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Michalow J, Walters MK, Edun O, Wybrant M, Davies B, Kufa T, Mathega T, Chabata ST, Cowan FM, Cori A, Boily MC, Imai-Eaton JW. Aetiology of vaginal discharge, urethral discharge, and genital ulcer in sub-Saharan Africa: A systematic review and meta-regression. PLoS Med 2024; 21:e1004385. [PMID: 38768094 PMCID: PMC11104670 DOI: 10.1371/journal.pmed.1004385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 03/26/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Syndromic management is widely used to treat symptomatic sexually transmitted infections in settings without aetiologic diagnostics. However, underlying aetiologies and consequent treatment suitability are uncertain without regular assessment. This systematic review estimated the distribution, trends, and determinants of aetiologies for vaginal discharge, urethral discharge, and genital ulcer in sub-Saharan Africa (SSA). METHODS AND FINDINGS We searched Embase, MEDLINE, Global Health, Web of Science, and grey literature from inception until December 20, 2023, for observational studies reporting aetiologic diagnoses among symptomatic populations in SSA. We adjusted observations for diagnostic test performance, used generalised linear mixed-effects meta-regressions to generate estimates, and critically appraised studies using an adapted Joanna Briggs Institute checklist. Of 4,418 identified records, 206 reports were included from 190 studies in 32 countries conducted between 1969 and 2022. In 2015, estimated primary aetiologies for vaginal discharge were candidiasis (69.4% [95% confidence interval (CI): 44.3% to 86.6%], n = 50), bacterial vaginosis (50.0% [95% CI: 32.3% to 67.8%], n = 39), chlamydia (16.2% [95% CI: 8.6% to 28.5%], n = 50), and trichomoniasis (12.9% [95% CI: 7.7% to 20.7%], n = 80); for urethral discharge were gonorrhoea (77.1% [95% CI: 68.1% to 84.1%], n = 68) and chlamydia (21.9% [95% CI: 15.4% to 30.3%], n = 48); and for genital ulcer were herpes simplex virus type 2 (HSV-2) (48.3% [95% CI: 32.9% to 64.1%], n = 47) and syphilis (9.3% [95% CI: 6.4% to 13.4%], n = 117). Temporal variation was substantial, particularly for genital ulcer where HSV-2 replaced chancroid as the primary cause. Aetiologic distributions for each symptom were largely the same across regions and population strata, despite HIV status and age being significantly associated with several infection diagnoses. Limitations of the review include the absence of studies in 16 of 48 SSA countries, substantial heterogeneity in study observations, and impeded assessment of this variability due to incomplete or inconsistent reporting across studies. CONCLUSIONS In our study, syndrome aetiologies in SSA aligned with World Health Organization guidelines without strong evidence of geographic or demographic variation, supporting broad guideline applicability. Temporal changes underscore the importance of regular aetiologic re-assessment for effective syndromic management. PROSPERO NUMBER CRD42022348045.
