Association between genital schistosomiasis and HIV in rural Zimbabwean women

Refining the Schistosoma haematobium recombinase polymerase amplification (Sh-RPA) assay: moving towards point-of-care use in endemic settings

BACKGROUND

Urogenital schistosomiasis is caused by the parasitic trematode Schistosoma haematobium. Sensitive and specific point-of-care diagnostics are needed for elimination of this disease. Recombinase polymerase amplification (RPA) assays meet these criteria, and an assay to diagnose S. haematobium has been developed (Sh-RPA). However, false-positive results can occur, and optimisation of reaction conditions to mitigate these is needed. Ease of use and compatibility of DNA extraction methods must also be considered.

METHODS

Using synthetic DNA, S. haematobium genomic DNA (gDNA), and urine samples from clinical cases, Sh-RPA reactions incorporating different betaine concentrations (0 M, 1 M, 2.5 M, 12.5 M) and the sample-to-water ratios were tested to determine effects on assay specificity and sensitivity. In addition, five commercial DNA extraction kits suitable for use in resource-limited settings were used to obtain gDNA from single S. haematobium eggs and evaluated in terms of DNA quality, quantity, and compatibility with the Sh-RPA assay. All samples were also evaluated by quantitative polymerase chain reaction (qPCR) to confirm DNA acquisition.

RESULTS

The analytical sensitivity of the Sh-RPA with all betaine concentrations was ≥ 10 copies of the synthetic Dra1 standard and 0.1 pg of S. haematobium gDNA. The addition of betaine improved Sh-RPA assay specificity in all reaction conditions, and the addition of 2.5 M of betaine together with the maximal possible sample volume of 12.7 µl proved to be the optimum reaction conditions. DNA was successfully isolated from a single S. haematobium egg using all five commercial DNA extraction kits, but the Sh-RPA performance of these kits varied, with one proving to be incompatible with RPA reactions.

CONCLUSIONS

The addition of 2.5 M of betaine to Sh-RPA reactions improved reaction specificity whilst having no detrimental effect on sensitivity. This increases the robustness of the assay, advancing the feasibility of using the Sh-RPA assay in resource-limited settings. The testing of commercial extraction kits proved that crude, rapid, and simple methods are sufficient for obtaining DNA from single S. haematobium eggs, and that these extracts can be used with Sh-RPA in most cases. However, the observed incompatibility of specific kits with Sh-RPA highlights the need for each stage of a molecular diagnostic platform to be robustly tested prior to implementation.

Knowledge and management of female genital schistosomiasis in sub-Saharan Africa: A scoping review protocol

Background

Approximately 20 to 120 million women of reproductive age worldwide are thought to be affected by female genital schistosomiasis (FGS). It is a preventable manifestation of schistosomiasis in adolescent girls and women, which remains underreported, underdiagnosed, or misdiagnosed, and largely untreated.

Objective

This study aimed to map evidence on the knowledge and management of FGS from 1950 to 2022 in sub-Saharan Africa.

Method

The Arksey and O'Malley and Levac et al. framework suggestions and a guideline from Joanna Briggs Institute will be employed. Search for literature will be in PubMed, Scopus, Cochrane, Web of Science, MEDLINE via PubMed, and Google Scholar from 1950 to 2022 for useful published research articles using key phrases or search terms and grey literature with limitations for studies conducted in sub-Saharan Africa. Two reviewers will screen the articles. Kappa coefficients by Cohen statistics will be computed for inter-screener agreement, and the selected articles will be evaluated using Mixed Method Appraisal Tool (MMAT).

Results

The researchers will map and explore the evidence of the knowledge and management of FGS in the subregion. The years of publications, countries of study, and settings will be reported, and the identified research gaps will be reported.

Conclusion

The researchers anticipate that this study will determine and map the evidence on the knowledge and management of FGS in sub-Saharan Africa; identify knowledge and management gaps, and direct future research.

Contribution

This study will add to the literature on FGS and direct future research regarding the knowledge and management of FGS.

Zipime-Weka-Schista study protocol: a longitudinal cohort study and economic evaluation of an integrated home-based approach for genital multipathogen screening in women, including female genital schistosomiasis, human papillomavirus, Trichomonas and HIV in Zambia

INTRODUCTION

Multiplathogen home-based self-sampling offers an opportunity to increase access to screening and treatment in endemic settings with high coinfection prevalence of sexually transmitted (HIV, Trichomonas vaginalis (Tv), human papillomavirus (HPV)) and non-sexually transmitted pathogens (Schistosoma haematobium (Sh)). Chronic coinfections may lead to disability (female genital schistosomiasis) and death (cervical cancer). The Zipime-Weka-Schista (Do self-testing sister!) study aims to evaluate the validity, acceptability, uptake, impact and cost-effectiveness of multipathogen self-sampling for genital infections among women in Zambia.

METHODS AND ANALYSIS

This is a longitudinal cohort study aiming to enrol 2500 non-pregnant, sexually active and non-menstruating women aged 15-50 years from two districts in Zambia with 2-year follow-up. During home visits, community health workers offer HIV and Tv self-testing and cervicovaginal self-swabs for (1) HPV by GeneXpert and, (2) Sh DNA detection by conventional (PCR)and isothermal (recombinase polymerase assay) molecular methods. Schistosoma ova and circulating anodic antigen are detected in urine. At a clinic follow-up, midwives perform the same procedures and obtain hand-held colposcopic images. High-risk HPV positive women are referred for a two-quadrant cervical biopsy according to age and HIV status. A cost-effectiveness analysis is conducted in parallel.

ETHICS AND DISSEMINATION

The University of Zambia Biomedical Research Ethics Committee (UNZABREC) (reference: 1858-2021), the London School of Hygiene and Tropical Medicine (reference: 25258), Ministry of Health and local superintendents approved the study in September 2021.Written informed consent was obtained from all participants prior to enrolment. Identifiable data collected are stored securely and their confidentiality is protected in accordance with the Data Protection Act 1998.

Female genital schistosomiasis is a neglected public health problem in Tanzania: Evidence from a scoping review

Schistosoma haematobium, the parasite that causes urogenital schistosomiasis, is widely prevalent in Tanzania. In addition to well-known effects on the urinary tract, S. haematobium also causes clinically- evident damage to the reproductive tract in approximately half of infected women, which is known as female genital schistosomiasis (FGS). FGS has major gynecologic and social consequences on women's reproductive health, yet little information is available regarding FGS in Tanzania. To cover that gap, we conducted the present scoping review to examine the epidemiology of FGS in Tanzania (both in the mainland and Zanzibar island) and to make recommendations for future work in this area. The available evidence from community-based and hospital-based retrospective studies indicates that FGS is a significant health problem in the country. Very few community-based studies have been reported from mainland Tanzania, and Zanzibar. Our review highlights the scarcity of efforts to address FGS in Tanzania and the need for additional community-based studies. The studies will help us understand the true burden of the disease nationwide, to assess the impact of praziquantel on FGS lesions, and to address social and mental health in relation to FGS. This review emphasizes integration of delivery of FGS related services in primary health care systems through the reproductive health clinics which covers sexually transmitted infections, HIV and cervical cancer screening. These actions are essential if this neglected gynecological disease is to be addressed in Tanzania.

Integration of female genital schistosomiasis into HIV/sexual and reproductive health and rights and neglected tropical diseases programmes and services: a scoping review

Female genital schistosomiasis (FGS) affects approximately 56 million women and girls across sub-Saharan Africa and is associated with up to a threefold increased prevalence of HIV. Integrating FGS with HIV programmes as part of comprehensive sexual and reproductive health (SRH) services may be one of the most significant missed opportunities for preventing HIV incidence among girls and women. A search of studies published until October 2021 via Scopus and ProQuest was conducted using PRISMA guidelines to assess how FGS can be integrated into HIV/SRH and neglected tropical diseases (NTDs) programmes and services. Data extraction included studies that integrated interventions and described the opportunities and challenges. A total of 334 studies were identified, with 22 eligible for analysis and summarised conducting a descriptive numerical analysis and qualitative review. We adapted a framework for integrated implementation of FGS, HIV, and HPV/cervical cancer to thematically organise the results, classifying them into five themes: awareness and community engagement, diagnosis, treatment, burden assessment, and economic evaluation. Most activities pertained to awareness and community engagement (n = 9), diagnosis (n = 9) and were primarily connected to HIV/AIDS (n = 8) and school-based services and programming (n = 8). The studies mainly described the opportunities and challenges for integration, rather than presenting results from implemented integration interventions, highlighting an evidence gap on FGS integration into HIV/SRH and NTD programmes. Investments are needed to realise the potential of FGS integration to address the burden of this neglected disease and improve HIV and SRH outcomes for millions of women and girls at risk.

Cytobrush and cotton swab as sampling tools for molecular diagnosis of female genital schistosomiasis in the uterine cervix

Female genital schistosomiasis (FGS) caused by Schistosoma haematobium is a neglected chronic parasitic disease. Diagnosis relies mainly on a colposcopy, which reveals non-specific lesions. This study aimed to assess the performance of two sampling methods for the molecular diagnosis of FGS in the uterine cervix. We conducted a descriptive cross-sectional study in women of reproductive age in Saint Louis, Senegal, who presented for cervical cancer screening. Cotton swab and cytobrush samples were collected from the cervix and examined by real-time PCR. The PCR results obtained using the cotton swabs were compared with those obtained using cytobrush. Of the 189 women recruited, 56 (30%) were found to be positive for S. haematobium infection via real-time PCR. Women aged 40-54 years were predominantly infected (45%) followed by those aged 25-39 years (36%). Numerically more PCR-positive specimens were identified using cytobrush sampling. Of the 89 women who underwent both cytobrush and cotton swab sampling, 27 were PCR-positive in the cytobrush sampling vs 4 in the swab sampling. The mean Ct-value was 31.0 ± 3.8 for cytobrush-based PCR vs 30.0 ± 4.4 for swab-based PCR. The results confirm that real-time PCR can detect Schistosoma haematobium DNA in the uterine cervix. The next step will be to compare PCR with the other diagnostic methods of FGS.

