The Correlation of Contraception with Sexually Transmitted

Infection and HIV Infections on Female Sex Workers in Surakarta

Ambar Aliwardani, Putti Fatiharani Dewi, Rini Hastuti, Mardiana, Endra Yustin Ellistasari

Dermatovenereology Departement, Dr. Moewardi General Hospital/Faculty of Medicine

Sebelas Maret University, Surakarta, Indonesia

Keywords: Sexually Transmitted Infections, HIV Infections, contraception

Abstract: The control and prevention of Sexually Transmitted Infections (STIs) and Human Immunodeficiency Virus

(HIV) infections still a major challenge especially in developing countries. One of the high risk groups that

can spread STIs and HIV infection are female sex workers (FSWs). Condom as one of contraception can be

used as a way in preventing transmission of STIs and HIV infection. However the other method, especially

hormonal contraception such as Oral contraception pills (OCPs) and Injection can increase the risk of STIs

and HIV infection. The purpose of this study was to determine the correlation between the use of contraception

with the occurrence of STIs and HIV infection in FSWs in Surakarta. A cross sectional study was conducted

FSWs in several areas in Surakarta. A total 75 female sex workers completed a questionnaire and provided

blood samples for HIV and syphilis testing, endocervical and vaginal swab were performed for STIs

examination. Chi Square Test was used for the statistical analysis. There was a significant correlation between

the use of hormonal contraceptive especially in implant with HIV incident.

1 INTRODUCTION

Sexually Transmitted Infections (STIs) are still a

major public health problem for developed and

developing countries, despite the availability of

therapies and effective preventive measures.More

than 1 millions STIs are occurred everyday

worldwide. Each year, it is estimated 357 millions new

infections have 1 of 4 STIs such as chlamydia (131

milion), gonorrhoeae (78 million), syphilis (5.5

million) and trichomoniasis (143 million) (WHO,

2016).The association between STIs and Human

Immunodeficiency Virus (HIV) infection has been

widely reported whereas STIs can increase the risk of

HIV transmission. Untreated STIs can increase the

risk of transmitting HIV infection up to 3 times higher

than people without STIs (Gyawale and Pokhrel,

2014).

The global HIV prevalence in the world is

increasing especially in the female population. By

2012 in the world 35.3 million people infected with

HIV and 1.6 million people died from acquired

immunodeficiency syndrome (AIDS) (Mabey,

2014).The regions with the highest mortality rates are

Sub Saharan Africa, the Caribbean, and South and

Southeast Asia in Asia, Indonesia ranks in the top five

highest in the number of people living with HIV

whereas in 2012 there were 370 thousands new cases

of HIV infection and HIV epidemic in the region has

been concentrated in key populations at higher risk of

HIV exposure, including commercial sex worker

(Dokubo et al., 2013).In Central Java, particularly in

Surakarta, based on the data from the Surakarta AIDS

Commission (KPA) in 2015 in the FSWs group there

were 263 new STIs cases and 77 new HIV infections

(Komisi Penanggulangan AIDS, 2016).

Contraception can be used as a way of preventing

transmission of STIs and HIV infection in sex

workers. Using contraception has several benefits i.e

prevention of unplanned pregnancies and protection

against STIs, reduction in the risk of Pelvic

Inflammatory Diseases (PID) and also protection from

HIV infection especially in high risk group like FSWs.

There are many methods of contraception such as

the barrier method of male and female condoms,

hormonal methods of contraception, including oral

contraception pills (OCPs), combination of estrogen

and progestin injectable, progestin-only injectable

such as depo-medroxyprogesterone acetate (DMPA),

and hormone containing technologies i.eimplants,

intrauterine devices (IUD), patches, and rings

(Morrison and Cates, 2008;Baeten and Heffron,

2015).

136

Aliwardani, A., Dewi, P., Hastuti, R., Mardiana, . and Ellistasari, E.

The Corelation of Contraception with Sexually Transmitted Infection and HIV Infections on Female Sex Workers in Surakarta.

DOI: 10.5220/0008152501360140

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 136-140

ISBN: 978-989-758-494-7

There have been many literatures reviewing the

effect of different contraception on the risk of STIs

and HIV. In general, they all come to the same

conclusion that male condoms used correctly and

consistenly provide good protection against mostSTIs,

both bacterial and viral (Steiner et al., 2008).

