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Addressing the high prevalence of gonorrhoea and chlamydia among female sex workers in Indonesia: results of an enhanced, comprehensive intervention
  1. Liesbeth J M Bollen1,
  2. Atiek Sulistyarni Anartati1,
  3. Guy Morineau1,
  4. Siti Sulami1,
  5. Ciptasari Prabawanti1,
  6. Fonny J Silfanus2,
  7. Prima Kartika Esti3,
  8. Nurhayati1,
  9. Tiara Mahatmi1,
  10. Leo Sutarman4,
  11. Wahyu Rahadi5,
  12. Chawalit Natpratan1,
  13. Robert Magnani1
  1. 1Family Health International, Country Office, Jakarta, Indonesia
  2. 2National AIDS Commission, Jakarta, Indonesia
  3. 3Subdirectorate AIDS & STI, Ministry of Health, Jakarta, Indonesia
  4. 4Family Health International, Riau Island Office, Kijang, Indonesia
  5. 5Family Health International, Central Java Office, Semarang, Indonesia
  1. Correspondence to Dr Liesbeth J M Bollen, Aksi Stop AIDS, Family Health International, Country Office for Indonesia, Komplek Ditjen PP & PL Depkes RI, Jalan Percetakan Negara no 29, Jakarta 10560, Indonesia; lbollen{at}fhi.or.id

Abstract

Objectives The authors developed a comprehensive STI-control programme to decrease gonorrhoea and chlamydia prevalence, and increase consistent condom use among brothel-based sex workers in Indonesia.

Methods The STI-control programme for brothel-based sex workers in Bintan Island (Riau Islands) and Salatiga (Central Java) included (1) provision of adequate drugs for gonorrhoea and chlamydia as periodic presumptive treatment (PPT) followed by syndromic treatment; (2) condom-use promotion by involving the local community and ensuring sufficient condom supply. Endocervical samples were collected and tested for gonorrhoea and chlamydia by PCR. Cross-sectional assessments of gonorrhoea and chlamydia prevalence, and consistent condom use with clients in the last week were made at several time points for sex workers attending the STI clinic.

Results 580 sex workers participated in the programme. A steady decrease in prevalence was observed for gonorrhoea (36.1–7.6%) and chlamydia (33.7–10.2%) (both p<0.01) among sex workers in Bintan from March 2008 until June 2009. Sex workers in Salatiga showed a sharp initial decrease in prevalence, followed by an increase after provision of the old drug regimen. Gonorrhoea and/or chlamydia prevalence among those who had received at least one PPT round was lower compared with that in newcomers (p<0.01). The proportion of sex workers reporting consistent condom use doubled to 40% in June 2009 compared with November 2007 (p<0.01).

Conclusion The STI-control programme was effective in reducing infection prevalence and increasing condom use among sex workers. This intervention has been scaled up and may decrease national STI levels and reduce HIV transmission.

  • Chlamydia
  • comdoms
  • gonorrhoea
  • prostitution
  • STD control

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Introduction

Periodic presumptive treatment (PPT) is considered a short-term intervention to rapidly reduce STI rates.1 2 Once STI prevalence rates are brought down, longer-term strategies are needed to maintain a lower STI prevalence.2 Sustainability of the intervention is important, as shown by a study providing one-time presumptive treatment for sex workers in the Philippines, which resulted in a rapid decrease in gonorrhoea and chlamydia prevalence but returned to preintervention levels after 6 months.3 A systematic review of interventions for prevention of STI and HIV among sex workers in resource-limited settings emphasised the importance of structural interventions, policy change and empowerment of sex workers.4

The prevalence of gonococcal and chlamydial infection among female sex workers in Indonesia has remained high over the last 15 years.5 6 A 2007 report showed gonorrhoea and chlamydial infection prevalence by PCR among 3316 sex workers in eight cities to be 31.5% and 35.6%, respectively.6 Several factors have contributed to persistently high STI prevalence among sex workers in Indonesia, including insufficient condom use,5 6 insufficient coverage of STI screening and treatment programmes, and ineffective first-line STI drugs.7 Although gonorrhoea resistance to quinolones has been reported in Indonesia7 8 and its use not recommended in the 2006 national STI treatment guidelines,9 they continue to be widely used in Indonesia.

We designed a comprehensive STI-control strategy consisting of a combination of interventions tailored to the local context including structural interventions with the objective of sustaining a lower STI prevalence. We assessed the effect of this comprehensive STI-control strategy on the prevalence of gonorrhoea and chlamydia, and monitored consistent condom use among sexworkers at two sites in Indonesia.