Prospective pilot study on the relationship between seminal HIV-1 shedding and genital schistosomiasis in men receiving antiretroviral therapy along Lake Malawi

Male genital schistosomiasis (MGS) is hypothesized to increase seminal shedding of HIV-1. This prospective pilot study assessed seminal HIV-1 RNA shedding in men on long-term ART with and without a diagnosis of MGS. Study visits occurred at 0, 1, 3, 6 and 12 months. MGS was diagnosed by egg positivity on semen microscopy or PCR of seminal sediment. After optimization of the HIV-RNA assay, we examined 72 paired plasma and semen samples collected from 31 men (15 with and 16 without MGS) over 12 months. HIV-1 RNA was detected in 7/72 (9.7%) seminal samples and 25/72 (34.7%) plasma samples. When comparing sample pairs, 5/72 (6.9%) showed HIV-1 RNA detection only in the seminal sample. Overall, 3/31 (9.7%) participants, all with MGS, had detectable HIV-1 RNA in semen while plasma HIV-1 RNA was undetectable (< 22 copies/mL), with seminal levels ranging up to 400 copies/mL. Two participants showing HIV-1 RNA in seminal fluid from the MGS-negative group also had concomitant HIV-1 RNA detection in plasma. The findings suggest that MGS can be associated with low-level HIV-1 RNA shedding despite virologically suppressive ART. Further studies are warranted to confirm these observations and assess its implications.

Cytokine Gene Expression Profiles during HIV and Helminth Coinfection in Underprivileged Peri-Urban South African Adults

BACKGROUND

Intestinal helminth parasites are potent stimulators of T helper type 2 (Th2) and regulatory Th3 anti-inflammatory immune responses, while human immunodeficiency virus (HIV) infections are activators of predominantly T helper type 1(Th1) pro-inflammatory responses. Studies investigating the immune profiles of individuals coinfected with helminths and HIV are scarce. Although it is well known that helminths cause a type 2 immune response during the chronic stage of infection that is characterised by Th2 cell differentiation, eosinophil recruitment, and alternative macrophage activation, the immune mechanisms that regulate tissue damage at the time of parasite invasion are poorly understood.

AIM

The aim of the study was to determine the cytokine gene expression profiles during HIV and helminth coinfection in underprivileged South African adults living in a peri-urban area with poor sanitary conditions and a lack of clean water supply.

METHOD

Study participants (n = 164) were subdivided into uninfected controls, HIV-infected, helminth-infected, and HIV and helminth-coinfected groups. The Kato-Katz and Mini Parasep techniques and Ascaris lumbricoides-specific Immunoglobulin E (IgE) and Immunoglobulin G4 (IgG4) levels were used to detect helminth infections. Participants' HIV status was determined using two HIV1/2 antibody test kits. RNA was isolated from white blood cells for cytokine (Th1-, Th2-, and Th17-related) and transcription factor gene expression profiling using real-time PCR.

RESULTS

Multivariate regression data were adjusted for age, gender, BMI, antiretroviral treatment (ART), and nutritional supplement intake. The HIV and helminth-coinfected group had significantly higher tumour necrosis factor alpha (TNF-α) (adjusted β = 0.53, p = 0.036), interleukin 2 (IL-2) (adjusted β = 6.48, p = 0.008), and interleukin 17 (IL-17) (adjusted β = 1.16, p = 0.001) levels and lower GATA binding protein 3 (GATA3) levels (adjusted β = -0.77, p = 0.018) compared to the uninfected controls. No statistical significance was noted for Th2-related cytokines.

CONCLUSION

The coinfected group had higher proinflammatory Th1- and Th17-related cytokine gene expression profiles compared to the uninfected controls. The findings suggest that pro-inflammatory responses are elevated during coinfection, which supports the hypothesis that helminths have a deleterious effect on HIV immune responses.

Improving the Response of Health Systems to Female Genital Schistosomiasis in Endemic Countries through a Gender-Sensitive Human Rights-Based Framework

The right to health was enshrined in the constitution of the World Health Organization in 1946 and in the Universal Declaration of Human Rights in 1948, which also guaranteed women's fundamental freedoms and dignity. The Declaration of Human Rights was signed by almost every country in the world. Nonetheless, gender inequalities in health and health systems continue to persist, especially in lower and middle income countries that are disproportionately affected by a litany of neglected diseases. In this paper, we focus on one of the most neglected human rights, development, and reproductive health issues globally, female genital schistosomiasis (FGS), which imposes enormous unacknowledged suffering on an estimated 56 million women and girls in Sub-Saharan Africa. Despite increasing calls for attention to FGS, no country has fully incorporated it into its health system. An appropriate response will require a comprehensive approach, guided by human rights mandates and the redress of FGS-related gender inequalities. In this paper, we propose the application of existing human rights and its clients, women, and girls affected by FGS as rights holders. Within the different components or building blocks of the health system, we propose elements of an appropriate health system response using the four components identified within the FGS Accelerated Scale Together (FAST) Package-awareness raising, prevention of infection, training of health personnel, and diagnosis and treatment. The framework is aspirational, its recommended elements and actions are not exhaustive, and countries will need to adapt it to their own situations and resource availability. However, it can be a useful guide to help health systems define how to begin to incorporate FGS into their programming in a way that responds to their human rights obligations in a gender- and culturally sensitive manner.

Establishing and Integrating a Female Genital Schistosomiasis Control Programme into the Existing Health Care System

Female genital schistosomiasis (FGS) is a complication of Schistosoma haematobium infection, and imposes a health burden whose magnitude is not fully explored. It is estimated that up to 56 million women in sub-Saharan Africa have FGS, and almost 20 million more cases will occur in the next decade unless infected girls are treated. Schistosomiasis is reported throughout the year in South Africa in areas known to be endemic, but there is no control programme. We analyze five actions for both a better understanding of the burden of FGS and reducing its prevalence in Africa, namely: (1) schistosomiasis prevention by establishing a formal control programme and increasing access to treatment, (2) introducing FGS screening, (3) providing knowledge to health care workers and communities, (4) vector control, and (5) water, sanitation, and hygiene. Schistosomiasis is focal in South Africa, with most localities moderately affected (prevalence between 10% and 50%), and some pockets that are high risk (more than 50% prevalence). However, in order to progress towards elimination, the five actions are yet to be implemented in addition to the current (and only) control strategy of case-by-case treatment. The main challenge that South Africa faces is a lack of access to WHO-accredited donated medication for mass drug administration. The establishment of a formal and funded programme would address these issues and begin the implementation of the recommended actions.

Prevalence and risk factors for blood filariasis among HIV-infected adults in Gabon, Central Africa: a pilot study

BACKGROUND

The level of blood filariasis parasitaemia as well as the frequency of and the relationship between cotrimoxazole prophylaxis (CTX-P), antiretroviral therapy (ART) intake and CD4 cell count among people living with human immunodeficiency virus (PLHIV) in rural areas of Gabon were being studied.

METHODS

Sociodemographic data and recent biological tests of PLHIV and HIV-negative participants were collected. Loa loa and Mansonella perstans microfilaria were detected by direct microscopy examination and leucoconcentration.

RESULTS

Overall, 209 HIV-positive and 148 HIV-negative subjects were enrolled. The overall prevalence of microfilaria was comparable between PLHIV (19.9% [n=41/206]) and HIV-negative participants (14.8% [n=22/148]) (p=0.2). The L. loa infection rate was comparable between HIV-positive (9.2%) and HIV-negative participants (6.8%) (p=0.2), while the M. perstans infection rate was 14-fold higher among PLHIV (p<0.01). L. loa parasitaemia was 6-fold lower in PLHIV receiving CTX-P (median 150 mf/mL [interquartile range {IQR} 125-350]) than in patients without (900 [550-2225]) (p<0.01). Among subjects with a CD4 cell count <200 cells/μL, the prevalence of M. perstans was 7-fold higher than that of L. loa (20.6% vs 2.9%).

CONCLUSIONS

This study suggests a similar exposure to L. loa infection of PLHIV and HIV-negative patients while M. perstans is more frequently found in HIV-positive individuals, notably those with a CD4 count <200 cells/μL.

Review of 2022 WHO guidelines on the control and elimination of schistosomiasis

Schistosomiasis is a helminthiasis infecting approximately 250 million people worldwide. In 2001, the World Health Assembly (WHA) 54.19 resolution defined a new global strategy for control of schistosomiasis through preventive chemotherapy programmes. This resolution culminated in the 2006 WHO guidelines that recommended empirical treatment by mass drug administration with praziquantel, predominately to school-aged children in endemic settings at regular intervals. Since then, school-based and community-based preventive chemotherapy programmes have been scaled-up, reducing schistosomiasis-associated morbidity. Over the past 15 years, new scientific evidence-combined with a more ambitious goal of eliminating schistosomiasis and an increase in the global donated supply of praziquantel-has highlighted the need to update public health guidance worldwide. In February, 2022, WHO published new guidelines with six recommendations to update the global public health strategy against schistosomiasis, including expansion of preventive chemotherapy eligibility from the predominant group of school-aged children to all age groups (2 years and older), lowering the prevalence threshold for annual preventive chemotherapy, and increasing the frequency of treatment. This Review, written by the 2018-2022 Schistosomiasis Guidelines Development Group and its international partners, presents a summary of the new WHO guideline recommendations for schistosomiasis along with their historical context, supporting evidence, implications for public health implementation, and future research needs.

Hookworm infection associates with a vaginal Type 1/Type 2 immune signature and increased HPV load

Helminth infection-driven changes to immunity in the female reproductive tract (FRT) is an immune axis that is currently understudied but can have major implications for the control of FRT infections. Here we address how human hookworm infection associates with vaginal immune profile and risk of Human papillomavirus (HPV) infection. Stool, blood, cervical swabs and vaginal flushes were collected from women from the Central region of Togo to screen for hookworms (Ancylostoma duodenale) and high carcinogenic risk HPV types, via Kato Katz and PCR, respectively. Cytokine, chemokine and immunoglobulin levels were analysed in cervicovaginal lavages and plasma samples. A pronounced mixed Type 1/Type 2 immune response was detected in the vaginal fluids of women with hookworm infection and this immune signature was a notable feature in hookworm-HPV co-infected women. Moreover, hookworm infection is positively associated with increased risk and load of HPV infection. These findings highlight helminth infection as a significant risk factor for acquiring a sexually transmitted viral infection and potentially raising the risk of subsequent pathology.

The Road to Elimination: Current State of Schistosomiasis Research and Progress Towards the End Game

The new WHO Roadmap for Neglected Tropical Diseases targets the global elimination of schistosomiasis as a public health problem. To date, control strategies have focused on effective diagnostics, mass drug administration, complementary and integrative public health interventions. Non-mammalian intermediate hosts and other vertebrates promote transmission of schistosomiasis and have been utilized as experimental model systems. Experimental animal models that recapitulate schistosomiasis immunology, disease progression, and pathology observed in humans are important in testing and validation of control interventions. We discuss the pivotal value of these models in contributing to elimination of schistosomiasis. Treatment of schistosomiasis relies heavily on mass drug administration of praziquantel whose efficacy is comprised due to re-infections and experimental systems have revealed the inability to kill juvenile schistosomes. In terms of diagnosis, nonhuman primate models have demonstrated the low sensitivity of the gold standard Kato Katz smear technique. Antibody assays are valuable tools for evaluating efficacy of candidate vaccines, and sera from graded infection experiments are useful for evaluating diagnostic sensitivity of different targets. Lastly, the presence of Schistosomes can compromise the efficacy of vaccines to other infectious diseases and its elimination will benefit control programs of the other diseases. As the focus moves towards schistosomiasis elimination, it will be critical to integrate treatment, diagnostics, novel research tools such as sequencing, improved understanding of disease pathogenesis and utilization of experimental models to assist with evaluating performance of new approaches.

