Chlamydia trachomatis and Neisseria gonorrhoeae in HIV-infected Pregnant Women and Adverse Infant Outcomes

Prevalence of bacterial vaginosis, sexually transmitted infections and their association with HPV infections in asymptomatic women attending antenatal care in Ethiopia

Sexually transmitted infections (STIs) and human papillomavirus (HPV) infections are common among women of reproductive age and can lead to infertility, adverse pregnancy outcomes, neonatal infections and cervical cancer. In countries with limited medical coverage, untreated infections contribute to high morbidity. This study aimed to expand the current knowledge on the prevalence of bacterial vaginosis (BV) and STIs in pregnant Ethiopian women and assess the association of these conditions with HPV infections. Socio-demographic data and vaginal lavage samples were collected from 779 asymptomatic women aged 18 to 45 years (median age, 25.9 years) attending antenatal care in seven centres across Ethiopia. Multiplex polymerase chain reaction was used to test for BV, Chlamydia trachomatis, Trichomonas vaginalis, Neisseria gonorrhoeae, herpes simplex virus types 1 and 2 (HSV-1/2), Mycoplasma, Ureaplasma, Candida species and HPV. Overall, 26.8% (95% confidence interval (CI): 23.7-29.9) of women tested positive for BV or one of the following STIs: C. trachomatis, T. vaginalis, N. gonorrhoeae, Mycoplasma genitalium, HSV-1/2 or Ureaplasma urealyticum. Additionally, 22.1% tested positive for at least one high-risk HPV type. Chlamydia trachomatis and HSV-2 were significantly more common among women who were positive for HPV and high-risk HPV. This study reveals a high prevalence of asymptomatic pregnant women who are positive for BV, STIs or HPV, putting them at risk of adverse pregnancy outcomes, secondary infertility or cervical cancer in a country with limited medical coverage. Screening and treating these women could be crucial in reducing morbidity.

Identifying the Impact of Chlamydia trachomatis Screening and Treatment on Mother-to-Child Transmission, and Respiratory Neonatal Outcomes in Mexico

Chlamydia trachomatis (C. trachomatis) screening and treatment in pregnancy allows the opportunity to reduce adverse pregnancy and neonatal outcomes worldwide. Although C. trachomatis infection is easily treated and cured with antibiotics, only some countries have routine pregnancy screening and treatment programs. We therefore evaluated whether just one maternal screening for C. trachomatis is enough to prevent adverse pregnancy and negative neonatal outcomes. Among the 4087 first-time gynecological-obstetric consultations granted at the National Institute of Perinatology in 2018, we selected the study population according to a case-cohort design. Antenatal C. trachomatis screening and treatment interventions were performed on 628 pregnant women using COBAS® TaqMan CT. C. trachomatis DNA was also detected in samples from 157 infants of these mothers. In the maternal cohort, incidence of C. trachomatis infection was 10.5%. The vertical transmission rate was 1.5% for the cohort of mothers who tested positive for C. trachomatis and received treatment, and 29.7% for those with a negative test. By evaluating symptomatic neonatal infection, the hazard rate of perinatal pneumonia was 3.6 times higher in C. trachomatis-positive babies than in C. trachomatis-negative babies. Despite the low rate of mother-to-child transmission in women positive for C. trachomatis, possible maternal infection that is not detected in pregnancy significantly increases the risk of neonatal infection with consequent perinatal pneumonia.

Feasibility and acceptability of sexually transmitted infection screening during antenatal care of women in Dhaka, Bangladesh

BACKGROUND

Sexually transmitted infections (STIs) are a major public health concern worldwide. Untreated STIs may have serious sequelae, particularly in pregnant women. The objective of this study was to assess the feasibility and acceptability of screening and treating common STIs in women during pregnancy in Bangladesh.

METHODS

Women were enrolled from four maternity clinics/hospitals serving the lower-middle class population in Dhaka, Bangladesh. The participants were interviewed, and vaginal swab samples were collected by clinical staff. Specimens were tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis and high-risk Human Papilloma Viruses (HPVs) using GeneXpert (Cepheid, Sunnyvale, California). Women were informed of their test results and were provided treatment for curable infections. A test of cure was performed.

RESULTS

Out of 1157 pregnant women approached, 1000 (86.4%) participated. Ninety-one percent women learned of their test results on the same day of testing. Out of the 996 valid results, 7 (0.7%) tested positive for Chlamydia trachomatis and 1 (0.1%) for Trichomonas vaginalis. There were no gonorrhoea cases. Out of the 971 women with valid results for high-risk HPVs, 46 (4.7%) tested positive.

CONCLUSIONS

Screening women for STIs during antenatal care was highly feasible and well-accepted in Bangladesh. While the prevalence of common curable STIs was very low, hrHPV infection prevalence was moderately high. Our findings support period monitoring of STIs and continued prevention efforts for cervical cancer in Bangladesh.

Prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Mycoplasma genitalium and risk factors among pregnant women in Brazil: Results from the national molecular diagnosis implementation project

BACKGROUND

Sexually transmitted infections (STIs) are a public health problem. The aim of the present study was to assess the prevalence and risk factors associated with at least one STI (Chlamydia trachomatis [CT], Neisseria gonorrhoeae [NG], Trichomonas vaginalis [TV], and Mycoplasma genitalium [MG]) in Brazil.

METHODS

A cross-sectional study was conducted using secondary data from the pilot implementation of the National Service for molecular diagnosis of CT, NG, TV, and MG in pregnancy. We obtained Ministry of Health surveillance data from the implementation project. Data encompassing pregnant women aged 15-49 years from public antenatal clinics in Brazil in 2022 were included.

RESULTS

A total of 2728 data of pregnant women were analyzed. The prevalence of at least one infection was 21.0% (573), with the highest prevalence in the Southeast region (23.3%) and the lowest in the Center-West region (15.4%). The prevalence of CT was 9.9% (270), NG 0.6% (16), TV 6.7% (184), and MG 7.8% (212). Factors associated with any infection were from 15 to 24 years (AOR = 1.93; 95% CI: 1.58-2.35); reported family income up to US$400 (AOR = 1.79; 95% CI: 1.03-3.34); declared not living maritally with their partners (AOR = 1.90, 95% CI: 1.52-2.37) and had more than one sexual partner in their lifetime (AOR = 2.09, 95% CI: 1.55-2.86).

CONCLUSION

This study showed a high prevalence of at least one STI among pregnant women in Brazil, particularly among younger women. It also provides up-to-date national data on CT, NG, TV, and MG infections in this population. These findings underscore the importance of enhancing access to STI screening for young pregnant women within the Brazilian public health system.

Trimethoprim-Sulfamethoxazole Plus Azithromycin to Prevent Malaria and Sexually Transmitted Infections in Pregnant Women With HIV (PREMISE): A Randomized, Double-Masked, Placebo-Controlled, Phase IIB Clinical Trial

Background

This trial tested the effectiveness of a novel regimen to prevent malaria and sexually transmitted infections (STIs) among pregnant women with HIV in Cameroon. Our hypothesis was that the addition of azithromycin (AZ) to standard daily trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis would reduce malaria and STI infection rates at delivery.

Methods

Pregnant women with HIV at gestational age <28 weeks were randomized to adjunctive monthly oral AZ 1 g daily or placebo for 3 days and both groups received daily standard oral TMP-SMX through delivery. Primary outcomes were (1) positive peripheral malaria infection by microscopy or polymerase chain reaction and (2) composite bacterial genital STI (Chlamydia trachomatis, Neisseria gonorrhoeae, or syphilis) at delivery. Relative risk and 95% confidence intervals were estimated using 2 × 2 tables with significance as P < .05.

Results

Pregnant women with HIV (n = 308) were enrolled between March 2018 and August 2020: 155 women were randomized to TMP-SMX-AZ and 153 women to TMP-SMX-placebo. Groups were similar at baseline and loss to follow up was 3.2%. There was no difference in the proportion with malaria (16.3% in TMP-SMX-AZ vs 13.2% in TMP-SMX; relative risk, 1.24 [95% confidence interval, .71-2.16]) or STI at delivery (4.2% in TMP-SMX-AZ vs 5.8% in TMP-SMX; relative risk, 0.72 [95% confidence interval, .26-2.03]). Adverse birth outcomes were not significantly different, albeit lower in the TMP-SMX-AZ arm (preterm delivery 6.7% vs 10.7% [P = .3]; low birthweight 3.4% vs 5.4% [P = .6]).

Conclusions

The addition of monthly azithromycin to daily TMP-SMX prophylaxis in pregnant women living with HIV in Cameroon did not reduce the risk of malaria or bacterial STI at delivery.

Prevalence and Predictors of Chlamydia trachomatis and Neisseria gonorrhoeae Among HIV-Negative Pregnant Women in Kenya

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections in pregnancy contribute to adverse perinatal outcomes. We identified predictors of CT and/or NG infection among pregnant Kenyan women.

METHODS

Women without HIV were enrolled at 2 antenatal clinics in Western Kenya. Both CT and NG were assessed using endocervical samples for nucleic acid amplification tests. Poisson regression models were used to evaluate potential CT/NG risk factors. Classification and regression trees were generated to evaluate the joint effects of predictors.

RESULTS

Overall, 1276 women had both CT and NG assessments. Women enrolled at a median of 26 weeks' gestation (interquartile range, 22-31 weeks), median age was 22 years (interquartile range, 19-27 years), and 78% were married. In total, 98 (7.7%) tested positive for CT/NG: 70 (5.5%) for CT and 32 (2.5%) for NG, 4 of whom (0.3%) had coinfections. Two-thirds (66%) of CT/NG cases were asymptomatic and would have been missed with only syndromic management. Risk factors of CT/NG included age <22 years, crowded living conditions, being unmarried, being in partnerships for <1 year, abnormal vaginal discharge, sexually transmitted infection history, and Trichomonas vaginalis diagnosis ( P < 0.1). Classification and regression tree analyses identified unmarried women <22 years in relationships for <1 year as 6.1 times more likely to have CT/NG compared with women without these characteristics (26% vs. 6%, adjusted prevalence ratio = 6.1, 95% confidence interval = 3.55-10.39, P < 0.001).