Methods

The Indonesian Ministry of Health, the National AIDS Commission and international partners collaborated on an enhanced intervention model for STI control among female sex workers, consisting of (1) provision of adequate drugs for gonorrhoea and chlamydia as PPT followed by syndromic treatment; (2) condom-use promotion by involving the local community and ensuring sufficient condom supply.

Routine services

The programme was implemented at two sites, Bintan Island (Riau Islands Province) and Salatiga (Central Java Province), for brothel-based sex workers. Routine services in this area included outreach from local non-government organisations providing counselling, condom promotion and referral for routine STI check-up. Condoms were available at socially marketed prices. Routine clinical services included syndromic management of STIs, syphilis serological screening and treatment, prevention counselling and voluntary counselling and testing for HIV.

Clinical services

Sex workers visiting the clinics were offered participation in the STI-control programme as part of routine clinical services and were requested to visit the clinic monthly. Informed consent was obtained, and participants received PPT (cefixime 400 mg and azithromycin 1 g single dose) directly observed by clinic staff at baseline (March 2008), at the 1-month visit (April 2008), 2-month visit (May 2008) and 15-month visit (June 2009). Endocervical samples were collected from sex workers attending the STI clinic at baseline, at the 2-month visit, 5-month visit (August 2008) and 15-month visit for detection of gonorrhoea and chlamydia by PCR. Women were informed about the possibility to receive their PCR test results at a nearby clinic by showing their participant number. Demographics, clinical data and information on condom use with clients were collected by nurses or doctors as part of clinical services. Testing and treatment were provided free of charge.

After the third PPT round in May 2008, the clinics returned to providing routine enhanced syndromic management for cervicitis, defined as clinician-observed mucopurulent endocervical exudate or mucopus/blood on endocervical swab, or presence of intracellular diplococci or polymorphonuclear leucocytes on cervical samples by light microscopy. The Bintan clinic provided cervicitis treatment with the new drug regimen, while the Salatiga clinic provided syndromic treatment for cervicitis with the old regimen (ciprofloxacin 500 mg and doxycycline 100 mg twice daily for 7 days). The divergent practices at the two sites were due to a misunderstanding as to when the financing of the new drug regimen for routine screening was to be shifted from international donor to local health district funding. Sex workers visiting the clinic for the first time after May 2008 were offered one round of PPT followed by syndromic management.

Laboratory procedures

Endocervical swabs were placed in transport media, stored in the refrigerator and sent to the National Institute of Health Research and Development laboratory (Jakarta, Indonesia) within 7 days. Samples were diluted and tested for Chlamydia trachomatis and Neisseria gonorrhoeae by polymerase chain reaction analysis (Roche Amplicor Diagnostic System, Basel, Switzerland) according to the manufacturer's instructions, including negative and positive controls per 10 samples and internal controls for each sample.

Community mobilisation and condom-use promotion

Following a community mobilisation model that has proven successful elsewhere in Indonesia, Working Groups of local stakeholders consisting of political leaders, representatives of the police or military, public health personnel, pimps, brothel managers and sex workers were formed in November 2007. The Working Groups developed local regulations on consistent condom use and STI screening. Condom use was encouraged by clinic staff, outreach workers and local stakeholders, and adequate condom supply was ensured by the Working Groups. Safe-sex packages consisting of five condoms and information/education material were distributed to sex workers. The oversight of all non-clinical aspects of the initiative was done by the local Working Groups.

Data analysis

Data entry was done at the STI clinic, and data analysis was performed at the national Family Health International office in Jakarta using Stata 7.0 (Stata Corporation, College Station, Texas). Population-based cross-sectional assessments were done among sex workers attending the STI clinic. The age and number of clients were collected from routine medical records of sex workers from their first clinic visit. Gonorrhoea and chlamydia prevalence, and proportion of sex workers reporting consistent condom use with clients in the last week were assessed at several time points. Prevalence of gonorrhoea and/or chlamydia was assessed among sex workers visiting the clinic once (prior to receiving PPT) and was compared with the prevalence among those who had received at least one PPT round. χ2 tests were used to test for differences in proportions; p values less than 0.05 were considered as significant.