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Affiliation(s)
- Julia Michalow
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Magdalene K. Walters
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Olanrewaju Edun
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Max Wybrant
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Bethan Davies
- MRC Centre for Environment and Health, Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom
| | - Tendesayi Kufa
- Centre for HIV & STI, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Thabitha Mathega
- Centre for HIV & STI, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Sungai T. Chabata
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR), Harare, Zimbabwe
| | - Frances M. Cowan
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR), Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Anne Cori
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Marie-Claude Boily
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Jeffrey W. Imai-Eaton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Müller EE, Gumede LYE, Maseko DV, Mahlangu MP, Venter JME, Da Costa Dias B, Nhlapho D, Kularatne RS. Emergence of high-level azithromycin-resistant Neisseria gonorrhoeae causing male urethritis in Johannesburg, South Africa, 2021. Sex Health 2024; 21:NULL. [PMID: 38029797 DOI: 10.1071/sh23143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/08/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND In South Africa, Neisseria gonorrhoeae , which is the predominant cause of male urethritis, is treated syndromically using dual ceftriaxone and azithromycin therapy. We determined antimicrobial susceptibilities of N. gonorrhoeae isolates from urethral discharge specimens, and genetically characterised those with elevated minimum inhibitory concentrations (MICs) for first-line antimicrobials. METHODS Routine antimicrobial susceptibility testing (AST) of N. gonorrhoeae isolates included E-test for ceftriaxone, cefixime and gentamicin and agar dilution for azithromycin and spectinomycin. Neisseria gonorrhoeae Sequence Typing for Antimicrobial Resistance (NG-STAR) was performed for isolates with elevated MICs to identify antimicrobial resistance (AMR) determinants, and Neisseria gonorrhoeae Multi-Antigen Sequence Typing (NG-MAST) was used to determine strain relatedness. RESULTS N. gonorrhoeae was cultured from urethral discharge swab specimens obtained from 196 of 238 (82.4%) men presenting to a primary healthcare facility in Johannesburg in 2021. All viable isolates were susceptible to extended-spectrum cephalosporins. Four isolates had high azithromycin MICs ranging from 32mg/L to >256mg/L and grouped into two novel NG-MAST and NG-STAR groups. Two isolates from Group 1 (NG-MAST ST20366, NG-STAR ST4322) contained mutated mtrR (G45D) and 23S rRNA (A2059G) alleles, while the two isolates from Group 2 (NG-MAST ST20367, NG-STAR ST4323) had different mutations in mtrR (A39T) and 23S rRNA (C2611T). CONCLUSIONS We report the first cases of high-level azithromycin resistance in N. gonorrhoeae from South Africa. Continued AMR surveillance is critical to detect increasing azithromycin resistance prevalence in N. gonorrhoeae , which may justify future modifications to the STI syndromic management guidelines.
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Affiliation(s)
- Etienne E Müller
- Centre for HIV and Sexually Transmitted Infections, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Lindy Y E Gumede
- Centre for HIV and Sexually Transmitted Infections, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Dumisile V Maseko
- Centre for HIV and Sexually Transmitted Infections, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Mahlape P Mahlangu
- Centre for HIV and Sexually Transmitted Infections, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Johanna M E Venter
- Centre for HIV and Sexually Transmitted Infections, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Bianca Da Costa Dias
- Centre for HIV and Sexually Transmitted Infections, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Duduzile Nhlapho
- Centre for HIV and Sexually Transmitted Infections, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Ranmini S Kularatne
- Centre for HIV and Sexually Transmitted Infections, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa; and Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; and Present address: Labtests Auckland and Northland Pathology, Mt Wellington, Auckland, New Zealand
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Peters RPH, Jung H, Mitchev N, Mdingi MM, Gigi R, Shroufi A, Martinez FP, Bamford C. Antimicrobial Resistance and Molecular Typing of Neisseria gonorrhoeae Isolates From the Eastern Cape Province in South Africa. Sex Transm Dis 2023; 50:821-826. [PMID: 37820114 DOI: 10.1097/olq.0000000000001877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND There is a paucity of Neisseria gonorrhoeae antimicrobial resistance data from resource-constrained settings because of the lack of diagnostic testing and limited scale of surveillance programs. This study aimed to determine the antimicrobial resistance profile of N. gonorrhoeae in the rural Eastern Cape province of South Africa. METHODS Specimens for N. gonorrhoeae culture were obtained from men with urethral discharge and women with vaginal discharge attending primary health care facilities. Direct inoculation of the agar plates was performed followed by culture and drug susceptibility testing using the Etest at the laboratory. Whole-genome sequencing of the isolates was performed to identify resistance-determining variants. RESULTS One hundred N. gonorrhoeae isolates were obtained. Most strains were nonsusceptible to ciprofloxacin (76%), tetracycline (75%), and penicillin G (72%). The gyrA S91F mutation was present in 68 of 72 ciprofloxacin-resistant isolates (94%), with concurrent parC mutations in 47 of 68 (69%); gyrA I250M was the only mutation in 4 other resistant strains. One azithromycin-resistant isolate was identified with a minimal inhibitory concentration (MIC) of 8.0 mg/L and the 23S rDNA gene mutation C2597T. The median MIC of cefixime was 0.016 mg/L (range, 0.016-0.064 mg/L), and that of ceftriaxone was 0.016 mg/L (range, 0.016 mg/L). Whole-genome sequencing showed 58 sequence types as revealed in N. gonorrhoeae sequence typing for antimicrobial resistance and 70 sequence types in N. gonorrhoeae multiantigen sequence typing. CONCLUSIONS This study confirmed high rates of N. gonorrhoeae antimicrobial resistance to ciprofloxacin, penicillin G, and tetracycline in our setting. The MICs of cephalosporins are reassuring for ceftriaxone use in syndromic treatment regimens, but the identification of azithromycin resistance warrants further attention.
