Men and women in Nairobi, Kenya, wait approximately one week after the appearance of sexually transmitted disease (STD) symptoms to seek treatment at a health clinic, according to a survey of 471 men and women attending a public STD clinic.¹ Furthermore, once they receive a referral for STD treatment, women wait longer than men to attend an STD clinic for follow-up treatment (29 days vs. 23 days). Nearly two-thirds of women and one-third of men report having had sex while symptomatic, and fewer than one in five women and one in four men report having used condoms while symptomatic.

From February to May 1998, researchers interviewed men and women who attended a public STD clinic that serves as a referral facility for 50 public and private primary health clinics in Nairobi. New patients leaving the clinic were approached by an interviewer; 471 people agreed to participate in the study. The interview included questions about demographic characteristics, health-seeking behavior and sexual behavior. The researchers later linked patients' interview responses to their medical records.

Overall, 234 men and 237 women participated in the study. The women were significantly younger, on average, than the men (25 vs. 28 years), and the women were significantly more likely than the men to be married (61% vs. 51%). In addition, the women were significantly more likely than the men to report that they did not have an income (46% vs. 11%), though there was no significant difference between the sexes in their level of education.

Among the men, 77% received a diagnosis of urethritis, 8% of genital ulcer disease and 3% of other infections; 8% received a diagnosis of having no STD. Among women, 40% had cervicitis, 35% vaginosis, 13% pelvic inflammatory disease, 8% genital ulcer disease and 2% other infections; 6% of women did not have an STD. Men were significantly more likely than women to have a history of STDs (45% vs. 30%) and to have attended the STD clinic in the past (34% vs. 24%).

Men were more likely than women to report coming directly to the STD clinic for their current STD treatment (67% vs. 55%), while women first attended another clinic. Women and men reported first seeking treatment a median of seven days following the appearance of STD symptoms. When men and women were referred to the STD clinic, they delayed even longer: Men delayed attending the STD clinic for a median of 23 days and women delayed for a median of 29 days. For genital ulcer disease, the delay was shorter--a median of 14 days for men and 16 days for women. In the case of vaginitis, women waited a median of 46 days before attending the STD clinic.

Significantly more women than men reported that they had engaged in sex while they had STD symptoms (62% vs. 34%). Women were significantly more likely than men to report that they had had only one sexual partner while they had symptoms (94% vs. 68%) and that their sexual partner was their spouse (66% vs. 53%). Men were significantly more likely than women to report having exchanged money for sex while they had symptoms (13% vs. 1%).

There was no significant difference between the proportions of men and women who said they had used condoms while they had STD symptoms (22% and 18%). However, significantly fewer men than women said they had used a condom with their spouse while symptomatic (29% vs. 58%). Overall, men were more likely than women to report having used condoms ever in their lives (63% vs. 48%).

Among clinic patients who were married, 5% of men and 48% of women said they thought their spouse had extramarital affairs. Moreover, 68% of men reported having extramarital affairs themselves, compared with only 6% of women. Among unmarried patients who reported having a regular partner (76 men and 57 women), significantly more men (34%) than women (8%) said they had other partners. Only 14% of the men and women responded to a question regarding the source of their current STD; of the men, most blamed their regular partner.

The investigators suggest that men's and women's lack of awareness about the need to receive prompt treatment, the lack of STD services in the Nairobi area and the lack of financial resources, particularly among women, are all possible reasons that people in the study delayed seeking treatment. The researchers speculate that significantly more women than men engaged in sex while symptomatic because women in Kenyan society often are unable to refuse sex or to negotiate safe sex. They also note that even people with a "low-risk profile," such as the women in their study who were married or in a relationship with a regular partner and reported only one sexual partner, "may be at risk through their spouses or regular partners." Therefore, the researchers say, "interventions should extend beyond the high-risk groups, and men especially should be targeted." Furthermore, they recommend expanding STD treatment "to more, if not all, primary healthcare clinics in Nairobi."--B. Brown

REFERENCE

1. Fonck K et al., Healthcare-seeking behavior and sexual behavior of patients with sexually transmitted diseases in Nairobi, Kenya, Sexually Transmitted Diseases, 2001, 28(7):367-371.