An update on female and male genital schistosomiasis and a call to integrate efforts to escalate diagnosis, treatment and awareness in endemic and non-endemic settings: The time is now

The last decades have brought important insight and updates in the diagnosis, management and immunopathology of female genital schistosomiasis (FGS) and male genital schistosomiasis (MGS). Despite sharing a common parasitic aetiological agent, FGS and MGS have typically been studied separately. Infection with Schistosoma haematobium manifests with gender-specific clinical manifestations and consequences of infection, albeit having a similar pathogenesis within the human genital tract. Schistosoma haematobium is a known urinary bladder carcinogen, but its potential causative role in other types of neoplasia, such as cervical cancer, is not fully understood. Furthermore, the impact of praziquantel treatment on clinical outcomes remains largely underexplored, as is the interplay of FGS/MGS with relevant reproductive tract infections such as HIV and Human Papillomavirus. In non-endemic settings, travel and immigrant health clinics need better guidance to correctly identify and treat FGS and MGS. Our review outlines the latest advances and remaining knowledge gaps in FGS and MGS research. We aim to pave a way forward to formulate more effective control measures and discuss elimination targets. With a growing community awareness in health practitioners, scientists and epidemiologists, alongside the sufferers from these diseases, we aspire to witness a new generation of young women and men free from the downstream disabling manifestations of disease.

Reduction of testosterone levels in Schistosoma haematobium- or Schistosoma mansoni-infected men: a cross-sectional study in two schistosomiasis-endemic areas of the Adamawa region of Cameroon

BACKGROUND

The incidence of schistosomiasis-induced male reproductive dysfunction and infertility is probably underestimated compared to female genital schistosomiasis. This study aimed to investigate the impact of Schistosoma haematobium or S. mansoni infection on the reproductive function of men of reproductive age in Tibati and Wouldé, two endemic schistosomiasis areas in the Adamawa region of Cameroon.

METHODS

A total of 89 men of reproductive age (range 14-56 years) from two localities were enrolled in the study, with 51 in Tibati and 38 in Wouldé. Each participant was submitted to a questionnaire to document data on sociodemographic and stream contact behaviors. A medical examination was performed to measure the testes' circumference and evaluate genital tract pathologies. Stool and urine samples were collected and screened for the presence of S. haematobium or S. mansoni ova. Blood serum was used to assess the levels of transaminases and testosterone.

RESULTS

Schistosoma haematobium was present only in Tibati, with a prevalence of 31.37%. The S. mansoni prevalence was 3.92% at Tibati and 44.71% at Wouldé. The intensity of infection was 22.12 ± 9.57 eggs/10 mL for S. haematobium and 128.10 ± 3.76 epg for S. mansoni. Serum transaminase activity and the mean testicular circumference of Schistosoma-positive individuals were close to Schistosoma-negative individuals. However, the testes size was more prominent in S. mansoni-positive individuals than in S. haematobium-positive individuals (P < 0.05). The serum testosterone levels of S. haematobium- and S. mansoni-positive men were significantly reduced by 56.07% (P < 0.001) and 51.94% (P < 0.01), respectively, in comparison to those of Schistosoma-negative men. A significant and negative correlation was established between schistosomiasis and the low serum testosterone level. Male genital tract pathologies such as scrotal abnormalities, varicocele, nodular epididymis, inguinal hernia, and hydrocele were recorded in both Schistosoma-positive and Schistosoma-negative men. However, no significant link was established between schistosomiasis infection and these pathologies.

CONCLUSION

These results demonstrated that infection with S. haematobium or S. mansoni is associated with low production of the reproductive hormone testosterone and may be a significant cause of male infertility.

Human rights as a framework for eliminating female genital schistosomiasis

Female genital schistosomiasis (FGS) affects tens of millions of women and girls in sub-Saharan Africa, yet this inequitable threat is often overlooked by advocates in both the neglected tropical disease (NTD) and sexual and reproductive health and rights (SRHR) communities. FGS causes both acute infection and long-term sexual and reproductive health harm to marginalized women and girls, with gender, poverty, and rurality combining to invisibilize the disease. Human rights and gender imperatives can help to galvanize efforts to control and eliminate FGS, as they have for other NTDs. Specifically, international human rights obligations can frame state efforts to address FGS across healthcare settings, upstream social determinants of health, scientific research, and policy implementation. This article analyzes human rights–based approaches to FGS control and elimination efforts, outlining several areas for forward-looking reforms to health policy, programing, and practice. Building from the lessons learned in applying human rights–based approaches to advance progress on other NTDs, this analysis seeks to provide the NTD community with shared understanding around international legal obligations to engage SRHR advocates and draw heightened attention to FGS. Such human rights–based approaches to FGS control and elimination can help to reduce stigma and improve care for the millions of women and girls currently affected by this preventable disease.

Female genital schistosomiasis (FGS) affects over 56 million women and girls in sub-Saharan Africa alone, yet this inequitable threat is largely ignored by global health advocates, program managers, and policymakers. The lack of international attention undermines efforts to eliminate schistosomiasis globally. International human rights law can help to reverse this neglect and shape the role of the international community in supporting elimination of FGS as a public health problem, as has been done for other neglected tropical diseases (NTDs). This analysis provides the NTD community with shared language around international legal obligations to engage sexual and reproductive health and rights (SRHR) advocates and draw attention to this often overlooked condition. Working together, these two communities can reduce stigma and improve the health and well-being of the millions of marginalized women and girls affected by this preventable disease.

Validation of the isothermal Schistosoma haematobium Recombinase Polymerase Amplification (RPA) assay, coupled with simplified sample preparation, for diagnosing female genital schistosomiasis using cervicovaginal lavage and vaginal self-swab samples

BACKGROUND

Female genital schistosomiasis (FGS) is a neglected and disabling gynecological disease that can result from infection with the parasitic trematode Schistosoma haematobium. Accurate diagnosis of FGS is crucial for effective case management, surveillance and control. However, current methods for diagnosis and morbidity assessment can be inaccessible to those at need, labour intensive, costly and unreliable. Molecular techniques such as PCR can be used to reliably diagnose FGS via the detection of Schistosoma DNA using cervicovaginal lavage (CVL) samples as well as lesser-invasive vaginal self-swab (VSS) and cervical self-swab samples. PCR is, however, currently unsuited for use in most endemic settings. As such, in this study, we assessed the use of a rapid and portable S. haematobium recombinase polymerase amplification (Sh-RPA) isothermal molecular diagnostic assay, coupled with simplified sample preparation methodologies, to detect S. haematobium DNA using CVL and VSS samples provided by patients in Zambia.

METHODOLOGY/PRINCIPAL FINDINGS

VSS and CVL samples were screened for FGS using a previously developed Sh-RPA assay. DNA was isolated from VSS and CVL samples using the QIAamp Mini kit (n = 603 and 527, respectively). DNA was also isolated from CVL samples using two rapid and portable DNA extraction methods: 1) the SpeedXtract Nucleic Acid Kit (n = 223) and 2) the Extracta DNA Tissue Prep Kit (n = 136). Diagnostic performance of the Sh-RPA using VSS DNA extacts (QIAamp Mini kit) as well as CVL DNA extracts (QIAamp Mini kit, SpeedXtract Nucleic Acid Kit and Extracta DNA Tissue Prep Kit) was then compared to a real-time PCR reference test. Results suggest that optimal performance may be achieved when the Sh-RPA is used with PuVSS samples (sensitivity 93.3%; specificity 96.6%), however no comparisons between different DNA extraction methods using VSS samples could be carried out within this study. When using CVL samples, sensitivity of the Sh-RPA ranged between 71.4 and 85.7 across all three DNA extraction methods when compared to real-time PCR using CVL samples prepared using the QIAamp Mini kit. Interestingly, of these three DNA extraction methods, the rapid and portable SpeedXtract method had the greatest sensitivity and specificity (85.7% and 98.1%, respectively). Specificity of the Sh-RPA was >91% across all comparisons.

CONCLUSIONS/SIGNIFICANCE

These results supplement previous findings, highlighting that the use of genital self-swab sampling for diagnosing FGS should be explored further whilst also demonstrating that rapid and portable DNA isolation methods can be used to detect S. haematobium DNA within clinical samples using RPA. Although further development and assessment is needed, it was concluded that the Sh-RPA, coupled with simplified sample preparation, shows excellent promise as a rapid and sensitive diagnostic tool capable of diagnosing FGS at the point-of-care in resource-poor schistosomiasis-endemic settings.

Addressing a silent and neglected scourge in sexual and reproductive health in Sub-Saharan Africa by development of training competencies to improve prevention, diagnosis, and treatment of female genital schistosomiasis (FGS) for health workers

Background

Schistosomiasis is an acute and chronic disease caused by parasitic worms, that can take two main forms: intestinal or urogenital. If left untreated, the urogenital form can lead to female genital schistosomiasis (FGS) in women and girls; frequently resulting in severe reproductive health complications which are often misdiagnosed as sexually-transmitted infections (STIs) or can be confused with cervical cancer. Despite its impact on women’s reproductive health, FGS is typically overlooked in medical training and remains poorly recognized with low awareness both in affected communities and in health professionals. FGS has been described as the one of the most neglected sexual and reproductive health issues in sub-Saharan Africa (Swai in BMC Infect Dis 6:134, 2006; Kukula in PLoS Negl Trop Dis 13:e0007207; Joint United Nations Programme on HIV/AIDS (UNAIDS) 2019). Increased knowledge and awareness of FGS is required to end this neglect, improve women’s reproductive health, and decrease the burden of this preventable and treatable neglected tropical disease.

Methods

We conducted interactive virtual workshops, in collaboration with the World Health Organization (WHO), engaging 64 participants with medical and public health backgrounds from around the world to establish standardized skills (or competencies) for prevention, diagnosis, and treatment of FGS at all levels of the health system. The competencies were drafted in small groups, peer-reviewed, and finalized by participants.

Results

This participatory process led to identification of 27 skills needed for FGS prevention, diagnosis, and management for two categories of health workers; those working in a clinical setting, and those working in a community setting. Among them, ten relate to the diagnosis of FGS including three that involve a pelvic exam and seven that do not. Six constitute the appropriate behaviors required to treat FGS in a clinical setting. Eleven address the community setting, with six relating to the identification of women at risk and five relating to prevention.