CONCLUSIONS

Chlamydia trachomatis / Neisseria gonorrhoeae was frequently asymptomatic and common among young unmarried women in newer partnerships in this cohort. Integrating CT/NG testing into routine antenatal care may be beneficial, especially for young women in Kenya.

Progesterone-mediated immunoregulation of cytokine signaling by miRNA-133a and 101-3p in Chlamydia trachomatis-associated recurrent spontaneous abortion

miRNAs regulate the expression of various genes involved in cellular and metabolic pathways in pregnancy related complications including recurrent spontaneous abortion (RSA). Modulation of progesterone and associated pro-inflammatory cytokines by miRNAs in Chlamydia trachomatis-associated RSA is still under investigation. Present study aimed to evaluate the expression/correlation of serum-circulating miRNAs-133a, 101-3p, 320b, 146b-5p, 24, 559, progesterone and few cytokines in C. trachomatis-positive spontaneous aborters. Non-heparinized blood and urine was collected from 120 patients with history of RSA (Group I) and 120 patients with ≥ 2 successful deliveries (Group II) attending Department of Obstetrics and Gynecology, Safdarjung hospital, New Delhi, India. C. trachomatis detection was performed by PCR and chlamydial load by real time PCR. Progesterone concentration was estimated by ELISA. miRNAs and cytokine expression was studied by quantitative real-time PCR and correlated with progesterone expression. Twenty six patients were found to be positive for C. trachomatis. miRNAs- 133a, 101-3p showed maximum upregulation in infected versus control patients. miRNA expression showed positive correlation with chlamydial load. Progesterone concentration showed significant decrease while cytokines (IL-6, IFN-γ, TNF-α) were significantly upregulated in C. trachomatis-positive patients. Positive correlation was observed between expression of miRNAs-133a and 101-3p and cytokines while negative correlation was observed with progesterone in infected RSA patients. Correlation between progesterone and cytokines was found to be significantly negative in infected RSA patients. Although further validation is required, the study concludes that miR-133a and 101-3p are of clinical importance and have a role in immunoregulation of progesterone and cytokines in infection associated RSA.

Vaccine value profile for cytomegalovirus

Cytomegalovirus (CMV) is the most common infectious cause of congenital malformation and a leading cause of developmental disabilities such as sensorineural hearing loss (SNHL), motor and cognitive deficits. The significant disease burden from congenital CMV infection (cCMV) led the US National Institute of Medicine to rank CMV vaccine development as the highest priority. An average of 6.7/1000 live births are affected by cCMV, but the prevalence varies across and within countries. In contrast to other congenital infections such as rubella and toxoplasmosis, the prevalence of cCMV increases with CMV seroprevalence rates in the population. The true global burden of cCMV disease is likely underestimated because most infected infants (85-90 %) have asymptomatic infection and are not identified. However, about 7-11 % of those with asymptomatic infection will develop SNHL throughout early childhood. Although no licensed CMV vaccine exists, several candidate vaccines are in development, including one currently in phase 3 trials. Licensure of one or more vaccine candidates is feasible within the next five years. Various models of CMV vaccine strategies employing different target populations have shown to provide substantial benefit in reducing cCMV. Although CMV can cause end-organ disease with significant morbidity and mortality in immunocompromised individuals, the focus of this vaccine value profile (VVP) is on preventing or reducing the cCMV disease burden. This CMV VVP provides a high-level, comprehensive assessment of the currently available data to inform the potential public health, economic, and societal value of CMV vaccines. The CMV VVP was developed by a working group of subject matter experts from academia, public health groups, policy organizations, and non-profit organizations. All contributors have extensive expertise on various elements of the CMV VVP and have described the state of knowledge and identified the current gaps. The VVP was developed using only existing and publicly available information.

Global prevalence of Neisseria gonorrhoeae infection in pregnant women: a systematic review and meta-analysis

BACKGROUND

Neisseria gonorrhoeae infection (gonorrhoea) is associated with several pregnancy complications, including preterm labour, spontaneous abortion, stillbirth, miscarriage, growth retardation, and intrauterine death.

OBJECTIVES

We performed a systematic review and meta-analysis to estimate the global and regional prevalence of gonorrhoea in pregnant women as a scientific basis for further studies.

DATA SOURCES

We systematically searched PubMed/MEDLINE, Web of Science, Embase, Scopus, and SciELO databases from inception to 10 July 2022.

STUDY ELIGIBILITY CRITERIA

We included cross-sectional, cohort, and case-control studies that reported the prevalence of gonorrhoea in pregnant women. In addition, we included baseline data for randomized controlled trials.

PARTICIPANTS

Pregnant women who were tested for gonorrhoea.

METHODS

Pooled prevalence estimates at 95% CIs were calculated using a random-effects meta-analysis model. We stratified countries according to WHO-defined regions and socio-economic factors. Moreover, sub-group-, meta-regression, and sensitivity analyses were conducted to investigate the effects of pre-determined factors on prevalence estimates and heterogeneity.

RESULTS

We identified 235 studies (249 datasets) on 19 104 175 pregnant women from 71 countries. The worldwide pooled prevalence of gonorrhoea in pregnant women was estimated at 1.85% (95% CI 1.73-1.97%), with the highest rate in the African region (3.53%) (2.84-4.29%) and the lowest rate in the European region (0.52%) (0.27-0.84%). Overall, the prevalence estimates were high among low-income countries (3.03%), pregnant women with HIV (2.81%), and pregnant women <20 years old (8.06%). A significant decreasing trend in prevalence was observed over time (β = -0.0008, 95% CI -0.0012 to -0.0004, p 0.001).

DISCUSSION

Our findings indicate that a substantial number of pregnant women have been infected with gonorrhoea globally, which calls for immediate public health measures to reduce the potential risk of infection. The study highlights the inadequacy or lack of data for many countries, emphasizing the need to expand systematic data collection efforts at national and regional levels.

Prevalence of curable STIs and bacterial vaginosis during pregnancy in sub-Saharan Africa: a systematic review and meta-analysis

OBJECTIVE

STIs remain a global public health problem with a high burden among pregnant women. STIs in pregnant women may lead to various adverse pregnancy outcomes. In most sub-Saharan African countries, syndromic management is used for screening and treatment of STIs. We aimed to update and summarise pooled prevalence of curable STIs and bacterial vaginosis (BV) among pregnant women in sub-Saharan Africa.

METHODS

Electronic databases and reference lists of relevant published and unpublished studies were searched from March 2015 to October 2020. Studies were included if they estimated prevalence of Chlamydia trachomatis (CT), Trichomonas vaginalis (TV), Neisseria gonorrhoeae (NG), Treponema pallidum (syphilis), Mycoplasma genitalium (MG) and BV among pregnant women in sub-Saharan Africa. Meta-analyses were performed with observed prevalences corrected for diagnostic errors to estimate the pooled prevalence of diagnosed infections by region.

RESULTS

A total of 48 studies met the inclusion criteria, providing 85-point prevalence estimates for curable STIs and BV. Pooled prevalence estimates (with 95% CI and number of women tested) were as follows: MG: 13.5% (4.0-27.2, n=1076); CT: 10.8% (6.9-15.5, n=6700); TV: 13.8% (10.0-18.0, n=9264); NG: 3.3% (2.1-4.7, n=6019); syphilis: 2.9% (2.0-4.0, n=95 308) and BV: 36.6% (27.1-46.6, n=5042). By region, BV was the most prevalent and ranged from 28.5% (24.5-32.8, n=1030) in Eastern Africa to 52.4% (33.5-70.9, n=2305) in Southern Africa; NG had the lowest prevalence, ranging from 1.4% (95% CI 0.1 to 3.1, n=367) in Central Africa to 4.4% (95% CI 2.6 to 6.4, n=4042) in Southern Africa.

CONCLUSION

The prevalence of curable STIs and BV in sub-Saharan Africa is substantial in pregnant women but most prevalent in Southern Africa where HIV prevalence is highest. It is crucial to integrate screening of curable STIs into antenatal care programmes that have previously focused on diagnosis and treatment of syphilis and HIV.

Sustained Virologic Suppression Reduces HIV-1 DNA Proviral Levels and HIV Antibodies in Perinatally HIV-Infected Children Followed from Birth

The extent to which perinatally HIV-infected children, following cART initiation, develop a low proviral reservoir burden over time, as measured by HIV DNA droplet-digital polymerase chain reaction (ddPCR) and the effect on HIV antibody is not well characterized. We measured proviral HIV DNA and plasma RNA virus load (VL) in 37 perinatally HIV-infected children at 6 months of age who initiated stable cART. At 6-11 years of age, HIV proviral DNA, HIV VL (RNA), and HIV antibody by Western Blot (WB) were assessed. CART was initiated before 6 months of age in 13 children and after 6 months in 24. At school age, the HIV DNA levels did not differ by the timing of cART, and the HIV DNA levels were lower in children with negative/indeterminate WB (p = 0.0256). Children with undetectable HIV RNA VL > 50% of the time since cART initiation had lower median DNA VL than children with undetectable VL < 50% of the time (p = 0.07). Long-term viral suppression in perinatally HIV-infected children is associated with a decrease in HIV antibodies and reduced HIV reservoirs.

