Abstract
Background:
Sexually transmitted infections (STIs) continue to cause morbidity among women in resource-constrained settings, where asymptomatic infections are often overlooked due to syndromic management protocols. We investigated correlates of asymptomatic STIs among women in the Dominican Republic (DR).
Methods:
We analyzed data collected from cisgender women in DR between 2015–2019. Classified groups included pregnant youth (PY), people with HIV (PWH), residents of bateyes (RB), and sex workers (SW). Nucleic acid amplification or rapid plasma reagin tests detected STIs (Chlamydia/Gonorrhoeae/Syphilis/Trichomonas). Asymptomatic comprised no self-reported vaginal discharge, dysuria, groin lymphadenopathy, and genital/anal pain/ulcers. Logistic regressions identified sociodemographic, clinical, and behavioral correlates.
Results:
Among 833 asymptomatic women (median age 29, IQR 19–37), 35% were PY, 27% PWH, 11% RB, and 27% SW. STI prevalence was 24%: most (61%) had Chlamydia and few (≤25%) had Gonorrhoeae, Syphilis, or Trichomonas. Asymptomatic STI correlates included age ≤24 (Adjusted Odds Ratio [aOR]=2.32, [1.65–3.28]), early (≤14) sexual debut (aOR=1.56, [1.11–2.18]), greater mobility (aOR=1.41, [1.01–1.97]), lack of regular doctor (aOR=1.42, [1.01–1.99]), and drug use in last six months (aOR=1.88, [1.07–3.26]).
Conclusions:
Correlates of asymptomatic STIs—age, sexual debut, mobility, healthcare access, and drug use—should inform targeted screening and prevention efforts where diagnostic testing is not widely available.
Keywords: STI screening and prevention, syndromic management, global health, social determinants of health
INTRODUCTION
Sexually transmitted infections (STIs) remain a major cause of morbidity globally, with nearly one million new infections occurring each day.1 Beyond their direct effect on reproductive health, STIs may facilitate HIV transmission.2–4 In most resource-constrained settings, STIs are managed syndromically based on clinical signs and symptoms because of the costs associated with laboratory diagnostics.5 Syndromic management is inexpensive and readily implemented, but a large proportion of STIs are asymptomatic, and syndromes are often nonspecific. As a result, STIs are both undertreated and overtreated, which drives antimicrobial resistance.6,7 These limitations have prompted calls for improved screening strategies to address asymptomatic STIs in particular.6,8
Because syndromic management remains the standard of care in most low- and middle-income countries (LMICs), identifying correlates of asymptomatic STIs will be crucial to informing the implementation of more effective and targeted STI screening and prevention strategies. This is especially critical for cisgender women, who disproportionately experience STI-related sequelae including infertility, chronic pelvic pain, and adverse pregnancy outcomes. This burden is amplified by social, financial, and structural barriers.9
Despite this recognized need, research on the correlates of asymptomatic STIs in cisgender women is limited. A study examining Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infection in 246 asymptomatic women in Uganda identified associations with age <25 years and multiple sexual partners.10 Another study in Canada used sexual health clinic visit records to identify asymptomatic patients at increased risk for CT and NG by creating a risk-scoring algorithm, which included younger age, non-White ethnicity, multiple sexual partners, and previous infection.11 A third study conducted in China among 454 female sex workers examined the factors associated with “underreporting” STIs, defined as no self-reported STI but detection of CT, NG, Trichomonas vaginalis (TV), Treponema pallidum (TP), or genital warts through laboratory testing or clinical examination. Underreporting was associated with younger age, duration of sex work, poorer knowledge of STIs, and lower perceived risk.12 Otherwise, much of the remaining literature on the correlates of asymptomatic STIs centers on men who have sex with men (MSM).13,14
While STI surveillance efforts in the Dominican Republic (DR), an LMIC where syndromic management is the norm, are limited, data from HIV surveillance suggest that certain populations may be disproportionately affected. These include MSM, sex workers (SW), transgender women (TGW), and Haitian migrants.15 In the DR, bateyes are isolated sugar cane worker settlements largely populated by people of Haitian descent. Our group found that STI prevalence was high among six marginalized populations: pregnant youth (PY), people with HIV (PWH), residents of bateyes (RB), SW, MSM, and TGW.16
Given that the correlates of asymptomatic STIs are not well-established, especially among women in resource-constrained settings, we sought to investigate this question in a sample of cisgender women in the DR. We examined correlates of asymptomatic CT, NG, TP, and TV. We hypothesized that younger age, multiple sexual partners, poorer knowledge of STIs, and substance use would be associated with asymptomatic STIs. We included these infections because clear guidance exists in the United States recommending asymptomatic screening in women at risk for STI acquisition, and they can be readily cured with antimicrobials.17
MATERIALS AND METHODS
Data Source and Population
This analysis used data from a time- and place-sampling study conducted by our group in and around two cities in the DR, Santo Domingo and La Romana, between May 2015 and March 2019. The study aimed to evaluate the prevalence and risk factors for STIs among five adult (aged 18–60 years) populations, PWH, RB, SW, MSM, and TGW, and one youth (aged 15–24 years) population, PY.16 Study methods have been described elsewhere.16 In brief, PY and PWH were recruited using a clinic-based strategy. PY were attending obstetric clinic visits, and PWH were receiving care in HIV treatment centers. RB, SW, MSM, and TGW were recruited using a venue-based strategy that engaged experienced recruiters from the local community. RB lived in one of seven bateyes in the La Romana area or one of four bateyes in the Santo Domingo area. SW solicited across multiple types of establishments and self-identified as sex workers. A structured sampling method was used to ensure proportionate representation from different sex work venue types. Participants self-reported data via a structured questionnaire and specimens were collected for comprehensive STI screening.
We restricted the analytic sample to cisgender women and classified them by STI symptom status. We defined women as asymptomatic if they reported no vaginal discharge, pain on urination, swollen groin lymph nodes, and genital or anal pain or ulcers. Because they would be treated under a syndromic management model, we excluded symptomatic women from the primary analytic sample but included them in triangulation analyses.
This study adhered to the STROBE checklist for cross-sectional studies (Supplemental Material 1).
Outcome
Our outcome of interest was detection of either CT, NG, TV, or TP. CT and NG were detected through nucleic acid amplification test (NAAT) from a urogenital, pharyngeal, or rectal sample. TV was detected through urogenital NAAT. TP was based on a reactive rapid plasma reagin with reactive confirmatory fluorescent treponemal antibody absorption test.
