Integration of preventing mother-to-child transmission of HIV and syphilis testing and treatment in antenatal care services in the Northern Cape and Gauteng provinces, South Africa

Completion of four or more ANC visits among women of reproductive age in Iganga district in Uganda: a quantitative study on the role of service-level factors

BACKGROUND

Evidence indicates that antenatal care (ANC) has both indirect and direct effects on maternal and perinatal morbidity and mortality reduction. In Uganda, the ANC attendance rate stands at 97.3% for one visit, but 59.9% for four or more visits. Given the imminent shift to the eight-contact ANC model in Uganda, combined with a lack of universal coverage for completion of four ANC visits, there is need for research that provides information on the factors that differentiate completers of recommended ANC attendances from non-completers. The aim of this quantitative study was to assess service- level factors affecting completion of ANC attendance defined by completion of four or more visits among women of reproductive age in Iganga district in Uganda.

METHODS

Facility assessment scores on the service-level factors of interest for health facilities were obtained using a service level index tool. The relationship between the ANC completion rates of clients sampled from records at the health facilities and facility scores on service-level factors of interest were analyzed. Regression was conducted to determine the predictive relationship between ANC service availability, ANC service content, and ANC service organization, and completion of ANC attendance.

RESULTS

The model was statistically significant, χ2 (6) = 26.118, p ˂ 0.05, and accounted for approximately 17.3% of the variance of ANC attendance completion (R2 = .173). Completion of ANC attendance was primarily predicted by better timing of provision of ANC services, and to a lesser extent by higher levels of availability of medicines and medical supplies.

CONCLUSIONS

This study demonstrated that service-level factors have a predictive value for completion of ANC attendance. The findings can be used to improve availability, content, and organization of ANC services with the aim of enhancing positive experiences for clients and motivating them to complete the recommended number of ANC visits.

Uptake of HIV testing among aging adults in Agincourt, South Africa: perception of community, social network, and individual characteristics

This cross-sectional study examined the impact of perception of community, social network and individual variables on the likelihood of voluntary HIV testing of people 40 years and older living in Agincourt, South Africa. The data came from Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in SA (HAALSI) Cohort from Agincourt. We applied three logistic regression models. Results showed that voluntary uptake of HIV testing was significantly associated with two network factors, namely friendships within the network and frequency of fighting in the network. At the community level, attachment to place was significantly associated with voluntary testing, while at the individual level, education, sexual behaviour, employment and age were significantly associated with the voluntary uptake of HIV testing. The implications of these findings are that age-appropriate interventions must be devised to sensitise older people in Agincourt about HIV risks. Also, leadership at the community level and in social networks must encourage members to consider voluntary testing for their own and community interests.

Prevalence of sexually transmitted infections among cervical cancer suspected women at University of Gondar Comprehensive Specialized Hospital, North-west Ethiopia

Background

Sexually transmitted infections (STIs) such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and Syphilis have continued a significant public health problem, especially in areas with substandard infection prevention and control programs. It is known that STIs are largely associated with the increased occurrence of cervical cancer. To date, little is known about the burden of STIs among cervical cancer suspected women in Ethiopia.

Objectives

To assess the seroprevalence of STIs and associated risk factors among cervical cancer suspected women with special emphasis on HIV, HBV, HCV, and Syphilis.

Methods

A hospital-based cross-sectional study was conducted among cervical cancer suspected women at the University of Gondar Comprehensive Specialized Hospital from February to April 2017. A pre-tested and structured questionnaire was used to collect data on patients’ characteristics. The patient’s serum or plasma samples were tested for HIV, HBV, HCV, and syphilis using enzyme-linked immunosorbent assay. In all aspects, the standard operational procedure was strictly followed. Data were analyzed using SPSS version 20 software and presented using tables. Statistical associations were measured using bivariate and multivariable logistic regression. A p-value of below 0.05 was considered statistically significant.

Result

A total of 403 cervical cancer suspected women with the mean age of 42.54 (SD + 11. 24) years were enrolled in the study. The overall prevalence of STIs was 16.6% (67/403) and the prevalence of HIV, HBV, HCV, and syphilis was 36/403 (8.9%), 10/403 (2.5%), 4/403 (1%), and 29/403 (7.2%) respectively. History of multiple sexual partners (Adjusted OR = 3.02, 95%CI 1.57–5.79, P = 0.001), alcohol addiction (Adjusted OR = 2.2, 95%CI 1.07–4.5, P = 0.031), history of STI (Adjusted OR = 3.38; 95% CI: 1.76–6.47, P = 0.00) and not use of condom (Adjusted OR = 4.99; 95% CI: 1.5–16.16, P = 0.007) were significantly associated with STIs.

Conclusion

The prevalence of STIs was generally higher among cervical cancer suspected patients. Health education is encouraged to promote awareness about the prevention of STIs.