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Affiliation(s)
| | - Hyunsul Jung
- Department of Medical Microbiology, University of Pretoria, Pretoria
| | - Nireshni Mitchev
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Mandisa M Mdingi
- From the Research Unit, Foundation for Professional Development, East London
| | | | - Amir Shroufi
- Drugs for Neglected Diseases Initiative (DNDi) & Global Antibiotic Research & Development Partnership (GARDP) Southern Africa, Cape Town, South Africa
| | - Fernando P Martinez
- Global Antibiotic Research & Development Partnership (GARDP), Geneva, Switzerland
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Kittiyaowamarn R, Girdthep N, Cherdtrakulkiat T, Sangprasert P, Tongtoyai J, Weston E, Borisov A, Dunne EF, Chinhiran K, Woodring J, Ngarmjiratam N, Masciotra S, Frankson R, Sirivongrangson P, Unemo M, Wi T. Neisseria gonorrhoeae antimicrobial susceptibility trends in Bangkok, Thailand, 2015-21: Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP). JAC Antimicrob Resist 2023; 5:dlad139. [PMID: 38115859 PMCID: PMC10729850 DOI: 10.1093/jacamr/dlad139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023] Open
Abstract
Objectives Rising antimicrobial resistance (AMR) in Neisseria gonorrhoeae is a global public health concern. Many ceftriaxone-resistant cases have been linked to Asia. In the WHO/CDC global Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP), we conducted AMR surveillance at two clinical sites in Bangkok, Thailand, 2015-21. Methods Urethral discharge samples, from males with urethral discharge and/or dysuria, were Gram-stained and cultured. ETEST was performed to determine AMR. EGASP MIC alert values, CLSI and EUCAST breakpoints were used. Results In 2015-21, gonococcal isolates were cultured from 1928 cases; most (64.1%) were males reporting having sex with females. The sensitivity and specificity of Gram-stained microscopy compared with culture for detection of gonococci were 97.5% and 96.6%, respectively. From 2015 to 2021, the azithromycin MIC90 increased from 0.125 to 1 mg/L, and the MIC90 of ceftriaxone and cefixime increased from 0.008 and ≤0.016 mg/L to 0.032 and 0.064 mg/L, respectively. Eight EGASP MIC alert values (in seven isolates) were identified. Five alert values were for cefixime (all resistant according to EUCAST breakpoints) and three for azithromycin (all resistant according to EUCAST breakpoints). The average annual resistance to ciprofloxacin during 2015-21 was 92%. Conclusions A continuous high susceptibility to ceftriaxone, Thailand's first-line gonorrhoea treatment, was found. However, the increasing MICs of ceftriaxone, cefixime and azithromycin are a substantial threat, especially considering these are the last remaining options for the treatment of gonorrhoea. To monitor AMR, continuous and quality-assured gonococcal AMR surveillance such as the Thai WHO/CDC EGASP, ideally including WGS, is imperative globally.