Predictors of adverse pregnancy outcomes among Kenyan women with HIV on antiretroviral treatment in pregnancy

OBJECTIVE

The aim of this study was to understand predictors of adverse pregnancy outcomes (APOs) among women on antiretroviral treatment (ART).

DESIGN

A longitudinal cohort.

METHODS

Participants from the Mobile WAChX trial were evaluated for APOs, including stillbirth (fetal death at ≥20 weeks' gestation), preterm birth (PTB, livebirth at <37 weeks' gestation,) and neonatal death (NND, ≤28 days after live birth). Predictors were determined by univariable and multivariable Cox proportional hazards and log-binomial models.

RESULTS

Among 774 women included, median age was 27 years and 29.0% had unsuppressed HIV viral load (>1000 copies/ml) at enrollment. Half (55.1%) started ART prepregnancy, 89.1% on tenofovir-based regimens. Women with depression had a higher risk of stillbirth (adjusted hazard ratio [aHR] 2.93, 95% confidence interval (95% CI) 1.04-8.23), and women with lower social support score had higher risk of late stillbirth (aHR 11.74, 2.47-55.86). Among 740 livebirths, 201 (27.2%) were preterm and 22 (3.0%) experienced NND. PTB was associated with unsuppressed maternal viral load (adjusted prevalence ratio [aPR] 1.28, 95% CI 1.02-1.61), intimate partner violence (IPV) in pregnancy (aPR 1.94, 95% CI 1.28-2.94), and history of any sexually transmitted infection (STI) (aPR 1.63, 95% CI 1.06-2.51). NND was associated with PTB (aPR 2.53, 95% CI 1.10-5.78) and STI history (aPR 4.25, 95% CI 1.39-13.06). Most associations retained significance in the subgroup of women with viral suppression.

CONCLUSION

Maternal viremia during pregnancy predicted PTB as did IPV, lower education, and STI history, while psychosocial stressors predicted stillbirth. Implementing mental health services, ART adherence, partner support, and routine STI screening and treatment could reduce APOs among women with HIV in sub-Saharan Africa settings.

Adverse Neonatal Outcomes Associated With Maternal Sexually Transmitted Infections From a Public Health Clinic Cohort in Southern Brazil

Pregnant women at public medical centers in Porto Alegre, Brazil, were recruited for a study on screening and treatment of sexually transmitted infections (STIs). STIs were detected in 79 (23%) of 350 pregnant women and were found to be associated with infant low birth weight (adjusted odds ratio 5.8; 95% confidence interval 1.9-18).

Impact of aetiological screening of sexually transmitted infections during pregnancy on pregnancy outcomes in South Africa

BACKGROUND

Sexually transmitted infections (STIs) during pregnancy may increase the risk of adverse pregnancy outcomes. STI syndromic management is standard of care in South Africa but has its limitations. We evaluated the impact of diagnosing and treating curable STIs during pregnancy on adverse pregnancy and birth outcomes.

METHODS

We combined data from two prospective studies of pregnant women attending public sector antenatal care (ANC) clinics in Tshwane District and Cape Town, South Africa. Pregnant women were enrolled, tested and treated for STIs. We evaluated the association between any STI at the first ANC visit and a composite adverse pregnancy outcome (miscarriage, stillbirth, preterm birth, early neonatal death, or low birthweight) using modified Poisson regression models, stratifying by HIV infection and adjusting for maternal characteristics.

RESULTS

Among 619 women, 61% (n = 380) were from Tshwane District and 39% (n = 239) from Cape Town; 79% (n = 486) were women living with HIV. The prevalence of any STI was 37% (n = 228); C. trachomatis, 26% (n = 158), T. vaginalis, 18% (n = 120) and N. gonorrhoeae, 6% (n = 40). There were 93% (n = 574) singleton live births, 5% (n = 29) miscarriages and 2% (n = 16) stillbirths. Among the live births, there were 1% (n = 3) neonatal deaths, 7% (n = 35) low birthweight in full-term babies and 10% (n = 62) preterm delivery. There were 24% (n = 146) for the composite adverse pregnancy outcome. Overall, any STI diagnosis and treatment at first ANC visit was not associated with adverse outcomes in women living with HIV (adjusted relative risk (aRR); 1.43, 95% CI: 0.95-2.16) or women without HIV (aRR; 2.11, 95% CI: 0.89-5.01). However, C. trachomatis (aRR; 1.57, 95% CI: 1.04-2.39) and N. gonorrhoeae (aRR; 1.69, 95% CI: 1.09-3.08), were each independently associated with the composite adverse outcome in women living with HIV.

CONCLUSION

Treated STIs at the first ANC visit were not associated with adverse pregnancy outcome overall. In women living with HIV, C. trachomatis or N. gonorrhoeae at first ANC were each independently associated with adverse pregnancy outcome. Our results highlights complex interactions between the timing of STI detection and treatment, HIV infection and pregnancy outcomes, which warrants further investigation.

Women's knowledge and hypothetical acceptance of expedited partner therapy for chlamydia

Background Expedited partner therapy (EPT) for chlamydia can be an important public health tool to treat the sex partners of newly diagnosed individuals, especially when those sex partners are women of reproductive ages. Untreated and repeat chlamydia infections increase a woman's risk for subfertility. This study aimed to determine the knowledge of EPT, and the factors associated with EPT knowledge, among reproductive-aged women. Methods Women aged 18-40 years were recruited for a community sample from a large state fair; 871 women completed a questionnaire for this study. Women reported on their knowledge of sexually transmitted infections, and about their knowledge and attitudes toward EPT. Using a hypothetical example, women were asked if they would accept EPT. Results This community sample of reproductive-aged women found overwhelming hypothetical support for chlamydia testing, partner notification, and partner treatment. However, only 12% of women reported having heard of EPT prior to the survey; once EPT was described, there were high levels of support for EPT and the belief that EPT could reduce chlamydia rates. Half of the women strongly agreed that EPT could reduce chlamydia rates, and 48% supported the state law allowing for EPT. Working in the healthcare field was the only independent determinant of prior EPT knowledge, increasing the odds of hearing about EPT by more than 2.5-fold. Conclusions Despite overwhelming support of the tenets of EPT, our results indicate that prior knowledge of EPT is low among women, meaning that education about EPT is needed for those outside of the healthcare field.

Identifying youth at high risk for sexually transmitted infections in community-based settings using a risk prediction tool: a validation study

BACKGROUND : Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are the most common bacterial sexually transmitted infections (STIs) worldwide. In the absence of affordable point-of-care STI tests, WHO recommends STI testing based on risk factors. This study aimed to develop a prediction tool with a sensitivity of > 90% and efficiency (defined as the percentage of individuals that are eligible for diagnostic testing) of < 60%.

METHODS

This study offered CT/NG testing as part of a cluster-randomised trial of community-based delivery of sexual and reproductive health services to youth aged 16-24 years in Zimbabwe. All individuals accepting STI testing completed an STI risk factor questionnaire. The outcome was positivity for either CT or NG. Backwards-stepwise logistic regression was performed with p ≥ 0.05 as criteria for exclusion. Coefficients of variables included in the final multivariable model were multiplied by 10 to generate weights for a STI risk prediction tool. A maximum likelihood Receiver Operating Characteristics (ROC) model was fitted, with the continuous variable score divided into 15 categories of equal size. Sensitivity, efficiency and number needed to screen were calculated for different cut-points.

RESULTS

From 3 December 2019 to 5 February 2020, 1007 individuals opted for STI testing, of whom 1003 (99.6%) completed the questionnaire. CT/NG prevalence was 17.5% (95% CI 15.1, 19.8) (n = 175). CT/NG positivity was independently associated with being female, number of lifetime sexual partners, relationship status, HIV status, self-assessed STI risk and past or current pregnancy. The STI risk prediction score including those variables ranged from 2 to 46 with an area under the ROC curve of 0.72 (95% CI 0.68, 0.76). Two cut-points were chosen: (i) 23 for optimised sensitivity (75.9%) and specificity (59.3%) and (ii) 19 to maximise sensitivity (82.4%) while keeping efficiency at < 60% (59.4%).

CONCLUSIONS

The high prevalence of STIs among youth, even in those with no or one reported risk factor, may preclude the use of risk prediction tools for selective STI testing. At a cut-point of 19 one in six young people with STIs would be missed.

Integrating Sexually Transmitted Infection Testing and Treatment With Routine HIV Care in Gaborone, Botswana

BACKGROUND

Sexually transmitted infection (STI) testing is not routinely offered in many countries, and management is symptoms based. Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are associated with an increased risk of HIV transmission. We assess the feasibility and acceptability of integrating CT/NG testing into routine HIV care in Botswana, as well as the prevalence and correlates of CT/NG infections.

METHOD

A prospective study was conducted at an HIV clinic in Gaborone between February and October 2019. Eligibility criteria included the following: ≥18 years, HIV infected, and not treated for CT/NG in the past month. Participants self-collected samples and responded to a questionnaire on sociodemographic and health characteristics. Samples were processed using the GeneXpert. Patients were offered same-day results in person or by telephone. Those who tested positive were treated.

RESULTS

Of 806 patients informed of the study, 526 (65%) expressed interest and 451 (60%) were enrolled. The median age was 48 years, and 66% were women. All participants provided self-collected samples, were successfully tested, and received results. Almost all reported sample self-collection was easy. The prevalence of CT/NG was 5%. Most participants (73%) with a positive result were asymptomatic. Among infected, 20 (91%) received same-day results and all were treated. Younger age, female sex, and pain during sex were associated with having CT/NG.

CONCLUSIONS

Integrating STI testing into routine HIV care was feasible, self-collecting specimens was highly acceptable, but uptake of testing was low. Where blanket screening to the entire clinic population may not be feasible because of resource limitation, one strategy could be to prioritize sexually active patients, younger patients, and women.