Standardised protocol for a prospective cross-sectional multicentre clinic-based evaluation of two dual point-of-care tests for the screening of HIV and syphilis in men who have sex with men, sex workers and pregnant women

INTRODUCTION

Dual point-of-care tests (POCTs) for detecting antibodies to HIV and syphilis have been developed for use with venous whole blood, serum/plasma or finger-prick capillary whole blood. Several tests are commercially available showing encouraging performance compared with 'gold-standard' reference tests in laboratory-based studies. However, data on their performance in the field are limited. This prospective cross-sectional study will conduct a clinic-based evaluation to assess the performance characteristics and acceptability to end-users of two dual HIV/syphilis POCTs for the screening of HIV and syphilis among men who have sex with men (MSM), sex workers (SWs) and pregnant women (PW). This master protocol outlines the overall research approach that will be used in seven countries.

METHOD AND ANALYSIS

MSM, SWs and PW presenting at clinic evaluation sites in high, low and middle-income countries will be enrolled. The (WHO preapproved) POCTs to be evaluated are SD Bioline HIV/Syphilis Duo (Abbott) and Dual Path Platform HIV-Syphilis Assay (Chembio). Finger-prick blood will be collected to perform POCTs and compared with laboratory results (venepuncture blood). Procedures will be carried out by trained healthcare staff and tests performed according to the manufacturers' directions. Sample size was calculated based on local prevalence of HIV and syphilis. The sensitivity, specificity, positive and negative predictive values for each POCT will be calculated. The study is ongoing with recruitment expected to be completed in all countries by mid to late 2021.

ETHICS AND DISSEMINATION

This core protocol was independently peer reviewed and approved by the Research Project Review Panel (RP2) of the WHO Department of Sexual and Reproductive Health and Research and by the WHO Ethics Review Committee (ERC). The protocol has been adapted to individual countries and approved by RP2, ERC and institutional review boards at each site. Results will be disseminated through peer-reviewed journals and relevant conferences.

Performance of a Dual Human Immunodeficiency Virus/Syphilis Rapid Test Compared With Conventional Serological Testing for Syphilis and Human Immunodeficiency Virus in a Laboratory Setting: Results From the Zimbabwe STI Etiology Study

BACKGROUND

Dual human immunodeficiency virus (HIV)/syphilis rapid, point-of-care testing may enhance syphilis screening among high-risk populations, increase case finding, reduce time to treatment, and prevent complications. We assessed the laboratory-based performance of a rapid dual HIV/syphilis test using serum collected from patients enrolled in the Zimbabwe Sexually Transmitted Infections (STI) Etiology study.

METHODS

Blood specimens were collected from patients presenting with STI syndromes in 6, predominantly urban STI clinics in different regions of Zimbabwe. All specimens were tested at a central research laboratory using the Standard Diagnostics Bioline HIV/Syphilis Duo test. The treponemal syphilis component of the dual rapid test was compared with the Treponema pallidum hemagglutination assay (TPHA) as a gold standard comparator, both alone or in combination with a nontreponemal test, the rapid plasma reagin test. The HIV component of the dual test was compared with a combination of HIV rapid tests conducted at the research laboratory following the Zimbabwe national HIV testing algorithm.

RESULTS

Of 600 men and women enrolled in the study, 436 consented to serological syphilis and HIV testing and had specimens successfully tested by all assays. The treponemal component of the dual test had a sensitivity of 66.2% (95% confidence interval [CI], 55.2%-77.2%) and a specificity of 96.4% (95% CI, 94.5%-98.3%) when compared with TPHA; the sensitivity increased to 91.7% (95% CI, 82.6%-99.9%) when both TPHA and rapid plasma reagin were positive. The HIV component of the dual test had a sensitivity of 99.4% (95% CI, 98.4%-99.9%) and a specificity of 100% (95% CI, 99.9%-100%) when compared with the HIV testing algorithm.

CONCLUSIONS

Laboratory performance of the SD Bioline HIV/Syphilis Duo test was high for the HIV component of the test. Sensitivity of the treponemal component was lower than reported from most laboratory-based evaluations in the literature. However, sensitivity of the test increased substantially among patients more likely to have active syphilis for which results of both standard treponemal and nontreponemal tests were positive.

Modelling the impact of screening for chlamydia and gonorrhoea in youth and other high-prevalence groups in a resource-limited setting

OBJECTIVES

Modelling the potential impact of screening for chlamydia and gonorrhoea in youth and other populations in a resource-limited setting.

METHODS

We extended an agent-based model of heterosexual chlamydia and gonorrhoea transmission in South Africa to investigate the impact of screening strategies in key populations including youth, patients in HIV care, pregnant women and female sex workers (FSWs). Additionally, we compared the modelled impact of a standardised screening programme to results obtained from other published mathematical models of chlamydia screening.

RESULTS

All strategies resulted in reductions in general and targeted population chlamydia and gonorrhoea transmission. Opportunistic screening of patients in youth and HIV care was shown to be the most effective, and FSW screening was shown to be the most efficient strategy. Differences between models could be attributed to differences in the modelled heterogeneity in sexual behaviour as well as differences in assumptions about immunity following chlamydia recovery.

CONCLUSIONS

Taking modelling assumptions into account, opportunistic chlamydia and gonorrhoea screening of youth and those in HIV care represents a viable intervention for reducing sexually transmitted infections in the South African population.