Several

studies have suggested a possibble link between

hormonal contraception use and enhanced HIV-1

suspectibility, although other studies have found no

such link. Study by Grabowski et all suggested that

hormonal contraception especially DMPA might

increase HIV risk.They reported that DMPA injection

could increased genital inflammation and increased

cervical DNA shedding (expressed either as

detectability or quantity) (Baeten and Heffron, 2015).

It is still debatable whether contraception use is

related to STIs and HIV. Therefore we conducted this

cross sectional study to investigate the correlation of

contraception with STIs and HIV among FSWs in

Surakarta.

2 METHODS

Cross sectional study was conducted in FSWs in

Surakarta. Female sex workers (FSWs) who were still

actively working willing to be interviewed and fill in

questionnaires, undergo endocervical and vaginal

swab examinations were performed at the sites.

Laboratory examinations were performed at dr.

Moewardi Hospital using Gram examination for Non-

Specific Genital Infection (NSGI), Neisseria

gonorhoea and Bacterial Vaginosis (BV), NaCl for

Trichomonas Vaginalis (TV), KOH for

Vulvovaginalis Candidiasis (VVC), Acetowhite test

for Condiloma Acuminata (CA) and Rapid Test for

Syphilis and HIV . All data were analyzed with

SPSSversion 17, Chi Square Test was used for the

stastitical analysis, p<0.05 was considered

significant.

3 RESULT

The total subjects were 75 FSWs. Most of FSWs aged

between 26-49, with the longest time being FSWs

was <5 years. Most of these FSWs had more than

twice sexual intercourse in a week (71%).

Contraception with 3 month injection was the most

preferable contraception used by FSWs. The

incidence of STIs in this study was 53.33%. STIs

were found in 40 WPS, consisting of Bacterial

Vaginosis 18.67%, Syphilis 14.67%, Vulvo vaginalis

Candidiosis 9.3%, Trichomoniasis 5.3%, Non-

Specific Genital Infection (2.6%), Cervicitis

Gonorrhoeae (1.33%) and Condyloma Acuminata

(1.33%).

Based on table 2 , there were no significant

correlation between contraceptive use with STIs and

HIV. However implant contraception had a

significant correlation with HIV infection (P value <

0.002, Contingency Coeficient (CC) 44.7%).

4 DISCUSSION

The use of contraception is closely relatedto

prevention efforts of STIs and HIV. Given the

different cultures and contraceptive practices, several

methods of providing protection from unintended

pregnancy, STIs and HIV infection should ideally be

available.

Globally more than 100 million women use

hormonal contraception in which it is associated with

potential effects of HIV infection. The association of

the effects of hormonal contraception with the risk of

HIV infection remains a matter of debate.Hormonal

contraception could act through a number of

biological. There are multiple mechanisms by which

the use of hormonal contaception might increase a

woman’s suspectibility to HIV infection. The

possible mechanism include the ability of oral

contraception to increase cervical ectopy which then

increases the susceptibility to STIs including HIV,

increased cervical chlamydial infection, a

hypoestrogenic effect associated with DMPA

injection use resulting in thining of the vaginal

epitelium, reduction in hydrogen peroxide producing

lactobacilli (and thereby decreased vaginal acidity)

and irregular uterine bleeding, suppression of the

local (cell-mediated) immune response and increased

recruitment of inflammatory and other target cells to

the genital tract or through a direct effect on the

infecting virus inoculum by upregulating HIV gene

expression and associated viral replication (Morrison

and Cates, 2008;Baeten and Heffron, 2015).

A prospective study revealed an increased

incidence of STIs in women using hormonal

contraception.Study by Borgdorff H in Rwandan

female sex workers reported that oral contraception

(OCPs) use was associated with increased Chlamydia

trachomatis incidence and injectable use significantly

associated with candidiasis incidence (H Borgdoff et

al., 2015).

A systematic review and meta analysis by

LAVodstrcilreported that hormonal contraception use

was associated with a significant reduced risk of

Bacterial Vaginosis (Vodstrcil et al., 2013).However,

The Corelation of Contraception with Sexually Transmitted Infection and HIV Infections on Female Sex Workers in Surakarta

137

in our study the oral contraception group had high rate

of BV infection (2.67%) followed by Cervicitis

gonorrhoeae infection (1.33%) while in the

contraceptive injection group

Table 1. Demographic characteristics of Female Sex Workers in Surakarta.

