In women, Neisseria gonorrhea and Chlamydia trachomatis may cause cervicitis. The complications of untreated cervicitis include pelvic inflammatory disease (PID) and tubo-ovarian abscess. If untreated, these infections can lead to scarring of the fallopian tubes, which increases the risk of ectopic pregnancy. Aggressive surveillance and treatment of STIs is thus important not only for decreasing HIV transmission, but also for reducing pregnancy-related deaths.

Because STIs are often asymptomatic (particularly in women), ZL medical staff improve case detection by relying not only on self-reported symptoms, but also on algorithms incorporating context-specific epidemiological risk factors elucidated through local research.^143–145 Risk assessment algorithms are useful as a screening tool and are especially helpful in settings where confirmatory testing is not available. As may be true in many resource-poor settings, the risk factors elucidated by ZL (as outlined in Protocol 2.5) are tied not only to a woman’s age and number of sexual partners but also to economic stressors. The risk factors included in Protocol 2.5 are specific to women in rural Haiti; other settings should rely on risk factors for cervical infection specific to that context. Note that, in the absence of laboratory testing, ZL staff recommend that all pregnant women receive empiric treatment for chlamydia and gonorrhea.

Per Protocol 2.6, all women presenting with lower abdominal pain should undergo a pregnancy test, a speculum exam with cervical gram stain or DNA probe to assess for cervicitis, and a bimanual exam to assess for PID, tubo-ovarian abscess, or ectopic pregnancy.¹⁴⁶ Women with symptoms of vaginal discharge should receive empiric treatment for STIs per Protocol 2.7. However, the majority of women with STIs are asymptomatic; thus, as mentioned, screening should extend beyond the syndromic approach.