Inequalities in access to HIV and syphilis tests in prenatal care in Brazil

This study aims to evaluate the social determinants of access to HIV and VDRL tests during pregnancy in Brazil. The dependent variables were based on prenatal care access: prenatal care appointments, no HIV and syphilis tests. The independent variables at the first level were formal education level, age, race, work and participation in the Family Income program conditional cash transfer program. The city-level variables were the human development index (HDI), Gini index, and indicators related to health services. An exploratory analysis was performed assessing the effect of each level through prevalence ratios (PR) calculation. A multilevel mixed-effect Poisson regression model was constructed for all outcomes to verify the effect of individual level and with both the individual and contextual levels. Regarding prenatal appointments, the main implicated factors were related to individual socioeconomic position (education level and participation in the Family Income Program conditional cash transfer program), however only HDI maintained significance for the city-level context. The city-level variance dropped from 0.049 to 0.042, indicating an important between-city effect. Regarding the outcomes performing tests in prenatal care, the worst conditions such as contextual (HDI > 0.694, p < 0.001; Gini index ≥ 0.521, p < 0.001) and individual (> 8 years of schooling, p < 0.001) showed a risk effect in the final model. Variables related to health services did not show significant effects. They were associated with individual socioeconomic position and a city-level contextual effect. These findings indicate the importance of strengthening HIV and syphilis infection control programs during pregnancy.

Toward Improving Accessibility of Point-of-Care Diagnostic Services for Maternal and Child Health in Low- and Middle-Income Countries

Point-of-care (POC) testing can improve health care provision in settings with limited access to health care services. Access to POC diagnostic services has shown potential to alleviate some diagnostic challenges and delays associated with laboratory-based methods in low- and middle-income countries. Improving accessibility to POC testing (POCT) services during antenatal and perinatal care is among the global health priorities to improve maternal and child health. This review provides insights on the availability of POC testing designed for diagnosing HIV, syphilis, and malaria in pregnancy to improve maternal and child health. In addition, factors such as accessibility of POC testing, training of health work force, and the efficiency of POC testing services delivery in low- and middle-income countries are discussed. A framework to help increase access to POC diagnostic services and improve maternal and child health outcomes in low- and middle-income countries is proposed.

Mother-to-child transmission prevention of human immunodeficiency virus, syphilis and hepatitis B virus

BACKGROUND

China is the first country to initiate a nationwide program for prevention of mother-to-child transmission of human immunodeficiency virus, syphilis and hepatitis B virus by an integrated approach. However, the progress of this program remains unreported at national or local level for China. Therefore, we performed a hospital-based longitudinal study to assess the integrated prevention effect in Hunan, South-central China.

METHODS

This study was conducted at 123 counties in Hunan and covered all local hospitals providing midwifery and antenatal care services from 2010 to 2016. We used the Cochran-Armitage test to examine the temporal changes of the indicators related with prevention of mother-to-child transmission. Besides, we used Spearman rank correlation analysis to assess the association between mother-to-child transmission rates and the process indicators related with prevention of mother-to-child transmission.

RESULTS

After implementation of integrated prevention program, the indicators related with prevention of mother-to-child transmission are moving in the right direction. From 2010 to 2016, mother-to-child transmission rates significantly decreased from 19.4% to 9.6% for human immunodeficiency virus, and from 116.3 to 13.6 cases per 100,000 live births for syphilis. The proportion of children receiving hepatitis B immunoglobulin injection within 24h after birth increased from 95.2% to 98.9% among exposed neonates. Mother-to-child transmission rates were negatively associated with the process indicators related with prevention of mother-to-child transmission (all P<0.05).

CONCLUSIONS

Our prevention program of mother-to-child transmission for three diseases by an integrated approach proved to be viable and effective. Our model may be of interest to other countries.

HIV and syphilis testing preferences among men who have sex with men and among transgender women in Lima, Peru

BACKGROUND

Men who have sex with men (MSM) and transgender women in Peru are at high risk for acquiring syphilis and HIV infection. The World Health Organization highly recommends screening for HIV and syphilis to reduce morbidity and mortality associated with untreated infections. We aimed to identify factors associated with dual testing preferences for HIV and syphilis infection among MSM and transgender women in Lima, Peru.

METHODS

We used conjoint analysis, an innovative method for systematically estimating consumer preferences. We created eight hypothetical test profiles varying across six dichotomous attributes: cost (free vs. $4), potential for false positive syphilis result (no false positive vs. some risk of false positive), time-to-result (20 minutes vs. 1 week), blood draw method (finger prick vs. venipuncture), test type (rapid vs. laboratory), and number of draws (1 vs. 2). We fit a conjoint analysis model for each participant using a simple main effects ANOVA. Attribute importance values were calculated using percentages from relative ranges in the attribute's utility values. Results were summarized across participants and averages were reported.

RESULTS

We recruited 415 MSM/transgender women over 18 years of age from two STD clinics in Lima, Peru. No potential for syphilis false positive result (no false positive vs. some potential for false positive) had the largest average impact on willingness to use the test and on average accounted for 23.8% of test type preference, followed by cost (free vs. ~USD$4; 21.6%), time to results (20 minutes vs. 1 week; 17.4%), number of blood draws (1 draw vs. 2 draws; 13.8%), method of blood draw (fingerprick vs. venipuncture; 13.7%), and test type (rapid POC vs. laboratory; 9.7%).