Characteristic Frequency (n=75) Percent (%)

Current Age <25 years of age 2 2.6

26-49years of age 69 92

>50 years of age 4 5.3

Length of work <5 years 39 52

5-10 years 20 26.67

>10 years 16 21.33

Sex Frequency>2x/week Yes 71 94.6

No 4 5.3

Condom use Always 42 56

Occasionally 33 44

Contraceptive Method No 25 33.33

Injectionof 3 months 22 2.3

Injectionof 1 month 10 13.3

Pill 11 14.6

Implant 5 6.67

IUD 2 2.67

HIV Yes 3 4

No 72 96

STIs No 35 46.67

Bacterial Vaginosis 14 18.67

Syphilis 11 14.67

Vulvovaginalis Candidiasis 7 9.3

Trichomoniasis 4 5.3

Non Specific Genital

Infection

2 2.6

Cervicitis Gonorrhoeae 1 1.33

CondilomaAcuminata 1 1.33

the incidence of STIs including BV (6.67%), NSGI

(1.33%) and Trichomoniasis ( 2.67%). There was no

significant correlation between the length

contraception use with the incidence of STIs or HIV

infection.

Some cross sectional studies reported that

hormonal contraception was use significantly

associated with increased amount of HIV-1 DNA in

genital tract. The only prospective study by Wang

measured HIV-1DNA levels before and after

initiation of hormonal contraception confirmed the

findings that 2 months after the initiation of hormonal

contraception, endocervical HIV-1 DNA increased

(Blish and Baeten, 2011).Study by CB Polis et all

assessed genital viral shedding comparing the

levonorgestrel implant reported no change in cervical

or vaginal tract (CB Polis et al., 2013).In our study

revealed a significant correlation between the use of

hormonal contraception (the implant group) and the

incidence of HIV infection (P value < 0.002,

Contingency Coeficient (CC) 44.7%).

Mechanical barriers contraception, such as

condom, may provide some protection against

bacterial STIs, their impact on HIV prevention is

currently under study. One analysis by AN Turner et

all compared findings from case crossover design

with a traditional cohort analysis found that condoms

were significantly protective against STIs especially

chlamydial and gonococcal infection

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Table 2. The correlation between contraception, STIs and HIV.

STIs P Value HIV P Value

No Yes

Contraceptive Yes

30 (40%) 20(26.7%) 0.509 48 (64%) 2 (2.7%) 1.000

13(17.3%) 12 (16%) 24 (32%) 1 (1.3%)

Total 33(57.3%) 32(42.7%) 72 (96%) 3 (4%)

Condom Always 24(32%) 18(24%) 0.970 40(53.3%) 2(2.7%) 0.704

Occasionally 19(25.3%) 14(18.7%) 32(42.7%) 11.3%)

Total 43(57.3) 32(42.6%) 72(96%) 3(4%)

Contraceptive

Types

Injection 3

month

13(17.3%) 9 (12%) 0.875 22(29,3%) 0 (0%)

Injection 1

month

7 (9.3%) 3 (4%) 10(13.3%) 0 (0%)

Pill 7 (9.3%) 4 (5.3%) 11(14.6%) 0 (0%)

Implant* 2 (2.7%) 3 (4%) 3 (4%) 2 (2,7%) 0.002*

IUD 1 (1.3%) 1 (1.3%) 2 (2.7%) 0 (0%)

Total 30(39.9%) 20(26.6%) 48(63.9%) 2(2,7%)

Contraceptive

Use

< 1 year 4 (18.2%) 2 (9.1%) 0.469 6 (27.3%) 0 (0%) 0.592

2-5 years 2 (9.1%) 3 (13.1%) 5 (22.7%) 0 (0%)

>5 years 4 (18.2%) 7 (31.8%) 10(45.5%) 1 (4.5%)

Total 10(45.5%) 12(54,5%) 21(95.5%) 1(4.5%)

*Significant statistically

(Turner et al., 2011). The study in Surakarta revealed

a significant relation between condom use and the

incidence of STIs and HIV among FSWs in surakarta

(Yuliarto et al., 2017).

our study revealed that the use

of either condom and iud contraception had no

correlation with stis and hiv infection

5 CONCLUSION

The use of implant contraception is significantly

correlated with HIV infection. However the use

contraception including condom and the length of

contraception use have no significant correlation with

STIs and HIV infection among FSWs. Further study

with larger sample size is needed in order to

generalized these findings.

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