Chlamydia trachomatis Screening and Treatment in Pregnancy to Reduce Adverse Pregnancy and Neonatal Outcomes: A Review

Chlamydial trachomatis infection has been associated with adverse pregnancy and neonatal outcomes such as premature rupture of membranes, preterm birth, low birth weight, conjunctivitis, and pneumonia in infants. This review evaluates existing literature to determine potential benefits of antenatal screening and treatment of C. trachomatis in preventing adverse outcomes. A literature search revealed 1824 studies with 156 full-text articles reviewed. Fifteen studies were selected after fulfilling inclusion criteria. Eight studies focused on chlamydial screening and treatment to prevent adverse pregnancy outcomes such as premature rupture of membranes, preterm birth, low birth weight, growth restriction leading to small for gestational age infants, and neonatal death. Seven studies focused on the effects of chlamydial screening and treatment on adverse infant outcomes such as chlamydial infection including positive mucosal cultures, pneumonia, and conjunctivitis. Given the heterogeneity of those studies, this focused review was exclusively qualitative in nature. When viewed collectively, 13 of 15 studies provided some degree of support that antenatal chlamydial screening and treatment interventions may lead to decreased adverse pregnancy and infant outcomes. However, notable limitations of these individual studies also highlight the need for further, updated research in this area, particularly from low and middle-income settings.

Chlamydia, gonorrhea, and incident HIV infection during pregnancy predict preterm birth despite treatment

BACKGROUND

Identifying predictors of preterm birth (PTB) in high burden regions is important as PTB is the leading cause of global child mortality.

METHODS

This analysis was nested in a longitudinal study of peripartum HIV incidence in Kenya. HIV-seronegative women enrolled in pregnancy were screened with nucleic acid amplification tests (chlamydia and gonorrhea), RPR (syphilis), wet mount microscopy (Trichomonas and yeast), and Gram stain (bacterial vaginosis); sexually transmitted infection (STI) treatment was provided. PTB predictors were determined using log binomial regression.

FINDINGS

Among 1244 mothers of liveborn infants, median age was 22 years (IQR 19 - 27), median gestational age at enrollment was 26 weeks (IQR 22 - 31) and at delivery was 39.1 weeks (IQR 37.1 - 40.9). PTB occurred in 302 women (24.3%). Chlamydia was associated with a 1.59-fold (p=0.006), gonorrhea a 1.62-fold (p=0.04) and incident HIV a 2.08-fold (p=0.02) increased prevalence of PTB. Vaginal discharge and cervical inflammation were significantly associated with PTB, as were age ≤21 (prevalence ratio [PR] =1.39, p=0.001) and any STI (PR=1.47, p=0.001). Chlamydia and incident HIV remained associated with PTB in multivariable models.

INTERPRETATION

STIs and incident HIV in pregnancy predicted PTB despite treatment, suggesting need for earlier treatment and interventions to decrease genital inflammation.

Predicting Sexually Transmitted Infections Among HIV+ Adolescents and Young Adults: A Novel Risk Score to Augment Syndromic Management in Eswatini

BACKGROUND

Despite poor predictive power, syndromic screening is standard of care for diagnosing sexually transmitted infections (STIs) in low-resource, high HIV-burden settings. Predictive models may augment syndromic screening when diagnostic testing is not universally available for screening high-risk patient populations such as adolescents and young adults living with HIV.

SETTING

Four hundred fifteen adolescents and young adults living with HIV, age 15-24 years, participated from 3 clinical sites in Eswatini, provided urine, sexual and medical history, and completed physical examination.

METHODS

STI cases were defined by a positive Xpert result for Chlamydia trachomatis, Neisseria gonorrhea, or Trichomonas vaginalis. Features predictive of an STI were selected through Least Absolute Shrinkage and Selection Operator (LASSO) with 5-fold cross validation. Various model strategies were compared with parametric area under the Receiver Operator Curve (AUC) estimation and inferences were made with bootstrapped standard errors.

RESULTS

Syndromic screening poorly predicted STIs [AUC 0.640 95% Confidence Interval (95% CI): 0.577 to 0.703]. A model considering 5 predictors (age group, sex, any sexual activity, not always using condoms (either self or partner), a partner who was 25 years or older, and horizontal or unknown mode of HIV acquisition) predicted STIs better than syndromic screening [AUC: 0.829 (95% CI: 0.774 to 0.885)] and was improved when the risk score was supplemented with leukocyte esterase (LE) testing [AUC: 0.883 (95% CI: 0.806 to 0.961)].

CONCLUSIONS

This simple predictive model, with or without leukocyte esterase testing, could improve STI diagnosis in HIV-positive adolescents and young adults in high burden settings through complementary use with syndromic screening and to guide patient selection for molecular STI diagnostic tests.

Mother-to-child transmission of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis in HIV-infected pregnant women in South Africa

BACKGROUND

Sexually transmitted infections (STIs) can be transmitted from mother to neonate. We determined the frequency of mother-to-child transmission (MTCT) of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis to the newborn nasopharynx.

METHODS

This study was nested in a cohort study of etiologic testing versus syndromic management for STIs among pregnant women living with human immunodeficiency virus in South Africa. Mothers were tested for STIs using the GeneXpert platform within 60 days after delivery. Nasopharyngeal swabs were obtained from newborns of mothers with a positive STI test; these were then tested by Xpert® on the same day based on the maternal STI diagnosis.

RESULTS

We tested nasopharyngeal swabs from 85 STI-exposed newborns; 74 (87%) were tested within 2 weeks after birth (median five; range 2-12 days). MTCT frequency of any STI was 30/74 (41%); 43% (23/53) for C. trachomatis, 29% (2/7) for N. gonorrhoeae, and 24% (6/25) for T. vaginalis. Also, 4/11 (36%) swabs obtained between 14 and 60 days after delivery tested positive for STI.

CONCLUSIONS

There was a high frequency of MTCT of STIs to the nasopharynx of newborns in our setting. The impact of nasopharyngeal colonization and the benefits of STI testing on newborn health remain to be determined.

Prevalence, risk factors and association with delivery outcome of curable sexually transmitted infections among pregnant women in Southern Ethiopia

INTRODUCTION

Curable sexually transmitted infections (STIs) such as infection with Chlamydia trachomatis (C. trachomatis), Neisseria gonorrhoeae (N. gonorrhoeae), and Trichomonas vaginalis (T. vaginalis) can lead to adverse pregnancy and birth outcome. There are limited data on the prevalence and correlate of STI in Ethiopia, yet pregnant women are not screened for curable STI. Hence in this study, the prevalence of STIs and associated risk factors were assessed.

METHODOLOGY

A cross- sectional study was conducted on consecutive women attending the delivery ward at the Hawassa comprehensive and specialized hospital. Vaginal swabs collected at the time of labor and delivery were tested for C. trachomatis, N. gonorrhoeae and T. vaginalis using GeneXpert. Study participants responded to a questionnaire about their previous and current obstetric history and socio-demographic characteristics. Possible independent factors for curable STIs were assessed by chi-square, bivariable, and multivariable, logistic regression.

RESULTS

Of the 350 vaginal swabs tested, 51 (14.6%, 95% CI: 10.9-18.3) were positive for one or more curable STIs. The prevalence of C. trachomatis, N. gonorrhoeae and T. vaginalis were 8.3%, 4.3%, and 3.1%, respectively. STIs was associated (p<0.005) with the delivery outcomes birth weight and gestational age. A 3-fold increase in odds of acquisition STIs was found in currently unmarried women (AOR, 3.5; 95% CI: 1.1-10.4; p = 0.028), in women <25 years (AOR, 2.7; 95% CI 1.1-6.6; p = 0.031). Women reporting presence of vaginal discharge (AOR, 7.7; 95% CI: 3.2-18.6; p < 0.001) and reporting pain during urination (AOR, 6.5; 95% CI: 2.6-16.2; p <0.001) found to associate with curable STIs.

CONCLUSION

The higher magnitude of STIs found in this population, and the absence of symptoms in many illustrate the need for systematic follow-up during routine antenatal care primarily history taking and asking for signs and symptoms to provide early management and avoid long term sequelae.

High Prevalence of Sexually Transmitted Infections in Pregnant Women Living in Southern Brazil

BACKGROUND

Porto Alegre, Brazil, has the highest rates of congenital syphilis and HIV in the country. Other treatable sexually transmitted infections (STIs) are associated with poor pregnancy and neonatal outcomes, but are only diagnosed by syndromic algorithms.

METHODS

Between September 2018 and November 2019, we offered all pregnant women clinic-based STI testing for HIV antibody and treponemal antibody (via lateral flow assay rapid tests provided by the Brazilian Government) and for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis (via polymerase chain reaction-based testing provided by Gene Xpert, Sunnyvale, CA) in 10 public prenatal health clinics in Porto Alegre. Participating women answered a brief survey via audio computer-assisted survey instrument regarding demographics, partnerships, and sexual behaviors. All infected individuals received appropriate treatment and referrals.

RESULTS

Of 400 pregnant women recruited, 94 (24%) were diagnosed with an STI, including 2% with HIV, 11% with syphilis, 9% with chlamydia, 1% with gonorrhea, 5% with trichomoniasis, and 3% with more than 1 STI. In our multivariate analysis, younger age (adjusted odds ratio [AOR], 1.1; 95% confidence interval [CI], 1-1.2), being non-White (AOR, 1.8; 95% CI, 1.1-3.1), having less education (AOR, 2; 95% CI, 1.2-3.4), and having a relationship <1 year (AOR, 2; 95% CI, 1.1-3.6) were all independent predictors of women having an STI. Endorsing symptoms of an STI (e.g., vaginal ulcers/lesions and vaginal discharge) was not predictive of having a laboratory-diagnosed STI (OR, 1.1; 95% CI, 0.7-1.7).