Conclusion

Defining the skills necessary for FGS management is a critical step to prepare for proper diagnosis and treatment of women and girls in sub-Saharan Africa by trained health professionals. The suggested competencies can now serve as the foundation to create educative tools and curricula to better train health care workers on the prevention, diagnosis, and management of FGS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01252-2.

Schistosomiasis belongs to the group of neglected tropical diseases (NTDs) found in tropical and subtropical countries, disproportionately affecting poor populations with limited access to safe water and adequate sanitation. Female genital schistosomiasis (FGS) is a chronic disease caused by parasitic worms, schistososomes, transmitted by contact with infested fresh water. When left untreated, FGS can lead to severe reproductive health complications, such as sub-or infertility and ectopic pregnancy. FGS is a leading neglected issue in sexual and reproductive health in sub-Saharan Africa; however, health professionals are not familiar with it, leading to misdiagnosis and improper treatment. A critical challenge in addressing the burden of FGS is the knowledge gap about the disease in communities and health professionals in endemic areas and the world at large. As part of an FGS Accelerated Scale Together (FAST) package, and in an attempt to address the knowledge gap in health professionals, we organized an interactive workshop bringing together a group of 64 participants working in sexual and reproductive health generally, and/or FGS specifically. Together, we developed a comprehensive set of required skills for health workers training on FGS. The workshop participants drafted 27 skills (or competencies) to diagnose, treat, and prevent FGS. Establishing what health workers must know is a crucial first step towards the integration of FGS into women’s health care. The competencies are now available and can be used as a framework in the development of training for health professionals, opening the doors to better reproductive health for women.

"Female genital schistosomiasis is a sexually transmitted disease": Gaps in healthcare workers' knowledge about female genital schistosomiasis in Tanzania

Female Genital Schistosomiasis is a gynecological disease that is a complication of parasitic Schistosoma haematobium infection and affects at least 40 million girls and women, mostly in sub-Saharan Africa. Little is known about how healthcare workers in endemic areas perceive and manage (diagnose and treat) Female Genital Schistosomiasis. We conducted cross-sectional focus group discussions and key informant interviews among healthcare workers in northwestern Tanzania. Healthcare workers, particularly those working in areas where S. haematobium is highly endemic, were purposively sampled to participate in the study. Discussions and interviews were digitally recorded, transcribed, and analyzed using NVivo version 12. Most healthcare workers lacked knowledge and skills to manage Female Genital Schistosomiasis. They also had multiple misconceptions about its aetiology, modes of transmission, symptoms, and management. Healthcare workers did not consider Female Genital Schistosomiasis in differential diagnoses of women presenting with gynecologic symptoms except sometimes in patients who did not respond to the initial therapy for sexually transmitted infections. Healthcare facilities had limited capacity to manage Female Genital Schistosomiasis. Our findings show critical gaps in both the knowledge of healthcare workers to manage Female Genital Schistosomiasis and in the capacity of healthcare facilities to manage it. To fill these gaps, two urgent needs must be fulfilled: first, training healthcare workers (particularly those working in schistosomiasis-endemic settings) on Female Genital Schistosomiasis, and second, stocking healthcare facilities with necessary medical equipment and supplies for managing this disease.

The parasitology of female genital schistosomiasis

Female genital schistosomiasis (FGS) is the gynaecological presentation of Schistosoma haematobium infection, resulting from egg deposition in the female genital tract. Despite the fact that this condition has been reported in the early days of the discovery of S. haematobium in Egypt, its existence has been grossly neglected, causing many women in schistosomiasis-endemic areas to go through a preventable, debilitating, and stigmatizing presentation of FGS. To prevent this, increasing awareness of FGS is necessary for all, especially healthcare providers, to improve the diagnosis, management, and treatment. As proposed by the FAST package project, several healthcare professionals with different specializations are expected to be involved in the management of FGS. It is therefore important that basic updated knowledge on the parasitology of the disease be acquired by healthcare professionals. This review provides basic information necessary to improve the knowledge of FGS among healthcare professionals in areas endemic to schistosomiasis. Armed with these basic details, healthcare professionals can improve their confidence in the management and treatment of FGS, contributing significantly to the control and prevention of FGS in endemic areas.

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A review of female genital schistosomiasis.

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Data on the life-cycle of Schistosoma haematobium, and pathogenesis and clinical features of female genital schistosomiasis.

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Summary of diagnostic methods and treatment, control and prevention of female genital schistosomiasis.

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Increasing awareness among healthcare workers is key to the management, control, and prevention of the disease.

Association of Female Genital Schistosomiasis With the Cervicovaginal Microbiota and Sexually Transmitted Infections in Zambian Women

BACKGROUND

The cervicovaginal microbiota, including sexually transmitted infections (STIs), have not been well described in female genital schistosomiasis (FGS).

METHODS

Women (aged 18-31, sexually active, nonpregnant) were invited to participate at the final follow-up of the HPTN 071 (PopART) Population Cohort in January-August 2018. We measured key species of the cervicovaginal microbiota (Lactobacillus crispatus, L. iners, Gardnerella vaginalis, Atopobium vaginae, and Candida) and STIs (Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Mycoplasma genitalium) using quantitative PCR (qPCR). We evaluated associations of the microbiota and STI presence and concentration with FGS (qPCR-detected Schistosoma DNA in any of 3 genital specimens).

RESULTS

The presence and concentration of key cervicovaginal species did not differ between participants with (n = 30) or without FGS (n = 158). A higher proportion of participants with FGS had T. vaginalis compared with FGS-negative women (P = .08), with further analysis showing that T. vaginalis was more prevalent among women with ≥2 Schistosoma qPCR-positive genital specimens (50.0%, 8/16) than among FGS-negative women (21.5%, 34/158; P = .01).

CONCLUSIONS

We found weak evidence of an association between the presence of T. vaginalis and FGS, with a stronger association in women with a higher-burden FGS infection. Additional research is needed on potential between-parasite interactions, especially regarding HIV-1 vulnerability.

"We know about schistosomiasis but we know nothing about FGS": A qualitative assessment of knowledge gaps about female genital schistosomiasis among communities living in Schistosoma haematobium endemic districts of Zanzibar and Northwestern Tanzania

BACKGROUND

Schistosoma haematobium causes urogenital schistosomiasis and is widely distributed in Tanzania. In girls and women, the parasite can cause Female Genital Schistosomiasis (FGS), a gynecological manifestation of schistosomiasis that is highly neglected and overlooked by public health professionals and policy makers. This study explored community members' knowledge, attitudes and perceptions (KAP) on and health seeking behavior for FGS.

METHODS/PRINCIPAL FINDINGS

Using qualitative research methods-including 40 Focus Group Discussions (FGDs) and 37 Key Informant Interviews (KIIs)-we collected data from 414 participants (Males n = 204 [49.3%] and Females n = 210 [50.7%]). The study engaged 153 participants from Zanzibar and 261 participants from northwestern Tanzania and was conducted in twelve (12) purposively selected districts (7 districts in Zanzibar and 5 districts in northwestern Tanzania). Most participants were aware of urogenital schistosomiasis. Children were reported as the most affected group and blood in urine was noted as a common symptom especially in boys. Adults were also noted as a risk group due to their involvement in activities like paddy farming that expose them to infection. Most participants lacked knowledge of FGS and acknowledged having no knowledge that urogenital schistosomiasis can affect the female reproductive system. A number of misconceptions on the symptoms of FGS and how it is transmitted were noted. Adolescent girls and women presenting with FGS related symptoms were reported to be stigmatized, perceived as having a sexually transmitted infection (STI), and sometimes labeled as "prostitutes". Health seeking behavior for FGS included a combination of traditional medicine, self-treatment and modern medicine.

CONCLUSION/SIGNIFICANCE

Community members living in two very different areas of Tanzania exhibited major, similar gaps in knowledge about FGS. Our data illustrate a critical need for the national control program to integrate public health education about FGS during the implementation of school- and community-based mass drug administration (MDA) programs and the improvement of water, sanitation and hygiene (WASH) facilities.

Female Genital Schistosomiasis and HIV-1 Incidence in Zambian Women: A Retrospective Cohort Study

Background

Female genital schistosomiasis (FGS) has been associated with prevalent HIV-1. We estimated the incidence of HIV-1 infection in Zambian women with and without FGS.

Methods

Women (aged 18–31, nonpregnant, sexually active) were invited to participate in this study in January–August 2018 at the final follow-up of the HPTN 071 (PopART) Population Cohort. HIV-1-negative participants at enrollment (n = 492) were included in this analysis, with testing to confirm incident HIV-1 performed in HPTN 071 (PopART). The association of incident HIV-1 infection with FGS (Schistosoma DNA detected by polymerase chain reaction [PCR] in any genital specimen) was assessed with exact Poisson regression.

Results

Incident HIV-1 infections were observed in 4.1% (20/492) of participants. Women with FGS were twice as likely to seroconvert as women without FGS but with no statistical evidence for a difference (adjusted rate ratio, 2.16; 95% CI, 0.21–12.30; P = .33). Exploratory analysis suggested an association with HIV-1 acquisition among women with ≥2 positive genital PCR specimens (rate ratio, 6.02; 95% CI, 0.58–34.96; P = .13).

Conclusions

Despite higher HIV seroconversion rates in women with FGS, there was no statistical evidence of association, possibly due to low power. Further longitudinal studies should investigate this association in a setting with higher schistosomiasis endemicity.

Impact of human immunodeficiency virus on pulmonary vascular disease

With the advent of anti-retroviral therapy, non-AIDS-related comorbidities have increased in people living with HIV. Among these comorbidities, pulmonary hypertension (PH) is one of the most common causes of morbidity and mortality. Although chronic HIV-1 infection is independently associated with the development of pulmonary arterial hypertension, PH in people living with HIV may also be the outcome of various co-morbidities commonly observed in these individuals including chronic obstructive pulmonary disease, left heart disease and co-infections. In addition, the association of these co-morbidities and other risk factors, such as illicit drug use, can exacerbate the development of pulmonary vascular disease. This review will focus on these complex interactions contributing to PH development and exacerbation in HIV patients. We also examine the interactions of HIV proteins, including Nef, Tat, and gp120 in the pulmonary vasculature and how these proteins alter the endothelial and smooth muscle function by transforming them into susceptible PH phenotype. The review also discusses the available infectious and non-infectious animal models to study HIV-associated PAH, highlighting the advantages and disadvantages of each model, along with their ability to mimic the clinical manifestations of HIV-PAH.

