Screening and syndromic approaches to identify gonorrhea and chlamydial infection among women

Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae infection and associated factors among asymptomatic pregnant women in Botswana

BACKGROUND

Chlamydia trachomatis (C. trachomatis) and Neisseria gonorrhoeae (N. gonorrhoeae) are curable sexually transmitted infections (STIs) that cause adverse pregnancy and neonatal outcomes. Most countries, including Botswana, do not offer C. trachomatis or N. gonorrhoeae screening during antenatal care (ANC) and instead use a syndromic approach for management of STIs.

METHODS

The Maduo Study is a prospective, cluster-controlled trial in Botswana evaluating the impact of diagnostic screening for antenatal C. trachomatis and N. gonorrhoeae infections to prevent adverse neonatal outcomes. Using baseline data from the Maduo Study (March 2021-March 2022), we determined the prevalence of C. trachomatis and N. gonorrhoeae infection among asymptomatic pregnant women in Botswana and correlates of infection using multivariable logistic regression.

RESULTS

Of 251 women who underwent C. trachomatis and N. gonorrhoeae screening at first ANC visit, 55 (21.9%, 95%CI 17.0-27.5) tested positive for C. trachomatis, 1 (0.4%, 95%CI 0-2.2) for N. gonorrhoeae; and 2 (0.8%, 95%CI 0-2.8) for dual C. trachomatis and N. gonorrhoeae infection. Older age was associated with lower odds (aOR 0.93; 95%CI 0.88-0.98; p = 0.011) while any alcohol use during pregnancy was associated with higher odds (aOR = 3.53; 95%CI 1.22-10.16; p = 0.020) of testing positive for C. trachomatis or N. gonorrhoeae.

CONCLUSIONS

A high frequency of C. trachomatis infections was detected among asymptomatic pregnant women in Botswana indicating that many antenatal STIs are missed by the syndromic management approach. Our results highlight the need for diagnostic C. trachomatis screening during ANC in Botswana and other low- and middle-income countries that rely solely on the syndromic approach for management of STIs.

Point-of-care testing for sexually transmitted infections in low-resource settings

BACKGROUND

Both the global incidence and prevalence of sexually transmitted infections continue to increase, affecting hundreds of millions of individuals, particularly in low-to middle-income countries. While a definitive diagnosis is desirable to inform STI treatment, syndromic management is the most widely used strategy in resource-limited settings. With the development of point-of-care (POC) tests, it is important to discuss how laboratories will need to adapt to new training and supervisory roles in support of testing which will largely be performed by peripheral clinical staff.

OBJECTIVES

To discuss potential applications of STI POC tests, how they could improve existing STI control strategies and the role of clinical and reference laboratories in support of initiatives to improve STI management and control activities.

SOURCES

Narrative literature review and expert opinion.

CONTENT

The paper outlines the current status of the STI epidemic worldwide and discusses the problems associated with current approaches to control these infections, particularly in low resource settings. The roles of clinical and reference laboratories will need to change in order to provide support for POC and near-patient STI testing as these technologies are introduced into clinical as well as laboratory settings.

IMPLICATIONS

Laboratories will be expected to play a leading role in the introduction and implementation of POC and near-patient STI testing. They will be required to facilitate training and provide technical and supervisory support to clinical staff on the use of these technologies to augment existing STI management and surveillance programs. In order to provide quality service, they will need to develop, introduce and maintain sustainable local QC and EQA systems. Evidence from implementation research for introduction and scale up of STI POCTs in different STI epidemic and laboratory infrastructure settings is required.

Risk-based screening to identify reproductive tract infection among HIV-infected women desiring use of intrauterine contraceptives

BACKGROUND

Reproductive tract infections (RTIs) are a major cause of morbidity and mortality, yet RTI testing remains limited in resource-constrained settings. We assessed performance of an existing RTI risk assessment screening tool among women living with HIV (WLHIV) considering intrauterine contraceptive (IUC) use.

METHODS

We conducted a cross-sectional analysis among WLHIV screened for participation in an IUC trial in Cape Town, South Africa (NCT01721798). RTI testing included Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis and bacterial vaginosis. Tool scoring was based on five separately scored criteria: (1) age under 25 years, (2) cohabitation with a partner, (3) secondary education, (4) self-reported intermenstrual bleeding and (5) number of current sexual partners and condom use frequency (score 0-5). We assessed tool performance in detecting RTI at 0 vs 1-5, 0-1 vs 2-5 and 0-2 vs 3-5 score thresholds.

RESULTS

Of 303 women, 52% (n=157) reported antiretroviral therapy use and median age was 31 years. The prevalence of any RTI was 38% (gonorrhoea=7%, chlamydia=11%, trichomoniasis=12% and bacterial vaginosis=18%) and 8% of women had multiple RTIs. Overall, 4%, 27% and 69% of women had screening tool scores of 0, 1 or 2+, respectively. At a threshold of at least one scored criterion, the tool demonstrated high sensitivities (95%-97%) but low specificities (3%-4%) for detecting any RTI. Increasing the score threshold and/or inclusion of abnormal vaginal discharge marginally improved specificity.

