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Wynn A, Mussa A, Ryan R, Babalola CM, Hansman E, Ramontshonyana K, Tamuthiba L, Ndlovu N, Wilson ML, Ramogola-Masire D, Klausner JD, Morroni C. Evaluating Chlamydia trachomatis and Neisseria gonorrhoeae screening and treatment among asymptomatic pregnant women to prevent preterm birth and low birthweight in Gaborone, Botswana: A secondary analysis from a non-randomised, cluster-controlled trial. BJOG 2024; 131:1259-1269. [PMID: 38351649 DOI: 10.1111/1471-0528.17775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 01/05/2024] [Accepted: 01/18/2024] [Indexed: 07/04/2024]
Abstract
OBJECTIVE To evaluate the impact of screening and treating asymptomatic pregnant women for Chlamydia (C.) trachomatis and Neisseria (N.) gonorrhoeae infections on the frequency of preterm birth or low birthweight infants in Botswana. DESIGN Non-randomised, cluster-controlled trial. SETTING Four antenatal care clinics in Gaborone, Botswana. POPULATION Pregnant women aged ≥15 years, attending a first antenatal care visit, ≤27 weeks of gestation and without urogenital symptoms were eligible. METHODS Participants in the intervention clinics received screening (GeneXpert®, Cepheid) during pregnancy and at the postnatal visit. Participants in the standard-of-care clinics received screening at the postnatal visit only. We used multivariable logistic regression and post-estimation predictive margins analysis. Post-hoc analysis was conducted among sub-samples stratified by parity. MAIN OUTCOME MEASURES Preterm birth (<37 weeks of gestation) and low birthweight (<2500 g). RESULTS After controlling for parity, hypertension, antenatal care visits and clinic site, the predicted prevalence of preterm birth or low birthweight was lower in the intervention arm (11%) compared with the standard-of-care arm (16%) (adjusted odds ratio [aOR] 0.59; 95% confidence interval [CI] 0.28-1.24). In post-hoc analysis, the intervention was more effective than the standard-of-care (aOR 0.20; 95% CI 0.07-0.64) among nulliparous participants. CONCLUSION A C. trachomatis and N. gonorrhoeae infection screening and treatment intervention among asymptomatic pregnant women may have reduced preterm birth or low birthweight outcomes, but results were not statistically significant. Post-hoc analysis found that the intervention reduced adverse outcomes among nulliparous participants.
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Affiliation(s)
- Adriane Wynn
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, La Jolla, California, USA
- Botswana Harvard AIDS Institute Partnership, Princess Marina Hospital, Gaborone, Botswana
| | - Aamirah Mussa
- Botswana Harvard AIDS Institute Partnership, Princess Marina Hospital, Gaborone, Botswana
- Old Medical School, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Rebecca Ryan
- Botswana Harvard AIDS Institute Partnership, Princess Marina Hospital, Gaborone, Botswana
| | - Chibuzor M Babalola
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Emily Hansman
- David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Lefhela Tamuthiba
- Botswana Harvard AIDS Institute Partnership, Princess Marina Hospital, Gaborone, Botswana
| | - Neo Ndlovu
- Botswana Harvard AIDS Institute Partnership, Princess Marina Hospital, Gaborone, Botswana
| | - Melissa L Wilson
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynaecology, University of Botswana, Sir Ketumile Masire Teaching Hospital/G5038, Gaborone, Botswana
| | - Jeffrey D Klausner
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Chelsea Morroni
- Botswana Harvard AIDS Institute Partnership, Princess Marina Hospital, Gaborone, Botswana
- MRC Centre for Reproductive Health, University of Edinburgh, The Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, UK
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Wong A, Applegate T, Boettiger DC, Varma R, Guy R, Medland N. Unnecessary antibiotic use in men who have sex with men (MSM) with anogenital symptoms attending a sexual health clinic: a retrospective analysis. Sex Transm Infect 2024:sextrans-2024-056120. [PMID: 38871452 DOI: 10.1136/sextrans-2024-056120] [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: 01/28/2024] [Accepted: 05/29/2024] [Indexed: 06/15/2024] Open
Abstract
OBJECTIVES To quantify the amount of unnecessary antibiotics, in particular ceftriaxone, given to men who have sex with men (MSM) with anogenital symptoms as part of presumptive management in an urban sexual health clinic and examine factors associated with unnecessary ceftriaxone. METHODS This is a retrospective cross-sectional analysis of electronic records from all visits involving MSM reporting symptoms of bacterial sexually transmitted infection (STI) and who received presumptive antibiotics at Sydney Sexual Health Centre. The following variables were extracted: demographic and sexual behaviour data, presenting symptoms, prior STI diagnoses, use of anoscopy, use of point-of-care microscopy, prescriptions of antibiotics and subsequent nucleic acid amplification testing (NAAT) results for chlamydia and gonorrhoea in all anatomical sites (urethra, pharynx and rectum). We defined unnecessary antibiotic as an agent prescribed to treat an STI organism that was subsequently not detected. RESULTS Among 1061 visits in this analysis, 41.8% yielded negative NAAT results for both chlamydia and gonorrhoea in all anatomical sites. There were 44.3% of visits which had positive gonorrhoea NAAT result in at least one anatomical site. There were 187 courses of ceftriaxone prescribed in patients who tested negative for gonorrhoea in all anatomical sites and therefore were unnecessary. Unnecessary ceftriaxone prescribing occurred in 50.2% of visits with anorectal symptoms, 19.6% of scrotal symptoms and 7.3% of urethral symptoms. Microscopy was associated with significantly less unnecessary ceftriaxone in urethral but not anorectal or scrotal presentations. In multivariable analysis, the following factors were associated with a higher likelihood of unnecessary ceftriaxone use: anorectal symptoms, scrotal symptoms, gonorrhoea in the preceding year, contact of a bacterial STI and living with HIV. CONCLUSIONS This study highlights the significant amount of unnecessary ceftriaxone used for STI symptoms in MSM. A new pathway incorporating rapid point-of-care molecular testing in symptomatic patients may improve the precision of antibiotic prescribing and reduce unnecessary use.