Covariates
Theoretical Basis for Variable Selection
Variable selection was guided by a socioecologic theory of change (ToC) describing individual, behavioral, and structural determinants of STIs in asymptomatic women. The ToC informed our literature review and identified younger age, early sexual debut, multiple sexual partners, previous infection, poor STI knowledge, lower educational attainment, poor access to healthcare, minoritized ethnicity, substance use, and depression as potential correlates of STI symptom perception. The ToC also included stressors that could alter the saliency of STI symptoms (e.g., housing instability, mobility, intimate partner violence, and poverty), and possible correlates of lower perceived risk (e.g., partnered relationship status, infrequent condom use, and anal sex). Proxy variables in the dataset were selected for analysis based on this ToC and scientific evidence.
Sociodemographic
We grouped age into four bands (<24, 25–34, 35–44, >45) based on statistical distribution, and dichotomized into ≤24 and >24 to analyze adolescent girls and young women. Employment status reflected regular vs irregular/no work. We categorized monthly income, reported in Dominican pesos, into the following six levels: ≤$3,500, $3,501-$6,000, $6,001-$10,000, $10,001-$20,000, >$20,000, and missing. The Dominican poverty line at the time of the study was $3,500 pesos, and at the data collection midpoint date of 3/31/2017, RD$47 = USD$1. Educational attainment indicated less than high school, some high school, and postsecondary. Relationship status measured if women were partnered vs not partnered. Women were defined as housing unstable if they had spent a night on the street or in a shelter, jail, transitional residency, or addiction treatment facility in the last six months. Mobility was defined as moving at least once in the last year. Lifetime experience of physical abuse, sexual coercion, or feeling threatened in a relationship (IPV) was dichotomized into yes vs no.
Clinical
Access to a regular doctor was captured as yes vs no/don’t know/don’t understand/refused. Women responding “don’t know” and “refused” could not be disaggregated from those reporting “no.” We dichotomized insurance status, STI history, and treatment for STI in the last six months as yes vs no. We assessed comprehensive STI knowledge based on correct responses to five questions: “Can you prevent STIs by taking birth control pills?” “Can you prevent STIs by using a condom?” “Can you prevent STIs by not having sex?” “Can you prevent STIs by washing your genitals after having sex?” and “Can you prevent STIs by urinating after having sex?”. We examined the proportion of women who answered all questions correctly. Patient Health Questionnaire-2 (PHQ2) scores were categorized into ≥3 (suggestive of major depression), <3, and missing.
Behavioral
We dichotomized age at sexual debut into ≤14 vs >14 years. Number of male sexual partners in the last six months was categorized into zero, one, and two or more. Considering oral, vaginal, and receptive anal sex, we defined condom use during the last six months as no sex, consistent (always used condoms), and inconsistent (sometimes or never used condoms). We also assessed report of receptive anal sex ever and in the last six months. Alcohol use before sex in the last six months was categorized as does not drink/no sex vs never vs sometimes/always. We defined substance use as smoking, snorting, or injecting any substance (e.g., marijuana, cocaine, crack, amphetamines, heroin, hallucinogens, other) during the past six months.
Statistical Analysis
Analyses were conducted using R V.4.4.0. Complete case analysis was performed using all factors except income and depressive symptoms due to their high level of incompleteness. We reported descriptive statistics by recruitment group, STI status, and specific STIs. For CT and NG, we described the frequency of urogenital, pharyngeal, and rectal infection. We reported the distribution of STIs detected among asymptomatic and symptomatic women.
Given the novelty of the question in this context and population, we used an exploratory analytic approach to identify sociodemographic, clinical, and behavioral correlates of STI detection among asymptomatic women from our list of theorized variables. We first conducted unadjusted logistic regression analyses. Variables with an unadjusted p≤0.10 were included in the initial multiple logistic regression model, and we applied backward selection, removing variables with the largest p-values and refitting the model until all retained variables had an adjusted p≤0.05.
To assess potential modification, we performed age-stratified (≤24 vs >24) analyses. Additionally, we examined correlates of STI detection among symptomatic women to understand potential differences by symptom status.
RESULTS
Table 1 presents baseline characteristics by study recruitment group. Among 833 asymptomatic women, 295 (35%) were PY, 222 (27%) PWH, 95 (11%) RB, and 221 (27%) SW. Median age was 24 years (IQR 19–37) overall, and 18 (IQR 17–20), 42 (IQR 35–48), 27 (IQR 22–37), and 28 (IQR 22–33) years among PY, PWH, RB, and SW, respectively. Around 43% (356/833) had moved during the last year. Approximately 65% (538/833) had a regular doctor and 51% (427/833) had health insurance. About 25% (210/833) reported a lifetime history of STI. Nearly 61% (504/833) answered all STI knowledge questions correctly. Approximately 36% (303/833) reported sexual debut at age ≤14 years. Overall, 41% (338/833) had more than one sexual partner in the last six months. Receptive anal sex was reported by 18% (146/833), and 8% (65/833) used drugs in the last six months, primarily marijuana (83%, 54/65) and cocaine (32%, 21/65; Supplemental Material 2).
Table 1.
Baseline characteristics of a sample of asymptomatic women in the Dominican Republic by study recruitment group
| Characteristic | Overall N=833 |
Pregnant Youth N=295 |
People with HIV N=222 |
Batey Residents N=95 |
Sex Workers N=221 |
|---|---|---|---|---|---|
| Sociodemographic | |||||
| Age | |||||
| <=24 | 420 (50.4%) | 295 (100.0%) | 3 (1.4%) | 37 (38.9%) | 85 (38.5%) |
| 25 to 34 | 161 (19.3%) | 0 (0.0%) | 46 (20.7%) | 30 (31.6%) | 85 (38.5%) |