CONCLUSION

The prevalence of RTIs observed in this population was high, and the screening tool had no discriminatory power to detect prevalent RTIs.

Diagnosing sexually transmitted infections in resource-constrained settings: challenges and ways forward

INTRODUCTION

Sexually transmitted infections (STIs) remain prevalent and are increasing in several populations. Appropriate STI diagnosis is crucial to prevent the transmission and sequelae of untreated infection. We reviewed the diagnostic accuracy of syndromic case management and existing point-of-care tests (POCTs), including those in the pipeline, to diagnose STIs in resource-constrained settings.

METHODS

We prioritized updating the systematic review and meta-analysis of the diagnostic accuracy of vaginal discharge from 2001 to 2015 to include studies until 2018. We calculated the absolute effects of different vaginal flowcharts and the diagnostic performance of POCTs on important outcomes. We searched the peer-reviewed literature for previously conducted systematic reviews and articles from 1990 to 2018 on the diagnostic accuracy of syndromic management of vaginal and urethral discharge, genital ulcer and anorectal infections. We conducted literature reviews from 2000 to 2018 on the existing POCTs and those in the pipeline.

RESULTS AND DISCUSSIONS

The diagnostic accuracy of urethral discharge and genital ulcer disease syndromes is relatively adequate. Asymptomatic Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections limit the use of vaginal discharge and anorectal syndromes. The pooled diagnostic accuracy of vaginal syndromic case management for CT/NG is low, resulting in high numbers of overtreatment and missed treatment. The absolute effect of POCTs was reduced overtreatment and missed treatment. Findings of the reviews on syndromic case management underscored the need for low-cost and accurate POCTs for the identification, first, of CT/NG, and, second, of Mycoplasma genitalium (MG) and Trichomonas vaginalis (TV) and NG and MG resistance/susceptibility testing. Near-patient POCT molecular assays for CT/NG/TV are commercially available. The prices of these POCTs remain the barrier for uptake in resource-constrained settings. This is driving the development of lower cost solutions.

CONCLUSIONS

The WHO syndromic case management guidelines should be updated to raise the quality of STI management through the integration of laboratory tests. STI screening strategies are needed to address asymptomatic STIs. POCTs that are accurate, rapid, simple and affordable are urgently needed in resource-constrained settings to support the uptake of aetiological diagnosis and treatment.

Symptom-Based Versus Laboratory-Based Diagnosis of Five Sexually Transmitted Infections in Female Sex Workers in Iran

Among 1337 Iranian adult female sex workers in 2015, we assessed the diagnostic value of 4 self-reported sexually transmitted infection (STIs) symptoms for detecting laboratory-confirmed gonorrhea, chlamydia, trichomoniasis, human papillomavirus (HPV), and syphilis. While 37.7% reported vaginal discharge (VD), 25.9% reported pain or burning (P/B), 3.0% reported genital ulcers (GU), and 1.4% reported genital warts (GW), the prevalence of laboratory-confirmed syphilis, gonorrhea, chlamydia, trichomoniasis, and HPV was 0.4, 1.3, 6.0, 11.9, and 41.9%, respectively. The sensitivity of VD was 40.3% for detecting tricomoniasis, 37.5% for chlamydia, and 37.5% for gonorrhea. The sensitivity of P/B ranged from 12.5% for gonorrhea to 25.2% for trichomoniasis. The sensitivity of GU and GW was very low for 5 STIs. The sensitivity of all symptoms combined was also lower than 50%. Among asymptomatic participants, 41.2% tested positive for HPV, 11.8% for trichomoniasis, and less than 6.6% for other STIs. Symptom-based case management and surveillance of STIs can lead to misclassification of a large proportion of cases.

The Performance of the Vaginal Discharge Syndromic Management in Treating Vaginal and Cervical Infection: A Systematic Review and Meta-Analysis

Background

This review aimed to synthesize and analyze the diagnostic accuracy and the likelihood of providing correct treatment of the syndromic approach Vaginal Discharge Flowchart in managing cervical infections caused by Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT), and vaginal infections caused by Trichomonas vaginalis (TV) and Bacterial vaginosis (BV) and Candida albicans. This review will inform updating the WHO 2003 guidelines on Vaginal Discharge syndromic case management.

Methods

A systematic review was conducted on published studies from 01-01-2000 to 30-03-2015 in multiple databases. Studies evaluating the diagnostic accuracy and validation of the WHO Vaginal Discharge Flowchart were included. Validation parameters including sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) and the 95% confidence intervals for the different types of the flowchart were taken as outcomes, re-calculated, and analysed using a fixed model meta-analysis for data pooling. The level of agreement between the index and reference test were determined by the Cohen’s Kappa co-efficiency test. Each individual study was assessed on quality using the QUADAS-2 tool.