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Affiliation(s)
- Arthur Wong
- Sydney Sexual Health Centre, Sydney, New South Wales, Australia
- The Kirby Institute, Kensington, New South Wales, Australia
| | | | | | - Rick Varma
- Sydney Sexual Health Centre, Sydney, New South Wales, Australia
- The Kirby Institute, Kensington, New South Wales, Australia
| | - Rebecca Guy
- The Kirby Institute, Kensington, New South Wales, Australia
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Manjate A, Sergon G, Kenga D, Golparian D, Tyulenev Y, Loquilha O, Mausse F, Guschin A, Langa JC, Passanduca A, Sacarlal J, Unemo M. Prevalence of sexually transmitted infections (STIs), associations with sociodemographic and behavioural factors, and assessment of the syndromic management of vaginal discharge in women with urogenital complaints in Mozambique. FRONTIERS IN REPRODUCTIVE HEALTH 2024; 6:1323926. [PMID: 38706519 PMCID: PMC11067503 DOI: 10.3389/frph.2024.1323926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 04/04/2024] [Indexed: 05/07/2024] Open
Abstract
In Mozambique, sexually transmitted infections (STIs) are estimated to be prevalent, but diagnosis and treatment of curable STIs rely only on syndromic management. We examined the prevalence of four non-viral STIs and HIV-1/2, based on etiological diagnosis, associations with sociodemographic and behavioural factors, and the STI diagnostic accuracy of the vaginal discharge syndromic management in women with urogenital complaints in Maputo, Mozambique. A cross-sectional study was performed in Maputo, Mozambique, February 2018-January 2019, enrolling 924 women of reproductive age with urogenital complaints. Endocervical/vaginal swabs were sampled and chlamydia, gonorrhoea, trichomoniasis and Mycoplasma genitalium infections were diagnosed using a multiplex real-time PCR (AmpliSens; InterLabServices). Serological testing was performed for HIV-1/2. A structured questionnaire collected metadata. All data were analyzed in STATA/IC 12.1 using descriptive statistics, chi-square tests and logistic regression model. About 40% of the women were less than 24 years old, 50.8% were single, 62.1% had their sexual debut between 12 and 17 years of age, and the main complaint was vaginal discharge syndrome (85%). The prevalence of chlamydia was 15.5%, trichomoniasis 12.1%, gonorrhoea 4.0%, M. genitalium 2.1%, and HIV-1/2 22.3%. The vaginal discharge syndrome flowchart had a sensitivity of 73.0%-82.5% and a specificity of 14%-15% for the detection of any individual non-viral STI in women with urogenital complaints. In total, 19.2% of the symptomatic women with chlamydia, trichomoniasis or gonorrhoea would not be detected and accordingly treated using the vaginal discharge syndromic management (missed treatment) and 70.0% of the women would be treated despite not being infected with any of these three STIs (overtreatment). In conclusion, a high prevalence of especially chlamydia, trichomoniasis, and HIV-1/2 was found in women of childbearing age with urogenital complaints in Maputo, Mozambique. Syndromic management of vaginal discharge revealed low accuracy in the detection of STIs in symptomatic women, especially low specificity, which resulted in under-treatment of STI-positive cases and incorrect or over-treatment of women with urogenital complaints, many of whom were negative for all the non-viral STIs. Etiological diagnosis is imperative for effective management of STIs in symptomatic and asymptomatic women.
