Summary
To identify factors associated with repeat visits among patients attending a clinic for sexually transmitted infections (STIs) in Kisumu, Kenya, we examined records of clinic visits from March 2009 to May 2010. Multivariable logistic regression identified factors associated with repeat visits occurring >30 days after the initial visit. Among 1473 clients (1296 single-visit individuals versus 177 individuals with repeat visits), the median age was 24 years, 67% were men and 8.6% self-reported being HIV-positive. In adjusted analyses, men with repeat visits were more likely to report ≥2 recent sexual partners (adjusted odds ratio [aOR] = 1.60) and being HIV-positive (aOR = 2.35). They were less likely to have been referred from other health facilities (aOR = 0.14) and more likely to have urethral discharge at their initial visit (aOR = 2.46). Among women, repeat visits were associated with vaginal discharge (aOR = 2.22), but attending the clinic with a partner was protective (aOR = 0.38). The association between sexual risk, HIV positivity and repeat visits among male clients highlights the need to focus intervention efforts on this group. For women, attending with a partner may reflect a decreased risk of re-infection if both partners are treated and counselled together.
Keywords: Kenya, syndromic management, sexually transmitted infection, repeat visit, re-infection, core transmitters
INTRODUCTION
Sexually transmitted infections (STIs) account for a significant proportion of morbidity and health expenditures in east Africa.1,2 Non-ulcerative STIs, such as gonorrhoea, chlamydia and trichomoniasis, have been associated with adverse pregnancy outcomes, infertility, and increased risk of HIV acquisition and transmission.3 Additionally, STIs impose a substantial economic burden among affected communities, particularly in developing countries where the majority of the population is under 40 years of age.2,3 Despite recognition of adverse health outcomes and associated economic burden, STI surveillance in resource-poor settings remains limited.4
Surveillance of STIs is necessary to assess the burden of disease within a community, in order to guide resources for intervention efforts and accurately monitor the effectiveness of interventions. Resource-poor settings often rely on syndromic management for diagnosing and treating STIs, due to limited access to diagnostic laboratory assays.1 While syndromic management has been shown to be effective in managing symptomatic urethritis, epidi-dymitis and genital ulcer diseases (GUDs),5 it does not address infection in asymptomatic individuals, and has limited application in women with vaginal discharge or related symptoms. Using population survey data from South Africa, because most STIs are asymptomatic, the proportion of the annual number of curable STI episodes detected by syndromic treatment among men with urethral discharge was estimated at just 15% for gonor-rhoea and 12% for chlamydia.6 Syndromic management did not reduce the prevalence of STIs over time at the community level.6
Our objective was to determine the demographic, health history and behavioural factors associated with repeat STI clinic visits. We used repeat visits as a proxy for newly acquired or re-acquired STIs. Characterizing the clinic population can provide a baseline to evaluate and enhance prevention and treatment efforts. In addition, understanding factors associated with repeat clinic visits may assist in identifying those at high risk for re-infection, as these individuals may be core transmitters.7 – 9 Targeting interventions to core transmitters may be a resource-efficient way to interrupt STI transmission.9
METHODS
Study population and setting
The Nyanza Reproductive Health Society (NRHS) has been conducting research and surveillance of STIs in the Nyanza province of Kenya since 2002. In 2006, NRHS established the Partners in Reproductive Health (PIRH) project to evaluate and treat clients and their partners for STIs according to syndromic management guidelines, and to provide STI risk reduction counselling and HIV testing. This paper reports the results of a record-based retrospective cohort study consisting of clients seen at the PIRH clinic in Kisumu, Kenya, from March 2009 to May 2010. Analysis of these data was approved by the Institutional Review Board of the University of Illinois, Chicago and the Kenyatta National Hospital/University of Nairobi Ethical Review Board.