| 35 to 44 | 146 (17.5%) | 0 (0.0%) | 82 (36.9%) | 21 (22.1%) | 43 (19.5%) |
| >=45 | 106 (12.7%) | 0 (0.0%) | 91 (41.0%) | 7 (7.4%) | 8 (3.6%) |
| Age (binary) | |||||
| >24 | 413 (49.6%) | 0 (0.0%) | 219 (98.6%) | 58 (61.1%) | 136 (61.5%) |
| <=24 | 420 (50.4%) | 295 (100.0%) | 3 (1.4%) | 37 (38.9%) | 85 (38.5%) |
| Employment status | |||||
| Irregular or no income | 630 (75.6%) | 246 (83.4%) | 157 (70.7%) | 77 (81.1%) | 150 (67.9%) |
| Regular work | 203 (24.4%) | 49 (16.6%) | 65 (29.3%) | 18 (18.9%) | 71 (32.1%) |
| Monthly income (pesos) | |||||
| <=3,500 | 323 (42.9%) | 181 (71.5%) | 82 (40.2%) | 44 (48.9%) | 16 (7.8%) |
| 3,501–6,000 | 150 (19.9%) | 36 (14.2%) | 49 (24.0%) | 27 (30.0%) | 38 (18.4%) |
| 6,001–10,000 | 153 (20.3%) | 24 (9.5%) | 47 (23.0%) | 10 (11.1%) | 72 (35.0%) |
| 10,001–20,000 | 91 (12.1%) | 10 (4.0%) | 17 (8.3%) | 8 (8.9%) | 56 (27.2%) |
| >20,000 | 36 (4.8%) | 2 (0.8%) | 9 (4.4%) | 1 (1.1%) | 24 (11.7%) |
| Missing | 80 | 42 | 18 | 5 | 15 |
| Educational attainment | |||||
| Less than high school | 360 (43.2%) | 105 (35.6%) | 111 (50.0%) | 50 (52.6%) | 94 (42.5%) |
| Some high school | 404 (48.5%) | 170 (57.6%) | 90 (40.5%) | 37 (38.9%) | 107 (48.4%) |
| Postsecondary | 69 (8.3%) | 20 (6.8%) | 21 (9.5%) | 8 (8.4%) | 20 (9.0%) |
| Relationship status | |||||
| Not partnered | 389 (46.7%) | 70 (23.7%) | 136 (61.3%) | 27 (28.4%) | 156 (70.6%) |
| Partnered | 444 (53.3%) | 225 (76.3%) | 86 (38.7%) | 68 (71.6%) | 65 (29.4%) |
| Housing instability | |||||
| No | 595 (71.4%) | 257 (87.1%) | 184 (82.9%) | 78 (82.1%) | 76 (34.4%) |
| Yes | 238 (28.6%) | 38 (12.9%) | 38 (17.1%) | 17 (17.9%) | 145 (65.6%) |
| Moved in last year | |||||
| No | 477 (57.3%) | 157 (53.2%) | 162 (73.0%) | 62 (65.3%) | 96 (43.4%) |
| Yes | 356 (42.7%) | 138 (46.8%) | 60 (27.0%) | 33 (34.7%) | 125 (56.6%) |
| IPV ever | |||||
| No | 623 (74.8%) | 255 (86.4%) | 157 (70.7%) | 75 (78.9%) | 136 (61.5%) |
| Yes | 210 (25.2%) | 40 (13.6%) | 65 (29.3%) | 20 (21.1%) | 85 (38.5%) |
| Clinical | |||||
| Regular doctor | |||||
| Yes | 538 (64.6%) | 190 (64.4%) | 222 (100.0%) | 24 (25.3%) | 102 (46.2%) |
| No, Don’t Know, Don’t Understand, Refused | 295 (35.4%) | 105 (35.6%) | 0 (0.0%) | 71 (74.7%) | 119 (53.8%) |
| Insurance | |||||
| Yes | 427 (51.3%) | 113 (38.3%) | 160 (72.1%) | 55 (57.9%) | 99 (44.8%) |
| No | 406 (48.7%) | 182 (61.7%) | 62 (27.9%) | 40 (42.1%) | 122 (55.2%) |
| Self-reported history of STI | |||||
| No | 623 (74.8%) | 263 (89.2%) | 128 (57.7%) | 73 (76.8%) | 159 (71.9%) |
| Yes | 210 (25.2%) | 32 (10.8%) | 94 (42.3%) | 22 (23.2%) | 62 (28.1%) |
| Treated for STI in last 6 months | |||||
| No | 788 (94.6%) | 285 (96.6%) | 195 (87.8%) | 92 (96.8%) | 216 (97.7%) |
| Yes | 45 (5.4%) | 10 (3.4%) | 27 (12.2%) | 3 (3.2%) | 5 (2.3%) |
| Comprehensive STI knowledge | |||||
| No | 329 (39.5%) | 133 (45.1%) | 67 (30.2%) | 43 (45.3%) | 86 (38.9%) |
| Yes | 504 (60.5%) | 162 (54.9%) | 155 (69.8%) | 52 (54.7%) | 135 (61.1%) |
| PHQ2 score >=3 | |||||
| No | 684 (88.1%) | 255 (91.7%) | 179 (85.6%) | 76 (88.4%) | 174 (85.7%) |
| Yes | 92 (11.9%) | 23 (8.3%) | 30 (14.4%) | 10 (11.6%) | 29 (14.3%) |
| Missing | 57 | 17 | 13 | 9 | 18 |
| Behavioral | |||||
| Age at sexual debut | |||||
| >14 | 530 (63.6%) | 171 (58.0%) | 160 (72.1%) | 63 (66.3%) | 136 (61.5%) |
| <=14 | 303 (36.4%) | 124 (42.0%) | 62 (27.9%) | 32 (33.7%) | 85 (38.5%) |
| Male partners in last 6 months | |||||
| 0 | 90 (10.8%) | 9 (3.1%) | 73 (32.9%) | 5 (5.3%) | 3 (1.4%) |
| 1 | 405 (48.6%) | 224 (75.9%) | 118 (53.2%) | 56 (58.9%) | 7 (3.2%) |
| >=2 | 338 (40.6%) | 62 (21.0%) | 31 (14.0%) | 34 (35.8%) | 211 (95.5%) |
| Condom use | |||||
| No sex in last 6 months | 100 (12.0%) | 21 (7.1%) | 72 (32.4%) | 5 (5.3%) | 2 (0.9%) |
| Consistent | 118 (14.2%) | 4 (1.4%) | 56 (25.2%) | 7 (7.4%) | 51 (23.1%) |
| Inconsistent | 615 (73.8%) | 270 (91.5%) | 94 (42.3%) | 83 (87.4%) | 168 (76.0%) |
| Receptive anal sex ever | |||||
| No | 687 (82.5%) | 262 (88.8%) | 184 (82.9%) | 79 (83.2%) | 162 (73.3%) |
| Yes | 146 (17.5%) | 33 (11.2%) | 38 (17.1%) | 16 (16.8%) | 59 (26.7%) |
| Receptive anal sex in last 6 months | |||||
| No | 769 (92.3%) | 279 (94.6%) | 212 (95.5%) | 91 (95.8%) | 187 (84.6%) |
| Yes | 64 (7.7%) | 16 (5.4%) | 10 (4.5%) | 4 (4.2%) | 34 (15.4%) |
| Alcohol use before sex | |||||
| Doesn’t drink/No sex in last 6 months | 362 (43.5%) | 170 (57.6%) | 140 (63.1%) | 28 (29.5%) | 24 (10.9%) |
| Never | 137 (16.4%) | 51 (17.3%) | 43 (19.4%) | 25 (26.3%) | 18 (8.1%) |
| Sometimes/Always | 334 (40.1%) | 74 (25.1%) | 39 (17.6%) | 42 (44.2%) | 179 (81.0%) |
| Drug use in last 6 months | |||||
| No | 768 (92.2%) | 284 (96.3%) | 219 (98.6%) | 90 (94.7%) | 175 (79.2%) |
| Yes | 65 (7.8%) | 11 (3.7%) | 3 (1.4%) | 5 (5.3%) | 46 (20.8%) |
Table 2 presents characteristics by STI status. STI prevalence among asymptomatic women was 24% overall, and 34%, 27%, 22%, and 10% in PY, SW, RB, and PWH, respectively. Correlates of any STI based on X2 or Fisher’s exact test p-value ≤0.05 were PY group membership, PWH group non-membership, younger age, greater mobility, lack of regular doctor, uninsured status, early sexual debut, multiple partners, and drug use. Of the 202 women with STI, 176 had one infection (59% CT), 25 had two infections (primarily CT [80%] with NG [44%] or TV [40%]), and one had three infections (CT, TV, TP; Supplemental Material 3). Most women with CT (N=124) and NG (N=33) had rectal infections (82% and 67%, respectively), and the majority of those with CT and NG urogenital and pharyngeal infections also had a rectal infection. Forty-three women had TV and 29 had TP. Of the 115 rectal infections detected, 87% (100/115) reported never having had anal sex. Reporting of anal sex differed by symptom status (25% [77/304] of symptomatic women vs 18% [146/833] of asymptomatic women) and STI status (21% [182/860] of women without STI vs 15% [41/277] of women with STI). Among asymptomatic women who reported never having had anal sex and were positive for urogenital NG, 75% (9/12) had concomitant rectal NG. Similarly, among asymptomatic women who reported never having had anal sex and were positive for urogenital CT, 70% (33/47) had concomitant rectal CT. Supplemental Material 4 displays the distribution of specific STIs. Four PY were diagnosed with TP.