CONCLUSIONS

Etiologic-based screening for STIs was uniformly accepted by women attending both hospital-based and primary health clinics in the south of Brazil and can result in appropriate treatment of pregnant women.

Adverse pregnancy and neonatal outcomes associated with Neisseria gonorrhoeae: systematic review and meta-analysis

Objective

To examine associations between Neisseria gonorrhoeae (NG) infection during pregnancy and the risk of preterm birth, spontaneous abortion, premature rupture of membranes, perinatal mortality, low birth weight and ophthalmia neonatorum.

Data sources

We searched Medline, EMBASE, the Cochrane Library and Cumulative Index to Nursing and Allied Health Literature for studies published between 1948 and 14 January 2020.

Methods

Studies were included if they reported testing for NG during pregnancy and compared pregnancy, perinatal and/or neonatal outcomes between women with and without NG. Two reviewers independently assessed papers for inclusion and extracted data. Risk of bias was assessed using established checklists for each study design. Summary ORs with 95% CIs were generated using random effects models for both crude and, where available, adjusted associations.

Results

We identified 2593 records and included 30 in meta-analyses. Women with NG were more likely to experience preterm birth (OR 1.55, 95% CI 1.21 to 1.99, n=18 studies); premature rupture of membranes (OR 1.41, 95% CI 1.02 to 1.92, n=9); perinatal mortality (OR 2.16, 95% CI 1.35 to 3.46, n=9); low birth weight (OR 1.66, 95% CI 1.12 to 2.48, n=8) and ophthalmia neonatorum (OR 4.21, 95% CI 1.36 to 13.04, n=6). Summary adjusted ORs were, for preterm birth 1.90 (95% CI 1.14 to 3.19, n=5) and for low birth weight 1.48 (95% CI 0.79 to 2.77, n=4). In studies with a multivariable analysis, age was the variable most commonly adjusted for. NG was more strongly associated with preterm birth in low-income and middle-income countries (OR 2.21, 95% CI 1.40 to 3.48, n=7) than in high-income countries (OR 1.38, 95% CI 1.04 to 1.83, n=11).

Conclusions

NG is associated with a number of adverse pregnancy and newborn outcomes. Further research should be done to determine the role of NG in different perinatal mortality outcomes because interventions that reduce mortality will have the greatest impact on reducing the burden of disease in low-income and middle-income countries.

PROSPERO registration number

CRD42016050962.

Aetiological testing compared with syndromic management for sexually transmitted infections in HIV-infected pregnant women in South Africa: a non-randomised prospective cohort study

Objective

To measure the frequencies of sexually transmitted infections (STIs) and adverse pregnancy outcomes among women receiving either aetiological testing or syndromic management for STIs.

Design

Non‐randomised prospective cohort study.

Setting

Primary healthcare facilities in Tshwane, South Africa.

Population

HIV‐infected pregnant women attending antenatal care services.

Methods

Participants were enrolled to receive aetiological testing using Xpert® CT/NG and Xpert® TV assays or standard syndromic management. Outcome data were collected at the postnatal care visit (≤30 days from delivery) and from maternity records. Enrolment gestational age‐adjusted relative risk (aRR) was calculated.

Main outcome measures

STI prevalence at postnatal visit, and frequency of adverse pregnancy outcomes (preterm birth, low birthweight).

Results

We enrolled 841 women. The prevalence of any STI at baseline was 40%; Chlamydia trachomatis 30%, Neisseria gonorrhoeae 5.6%, Trichomonas vaginalis 20%. The prevalence of STIs at postnatal care was lower among those receiving aetiological testing compared with those receiving syndromic management (14% versus 23%; aRR 0.61; 95% CI 0.35–1.05). No difference was observed between study groups for frequency of preterm birth (23% versus 23%; aRR 1.2, 95% CI 0.81–1.8) and low birth weight (15% versus 13%; aRR 1.1, 95% CI 0.66–1.7).

Conclusions

Aetiological testing provides an effective intervention to reduce the high burden of STIs in pregnant women in South Africa; however, the optimal implementation strategy remains to be determined.

Tweetable abstract

Aetiological testing effectively reduces the burden of sexually transmitted infections in pregnancy.

Aetiological testing effectively reduces the burden of sexually transmitted infections in pregnancy.

Sexually transmitted infections in pregnancy - An update on Chlamydia trachomatis and Neisseria gonorrhoeae

Routine screening for Chlamydia and gonococcal infection in pregnancy is not widespread, especially in low- and middle-income countries (LMICs), despite their potential adverse consequences on pregnancy outcome. We conducted a systematic literature search of three major databases to review current literature surrounding Chlamydia trachomatis and Neisseria gonorrhoeae infections in pregnancy. We discuss the epidemiology and burden of both infections, detection methods, potential adverse feto-maternal and infant outcomes and provide an overview of treatment options. A total of 67 articles met the inclusion criteria. The prevalence of C. trachomatis and N. gonorrhoeae across all trimesters ranged between 1.0%-36.8% and 0-14.2% worldwide, respectively. The most common diagnostic method is the Nucleic acid amplification test (NAAT). In pregnancy, chlamydia is associated with preterm birth, spontaneous miscarriage, stillbirth and neonatal conjunctivitis, while gonorrhoea is mainly associated with preterm birth and stillbirth. Amoxicillin, erythromycin and azithromycin showed similar efficacy in the treatment of chlamydia in pregnancy, while ceftriaxone and cefixime were effective in treating gonorrhoea in pregnancy. Being largely asymptomatic infections in women, we opine that detection strategies with locally appropriate tools should be combined with the syndromic approach in LMICs, where there is a high burden of disease.

Point-of-Care Testing to Guide Treatment and Estimate Risk Factors for Sexually Transmitted Infections in Adolescents and Young People With Human Immunodeficiency Virus in Eswatini

BACKGROUND

The World Health Organization (WHO) estimates 127 million new cases of Chlamydia trachomatis (CT), 87 million new cases of Neisseria gonorrhea (NG), and 156 million new cases of Trichomonas vaginalis (TV) each year, which corresponds to 355 (219-606), 303 (216-468), and 243 (97.6-425) thousand disability-adjusted life-years. In low-resource settings, however, sexually transmitted infections (STIs) are treated syndromically and many individuals with asymptomatic infection may be missed, especially adolescents and young adults with human immunodeficiency virus (HIV).

METHODS

We enrolled patients aged 15-24 with HIV (N = 300) attending a family-centered HIV clinic in Mbabane, Eswatini. Participants completed a sexual history questionnaire and provided urine as well as oropharyngeal and/or vaginal swabs, if sexually active, for testing with Xpert CT/NG and TV tests. Analysis included bivariate and multivariate odds ratios and test sensitivity and specificity.

RESULTS

Sexually transmitted infection rates were highest (25.0%; 95% confidence interval [CI], 15.2-37.3) in females ages 20-24 who were ever sexually active. In patients with confirmed STIs, NG (15 of 32, 47%) was more common than CT (9 of 32, 28%) and TV (8 of 32, 25%). Syndromic screening alone had a sensitivity of 32.0% (95% CI, 14.9-53.3) and specificity of 86.0% (95% CI, 79.0-91.4) but varied by gender. The presence of an STI was associated with reporting new sexual partner(s) (OR = 2.6; 95% CI, 1.1-6.4), sometimes to never using condoms (OR = 4.2; 95% CI, 1.7-10.2), most recent sexual partner >25 years old (OR = 3.2; 95% CI, 1.3-7.9), and HIV diagnosis at age ≥15 years (OR = 3.4; 95% CI, 1.4-8.2).

CONCLUSIONS

Syndromic screening alone performed poorly. Routine diagnostic testing significantly increases STI detection and should be considered in high-risk populations, such as adolescents and young adults with HIV.

Prevalence and correlates of sexually transmitted infections in pregnancy in HIV-infected and- uninfected women in Cape Town, South Africa

OBJECTIVES

Sexually transmitted infections (STIs) are associated with adverse outcomes in pregnancy, including mother-to-child HIV transmission. Yet there are limited data on the prevalence and correlates of STI in pregnant women by HIV status in low- and middle-income countries, where syndromic STI management is routine.

METHODS

Between November 2017 and July 2018, we conducted a cross-sectional study of consecutive pregnant women making their first visit to a public sector antenatal clinic (ANC) in Cape Town. We interviewed women ≥18 years and tested them for Chlamydia trachomatis (CT), Neisseria gonorrhoea (NG) and Trichomonas vaginalis (TV) using Xpert assays (Cepheid, USA); results of syphilis serology came from routine testing records. We used multivariable logistic regression to identify correlates of STI in pregnancy.

RESULTS

In 242 women (median age 29 years [IQR = 24-34], median gestation 19 weeks [IQR = 14-24]) 44% were HIV-infected. Almost all reported vaginal sex during pregnancy (93%). Prevalence of any STI was 32%: 39% in HIV-infected women vs. 28% in HIV-uninfected women (p = 0.036). The most common infection was CT (20%) followed by TV (15%), then NG (5.8%). Of the 78 women diagnosed with a STI, 7 (9%) were identified and treated syndromically in ANC. Adjusting for age and gestational age, HIV-infection (aOR = 1.89; 95% CI = 1.02-3.67), being unmarried or not cohabiting with the fetus' father (aOR = 2.19; 95% CI = 1.16-4.12), and having STI symptoms in the past three days (aOR = 6.60; 95% CI = 2.08-20.95) were associated with STI diagnosis.

CONCLUSION

We found a high prevalence of treatable STIs in pregnancy among pregnant women, especially in HIV-infected women. Few women were identified and treated in pregnancy.

