Female Genital Schistosomiasis and HIV: Research Urgently Needed to Improve Understanding of the Health Impacts of This Important Coinfection

Coinfections in human papillomavirus associated cancers and prophylactic recommendations

The Human Papillomavirus (HPV) infection is responsible for more than 80% of reported cervical cancer and other virus-associated tumours. Although this global threat can be controlled using effective vaccination strategies, a growing perturbation of HPV infection is an emerging coinfection likely to increase the severity of the infection in humans. Moreover, these coinfections prolong the HPV infections, thereby risking the chances for oncogenic progression. The present review consolidated the clinically significant microbial coinfections/co-presence associated with HPV and their underlying molecular mechanisms. We discussed the gaps and concerns associated with demography, present vaccination strategies, and other prophylactic limitations. We concluded our review by highlighting the potential clinical as well as emerging computational intervention measures to kerb down HPV-associated severities.

[Consensus document for the management of schistosomiasis in Primary Care]

La esquistosomiasis humana es la enfermedad parasitaria con mayor morbimortalidad a nivel mundial después de la malaria. Es endémica en más de 78 países tropicales y subtropicales, sobre todo de África Subsahariana, estimándose que 236 millones de personas están infectadas. Puede causar graves complicaciones de salud a nivel genitourinario y hepatoesplénico, llegando a ocasionar la muerte de 300.000 personas cada año. El número de casos importados en los países occidentales se ha ido incrementado en los últimos años debido a la llegada de un importante número de migrantes procedentes de regiones endémicas y de un creciente número de viajeros que han visitado las mismas. Por otro lado, recientemente se han comunicado brotes de transmisión autóctona en Córcega (Francia) y Almería (España). Por todos estos aspectos, las autoridades sanitarias europeas han recomendado el cribado serológico de la enfermedad en todas las personas migrantes procedentes de zonas endémicas y que lleven menos de 5 años en Europa. Dado que atención primaria es habitualmente el primer punto de contacto de estas personas con el sistema sanitario, los médicos deben conocer los principales aspectos de la enfermedad, y ser dotados de los medios necesarios para su diagnóstico y tratamiento. Este documento ha sido elaborado por profesionales pertenecientes a 5 sociedades científicas de atención primaria (SEMFyC, SEMG, SEMERGEN), Pediatría (SEIP) y Medicina Tropical y Salud Internacional (SEMTSI), con objeto de establecer unas recomendaciones claras para el diagnóstico y el manejo de la esquistosomiasis en atención primaria.

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

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Supplementary Information

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

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

The parasitology of female genital schistosomiasis

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

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A review of female genital schistosomiasis.

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

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

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

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

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

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

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

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

The Impact of Neglected Tropical Diseases (NTDs) on Women's Health and Wellbeing in Sub-Saharan Africa (SSA): A Case Study of Kenya

Neglected Tropical Diseases (NTDs) trap individuals in a cycle of poverty through their devastating effects on health, wellbeing and social–economic capabilities that extend to other axes of inequity such as gender and/or ethnicity. Despite NTDs being regarded as equity tracers, little attention has been paid toward gender dynamics and relationships for gender-equitable access to NTD programs in sub-Saharan Africa (SSA). This paper examines the impact of NTDs on women’s health and wellbeing in SSA using Kenya as a case study. This research is part of a larger research program designed to examine the impact of NTDs on the health and wellbeing of populations in Kenya. Thematic analysis of key informants’ interviews (n = 21) and focus groups (n = 5) reveals first that NTDs disproportionately affect women and girls due to their assigned gender roles and responsibilities. Second, women face financial and time constraints when accessing health care due to diminished economic power and autonomy. Third, women suffer more from the related social consequences of NTDs (that is, stigma, discrimination and/or abandonment), which affects their health-seeking behavior. As such, we strongly suggest a gender lens when addressing NTD specific exposure, socio-economic inequities, and other gender dynamics that may hinder the successful delivery of NTD programs at the local and national levels.

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

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

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

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

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

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

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

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

Assessing the diversity and distribution of potential intermediate hosts snails for urogenital schistosomiasis: Bulinus spp. (Gastropoda: Planorbidae) of Lake Victoria

BACKGROUND

The Lake Victoria basin is one of the most persistent hotspots of schistosomiasis in Africa, the intestinal form of the disease being studied more often than the urogenital form. Most schistosomiasis studies have been directed to Schistosoma mansoni and their corresponding intermediate snail hosts of the genus Biomphalaria, while neglecting S. haematobium and their intermediate snail hosts of the genus Bulinus. In the present study, we used DNA sequences from part of the cytochrome c oxidase subunit 1 (cox1) gene and the internal transcribed spacer 2 (ITS2) region to investigate Bulinus populations obtained from a longitudinal survey in Lake Victoria and neighbouring systems during 2010-2019.

METHODS

Sequences were obtained to (i) determine specimen identities, diversity and phylogenetic positions, (ii) reconstruct phylogeographical affinities, and (iii) determine the population structure to discuss the results and their implications for the transmission and epidemiology of urogenital schistosomiasis in Lake Victoria.

RESULTS

Phylogenies, species delimitation methods (SDMs) and statistical parsimony networks revealed the presence of two main groups of Bulinus species occurring in Lake Victoria; B. truncatus/B. tropicus complex with three species (B. truncatus, B. tropicus and Bulinus sp. 1), dominating the lake proper, and a B. africanus group, prevalent in banks and marshes. Although a total of 47 cox1 haplotypes, were detected within and outside Lake Victoria, there was limited haplotype sharing (only Haplotype 6 was shared between populations from Lake Victoria open waters and neighbouring aquatic systems) - an indication that haplotypes are specific to habitats.

CONCLUSIONS

The Bulinus fauna of Lake Victoria consists of at least B. truncatus, B. tropicus, Bulinus sp. 1 (B. trigonus?) and B. ugandae. The occurrence and wide distribution of Bulinus species in Lake Victoria potentially implies the occurrence of urogenital schistosomiasis in communities living along the shores and on islands of the lake who depend solely on the lake for their livelihood. More in-depth studies are needed to obtain a better picture of the extent of the disease in the Lake Victoria basin.

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

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

Schistosoma and Other Relevant Helminth Infections in HIV-Positive Individuals-an Overview

For many years, researchers have postulated that helminthic infections may increase susceptibility to HIV, and that immune activation may have contributed to the extensive spread of HIV in sub-Saharan Africa. In the meantime, immunological studies have provided some evidence in support of this hypothesis, while cross-sectional clinical studies were able to further support the assumed association between HIV infection and selected helminthic co-infections. However, as many of the helminthic infections relevant to HIV-infected patients belong to the group of “neglected tropical diseases”, as defined by the World Health Organization, a certain lack of attention has inhibited progress in fully scaling up treatment and prevention efforts. In addition, despite the fact that the challenges of co-infections have preoccupied clinicians for over two decades, relevant research questions remain unanswered. The following review aims to provide a concise overview of associations between HIV and selected helminthic co-infections concerning aspects of HIV acquisition and transmission, clinical and immunological findings in co-infected individuals, as well as treatment and prevention efforts.