CONCLUSION

MSM/transgender women in Peru prioritized accuracy, cost, timeliness and number of blood draws for HIV and syphilis testing. Implementing a low cost, accurate, rapid and dual testing strategy for HIV and syphilis could improve screening uptake and accessibility of testing to accelerate time to treatment.

Adult gonorrhea, chlamydia and syphilis prevalence, incidence, treatment and syndromic case reporting in South Africa: Estimates using the Spectrum-STI model, 1990-2017

OBJECTIVES

To estimate trends in prevalence and incidence of syphilis, gonorrhea and chlamydia in adult men and women in South Africa.

METHODS

The Spectrum-STI tool estimated trends in prevalence and incidence of active syphilis, gonorrhea and chlamydia, fitting South African prevalence data. Results were used, alongside programmatic surveillance data, to estimate trends in incident gonorrhea cases resistant to first-line treatment, and the reporting gap of symptomatic male gonorrhea and chlamydia cases treated but not reported as cases of urethritis syndrome.

RESULTS

In 2017 adult (15-49 years) the estimated female and male prevalences for syphilis were 0.50% (95% CI: 0.32-0.80%) and 0.97% (0.19-2.28%), for gonorrhea 6.6% (3.8-10.8%) and 3.5% (1.7-6.1%), and for chlamydia 14.7% (9.9-21%) and 6.0% (3.8-10.4%), respectively. Between 1990 and 2017 the estimated prevalence of syphilis declined steadily in women and men, probably in part reflecting improved treatment coverage. For gonorrhea and chlamydia, estimated prevalence and incidence showed no consistent time trend in either women or men. Despite growing annual numbers of gonorrhea cases - reflecting population growth - the estimated number of first line treatment-resistant gonorrhea cases did not increase between 2008 and 2017, owing to changes in first-line antimicrobial treatment regimens for gonorrhea in 2008 and 2014/5. Case reporting completeness among treated male urethritis syndrome episodes was estimated at 10-28% in 2017.

CONCLUSION

South Africa continues to suffer a high STI burden. Improvements in access and quality of maternal, STI and HIV health care services likely contributed to the decline in syphilis prevalence. The lack of any decline in gonorrhea and chlamydia prevalence highlights the need to enhance STI services beyond clinic-based syndromic case management, to reinvigorate primary STI and HIV prevention and, especially for women, to screen for asymptomatic infections.

Assessing stakeholder perceptions of the acceptability and feasibility of national scale-up for a dual HIV/syphilis rapid diagnostic test in Malawi

OBJECTIVES

The WHO recommends pregnant women receive both HIV and syphilis testing at their first antenatal care visit, as untreated maternal infections can lead to severe, adverse pregnancy outcomes. One strategy for increasing testing for both HIV and syphilis is the use of point-of-care (rapid) diagnostic tests that are simple, proven effective and inexpensive. In Malawi, pregnant women routinely receive HIV testing, but only 10% are tested for syphilis at their first antenatal care visit. This evaluation explores stakeholder perceptions of a novel, dual HIV/syphilis rapid diagnostic test and potential barriers to national scale-up of the dual test in Malawi.

METHODS

During June and July 2015, we conducted 15 semistructured interviews with 25 healthcare workers, laboratorians, Ministry of Health leaders and partner agency representatives working in prevention of mother-to-child transmission in Malawi. We asked stakeholders about the importance of a dual rapid diagnostic test, concerns using and procuring the dual test and recommendations for national expansion.

RESULTS

Stakeholders viewed the test favourably, citing the importance of a dual rapid test in preventing missed opportunities for syphilis diagnosis and treatment, improving infant outcomes and increasing syphilis testing coverage. Primary technical concerns were about the additional procedural steps needed to perform the test, the possibility that testers may not adhere to required waiting times before interpreting results and difficulty reading and interpreting test results. Stakeholders thought national scale-up would require demonstration of cost-savings, uniform coordination, revisions to testing guidelines and algorithms, training of testers and a reliable supply chain.

CONCLUSIONS

Stakeholders largely support implementation of a dual HIV/syphilis rapid diagnostic test as a feasible alternative to current antenatal testing. Scale-up will require addressing perceived barriers; negotiating changes to existing algorithms and guidelines; and Ministry of Health approval and funding to support training of staff and procurement of supplies.

Prevalence of Curable Sexually Transmitted Infections in Pregnant Women in Low- and Middle-Income Countries From 2010 to 2015: A Systematic Review

BACKGROUND

Current literature comparing the prevalence rates of curable sexually transmitted infections (STIs) in pregnant women in various global regions is limited. As a result, antenatal screening practices for curable STIs in pregnant women, specifically Treponema pallidum (syphilis), Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), and Trichomonas vaginalis (TV) vary around the world, differing by country and particular STI.

METHODS

We conducted a systematic review of publications on STI prevalence among pregnant women in 30 different low- and middle-income countries. We searched PubMed for studies reporting prevalence of syphilis, CT, NG, and TV in pregnant women. English language studies published between January 1, 2010, and March 1, 2015, were included. The adjusted mean STI prevalence by region was calculated via multivariable linear regression adjusting for health care setting, women's mean age, study sample size, and sensitivity of diagnostic test.