Data collection and analysis
Demographic information, reason for visit, behavioural data, symptoms, physical examination findings, clinical diagnosis and treatment provided were collected using a standardized clinic form and entered into an electronic database. Demographic information, reason for visit and behavioural data were reported by clients at the clinic. Information regarding current symptoms, physical examination findings, diagnosis and treatment provided were recorded by the treating clinician. Available treatment options included acyclovir, azithromycin, benzathine penicillin, cefixime, ceftriaxone, clotrimazole cream, clotrimazole pessary, doxycycline, erythromycin, fluconazole, metronidazole, norfloxa-cin, podophyllin and spectinomycin. Beginning in February 2009, cefixime has been the first-line treatment for urethritis and cervicitis in our clinic.
The period of observation was from 1 March 2009 to 31 May 2010. Entry into the cohort began with an initial visit to the PIRH clinic. The outcome for analysis was any repeat visit to the clinic, defined as a repeat visit that occurred >30 days after the prior visit. Repeat visits that occurred ≤30 days after the prior visit were considered to be treatment follow-ups, and were less likely to represent a ‘new’ infection and were excluded from analysis.
Descriptive statistics were used to summarize demographic information, presenting illness, diagnosis and treatment. We used logistic regression to assess the association between repeat infections and characteristics at the initial visit. This involved 1296 single-visit individuals and 177 individuals with first repeat visits (occurring >30 days after the initial visit). Variables with overlapping content (e.g. symptoms and examination findings) and associations in similar directions were collapsed in the regression model. Variables with a P value <0.20 in chi-square analysis were entered into logistic regression. Variables maintaining a P value <0.10 in adjusted analyses are presented. Standard errors were estimated using a robust variance estimate. Models were run separately for men and women. Data were analysed using SAS/STAT 9.2 for Windows (SAS Institute Inc, Cary, NC, USA).
RESULTS
Study population
Over the 15-month study period, there were 2214 visits to the PIRH clinic. We excluded 103 (4.6%) visits with a reported prior visit date that occurred prior to the initiation of data collection (n = 32) or prior visit dates that could not be verified in the database (n = 71). From the remaining 2111 visits, we excluded 14 visits with missing age, 161 initial visits that occurred within 30 days of the end of observation and 11 visits where client identification numbers could not be verified. The remaining analyses include 1925 visits (range 1–18 visits) made by 1296 individuals. Of the 629 repeat visits, 452 occurred ≤30 days from the initial visit.
Overall, clients with early follow-up (≤30 days from the initial visit) did not differ from those with repeat visit (>30 days from initial visit) regarding gender, age, referral status, attending as individual versus couple or attending as a contact of someone with an STI (results available from authors). Men with repeat visits were more likely to be HIV-positive (14.3% versus 7.5%, P = 0.06), while the opposite was true for women (9.1% versus 20.1%, P = 0.04). Men with repeat visits were more likely to have multiple sexual partners (24.3% versus 3.8%, P < 0.01), while there was no difference in number of sexual partners for women. Men with repeat visits were more likely to be diagnosed with urethritis (48.6% versus 17.9%, P < 0.01) or clinically herpetic GUD (15.9% versus 7.9%, P = 0.02), while women with repeat visits were more likely to be pregnant (16.9% versus 7.5%, P = 0.04) and diagnosed with vaginitis (63.2% versus 24.8%, P < 0.01).
Client characteristics
Client characteristics are shown in Table 1. Overall, the mean age of clients was 24 years, and two-thirds of visits were made by men. By self-report, 8.6% of clients were HIV-positive (7.6% of men and 10.7% of women, P = 0.073). The proportion of men reporting two or more sexual partners in the past 30 days was 15.9%, compared with 2.1% of women (P < 0.001). Overall, 21.2% of men were circumcised (by physical exam). The most common diagnosis in men was urethritis (45.8%) followed by balanitis/posthitis (12.6%) and clinically herpetic GUD (11.9%). In women, the most common diagnosis was vaginitis (53.4%), followed by cervicitis (9.4%) and pelvic inflammatory disease (PID) (7.9%). Overall, 13.7% of women underwent speculum examination, and 39.7% a bimanual examination.
Table 1.