Sexual Behaviors of Human Immunodeficiency Virus-Infected Pregnant Women and Factors Associated With Sexually Transmitted Infection in South Africa

BACKGROUND

Sexual behaviors in human immunodeficiency virus (HIV)-infected pregnant women in South Africa are not well understood.

METHODS

Human immunodeficiency virus-infected pregnant women were recruited into a prospective cohort at first antenatal care visit. Sociodemographic information and self-collected vulvovaginal swab samples were collected from participants. Vulvovaginal swab samples were tested for Chlamydia trachomatis, Neisseria gonorrhoea, and Trichomonas vaginalis using GeneXpert. We investigated sexual behaviors, alcohol use, factors associated with condomless sex during pregnancy, and prevalent sexually transmitted infection (STI) among our cohort. We report descriptive, univariate and multivariable logistic regression results of sexual behaviors and alcohol use, factors associated with condomless sex at last sex, and having any STI during pregnancy adjusting for a priori confounders.

RESULTS

We recruited and enrolled 430 HIV-infected pregnant women. Median age was 30 years; median gestational age was 20 weeks. Eighty-nine percent of women reported sex during pregnancy. At last sex, 68% reported condomless sex; 18% reported having more than 1 sex partner in the past 12 months. Adjusting for age, income and relationship status, condom use at last sex was associated with prior knowledge of HIV status (adjusted odds ratio [aOR], 2.46; 95% confidence interval [CI], 1.54-3.92) and being in a concordant HIV-positive (aOR, 3.17; 95% CI, 1.84-5.50), or serodiscordant relationship (aOR, 6.50; 95% CI, 3.59-11.80). The prevalence of any STI was 41% (95% CI, 36%-45%). Adjusting for mothers' age and employment, odds of having an STI increased if the woman reported alcohol use during pregnancy (aOR, 1.96; 95% CI, 1.06-3.64) or if the father of the child was a non-cohabiting or casual partner (aOR, 1.42; 95% CI, 0.97-2.03).

CONCLUSIONS

Almost all HIV-infected pregnant women were sexually active during pregnancy and most women reported condomless sex at last sex. Condom use was associated with knowledge of serostatus and/or partner's serostatus before first antenatal care visit. Factors associated with having STIs included: alcohol use during pregnancy and father of child being a non-cohabiting partner.

Portable Infrared Isothermal PCR Platform for Multiple Sexually Transmitted Diseases Strand Detection

Rapid and portable PCR detection is essential for screening sexually transmitted infections regularly. We developed an infrared mediated RNA isothermal RT-PCR (IR-MERIT PCR) platform and its compatible multichamber microfluidic chip for simultaneous amplification and testing (SAT) detection. This microfluidic chip integrates RNA extraction, micropump, and multitarget detection function onto the same chip. By utilizing IR-light-emitting diode (LED) as heat source, this platform can fulfill isothermal amplification within 70 min.

Sexually transmitted infections during pregnancy and subsequent risk of stillbirth and infant mortality in Kenya: a prospective study

OBJECTIVES

We evaluated the relationship of sexually transmitted infections (STIs) and genital infections during pregnancy and subsequent risk for infant mortality and stillbirth.

METHODS

This was a nested longitudinal analysis using data from a study of peripartum HIV acquisition in Kenya. In the parent study, HIV-uninfected women were enrolled during pregnancy and followed until 9 months postpartum. For this analysis, women who tested positive for HIV at any point, had a non-singleton pregnancy or a spontaneous abortion <20 weeks were excluded. At enrolment, laboratory methods were used to screen for bacterial vaginosis (BV), vaginal yeast, Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV). Syphilis was diagnosed using rapid plasma reagin testing and genital ulcer disease (GUD) identified by clinical examination. Treatment of laboratory-confirmed STIs and syndromic management was provided per Kenyan national guidelines. Predictors of stillbirth and infant mortality were determined using logistic regression and Cox proportional hazards models.

RESULTS

Overall, among 1221 women, 55% had STIs or genital infections detected: vaginal yeast (25%), BV (22%), TV (6%), CT (5%), NG (2%) and syphilis (1%). Among women with STIs/genital infections (n=592), 34% had symptoms. Overall, 19/1221 (2%) women experienced stillbirths. Among 1202 live births, 34 infant deaths occurred (incidence 4.0 deaths per 100 person-years, 95% CI 2.8 to 5.5). After adjustment for maternal age, education and study site, stillbirth was associated with maternal GUD (adjusted OR=9.19, 95% CI1.91 to 44.35, p=0.006). Maternal NG was associated with infant mortality (adjusted HR=3.83, 95% CI1.16 to 12.68, p=0.028); there was some evidence that maternal CT was associated with infant mortality. Stillbirth or infant mortality were not associated with other genital infections.

CONCLUSIONS

STIs and genital infections were common, frequently asymptomatic and some associated with stillbirth or infant mortality. Expediting diagnosis and treatment of STIs in pregnancy may improve infant outcomes.

Reproductive health problems in rural South African young women: risk behaviour and risk factors

BACKGROUND

South African young women continue to be vulnerable, with high prevalence of teenage pregnancy, HIV, sexually transmitted infections (STIs) and female genital schistosomiasis (FGS). This study seeks to examine the underlying factors that may be associated with these four adverse reproductive health outcomes.

METHODS

In a cross-sectional study of 1413 sexually active of young women, we explored these four adverse reproductive health outcomes by considering socio-demographic factors, socio-economic factors, sexual risk behaviour, substance abuse and knowledge about reproductive health by using a questionnaire. Consenting participants were asked about previous pregnancies and were tested for HIV, STIs and FGS. Multivariable regression analyses were used to explore the factors associated with these four reproductive health outcomes.

RESULTS

1. Early pregnancy: Among the young women, 44.4% had already been pregnant at least once. Associated factors were hormonal contraceptives, (adjusted odds ratio (AOR): 17.94, 95% confidence interval (CI): 12.73-25.29), and sexual debut < 16 years (AOR: 3.83, 95% CI: 2.68-5.47). Living with both parents (AOR 0.37, 95% CI: 0.25-0.57) and having a steady partner (AOR: 0.43, 95% CI: 0.24-0.76) were identified as protective factors against pregnancy. 2. HIV: HIV prevalence was 17.1%. The odds of having HIV were higher in intergenerational (AOR: 2.06, 95% CI: 1.05-4.06) and intragenerational relationships (AOR: 1.51 95% CI: 1.06-2.15), compared to age-homogenous relationships. Other associated factors were: condom use (AOR: 1.60, 95% CI: 1.16-2.20), number of times treated for an STI (AOR: 1.32, 95% CI: 1.02-1.71), and total number of partners (AOR: 1.14, 95% CI: 1.03-1.28). 3. STIs: Participants who had at least one STI (40.5%) were associated with total partner number (AOR 1.17, 95% CI: 1.06-1.30), and testing HIV positive (AOR: 1.88, 95% CI 1.41-2.50). 4. FGS: FGS prevalence (19.7%) was associated with previous anti-schistosomal treatment (AOR: 2.18, 95% CI: 1.57-3.05).

CONCLUSION

There is a high prevalence of pregnancy, HIV, STIs and FGS among sexually active young women in rural KwaZulu-Natal. Multidisciplinary approaches are urgently needed for educational and health literacy programs prior to sexual debut, and health care facilities, which should be made accessible for young women.

Evaluation of antenatal rapid human immunodeficiency virus testing in rural South Africa

Introduction

South African guidelines recommend two rapid tests for diagnosing human immunodeficiency virus (HIV) using the serial HIV testing algorithm, but the accuracy and compliance to this algorithm is unknown in rural clinics. We evaluated the accuracy of HIV rapid testing and the time to receiving test results among pregnant women in rural KwaZulu-Natal (KZN).

Method

We observed the accuracy of rapid HIV testing algorithms for 208 consenting antenatal patients accessing voluntary HIV testing services in nine rural primary healthcare (PHC) clinics in KZN. A PHC-based HIV counsellor obtained finger-prick whole blood from each participant to perform rapid testing using the Advanced Quality™ One Step anti-HIV (1&2) and/or ABON™ HIV 1/2/O Tri-Line HIV test. A research nurse obtained venous blood for an enzyme-linked immunosorbent assay (ELISA) HIV test, which is the gold standard diagnostic test. We recorded the time of receipt of HIV test results for each test.

Results

Among 208 pregnant women with a mean age of 26 years, 72 women from nine rural PHC clinics were identified as HIV-positive by two rapid tests with an HIV-prevalence of 35% (95% Bayesian credibility intervals [BCI]: 28% - 41%). Of the 208 patients, 135 patients from six clinics were tested with the serial HIV testing algorithm. The estimated sensitivity and specificity for the 135 participants were 100% (95% confidence interval [CI]: 93% - 100%) and 99% (CI: 95% - 100%), respectively. The positive predictive value and negative predictive value were estimated at 98% (CI: 94% - 100%) and 95% (CI: 88% - 99%), respectively. All women received their HIV rapid test results within 20 min of testing. Test stock-out resulted in poor test availability at point-of-care, preventing performance of a second HIV test in three out of nine PHC clinics in rural KZN.

Conclusion

Despite the poor compliance with national guidelines for HIV rapid testing services, HIV rapid test results provided to pregnant women in rural PHC clinics in KZN were generally accurate and timely. Test stock-out was shown to be one of the barriers to test availability in rural PHC clinics, resulting in poor compliance with guidelines. We recommend a compulsory confirmation HIV rapid test for all HIV-negative test results obtained from pregnant patients in rural and resource-limited settings.

Acceptability and Feasibility of Integrating Point-of-Care Diagnostic Testing of Sexually Transmitted Infections into a South African Antenatal Care Program for HIV-Infected Pregnant Women

Background

Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV) infections may increase the risk of vertical transmission of the human immunodeficiency virus (HIV). In resource-limited settings, symptomatic screening, and syndromic management of sexually transmitted infections (STIs) during pregnancy continue to be the standard of care. In the absence of diagnostic testing, asymptomatic infections in pregnant women go untreated.

