Reproductive tract infections (R TIs), including but not limited to the sexually transmitted infections (STIs), are currently high on the public health agendas of most low-income countries. The reasons for this are manifold, but important contributing factors include the need to control the spread ofIDV, and the high costs to health care systems and infected individuals as a consequence of un- or mis-diagnosed infections. Strategies for the control and management of these infections in resource-poor settings have been advanced at a global policy level: syndromic management of symptomatic men and women is recommended in the absence of comprehensive laboratory facilities. This thesis describes a large cross sectional survey assessing the populationbased prevalence ofRTIs in one rural area of Bangladesh. The prevalence of these infections was determined from random selections of women and men. Patterns of health-care seeking behaviour were analysed, and the correlation between reported 5,ymptoms and the presence of infection was investigated. The prevalence of syphilis in pregnant women, and the incidence of ophthalmia neonatorum were also determined, and the cost-benefit of control strategies for these two problems in this population were investigated. Given that management of symptomatic persons forms a cornerstone of most national RTIISTI control programmes, the study described in this thesis also evaluated the efficacy of the most common syndromic algorithm in use (that for treating women with vaginal discharge). Training requirements for integrating the algorithm at primary health care level are also discussed as part of the findings, and finally the cost-effectiveness of the recommended algorithm was evaluated. Using the results of the five arms of the study, recommendations are advanced for RTIISTI control programmes in areas with similar epidemiological characteristics to those found in the population described in this study. Finally, areas where further research is needed are highlighted in the discussion.

Progestins are synthetic progestogens that prevent pregnancy by thickening the mucous of the cervix to prevent sperm entry and by disrupting implantation via alteration of the timing of endometrial changes occurring during a normal menstrual cycle. Various hormonal birth control methods utilize progestins, with some of the most effective types of birth control methods being long-acting reversible contraceptives. These include hormonal injections such as depot medroxyprogesterone acetate (DMPA), hormonal implants such as Nexplanon, and hormone-releasing intrauterine devices (IUDs) such as Mirena. Although there have been many studies on the safety and effectiveness of these methods, fewer studies have examined how these hormonal methods may impact the bacterial environment of the vagina, better known as the vaginal microbiome. The health of the vagina relies heavily on the bacteria composing the microbiome. Changes in species composition correlate with higher risk of sexually transmitted infections (STIs) and adverse pregnancy outcomes. When women select their preferred hormonal contraceptive method, they should know if it will impact their vaginal microbiome and increase susceptibility to disease. Twenty-one patients enrolled in this study, with one patient initiating DMPA, 14 initiating levonorgestrel (LNG) IUD, and 6 initiating the etonogestrel subdermal implant (ESI). At initiation, 3 months post initiation, and 6 months post initiation, no differences were seen in the vaginal microbiomes of each of the women enrolled in the study. Some differences in the vaginal microbiota of postpartum women and those who were not postpartum were seen. More specifically, enrichment of three families, Lachnospiraceae, Ruminococcaceae, and Erysipelotrichaceae, was seen in women who were more than 12 weeks postpartum, but the effects of those differences remain unclear. Although our sample size was small, the lack of changes in the vaginal microbiome in women initiating long-acting progestin contraception is reassuring; further study in this area is needed.

Background: The burden of Sexually transmitted infections (STIs) is high globally. The World Health Organisation (WHO) recommends syndromic management of these STIs, based on presentation with signs and symptoms, in resource-limited countries. Due to this syndromic approach, there is little current data on STI prevalence, including asymptomatic STIs, in high risk populations. Methods: We reviewed secondary data collected as part of the screening procedures of 6 clinical trials between 2012 and 2017 in Cape Town, South Africa. These trials recruited populations of different sexual orientation and gender, mostly key populations at risk of HIV and STI acquisition. Routine screening for STI symptoms and testing for Chlamydia, Gonorrhoea, Trichomonas, Syphilis and HIV was performed for all of the studies at screening/enrollment. Results: A total of 639 participants were screened; 411 (64.3%) self-identifying as female, 198 (31%) males, 29 (4.5%) transgender women and 01 (0.2%) transvestite. Median age was 20 years (IQR: 18-24), with the 15-24-year age category contributing 77% to the cohort. Laboratory testing diagnosed 239 (37.4%) people with STI infections in this cohort; only 28 (11.7%) people were symptomatic. 119 (88.8%) of Chlamydial, 64 (82.1%) of Gonorrhoeal, 23 (92%) of Trichomonal and 31(79.5%) of Syphilis infections elicited no signs and/or symptoms. Conclusion: A vast majority of STIs in this high-risk population were asymptomatic. Laboratory testing of causal organism was more reliable in diagnosing STIs than the use of signs and/or symptoms as recommended by WHO.