RESULTS

We identified 75 studies that met inclusion criteria, providing 116 point prevalence estimates for curable STIs among 3,489,621 pregnant women. Adjusted mean prevalence for NG ranged from 1.2% (95% confidence interval [CI], 1.0-1.3) in Latin America to 4.6% (95% CI, 4.0-5.2) in Southern Africa; syphilis prevalence ranged from 1.1% (95% CI, 0.5-1.6) in Asia to 6.5% (95% CI, 4.7-6.3) in Southern Africa; CT ranged from 0.8% (95% CI, 0.4-1.1) in Asia to 11.2% (95% CI, 6.0-16.4) in Latin America; and TV ranged from 3.9% (95% CI, 2.2-5.6) in Latin America to 24.6% (95% CI, 17.9-31.4) in Southern Africa.

CONCLUSIONS

Although we observed a wide variation in STI burden in pregnancy after adjusting for age, test, and health care setting, further valid comparison may depend on adjustment for access to care and screening practices.

Evidence of accessibility and utility of point-of-care diagnostics as an integral part of prevention of mother-to-child transmission services: systematic scoping review protocol

INTRODUCTION

Point-of-care (POC) testing has been shown to help improve healthcare access in resource-limited settings. However, there is paucity of evidence on accessibility of POC testing for prevention of mother-to-child transmission (PMTCT) in resource-limited settings. We propose to conduct a systematic scoping review to map the evidence on POC testing services for PMTCT.

METHODS AND ANALYSIS

A scoping review framework, proposed by Arksey and O'Malley, will guide the study. A comprehensive literature search will be performed in the following electronic databases: PubMed, Science Direct, Cochrane Central, Google Scholar and databases within EBSCOhost (Medline and CINAHL). The primary research articles published in peer-reviewed journals and grey articles addressing our question will be included. One reviewer will conduct title screening and the results will be exported to endnote library. Two independent reviewers will perform abstract, then full article screening in parallel. The same process shall be employed to extract data from eligible studies. Data analysis will involve a narrative summary of included studies and thematic content analysis aided by NVIVO software V.11. The mixed methods assessment tool will be used to assess the quality of studies that will be included.

ETHICS AND DISSEMINATION

Ethical approval is not applicable to this study. The study findings will be disseminated through publication in a peer-reviewed journal and presentations at conferences related to syphilis, HIV, PMTCT, bacterial infections and POC diagnostics.

TRIAL REGISTRATION NUMBER

CRD42017056267.

Field Evaluation of a Dual Rapid Immunodiagnostic Test for HIV and Syphilis Infection in Peru

BACKGROUND

Integrated prevention for HIV and syphilis is warranted because both syphilis and HIV infections have evidence-based, scalable interventions using current health care mechanisms. The advent of dual rapid point-of-care tests, single devices that can detect multiple infections using the same specimen, provides the opportunity to integrate the screening of syphilis into HIV prevention programs, potentially increasing the numbers of people tested and allowing for same-day testing and treatment. The aim of our study was to evaluate the MedMira Multiplo Rapid TP/HIV Antibody Test (MedMira Inc, Halifax, Nova Scotia, Canada), a qualitative, rapid immunoassay that detects antibodies to Treponema pallidum and HIV.

METHODS

The reference test for comparison to the T. pallidum component of the Multiplo TP/HIV Test was the T. pallidum particle agglutination assay. For the HIV component, the reference test included a fourth-generation enzyme immunoassay with a confirmatory Western blot test.

RESULTS

The sensitivity and specificity for the HIV antibody component were 93.8% (95% confidence interval [CI], 69.8%-99.8%) and 100% (95% CI, 97.7%-100%), respectively. The T. pallidum component of the test had a sensitivity of 81.0% (95% CI, 68.1%-94.6%) and a specificity of 100% (95% CI, 97.6%-100%).

CONCLUSIONS

Our study showed excellent performance of the HIV antibody component of the test and very good performance for the T. pallidum antibody component of the MedMira Multiplo Rapid TP/HIV Antibody Test, which should be considered to improve screening coverage. Use of effective dual tests will create improved access to more comprehensive care by integrating the screening of syphilis into HIV prevention programs.

Achieving development goals for HIV, tuberculosis and malaria in sub-Saharan Africa through integrated antenatal care: barriers and challenges

BACKGROUND

The global health community is currently transitioning from the Millennium Development Goals (MDGs) to the Sustainable Development Goals (SDGs). Unfortunately, progress towards maternal, newborn and infant health MDGs has lagged significantly behind other key health goals, demanding a renewed global effort in this key health area. The World Health Organization and other institutions heralded integrated antenatal care (ANC) as the best way to address the inter-related health issues of HIV, tuberculosis (TB) and malaria in the high risk groups of pregnant women and infants; integrated ANC services also offer a mechanism to address slow progress towards improved maternal health.