Findings

The search yielded 2,845 studies of which 16 met the eligibility criteria for final analysis. The diagnostic performance to identify cervical infections was low and resulted in a high proportion of over and missed treatment. The four flowcharts had a sensitivity between 27.37% in history and risk assessment and 90.13% with microscopy, with the inverse in specificity rates. The treatment performances between the flowcharts were inconsistent. The same applies to the use of vaginal discharge flowchart for treating vaginal infections. For vaginal infections the vaginal discharge flowchart had a good performance in flowchart 3 with 91.68% of sensitivity; 99.97% specificity; 99.93% PPV and 0.02% who missed their treatment and 8.32% of women who were over treated by the vaginal discharge flowchart

Conclusion

The vaginal discharge flowchart should focus on management of vaginal infection. It could be used as an intermediate approach for cervical infections for sex workers until a point of care test is available in resource poor settings.

Chlamydia Trachomatis and Neisseria Gonorrhoeae prevalence among women of reproductive age living in urogenital schistosomiasis endemic area in Ghana

Background

Many studies have shown an overlap in the epidemiology of sexually transmitted infections (STIs) and urogenital schistosomiasis among young women living in schistosomiasis endemic areas. Yet we found no study assessing the prevalence of STI infections in urogenital schistosomiasis endemic areas in Ghana. As part of an epidemiological study on urogenital schistosomiasis and HIV, we sought to assess the prevalence of both Chlamydia trachomatis (CT) and Neisseria gonorhoeae (NG) infections among women living in schistosomiasis endemic communities and explore the relationship between the sexually transmitted infections (STIs) and demographic characteristics, sexual behaviour and self-reported symptoms.

Methods

This was a cross-sectional study in which endocervical samples were collected from 191 women aged 15–49 years from October 2005 to March 2006. Samples were examined for CT and NG using Polymerase Chain Reaction (PCR). A structured questionnaire was also used to elicit information on study participant’s gynaecological and obstetric history and symptoms for genital infection. Chi-square test and binary logistic regression were used to assess association between CT and NG and other variables such as age, sexual behaviour and self-reported symptoms.

Results

The overall prevalence of CT and NG were 6.3% and 2.6% respectively.The highest prevalence rates of CT were in the 15 to 19 year group while only individuals between 15 and 39 years were positive for NG. There was no association between CT and age, contraceptive use and the other variables assessed. NG on the other hand was found to be associated with age, number of births and number of sexual partners only by chi-square test.

Conclusions

Our research revealed higher prevalence of CT and NG infections when compared to previous studies conducted among higher risk groups in non-urogenital schistosomiasis areas in Ghana. We therefore recommend further studies of these STIs in urogenital schistosomiasis endemic areas in the country.

Variation of a test's sensitivity and specificity with disease prevalence

BACKGROUND

Anecdotal evidence suggests that the sensitivity and specificity of a diagnostic test may vary with disease prevalence. Our objective was to investigate the associations between disease prevalence and test sensitivity and specificity using studies of diagnostic accuracy.

METHODS

We used data from 23 meta-analyses, each of which included 10-39 studies (416 total). The median prevalence per review ranged from 1% to 77%. We evaluated the effects of prevalence on sensitivity and specificity using a bivariate random-effects model for each meta-analysis, with prevalence as a covariate. We estimated the overall effect of prevalence by pooling the effects using the inverse variance method.

RESULTS

Within a given review, a change in prevalence from the lowest to highest value resulted in a corresponding change in sensitivity or specificity from 0 to 40 percentage points. This effect was statistically significant (p < 0.05) for either sensitivity or specificity in 8 meta-analyses (35%). Overall, specificity tended to be lower with higher disease prevalence; there was no such systematic effect for sensitivity.

INTERPRETATION

The sensitivity and specificity of a test often vary with disease prevalence; this effect is likely to be the result of mechanisms, such as patient spectrum, that affect prevalence, sensitivity and specificity. Because it may be difficult to identify such mechanisms, clinicians should use prevalence as a guide when selecting studies that most closely match their situation.

Is food insecurity associated with HIV risk? Cross-sectional evidence from sexually active women in Brazil

BACKGROUND

Understanding how food insecurity among women gives rise to differential patterning in HIV risks is critical for policy and programming in resource-limited settings. This is particularly the case in Brazil, which has undergone successive changes in the gender and socio-geographic composition of its complex epidemic over the past three decades. We used data from a national survey of Brazilian women to estimate the relationship between food insecurity and HIV risk.