The main goal of this thesis is to understand a community's perceptions of the potential impact of tourism on the spread of sexually transmitted infections (STIs) including HIV/AIDS in Monteverde, Costa Rica. In particular, I examine the ways in which globalization and increased travel affect the overall health and behavioral patterns among young people from a community reliant on tourism. The impact of migration and population movement on the spread of infectious diseases has already been well documented. Moreover, there is a clear understanding of the impact of sex tourism on the spread of STIs. However, this project seeks to understand the impact of tourism on a local population that does not have a formal commercial sex industry. Instead, the majority of sexual interactions between young local men and visiting women reflect more of an attitude of adventure and tend to be romantic in nature. Local men are inclined to have casual sexual relations with female tourists because foreign women are perceived as more liberal and sexually adventurous. Visiting women are attracted to the idea of an exotic, sexual relationship while on vacation. The interactions that result from these mentalities often lead to risky sexual behavior that could facilitate the transmission of STIs. This project was exploratory in nature. Data were collected from various sectors of the Monteverde community with a focus on their perceptions of the role tourism plays on changing local behavior. This project also seeks to understand the current level of sex education and STI prevention among the youth of the community. These data were used to create targeted interventions within the community in recognition of World AIDS DAY on December 1, 2003, and can inform the design of future education and prevention programs that are culturally appropriate.

Master of Public Health - MPH / The notification and treatment of sexual partner(s) is a key element in the prevention and control of sexually transmitted infections (STIs). Partner notification interrupts the chain of STI transmission, prevents STI complications and long-term sequelae in the sexual partner(s), and also prevents re-infection of the treated index patient. Partner notification is a recognized component of the syndromic management of STIs in Namibia and yet the partner notification rates in the country remain low - as low as 7% in the district of Windhoek currently. In this district, which has the highest number of STIs cases in Namibia, the specific factors that hinder partner notification have not yet been documented. This study sought to investigate the perceived and experienced barriers to partner notification amongst STI patients attending an urban primary health center in the district. An explorative, qualitative study with eight patients (four males and four females), aged 16 years and over, who presented with a new/recurrent episode or a STI follow up was conducted. The participants were purposively selected with the aid of the deputy nurse in charge of the health center after agreeing to take part in the study. The patients were asked about what they felt were personal, partner-relationship and health services related factors that hindered partner notification. Three health workers working at the health center served as key informants and were asked about barriers to partner notification based on their experience of delivering preventative and curative STI - related services over the past three or more years. Interviews with both patients and key informants were conducted in the health facility, recorded and later transcribed. Content analysis of the transcribed data was conducted to identify recurring themes across the different interviews. The results of the study suggest that the partner notification strategy was not functioning optimally as a result of a number of inter-twined factors. The factors can be categorized into personal barriers, partner-relationship dynamics and health services related barriers. The study found that participants considered there were barriers to partner notification across all these three categories. Commonly reported barriers included the stigma associated with STIs and the cultural and religious norms that do not promote discussion of topics related to sex and sexuality in general. Other barriers such as gender inequality, the fear of a partner's reaction to the notification, feelings of guilt associated with infidelity, the lack of communication between partners and the inability to locate partner(s) were highlighted by participants. Barriers associated with the health services included the lack of health education about the importance of partner notification, the absence of thorough risk reduction counseling, the current method of partner notification that is being utilized and the negative attitudes of health workers. It is suggested that having a greater understanding of these barriers and how to work with them in a health education or counseling sessions will allow health workers to address them more directly with their patients and in turn, hopefully improve the management and outcomes of partner notification strategies in the STI prevention and control program in the Windhoek district and potentially other districts in Namibia.