Objective

To describe the acceptability and feasibility of integrating diagnostic STI screening into first antenatal care visits for HIV-infected pregnant women.

Methods

HIV-infected pregnant women were recruited during their first antenatal care visit from three antenatal care clinics in Tshwane District, South Africa, between June 2016 and October 2017. Self-collected vaginal swabs were used to screen for CT, NG, and TV with a diagnostic point-of-care (POC) nucleic acid amplification test. Those with STIs were provided treatment per South African national guidelines.

Results

Of 442 eligible women, 430 (97.3%) agreed to participate and were tested. Of those with a positive STI test result (n = 173; 40.2%), 159 (91.9%) received same-day results and treatment; 100% of STI-infected women were treated within seven days.

Conclusions

Integration of POC diagnostic STI screening into first-visit antenatal care services was feasible and highly acceptable for HIV-infected pregnant women.

Beyond syndromic management: Opportunities for diagnosis-based treatment of sexually transmitted infections in low- and middle-income countries

Introduction

In light of the limited impact the syndromic management approach has had on the global sexually transmitted infection (STI) epidemic, we assessed a care model comprising point-of-care (POC) STI testing, immediate treatment, and expedited partner therapy (EPT) among a cohort of young women at high HIV risk in South Africa.

Methods and findings

HIV negative women presenting for STI care underwent POC testing for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV), and swabs were sent for NG culture and susceptibility testing. Results were available within 2 hours and women with STIs were immediately treated and offered EPT packs, including medication, condoms, and information for sexual partners. An EPT questionnaire was administered after one week, and women retested for STIs after 6 and 12 weeks. 267 women, median age 23 (IQR 21–26), were recruited and 88.4% (236/267) reported genital symptoms. STI prevalence was CT 18.4% (95%CI 13.7–23.0), NG 5.2% (95%CI 2.6–7.9) and TV 3.0% (95%CI 1.0–5.0). After 12 weeks, all but one NG and two CT infections were cleared. No cephalosporin-resistant NG was detected. Of 63/267 women (23.6%) diagnosed with STIs, 98.4% (62/63) were offered and 87.1% (54/62) accepted EPT. At one week 88.9% (48/54) stated that their partner had taken the medication. No allergic reactions or social harms were reported. Of 51 women completing 6-week follow up, detection rates were lower amongst women receiving EPT (2.2%, 1/46) compared to those who did not (40.0%, 2/5), p = 0.023. During focus group discussions women supported the care model, because they received a rapid, specific diagnosis, and could facilitate their partners’ treatment.

Conclusions

POC STI testing and EPT were acceptable to young South African women and their partners, and could play an important role in reducing STI reinfection rates and HIV risk. Larger studies should evaluate the feasibility and cost-effectiveness of implementing this strategy at population level.

Sexual risk during pregnancy and postpartum periods among HIV-infected and -uninfected South African women: Implications for primary and secondary HIV prevention interventions

BACKGROUND

HIV acquisition in pregnancy and breastfeeding contributes significantly toward pediatric HIV infection. However, little is known about how sexual behavior changes during pregnancy and postpartum periods which will help develop targeted HIV prevention and transmission interventions, including pre-exposure prophylaxis (PrEP).

METHODS

Cross-sectional study in HIV-infected and uninfected pregnant and postpartum women in Cape Town, South Africa. Interviewers collected survey data on demographic, sexual behaviors, and alcohol use among pregnant and post-partum women. We report descriptive results of sexual behavior by trimester and postpartum period, and results of multivariable logistic regression stratified by pregnancy status.

RESULTS

We enrolled 377 pregnant and postpartum women (56% pregnant, 40% HIV-infected). During pregnancy, 98% of women reported vaginal sex (8% anal sex, 44% oral sex) vs. 35% and 88% during the periods 0-6 and 7-12 months postpartum, respectively (p<0.05). More pregnant women reported having >1 partner in the past 12-months compared to postpartum women (18% vs. 13%, respectively, p<0.05). Sex frequency varied by trimester with greatest mean sex acts occurring during first trimester and >6-months postpartum (13 mean sex acts in first trimester; 17 mean sex acts >6-months postpartum). Pregnant women had increased odds of reporting condomless sex at last sex (aOR = 2.96;95%CI = 1.84-4.78) and ever having condomless sex in past 3-months (aOR = 2.65;95%CI = 1.30-5.44) adjusting for age, HIV status, and sex frequency compared to postpartum women.

CONCLUSION

We identified that sexual behaviors and risk behaviors were high and changing during pregnancy and postpartum periods, presenting challenges to primary and secondary HIV prevention efforts, including PrEP delivery to pregnant and breastfeeding women.

Chlamydia trachomatis and the risk of spontaneous preterm birth, babies who are born small for gestational age, and stillbirth: a population-based cohort study

BACKGROUND

Chlamydia trachomatis is one of the most commonly diagnosed sexually transmitted infections worldwide, but reports in the medical literature of an association between genital chlamydia infection and adverse obstetric outcomes are inconsistent.

METHODS

The Western Australia Data Linkage Branch created a cohort of women of reproductive age by linking records of birth registrations with the electoral roll for women in Western Australia who were born from 1974 to 1995. The cohort was then linked to both chlamydia testing records and the state perinatal registry for data on preterm births and other adverse obstetric outcomes. We determined associations between chlamydia testing, test positivity, and adverse obstetric outcomes using multivariate logistic regression analyses.

FINDINGS

From 2001 to 2012, 101 558 women aged 15 to 38 years had a singleton birth. Of these women, 3921 (3·9%) had a spontaneous preterm birth, 9762 (9·6% of 101 371 women with available data) had a baby who was small for gestational age, and 682 (0·7%) had a stillbirth. During their pregnancy, 21 267 (20·9%) of these women had at least one chlamydia test record, and 1365 (6·4%) of those tested were positive. Before pregnancy, 19 157 (18·9%) of these women were tested for chlamydia, of whom 1595 (8·3%) tested positive for chlamydia. Among all women with a test record, after adjusting for age, ethnicity, maternal smoking, and history of other infections, we found no significant association between a positive test for chlamydia and spontaneous preterm birth (adjusted odds ratio 1·08 [95% CI 0·91-1·28]; p=0·37), a baby who was small for gestational age (0·95 [0·85-1·07]; p=0·39), or stillbirth (0·93 [0·61-1·42]; p=0·74).

INTERPRETATION

A genital chlamydia infection that is diagnosed and, presumably, treated either during or before pregnancy does not substantially increase a woman's risk of having a spontaneous preterm birth, having a baby who is small for gestational age, or having a stillbirth.

FUNDING

Australian National Health and Medical Research Council.

Point-of-Care Sexually Transmitted Infection Diagnostics: Proceedings of the STAR Sexually Transmitted Infection-Clinical Trial Group Programmatic Meeting

The STAR STI-CTG programmatic meeting reviewed point-of-care sexually transmitted infection diagnostics including current and emerging technologies, clinical and public health benefits, international applications, regulatory considerations, and future developments.

The goal of the point-of-care (POC) sexually transmitted infection (STI) Diagnostics meeting was to review the state-of-the-art research and develop recommendations for the use of POC STI diagnostics. Experts from academia, government, nonprofit, and industry discussed POC diagnostics for STIs such as Chlamydia trachomatis, human papillomavirus, Neisseria gonorrhoeae, Trichomonas vaginalis, and Treponema pallidum. Key objectives included a review of current and emerging technologies, clinical and public health benefits, POC STI diagnostics in developing countries, regulatory considerations, and future areas of development. Key points of the meeting are as follows: (i) although some rapid point-of-care tests are affordable, sensitive, specific, easy to perform, and deliverable to those who need them for select sexually transmitted infections, implementation barriers exist at the device, patient, provider, and health system levels; (ii) further investment in research and development of point-of-care tests for sexually transmitted infections is needed, and new technologies can be used to improve diagnostic testing, test uptake, and treatment; (iii) efficient deployment of self-testing in supervised (ie, pharmacies, clinics, and so on) and/or unsupervised (ie, home, offices, and so on) settings could facilitate more screening and diagnosis that will reduce the burden of sexually transmitted infections; (iv) development of novel diagnostic technologies has outpaced the generation of guidance tools and documents issued by regulatory agencies; and (v) questions regarding quality management are emerging including the mechanism by which poor-performing diagnostics are removed from the market and quality assurance of self-testing is ensured.

Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis screening and treatment of pregnant women in Port-au-Prince, Haiti

In Haiti, routine screening for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV) among pregnant women is not conducted; yet these sexually transmitted infections (STIs) are associated with adverse birth and newborn health outcomes. We aimed to assess the acceptability and feasibility of screening and the prevalence of STIs among pregnant women in Port-au-Prince, Haiti. Pregnant women of at least 18 years of age who attend Haitian Study Group for Kaposi's sarcoma and Opportunistic Infections (GHESKIO) clinics in Port-au-Prince, Haiti provided self-collected vaginal swab specimens. Laboratory testing was done with Xpert® CT/NG and Xpert® TV. The results of this study showed that of the 322 pregnant women who visited GHESKIO for their regular scheduled appointments, 300 (93.2%) consented for CT, NG, and TV testing. Of those, 107 women (35.7%) tested positive for at least one STI. There were 42 (14.7%) cases of CT, 8 (2.8%) NG, and 83 (29.0%) TV infections. Most infections were treated - 122 of 133 (91.7%). In summary, we found that it was highly acceptable and feasible to implement CT, NG, and TV screening among pregnant women in Port-au-Prince, Haiti. We found high prevalence of STIs among pregnant women, which suggest that STI screening in this population may be warranted.