METHODS AND FINDINGS

We used data on 12,684 sexually active women from a national survey conducted in Brazil in 2006-2007. Self-reported outcomes were (a) consistent condom use, defined as using a condom at each occasion of sexual intercourse in the previous 12 mo; (b) recent condom use, less stringently defined as using a condom with the most recent sexual partner; and (c) itchy vaginal discharge in the previous 30 d, possibly indicating presence of a sexually transmitted infection. The primary explanatory variable of interest was food insecurity, measured using the culturally adapted and validated Escala Brasiliera de Segurança Alimentar. In multivariable logistic regression models, severe food insecurity with hunger was associated with a reduced odds of consistent condom use in the past 12 mo (adjusted odds ratio [AOR] = 0.67; 95% CI, 0.48-0.92) and condom use at last sexual intercourse (AOR = 0.75; 95% CI, 0.57-0.98). Self-reported itchy vaginal discharge was associated with all categories of food insecurity (with AORs ranging from 1.46 to 1.94). In absolute terms, the effect sizes were large in magnitude across all outcomes. Underweight and/or lack of control in sexual relations did not appear to mediate the observed associations.

CONCLUSIONS

Severe food insecurity with hunger was associated with reduced odds of condom use and increased odds of itchy vaginal discharge, which is potentially indicative of sexually transmitted infection, among sexually active women in Brazil. Interventions targeting food insecurity may have beneficial implications for HIV prevention in resource-limited settings.

Prevalence of Chlamydia infection among women visiting a gynaecology outpatient department: evaluation of an in-house PCR assay for detection of Chlamydia trachomatis

Background

Screening women for Chlamydia trachomatis infection in developing countries is highly desirable because of asymptomatic infection. The existing diagnostic methods in developing countries are not effective and their sensitivity fall below 45.0% which leads to further spread of infection. There is an urgent need for improved and cost effective diagnostic tests that will reduce the burden of sexually transmitted infections in the developing world.

Methods

Prevalence of C. trachomatis infection among women visiting gynaecology department of Hindu Rao hospital in Delhi, India was determined using Roche Amplicor Multi Well Plate kit (MWP) as well as using in-house PCR assay. We used 593 endocervical swabs for clinical evaluation of the in-house developed assay against Direct Fluorescence Assay (DFA; Group I n = 274) and Roche Amplicor MWP kit (Group II, n = 319 samples) and determined the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of the in-house developed assay.

Results

We detected 23.0% positive cases and there was a higher representation of women aged 18-33 in this group. An in-house PCR assay was developed and evaluated by targeting unique sequence within the gyrA gene of C. trachomatis. Specificity of the reaction was confirmed by using genomic DNA of human and other STI related microorganisms as template. Assay is highly sensitive and can detect as low as 10 fg of C. trachomatis DNA. The resolved sensitivity of in-house PCR was 94.5% compared with 88.0% of DFA assay. The high specificity (98.4%) and sensitivity (97.1%) of the in-house assay against Roche kit and availability of test results within 3 hours allowed for immediate treatment and reduced the risk of potential onward transmission.

Conclusions

The in-house PCR method is cost effective (~ 20.0% of Roche assay) and hence could be a better alternative for routine diagnosis of genital infection by C. trachomatis to facilitate improved screening and treatment management.

A cross-sectional study of reported symptoms for sexually transmissible infections among female sex workers in Papua New Guinea

BACKGROUND

Sexually transmissible infections (STIs) are common in female sex workers (FSWs), most of which are asymptomatic and therefore under-reported. Our aim was to determine the sensitivity and specificity of reported symptoms obtained via questionnaire augmented with leukocyte esterase (LE) urine dipstick test for the detection of Chlamydia trachomatis (Ct), Neisseria gonorrhea (Ng) and Trichomonas vaginalis (Tv) detected using polymerase chain reaction (PCR).

METHODS

In November 2003, a cohort of FSWs was screened for STIs and completed a questionnaire.

RESULTS

We enrolled 129 FSWs (90% participation rate) of whom 48 (37%), 30 (23%) and 53 (41%) were diagnosed with Ng, Ct and Tv, respectively, by PCR. Of those diagnosed with any of these infections, 78% reported anogenital symptoms and of those without infections, 28% reported symptoms. Anogenital symptoms were present in over 50% FSWs. Genital odour (present in 26%), lower abdominal pain (present in 29%), dysuria (present in 19%) had a sensitivity around (50%), specificity (>80%) and all were significantly associated with positive PCR results for individual organisms; however, the sensitivity of these symptoms to detect the presence of any positive PCR result was low (<50%). When LE urine dipstick test result of >1 was combined with the presence of three reported symptoms the sensitivity was 86%, specificity of 73% and a positive predictive value of 72%; a better predictor of infections.

CONCLUSIONS

Our finding suggest an approach that incorporates LE urine dipstick test >1 and multiple symptoms may be a feasible option for screening infections among FSWs in resource constraint settings.

A question of ethics: research and practice in reproductive health

The intent of the ethical guidelines and regulations, developed over time, that govern research on human subjects is to ensure that research participants are well-informed volunteers, protected from harm, ensured potential benefit, and enrolled in an egalitarian fashion. This study discusses ethical issues that researchers and program planners grapple with in the area of sexual and reproductive health. We illustrate the dilemmas that arise in the application of the ethical principles, how they have been addressed, lessons learned, and remaining challenges. The illustrations come both from research and from service-delivery situations.