Table 2.
Characteristics of a sample of asymptomatic women in the Dominican Republic by STI status
| Characteristic | Overall | Any STI | No STI | p-value* |
|---|---|---|---|---|
| N=833 (100%) | N=202 (24.2%) | N=631 (75.8%) | ||
| Recruitment Group | ||||
| Pregnant youth | <0.001 | |||
| No | 538 (64.6%) | 103 (19.1%) | 435 (80.9%) | |
| Yes | 295 (35.4%) | 99 (33.6%) | 196 (66.4%) | |
| People with HIV | <0.001 | |||
| No | 611 (73.3%) | 180 (29.5%) | 431 (70.5%) | |
| Yes | 222 (26.7%) | 22 (9.9%) | 200 (90.1%) | |
| Batey residents | 0.604 | |||
| No | 738 (88.6%) | 181 (24.5%) | 557 (75.5%) | |
| Yes | 95 (11.4%) | 21 (22.1%) | 74 (77.9%) | |
| Sex workers | 0.241 | |||
| No | 612 (73.5%) | 142 (23.2%) | 470 (76.8%) | |
| Yes | 221 (26.5%) | 60 (27.1%) | 161 (72.9%) | |
| Sociodemographic | ||||
| Age | <0.001 | |||
| <=24 | 420 (50.4%) | 136 (32.4%) | 284 (67.6%) | |
| 25 to 34 | 161 (19.3%) | 34 (21.1%) | 127 (78.9%) | |
| 35 to 44 | 146 (17.5%) | 27 (18.5%) | 119 (81.5%) | |
| >=45 | 106 (12.7%) | 5 (4.7%) | 101 (95.3%) | |
| Age (binary) | <0.001 | |||
| >24 | 413 (49.6%) | 66 (16.0%) | 347 (84.0%) | |
| <=24 | 420 (50.4%) | 136 (32.4%) | 284 (67.6%) | |
| Employment status | 0.325 | |||
| Irregular or no income | 630 (75.6%) | 158 (25.1%) | 472 (74.9%) | |
| Regular work | 203 (24.4%) | 44 (21.7%) | 159 (78.3%) | |
| Educational attainment | 0.708 | |||
| Less than high school | 360 (43.2%) | 92 (25.6%) | 268 (74.4%) | |
| Some high school | 404 (48.5%) | 95 (23.5%) | 309 (76.5%) | |
| Postsecondary | 69 (8.3%) | 15 (21.7%) | 54 (78.3%) | |
| Relationship status | 0.957 | |||
| Not partnered | 389 (46.7%) | 94 (24.2%) | 295 (75.8%) | |
| Partnered | 444 (53.3%) | 108 (24.3%) | 336 (75.7%) | |
| Housing instability | 0.557 | |||
| No | 595 (71.4%) | 141 (23.7%) | 454 (76.3%) | |
| Yes | 238 (28.6%) | 61 (25.6%) | 177 (74.4%) | |
| Moved in last year | 0.006 | |||
| 0 | 477 (57.3%) | 99 (20.8%) | 378 (79.2%) | |
| >=1 | 356 (42.7%) | 103 (28.9%) | 253 (71.1%) | |
| IPV ever | 0.720 | |||
| No | 623 (74.8%) | 153 (24.6%) | 470 (75.4%) | |
| Yes | 210 (25.2%) | 49 (23.3%) | 161 (76.7%) | |
| Clinical | ||||
| Regular doctor | 0.002 | |||
| Yes | 538 (64.6%) | 112 (20.8%) | 426 (79.2%) | |
| No, Don’t know, Don’t understand, or refused | 295 (35.4%) | 90 (30.5%) | 205 (69.5%) | |
| Insurance | <0.001 | |||
| Yes | 427 (51.3%) | 83 (19.4%) | 344 (80.6%) | |
| No | 406 (48.7%) | 119 (29.3%) | 287 (70.7%) | |
| Self-reported history of STI | 0.586 | |||
| No | 623 (74.8%) | 154 (24.7%) | 469 (75.3%) | |
| Yes | 210 (25.2%) | 48 (22.9%) | 162 (77.1%) | |
| Treated for STI in last 6 months | 0.455 | |||
| No | 788 (94.6%) | 189 (24.0%) | 599 (76.0%) | |
| Yes | 45 (5.4%) | 13 (28.9%) | 32 (71.1%) | |
| Comprehensive STI knowledge | 0.485 | |||
| No | 329 (39.5%) | 84 (25.5%) | 245 (74.5%) | |
| Yes | 504 (60.5%) | 118 (23.4%) | 386 (76.6%) | |
| Behavioral | ||||
| Age at sexual debut | <0.001 | |||
| >14 | 530 (63.6%) | 107 (20.2%) | 423 (79.8%) | |
| <=14 | 303 (36.4%) | 95 (31.4%) | 208 (68.6%) | |
| Male partners in last 6 months | 0.003 | |||
| 0 | 90 (10.8%) | 10 (11.1%) | 80 (88.9%) | |
| 1 | 405 (48.6%) | 96 (23.7%) | 309 (76.3%) | |
| >=2 | 338 (40.6%) | 96 (28.4%) | 242 (71.6%) | |
| Condom use | 0.119 | |||
| No sex in last 6 months | 100 (12.0%) | 16 (16.0%) | 84 (84.0%) | |
| Consistent | 118 (14.2%) | 29 (24.6%) | 89 (75.4%) | |
| Inconsistent | 615 (73.8%) | 157 (25.5%) | 458 (74.5%) | |
| Receptive anal sex ever | 0.250 | |||
| No | 687 (82.5%) | 172 (25.0%) | 515 (75.0%) | |
| Yes | 146 (17.5%) | 30 (20.5%) | 116 (79.5%) | |
| Receptive anal sex in last 6 months | 0.444 | |||
| No | 769 (92.3%) | 189 (24.6%) | 580 (75.4%) | |
| Yes | 64 (7.7%) | 13 (20.3%) | 51 (79.7%) | |
| Alcohol use before sex | 0.137 | |||
| Doesn’t drink/No sex in last 6 months | 362 (43.5%) | 80 (22.1%) | 282 (77.9%) | |
| Never | 137 (16.4%) | 29 (21.2%) | 108 (78.8%) | |
| Sometimes/Always | 334 (40.1%) | 93 (27.8%) | 241 (72.2%) | |
| Drug use in last 6 months | 0.002 | |||
| No | 768 (92.2%) | 176 (22.9%) | 592 (77.1%) | |
| Yes | 65 (7.8%) | 26 (40.0%) | 39 (60.0%) |
Chi-square or Fisher’s exact test
Table 3 presents our unadjusted and adjusted logistic regression models estimating the association between asymptomatic STIs and key sociodemographic, clinical, and behavioral correlates (model-building shown in Supplemental Material 5). We included age, mobility, access to a regular doctor, insurance status, sexual debut, number of partners, condom use, alcohol use before sex, and drug use in the initial adjusted model based on results of the unadjusted analysis. We did not include PY and PWH group membership in the adjusted analysis because of collinearity with age. After backwards elimination, age ≤24 (aOR 2.32, 95% CI 1.65–3.28), greater mobility (aOR 1.41, 95% CI 1.01–1.97), not having a regular doctor (aOR 1.42, 95% CI 1.01–1.99), age ≤14 at sexual debut (aOR 1.56, 95% CI 1.11–2.18), and drug use in the last 6 months (aOR 1.88, 95% CI 1.07–3.26) were associated with detection of any STI.