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Affiliation(s)
- Rossaphorn Kittiyaowamarn
- Bangrak STIs Center, Division of AIDS and STIs, Department of Disease Control and Prevention, Thailand Ministry of Public Health, Nonthaburi, Thailand
| | - Natnaree Girdthep
- Bangrak STIs Center, Division of AIDS and STIs, Department of Disease Control and Prevention, Thailand Ministry of Public Health, Nonthaburi, Thailand
| | - Thitima Cherdtrakulkiat
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Division of HIV Prevention, Thailand Ministry of Public Health—U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Pongsathorn Sangprasert
- Bangrak STIs Center, Division of AIDS and STIs, Department of Disease Control and Prevention, Thailand Ministry of Public Health, Nonthaburi, Thailand
| | - Jaray Tongtoyai
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Division of HIV Prevention, Thailand Ministry of Public Health—U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Emily Weston
- Division of STD Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Andrey Borisov
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Division of HIV Prevention, Thailand Ministry of Public Health—U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Eileen F Dunne
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Division of HIV Prevention, Thailand Ministry of Public Health—U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Kittipoom Chinhiran
- Bangrak STIs Center, Division of AIDS and STIs, Department of Disease Control and Prevention, Thailand Ministry of Public Health, Nonthaburi, Thailand
| | - Joseph Woodring
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Division of HIV Prevention, Thailand Ministry of Public Health—U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Nattapon Ngarmjiratam
- Bangrak STIs Center, Division of AIDS and STIs, Department of Disease Control and Prevention, Thailand Ministry of Public Health, Nonthaburi, Thailand
| | - Silvina Masciotra
- Division of HIV Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Division of HIV Prevention, Thailand Ministry of Public Health—U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Rebekah Frankson
- Division of STD Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Pachara Sirivongrangson
- Department of Disease Control and Prevention, Thailand Ministry of Public Health, Nonthaburi, Thailand
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other STIs, Department of Laboratory Medicine, Microbiology, Örebro University, Örebro, Sweden
- Institute for Global Health, University College London, London, UK
| | - Teodora Wi
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
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Shipitsyna E, Kularatne R, Golparian D, Müller EE, Vargas SK, Hadad R, Padovese V, Hancali A, Alvarez CS, Oumzil H, Camey E, Blondeel K, Toskin I, Unemo M. Mycoplasma genitalium prevalence, antimicrobial resistance-associated mutations, and coinfections with non-viral sexually transmitted infections in high-risk populations in Guatemala, Malta, Morocco, Peru and South Africa, 2019-2021. Front Microbiol 2023; 14:1130762. [PMID: 36910203 PMCID: PMC9994645 DOI: 10.3389/fmicb.2023.1130762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/03/2023] [Indexed: 02/25/2023] Open
Abstract
The prevalence of Mycoplasma genitalium (MG) and MG antimicrobial resistance (AMR) appear to be high internationally, however, prevalence data remain lacking globally. We evaluated the prevalence of MG and MG AMR-associated mutations in men who have sex with men (MSM) in Malta and Peru and women at-risk for sexually transmitted infections in Guatemala, South Africa, and Morocco; five countries in four WHO regions mostly lacking MG prevalence and AMR data, and estimated MG coinfections with Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV). Male urine and anorectal samples, and vaginal samples were tested for MG, CT, NG, and TV (only vaginal samples) using Aptima assays (Hologic). AMR-associated mutations in the MG 23S rRNA gene and parC gene were identified using ResistancePlus MG kit (SpeeDx) or Sanger sequencing. In total, 1,425 MSM and 1,398 women at-risk were recruited. MG was detected in 14.7% of MSM (10.0% in Malta and 20.0% Peru) and in 19.1% of women at-risk (12.4% in Guatemala, 16.0% Morocco, 22.1% South Africa). The prevalence of 23S rRNA and parC mutations among MSM was 68.1 and 29.0% (Malta), and 65.9 and 5.6% (Peru), respectively. Among women at-risk, 23S rRNA and parC mutations were revealed in 4.8 and 0% (Guatemala), 11.6 and 6.7% (Morocco), and 2.4 and 3.7% (South Africa), respectively. CT was the most frequent single coinfection with MG (in 2.6% of MSM and 4.5% of women at-risk), compared to NG + MG found in 1.3 and 1.0%, respectively, and TV + MG detected in 2.8% of women at-risk. In conclusion, MG is prevalent worldwide and enhanced aetiological MG diagnosis, linked to clinical routine detection of 23S rRNA mutations, in symptomatic patients should be implemented, where feasible. Surveillance of MG AMR and treatment outcome would be exceedingly valuable, nationally and internationally. High levels of AMR in MSM support avoiding screening for and treatment of MG in asymptomatic MSM and general population. Ultimately, novel therapeutic antimicrobials and/or strategies, such as resistance-guided sequential therapy, and ideally an effective MG vaccine are essential.