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Affiliation(s)
- Alice Manjate
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Departament de Microbiologia, Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Gladys Sergon
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Darlenne Kenga
- Departament de Microbiologia, Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Daniel Golparian
- WHO Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Yuriy Tyulenev
- Department of Healthcare, Moscow Scientific and Practical Center of Dermatovenereology and Cosmetology, Moscow, Russia
| | - Osvaldo Loquilha
- Departamento de Matemática e Informática, Faculdade de Ciências, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Fabião Mausse
- Departament de Microbiologia, Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Alexander Guschin
- Department of Healthcare, Moscow Scientific and Practical Center of Dermatovenereology and Cosmetology, Moscow, Russia
| | - José Carlos Langa
- Departament de Microbiologia, Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Alfeu Passanduca
- Departament de Microbiologia, Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Jahit Sacarlal
- Departament de Microbiologia, Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Magnus Unemo
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- WHO Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections, 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 RPH, Klausner JD, Mazzola L, Mdingi MM, Jung H, Gigi RMS, Piton J, Daniels J, de Vos L, Adamson PC, Gleeson B, Ferreyra C. Novel lateral flow assay for point-of-care detection of Neisseria gonorrhoeae infection in syndromic management settings: a cross-sectional performance evaluation. Lancet 2024; 403:657-664. [PMID: 38335982 PMCID: PMC11246789 DOI: 10.1016/s0140-6736(23)02240-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/14/2023] [Accepted: 10/04/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND A rapid and affordable point-of-care test is a priority for Neisseria gonorrhoeae control. WHO and Foundation for Innovative New Diagnostics (FIND) have a target product profile for a non-molecular N gonorrhoeae rapid point-of-care test that requires a clinical sensitivity of greater than 80% and a specificity over 95% to be considered useful in syndromic management; test turnaround time should be 30 min or under, and the test should cost less than US$3. A novel lateral flow assay (LFA) was developed to achieve that profile. METHODS In this cross-sectional study we evaluated the performance of the novel N gonorrhoeae lateral flow assay (NG-LFA) at the primary health-care level in South Africa. Male patients with urethral discharge syndrome and female patients with vaginal discharge syndrome were recruited from five primary health-care facilities in the Buffalo City Metropolitan Municipality health district of South Africa. First-void urine specimens and nurse-collected vaginal swabs were tested in-facility with the NG-LFA and Xpert CT/NG PCR assay. N gonorrhoeae multi-antigen sequence typing (NG-MAST) was performed on all LFA positive specimens. FINDINGS Between March 7, and Sept 19, 2022, we enrolled 200 male patients with urethral discharge and 200 female patients with vaginal discharge. The median age of male patients was 24 years (IQR 21-31 years), and the median age of female patients was 25 years (IQR 21-32 years). In addition, 23 male patients and 12 female patients who presented at the facility with a partner notification slip were enrolled of whom one (4%) and five (42%) were symptomatic, respectively. NG-LFA and Xpert results were available for all participants. In urine specimens, NG-LFA sensitivity was 96·1% (Wilson 95% CI 91·2-98·3; 123 LFA-positive among 128 PCR-positive specimens) and 91·7% in vaginal swab specimens (78·2-97·1; 33 LFA-positive among 36 PCR-positive). The specificity was 97·2% in urine specimens (90·4-99·2; 70 LFA-negative among 72 PCR-negative) and 96·3% in vaginal specimens (92·2-98·3; 158 LFA-negative among 164 PCR-negative). In 156 LFA-positive specimens, NG-MAST showed 93 different sequence types. INTERPRETATION The novel NG-LFA had excellent clinical sensitivity and specificity in symptomatic male and female patients. The test met the optimal requirement for sensitivity and the minimal requirement for specificity specified in the target product profile. NG-LFA could provide an important tool to optimise clinical management and reduce excess antibiotic use in settings without direct access to laboratory testing. FUNDING Global Antimicrobial Resistance Innovation Fund (GAMRIF) via FIND and National Institutes of Health.
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Affiliation(s)
- Remco P H Peters
- Foundation for Professional Development, Research Unit, East London, South Africa; Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa; Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa.
| | - Jeffrey D Klausner
- Keck School of Medicine, Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
| | - Laura Mazzola
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Mandisa M Mdingi
- Foundation for Professional Development, Research Unit, East London, South Africa
| | - Hyunsul Jung
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| | - Ranjana M S Gigi
- Foundation for Professional Development, Research Unit, East London, South Africa; Department of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Jeremie Piton
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Joseph Daniels
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | - Lindsey de Vos
- Foundation for Professional Development, Research Unit, East London, South Africa
| | - Paul C Adamson
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Birgitta Gleeson
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Cecilia Ferreyra
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
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Govender V, Moodley D, Naidoo M, Connoly C, Ngcapu S, Abdool Karim Q. High incidence of asymptomatic genital tract infections in pregnancy in adolescent girls and young women: need for repeat aetiological screening. Sex Transm Infect 2023; 99:482-488. [PMID: 37208192 DOI: 10.1136/sextrans-2022-055658] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 04/10/2023] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION Sexually transmitted infection (STI) prevalence and incidence estimates for pregnant adolescents are under-reported. We estimated prevalence and incidence of STIs in pregnant adolescents (15-19 years) in comparison with pregnant women 20-24 and >25 years. METHODS Pregnant women registering at primary care clinics in Umlazi, a periurban subdistrict in KwaZulu-Natal, South Africa, were enrolled in an HIV incidence cohort study during February 2017-March 2018. Women were examined for abnormal vaginal discharge, received empirical treatment, tested for HIV-1 and had vaginal swabs taken at their first and a subsequent visit in the third trimester. Vaginal swabs were stored for STI testing at completion of study and tested for Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium using PCR. RESULTS A total of 752 HIV-negative pregnant women were enrolled at a median gestational age of 17 weeks: 180 (23.9%), 291 (38.7%) and 281 (37.4%) in the 15-19, 20-24 and >25 years age groups. Pregnant adolescents had an STI prevalence of 26.7% at baseline, not significantly lower than the 20-24 (34.7%, OR 1.4; 95% CI 1.0 to 2.1, p=0.09) and >25 years (33.8%, OR 1.4; 95% CI 0.9 to 2.1, p=0.12) age groups. T. vaginalis (11.1%), C. trachomatis (7.8%) and N. gonorrhoeae (4.4%) were most prevalent in adolescents, a trend similar to the other age groups. Overall, 43.4% were symptomatic and treated at baseline. Overall, 40.7% (118 of 290) of women who tested negative for an STI at baseline tested positive at the repeat visit (incidence 19.5/100 person years). STI incidence in pregnant adolescents was 23.9/100 person years and comparable with older age groups (20.5/100 person years and 16.2/100 person years). At the repeat visit, 19.0% of all women with an STI were symptomatic and treated. Performance of syndromic management was poor at baseline (negative predictive value (NPV) 68.6%, positive predictive value (PPV) 34.0%) and at repeat visit (NPV 58.4%, PPV 34.3%). CONCLUSIONS Prevalence of asymptomatic curable STIs in pregnant adolescents is high and comparable with women >20 years old. Adolescents remain at substantial risk of asymptomatic incident STIs during pregnancy.