Table 3.
Unadjusted and adjusted logistic regression analysis of asymptomatic STIs among marginalized women in the Dominican Republic
| Unadjusted | Final model | |||
|---|---|---|---|---|
| Characteristic | OR [95% CI] | p-value | aOR [95% CI] | p-value |
| Recruitment group | ||||
| Pregnant youth | ||||
| No | — | |||
| Yes | 2.13 [1.54–2.95] | <0.001 | ||
| People with HIV | ||||
| No | — | |||
| Yes | 0.26 [0.16–0.41] | <0.001 | ||
| Batey residents | ||||
| No | — | |||
| Yes | 0.87 [0.51–1.43] | 0.605 | ||
| Sex workers | ||||
| No | — | |||
| Yes | 1.23 [0.86–1.75] | 0.241 | ||
| Sociodemographic | ||||
| Age (binary) | ||||
| >24 | — | — | ||
| <=24 | 2.52 [1.81–3.53] | <0.001 | 2.32 [1.65–3.28] | <0.001 |
| Employment status | ||||
| Irregular or no income | — | |||
| Regular work | 0.83 [0.56–1.20] | 0.325 | ||
| Educational attainment | ||||
| Less than high school | — | |||
| Some high school | 0.90 [0.64–1.25] | 0.513 | ||
| Postsecondary | 0.81 [0.42–1.47] | 0.503 | ||
| Relationship status | ||||
| Not partnered | — | |||
| Partnered | 1.01 [0.73–1.39] | 0.957 | ||
| Housing instability | ||||
| No | — | |||
| Yes | 1.11 [0.78–1.56] | 0.557 | ||
| Moved in last year | ||||
| No | — | — | ||
| Yes | 1.55 [1.13–2.14] | 0.007 | 1.41 [1.01–1.97] | 0.041 |
| IPV ever | ||||
| No | — | |||
| Yes | 0.93 [0.64–1.34] | 0.720 | ||
| Clinical | ||||
| Regular doctor | ||||
| Yes | — | — | ||
| No, Don’t know, Don’t understand, or refused | 1.67 [1.21–2.31] | 0.002 | 1.42 [1.01–1.99] | 0.042 |
| Insurance | ||||
| Yes | — | |||
| No | 1.72 [1.25–2.37] | <0.001 | ||
| Self-reported history of STI | ||||
| No | — | |||
| Yes | 0.90 [0.62–1.30] | 0.586 | ||
| Treated for STI in last 6 months | ||||
| No | — | |||
| Yes | 1.29 [0.64–2.45] | 0.456 | ||
| Comprehensive STI knowledge | ||||
| No | — | |||
| Yes | 0.89 [0.65–1.23] | 0.486 | ||
| Behavioral | ||||
| Age at sexual debut | ||||
| >14 | — | — | ||
| <=14 | 1.81 [1.31–2.49] | <0.001 | 1.56 [1.11–2.18] | 0.01 |
| Male partners in last 6 months | ||||
| 0 | — | |||
| 1 | 2.49 [1.29–5.28] | 0.010 | ||
| >=2 | 3.17 [1.65–6.76] | 0.001 | ||
| Condom use | ||||
| No sex in last 6 months | — | |||
| Consistent | 1.71 [0.88–3.44] | 0.121 | ||
| Inconsistent | 1.80 [1.05–3.27] | 0.041 | ||
| Receptive anal sex ever | ||||
| No | — | |||
| Yes | 0.77 [0.49–1.18] | 0.251 | ||
| Receptive anal sex in last 6 months | ||||
| No | — | |||
| Yes | 0.78 [0.40–1.43] | 0.445 | ||
| Alcohol use before sex | ||||
| Doesn’t drink/No sex in last 6 months | — | |||
| Never | 0.95 [0.58–1.51] | 0.822 | ||
| Sometimes/Always | 1.36 [0.96–1.92] | 0.080 | ||
| Drug use in last 6 months | ||||
| No | — | — | ||
| Yes | 2.24 [1.32–3.77] | 0.003 | 1.88 [1.07–3.26] | 0.025 |
N=833; 202 (24%) had STI; See Supplemental Material 5 for interim adjusted models
Table 4 presents age-stratified results (model-building shown in Supplemental Material 6). For women ≤24 years of age, we included RB group membership, access to a regular doctor, sexual debut, condom use, and receptive anal sex in the initial adjusted model. After backwards elimination, not having a regular doctor (aOR 1.72, 95% CI 1.11–2.66) and age ≤14 at sexual debut (aOR 2.00, 95% CI 1.30–3.08) exhibited positive associations, while RB group membership (aOR 0.37, 95% CI 0.14–0.84) and receptive anal sex in the last six months (aOR 0.12, 95% CI 0.02–0.42) had negative associations. For women >24 years of age, we included mobility, PWH and RB group membership, insurance status, number of partners, condom use, receptive anal sex, alcohol use before sex, and drug use in the initial adjusted model. After backwards elimination, RB group membership (aOR 2.06, 95% CI 0.98–4.17), uninsured status (aOR 2.07, 95% CI 1.20–3.60), multiple partners (aOR 2.99, 95% CI 1.17–9.23), and drug use in the last six months (aOR 2.75, 95% CI 1.19–6.26) were associated with STI. SW group membership was not included in the adjusted analysis because of its association with number of partners.
