other resource-poor settings where sex work and STIs are common and appropriate STI diagnostics lacking.