Client characteristics, March 2009 through May 2010
| Overall, n = 1473 n (%) |
|
|---|---|
| Median age (years) | |
| Men | 24.0 |
| Women | 22.0 |
| Gender | |
| Male | 993 (67.4) |
| Female | 480 (32.6) |
| Number of sexual partners in the past 30 days | |
| Men | |
| None | 205 (20.7) |
| One | 627 (63.4) |
| 2 or more | 157 (15.9) |
| Women | |
| None | 132 (27.7) |
| One | 334 (70.2) |
| 2 or more | 10 (2.1) |
| Self-reported HIV-positive | |
| Men | 59 (7.6) |
| Women | 43 (10.7) |
| Men: circumcised? | |
| Yes | 207 (21.2) |
| Diagnoses in men* | |
| Urethritis | 452 (45.8) |
| Non-herpetic genital ulcer disease | 43 (5.1) |
| Herpetic genital ulcer disease | 117 (11.9) |
| Balanitis/posthitis | 124 (12.6) |
| Any diagnosis† | 865 (87.5) |
| Speculum exam | |
| Yes | 58 (13.7) |
| No | 367 (86.4) |
| Bimanual exam | |
| Yes | 177 (39.7) |
| No | 269 (60.3) |
| Diagnoses in women | |
| Vaginitis | 245 (53.4) |
| Cervicitis | 43 (9.4) |
| Pelvic inflammatory disease | 36 (7.9) |
| Non-herpetic genital ulcer disease | 9 (2.0) |
| Herpetic genital ulcer disease | 21 (4.6) |
| Any diagnosis† | 418 (90.7) |
Not all cells sum to n due to missing data
Diagnostic categories are not mutually exclusive (i.e. some individuals had multiple diagnoses). Proportions are calculated by gender (i.e. for diagnoses in men, number of men is the denominator);
Not all diagnoses listed
Factors associated with repeat visits
Having a repeat visit was not associated with gender or age (Table 2). Men with repeat visits were more likely to report two or more sexual partners or no sexual partners in the past 30 days than one sexual partner (18.0% and 16.8% versus 8.0%, respectively, P = 0.001). Men with repeat visits were more likely to report being HIV-positive than those with single visits (14.3% versus 6.3%, P = 0.008). Being referred to the clinic was less common among men with repeat visits than among men with single visits (2.0% versus 14.7%, P = 0.002). Men with repeat visits had a higher prevalence of urethral discharge in the past six months compared with men with a single visit (11.4% versus 4.2%, P = 0.002). There was no difference between men with single visits compared with those with repeat visits with respect to receiving any pharmacological treatment, attending individually or with a partner, symptoms of GUD, genital warts or dysuria, diagnosis of urethritis, GUD or balanoposthitis and circumcision status.
Table 2.
Factors associated with repeat visits: results of chi-square analyses
| Variable* | Had a repeat visit n = 177 n (%) |
Did not have a repeat visit n = 1296 n (%) |
Chi-square P value |
|---|---|---|---|
| Sex | |||
| Female | 70 (14.6) | 410 (85.4) | |
| Male | 107 (10.8) | 886 (89.2) | 0.495 |
| Median age (years)† | |||
| Men | 24.0 | 24.0 | 0.246 |
| Women | 22.0 | 22.0 | 0.333 |
| Referred to the clinic | |||
| Men: yes | 2 (1.9) | 104 (11.7) | 0.001 |
| Women: yes | 3 (4.3) | 75 (18.3) | 0.002 |
| Type of session: individual (versus couple) | |||
| Men: individual | 102 (95.3) | 801 (93.4) | 0.433 |
| Women: individual | 62 (88.6) | 286 (73.0) | 0.007 |
| Attending clinic as contact of someone with STI | |||
| Men: yes | 4 (3.9) | 32 (3.9) | 0.999 |
| Women: yes | 7 (10.3) | 75 (20.4) | 0.062 |
