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Socio-demographic and behavioural factors associated with high incidence of sexually transmitted infections in female sex workers in Madagascar following presumptive therapy

Frieda M-T. Behets A B F , Kathleen Van Damme A C , Andry Rasamindrakotroka D , Marcia Hobbs A , Kristi McClamroch A B , Justin Ranjalahy Rasolofomanana D , Leonardine Raharimalala D , Gina Dallabetta C and Jocelyne Andriamiadana E
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A Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, McGavran-Greenberg Hall, CB# 7435, Chapel Hill, NC 27599-7435, USA.

B Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, 226 Old Clinic, CB# 7005, Chapel Hill, NC 27599-7005, USA.

C Family Health International, PO Box 13950, Research Triangle Park, NC, 27709, USA.

D Ministry of Health, BP 88 Ambohidahy, Antananarivo, Madagascar.

E USAID, BP 5253 Anosy, Antananarivo, Madagascar.

F Corresponding author. Email:

Sexual Health 2(2) 77-84
Submitted: 29 September 2004  Accepted: 24 February 2005   Published: 16 June 2005


Background: Too little is known about the many women who generate income in Madagascar by trading sex. Methods: Clinical and laboratory exams were offered to 493 non-care seeking female sex workers (SWs) in Antananarivo and 493 in Tamatave. SWs were recruited by peers in their community; they were interviewed, counselled and treated for sexually transmitted infections (STIs) at recruitment and re-evaluated 2 months later. Results: One hundred and eighty six (38%) of the SWs in Antananarivo and 113 (23%) in Tamatave did not complete primary school (P < 0.0001). The incidence rates per person per month in Antananarivo and Tamatave, respectively, were 0.09 and 0.08 for gonorrhoea; 0.05 and 0.03 for chlamydia; 0.24 and 0.15 for trichomoniasis; 0.07 and 0.05 for syphilis. At follow-up, consistent condom use with clients was reported by 56 (12%) SWs in Antananarivo and 137 (29%) in Tamatave (P < 0.0001); 320 (70%) SWs in Antananarivo and 11 (2%) in Tamatave reported sex with a non-paying partner in the past month (P < 0.0001). In Antananarivo, 422 (92%) of the SWs thought they were at no or low risk of having an STI compared to 100 (21%) in Tamatave (P = 0.02). At follow-up, 277 (61%) SWs reported no birth control for their last sex act in Antananarivo, compared to 26 (5%) in Tamatave (P < 0.0001). Socio-demographic and behavioural risk factors for incident gonorrhoea, chlamydia and trichomoniasis varied by city. Conclusions: Strategies to address the needs of women who trade sex should include educational and economic opportunities; should tackle male partners of SWs; promote dual protection against unintended pregnancy and STIs, while taking into account local socio-demographic and behavioural characteristics.


We are grateful for the assistance from the following individuals: Rob Krysiak, Onja Rahamefy, Dimisoa Rakotondramarina, Andriamahenina Ramamonjisoa, Jean René Randriasamimanana, Norbert Ratsimbazafy, Perle Rasanjimanana, Andry Rasoloarimanana, Solofoson Rakotonandrasana, Benjamin Ravelojaona, Marie Madeleine Razafinoro, Cherif Soliman, Richard Steen, Johannes Van Dam, Dr Vololona Rasolofo, Dr Arline Sahondra Vololona, Dr Mariette Ralalaharimanga, Dr Jean Razafindramonjy, Dr Aime Ramambazafy, Dr Rene Randriamanga, Dr Solofoson Rakotonandrasana, Dr Mamitiana Andrianalinera, Dr Simon Razafindrabe, Dr Claire Rasoazananoro, Dr Charles Rakotonirina, Dr Martin Rakotomanga, Dr Marie Rasoa, Dr Kotozafitsimiheloka, Dr Elise Rasoanjanahary, Dr Charlotte Razanasolonambinina, Dr Jules Randriamanana, Dr Josephine Rasoamialinoro, Dr Solange Razanamalala. Without the sustained support of Ms Wendy Githens Benazerga this research would not have been possible.

This study was funded by the USA Agency for International Development through Futures Group International and Family Health International’s Implementing AIDS Control and Prevention (IMPACT) Project (HPA-A-00-97-00017-00) and Population Council’s HORIZONS Project (HRN-A-00-97-00012-00). Pfizer provided free azithromycin. The contents of this report do not necessarily reflect the reviews or policies of the funding agencies.


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