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Affiliation(s)
- Vani Govender
- Centre for the AIDS Program of Research in South Africa, CAPRISA, Durban, KwaZulu-Natal, South Africa
- Obstetrics and Gynaecology, University of KwaZulu-Natal College of Health Sciences, Durban, KwaZulu-Natal, South Africa
| | - Dhayendre Moodley
- Centre for the AIDS Program of Research in South Africa, CAPRISA, Durban, KwaZulu-Natal, South Africa
- Obstetrics and Gynaecology, University of KwaZulu-Natal College of Health Sciences, Durban, KwaZulu-Natal, South Africa
| | - Megeshinee Naidoo
- Centre for the AIDS Program of Research in South Africa, CAPRISA, Durban, KwaZulu-Natal, South Africa
| | - Cathy Connoly
- Department of Biostatistics, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Sinaye Ngcapu
- Centre for the AIDS Program of Research in South Africa, CAPRISA, Durban, KwaZulu-Natal, South Africa
- Department of Medical Microbiology, University of KwaZulu-Natal College of Health Sciences, Durban, KwaZulu-Natal, South Africa
| | - Quarraisha Abdool Karim
- Centre for the AIDS Program of Research in South Africa, CAPRISA, Durban, KwaZulu-Natal, South Africa
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Babalola CM, Peters RPH, Mukomana F, Mdingi M, Gigi RMS, Muzny CA, Taylor CM, Medina-Marino A, Klausner JD. A Call to Standardize the Definition and Method of Assessing Women for Vaginal Discharge Syndrome in Pregnancy. Open Forum Infect Dis 2023; 10:ofad157. [PMID: 37035494 PMCID: PMC10077826 DOI: 10.1093/ofid/ofad157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/20/2023] [Indexed: 04/09/2023] Open
Affiliation(s)
- Chibuzor M Babalola
- Department of Population and Public Health Science, University of Southern California, Los Angeles, California, USA
| | - 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, University of Cape Town, Cape Town, South Africa
| | - Freedom Mukomana
- Research Unit, Foundation for Professional Development, East London, South Africa
| | - Mandisa Mdingi
- Research Unit, Foundation for Professional Development, East London, South Africa
| | - Ranjana M S Gigi
- Research Unit, Foundation for Professional Development, East London, South Africa
- Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | - Christina A Muzny
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Christopher M Taylor
- Department of Microbiology, Immunology and Parasitology, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - Andrew Medina-Marino
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey D Klausner
- Department of Population and Public Health Science, University of Southern California, Los Angeles, California, USA
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de Voux A, Mvududu R, Happel A, Jaspan HB, Nyemba DC, Mashele N, Myer L, Davey DLJ. Point-of-Care Sexually Transmitted Infection Testing Improves HIV Preexposure Prophylaxis Initiation in Pregnant Women in Antenatal Care in Cape Town, South Africa, 2019 to 2021. Sex Transm Dis 2023; 50:92-97. [PMID: 36630416 PMCID: PMC9906800 DOI: 10.1097/olq.0000000000001729] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background Pre-exposure prophylaxis (PrEP) programs present a platform for diagnostic STI testing in low- and middle-income countries, and availability of targeted STI testing has been hypothesized to influence PrEP use. We evaluated the association of STI testing modality and PrEP uptake among pregnant women in antenatal care. Methods We enrolled pregnant, HIV-uninfected women (≥16 years) at their first antenatal visit with follow-up through 12 months postpartum. Women were offered oral PrEP and tested for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) using a point-of-care (Cepheid, August 2019–November 2020) or laboratory-based (Thermofisher, December 2020–October 2021) test. We compared the proportion of women initiating and continuing PrEP by STI test adjusting for confounders. Results We evaluated 1194 women (median age=26 years [IQR:22–31]) with a STI result (46% POC and 54% laboratory-based). The prevalence of any STI was the same in POC-tested (28%) and laboratory-tested (28%) women — 25% versus 23% for CT (p-value=0.35) and 7% versus 9% for NG (p-value=0.11). Mean time from testing to result was 0 for POC and 26 days for laboratory testing and mean time from testing to treatment was 3 for POC and 38 days for laboratory testing. Receiving a POC STI test was associated with higher PrEP initiation compared to women receiving a laboratory-based test (90% versus 78%; adjusted odds ratio=2.1; 95% CI:1.5–2.9), controlling for age, gravidity, STI diagnosis, intimate partner violence, gestational age, employment, HIV risk perception, and cohabiting status. Conclusion POC STI testing, offering same-day results and treatment initiation, may increase PrEP initiation among pregnant women in antenatal care. A study of HIV-uninfected pregnant women in South Africa found that women offered point-of-care STI testing had a higher odds of initiating HIV pre-exposure prophylaxis than women offered laboratory-based testing.