Re-infection was assessed among women with prevalent infections (gonorrhoea and/or chlamydia at the last clinic visit) and assessments from at least two time points; a previous negative PCR test was considered as new infection, a previous positive test was considered either treatment failure or re-infection, and a previous positive test followed by a negative and a positive test was considered re-infection. Predictors of prevalent infection (gonorrhoea and/or chlamydia at the last clinic visit) such as site (Bintan vs Salatiga), age, number of clients and consistent condom use were compared between women with prevalent infection and without an infection at their last visit.

Project approval

This project was approved by the Ministry of Health, and the STI surveillance protocol was approved by the Indonesian Ethics Committee for National Health Research.

Results

A total of 580 brothel-based sex workers (265 in Bintan and 315 in Salatiga) participated in the programme from March 2008 to June 2009. Information on age and number of clients was available on 525 women; the median age at the first visit was 26 years (range 17–51 years), and the median number of sex partners in the last week was 3 (range 0–21). The project provided 365 sex workers (166 in Bintan and 199 in Salatiga) with the first PPT round in March 2008. Two-hundred and eighty-one sex workers (138 in Bintan and 143 in Salatiga) visited the clinic only once for PPT and collection of an endocervical specimen for PCR testing.

Among sex workers in Bintan, the gonorrhoea prevalence showed a steady decrease from 36.1% to 7.6% and chlamydia from 33.7% to 10.2% (both p<0.01) from baseline to the 15-month visit (figure 1). The 23.6% gonorrhoea prevalence among sex workers in Salatiga showed a sharp decrease (to 5.5% in May 2008) and increased after providing treatment with the old regimen (ciprofloxacin and doxycyline) (to 19.5% in August 2008); the 27.1% chlamydia prevalence decreased initially (to 9.7% in May 2008) and increased again (to 18.8% in August 2008). After switching to the new drug regimen, the prevalence decreased further in Salatiga in June 2009 (figure 1).

Figure 1

Gonorrhoea and chlamydia prevalence, and consistent condom use with clients during the last week among female sex workers visiting STI clinics in Bintan, Riau Island and Salatiga, Central Java, at several time points. Bintan: decrease in prevalence of gonorrhoea (36.1% vs 7.6%; p<0.01) and chlamydia (33.7% vs 10.2%; p<0.01) from May 2008 to June 2009; consistent condom use increased from November 2007 to June 2009 (22.2% vs 41.6%; p<0.01). Salatiga: decrease in prevalence of gonorrhoea (23.6% vs 13.2%; p=0.01) and chlamydia (27.1% vs 20.4%; p=0.13) from May 2008 to June 2009; consistent condom use increased from November 2007 to June 2009 (19.8% vs 42.1%; p<0.01).

Sex workers who visited the clinic once for PPT had gonorrhoea and/or chlamydia prevalence of 35.9% (101/281) prior to receiving PPT, compared with 19.6% (58/299) among those who had already received at least one PPT round (p<0.01). We did not find any difference between those who had received one PPT round compared with those who had received two or three rounds; 19.1% (18/94) vs 19.5% (40/205); this was similar for Bintan and Salatiga.

Between May and August 2008, clinics provided syndromic treatment for cervicitis. Many (71%) sex workers in Bintan were diagnosed as having cervicitis and received the new treatment regimen; around half (55%) of sex workers in Salatiga were diagnosed as having cervicitis and received the old treatment regimen; the Salatiga site provided the new drug regimen in August 2008 onwards and was brought under a national roll-out of the intervention model sponsored by the National AIDS Commission in December 2008.

Among the 299 sex workers who visited the clinic at least twice for a PCR test, 58 sex workers had gonorrhoea and/or chlamydia at their last visit with a total of 67 infections. Of these 67 infections, 33 (10 in Batam and 23 in Salatiga) followed a negative PCR test and should be considered as new infections, 20 (eight in Batam and 12 in Salatiga) followed a positive PCR test and could present either a treatment failure or reinfection, and 14 (four in Batam and 10 in Salatiga) followed a negative test after a previous positive test and could be considered as reinfection. The median age and median number of clients in the last week were similar among the 58 sex workers with a prevalent infection compared with the 241 without infections (27 years and three clients, respectively). Thirty-three per cent of sex workers with a prevalent infection reported consistent condom use with clients in the last week compared with 36% among those without infections (p=0.8).

The proportion of sex workers in Bintan reporting consistent condom use with clients in the last week increased steadily from 22.2% in November 2007 to 41.6% in June 2009 (p<0.01); a similar increase in consistent condom use was observed among sex workers in Salatiga (19.8% in November 2007 vs 42.1% in June 2009; p<0.01) (figure 1).