Chlamydia and gonorrhoea in pregnant Batswana women: time to discard the syndromic approach?

BACKGROUND

Chlamydia and gonorrhoea are major causes of morbidity among women in developing countries. Both infections have been associated with pregnancy-related complications, and case detection and treatment in pregnancy is essential. In countries without laboratory support, the diagnosis and treatment of cervical infections is based on the syndromic approach. In this study we measured the prevalence of chlamydia and gonorrhoea among antenatal care attendees in Botswana. We evaluated the syndromic approach for the detection of cervical infections in pregnancy, and determined if risk scores could improve the diagnostic accuracy.

METHODS

In a cross-sectional study, 703 antenatal care attendees in Botswana were interviewed and examined, and specimens were collected for the identification of C trachomatis, N gonorrhoeae and other reproductive tract infections. Risk scores to identify attendees with cervical infections were computed based on identified risk factors, and their sensitivities, specificities, likelihood ratios and predictive values were calculated.

RESULTS

The prevalence of chlamydia was 8%, and gonorrhoea was found in 3% of the attendees. Symptoms and signs of vaginal discharge did not predict cervical infection, and a syndromic approach failed to identify infected women. Age (youth) risk factor most strongly associated with cervical infection. A risk score with only sociodemographic factors had likelihood ratios equivalent to risk scores which incorporated clinical signs and microscopy results. However, all the evaluated risk scores were of limited value in the diagnosis of chlamydia and gonorrhoea. A cut-off set at an acceptable sensitivity to avoid infected antenatal care attendees who remained untreated would inevitably lead to considerable over-treatment.

CONCLUSION

Although in extensive use, the syndromic approach is unsuitable for diagnosing cervical infections in antenatal care attendees in Botswana. None of the evaluated risk scores can replace this management. Without diagnostic tests, there are no adequate management strategies for C trachomatis and N gonorrhoeae in pregnant women in Botswana, a situation which is likely to apply to other countries in sub-Saharan Africa. Screening for cervical infections in pregnant women is an essential public health measure, and rapid tests will hopefully be available in developing countries within a few years.

Prioritizing health problems in women in developing countries: comparing the financial burden of reproductive tract infections, anaemia and depressive disorders in a community survey in India

OBJECTIVES

To compare the health care and opportunity costs of three common health problems [depressive disorders, reproductive tract infections (RTIs) and anaemia] affecting women and their associated risks of catastrophic health expenditure (defined a priori as out-of-pocket expenditure on health care exceeding 10% of the total monthly household income).

METHODS

Cross-sectional survey of 2494 women who consented to participate, from a randomly selected sample of 3000 women aged 18-50, living in the catchment area of a primary health centre in Goa, India. Depressive disorders were diagnosed with the Revised Clinical Interview Schedule; anaemia on the basis of a fingerprick sample of blood using the Haemocue system; and RTI using PCR, culture and microscopy with vaginal or urine specimens. Economic consequences were measured using the Costs of Illness Schedule and the WHO Disability Assessment Schedule. Health provision costs were calculated using previously derived unit costs for services for the main types of health care provider.

RESULTS

Catastrophic health expenditure, defined a priori as >10% of total household income spent out of pocket on health in the previous month, was reported by 138 women (5.5%; CI: 4.7-6.5%); they were more likely to report economic difficulties, such as having gone hungry in the past 3 months because of lack of money (OR 1.99, CI 1.1-3.6, P = 0.02). Only depressive disorder was associated with significantly higher health care costs, lost time costs and risk of catastrophic health expenditure (OR 2.66, CI 1.6-4.4, P < 0.001, after adjustment for possible sociodemographic confounders and other physical health problems). There was a linear association between the psychological morbidity score (arranged into quintile groups) and the risk of catastrophic health expenditure (adjusted).

CONCLUSIONS

If economic arguments were considered a key driver for global health policy, then depressive disorder should be considered a major health priority for women in developing countries.

The burden and determinants of reproductive tract infections in India: a population based study of women in Goa, India

BACKGROUND/OBJECTIVE

Reproductive tract infections (RTI) present major health, social, and economic problems in developing countries. Our objective was to describe the prevalence and risk factors of RTIs in a population based sample of women aged 18-45 years.

METHOD

2494 women of 3000 randomly selected from the population defined by a primary health centre catchment area consented to participate. Participants were interviewed regarding complaints and risk factors. Laboratory specimens were collected for the diagnosis of RTIs. Analyses of risk factors were carried out separately for the outcomes of sexually transmitted infections: chlamydia, gonorrhoea, trichomoniasis; and endogenous infections: bacterial vaginosis (BV) and candida.