Schistosomiasis with a Focus on Africa

Schistosomiasis is a common neglected tropical disease of impoverished people and livestock in many developing countries in tropical Africa, the Middle East, Asia, and Latin America. Substantial progress has been made in controlling schistosomiasis in some African countries, but the disease still prevails in most parts of sub-Saharan Africa with an estimated 800 million people at risk of infection. Current control strategies rely primarily on treatment with praziquantel, as no vaccine is available; however, treatment alone does not prevent reinfection. There has been emphasis on the use of integrated approaches in the control and elimination of the disease in recent years with the development of health infrastructure and health education. However, there is a need to evaluate the present status of African schistosomiasis, primarily caused by Schistosoma mansoni and S. haematobium, and the factors affecting the disease as the basis for developing more effective control and elimination strategies in the future. This review provides an historical perspective of schistosomiasis in Africa and discusses the current status of control efforts in those countries where the disease is endemic.

Male Genital Schistosomiasis Along the Shoreline of Lake Malawi: Baseline Prevalence and Associated Knowledge, Attitudes and Practices Among Local Fishermen in Mangochi District, Malawi

Male genital schistosomiasis (MGS) is an often-overlooked chronic consequence of urogenital schistosomiasis (UGS) associated with Schistosoma haematobium eggs and associated pathologies in the genital system of afflicted men. Despite the first formal description of MGS in 1911 by Madden, its epidemiology, diagnostic testing and case management of today are not well-described. However, since several interactions between MGS and the Human Immunodeficiency Virus (HIV) are known, there is renewed public health interest in MGS across sub-Saharan Africa (SSA). To shed new light upon MGS in Malawi, a longitudinal cohort study was set up among fishermen along the southern shoreline of Lake Malawi in Mangochi District, Malawi, to document its prevalence and assess mens' knowledge, attitudes and practices (KAP). After providing informed written consent, fishermen (n = 376) aged 18+ years (median age: 30 years, range: 18-70 years) were recruited and submitted urine and semen for point-of-care (POC) field and laboratory diagnostic parasitological tests. Individual questionnaires were administered to assess their KAP, with praziquantel (PZQ) treatment provided to all participants. Baseline prevalence of MGS (S. haematobium eggs in semen) was 10.4% (n = 114, median: 5.0 eggs per ml, range: 0.1-30.0) while for UGS (S. haematobium eggs in urine) was 17.1% (n = 210, median: 2.3 eggs per 10 ml, range: 0.1-186.0) and 3.8% were positive by POC circulating cathodic antigen (POC-CCA), indicative of a Schistosoma mansoni infection. Just under 10% of participants reported having experienced symptoms associated with MGS, namely genital or coital pain, or haemospermia. A total of 61.7% reported previous difficulties in accessing PZQ therapy, with 34.8% having received PZQ therapy before. There was a significant correlation between MGS infection and the frequency of fishing in a week (rho = -0.25, n = 100, p = 0.01). In conclusion, MGS is prevalent among local fishermen yet knowledge of the disease is poor. We therefore call for improved availability and accessibility to MGS diagnostics, PZQ treatment within ongoing control interventions. This will improve the lives and reproductive health of men, their partners and communities in this shoreline environment of Lake Malawi.

Effects of schistosomes on host anti-viral immune response and the acquisition, virulence, and prevention of viral infections: A systematic review

Although a growing number of studies suggest interactions between Schistosoma parasites and viral infections, the effects of schistosome infections on the host response to viruses have not been evaluated comprehensively. In this systematic review, we investigated how schistosomes impact incidence, virulence, and prevention of viral infections in humans and animals. We also evaluated immune effects of schistosomes in those coinfected with viruses. We screened 4,730 studies and included 103. Schistosomes may increase susceptibility to some viruses, including HIV and Kaposi’s sarcoma-associated herpesvirus, and virulence of hepatitis B and C viruses. In contrast, schistosome infection may be protective in chronic HIV, Human T-cell Lymphotropic Virus-Type 1, and respiratory viruses, though further research is needed. Schistosome infections were consistently reported to impair immune responses to hepatitis B and possibly measles vaccines. Understanding the interplay between schistosomes and viruses has ramifications for anti-viral vaccination strategies and global control of viral infections.

Many studies have described the effects of parasitic Schistosoma worm infections on the way that humans and animals respond to a variety of viral infections. Our goal was to evaluate, in a systematic manner, how having a schistosome parasitic infection affects a host’s susceptibility to viral infections, the clinical disease course of viral infections, and prevention of viral infections by vaccines. We also assessed the effects of schistosome infection on the host immune response to viruses. We screened 4,730 studies for potential relevance and included 103 of them in this review. Overall, our analysis showed that schistosome infection impairs the host response to many viruses. This includes increasing host susceptibility to HIV and possibly Kaposi’s sarcoma-associated herpesvirus, worsening the severity of clinical disease in hepatitis B and C infections, and decreasing immune responses to vaccines for hepatitis B and possibly measles. The studies that we analyzed also suggested that schistosome infection may protect the host against poor clinical outcomes from some viral infections including Human T-cell Lymphotropic Virus-Type 1, respiratory viruses, and chronic HIV. We discuss how these findings might be interpreted, and the additional research needed, in order to improve anti-viral vaccination strategies and control of viral infections globally.

Mapping Schistosoma haematobium for Novel Interventions against Female Genital Schistosomiasis and Associated HIV Risk in KwaZulu-Natal, South Africa

Women with female genital schistosomiasis (FGS) have been found to have genital symptoms and a three-fold higher risk of HIV infection. Despite WHO recommendations, regular antischistosomal mass drug administration (MDA) has not yet been implemented in South Africa possibly because of the lack of updated epidemiological data. To provide data for future prevention efforts against FGS and HIV, this study explored Schistosoma haematobium prevalence in girls and young women and the effects of antischistosomal MDA, respectively. Urinary schistosomiasis and genital symptoms were investigated in 70 randomly selected secondary schools in three districts within KwaZulu-Natal and 18 primary schools. All study participants were treated for schistosomiasis, and schools with the highest urinary prevalence were followed up after 1 and 4 years of MDA. At baseline, urine analysis data showed that most schools were within the moderate-risk prevalence category where biennial antischistosomal MDA is recommended, as per WHO guidelines. Young women had high prevalence of genital symptoms (36%) after correcting for sexually transmitted infections. These symptoms may be caused by infection with schistosomes. However, FGS cannot be diagnosed by urine analysis alone. In KwaZulu-Natal rural schools, this study suggests that antischistosomal MDA with praziquantel could prevent genital symptoms in more than 200,000 young women. Furthermore, it is feasible that more than 5,000 HIV infections could be prevented in adolescent girls and young women by treatment and prevention of FGS.

Cervicovaginal bacterial communities in reproductive-aged Tanzanian women with Schistosoma mansoni, Schistosoma haematobium, or without schistosome infection

Schistosome infection is recognized as a potentially modifiable risk factor for HIV in women by the World Health Organization. Alterations in cervicovaginal bacteria have been associated with HIV acquisition and have not been studied in schistosome infection. We collected cervical swabs from Tanzanian women with and without S. mansoni and S. haematobium to determine effects on cervicovaginal microbiota. Infected women were treated, and follow-up swabs were collected after 3 months. 16S rRNA sequencing was performed on DNA extracted from swabs. We compared 39 women with S. mansoni with 52 uninfected controls, and 16 with S. haematobium with 27 controls. S. mansoni-infected women had increased abundance of Peptostreptococcus (p = 0.026) and presence of Prevotella timonesis (p = 0.048) compared to controls. High-intensity S. haematobium infection was associated with more diverse cervicovaginal bacterial communities than uninfected controls (p = 0.0159). High-intensity S. mansoni infection showed a similar trend (p = 0.154). At follow-up, we observed increased alpha diversity in S. mansoni (2.53 vs. 1.72, p = 0.022) and S. haematobium (2.05 vs. 1.12, p = 0.066) infection groups compared to controls. Modifications in cervicovaginal microbiota, particularly increased diversity and abundance of taxa associated with bacterial vaginosis and HIV (Peptostreptococcus, Prevotella), were associated with schistosome infection.

Macroscopic and microscopic imaging modalities for diagnosis and monitoring of urogenital schistosomiasis

Urogenital schistosomiasis remains a major global challenge. Optimal management of this infection depends upon imaging-based assessment of sequelae. Although established imaging modalities such as ultrasonography, plain radiography, magnetic resonance imaging (MRI), narrow band imaging, and computerized tomography (CT) have been used to determine tissue involvement by urogenital schistosomiasis, newer refinements in associated technologies may lead to improvements in patient care. Moreover, application of investigational imaging methods such as confocal laser endomicroscopy and two-photon microscopy in animal models of urogenital schistosomiasis are likely to contribute to our understanding of this infection's pathogenesis. This review discusses prior use of imaging in patients with urogenital schistosomiasis and experimentally infected animals, the advantages and limitations of these modalities, the latest radiologic developments relevant to this infection, and a proposed future diagnostic standard of care for management of afflicted patients.

Cervicovaginal Immune Activation in Zambian Women With Female Genital Schistosomiasis

HIV-1 infection disproportionately affects women in sub-Saharan Africa, where areas of high HIV-1 prevalence and Schistosoma haematobium endemicity largely overlap. Female genital schistosomiasis (FGS), an inflammatory disease caused by S. haematobium egg deposition in the genital tract, has been associated with prevalent HIV-1 infection. Elevated levels of the chemokines MIP-1α (CCL-3), MIP-1β (CCL-4), IP-10 (CXCL-10), and IL-8 (CXCL-8) in cervicovaginal lavage (CVL) have been associated with HIV-1 acquisition. We hypothesize that levels of cervicovaginal cytokines may be raised in FGS and could provide a causal mechanism for the association between FGS and HIV-1. In the cross-sectional BILHIV study, specimens were collected from 603 female participants who were aged 18–31 years, sexually active, not pregnant and participated in the HPTN 071 (PopART) HIV-1 prevention trial in Zambia. Participants self-collected urine, and vaginal and cervical swabs, while CVLs were clinically obtained. Microscopy and Schistosoma circulating anodic antigen (CAA) were performed on urine. Genital samples were examined for parasite-specific DNA by PCR. Women with FGS (n=28), defined as a positive Schistosoma PCR from any genital sample were frequency age-matched with 159 FGS negative (defined as negative Schistosoma PCR, urine CAA, urine microscopy, and colposcopy imaging) women. Participants with probable FGS (n=25) (defined as the presence of either urine CAA or microscopy in combination with one of four clinical findings suggestive of FGS on colposcope-obtained photographs) were also included, for a total sample size of 212. The concentrations of 17 soluble cytokines and chemokines were quantified by a multiplex bead-based immunoassay. There was no difference in the concentrations of cytokines or chemokines between participants with and without FGS. An exploratory analysis of those women with a higher FGS burden, defined by ≥2 genital specimens with detectable Schistosoma DNA (n=15) showed, after adjusting for potential confounders, a higher Th2 (IL-4, IL-5, and IL-13) and pro-inflammatory (IL-15) expression pattern in comparison to FGS negative women, with differences unlikely to be due to chance (p=0.037 for IL-4 and p<0.001 for IL-5 after adjusting for multiple testing). FGS may alter the female genital tract immune environment, but larger studies in areas of varying endemicity are needed to evaluate the association with HIV-1 vulnerability.

