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Background Madagascar has restrictive abortion laws with no explicit exception to preserve the woman’s life. This study aimed to estimate the incidence of abortion in the country and examine the methods, consequences, and risk factors of these abortions. Methods We interviewed 3179 women between September 2015 and April 2016. Women were selected from rural and urban areas of ten districts via a multistage, stratified cluster sampling survey and asked about any induced abortions within the previous 10 years. Analyses used survey weighted estimation procedures. Quasi-Poisson regression was used to estimate the incidence rate of abortions. Logistic regression models with random effects to account for the clustered sampling design were used to estimate the risk of abortion complications by abortion method, provider, and month of pregnancy, and to describe risk factors of induced abortion. Results For 2005–2016, we estimated an incidence rate of 18.2 abortions (95% CI 14.4–23.0) per 1000 person-years among sexually active women (aged 18–49 at the time of interview). Applying a multiplier of two as used by the World Health Organization for abortion surveys suggests a true rate of 36.4 per 1000 person-year of exposure. The majority of abortions involved invasive methods such as manual or sharp curettage or insertion of objects into the genital tract. Signs of potential infection followed 29.1% (21.8–37.7%) of abortions. However, the odds of potential infection and of seeking care after abortion did not differ significantly between women who used misoprostol alone and those who used other methods. The odds of experiencing abortion were significantly higher among women who had ever used contraceptive methods compared to those who had not. However, the proportion of women with a history of abortion was significantly lower in rural districts where contraception was available from community health workers than where it was not. Conclusions Incidence estimates from Madagascar are lower than those from other African settings, but similar to continent-wide estimates when accounting for underreporting. The finding that the majority of abortions involved invasive procedures suggests a need for strengthening information, education and communications programs on preventing or managing unintended pregnancies.

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.

Background: Sex work is frequently one of the few options women in low-income countries have to generate income for themselves and their families. Treating and preventing sexually transmitted infections (STIs) among sex workers (SWs) is critical to protect the health of the women and their communities; it is also a cost-effective way to slow the spread of HIV. Outside occasional research settings however SWs in low-income countries rarely have access to effective STI diagnosis. Objectives: To develop adequate affordable and acceptable STI control strategies for SWs. methods In collaboration with SWs we evaluated STIs and associated demographic behavioural and clinical characteristics in SWs living in two cities in Madagascar. Two months post-treatment and counselling incident STIs and associated factors were determined. Evidence-based STI management guidelines were developed with SW representatives. Results: At baseline two of 986 SWs were HIV(+); 77.5% of the SWs in Antananarivo and 73.5% in Tamatave had at least one curable STI. Two months post-treatment 64.9% of 458 SWs in Antananarivo and 57.4% of 481 women in Tamatave had at least one STI. The selected guidelines include speculum exams; syphilis treatment based on serologic screening; presumptive treatment for gonorrhoea chlamydia and trichomoniasis during initial visits and individual risk-based treatment during 3-monthly follow-up visits. SWs were enthusiastic productive partners. Conclusions: A major HIV epidemic can still be averted in Madagascar but effective STI control is needed nationwide. SWs and health professionals valued the participatory research and decision-making process. Similar approaches should be pursued in other resource-poor settings where sex work and STIs are common and appropriate STI diagnostics lacking. (authors)