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Affiliation(s)
- Alex de Voux
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Rufaro Mvududu
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Anna Happel
- Division of Immunology, Department of Pathology, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Heather B Jaspan
- Division of Immunology, Department of Pathology, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Seattle Children’s Research Institute, Seattle, Washington, United States of America
- Department of Pediatrics and Global Health, University of Washington, Seattle, Washington, United States of America
| | - Dorothy Chiwoniso Nyemba
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nyiko Mashele
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Dvora Leah Joseph Davey
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, United States of America
- Division of Infectious Diseases, Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, United States of America
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Zhu X, Liu L, Yixi L, Yang Y, Zhang Y, Yang Z, Chen H, Dong J, Yang S. The prevalence and risk factors of Trichomonas vaginalis in Wuhan and the Tibetan area, China: a two-center study. Parasitol Res 2023; 122:265-273. [PMID: 36434317 PMCID: PMC9816191 DOI: 10.1007/s00436-022-07726-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 11/10/2022] [Indexed: 11/27/2022]
Abstract
Trichomonas vaginalis (T. vaginalis) infection is one of the most common sexually transmitted infections worldwide and is associated with several complications. However, the paucity of research regarding the prevalence of T. vaginalis infection in the Tibetan area limits control efforts. We aimed to evaluate the prevalence of T. vaginalis infection in the Tibetan area by a comparison with the prevalence of T. vaginalis in Wuhan city and to unveil the potential risk factors in the Tibetan area. This descriptive, cross-sectional study was conducted among adult women attending gynecology outpatient clinics in two public hospitals (one in Shannan city of Tibet and one in Wuhan city) in China in 2020. Data were retrieved from the medical record system and laboratory information management system, including T. vaginalis infection, bacterial vaginosis, and vulvovaginal candidiasis by wet mount microscopy or nucleic acid hybridization of vaginal secretions from patients. The associations of variables associated with T. vaginalis prevalence were quantified by odds ratios with 95% confidence intervals. The overall prevalence rates of T. vaginalis infection in the Tibetan area and Wuhan city were 20.94% and 2.84%, respectively. The statistically significant factors for the higher prevalence of T. vaginalis infection in the Tibetan area included tertiary educational status (AOR: 0.36 [95% CI: 0.16-0.81]), yearly family income > ¥100,000 (AOR: 0.48 [95% CI: 0.26-0.91]), clinical symptoms (AOR: 4.58[95% CI: 2.32-9.04]), and III-IV grade vaginal cleanliness (AOR: 29.71 [95% CI: 3.95-223.56]) in the multivariate logistic analysis. Interventions targeting improved living standards as well as women's educational level and promoting reproductive hygiene habits are recommended to contribute to the reduction in T. vaginalis infection in the Tibetan area.