DISCUSSION

There is remarkably limited evidence on best practice approaches of program implementation, acceptability and effectiveness for integrated ANC models targeting multiple diseases. Here, we discuss current integrated ANC global guidelines and the limited literature describing integrated ANC implementation and evidence for their role in addressing HIV, malaria and TB during pregnancy in sub-Saharan Africa. We highlight the paucity of data on the effectiveness of integrated ANC models and identify significant structural barriers in the health system (funding, infrastructure, distribution, human resources), the adoption system (limited buy-in from implementers, leadership, governance) and, in the broader context, patient-centred barriers (fear, stigma, personal burdens) and barriers in funding structures. We highlight recommendations for action and discuss avenues for the global health community to develop systems to integrate multiple disease programs into ANC models of care that better address these three priority infectious diseases. With the current transition to the SDGs and concerns regarding the failure to meet maternal health MDGs, the global health community, researchers, implementers and funding bodies must work together to ensure the establishment of quality operational and implementation research to inform integrated ANC models. It is imperative that the global health community engages in a timely discussion about such implementation innovations and instigates appropriate actions to ensure advances in maternal health are sufficient to meet applicable SDGs.

HIV surveillance in Rwanda: readiness assessment to transition from antenatal care-based to prevention of mother-to-child transmission program-based HIV surveillance

BACKGROUND

In 2013, the World Health Organization (WHO) recommended that for efficiency and ethical considerations, transitioning from antenatal clinic-based surveillance to prevention of mother-to-child transmission (PMTCT)-based routine data should be investigated. An assessment of the readiness for this transition was carried out in Rwanda in 2011 and 2013.

METHODS

This assessment applied the WHO recommended method. Individual HIV rapid testing at site was compared to antenatal surveillance results at all existing 30 sites, involving 13 292 women. In addition, PMTCT HIV testing quality assurance and PMTCT routine data quality were assessed at 27 out of the 30 sites.

RESULTS

All sentinel sites provided PMTCT services and had a high uptake of HIV testing (more than 90%). At all sites, PMTCT data were recorded in longitudinal and standardized antenatal clinic registers. Twenty-six out of 27 sites had HIV result completeness above 90%. A positive percentage agreement of 97.5% and negative percentage agreement of 99.9% were observed between routine PMTCT and sero-surveillance HIV test results. Of 27 sites, 25 scored more than 80% in all phases of HIV testing quality assurance.

CONCLUSIONS

According to WHO standards, Rwanda antenatal care HIV sero-surveillance is ready to transition to PMTCT-based sero-surveillance.

Attributes of diagnostic tests to increase uptake of dual testing for syphilis and HIV in Port-au-Prince, Haiti

Introduction Syphilis and HIV screening is highly recommended for pregnant women and those at risk for infection. We used conjoint analysis to identify factors associated with testing preferences for HIV and syphilis infection. Methods We recruited 298 men and women 18 years and over seeking testing or care at GHESKIO (Haitian Study Group for Kaposi's Sarcoma and Opportunistic Infections) clinics. We created eight hypothetical dual HIV-syphilis test profiles varying across six dichotomous attributes. Participants were asked to rate each profile using Likert preference scales. An impact score was generated for each attribute by taking the difference between the preference scores for the preferred and non-preferred level of each attribute. Two-sided one-sample t-test was used to generate p values. Results Of 298 study participants, 61 (20.5%) were male. Of 237 females, 49 (20.7%) were pregnant. Cost (free vs. US$4; p < .0001) had the highest impact on willingness to test, followed by number of blood draws (1 vs. 2; p < .0001), blood draw method (fingerprick vs. venipuncture; p < .0001), test type (rapid vs. laboratory; p = .0005), and time-to-result (20 minutes vs. 1 week; p = .0139). Conclusion HIV and syphilis testing preferences for this study sample in Port-au-Prince prioritized cost, single fingerprick, laboratory-based testing and timeliness.

Current Perspectives on Prevention of Mother-to-Child Transmission of Syphilis

This article aims to provide an update on the prevention of mother-to-child transmission of syphilis by drawing upon some important basic concepts and reviewing the most recent literature on the diagnosis and treatment of syphilis in pregnancy. New technologies, such as automated and point-of-care immunologic tests, are shifting some paradigms, which will certainly be further investigated in the forthcoming years. This is the time to carefully evaluate traditional as well as new strategies to prevent congenital syphilis. Adverse outcomes of mother-to-child transmission of syphilis can be prevented with antenatal screening and penicillin therapy, which proved to have an excellent cost-benefit ratio even in populations with a low prevalence of syphilis. However, syphilis epidemiology is influenced by socioeconomic and cultural factors, and major challenges are faced by poor and developing countries in which the severity of the problem is extremely alarming. On the other hand, the emergence of new technologies has raised doubts about the best algorithm to be used when proper laboratory resources are available. Conditions are quite heterogeneous across populations, and some procedures should not be generalized while there is no evidence that supports some changes and while in-depth studies about local conditions are not conducted. Official organizations need to be alert in order to avoid isolated decisions and ensure that evidence-based guidelines be used in the management of syphilis in pregnancy.