Women seeking care in Madagascar for genital discharge ( n =1066) were evaluated for syphilis seroreactivity; bacterial vaginosis (BV) and trichomoniasis. Chlamydial infection was assessed by ligase chain reaction (LCR) and by direct immunofluorescence (IF); gonorrhoea by direct microscopy, culture and LCR. Leucocytes were determined in endocervical smears and in urine using leucocyte esterase dipstick (LED). Gonococcal isolates were tested for minimal inhibitory concentrations. BV was found in 56%, trichomoniasis in 25%, and syphilis in 6% of the women. LCR detected gonorrhoea in 13% and chlamydial infection in 11% of the women. Detection of Gram(-) intracellular diplococci in endocervical smears, and gonococcal culture were respectively 23% and 57% sensitive and 98% and 100% specific compared to LCR. Chlamydia antigen detection by IF was 75% sensitive and 77% specific compared to LCR. Leucocytes in endocervical smears and LED testing lacked precision to detect gonococcal and chlamydial infections. Of 67 gonococcal strains evaluated, 19% were fully susceptible to penicillin, 33% to tetracycline; all were susceptible to ciprofloxacin, ceftriaxone, and spectinomycin. Patients who present with genital discharge in Madagascar should be treated syndromically for gonococcal and chlamydial infections and screened for syphilis. Gonorrhoea should be treated with ciprofloxacin.

To examine sexually transmitted infections (STIs) and associated socio-demographic and behavioural factors in women seeking care for genital discharge syndrome in Antananarivo, Madagascar.One thousand and sixty-six consecutive symptomatic women were interviewed and examined; bacterial vaginosis (BV), vulvovaginal candidiasis, trichomoniasis (TV), cervical infection (CI) due to chlamydial or gonococcal infections, and syphilis seroreactivity were determined by laboratory diagnosis. Associations between STIs and individual characteristics were evaluated using bivariate and logistic regression analyses.The prevalence of BV, TV, CI, and syphilis seroreactivity was, respectively, 85%, 16%, 49%, 16% in 94 prostitutes; 70%, 18%, 30%, 13% in 96 occasional sex traders; and 53%, 24%, 17%, and 4% in 876 general women. CI was independently and positively associated with a symptomatic partner, new sex partner in last 3 months, unfaithful partner, prostitution, joblessness and being25 years old. Syphilis was associated with low schooling, young age at coital debut, sex trading, and1 sex partner in the previous 3 months.These high STI rates and associated characteristics suggest the local vulnerability to rapid HIV spread and show the need for prevention efforts that involve youth, prostitutes, occasional sex traders, sex clients, and men who have concurrent sexual partnerships.

Ulcer material from consecutive patients attending clinics in Antananarivo, Madagascar, was tested using multiplex polymerase chain reaction (M-PCR) to detect Treponema pallidum, Haemophilus ducreyi, and herpes simplex virus. Sera were tested for syphilis and for IgG and IgM antibodies to Chlamydia trachomatis by microimmunofluorescence testing (MIF). By M-PCR, 33% of 196 patients had chancroid, 29% had syphilitic ulcers, and 10% had genital herpes; 32% of the ulcer specimens were M-PCR negative. Compared with M-PCR, syphilis serology was 72% sensitive and 83% specific. The sensitivity of clinical diagnosis of syphilis, chancroid, and genital herpes was 93%, 53%, and 0% and specificity was 20%, 52%, and 99%, respectively. Less schooling was associated with increased prevalence of syphilitic ulcers (P=.001). Sixteen patients (8%) were clinically diagnosed with lymphogranuloma venereum (LGV); 1 plausible case of LGV was found by MIF. In Madagascar, primary care of genital ulcers should include syndromic treatment for syphilis and chancroid.