Effect of methyl gallate on immune response of Biomphalaria alexandrina (Ehrenberg, 1831) snails to infection with Schistosoma mansoni (Sambon, 1907)

Schistosomiasis still affects a lot of people in many developing countries. Reducing the disease dissemination has been the target of various studies. As methyl gallate has antioxidant properties, it is assumed that it can be a good candidate for stimulating the immune response of snails. So, the aim of this work is to investigate the potential of using methyl gallate as an immunostimulant to Biomphalaria alexandrina snails in order to prevent the development of invading miracidia into infective cercariae. The infected snails were exposed to three concentrations of methyl gallate for two periods: 24 and 72 h. The results indicated that the most effective concentration was the lowest one: 125 mg/L of methyl gallate for 72 h, as it reduced both infection rate and mean number of shed cercariae. Also, it increased the total number of snails' hemocytes in hemolymph, which were observed in head-foot region and digestive gland of treated snails surrounding degenerated sporocysts and cercariae. In addition, hydrogen peroxide showed its highest content in tissues of snails exposed to 125 mg/L of methyl gallate for 72 h. In conclusion, methyl gallate can be considered as one of the most promising immunostimulants of B. alexandrina snails against infection with Schistosoma mansoni.

Female Genital Schistosomiasis (FGS) in Cameroon: A formative epidemiological and socioeconomic investigation in eleven rural fishing communities

BACKGROUND

Female Genital Schistosomiasis (FGS) is most often caused by presence of Schistosoma haematobium eggs lodged in the female reproductive tract which results in chronic fibrosis and scarring. In Cameroon, despite high community prevalences of urine-patent S. haematobium infections, FGS has yet to be studied in depth. To shed light on the clinical prevalence and socioeconomic effects of FGS, we undertook a formative community-based epidemiological and qualitative survey.

METHOD

A cross sectional multidisciplinary study of 304 girls and women from 11 remote rural fishing communities in Cameroon was undertaken using parasitological sampling, clinical colposcopy, and interviews. The lived experiences of those with FGS were documented using a process of ethnography with participant observation and in-depth interviews.

RESULT

Amongst 304 women and girls aged >5 years (Median age: 18; Interquartile range: 9.6-28), 198 females were eligible for FGS testing and 58 adult women were examined by clinical colposcopy. Of these, 34 were positive for FGS (proportion: 58.6%; 95% CI: 45.8-70.4), younger girls showing a higher FGS prevalence, and older women not shedding eggs showing a pattern for cervical lesions from earlier infection. In a subset of women with FGS selected purposively (12/58), in-depth interviews with participant observation revealed out-of-pocket expenditures of up to 500USD related health spending for repeated diagnosis and treatment of gynecological illnesses, and 9 hours daily lost reproductive labour. Psychosocial unrest, loss in social capital, and despair were linked with sub-fertility and persistent vaginal itch.

CONCLUSION

With our first formative evidence on prevalence, socioeconomic effects and experiences of FGS amongst women and girls in Cameroon, we have clarified to a new level of detail the deficit in provision of and access to peripheral health services in remote areas of Cameroon. Using this information, there is now strong evidence for national programs and services on women's health and schistosomiasis to update and revise policies targeted on prevention and management of FGS. We therefore stress the need for regular provision of Praziquantel treatment to adolescent girls and women in S. haematobium endemic areas, alongside better access to tailored diagnostic services that can detect FGS and appropriately triage care at primary health level.

Impact of Helminth Infections on Female Reproductive Health and Associated Diseases

A growing body of knowledge exists on the influence of helminth infections on allergies and unrelated infections in the lung and gastrointestinal (GI) mucosa. However, the bystander effects of helminth infections on the female genital mucosa and reproductive health is understudied but important considering the high prevalence of helminth exposure and sexually transmitted infections in low- and middle-income countries (LMICs). In this review, we explore current knowledge about the direct and systemic effects of helminth infections on unrelated diseases. We summarize host disease-controlling immunity of important sexually transmitted infections and introduce the limited knowledge of how helminths infections directly cause pathology to female reproductive tract (FRT), alter susceptibility to sexually transmitted infections and reproduction. We also review work by others on type 2 immunity in the FRT and hypothesize how these insights may guide future work to help understand how helminths alter FRT health.

Association of schistosomiasis and HIV infections: A systematic review and meta-analysis

Background:

Female genital schistosomiasis (FGS) affects up to 56 million women in sub-Saharan Africa and may increase risk of HIV infection.

Methods:

To assess the association of schistosomiasis with HIV infection, peer-reviewed literature published until 31 December 2018 was examined and a pooled estimate for the odds ratio was generated using Bayesian random effects models.

Results:

Of the 364 abstracts that were identified, 26 were included in the summary. Eight reported odds ratios of the association between schistosomiasis and HIV; one reported a transmission hazard ratio of 1.8 (95% CI, 1.2–2.6) among women and 1.4 (95% CI, 1.0–1.9) among men; 11 described the prevalence of schistosomiasis among HIV-positive people (range, 1.5–36.6%); and six reported the prevalence of HIV among people with schistosomiasis (range, 5.8–57.3%). Six studies were selected for quantitative analysis. The pooled estimate for the odds ratio of HIV among people with schistosomiasis was 2.3 (95% CI, 1.2–4.3).

Conclusions:

A significant association of schistosomiasis with HIV was found. However, a specific summary estimate for FGS could not be generated. A research agenda was provided to determine the effect of FGS on HIV infection. The WHO’s policy on mass drug administration for schistosomiasis may prevent HIV.

Acceptability and feasibility of genital self-sampling for the diagnosis of female genital schistosomiasis: a cross-sectional study in Zambia

Background: Female genital schistosomiasis (FGS) is a neglected and disabling gynaecological disorder that is difficult to diagnose and is part of the wider spectrum of urogenital disease caused by the waterborne parasite  Schistosoma haematobium. Over 90% of human schistosomiasis cases are found in sub-Saharan Africa with 3.8 million people infected with schistosomes in Zambia. Reported FGS prevalence ranges from 33-75% of those with urinary schistosomiasis in endemic areas, suggesting a potentially high FGS burden in Zambia alone. The Bilharzia and HIV

(BILHIV) study evaluated home self-sampling genital collection methods for the diagnosis of FGS.

Methods: Eligible participants included non-pregnant, sexually active women aged 18-31 who were previously recruited for the HPTN 071

(PopART) trial in Livingstone, Zambia. Household demographic and symptom questionnaires were administered by community workers. Participants were offered vaginal and cervical self-swabs and a urine cup. Cervicovaginal lavage (CVL) was performed in clinic by midwives. Information was collected from participants on the acceptability and feasibility of genital self-sampling.

Results: From January-August 2018, 603 women were enrolled, and 87.3% (527/603) completed clinic follow up. A high proportion of participants indicated that self-collection of specimens was “easy” or “very easy” on a 5-point Likert scale. A high proportion of women would be willing to self-collect all three specimens again in future: vaginal swab 96.7%

(583/603), cervical swab 96.5% (582/603), and urine 96.2% (580/603). Overall, 90.0% (543/603) preferred to self-collect samples at home, compared with sampling in the clinic Home-based self-sampling was preferred over provider-based sampling in the clinic due to greater privacy 65.0% (353/543), convenience 51.4% (279/543) and lack of needed transportation 17.7% (96/543).

Conclusions: Home based genital self-sampling for FGS diagnosis is highly acceptable. This scalable method may inform future efforts for community-based diagnosis of FGS

Beyond the barrier: Female Genital Schistosomiasis as a potential risk factor for HIV-1 acquisition

Female genital schistosomiasis (FGS) results from egg-deposition in the female reproductive tract primarily by the waterborne parasite Schistosoma (S.) haematobium, and less commonly by Schistosoma (S.) mansoni. FGS affects an estimated 20-56 million women worldwide, mostly in sub-Saharan Africa. There is cross-sectional evidence of increased HIV-1 prevalence in schistosomiasis-infected women, but a causal relationship between FGS and either HIV-1 acquisition or transmission has not been fully established. Beyond the pathognomonic breach in the cervicovaginal barrier caused by FGS, this narrative review explores potential mechanisms for a synergistic relationship between S. haematobium infection, FGS, and HIV-1 acquisition through vaginal inflammation and target cell recruitment.

Schistosoma haematobium infection and environmental factors in Southwestern Tanzania: A cross-sectional, population-based study

Schistosomiasis is a leading cause of morbidity in Africa. Understanding the disease ecology and environmental factors that influence its distribution is important to guide control efforts. Geographic information systems have increasingly been used in the field of schistosomiasis environmental epidemiology. This study reports prevalences of Schistosoma haematobium infection and uses remotely sensed and questionnaire data from over 17000 participants to identify environmental and socio-demographic factors that are associated with this parasitic infection. Data regarding socio-demographic status and S. haematobium infection were obtained between May 2006 and May 2007 from 17280 participants (53% females, median age = 17 years) in the Mbeya Region, Tanzania. Combined with remotely sensed environmental data (vegetation cover, altitude, rainfall etc.) this data was analyzed to identify environmental and socio-demographic factors associated with S. haematobium infection, using mixed effects logistic regression and geostatistical modelling. The overall prevalence of S. haematobium infection was 5.3% (95% confidence interval (CI): 5.0-5.6%). Multivariable analysis revealed increased odds of infection for school-aged children (5-15 years, odds ratio (OR) = 7.8, CI: 5.9-10.4) and the age groups 15-25 and 25-35 years (15-25 years: OR = 5.8, CI: 4.3-8.0, 25-35 years: OR = 1.6, CI: 1.1-2.4) compared to persons above 35 years of age, for increasing distance to water courses (OR = 1.4, CI: 1.2-1.6 per km) and for proximity to Lake Nyasa (<1 km, OR = 4.5, CI: 1.8-11.4; 1-2 km, OR = 3.5, CI: 1.7-7.5; 2-4 km; OR = 3.3, CI: 1.7-6.6), when compared to distances >4 km. Odds of infection decreased with higher altitude (OR = 0.7, CI: 0.6-0.8 per 100 m increase) and with increasing enhanced vegetation index EVI (OR = 0.2, CI: 0.1-0.4 per 0.1 units). When additionally adjusting for spatial correlation population density became a significant predictor of schistosomiasis infection (OR = 1.3, CI: 1.1-1.5 per 1000 persons/km2) and altitude turned non-significant. We found highly focal geographical patterns of S. haematobium infection in Mbeya Region in Southwestern Tanzania. Despite low overall prevalence our spatially heterogeneous results show that some of the study sites suffer from a considerable burden of S. haematobium infection, which is related to various socio-demographic and environmental factors. Our results could help to design more effective control strategies in the future, especially targeting school-aged children living in low altitude sites and/or crowded areas as the persons at highest need for preventive chemotherapy.