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Affiliation(s)
- Elena Shipitsyna
- World Health Organization Collaborating Centre for Gonorrhoea and Other STIs, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.,Department of Medical Microbiology, D.O. Ott Research Institute of Obstetrics, Gynecology and Reproductology, St. Petersburg, Russia
| | - Ranmini Kularatne
- Labtests Laboratory and Head Office, Mt Wellington, Auckland, New Zealand.,Department of Clinical Microbiology & Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Daniel Golparian
- World Health Organization Collaborating Centre for Gonorrhoea and Other STIs, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Etienne E Müller
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Silver K Vargas
- School of Public Health and Administration, Centre for Interdisciplinary Investigation in Sexuality, AIDS, Society and Laboratory of Sexual Health, Universidad Peruana Cayetano Heredia, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Ronza Hadad
- World Health Organization Collaborating Centre for Gonorrhoea and Other STIs, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Valeska Padovese
- Genitourinary Clinic, Department of Dermatology and Venereology, Mater Dei Hospital, Msida, Malta
| | - Amina Hancali
- STIs Laboratory, National Institute of Hygiene, Ministry of Health, Rabat, Morocco
| | | | - Hicham Oumzil
- STIs Laboratory, National Institute of Hygiene, Ministry of Health, Rabat, Morocco.,Faculty of Medicine and Pharmacy, University Mohamed V, Rabat, Morocco
| | - Elsy Camey
- Sida y Sociedad ONG (SISO), Escuintla, Guatemala
| | - Karel Blondeel
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland.,Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Igor Toskin
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Magnus Unemo
- World Health Organization Collaborating Centre for Gonorrhoea and Other STIs, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.,Institute for Global Health, University College London (UCL), London, United Kingdom
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Peters RP, Garrett N, Chandiwana N, Kularatne R, Brink AJ, Cohen K, Gill K, Chidarikire T, Wattrus C, Nel JS, Moosa MY, Bekker LG. Southern African HIV Clinicians Society 2022 guideline for the management of sexually transmitted infections: Moving towards best practice. South Afr J HIV Med 2022; 23:1450. [PMID: 36299557 PMCID: PMC9575338 DOI: 10.4102/sajhivmed.v23i1.1450] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 08/12/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Remco P.H. Peters
- Research Unit, Foundation for Professional Development, East London, South Africa,Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa,Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa,Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Nomathemba Chandiwana
- Ezintsha, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa
| | - Ranmini Kularatne
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Adrian J. Brink
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Karen Cohen
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Katherine Gill
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | | | - Camilla Wattrus
- Southern African HIV Clinicians Society (SAHCS), Johannesburg, South Africa
| | - Jeremy S. Nel
- Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Mahomed Y.S. Moosa
- Department of Infectious Disease, Division of Internal Medicine, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
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