Table 4.
Unadjusted and adjusted logistic regression analysis of asymptomatic STIs among marginalized women in the Dominican Republic, stratified by age group
| Age <=24 | Age >24 | |||||||
|---|---|---|---|---|---|---|---|---|
| Unadjusted | Final Model | Unadjusted | Final Model | |||||
| Characteristic | OR [95% CI] | p-value | aOR [95% CI] | p-value | OR [95% CI] | p-value | aOR [95% CI] | p-value |
| Recruitment group | ||||||||
| Pregnant youth | ||||||||
| No | — | N/A | ||||||
| Yes | 1.20 [0.77–1.90] | 0.428 | N/A | |||||
| People with HIV | ||||||||
| No | — | — | ||||||
| Yes | 1.04 [0.05–11.0] | 0.972 | 0.35 [0.20–0.61] | <0.001 | ||||
| Batey residents | ||||||||
| No | — | — | — | — | ||||
| Yes | 0.46 [0.18–1.02] | 0.073 | 0.37 [0.14–0.84] | 0.026 | 1.85 [0.92–3.55] | 0.071 | 2.06 [0.98–4.17] | 0.049 |
| Sex workers | ||||||||
| No | — | — | ||||||
| Yes | 1.10 [0.66–1.81] | 0.702 | 2.04 [1.19–3.49] | 0.009 | ||||
| Sociodemographic | ||||||||
| Employment status | ||||||||
| Irregular or no income | — | — | ||||||
| Regular work | 0.95 [0.57–1.55] | 0.842 | 0.77 [0.40–1.40] | 0.408 | ||||
| Educational attainment | ||||||||
| Less than high school | — | — | ||||||
| Some high school | 0.72 [0.46–1.11] | 0.133 | 0.80 [0.45–1.38] | 0.426 | ||||
| Postsecondary | 1.24 [0.54–2.77] | 0.606 | 0.36 [0.08–1.07] | 0.106 | ||||
| Relationship status | ||||||||
| Not partnered | — | — | ||||||
| Partnered | 0.79 [0.52–1.20] | 0.268 | 0.86 [0.50–1.47] | 0.593 | ||||
| Housing instability | ||||||||
| No | — | — | ||||||
| Yes | 1.19 [0.74–1.87] | 0.470 | 1.20 [0.68–2.07] | 0.520 | ||||
| Moved in last year | ||||||||
| No | — | — | ||||||
| Yes | 1.11 [0.73–1.66] | 0.632 | 2.12 [1.24–3.61] | 0.006 | ||||
| IPV ever | ||||||||
| No | — | — | ||||||
| Yes | 1.18 [0.70–1.95] | 0.520 | 0.96 [0.53–1.68] | 0.895 | ||||
| Clinical | ||||||||
| Regular doctor | ||||||||
| Yes | — | — | — | |||||
| No, don’t know, don’t understand, or refused | 1.56 [1.03–2.36] | 0.035 | 1.72 [1.11–2.66] | 0.015 | 1.40 [0.79–2.43] | 0.239 | ||
| Insurance | ||||||||
| Yes | — | — | — | |||||
| No | 1.04 [0.68–1.59] | 0.862 | 2.23 [1.31–3.81] | 0.003 | 2.07 [1.20–3.60] | 0.009 | ||
| Self-reported history of STI | ||||||||
| No | — | — | ||||||
| Yes | 0.90 [0.50–1.55] | 0.706 | 1.41 [0.82–2.42] | 0.207 | ||||
| Treated for STI in last 6 months | ||||||||
| No | — | — | ||||||
| Yes | 1.40 [0.35–5.00] | 0.604 | 1.95 [0.83–4.24] | 0.106 | ||||
| Comprehensive STI knowledge | ||||||||
| No | — | — | ||||||
| Yes | 1.10 [0.73–1.67] | 0.645 | 0.81 [0.47–1.42] | 0.457 | ||||
| Behavioral | ||||||||
| Age at sexual debut | ||||||||
| >14 | — | — | — | |||||
| <=14 | 1.89 [1.25–2.87] | 0.003 | 2.00 [1.30–3.08] | 0.002 | 1.44 [0.83–2.47] | 0.190 | ||
| Male partners in last 6 months | ||||||||
| 0 | — | — | — | |||||
| 1 | 0.60 [0.19–2.08] | 0.394 | 2.36 [0.92–7.28] | 0.096 | 2.03 [0.77–6.36] | 0.18 | ||
| >=2 | 0.77 [0.23–2.69] | 0.663 | 4.13 [1.70–12.4] | 0.004 | 2.99 [1.17–9.23] | 0.033 | ||
| Condom use | ||||||||
| No sex in last 6 months | — | — | ||||||
| Consistent | 0.60 [0.20–1.80] | 0.363 | 3.76 [1.41–11.9] | 0.013 | ||||
| Inconsistent | 0.49 [0.21–1.17] | 0.102 | 3.01 [1.25–8.95] | 0.025 | ||||
| Receptive anal sex ever | ||||||||
| No | — | — | ||||||
| Yes | 0.40 [0.19–0.79] | 0.012 | 1.75 [0.96–3.12] | 0.061 | ||||
| Receptive anal sex in last 6 months | ||||||||
| No | — | — | — | |||||
| Yes | 0.17 [0.03–0.58] | 0.017 | 0.12 [0.02–0.41] | 0.004 | 2.28 [1.03–4.73] | 0.032 | ||
| Alcohol use before sex | ||||||||
| Doesn’t drink/No sex in last 6 months | — | — | ||||||
| Never | 0.66 [0.34–1.23] | 0.207 | 1.71 [0.79–3.62] | 0.163 | ||||
| Sometimes/Always | 1.25 [0.80–1.95] | 0.321 | 1.74 [0.96–3.19] | 0.070 | ||||
| Drug use in last 6 months | ||||||||
| No | — | — | — | |||||
| Yes | 1.56 [0.73–3.27] | 0.241 | 3.81 [1.76–7.99] | <0.001 | 2.75 [1.19–6.26] | 0.017 | ||
Total sample is 420; 136 (32%) had STI; N/A = Not applicable
Finally, among 304 symptomatic women, STIs were detected in 75 (25%; Supplemental Material 7). The prevalence by group was 35% (27/78) in PY, 6% (4/63) in PWH, 24% (15/63) in RB, and 29% (29/100) in SW. We included age, treatment for STI in last six months, comprehensive STI knowledge, and receptive anal sex ever in the initial adjusted model based on results of the unadjusted analysis. After backwards elimination, only receptive anal sex ever (OR 0.42, 95% CI 0.20–0.83) was associated with lower odds of STI.