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Affiliation(s)
- Xiaowu Zhu
- grid.412839.50000 0004 1771 3250Department of Gynecology and Obstetrics, Union Hospital, Wuhan, Hubei China
| | - Linlin Liu
- grid.412839.50000 0004 1771 3250Department of Gynecology and Obstetrics, Union Hospital, Wuhan, Hubei China
| | - Lamu Yixi
- Department of Gynecology and Obstetrics, Maternal and Child Health Hospital, Shannan, Tibet, China
| | - Yanan Yang
- Department of Gynecology and Obstetrics, Maternal and Child Health Hospital, Shannan, Tibet, China
| | - Yan Zhang
- Department of Gynecology and Obstetrics, Maternal and Child Health Hospital, Shannan, Tibet, China
| | - Zhen Yang
- Department of Gynecology and Obstetrics, Maternal and Child Health Hospital, Shannan, Tibet, China
| | - Huali Chen
- Department of Gynecology and Obstetrics, Maternal and Child Health Hospital, Yingcheng, Hubei China
| | - Jinfeng Dong
- grid.411634.50000 0004 0632 4559Department of Gynecology and Obstetrics, The Third People’s Hospital, Jianli, Hubei China
| | - Shouhua Yang
- grid.412839.50000 0004 1771 3250Department of Gynecology and Obstetrics, Union Hospital, Wuhan, Hubei China
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9
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Genital Tract Infections in Women, Pregnancy and Neonates. Obstet Gynecol Clin North Am 2022; 49:751-769. [DOI: 10.1016/j.ogc.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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10
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Significant Associations between Chlamydia trachomatis and Neisseria gonorrhoeae Infections in Human Immunodeficiency Virus-Infected Pregnant Women. Infect Dis Obstet Gynecol 2022; 2022:7930567. [PMID: 35754526 PMCID: PMC9232329 DOI: 10.1155/2022/7930567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 06/07/2022] [Indexed: 11/17/2022] Open
Abstract
There is a lack of data on the burden of Chlamydia trachomatis and Neisseria gonorrhoeae among human immunodeficiency virus- (HIV-) infected pregnant women in South Africa. We conducted a cross-sectional study which included 385 HIV-infected pregnant women attending antenatal clinic at the King Edward VIII Hospital in Durban, South Africa. The women provided vaginal swabs which were tested for C. trachomatis and N. gonorrhoeae. The prevalence of the individual STIs was as follows: C. trachomatis (47/385, 12.2%) and N. gonorrhoeae (16/385, 4.1%). Having a circumcised partner, testing positive for N. gonorrhoeae, and perceiving themselves of being at risk for infection were shown to increase the risk for C. trachomatis infection. Without controlling for the other factors, testing positive for N. gonorrhoeae increased the risk for C. trachomatis infection by 10-fold (OR: 10.17, 95% CI: 3.39-29.66, p < 0.001). Similarly, adjusting for the other factors, the risk for C. trachomatis infection in women who tested positive for N. gonorrhoeae was 9-fold (OR: 9.16, 95% CI: 2.19-40.18, p = 0.003). The following factors were associated with the increased risk of N. gonorrhoeae infection: not knowing their partner's HIV status, partner having other partners, and C. trachomatis infection status. Without controlling for the other factors, testing positive for C. trachomatis increased the risk for N. gonorrhoeae infection by 6-fold (OR: 6.52, 95% CI: 2.22-18.49, p < 0.001). Similarly, adjusting for the other factors, the risk for N. gonorrhoeae infection in women who tested positive for C. trachomatis was 6-fold (OR: 6.09, 95% CI: 1.73-22.03, p = 0.005). We found a significant association between C. trachomatis and N. gonorrhoeae in the pregnant women and the risk factors associated with these pathogens. Future studies are urgently required to investigate the impact of C. trachomatis/N. gonorrhoeae coinfections in HIV pregnant women since this data is lacking in our setting. In addition, etiological screening of C. trachomatis and N. gonorrhoeae during antenatal clinic is urgently required to prevent adverse pregnancy and birth outcomes associated with these infections.
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11
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Detection of metronidazole resistance in Trichomonas vaginalis using uncultured vaginal swabs. Parasitol Res 2022; 121:2421-2432. [PMID: 35657426 DOI: 10.1007/s00436-022-07548-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 05/12/2022] [Indexed: 10/18/2022]
Abstract
Trichomonas vaginalis (T. vaginalis) is the most prevalent sexually transmitted infection (STI) globally. Metronidazole is the drug of choice for treating T. vaginalis infections although metronidazole-resistant T. vaginalis has been reported in clinical isolates. The purpose of this study was to determine the presence of mutations in nitroreductase genes associated with metronidazole resistance in vaginal swabs testing positive for T. vaginalis. This study included 385 human immunodeficiency virus (HIV)-positive pregnant women. Vaginal swabs were collected from consenting pregnant women and used for the detection of T. vaginalis using the TaqMan assay. From the vaginal swabs, nitroreductase genes ntr4 and ntr6 containing mutations associated with metronidazole resistance were amplified using a quantitative polymerase chain reaction (PCR) assay. To validate the PCR assay, T. vaginalis cultured isolates with known metronidazole resistance profiles were used as controls in the mutation detection assays. The prevalence of T. vaginalis in the study population was 12.2% (47/385). Mutations associated with resistance to metronidazole were detected in more than 40% of the samples tested, i.e. 21/47 (45%) and 24/47 (51%) for ntr4 and ntr6, respectively. A total of 19 samples (40%) carried mutations for both ntr4 and ntr6 genes associated with metronidazole resistance. The validation assays showed a positive correlation between phenotypic and genotypic resistance profiles. This study found a high prevalence of mutations associated with metronidazole resistance. This is concerning since metronidazole is currently used in the syndromic management of STIs in South Africa. Molecular-based assays for monitoring metronidazole resistance profiles using nitroreductase genes may serve as a feasible method for antimicrobial surveillance studies for T. vaginalis.