High prevalence of asymptomatic sexually transmitted infections among human immunodeficiency virus-infected pregnant women in a low-income South African community

There is a lack of evidence on the burden of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV) among HIV-infected pregnant women in South Africa. We conducted a cross-sectional analysis of HIV-infected pregnant women in two healthcare facilities in a South African township to determine the prevalence of CT, NG and TV. HIV-infected pregnant women were recruited during the first antenatal care visit for their current pregnancy and requested to self-collect vulvovaginal swab specimens. Specimens were tested for CT, NG and TV using the Xpert® assay (Cepheid, Sunnyvale, CA). Of 247 tested for CT, NG and TV, 47.8% tested positive for at least one organism; CT = 36.8%, TV = 23.9%, NG = 6.9%. Forty three (17.4%) had multiple infections, of which 42 included CT as one of the infecting organisms. Of the 118 participants who tested positive for at least one sexually transmitted infection (STI), 23.7% reported STI-like symptoms. Among women who tested positive for CT, 29.7% reported symptoms while 47.1 and 27.1% of those who tested positive for NG and TV, respectively, reported symptoms. The high STI prevalence coupled with the low symptom prevalence among infected individuals justifies the use of diagnostic screening approaches rather than syndromic management of STIs in this setting.

Prevalence and impact of sexually transmitted infections in pregnant women in central Ethiopia

Human immunodeficiency virus (HIV) continues to be a major global public health issue and omnipresent sexually transmitted infections (STIs) increase the risk of HIV acquisition. Moreover, STIs and HIV in pregnant women can harm the unborn child. In this study, we systematically investigated the prevalence of HIV, relevant STIs and vaginal group B streptococcus colonization among pregnant women presenting at Asella Teaching Hospital in central Ethiopia and their effect on perinatal mortality. A follow-up was performed six weeks after delivery. A total of 580 women were included, of which 26.6% tested positive for at least one pathogen ( Chlamydia trachomatis 9.8%, trichomoniasis 5.3%, hepatitis B 5.3%, gonorrhoea 4.3%, group B streptococcus 2.4%, syphilis 2.2%, HIV 2.1%). None of the HIV infections were previously undiagnosed, indicating effective HIV screening activities in the region. Follow-up data were available for 473 (81.6%) children, of which 37 (7.8%) were stillborn or died within the first six weeks of life. Infection with Trichomonas vaginalis and recruitment at obstetric ward (versus antenatal care) were associated with mortality. High prevalence of STIs in pregnant women and their impact on the unborn child demonstrate the need for screening and treatment programmes in order to prevent perinatal mortality.

Cytomegalovirus Urinary Shedding in HIV-infected Pregnant Women and Congenital Cytomegalovirus Infection

BACKGROUND

Cytomegalovirus (CMV) urinary shedding in pregnant women infected with human immunodeficiency virus (HIV) was evaluated to determine whether it poses an increased risk for congenital CMV infection (cCMV).

METHODS

A subset of mother-infant pairs enrolled in the perinatal NICHD HPTN 040 study (distinguished by no antiretroviral use before labor) was evaluated. Maternal and infant urines were tested by qualitative real-time polymerase chain reaction (RT-PCR) for CMV DNA with quantitative RT-PCR performed on positive specimens.

RESULTS

Urine specimens were available for 260 women with 85.4% from the Americas and 14.6% from South Africa. Twenty-four women (9.2%) had detectable CMV viruria by qualitative PCR. Maternal CMV viruria was not associated with mean CD4 cell counts or HIV viral load but was associated with younger maternal age (P = .02). Overall, 10 of 260 infants (3.8%) had cCMV. Women with detectable peripartum CMV viruria were more likely to have infants with cCMV than those without: 20.8% (5/24) versus 2.1% (5/236), (P = .0001). Women with CMV viruria had significantly higher rates of HIV perinatal transmission (29.2% vs. 8.1%, P = .002). They were 5 times (adjusted odds ratio [aOR] = 5.6, 95% confidence interval [CI] 1.9-16.8) and nearly 30 times (aOR, 29.7; 95% CI, 5.4-164.2) more likely to transmit HIV and CMV to their infants, respectively. Maternal gonorrhea (aOR, 19.5; 95% CI, 2.5-151.3) and higher maternal HIV log10 viral load (OR, 2.8; 95% CI, 1.3-6.3) were also significant risk factors for cCMV.

CONCLUSION

In this cohort of HIV-infected pregnant women not on antiretrovirals, urinary CMV shedding was a significant risk factor for CMV and HIV transmission to infants.

CLINICAL TRIALS REGISTRATION NUMBER

NCT00099359.

Pregnancy Outcomes in Association with STDs including genital HSV-2 shedding in a South African Cohort Study

OBJECTIVES

Genital herpes simplex virus-2 (HSV-2) shedding in pregnant women in association with neonatal herpes infection has been widely studied but there is limited evidence of its association with pregnancy outcomes.

METHODS

In this retrospective observational study, we included a subgroup of pregnant women who were enrolled in a randomized control behavioural intervention study that was conducted in South Africa in 2008-2010. In pregnancy, women had a HIV rapid test done and a genital swab taken to test for curable STIs and HSV-2 DNA. Subsequent visits were scheduled for 6, 10, 14 weeks and 9 months post-delivery. Pregnancy outcomes were documented at the 6-week or 10-week postpartum visit. Women were treated syndromically for curable STIs.

RESULTS

Among 615 women included in this data analysis, 36.6% (n=225) tested HIV positive and 8.3% (n=51) tested positive for genital HSV-2 shedding during pregnancy. Women <24 years and HIV-1 seropositive women were 1.5 and 2.5 times more likely to test positive for HSV-2 genital shedding respectively. STI treatment records were available for 158/205 (77.1%) women; all 87 women with symptomatic STIs were treated the same day, and 50/71 (70.4%) asymptomatic women received treatment at the subsequent visit. Remaining 21 (29.6%) asymptomatic women did not receive treatment because they failed to return for antenatal follow-up. In a multivariable regression analysis, genital HSV-2 shedding, HIV-1, Neisseria gonorrhoea, Chlamydia trachomatis and Trichomanas vaginalis were not associated with preterm deliveries, still births and low birth weight. However with stratification by treatment for a STI, asymptomatic women who were not treated were 3.3 times more likely to deliver prematurely (33.3%; n=6/18) when compared to women who were treated during pregnancy (13.2%; n=15/114) (p=0.042).

CONCLUSIONS

Genital HSV-2 shedding in pregnancy does not appear to alter pregnancy outcomes. Untreated curable STIs (T.vaginalis, C.trachomatis, N.gonorrhoea) were more likely associated with preterm births.

Point-of-Care Diagnostics for Improving Maternal Health in South Africa

Improving maternal health is a global priority, particularly in high HIV-endemic, resource-limited settings. Failure to use health care facilities due to poor access is one of the main causes of maternal deaths in South Africa. "Point-of-care" (POC) diagnostics are an innovative healthcare approach to improve healthcare access and health outcomes in remote and resource-limited settings. In this review, POC testing is defined as a diagnostic test that is carried out near patients and leads to rapid clinical decisions. We review the current and emerging POC diagnostics for maternal health, with a specific focus on the World Health Organization (WHO) quality-ASSURED (Affordability, Sensitivity, Specificity, User friendly, Rapid and robust, Equipment free and Delivered) criteria for an ideal point-of-care test in resource-limited settings. The performance of POC diagnostics, barriers and challenges related to implementing POC diagnostics for maternal health in rural and resource-limited settings are reviewed. Innovative strategies for overcoming these barriers are recommended to achieve substantial progress on improving maternal health outcomes in these settings.

A Systematic Review of Point of Care Testing for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis

Objectives. Systematic review of point of care (POC) diagnostic tests for sexually transmitted infections: Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV). Methods. Literature search on PubMed for articles from January 2010 to August 2015, including original research in English on POC diagnostics for sexually transmitted CT, NG, and/or TV. Results. We identified 33 publications with original research on POC diagnostics for CT, NG, and/or TV. Thirteen articles evaluated test performance, yielding at least one test for each infection with sensitivity and specificity ≥90%. Each infection also had currently available tests with sensitivities <60%. Three articles analyzed cost effectiveness, and five publications discussed acceptability and feasibility. POC testing was acceptable to both providers and patients and was also demonstrated to be cost effective. Fourteen proof of concept articles introduced new tests. Conclusions. Highly sensitive and specific POC tests are available for CT, NG, and TV, but improvement is possible. Future research should focus on acceptability, feasibility, and cost of POC testing. While pregnant women specifically have not been studied, the results available in nonpregnant populations are encouraging for the ability to test and treat women in antenatal care to prevent adverse pregnancy and neonatal outcomes.

Chlamydia trachomatis Infection in Pregnancy: The Global Challenge of Preventing Adverse Pregnancy and Infant Outcomes in Sub-Saharan Africa and Asia

Screening and treatment of sexually transmitted infections (STIs) in pregnancy represents an overlooked opportunity to improve the health outcomes of women and infants worldwide. Although Chlamydia trachomatis is the most common treatable bacterial STI, few countries have routine pregnancy screening and treatment programs. We reviewed the current literature surrounding Chlamydia trachomatis in pregnancy, particularly focusing on countries in sub-Saharan Africa and Asia. We discuss possible chlamydial adverse pregnancy and infant health outcomes (miscarriage, stillbirth, ectopic pregnancy, preterm birth, neonatal conjunctivitis, neonatal pneumonia, and other potential effects including HIV perinatal transmission) and review studies of chlamydial screening and treatment in pregnancy, while simultaneously highlighting research from resource-limited countries in sub-Saharan Africa and Asia.