DISCUSSION
In this sample of women drawn from populations at elevated risk of STI acquisition in the DR, STIs were prevalent. Notably, STI prevalence was similar among asymptomatic and symptomatic women, highlighting the poor correlation between STI symptoms and infection status. These findings underscore the limitations of syndromic management, including its potential to lead to overtreatment: 76% of symptomatic women were found not to have CT, NG, TV, or TP, though would likely have been offered antibiotics if presenting for clinical care. Furthermore, our analysis revealed different correlates of STIs in asymptomatic women (age, sexual debut, mobility, drug use, and healthcare access) vs symptomatic women (anal sex), suggesting that specific attention to the asymptomatic population is merited. The dearth of literature regarding the correlates of asymptomatic STIs as opposed to STIs in general is a gap this analysis addressed.
Because of the adverse pregnancy outcomes associated with CT, NG, TP, and TV infection, the high prevalence of asymptomatic STIs among PY (32%) is particularly concerning.18–21 The diagnosis of syphilis in four PY during the study further emphasizes the need for asymptomatic screening: the consequences of congenital syphilis are often devastating, and include preterm birth, stillbirth, and neonatal death.20 An estimated 67% of pregnant women with untreated syphilis experience an adverse pregnancy outcome.22
Our adjusted overall analysis showed that younger age, early sexual debut, greater mobility, drug use, and limited healthcare access were associated with asymptomatic STIs. These findings suggest that in resource-constrained settings, women with these risk factors should be prioritized for STI screening. As the pipeline of point-of-care STI tests (POCTs) grows and POCTs are rolled out in the field, understanding who may benefit most from asymptomatic screening will enable the efficient use of limited resources. Several POCTs are commercially available for NG, CT, TP, and TV,23 though cost and other barriers at the health system, device, and provider levels have prevented widespread implementation in LMICs thus far.24 Nevertheless, there is growing recognition of the potential role for accurate and affordable POCTs in settings where syndromic management is the norm.6
Identifying risk factors for asymptomatic infection will also inform the implementation of existing and new STI prevention interventions, including HIV pre-exposure prophylaxis. One innovation, doxycycline post-exposure prophylaxis (doxyPEP), warrants particular mention. While shown to be effective in MSM and TGW,25,26 a recent trial did not demonstrate efficacy in cisgender women,27 though further evaluation is ongoing. Given that the most efficient prescribing strategies for doxyPEP seem to be based on STI history,28 and recently published guidelines recommend discussion of doxyPEP with MSM and TGW diagnosed with STI in the past year,29 elucidating correlates of asymptomatic STIs could help identify candidates for this intervention.
Our study has several strengths including the use of a detailed behavioral questionnaire. The relatively high prevalence of STIs in our sample indicated a population at high need. The higher prevalence enabled us to conduct more robust and nuanced analyses. However, self-reported data on potentially stigmatized behaviors may be subject to social desirability bias. Our findings that most women with rectal STIs reported never having had anal sex and that self-reported receptive anal sex was protective for STIs among younger women were surprising, especially given that the most common site of CT/NG infection was rectal. These observations suggest that self-report of anal sex may not be a reliable marker for site-specific risk, and support routine extragenital testing. In our sample, anal sex was differentially reported by infection status, and whether this occurred by chance or confounding needs further exploration. One contributor to these findings might be the phenomenon of autoinoculation: it is possible to have a rectal STI without direct exposure through anal sex.30 The substantial proportion of women who reported never having had anal sex whose urogenital CT/NG infection was accompanied by a concomitant rectal infection lends some credence to this idea. Our time- and place-sampling methodology, although effective for reaching high need populations such as PY, PWH, BR, and SW, limits generalizability to all women in the DR. Finally, our cross-sectional study design precludes causal inference.
In conclusion, this study highlights the substantial limitations of syndromic STI management, and is among the first to investigate the correlates of asymptomatic STIs in women in resource-constrained settings. Our finding that younger age, early sexual debut, greater mobility, drug use, and poor healthcare access are associated with asymptomatic STIs suggests that women with these risk factors may benefit most from future STI screening and prevention initiatives. Further examination of these associations, particularly using longitudinal data, will be necessary to achieve a deeper understanding of the correlates and predictors of asymptomatic STIs.
Supplementary Material
ABBREVIATION LIST
- CT
Chlamydia trachomatis
- DoxyPEP
Doxycycline post-exposure prophylaxis
- DR
Dominican Republic
- IPV
Intimate partner violence
- LMIC
Low- and middle-income country
- MSM
Men who have sex with men
- NAAT
Nucleic acid amplification test
- NG
Neisseria gonorrhoeae
- PHQ2
Patient Health Questionnaire-2
- POCT
Point-of-care test
- PWH
People with HIV
- PY
Pregnant youth
- RB
Residents of bateyes
- STI
Sexually transmitted infection
- SW
Sex workers
- TGW
Transgender women
- ToC
Theory of change
- TP
Treponema pallidum
- TV
Trichomonas vaginalis
REFERENCES
- 1.World Health Organization. Global progress report on HIV, viral hepatitis, and sexually transmitted infections, 2021. Published July 15, 2021. Accessed January 24, 2024. https://www.who.int/publications/i/item/9789240027077
- 2.Wasserheit JN. Epidemiological synergy: interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sex Transm Dis. 1992;19(2):61–77. [PubMed] [Google Scholar]
- 3.Laga M, Manoka A, Kivuvu M, et al. Non-ulcerative sexually transmitted diseases as risk factors for HIV-1 transmission in women. AIDS. 1993;7(1):95–102. doi: 10.1097/00002030-199301000-00015 [DOI] [PubMed] [Google Scholar]
- 4.Cohen MS. Sexually transmitted diseases enhance HIV transmission: no longer a hypothesis. The Lancet. 1998;351:S5–S7. doi: 10.1016/S0140-6736(98)90002-2 [DOI] [PubMed] [Google Scholar]
- 5.World Health Organization. Guidelines for the management of symptomatic sexually transmitted infections. Published July 15, 2021. Accessed January 24, 2024. https://www.who.int/publications/i/item/9789240024168 [PubMed]