| Self-reported HIV status | |||
| Men: self-reported HIV-positive | 12 (14.3) | 42 (6.3) | 0.008 |
| Women: self-reported HIV-positive | 6 (9.1) | 35 (10.6) | 0.712 |
| Number of sexual partners, past 30 days | |||
| Men | |||
| None | 30 (28.0) | 175 (19.8) | |
| One | 51 (47.7) | 576 (65.3) | |
| Two or more | 26 (24.3) | 131 (14.9) | 0.001 |
| Women | |||
| None | 26 (37.1) | 106 (26.1) | |
| One | 44 (62.9) | 290 (71.4) | |
| Two or more | 0 (0.0) | 10 (2.5) | 0.101 |
| Symptoms and exam findings in men | |||
| Current urethral discharge, by history or exam | 41 (38.2) | 358 (40.5) | 0.671 |
| Urethral discharge past 6 months | 12 (11.4) | 34 (3.9) | 0.001 |
| Dysuria | 52 (49.1) | 395 (44.7) | 0.398 |
| Genital ulcer, history or exam | 22 (20.6) | 168 (19.0) | 0.695 |
| Balanitis | 3 (2.8) | 67 (7.7) | 0.072 |
| Circumcised | 18 (16.8) | 189 (21.7) | 0.244 |
| Diagnoses in men | |||
| Urethritis | 52 (48.6) | 400 (45.4) | 0.531 |
| Genital ulcer disease: clinically herpetic | 17 (15.9) | 100 (11.4) | 0.180 |
| Genital ulcer disease: clinically non-herpetic | 3 (3.0) | 40 (5.4) | 0.324 |
| Balanitis, posthitis | 10 (9.4) | 114 (13.0) | 0.279 |
| Pharmacological treatment in men | |||
| Cefixime | 47 (44.8) | 382 (43.5) | 0.799 |
| Doxycycline | 48 (45.3) | 402 (46.3) | 0.841 |
| Metronidazole | 3 (2.8) | 30 (3.5) | 1.000 |
| Symptoms in women | |||
| Genital ulcer | 2 (2.0) | 43 (10.6) | 0.060 |
| Lower abdominal pain | 13 (18.8) | 113 (28.5) | 0.099 |
| Women: pregnant or suspected pregnant | 11 (16.9) | 29 (7.8) | 0.022 |
| Diagnoses in women | |||
| Vaginitis | 43 (63.2) | 202 (51.7) | 0.077 |
| Cervicitis | 3 (4.4) | 40 (10.2) | 0.129 |
| Pelvic inflammatory disease | 2 (3.0) | 34 (8.7) | 0.113 |
| Genital ulcer disease: clinically herpetic | 1 (1.5) | 20 (5.1) | 0.202 |
| Genital ulcer disease: clinically non-herpetic | 1 (1.6) | 8 (2.1) | 0.789 |
| Pharmacological treatment in women | |||
| Cefixime | 8 (11.4) | 144 (36.0) | 0.001 |
| Doxycycline | 11 (15.7) | 135 (33.6) | 0.003 |
| Metronidazole | 9 (13.0) | 101 (25.0) | 0.030 |
Not all cells sum to n due to missing responses; Fisher’s exact test used where cell size ≤5
All findings refer to initial visit, except for completed prior treatment;
Median age compared between groups by Wilcoxon rank sum test
Women with repeat visits did not differ from those with single visits with regard to the type of session (individual or couples attendance), self-reported HIV status, or symptoms of vaginal discharge, genital warts, genital itching or dysuria. Women with repeat visits had a slightly higher prevalence of zero sexual partners in the past 30 days than one or more sexual partners (P = 0.079). As with men, being referred to the clinic was less common among women with repeat visits than those with a single visit (4.5% versus 23%, P = 0.002). Compared with women with single visits, those with repeat visits were less likely to have received STI-specific antibiotic regimens at their initial visit: cefixime (11% versus 36%, P = 0.001), doxycycline (15.7% versus 33.6%, P = 0.003) or metroni-dazole (13% versus 25%, P = 0.030). Additionally, diagnoses of cervicitis and PID were significantly less common among women with repeat visits than women with single visits.