Data concerning the spectrum and antimicrobial susceptibility of STDs in Madagascar are scarce.Improvement of STD patient management in Madagascar.Assessment of the spectrum of STDs and improvement of therapy.Etiologic study of 400 patients (169 men, 231 women) under consultation at the major STD service in Antananarivo for one or more of the STD syndromes, urethral discharge, cervicovaginal discharge, genital ulcers, or condylomata according to a fixed diagnostic schedule.Of genital ulcers, syphilis accounted for 46%, lymphogranuloma venereum for 24%, chancroid for 16%, and herpes for 1%. Of the syphilis cases, 51% presented as condyloma lata. Discharge was found in 124 men and 210 women. Counting concomitant infections separately, gonorrhea occurred in 69% of the men and 20% of the women with discharges, chlamydia infection in 42% and 52%, trichomoniasis in 9% and 31%, candidiasis in 12% and 30%. Bacterial vaginosis was found in 37% of the women with discharges. In 32% of male and 71% of female gonorrhea cases, there was concurrent chlamydia infection. Infection with HIV 1 or 2 was not detected. Determination of the antibiotic susceptibility of Neisseria gonorrhoea revealed high efficacy of ampicillin, ciprofloxacin, and spectinomycin; but frequent resistance to tetracycline and cotrimoxazole.High priority should be given to the management of infections with chlamydia and with Treponema pallidum as well as to educational measures to increase awareness of genital ulcer disease.Between November 1992 and April 1993, interviews were conducted with 400 patients (169 men, 231 women) aged 14-52 years at the sexually transmitted disease (STD) clinic of the Institut d'Hygiene Sociale in Antananarivo, Madagascar, to determine the pattern of STDs and to improve treatment of the leading STDs. The 400 patients presented with 434 syndromes. 124 men had urethral discharge. 210 women had cervicovaginal discharge. 43 men and 18 women had genital ulcers. Clinicians could not establish a diagnosis in 33 patients. 171 patients had more than one infection. Chlamydia infection was the most common infection associated with another STD (gonorrhea in 22% of men and 11% of women with discharge, trichomoniasis in 2.4% of men and 13% of women, candidiasis in 1.6% of men and 9% of women, and bacterial vaginosis in 15% of women with discharge). Gonorrhea was the most common etiology for male discharge (69%) while chlamydia infection was for female discharge (52%). Women with discharge were more likely than men with discharge to have chlamydia infection (52% vs. 42%), trichomoniasis (30% vs. 9%; p 0.00001), and candidiasis (32% vs. 12%; p 0.00001). 37% of women with discharge had bacterial vaginosis. Chlamydia infection was the most common STD in this population (45%). 32% of male and 71% of female gonorrhea cases also had chlamydia infection. 70 patients had syphilis. 36 of them had secondary stage syphilis. No one had HIV-1 or HIV-2 infection. The most efficacious antibiotics for gonorrhea were ampicillin, ciprofloxacin, and spectinomycin (100% susceptibility). 31% and 26% of isolates were susceptible to tetracycline and cotrimoxazole, respectively. Public facilities in Madagascar do not have the capabilities to diagnosis chlamydia, resulting in many untreated chlamydia cases. These findings stress the need to improve combined treatment of gonorrhea and chlamydia infection and for educational efforts to increase awareness of genital ulcer disease.

HIV and syphilis seroprevalence surveys were conducted in Antananarivo Toamasina and Toliary to estimate the number of people infected with HIV in Madagascar. Samples were taken from women attending antenatal clinics and patients seeking care for STDs during the middle of 1995. Antenatal women were of mean age 25.2 years; STD patients 28.0 years; and prostitutes 24.3 years. The 777 male STD patients were of mean age 29.7 years; the 798 female STD patients 26.5 years. Genital ulcers during the preceding six months were reported by 7.3% of 1581 pregnant women 20.3% of 1567 STD patients and 10.6% of prostitutes with women reporting a history of genital ulcers less often than men. Female STD patients reported genital discharge more often than male STD patients. Of 779 syphilis seroreactors 480 had an RPR endpoint reactivity titre of at least 1:8. Syphilis seroreactivity rates did not vary significantly by city but inversely correlated with years of schooling. Among prostitutes syphilis seroprevalence increased with age. Estimates of HIV prevalence per 100000 adult Malagasy increased from 20 in 1989 to 70 in 1995 and the total number of HIV-infected people in Madagascar was calculated at 5000. This low but increasing HIV prevalence does not warrant complacency. Moreover the high seroprevalence of syphilis infection is unacceptable. Urgent action should be taken to control syphilis and other STDs in the country to prevent the further spread of HIV. The nationwide control of STDs will require external donor assistance in this poor country.