Discussion

We showed a decrease in gonorrhoea and chlamydia prevalence among brothel-based sex workers in two sites in Indonesia following implementation of a comprehensive STI-control programme. A sharp decline in gonorrhoea and chlamydia prevalence was observed after provision of PPT, and the prevalence remained low after 15 months since the start of the programme. The successful implementation of this programme is encouraging for clinic staff and public health officials after observing high STI prevalence among sex workers for the last 15 years.

Our results are comparable with experience elsewhere in demonstrating that presumptive treatment of STIs among populations with high STI prevalence can rapidly reduce the STI prevalence.1 2 We returned to syndromic STI management which resulted in overestimation of infection rates and overtreatment. While sensitive, specific and affordable tests are being developed,10 the Indonesian healthcare system will have to rely on syndromic diagnosis of cervicitis with low specificity.11

Although we did not plan to compare the old and new treatment regimens, these data clearly demonstrate the importance of providing potent drugs as part of routine STI services after completing PPT. A low prevalence of gonorrhoea and chlamydia was sustained in Bintan following syndromic treatment for cervicitis with the new drug regimen, whereas resuming the old drug regimen resulted in increased prevalence in Salatiga. Additional funding was allocated to purchase the new drug regimen, and adequate treatment of sex workers with cervicitis was resumed in Salatiga in August 2008.

Development of antimicrobial resistance to cefixime and azithromycin has been mentioned as a concern for providing PPT. However, this seems rather unlikely, as treatment is provided as a single-dose regimen and is administered under direct supervision, thus limiting poor adherence which has been associated with development of resistance.1

New infections and reinfections seemed common in our population, which is likely due to insufficient condom use, although we could not show this association in our limited sample size. Unfortunately, we collected only few behavioural data as part of this project, which did not allow for detailed analysis of factors associated with new or reinfections. Identification of sex workers at risk for new or reinfections will help in targeting prevention efforts, which will be explored during scale-up of the STI-control programme.

The proportion of sex workers reporting consistent condom use with clients increased significantly during the programme at both sites. However, it remained below 50% and is considered insufficient for STI and HIV transmission prevention. Although many countries in the Southeast Asian region have shown successful implementation of 100% condom use programmes,12 13 the situation in Indonesia remains challenging with a resource-constrained public health system and a socio-political environment that has grown less supportive of condom use for HIV prevention. For example, no funding for condoms was provided in the government budget in 2008 and 2009, and the Indonesian Family Planning Commission had to remove condom-vending machines from commercial sex hotspots in 2007 due to pressure from conservative religious groups. Prevention programmes have begun to target clients of sex workers to adopt safer sex behaviours, and efforts continue to address barriers to use condoms with clients. These programmes will eventually work towards empowering sex workers to reduce their vulnerability to STIs and HIV.14

Half of the sex workers received only one round of PPT, which most likely results from high mobility. Indeed, most commercial sex hotspots in Indonesia experience high rates of turnover of sex workers, typically between 50 and 100% annually. This suggests that effective interventions must be implemented at many and ideally all commercial sex sites throughout Indonesia if the initiative is to have significant impact on STI and HIV transmission at the national level. Based on these data, the Indonesian National AIDS Commission has scaled up the intervention model to 14 sites across Indonesia in 2009 with preliminary successful results showing a decrease in gonorrhoea and chlamydia prevalence but with ongoing challenges to increase the proportion of sex workers using condoms consistently. The Ministry of Health, with support from The Global Fund to fight AIDS, will continue to implement this intervention and will expand to three additional sites. The scale-up of this intervention and inclusion of clients of sex workers in the prevention efforts may reduce national STI prevalence rates and eventually reduce HIV transmission.

Key messages

  • A comprehensive STI-control programme, involving the local community, consisting of provision of adequate STI treatment, ensuring condom availability and promoting condom use resulted in a rapid decline of gonorrhoea and chlamydia prevalence which was sustainable after 15 months.

  • Although the proportion of sex workers reporting consistent condom use with clients in the last week increased significantly since the start of the intervention, it still remains insufficient to prevent STI and HIV transmission.

  • The successful implementation of the STI-control programme resulted in the decision by the National AIDS commission and the Ministry of Health to scale up this intervention to reduce national STI prevalence and HIV transmission.

References

Footnotes

  • Funding USAID and Indonesian Partnership Fund.

  • Competing interests None.

  • Ethics approval Ethics approval was provided by The Indonesian Ethics Committee for National Health Research.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.