RESULTS

Endogenous infections were relatively common (BV 17.8%; candida 8.5%), and sexually transmitted infections (STI) were infrequent (4.2%). Factors indicative of poverty and marginalisation were associated with STIs and BV. Gender disadvantage, particularly spousal violence, was associated with BV, while concern about a husband's extramarital relationships, an indicator of sexual risk, was associated with STI. Husband's discharge was strongly associated with STI, and a non-white vaginal discharge was associated with both STI and BV. Condom use and oral contraceptive use were associated with a reduced risk of BV.

CONCLUSIONS

Most of the population burden of RTIs is attributed to endogenous infections. Socioeconomic deprivation and gender disadvantage are associated with raised risk for BV, while the risk factors for STIs indicated that disadvantaged women were likely to be infected by their husbands.

Use of methodological search filters to identify diagnostic accuracy studies can lead to the omission of relevant studies

OBJECTIVE

To determine the usefulness of methodological filters in search strategies for diagnostic studies in systematic reviews.

STUDY DESIGN AND SETTING

We made an inventory of existing methodological search filters for diagnostic accuracy studies and applied them in PubMed to a reference set derived from 27 published systematic reviews in a broad range of clinical fields. Outcome measures were the fraction of not identified relevant studies and the reduction in the number of studies to read.

RESULTS

We tested 12 search filters. Of the studies included in the systematic reviews, 2%-28% did not pass the sensitive search filters, 4%-24% did not pass the accurate filters, and 39%-42% did not pass the specific filters. Decrease in number-needed-to-read when a search filter was used in a search strategy for a diagnostic systematic review varied from 0% to 77%.

CONCLUSION

The use of methodological filters to identify diagnostic accuracy studies can lead to omission of a considerable number of relevant studies that would otherwise be included. When preparing a systematic review, it may be preferable to avoid using methodological filters.

Evidence of bias and variation in diagnostic accuracy studies

BACKGROUND

Studies with methodologic shortcomings can overestimate the accuracy of a medical test. We sought to determine and compare the direction and magnitude of the effects of a number of potential sources of bias and variation in studies on estimates of diagnostic accuracy.

METHODS

We identified meta-analyses of the diagnostic accuracy of tests through an electronic search of the databases MEDLINE, EMBASE, DARE and MEDION (1999-2002). We included meta-analyses with at least 10 primary studies without preselection based on design features. Pairs of reviewers independently extracted study characteristics and original data from the primary studies. We used a multivariable meta-epidemiologic regression model to investigate the direction and strength of the association between 15 study features on estimates of diagnostic accuracy.

RESULTS

We selected 31 meta-analyses with 487 primary studies of test evaluations. Only 1 study had no design deficiencies. The quality of reporting was poor in most of the studies. We found significantly higher estimates of diagnostic accuracy in studies with nonconsecutive inclusion of patients (relative diagnostic odds ratio [RDOR] 1.5, 95% confidence interval [CI] 1.0-2.1) and retrospective data collection (RDOR 1.6, 95% CI 1.1-2.2). The estimates were highest in studies that had severe cases and healthy controls (RDOR 4.9, 95% CI 0.6-37.3). Studies that selected patients based on whether they had been referred for the index test, rather than on clinical symptoms, produced significantly lower estimates of diagnostic accuracy (RDOR 0.5, 95% CI 0.3-0.9). The variance between meta-analyses of the effect of design features was large to moderate for type of design (cohort v. case-control), the use of composite reference standards and the use of differential verification; the variance was close to zero for the other design features.

INTERPRETATION

Shortcomings in study design can affect estimates of diagnostic accuracy, but the magnitude of the effect may vary from one situation to another. Design features and clinical characteristics of patient groups should be carefully considered by researchers when designing new studies and by readers when appraising the results of such studies. Unfortunately, incomplete reporting hampers the evaluation of potential sources of bias in diagnostic accuracy studies.

Integration of sexual and reproductive health services in KwaZulu-Natal, South Africa

An integrated sexual and reproductive health package is widely regarded as essential for meeting the needs of both men and women. The practical realities of integration in KwaZulu-Natal, South Africa, were examined from the perspective of both providers and clients. Only minorities of clients received any assessment of reproductive and sexual health needs over and above their main presenting need or problem. The majority would have welcomed such assessments and many were classified as being in need, particularly for advice and services with regard to sexually transmitted infections, including HIV. Most providers were positive about integration, but their ability to practice an active form of integration was limited by inadequate training and time constraints. While training defects can be remedied, the time constraints posed by heavy patient loads are less tractable. More skillful use of booking clerks or the introduction of lay counsellors are also possible solutions.