Economic evaluations of human schistosomiasis interventions: a systematic review and identification of associated research needs

Background: Schistosomiasis is one of the most prevalent neglected tropical diseases (NTDs) with an estimated 229 million people requiring preventive treatment worldwide. Recommendations for preventive chemotherapy strategies have been made by the World Health Organization (WHO) whereby the frequency of treatment is determined by the settings prevalence. Despite recent progress, many countries still need to scale up treatment and important questions remain regarding optimal control strategies. This paper presents a systematic review of the economic evaluations of human schistosomiasis interventions. Methods: A systematic review of the literature was conducted on 22nd August 2019 using the PubMed (MEDLINE) and ISI Web of Science electronic databases. The focus was economic evaluations of schistosomiasis interventions, such as cost-effectiveness and cost-benefit analyses. No date or language stipulations were applied to the searches. Results: We identified 53 relevant health economic analyses of schistosomiasis interventions. Most studies related to Schistosoma japonicum followed by S. haematobium. Several studies also included other NTDs. In Africa, most studies evaluated preventive chemotherapy, whereas in China they mostly evaluated programmes using a combination of interventions (such as chemotherapy, snail control and health education). There was wide variation in the methodology and epidemiological settings investigated. A range of effectiveness metrics were used by the different studies. Conclusions: Due to the variation across the identified studies, it was not possible to make definitive policy recommendations. Although, in general, the current WHO recommended preventive chemotherapy approach to control schistosomiasis was found to be cost-effective. This finding has important implications for policymakers, advocacy groups and potential funders. However, there are several important inconsistencies and research gaps (such as how the health benefits of interventions are quantified) that need to be addressed to identify the resources required to achieve schistosomiasis control and elimination.

Aquatic macrophytes and macroinvertebrate predators affect densities of snail hosts and local production of schistosome cercariae that cause human schistosomiasis

Background

Schistosomiasis is responsible for the second highest burden of disease among neglected tropical diseases globally, with over 90 percent of cases occurring in African regions where drugs to treat the disease are only sporadically available. Additionally, human re-infection after treatment can be a problem where there are high numbers of infected snails in the environment. Recent experiments indicate that aquatic factors, including plants, nutrients, or predators, can influence snail abundance and parasite production within infected snails, both components of human risk. This study investigated how snail host abundance and release of cercariae (the free swimming stage infective to humans) varies at water access sites in an endemic region in Senegal, a setting where human schistosomiasis prevalence is among the highest globally.

Methods/Principal findings

We collected snail intermediate hosts at 15 random points stratified by three habitat types at 36 water access sites, and counted cercarial production by each snail after transfer to the laboratory on the same day. We found that aquatic vegetation was positively associated with per-capita cercarial release by snails, probably because macrophytes harbor periphyton resources that snails feed upon, and well-fed snails tend to produce more parasites. In contrast, the abundance of aquatic macroinvertebrate snail predators was negatively associated with per-capita cercarial release by snails, probably because of several potential sublethal effects on snails or snail infection, despite a positive association between snail predators and total snail numbers at a site, possibly due to shared habitat usage or prey tracking by the predators. Thus, complex bottom-up and top-down ecological effects in this region plausibly influence the snail shedding rate and thus, total local density of schistosome cercariae.

Conclusions/Significance

Our study suggests that aquatic macrophytes and snail predators can influence per-capita cercarial production and total abundance of snails. Thus, snail control efforts might benefit by targeting specific snail habitats where parasite production is greatest. In conclusion, a better understanding of top-down and bottom-up ecological factors that regulate densities of cercarial release by snails, rather than solely snail densities or snail infection prevalence, might facilitate improved schistosomiasis control.

Over 800 million people are at risk of schistosomiasis and environmental factors that regulate densities of cercariae parasites that infect humans remain poorly understood. We sampled a spatially extensive area at 36 water-access points in northern Senegal, and quantified densities of snail intermediate hosts, snail predators, and aquatic vegetation in each sample, as well as cercariae released from snails after they were brought to the laboratory. We found that the quantity of submerged aquatic vegetation, particularly Ceratophyllum spp., was positively associated with schistosome cercariae released per infected snail, and total potential cercariae released by the collected snails per water access site. In contrast, the abundance of aquatic predators near infected snails (in the same sweep) was negatively associated with the per-capita cercarial release by infected snails, but positively associated with total snail abundance per site. Additionally, snail densities and potential cercarial densities (estimated as the sum of cercariae released by all collected, infected snails at a site) were only weakly correlated, suggesting that snail densities alone might not accurately reflect total potential of those snails to emit schistosome cercariae. Overall, a better understanding of aquatic factors that can influence the production of schistosome cercariae under field conditions, rather than snail host abundance alone, might facilitate improvements in schistosomiasis monitoring and control.

Integration of prevention and control measures for female genital schistosomiasis, HIV and cervical cancer

Female genital schistosomiasis as a result of chronic infection with Schistosoma haematobium (commonly known as bilharzia) continues to be largely ignored by national and global health policy-makers. International attention for large-scale action against the disease focuses on whether it is a risk factor for the transmission of human immunodeficiency virus (HIV). Yet female genital schistosomiasis itself is linked to pain, bleeding and sub- or infertility, leading to social stigma, and is a common issue for women in schistosomiasis-endemic areas in sub-Saharan Africa. The disease should therefore be recognized as another component of a comprehensive health and human rights agenda for women and girls in Africa, alongside HIV and cervical cancer. Each of these three diseases has a targeted and proven preventive intervention: antiretroviral therapy and pre-exposure prophylaxis for HIV; human papilloma virus vaccine for cervical cancer; and praziquantel treatment for female genital schistosomiasis. We discuss how female genital schistosomiasis control can be integrated with HIV and cervical cancer care. Such a programme will be part of a broader framework of sexual and reproductive health and rights, women's empowerment and social justice in Africa. Integrated approaches that join up multiple public health programmes have the potential to expand or create opportunities to reach more girls and women throughout their life course. We outline a pragmatic operational research agenda that has the potential to optimize joint implementation of a package of measures responding to the specific needs of girls and women.

Genital self-sampling compared with cervicovaginal lavage for the diagnosis of female genital schistosomiasis in Zambian women: The BILHIV study

BACKGROUND

Given the potentially causal association of female genital schistosomiasis (FGS) with HIV-1 infection, improved diagnostics are urgently needed to scale-up FGS surveillance. The BILHIV (bilharzia and HIV) study assessed the performance of home-based self-collection methods (cervical and vaginal swabs) compared to cervicovaginal lavage (CVL) for the detection of Schistosoma DNA by real-time polymerase chain reaction (PCR).

METHODS

Between January and August 2018, a consecutive series of female participants from the Population-Cohort of the previous HIV prevention trial HPTN 071 (PopART), resident in Livingstone, Zambia were invited to take part in BILHIV if they were 18-31 years old, non-pregnant and sexually active. Genital self-collected swabs and a urine specimen were obtained and a questionnaire completed at home visits. CVL was obtained at clinic follow-up.

RESULTS

603 women self-collected genital swabs. Of these, 527 women had CVL performed by a mid-wife during clinic follow-up. Schistosoma DNA was more frequently detected in genital self-collected specimens (24/603, 4.0%) compared to CVL (14/527, 2.7%). Overall, 5.0% (30/603) women had female genital schistosomiasis, defined as a positive PCR by any genital sampling method (cervical swab PCR, vaginal swab PCR, or CVL PCR) and 95% (573/603) did not have a positive genital PCR. The sensitivity of any positive genital self-collected swab against CVL was 57.1% (95% CI 28.9-82.3%), specificity 97.3% (95.5-98.5%). In a subset of participants with active schistosome infection, determined by detectable urine Circulating Anodic Antigen (CAA) (15.1%, 91/601), positive PCR (4.3%, 26/601), or positive microscopy (5.5%, 33/603), the sensitivity of any positive self-collected specimen against CVL was 88.9% (51.8-99.7%).

CONCLUSIONS

Genital self-sampling increased the overall number of PCR-based FGS diagnoses in a field setting, compared with CVL. Home-based sampling may represent a scalable alternative method for FGS community-based diagnosis in endemic resource limited settings.

Interactions of Schistosoma and HIV in Sub-Saharan Africa: A Systematic Review

Schistosomiasis is an acute and chronic parasitic disease caused by blood flukes of the genus Schistosoma. More than 220 million people worldwide were estimated to have active schistosomiasis in 2017, 90% of whom live on the African continent, but only 102 million were reported to have received treatment. Africa is also disproportionately burdened by HIV, with an estimated 26 million people living with HIV in 2017. Given these overlapping epidemics, we conducted a systematic review to ascertain the contribution of schistosomes to HIV acquisition risk, the contribution of HIV to schistosome acquisition, the impact of HIV on schistosomiasis-related morbidity, the impact of schistosomes on HIV disease progression and immune response, the impact of HIV on the efficacy of praziquantel treatment, and the impact of HIV on egg shedding. We reviewed studies of people living in sub-Saharan Africa coinfected with HIV and Schistosoma spp. between January 1996 and July 2018. We found that 1) infection with Schistosoma haematobium increases the risk of HIV acquisition, 2) there is currently a lack of data on whether HIV infection increases the risk of Schistosoma acquisition, 3a) HIV coinfection was not an accelerating factor for adverse Schistosoma outcomes, 3b) schistosomiasis may be an important contributor to immune activation in HIV coinfected people, 4) praziquantel use in coinfected people may improve immune reconstitution on antiretroviral therapy for HIV, and 5) there is evidence that HIV infection reduces egg excretion in individuals infected with Schistosoma mansoni.

A systematic review and meta-analysis to assess the association between urogenital schistosomiasis and HIV/AIDS infection

Background

Urogenital schistosomiasis and HIV/AIDS infections are widespread in sub-Saharan Africa (SSA) leading to substantial morbidity and mortality. The co-occurrence of both diseases has led to the possible hypothesis that urogenital schistosomiasis leads to increased risk of acquiring HIV infection. However, the available evidence concerning this association is inconsistent. The aim of this study was to systematically review and quantitatively synthesize studies that investigated the association between urogenital schistosomiasis and HIV/AIDS infection.