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12
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Jiang W, Ronen K, Osborn L, Drake AL, Unger JA, Matemo D, Enquobahrie DA, Kinuthia J, John-Stewart G. Predictors of adverse pregnancy outcomes among Kenyan women with HIV on antiretroviral treatment in pregnancy. AIDS 2022; 36:1007-1019. [PMID: 35652673 PMCID: PMC9178912 DOI: 10.1097/qad.0000000000003215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to understand predictors of adverse pregnancy outcomes (APOs) among women on antiretroviral treatment (ART). DESIGN A longitudinal cohort. METHODS Participants from the Mobile WAChX trial were evaluated for APOs, including stillbirth (fetal death at ≥20 weeks' gestation), preterm birth (PTB, livebirth at <37 weeks' gestation,) and neonatal death (NND, ≤28 days after live birth). Predictors were determined by univariable and multivariable Cox proportional hazards and log-binomial models. RESULTS Among 774 women included, median age was 27 years and 29.0% had unsuppressed HIV viral load (>1000 copies/ml) at enrollment. Half (55.1%) started ART prepregnancy, 89.1% on tenofovir-based regimens. Women with depression had a higher risk of stillbirth (adjusted hazard ratio [aHR] 2.93, 95% confidence interval (95% CI) 1.04-8.23), and women with lower social support score had higher risk of late stillbirth (aHR 11.74, 2.47-55.86). Among 740 livebirths, 201 (27.2%) were preterm and 22 (3.0%) experienced NND. PTB was associated with unsuppressed maternal viral load (adjusted prevalence ratio [aPR] 1.28, 95% CI 1.02-1.61), intimate partner violence (IPV) in pregnancy (aPR 1.94, 95% CI 1.28-2.94), and history of any sexually transmitted infection (STI) (aPR 1.63, 95% CI 1.06-2.51). NND was associated with PTB (aPR 2.53, 95% CI 1.10-5.78) and STI history (aPR 4.25, 95% CI 1.39-13.06). Most associations retained significance in the subgroup of women with viral suppression. CONCLUSION Maternal viremia during pregnancy predicted PTB as did IPV, lower education, and STI history, while psychosocial stressors predicted stillbirth. Implementing mental health services, ART adherence, partner support, and routine STI screening and treatment could reduce APOs among women with HIV in sub-Saharan Africa settings.
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Affiliation(s)
- Wenwen Jiang
- University of Washington, Seattle, Washington, USA
| | - Keshet Ronen
- University of Washington, Seattle, Washington, USA
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13
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Sexually transmitted infection screening to prevent adverse birth and newborn outcomes: study protocol for a randomized-controlled hybrid-effectiveness trial. Trials 2022; 23:441. [PMID: 35610666 PMCID: PMC9128231 DOI: 10.1186/s13063-022-06400-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 05/12/2022] [Indexed: 11/24/2022] Open
Abstract
Background Sexually transmitted infections (STIs) during pregnancy are associated with adverse birth outcomes, including preterm birth, low birth weight, perinatal death, and congenital infections such as increased mother-to-child HIV transmission. Prevalence of STIs among pregnant women in South Africa remains high, with most women being asymptomatic for their infection(s). Unfortunately, most STIs remain undetected and untreated due to standard practice syndromic management in accordance with World Health Organization (WHO) guidelines. Although lab-based and point-of-care molecular tests are available, optimal screening strategies during pregnancy, their health impact, and cost-effectiveness are unknown. Methods We will implement a 3-arm (1:1:1) type-1 hybrid effectiveness-implementation randomized-controlled trial (RCT). We will enroll 2500 pregnant women attending their first antenatal care (ANC) visit for their current pregnancy at participating health facilities in Buffalo City Metro District, Eastern Cape Province, South Africa. Participants allocated to arms 1 and 2 (intervention) will receive GeneXpert® point-of-care diagnostic testing for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis, with same-day treatment for detected infection(s). Arm 1 will additionally receive a test-of-cure 3 weeks post-treatment, while Arm 2 will receive a repeat test at 30–34 weeks’ gestation. Those allocated to Arm 3 will receive syndromic management (standard-of-care). The RE-AIM framework will be used to guide collection of implementation indicators to inform potential future scale up. Primary outcome measures include (1) frequency of adverse birth outcomes among study arms, defined by a composite measure of low birth weight and pre-term delivery, and (2) change in STI prevalence between baseline and birth outcome among intervention arms and compared to standard-of-care. Estimates and comparative costs of the different screening strategies relative to standard-of-care and the costs of managing adverse birth outcomes will be calculated. Cost-effectiveness will be assessed per STI and disability-adjusted life year averted. Discussion This trial is the first RCT designed to identify optimal, cost-effective screening strategies that decrease the burden of STIs during pregnancy and reduce adverse birth outcomes. Demonstrating the impact of diagnostic screening and treatment, compared to syndromic management, on birth outcomes will provide critical evidence to inform changes to WHO guidelines for syndromic management of STIs during pregnancy. Trial registration ClinicalTrials.gov NCT04446611. Registered on 25 June 2020.