The contribution of sexual and reproductive health services to the fight against HIV/AIDS: a review

Approximately 80% of HIV cases are transmitted sexually and a further 10% perinatally or during breastfeeding. Hence, the health sector has looked to sexual and reproductive health programmes for leadership and guidance in providing information and counselling to prevent these forms of transmission, and more recently to undertake some aspects of treatment. This paper reviews and assesses the contributions made to date by sexual and reproductive health services to HIV/AIDS prevention and treatment, mainly by services for family planning, sexually transmitted infections and antenatal and delivery care. It also describes other sexual and reproductive health problems experienced by HIV-positive women, such as the need for abortion services, infertility services and cervical cancer screening and treatment. This paper shows that sexual and reproductive health programmes can make an important contribution to HIV prevention and treatment, and that STI control is important both for sexual and reproductive health and HIV/AIDS control. It concludes that more integrated programmes of sexual and reproductive health care and STI/HIV/AIDS control should be developed which jointly offer certain services, expand outreach to new population groups, and create well-functioning referral links to optimize the outreach and impact of what are to date essentially vertical programmes.

Should family planning clinics provide clinical services for sexually transmitted infections? A case study from Côte d'Ivoire

OBJECTIVES

To evaluate the quality and usefulness of integrated sexually transmitted infection (STI) care at non-governmental family planning (FP) clinics in Côte d'Ivoire.

METHODS

Evaluation components included: (1) a survey measuring the prevalence of STI and the predictive value of the Ivorian vaginal discharge treatment algorithm, (2) client exit interviews, (3) direct observations of client-provider contacts, (4) the monitoring of the clinics' workload and available equipment and supplies and (5) interviews of programme managers and FP providers.

RESULTS

Among 368 FP clients surveyed, the prevalence of Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, B. vaginosis and Candida albicans were respectively 1.6, 5.7, 7.1, 44.8 and 5.2%. The positive predictive value of the national algorithm for the detection of cervicitis was only 6.3%, and was 17.9% among a subgroup of young, single women. Of 200 clients interviewed, 96% were satisfied with the services and 95% would return to the FP clinic if they had genital problems. In 215 observed client-provider contacts, 88% of 94 STI cases were correctly managed. Programme managers and providers reported no substantial work overload as a result of the integration of STI services.

CONCLUSIONS

The prevalence of cervical infections is relatively low in this population and the Ivorian algorithm that treats all women with vaginal discharge performs poorly. Over-treatment of cervicitis can be reduced by modifying the algorithm, although improved diagnostic tools are urgently needed to detect cervicitis in this population. Continued STI case management at the FP clinics is nevertheless justified because there exists an easily identifiable group of higher risk women who need STI care; and because of the demand by a large proportion of clients, the high prevalence of vaginal pathogens, and the limited costs to the FP programme.

Prevalence of sexually transmitted infections and performance of STI syndromes against aetiological diagnosis, in female sex workers of red light area in Surat, India

OBJECTIVES

To measure prevalence of selected sexually transmitted infections (STI) and HIV among female sex workers (SWs) in the red light area of Surat, India, and to evaluate the performance of STI syndrome guidelines (for general population women in India) in this group against the standard aetiological diagnosis of STIs by laboratory methods.

METHODS

In a cross sectional study, 124 out of an estimated total of 500 SWs were mobilised to a health camp near the red light area during 2000. After obtaining consent, a behavioural questionnaire was administered, followed by clinical examination and specimen collection for different STIs. 118 SWs completed all aspects of the survey. HIV testing was unlinked and anonymous.

RESULTS

The mean number of different sexual partners of SWs per day was five. 94.9% reported consistent condom use with the clients. 58.5% of SWs had no symptoms related to STDs at the time of examination. Reported symptoms included lower abdominal pain (19.5%), abnormal vaginal discharge (12.7%), painful sexual intercourse (12.7%), painful micturition (11.0%), itching around the genital area (10.2%), and genital ulcer (5.9%). The prevalence of STI "syndromes" were vaginal discharge syndrome 51.7%, pain in lower abdomen 19.5%, enlarged inguinal lymph nodes 11.9%, and genital ulcer 5.9%. Based on the laboratory reports (excluding HIV tests), 62 (52.5%) SWs did not have any of the four tested STIs. Prevalence of laboratory confirmed STIs were syphilis 22.7% (based on reactive syphilis serology tests), gonorrhoea 16.9%, genital chlamydial infection 8.5%, and trichomoniasis 14.4%. HIV prevalence was 43.2%. The performance of Indian recommended treatment guidelines for vaginal discharge syndrome (VDS) and genital ulcer syndrome (GUS) against aetiological diagnosis was poor.

CONCLUSION

Prevalence of different STIs and HIV among the FSWs in the Surat red light area is high despite high reported condom use with clients. Syndromic case management is missing a large number of asymptomatic cases and providing treatment in the absence of disease. Therefore, it is necessary to explore alternative strategies for control of STIs in female sex workers. STI services need to be improved.

Prevalence of sexually transmitted infections among antenatal women in Vanuatu, 1999-2000

BACKGROUND

The epidemiology of sexually transmitted infections (STIs) and HIV in Vanuatu is poorly defined.

GOAL

The goal was to determine the prevalence of laboratory-confirmed gonorrhea, chlamydia, trichomoniasis, syphilis seroreactivity, and HIV among pregnant women in Vila, Vanuatu.