Results of logistic regression analysis
In multivariable logistic regression analysis, we identified statistically significant factors associated with repeat visits among men (Table 3): urethral discharge symptoms in the past six months (adjusted odds ratio [aOR] = 2.46; 95% confidence interval [CI]: 1.20–5.05) and self-reported HIV positivity (aOR = 2.35; 95% CI: 1.20–4.62). Having two or more reported sexual partners in the past 30 days had an aOR of 1.60 for repeat visit and was marginally statistically significant (95% CI: 0.97–2.65). Having been referred to the clinic was protective (aOR = 0.14; 95% CI: 0.01–0.46). In women (Table 4), statistically signifi-cant protective factors in multivariable logistic regression were attending the clinic with a partner (aOR = 0.38; 95% CI: 0.17–0.88) and a diagnosis of cervicitis or PID (aOR = 0.30; 95% CI: 0.10–0.91). Women with vaginal discharge by history or examination were more likely to have a repeat visit, with an aOR of 2.22 (95% CI: 1.28–3.86). Women with GUD by history, exam or diagnosis were less likely to have a repeat visit, but this was marginally statistically significant (aOR = 0.27; 95% CI: 0.06–1.21).
Table 3.
Results of univariate and multivariate logistic regression: factors associated with repeat visits in male clients
| Variable | Unadjusted odds ratio [95% CI], P value | Adjusted odds ratio, n = 952 [95% CI], P value |
|---|---|---|
| Referral to clinic | 0.12 [0.03–0.48], 0.028 | 0.14 [0.03–0.59], 0.008 |
| Urethral discharge in the past 6 months | 3.20 [1.60–6.39], 0.001 | 2.46 [1.20–5.05], 0.014 |
| Two or more partners in past 30 days | 1.75 [1.08–2.82], 0.021 | 1.60 [0.97–2.65], 0.067 |
| Self-reported HIV- positive | 2.49 [1.26–4.95], 0.008 | 2.35 [1.20–4.62], 0.013 |
| No sex in the past 30 days | 1.74 [1.11–2.75], 0.016 | |
| One partner in the past 30 days | 0.21 [0.09–0.49], 0.003 |
CI = confidence interval
Table 4.
Results of univariate and multivariate logistic regression: factors associated with repeat visits in female clients
| Variable | Unadjusted odds ratio [95% confidence interval], P value | Adjusted odds ratio, n = 428 [95% confidence interval], P value |
|---|---|---|
| Session: couple versus individual | 0.37 [0.17–0.80], 0.012 | 0.38 [0.17–0.88], 0.024 |
| Vaginal discharge (by history, examination) | 2.07 [1.23–3.49], 0.006 | 2.22 [1.28–3.86], 0.005 |
| Genital ulcer (by history, examination or diagnosis) | 0.27 [0.06–1.13], 0.072 | 0.27 [0.06–1.21], 0.088 |
| Cervicitis or pelvic inflammatory disease diagnosis | 0.38 [0.15–0.99], 0.049 | 0.30 [0.10–0.91], 0.033 |
| Treatment with cefixime and/or doxycycline | 0.38 [0.20–0.74], 0.004 | |
| Referral to clinic | 0.20 [0.06–0.66], 0.008 | |
| Pregnant or suspected pregnant | 2.52 [1.18–5.36], 0.018 | |
| Attending clinic as contact to someone with sexually transmitted infection diagnosis | 2.23 [0.98–5.08], 0.056 | |
| Genital itching symptom | 1.63 [0.97–2.74], 0.064 | |
| Vaginitis diagnosis | 1.61 [0.95–2.74], 0.080 | |
| Treatment with metronidazole | 0.52 [0.25–1.09], 0.084 |
Adjusted model is adjusted for all variables presented
DISCUSSION
We identified a significant number of repeat visits (12% of all visits) among clients at our STI clinic in Kisumu, Kenya. In men, a repeat visit appeared to be more common among high-risk men: those with multiple sexual partners, pathognomonic STI symptoms and signs and HIV positivity. In women, repeat visits appeared to be prevented by attending the clinic with a male partner, and by having a syndromic diagnosis (cervicitis, PID, GUD) that was associated with a specific treatment regimen.