Background: The sexually transmitted infections (STIs), chlamydia and gonorrhea, disproportionately affect racial and ethnic minorities. Community attributes like poverty and prevalence of STIs, along with residential segregation and its impact on composition of sexual networks contribute to these disparate rates. The Southeast had the highest rates of chlamydial and gonorrheal infection among the four regions of the United States. Because relationships between race and place can confound national statistics, it is important to examine whether racial disparities within the region are associated with higher rates of infection. Purpose: The study aims to evaluate local geospatial clustering of gonorrhea and chlamydia rates in the Southeast, and their persistence during 2000-2005 and any associations with residential segregation, income inequality, unemployment and uninsured rates, and race. Methods: Using the Local Indicators of Spatial Association tests of spatial clustering, cluster maps were created for each STI outcome and year. Independent sample t-tests were then used to examine the difference in means of each community level variable across counties composing the high-rate clusters and all other counties in the region. Results: Over 60% of counties composing high-rate clusters persisted as high rate clusters over time, and were significantly associated with higher levels of community disadvantage than all other counties (p < 0.01). Overall gonorrhea rates decreased from 2000 to 2005 and chlamydia rates increased, while their associations with community disadvantage remained persistently strong over time. Conclusions: Counties with higher rates of chlamydia and gonorrhea persist over time and experience persistently higher levels of residential segregation and income inequality, as well as higher unemployment and uninsured rates, and higher proportions of blacks in the population. The social environment and segregated sexual networks may play important roles in the persistently high rates of chlamydia and gonorrhea observed for certain regions within the Southeast. Continued surveillance of reportable STIs and their probable predictors is needed in order to better understand the persistent disparities in STI rates across counties in the Southeast.

Sexually transmitted diseases (STDs) continue to remain a public health concern in the United States, especially among young people. Levels of knowledge with regard to STDs have been investigated in prior research; however, these investigations have been limited primarily to older adolescents and young adults. Grounded in the social cognitive and subjective culture theories, this quantitative, cross-sectional study assessed STD knowledge (other than HIV/AIDS) among 7th grade students attending a public middle school in the United States. Demographic differences (age, gender, and ethnicity) in STD knowledge were examined to determine if these demographic variables predict STD knowledge scores and if the Sexually Transmitted Disease Knowledge Questionnaire (STD-KQ) is a valid and reliable instrument among this study population. Chi-square analysis demonstrated that STD knowledge scores significantly differed by age only: Twelve-year-olds had higher STD scores than did 13-year-olds, contrary to research in older adolescents, which may be the result of confounding factors that warrant further investigation. Multiple regression analysis showed that age, gender, and ethnicity were not associated with STD knowledge scores. The STD-KQ was found to have face validity as well as high consistency and reliability among all questions related to STDs other than HIV/AIDS using Crohnbach's alpha. Content validity for individual STD-KQ items was shown using Lawshe's content validity ratio and subject matter experts. Results of the study support positive social change and highlight the need for earlier STD education, other than HIV/AIDS, with middle school children and the need to examine other factors that may impact STD knowledge within this age group.

The number of adolescents in the U.S. who engage in risk behaviors such as alcohol and drug use and unsafe sexual practices has reached alarming levels, with Hispanic adolescents in particular reporting high rates of substance use and sexual activity. This study explored risk and protective factors that influence high-risk behaviors in Hispanic adolescents. A theoretical model was developed based on an integration of Ecodevelopmental Theory and the Theory of Reasoned Action to investigate individual and social factors that affect the risk behaviors of Hispanic adolescents. This study was a cross-sectional, descriptive, secondary investigation of the baseline data of a combined sample of 493 Hispanic adolescent 7th and 8th graders and their immigrant parents who had been recruited for participation in the Familias Efficacy I and II studies. The hypothesized model of relationships included 3 direct effects variables: parent-adolescent communication about sex; adolescent condom use self-efficacy; and family functioning, which integrated 4 constructs: parental involvement; positive parenting; family communication; and parent-adolescent communication. The study model also included 3 indirect variables: parents' acculturation; differential acculturation; and parent's HIV knowledge. Three adolescent risk behaviors served as outcome variables: condom use; drinking alcohol while having sex ; and substance use. It was hypothesized that (1) family functioning, parent-adolescent communication about sex, and adolescent self efficacy would all be directly related to adolescent risk behaviors; (2) parent's acculturation would be related to adolescent risk behaviors indirectly through its association with parent's HIV knowledge and parent-adolescent communication about sex; and (3) differential acculturation would be related to adolescent risk behaviors indirectly through its association with family functioning, adolescent condom use self-efficacy, and parent-adolescent communication about sex. Cronbach's alpha computed for all measures yielded good to excellent reliability coefficients. Pearson linear correlation coefficients were calculated between all of the study variables, followed by confirmatory factor analysis to ascertain the feasibility of collapsing multiple indicators of family functioning and HIV/STIs risk behaviors into single latent variables. Finally, the hypothesized structural equation model was estimated. Beta coefficients were calculated to examine direct effects and Mackinnon's asymmetric distribution of product test was used to evaluate mediated effects. Data analysis failed to confirm any of the study hypotheses; however, post-hoc analyses yielded findings that merit further study. Family functioning emerged as the heart of the model, embedded within a web of direct and mediated relationships. Additional findings suggest that family functioning mediates the effect of parents' acculturation and of parents' HIV knowledge on adolescent risk behaviors. Study limitations include its cross-sectional design, self-report measures, convenience sample and integration of clinical and non-clinical samples. Suggestions are provided for researchers to further explore relationships among the variables, and recommendations made for community nursing practitioners to develop, implement and evaluate HIV/STIs prevention programs for Hispanic adolescents.