Methods

A systematic review basing on PRISMA guidelines was conducted. It is registered with PROSPERO, number CRD42018116648. We searched four databases, MEDLINE, EMBASE, Global Health and Global Index Medicus for studies investigating the association between urogenital schistosomiasis and HIV infection. Only studies published in English were considered. Results of the association were summarised by gender. A meta-analysis was performed for studies on females using random-effects model and a pooled OR with 95% confidence interval was reported.

Results

Of the 993 studies screened, only eight observational studies met the inclusion criteria. Across all studies, the reported unadjusted OR ranged from 0.78 to 3.76. The pooled estimate of unadjusted OR among females was 1.31 (95% CI: 0.87–1.99). Only four of the eight studies reported an adjusted OR. A separate meta-analysis done in the three studies among females that reported an adjusted OR showed that the pooled estimate was 1.85 (95% CI: 1.17–2.92). There were insufficient data to pool results for association between urogenital schistosomiasis and HIV infection in the males.

Conclusion

Our investigation supports the hypothesis of an association between urogenital schistosomiasis with HIV/AIDS infection in females. Due to insufficient evidence, no conclusion could be drawn in males with urogenital schistosomiasis. Large-scale prospective studies are needed in future.

Urogenital schistosomiasis, caused by parasitic trematode Schistosoma haematobium is a significant source of morbidity in sub Saharan Africa. HIV infection caused by a retrovirus is of two subtypes HIV 1 and HIV 2, with subtype HIV 1 being found worldwide and more aggressive, leading to HIV/AIDS. Research on both of these diseases in the same settings, has shown that these diseases cross paths. This has led to the suggestion that there could be a possible association between the two. Here we describe a systematic review that was carried out to determine if there is an association between UGS and HIV/AIDS infections. We searched all published articles available in MEDLINE, EMBASE, Global Health (CABI), and Global Index Medicus before 28^th January 2020. We found eight observational studies eligible to be included in the systematic review and no intervention study. Six of these studies were included in the meta-analysis. A summarized meta-analysis of the study findings with adjusted OR showed that there was a likely association between urogenital schistosomiasis and HIV/AIDS infections in females. However, due to limited papers in males, no conclusion could be drawn.

The cost of a school based mass treatment of schistosomiasis in Ugu District, KwaZulu Natal, South Africa in 2012

INTRODUCTION

The Neglected Tropical Diseases Roadmap of the WHO set targets for potential elimination as a "public health problem" for the period 2012-2020 in multiple countries in Africa, with the aim of global elimination of schistosomiasis as a "public health problem" by 2025.

AIM

The purpose of the study was to estimate the cost from a provider's perspective of the Department of Health's Schistosomiasis Mass Drug Administration (MDA) in Ugu District, KwaZulu-Natal in 2012, with a view to project the costs for the entire KwaZulu Natal Province.

METHODS

A total of 491 public schools and 16 independent schools in Ugu District, a predominantly rural district in KwaZulu-Natal with a total of 218 242 learners, were included in the schistosomiasis control programme. They were randomly selected from schools situated below an altitude of 300 meters, where schistosomiasis is endemic. A retrospective costing study was conducted using the provider's perspective to cost. Cost data were collected by reviewing existing records including financial statements, invoices, receipts, transport log books, equipment inventories, and information from personnel payroll, existing budget, and the staff diaries.

RESULTS

A total of 15571 children were treated in 2012, resulting in a total cost of the MDA programme of ZAR 2 137 143 and a unit cost of ZAR 137. The three main cost components were Medication Costs (37%), Human Resources Cost (36%) and Capital items (16%). The total cost for treating all eligible pupils in KwaZulu-Natal will be ZAR 149 031 888. However, should the capital cost be excluded, then the unit cost will be ZAR 112 per patient and this will translate to a total cost of ZAR 121 836 288.

CONCLUSIONS

Low coverage exacerbates the cost of the programme and makes a decision to support such a programme difficult. However, a normative costing study based on the integration of the programme within the Department of Health should be conducted.

Associations between schistosomiasis and HIV-1 acquisition risk in four prospective cohorts: a nested case-control analysis

INTRODUCTION

Globally, schistosomes infect approximately 200 million people, with 90% of infections in sub-Saharan Africa. Schistosomiasis is hypothesized to increase HIV-1 acquisition risk, and multiple cross-sectional studies reported strong associations. We evaluated this hypothesis within four large prospective cohorts.

METHODS

We conducted nested case-control analyses within three longitudinal cohorts of heterosexual HIV-1 serodiscordant couples and one female sex worker (FSW) cohort from Kenya and Uganda. The serodiscordant couples studies were conducted between 2004 and 2012 while the FSW cohort analysis included participant follow-up from 1993 to 2014. Cases HIV-1 seroconverted during prospective follow-up; three controls were selected per case. The presence of circulating anodic antigen in archived serum, collected prior to HIV-1 seroconversion, identified participants with active schistosomiasis; immunoblots determined the schistosome species. Data from serodiscordant couples cohorts were pooled, while the FSW cohort was analysed separately to permit appropriate confounder adjustment.

RESULTS

We included 245 HIV-1 seroconverters and 713 controls from the serodiscordant couples cohorts and 330 HIV-1 seroconverters and 962 controls from the FSW cohort. The prevalence of active schistosomiasis was 20% among serodiscordant couples and 22% among FSWs. We found no association between schistosomiasis and HIV-1 acquisition risk among males (adjusted odds ratio (aOR) = 0.99, 95% CI 0.59 to 1.67) or females (aOR = 1.21, 95% CI 0.64 to 2.30) in serodiscordant couples. Similarly, in the FSW cohort we detected no association (adjusted incidence rate ratio (aIRR) = 1.11, 95% CI 0.83 to 1.50). Exploring schistosome species-specific effects, there was no statistically significant association between HIV-1 acquisition risk and Schistosoma mansoni (serodiscordant couples: aOR = 0.90, 95% CI 0.56 to 1.44; FSW: aIRR = 0.83, 95% CI 0.53 to 1.20) or Schistosoma haematobium (serodiscordant couples: aOR = 1.06, 95% CI 0.46 to 2.40; FSW: aIRR = 1.64, 95% CI 0.93 to 2.87) infection.

CONCLUSIONS

Schistosomiasis was not a strong risk factor for HIV-1 acquisition in these four prospective studies. S. mansoni was responsible for the majority of schistosomiasis in these cohorts, and our results do not support the hypothesis that S. mansoni infection is associated with increased HIV-1 acquisition risk. S. haematobium infection was associated with a point estimate of elevated HIV-1 risk in the FSW cohort that was not statistically significant, and there was no trend towards a positive association in the serodiscordant couples cohorts.

Schistosomiasis Control: Leave No Age Group Behind

Despite accelerating progress towards schistosomiasis control in sub-Saharan Africa, several age groups have been eclipsed by current treatment and monitoring strategies that mainly focus on school-aged children. As schistosomiasis poses a threat to people of all ages, unfortunate gaps exist in current treatment coverage and associated monitoring efforts, preventing subsequent health benefits to preschool-aged children as well as certain adolescents and adults. Expanding access to younger ages through the forthcoming pediatric praziquantel formulation and improving treatment coverage in older ages is essential. This should occur alongside formal inclusion of these groups in large-scale monitoring and evaluation activities. Current omission of these age groups from treatment and monitoring exacerbates health inequities and has long-term consequences for sustainable schistosomiasis control.

Ecosyndemics: The potential synergistic health impacts of highways and dams in the Amazon

Ecosyndemics refer to disease interactions that result from environmental changes commonly caused by humans. In this paper, we push scholarship on ecosyndemics into new territory by using the ecosyndemic framework to compare two case studies-the Southern Interoceanic highway in Peru and the Belo Monte hydroelectric dam in Brazil-to assess the likelihood of socio-environmental factors interacting and leading to ill health in a syndemic fashion. Assessing these two case studies using an ecosyndemic perspective, we find that the construction of dams and highways in tropical forests create the conditions for increases in vector-borne illnesses, surges in sex work and sexually-transmitted infections, and increased psychological stress resulting from violence, delinquency, and the erosion of social cohesion. We suggest that these processes could interact synergistically to increase an individual's immune burden and a population's overall morbidity. However, we find differences in the impacts of the Interoceanic highway and the Belo Monte dam on food, water, and cultural systems, and observed that community and corporate-level actions may bolster health in the face of rapid socio-ecological change. Looking at the case studies together, a complex picture of vulnerability and resilience, risk and opportunity, complicates straight-forward predictions of ecosyndemic interactions resulting from these development projects but highlights the role that the ecosyndemic concept can play in informing health impact assessments and future research. We conclude by proposing a conceptual model of the potential interactions between psychological stress, vector-borne illnesses, and sexaully-transmitted infections and suggest that future investigations of synergistic interactions among these factors draw from the biological, social, and ecological sciences.

Acceptability and feasibility of genital self-sampling for the diagnosis of female genital schistosomiasis: a cross-sectional study in Zambia

Background: Female genital schistosomiasis (FGS) is a neglected and disabling gynaecological disorder that is difficult to diagnose and is part of the wider spectrum of urogenital disease caused by the waterborne parasite Schistosoma haematobium. Over 90% of human schistosomiasis cases are found in sub-Saharan Africa with 3.8 million people infected with schistosomes in Zambia. Reported FGS prevalence ranges from 33-75% of those with urinary schistosomiasis in endemic areas, suggesting a potentially high FGS burden in Zambia alone. The Bilharzia and HIV (BILHIV) study evaluated home self-sampling genital collection methods for the diagnosis of FGS. Methods: Eligible participants included non-pregnant, sexually active women aged 18-31 who were previously recruited for the HPTN 071 (PopART) trial in Livingstone, Zambia. Household demographic and symptom questionnaires were administered by community workers. Participants were offered vaginal and cervical self-swabs and a urine cup. Cervicovaginal lavage (CVL) was performed in clinic by midwives. Information was collected from participants on the acceptability and feasibility of genital self-sampling. Results: From January-August 2018, 603 women were enrolled, and 87.3% (527/603) completed clinic follow up. A high proportion of participants indicated that self-collection of specimens was “easy” or “very easy” on a 5-point Likert scale. A high proportion of women would be willing to self-collect all three specimens again in future: vaginal swab 96.7% (583/603), cervical swab 96.5% (582/603), and urine 96.2% (580/603). Home-based self-sampling was preferred over provider-based sampling in the clinic due to greater privacy 58.5% (353/603), convenience 46.3% (279/603) and need for transportation 15.9% (96/603). Conclusions: Home based genital self-sampling for FGS diagnosis is highly acceptable. This scalable method may inform future efforts for community-based diagnosis of FGS.