Strategies for detection of sexually transmitted infection among family planning clients in Jamaica

Context: Family planning clinics that plan to add sexually transmitted infe ction (STI) services should consider alternatives to modified World Health Organization (WHO) risk-inclusive algorithms for identifying infected women . Methods: A sample of 767 family planning clients from Kingston, Jamaica, we re interviewed and examined, and specimens were obtained to detect the agen ts that cause gonorrhea, chlamydia and trichomoniasis. Serum was tested to detect the bacteria that cause syphilis. Decision models for classifying wo men with STI were compared using clinical and statistical criteria. Models included STI classifications based on the weighted sum of STI risk factors, on the presence of two or more factors identified via an interview or on a n interview augmented with a urine dipstick test (i.e., rapid risk assessme nt), These models were compared with a modified WHO algorithm originally in tended for STI clients in Jamaica. Results: Individual factors associated with gonorrhea, chlamydia and tricho moniasis were urine leukocyte esterase dipstick test outcomes greater than 1+ (indicating the likelihood of infection based on the concentration of wh ite blood cell enzymes, on a scale of negative, trace, 1+, 2+ and 3+), mult iple partners in the past year, friable cervix and age less than 25 years. An additional risk factor for cervical infection atone (gonorrhea or chlamy dia) was spotting after sex. Reported vaginal discharge was not significant ly associated with infection. For cervical infection, the WHO risk-inclusiv e algorithm was least accurate (a positive predictive value of 14%.), the w eighted-risk algorithms were best (a positive predictive value of 23%), whi le the interview-alone and the rapid risk assessment were slightly less acc urate (positive predictive values of 20%). Conclusions: The modified WHO risk-inclusive algorithm appeared inappropria te for asymptomatic women. The rapid risk assessment was easier to perform and more predictive. Urine leukocyte esterase dipstick tests may be useful when pelvic examinations are not feasible. The STI assessment models, other than the WHO algorithm, should be evaluated in other settings where STI pr evalence is high, or where patients are unlikely to seek further evaluation , to better identify women in need of counseling, further evaluation or tre atment.