Magister Public Health - MPH / Background: STIs are of major public health concern in developing countries, not least because they facilitate transmission of HIV, but also because they are important causes of mortality and morbidity among African populations, resulting in, among other things, adverse birth outcomes, neonatal and infant infections, ectopic pregnancy, anogenital cancer,infertility, pelvic inflammatory disease, and death. Thus, effective treatment needs to be prompt and accurate to control the spread, and morbidity and mortality of STIs. Even though syndromic approach to the management of STIs is effective, most evaluations have focused on syndromic STI management within STI clinics as opposed to research studies. Partner notification is an integral component of the syndromic approach and is aimed at preventing onward transmission of infection as well as re-infection. It includes informing sexual partners of infected people of their exposure, administering presumptive treatment, and providing advice about the prevention of future infection.Methods: This is a cross sectional descriptive study based on a retrospective review of STI data of study participants in KICoS aged 18 to 34 years. A non probability convenience sampling method was used to recruit study participants. A total of 1,277 participants were prescreened into KICoS of whom 847 were enrolled into this study. Data was collected using CAPI and ACASI questionnaires as well as Teleforms which was analysed in SAS for windows 9.1. Results: Syndromic prevalence of STIs was 5.7% while the aetiological prevalence was 32.8%.Risk factors to STI acquisition included, being female, having multiple sexual partners,having lower than tertiary education, using recreational drugs and being HIV. Agreement between the interviewing methods as well between the syndromic and laboratory diagnosis ranged from fair to substantial. This was also true for the agreement between laboratory and CAPI as well as between the laboratory and ACASI. Sensitivity was generally low while specificity was high. Uptake of contact tracing cards was high though with very low uptake of contact treatment with only 2.1% and 0.4% partners of the syndromically and aetiologically diagnosed participants coming for treatment.Conclusions: STI is a problem in this community and thus there should be more emphasis on risk reduction messages in patient education to mitigate the spread of STIs. The performance of syndromic management was very poor against the aetiological diagnosis thus there needs to further review the use of syndromic diagnosis of STIs in research settings. Partner tracing needs to be intensified since there was very poor partner treatment even with high uptake of contact cards.Acknowledgements: This study would have not been what it was without the immense support I received from many individuals all of whom cannot be mentioned here. I would however want to thank the Dr Wairimu Chege (Principal Investigator, KICoS) for her inspiration and encouragement. I would also like to thank my supervisor, Ernie Kunneke for going through this study with me repeated times including on a ride to the airport. On the same note I would also like to thank my lecturers and student administrators at the SOPH. My gratitude also goes to my colleagues Richard Ndivo, Sherri Pals and Eleanor McLellan-Lemal for all the support they accorded me throughout this research.I would also want to give my heartfelt gratitude to my family. My daughter Akinyi who used to type with me at night, her mother Auma for understanding my late nights up and finally to my Parents Mr and Mrs Gideon and Monica Otieno for understanding the importance of education and taking me to school through all the difficulties. Last but not least I would like to express my gratitude to the almighty God for having seen me through this process.

Recent findings by Public Health Ontario (PHO) state that there were approximately 36, 346 confirmed cases of chlamydia in Ontario as of 2011. This represents an incidence rate that increased by 54% since 2006 rising from 177 to 272 per 100,000 in 2011. National rates only increased by 38% (210 to 290 per 100,000), meaning that Brant County rates surpassed both, increasing by over 100% (150 to 395 per 100,000). The main objective of this series of manuscripts is to develop a clear profile of re-infected individuals in comparison to non-repeaters, while considering co-infections wit gonorrhea. The secondary objective was to determine the sexual network as well as spatial distribution patterns of cases in Brant County. The study period is from January 1st, 2006 until December 31st, 2015, Data were extracted from the integrated public health information system (iPHIS). Basic descriptive statistics will be performed followed by a Cox-regression analysis in order to compare individuals who are repeaters with those who are not repeaters. Within the study period, there were 2,829 cases of chlamydia and 328 were reinfections. We identified twelve hotspots with high chlamydia infection rates of which, 58 per cent occurred within the previously identified core group, in the urban core of Brant County.