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14
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Wynn A, Mussa A, Ryan R, Hansman E, Simon S, Bame B, Moreri-Ntshabele B, Ramogola-Masire D, Klausner JD, Morroni C. Evaluating the diagnosis and treatment of Chlamydia trachomatis and Neisseria gonorrhoeae in pregnant women to prevent adverse neonatal consequences in Gaborone, Botswana: protocol for the Maduo study. BMC Infect Dis 2022; 22:229. [PMID: 35255814 PMCID: PMC8899784 DOI: 10.1186/s12879-022-07093-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are extremely common sexually transmitted infections (STIs) that are associated with adverse birth and neonatal outcomes, and the risk of vertical transmission of CT and NG during delivery is high. The majority of CT and NG infections are asymptomatic and missed by the standard of care in most countries (treatment based on symptoms). Thus, it is likely that missed maternal CT and NG infections contribute to preventable adverse health outcomes among women and children globally. This study aims to assess the effectiveness of CT and NG testing for asymptomatic pregnant women to prevent adverse neonatal outcomes, understand the inflammatory response linking CT and NG infections to adverse neonatal outcomes, and conduct an economic analysis of the CT and NG testing intervention. METHODS The Maduo ("results" in Setswana) is a prospective, cluster-controlled trial in Gaborone, Botswana to compare a near point-of-care CT and NG testing and treatment intervention implemented in "study clinics" with standard antenatal care (World Health Organization-endorsed "syndromic management" strategy based on signs and symptoms without laboratory confirmation) implemented in "standard of care clinics" among asymptomatic pregnant women. The primary outcome is vertical transmission of CT/NG infection. Secondary outcomes include preterm birth (delivery < 37 completed weeks of gestation) and/or low birth weight (< 2500 g). The trial will also evaluate immunological and inflammatory markers of adverse neonatal outcomes, as well as the costs and cost-effectiveness of the intervention compared with standard care. DISCUSSION The Maduo study will improve our understanding of the effectiveness and cost-effectiveness of CT and NG testing among asymptomatic pregnant women. It will also increase knowledge about the CT/NG-related immune responses that might drive adverse neonatal outcomes. Further, results from this study could encourage expansion of STI testing during antenatal care in low resource settings and improve maternal and neonatal health globally. TRIAL REGISTRATION This trial is registered with ClinicalTrials.gov (Identifier NCT04955717, First posted: July 9, 2021)).
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Affiliation(s)
- Adriane Wynn
- University of California, San Diego, USA. .,Botswana Sexual and Reproductive Health Initiative, Gaborone, Botswana.
| | - Aamirah Mussa
- Botswana Sexual and Reproductive Health Initiative, Gaborone, Botswana.,Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Rebecca Ryan
- Botswana Sexual and Reproductive Health Initiative, Gaborone, Botswana.,Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Selebaleng Simon
- Botswana Sexual and Reproductive Health Initiative, Gaborone, Botswana.,Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Bame Bame
- Botswana Sexual and Reproductive Health Initiative, Gaborone, Botswana.,Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | | | | | - Chelsea Morroni
- Botswana Sexual and Reproductive Health Initiative, Gaborone, Botswana.,Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana.,University of Edinburgh, Edinburgh, UK
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15
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Peters R, Klausner JD, de Vos L, Feucht UD, Medina-Marino A. Aetiological testing compared with syndromic management for sexually transmitted infections in HIV-infected pregnant women in South Africa: a non-randomised prospective cohort study. BJOG 2020; 128:1335-1342. [PMID: 33277768 PMCID: PMC8175473 DOI: 10.1111/1471-0528.16617] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 11/30/2022]
Abstract
Objective To measure the frequencies of sexually transmitted infections (STIs) and adverse pregnancy outcomes among women receiving either aetiological testing or syndromic management for STIs. Design Non‐randomised prospective cohort study. Setting Primary healthcare facilities in Tshwane, South Africa. Population HIV‐infected pregnant women attending antenatal care services. Methods Participants were enrolled to receive aetiological testing using Xpert® CT/NG and Xpert® TV assays or standard syndromic management. Outcome data were collected at the postnatal care visit (≤30 days from delivery) and from maternity records. Enrolment gestational age‐adjusted relative risk (aRR) was calculated. Main outcome measures STI prevalence at postnatal visit, and frequency of adverse pregnancy outcomes (preterm birth, low birthweight). Results We enrolled 841 women. The prevalence of any STI at baseline was 40%; Chlamydia trachomatis 30%, Neisseria gonorrhoeae 5.6%, Trichomonas vaginalis 20%. The prevalence of STIs at postnatal care was lower among those receiving aetiological testing compared with those receiving syndromic management (14% versus 23%; aRR 0.61; 95% CI 0.35–1.05). No difference was observed between study groups for frequency of preterm birth (23% versus 23%; aRR 1.2, 95% CI 0.81–1.8) and low birth weight (15% versus 13%; aRR 1.1, 95% CI 0.66–1.7). Conclusions Aetiological testing provides an effective intervention to reduce the high burden of STIs in pregnant women in South Africa; however, the optimal implementation strategy remains to be determined. Tweetable abstract Aetiological testing effectively reduces the burden of sexually transmitted infections in pregnancy. Aetiological testing effectively reduces the burden of sexually transmitted infections in pregnancy.
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Affiliation(s)
- Rph Peters
- Research Unit, Foundation for Professional Development, East London, South Africa.,Department of Medical Microbiology, CAPRHI School of Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - J D Klausner
- Division of Infectious Diseases: Global Health, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.,Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - L de Vos
- Research Unit, Foundation for Professional Development, East London, South Africa
| | - U D Feucht
- Department of Paediatrics, Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Pretoria, South Africa.,Maternal and Infant Health Care Strategies Research Unit, South African Medical Research Council, Pretoria, South Africa
| | - A Medina-Marino
- Research Unit, Foundation for Professional Development, East London, South Africa.,Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
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