Decline in syphilis seroprevalence among females of reproductive age in Northern Cape Province, South Africa, 2003-2012: utility of laboratory-based information

Strengthening current surveillance systems for syphilis is important to track and monitor disease burden. We used routinely collected laboratory information to generate surveillance estimates for syphilis trends among women of reproductive age (12-49 years) in the Northern Cape Province, a high syphilis burden region (2003 [8.6%] to 2011 [3.8%]) in South Africa. We extracted records meeting inclusion criteria from the National Health Laboratory Service electronic database for the period 2003-2012. A total of 286,024 women were included in the analysis. Syphilis seropositivity decreased between 2003 (5.7%) and 2012 (1.8%); p trend = 0.001, which was largely consistent with findings reported in the annual national syphilis and HIV survey from 2003 (8.6%) to 2011 (3.8%). Annually for the period from 2003 to 2012 there was an approximate 14% reduction in the prevalence ratio of syphilis seroprevalence (PR = 0.86, 95% CI = 0.85-0.87, p < 0.001). Three of five districts had significant decreases in syphilis seropositivity over this period. There were also declines in prevalence ratios for syphilis seropositivity for the various age groups for the period. This study shows that the national laboratory database in South Africa can be used as a complimentary surveillance tool to describe and understand trends in syphilis seroprevalence in South Africa.

Barriers and enablers to integrating maternal and child health services to antenatal care in low and middle income countries

Antenatal care (ANC) represents a delivery platform for a broad range of health services; however, these opportunities are insufficiently utilised. This review explores key barriers and enablers for successful integration of health s"ervices with ANC in different contexts. Data from peer‐reviewed and grey literature were organised using the SURE checklist. We identified 46 reports focusing on integration of HIV, tuberculosis, malaria, syphilis or nutrition services with ANC from Asia, Africa and the Pacific. Perspectives of service users and providers, social and political factors, and health system characteristics (such as resource availability and organisational structures) affected ease of integration.

Tweetable abstract

Health system factors, context and stakeholders must be considered for integrated antenatal care services.

Health system factors, context and stakeholders must be considered for integrated antenatal care services.

Antenatal syphilis screening using point-of-care testing in low- and middle-income countries in Asia and Latin America: a cost-effectiveness analysis

BACKGROUND

Untreated syphilis in pregnancy is associated with adverse clinical outcomes to the infant. In low- and middle-income countries in Asia and Latin America, 20%-30% of women are not tested for syphilis during pregnancy. We evaluated the cost-effectiveness of increasing the coverage for antenatal syphilis screening in 11 Asian and 20 Latin American countries, using a point-of-care immunochromatographic strip (ICS) test.

METHODS

The decision analytical cost-effectiveness models reported incremental costs per disability-adjusted life years (DALYs) averted from the perspectives of the national health care payer. Clinical outcomes were stillbirths, neonatal deaths, and congenital syphilis. DALYs were computed using WHO disability weights. Costs included the ICS test, three injections of benzathine penicillin, and nurse wages. Country-specific inputs included the antenatal prevalence of syphilis and the proportion of women in the antenatal care setting that are screened for syphilis infection as reported in the 2014 WHO baseline report on global sexually transmitted infection surveillance. Country-specific data on the annual number of live births, proportion of women with at least one antenatal care visit, and per capita gross national income were also included in the model.

RESULTS

The incremental cost/DALY averted of syphilis screening is US$53 (range: US$10-US$332; Prob<1*per capita GDP=99.71%) in Asia and US$60 (range: US$5-US$225; Prob<1*per capita GDP=99.77%) in Latin America. Universal screening may reduce the annual number of stillbirths by 20,344 and 4,270, neonatal deaths by 8,201 and 1,721, cases of congenital syphilis by 10,952 and 2,298, and avert 925,039 and 197,454 DALYs in the aggregate Asian and Latin American panel, respectively.

CONCLUSION

Antenatal syphilis screening is highly cost-effective in all the 11 Asian and 20 Latin American countries assessed. Our findings support the decision to expand syphilis screening in countries with currently low screening rates or continue national syphilis screening programs in countries with high rates.

Bottlenecks in the implementation of essential screening tests in antenatal care: Syphilis, HIV, and anemia testing in rural Tanzania and Uganda

OBJECTIVE

To identify and compare implementation bottlenecks for effective coverage of screening for syphilis, HIV, and anemia in antenatal care in rural Tanzania and Uganda; and explore the underlying determinants and perceived solutions to overcome these bottlenecks.

METHODS

In this multiple case study, we analyzed data collected as part of the Expanded Quality Management Using Information Power (EQUIP) project between November 2011 and April 2014. Indicators from household interviews (n=4415 mothers) and health facility surveys (n=122) were linked to estimate coverage in stages of implementation between which bottlenecks can be identified. Key informant interviews (n=15) were conducted to explore underlying determinants and analyzed using a framework approach.

RESULTS

Large differences in implementation were found within and between countries. Availability and effective coverage was significantly lower for all tests in Uganda compared with Tanzania. Syphilis screening had the lowest availability and effective coverage in both countries. The main implementation bottleneck was poor availability of tests and equipment. Key informant interviews validated these findings and perceived solutions included the need for improved procurement at the central level.

CONCLUSION

Our findings reinforce essential screening as a missed opportunity, caused by a lack of integration of funding and support for comprehensive antenatal care programs.

The need for further integration of services to prevent mother-to-child transmission of HIV and syphilis in Mwanza City, Tanzania

OBJECTIVE

To assess the operational integration of maternal HIV testing and syphilis screening in Mwanza, Tanzania.