Women with vaginal discharge at the initial visit, a syndrome with a broad differential treatment plan and which is generally associated with a variety of vaginal infectious agents, were associated with an increased likelihood of return to the clinic. This is not unexpected, as the sensitivity of vaginal discharge in syndromic management algorithms ranges from 30% to 60%, depending on the relative prevalences of bacterial vaginosis, trichomoniasis, gonorrhoea and chlamydia.10–13 While syndromic management has shown effectiveness in managing urethritis, epididymitis and GUD,5 it does not result in population level declines in STI prevalence due to the high prevalence of undetected infections.6,14,15 In Nyanza province, Kenya, 96% of health facilities rely primarily on syndromic management, while just 42% have any aetiological testing capabilities (37% with capabilities for syphilis detection, 20% for gonorrhoea and 1% for chlamydia; not inclusive or mutually exclusive), and these capabilities are often rudimentary; for Kenya as a whole, 79% of health facilities rely on syndromic management, with 53% having some basic aetiological testing capabilities.16 Effective population approaches to STI control will require active screening. With limited aetiological testing facilities and resources, this may be most efficiently achieved through targeting screening to core transmitters and through partner treatment. Although this approach has not been well studied in Kenya, a before-and-after study of patients treated for STIs in five primary health clinics in Nairobi showed that implementation of brief counselling on the importance of partner treatment increased partner follow-up from 15% to 39%.17
Women diagnosed with cervicitis or PID, diagnoses based largely on speculum and bimanual examination, were less likely to have a repeat visit. Conversely, women with findings of vaginal discharge were more likely to return to clinic. Repeat visits in women could represent treatment failure or an incorrect initial treatment regimen. This suggests that speculum examination and bimanual examination may have led to more effective care in women, through improved syndrome identification. Additionally, while cervicitis was a small proportion of overall visits, our use of cefixime may have contributed to the lower odds of repeat visits among women with cervicitis at their initial visit. In a previous study of our STI clinic clients, culture-positive gonococcal isolates from 2008 showed a high prevalence (16%) of quinolone resistance.18
Limitations
While we excluded visits occurring ≤30 days after the initial visit, visits that occurred >30 days after the initial visit may have occurred for reasons other than ‘new’ STI symptoms. As with visits occurring soon after the initial visit, these visits may represent delayed follow-up or treatment failure. Men with early follow-up may have lower risk for STI (fewer multiple sexual partners, lower self-reported HIV prevalence, less likely to have urethritis or clinically herpetic GUD diagnosis). Women with early follow-up were less likely to have a vaginitis diagnosis at the initial visit, and thus may have had more effective initial treatment or no need for additional follow-up. Thus, focusing on individuals with follow-up >30 days from the initial visit seems to appropriately target higher-risk men and women with potentially less efficacious initial treatment. Our analysis was not able to account for individuals who acquired infection prior to their first recorded visit, and some one-time visits in our database may have been repeat visits. There also may have been clients who had a re-infection but did not revisit our clinic.
The majority of the variables used in our analysis were symptoms, or treatments used to represent STI infections. A variable, or combinations of variables, could be used to represent the same infection. While examination of variance inflation factors showed that the covariates exhibited no significant collinearity, associations between the variables may have accounted for larger standard errors and CIs. Due to the nature of the variables, the results of analysis may not be reflec-tive of specific predictors of re-infection, but could reflect treatment failure or initial misdiagnosis.
CONCLUSIONS
In our STI clinic, men with repeat visits may identify a group of core transmitters: multiple recent sexual partners, repeat STIs and HIV positivity. Targeting them for STI intervention services may be a resource-efficient approach to STI control. The results of our analysis provide the basis for programmatic actions: stressing with clinicians and clients the importance of partner treatment and risk reduction counselling, and training clinicians to regularly perform bimanual and speculum examinations because they are associated with improved client outcomes, as indicated by reduced repeat visits in women.
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