STUDY DESIGN

A cross-sectional survey of 547 pregnant women attending a first-visit antenatal hospital clinic in Vila. Laboratory testing included polymerase chain reaction on tampons for chlamydia, gonorrhea, and trichomoniasis; testing of sera for syphilis with rapid plasmid reagin; and enzyme-linked immunosorbent assay for HIV.

RESULTS

The prevalence of trichomoniasis was 27.5% (150); of chlamydia, 21.5% (117); of gonorrhea, 5.9% (32); and of syphilis, 13 (2.4%). No HIV cases were detected; 214 women (40%) had > or =1 STI. Young age and single marital status were both significantly associated with infection (P < 0.001).

CONCLUSION

Chlamydial infection and trichomoniasis are hyperendemic among pregnant women in Vila. Young, single women are at greatest risk for infection.

Prevalence of gonococcal and chlamydial infections and sexual risk behavior among youth in Addis Ababa, Ethiopia

BACKGROUND

No community-based study on the magnitude of sexually transmitted diseases (STDs) has ever been conducted among young people in Ethiopia.

GOAL

To assess the magnitude of Chlamydia trachomatis and Neisseria gonorrhoeae infections and status of sexual risk behavior among youths (15-24 years old) in Addis Ababa, Ethiopia.

STUDY DESIGN

Youths in or out of school residing in two (of the six) administrative zones in Addis Ababa served as the study population. Participants filled out a self-administered questionnaire related to sexuality and its sociocultural determinants. First-void urine (FVU) was analyzed for gonorrhea and chlamydial infection by polymerase chain reaction (PCR).

RESULTS

A total of 561 youths took part in the study. Urine PCR was performed for 522 of them. Nine subjects (1.7%) were found to have and N gonorrhoeae and C trachomatis infections. There were five cases (1.0%) involving each agent. Double infection was noted in one female subject. All but one of the infections were detected among the out-of-school youths (chi-square = 4.5; < 0.05). None of these subjects complained of symptoms suggestive of an active STD. One-third (188/561) reported having had sexual intercourse. The prevalence among sexually active youths was thus 4.8% (9/188) for both infections combined (2.7% for each agent). While 7/52 (13.5%) of the sexually active females were found to also have STDs, only 2/136 (1.5%) of the males had an STD (chi-square = 8.0; < 0.01). Report of sexual activity was significantly associated with being male, an age of >/=20 years, out-of-school status, and report of alcohol/khat (amphetamine-like substance) consumption. Females reported less condom use, whether they were in or out of school and independent of age.

CONCLUSIONS

Out-of-school youths, especially females, took more sexual risk and were exceedingly susceptible to STDs. This calls for alternative group-targeted strategies for sex education, disease prevention, and STD screening and management.

Surveys on sexual health: recent developments and future directions

The increasingly widespread adoption of the term sexual health reflects a move away from the medicalisation of this specialty. The focus has shifted from clinical practice to lifestyle and behaviour; from clinician to client, and from treatment to prevention. This article discusses these themes, identifying their implications for sexual health research. Recent times have seen, for example, a growing number of studies combining biological and behavioural measures conducted by interdisciplinary teams able to combine biomedical measurements of morbidity with insights into the subjective interpretations of symptoms and consequences. Considerable progress has been made, too, in mounting community based studies, and much has been achieved in gaining compliance and refining sampling methods. Integrated sexual health services, encompassing more than contraceptive or prophylactic service provision, have provided the impetus to investigation of the costs and benefits of coordinated family planning and genitourinary medicine services. Despite its broader focus, there remain opportunities for sexual health research to expand its remit. Studies to date may have focused too narrowly on pathological, to the neglect of health enhancing, consequences of sexual behaviour.

Risk of clinical pelvic inflammatory disease attributable to an intrauterine device

Use of the intrauterine device (IUD) is avoided because of perceived risk of pelvic inflammatory disease (PID) associated with sexually transmitted Infections (STI). Calculation of the risk of clinical pelvic inflammatory disease showed that the estimated risk was low (0.15%), even with a high STI prevalence. This estimated risk argues for making IUDs more available.

Methodological issues in community-based studies of gynecological morbidity

This report describes the lessons learned from a series of community-based studies of gynecological morbidity among young married women in Karnataka State, India. Women's self-reports of symptoms of illness were found to be responsive to the context of the interview and the nature of questioning. In particular, women appeared much readier to report symptoms to lay interviewers after being invited to undergo a clinical examination in the near future than they were if no examination were offered. Little consistency was found in the results obtained from interviews, clinical examinations, and laboratory tests. Apparently, no alternative exists to the collection of biological specimens for laboratory analysis when estimates of disease prevalence are needed. Use of generic health-related quality-of-life assessments is recommended for future surveys. Prospective studies will yield more valuable data on these topics than will cross-sectional surveys.