- 6.Wi TE, Ndowa FJ, Ferreyra C, et al. Diagnosing sexually transmitted infections in resource-constrained settings: challenges and ways forward. J Int AIDS Soc. 2019;22(S6). doi: 10.1002/jia2.25343 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Manjate A, Sergon G, Kenga D, et al. Prevalence of sexually transmitted infections (STIs), associations with sociodemographic and behavioural factors, and assessment of the syndromic management of vaginal discharge in women with urogenital complaints in Mozambique. Frontiers in Reproductive Health. 2024;6. doi: 10.3389/frph.2024.1323926 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Fortas C, Delarocque-Astagneau E, Randremanana RV, Crucitti T, Huynh BT. Asymptomatic infections with Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis among women in low- and middle-income countries: a systematic review and meta-analysis. PLOS Global Public Health. 2024;4(5):e0003226. doi: 10.1371/journal.pgph.0003226 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Van Gerwen OT, Muzny CA, Marrazzo JM. Sexually transmitted infections and female reproductive health. Nat Microbiol. 2022;7(8):1116–1126. doi: 10.1038/s41564-022-01177-x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Mabonga E, Manabe YC, Elbireer A, et al. Prevalence and predictors of asymptomatic Chlamydia trachomatis and Neisseria gonorrhoeae in a Ugandan population most at risk of HIV transmission. Int J STD AIDS. 2021;32(6):510–516. doi: 10.1177/0956462420979799 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Falasinnu T, Gilbert M, Gustafson P, Shoveller J. Deriving and validating a risk estimation tool for screening asymptomatic chlamydia and gonorrhea. Sex Transm Dis. 2014;41(12):706–712. doi: 10.1097/OLQ.0000000000000205 [DOI] [PubMed] [Google Scholar]
- 12.Hong Y, Fang X, Zhou Y, Zhao R, Li X. Factors associated with sexually transmitted infection underreporting among female sex workers in China. J Womens Health. 2011;20(1):129–136. doi: 10.1089/jwh.2010.2139 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Rieg G, Lewis RJ, Miller LG, Witt MD, Guerrero M, Daar ES. Asymptomatic sexually transmitted infections in HIV-infected men who have sex with men: prevalence, incidence, predictors, and screening strategies. AIDS Patient Care STDS. 2008;22(12):947–954. doi: 10.1089/apc.2007.0240 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Duracinsky M, Dimi S, Carrieri MP, et al. Risk prediction score for screening asymptomatic sexually transmitted infections in HIV-positive French men who have sex with men (ANRS 9520 DRIVER). Am J Health Behav. 2022;46(5):558–566. doi: 10.5993/AJHB.46.5.6 [DOI] [PubMed] [Google Scholar]
- 15.The United States President’s Emergency Plan for AIDS Relief. Dominican Republic Country Operational Plan Strategic Direction Summary. Published April 1, 2020. Accessed March 3, 2024. https://www.state.gov/wp-content/uploads/2020/07/COP-2020-Dominican-Republic-with-Appendix-C.pdf
- 16.Amesty S, Perez-Figueroa R, Stonbraker S, et al. High burden of sexually transmitted infections among under-resourced populations in the Dominican Republic. Ther Adv Infect Dis. 2023;10. doi: 10.1177/20499361231193561 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Centers for Disease Control and Prevention. Sexually transmitted infections treatment guidelines, 2021: screening recommendations and considerations. Published 2021. Accessed January 25, 2024. https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm
- 18.Tang W, Mao J, Li KT, et al. Pregnancy and fertility-related adverse outcomes associated with Chlamydia trachomatis infection: a global systematic review and meta-analysis. Sex Transm Infect. 2020;96(5):322–329. doi: 10.1136/sextrans-2019-053999 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Vallely LM, Egli-Gany D, Wand H, et al. Adverse pregnancy and neonatal outcomes associated with Neisseria gonorrhoeae: systematic review and meta-analysis. Sex Transm Infect. 2021;97(2):104–111. doi: 10.1136/sextrans-2020-054653 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Gomez GB, Kamb ML, Newman LM, Mark J, Broutet N, Hawkes SJ. Untreated maternal syphilis and adverse outcomes of pregnancy: a systematic review and meta-analysis. Bull World Health Organ. 2013;91(3):217–226. doi: 10.2471/BLT.12.107623 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Silver BJ, Guy RJ, Kaldor JM, Jamil MS, Rumbold AR. Trichomonas vaginalis as a cause of perinatal morbidity. Sex Transm Dis. 2014;41(6):369–376. doi: 10.1097/OLQ.0000000000000134 [DOI] [PubMed] [Google Scholar]
- 22.World Health Organization. Syphilis. Published May 31, 2023. Accessed May 16, 2024. https://www.who.int/news-room/fact-sheets/detail/syphilis#:~:text=Congenital%20syphilis,-Untreated%20syphilis%20may&text=Sixty%20seven%20percent%20of%20women,due%20to%20infectious%20diseases%20worldwide.
- 23.Adamson PC, Loeffelholz MJ, Klausner JD. Point-of-care testing for sexually transmitted infections: a review of recent developments. Arch Pathol Lab Med. 2020;144(11):1344–1351. doi: 10.5858/arpa.2020-0118-RA [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Pai NP, Vadnais C, Denkinger C, Engel N, Pai M. Point-of-care testing for infectious diseases: diversity, complexity, and barriers in low- and middle-income countries. PLoS Med. 2012;9(9):e1001306. doi: 10.1371/journal.pmed.1001306 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Molina JM, Charreau I, Chidiac C, et al. Post-exposure prophylaxis with doxycycline to prevent sexually transmitted infections in men who have sex with men: an open-label randomised substudy of the ANRS IPERGAY trial. Lancet Infect Dis. 2018;18(3):308–317. doi: 10.1016/S1473-3099(17)30725-9 [DOI] [PubMed] [Google Scholar]
- 26.Luetkemeyer AF, Donnell D, Dombrowski JC, et al. Postexposure doxycycline to prevent bacterial sexually transmitted infections. New England Journal of Medicine. 2023;388(14):1296–1306. doi: 10.1056/NEJMoa2211934 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Stewart J, Oware K, Donnell D, et al. Doxycycline prophylaxis to prevent sexually transmitted infections in women. New England Journal of Medicine. 2023;389(25):2331–2340. doi: 10.1056/NEJMoa2304007 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Traeger MW, Mayer KH, Krakower DS, Gitin S, Jenness SM, Marcus JL. Potential impact of doxycycline post-exposure prophylaxis prescribing strategies on incidence of bacterial sexually transmitted infections. Clinical Infectious Diseases. Published online August 18, 2023. doi: 10.1093/cid/ciad488 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Bachmann LH, Barbee LA, Chan P, et al. CDC clinical guidelines on the use of doxycycline postexposure prophylaxis for bacterial sexually transmitted infection prevention, United States, 2024. MMWR Recommendations and Reports. 2024;73(2):1–8. doi: 10.15585/mmwr.rr7302a1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Visser M, Hoebe CJPA, Wolffs PFG, Heijne JCM. Anorectal Neisseria gonorrhoeae infections in women with and without reported anal sex and sex workers in sexual health centres in the Netherlands: a retrospective cohort study. Lancet Microbe. 2024;5(4):e326–e334. doi: 10.1016/S2666-5247(23)00376-2 [DOI] [PubMed] [Google Scholar]
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