METHODS

Interviews were conducted with 76 health workers (HW) from three antenatal clinics (ANC) and three maternity wards in 2008-2009 and 1137 consecutive women admitted for delivery. Nine ANC health education sessions and client flow observations were observed.

RESULTS

Only 25.0% of HWs reported they had received training in both prevention of mother-to-child transmission (PMTCT) and syphilis screening. HIV and syphilis tests were sometimes performed in different rooms and results recorded in separate registers with different formats and the results were not always given by the same person. At delivery, most women had been tested for both HIV (79.4%) and syphilis (88.1%) during pregnancy. Of those not tested antenatally for each infection, 70.1% were tested for HIV at delivery but none for syphilis.

CONCLUSION

Integration of maternal HIV and syphilis screening was limited. Integrated care guidelines and related health worker training should address this gap.

A review of recent advances in rapid point-of-care tests for syphilis

Syphilis is a curable disease, yet over 10million people worldwide are infected with syphilis each year. Syphilis case finding and subsequent treatment are key steps in syphilis control and prevention efforts. The advent of rapid point-of-care tests - which require minimal equipment, are easy to perform and are relatively low cost - have the potential to improve syphilis control by allowing for more widespread testing in clinical and non-clinical settings. However, strategies to maximise the potential public health impact of those tests are needed, and those include regulatory oversight, effective supply-chain management and quality assurance systems.

Evaluation of the SD Bioline HIV/Syphilis Duo assay at a rural health center in Southwestern Uganda

Background

Point-of-care tests have the capacity to improve healthcare delivery by reducing costs and delay associated with care. A novel point-of-care immunochromatographic test for dual diagnosis of both HIV and syphilis by detecting IgG, IgM and IgA antibodies to HIV, and specific and recombinant Treponema pallidum antigens has recently been developed, but has not been evaluated in rural field settings. We evaluated the performance of the SD Bioline Syphilis/HIV Duo (Duo) assay at a healthcare center in rural Uganda.

Methods

A convenience sample of pregnant women attending Kinoni Health Centre IV from March to May, 2013 was enrolled. Venous blood was collected and centrifuged for plasma isolation. Samples were tested with the Duo assay and compared with the Treponema pallidum hemaglutination assay and paired HIV rapid antibody tests as the reference standards. The ease of use and time required for the Duo assay were also assessed by laboratory technicians.

Results

Two hundred twenty women were enrolled with a mean age of 25.00 years (SD 5.41). The sensitivity and specificity of the Duo assay were 100% (95% CI 79.0 – 100%) and 100% (95% CI 97.6 – 100.0) respectively, for syphilis, and, 100% (75.9 – 100%) and 99.5% (96.8 – 99.9%) respectively, for HIV. The duo kit was found to be faster and easier to use than the current HIV and syphilis testing techniques.

Conclusion

The sensitivity and specificity of the SD Bioline HIV/Syphilis Duo test were excellent in a field setting in Uganda. The Duo assay should be further evaluated in alternate populations and with point-of-care specimens (e.g. whole blood from finger stick specimens), but shows promise as a tool for improved HIV and syphilis surveillance, diagnosis, and treatment in field settings.

Multisite Laboratory Evaluation of a Dual Human Immunodeficiency Virus (HIV)/Syphilis Point-of-Care Rapid Test for Simultaneous Detection of HIV and Syphilis Infection

Background.

 Recently, test developers have created rapid point-of-care tests that can simultaneously detect multiple infections within the same specimen using a single device. The SD BIOLINE Duo HIV/Syphilis rapid point-of-care test uses a solid-phase immunochromatographic assay to detect immunoglobulin (Ig)G, IgM, and IgA antibodies to human immunodeficiency virus (HIV)-specific antigens (HIV-1 gp41, sub O, HIV-2 gp36) and recombinant Treponema pallidum antigen (17 kDa) in human serum. This study was a multisite laboratory-based evaluation of the performance of SD BIOLINE HIV/Syphilis Duo test using previously characterized sera in 6 countries.

Methods.

 Laboratories in Ghana, Mexico, Laos, Togo, Kenya, and Myanmar participated in the evaluation during 2012–2013. Each site characterized sera using T pallidum particle agglutination assay or T pallidum hemagglutination assay and HIV enzyme immunoassay, Western blot, and/or HIV antibody rapid tests. Those gold standard test results were compared with SD BIOLINE Duo test results. We calculated the sensitivity and specificity of test performance and used the exact binomial method to calculate 95% confidence intervals (CIs).

Results.

 The sensitivity and specificity for the HIV antibody test component (n = 2336) were estimated at 99.91% (95% CI, 99.51% and 100%) and 99.67% (95% CI, 99.16% and 99.91%), respectively. For the T pallidum test component (n = 2059), the sensitivity and specificity were estimated at 99.67% (95% CI, 98.82% and 99.96%) and 99.72% (95% CI, 99.29% and 99.92%), respectively.

Conclusions.

 The sensitivity and specificity of the SD BIOLINE HIV/Syphilis Duo test were consistently high across sera specimens from 6 countries around the world. Dual rapid tests should be considered for improved HIV and syphilis screening coverage.