Sentinel surveillance of sexually transmitted infections in South Africa: a review

Impact of STIs on cervical cancer screening: Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae in visual inspection with acetic acid (VIA) positive women in Mozambique

BACKGROUND

Cervical cancer, primarily from HPV, is prevalent in countries like Mozambique, with HIV individuals at higher risk. The Visual Inspection with Acetic Acid (VIA) screening method can be influenced by STIs like Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG). This study examines CT and NG prevalence in HIV-positive and negative women using VIA in Mozambique's DREAM program.

METHODS

In this cross-sectional research conducted at a DREAM program facility in Maputo from 01/07/2021 to 31/05/2022, cervical specimens were taken from VIA-positive patients. CT/NG testing was performed using the Cobas® 4800 DNA CT/NG test. Statistical analyses focused on associations and prevalence rates, considering demographic, clinical, and exposure data.

RESULTS

Among 117 women, we observed a CT prevalence of 6.8% (8/117) and an NG prevalence of 2.6%(3/117). No significant associations between CT/NG infection rates and factors such as age, HIV status, VIA results, or high-risk HPV (hrHPV) was observed. We found a 47% prevalence of hrHPV infections among participants with cervical lesions; no significant association between hrHPV and CT/NG infections was observed.

CONCLUSION

This study highlights the prevalence of CT and NG in VIA-positive women in Mozambique, emphasizing the STI burden and suggesting integration of STI screening in cervical cancer prevention strategies.

Spatial variations in STIs among women enrolled in HIV prevention clinical trials in Durban, KwaZulu-Natal, South Africa

South Africa is faced with a high HIV and STI prevalence and incidence, respectively, with pockets of high burden areas driving these diseases. Localised monitoring of the HIV epidemic and STI endemic would enable more effective targeted prevention strategies. We assessed spatial variations in curable STI incidence among a cohort of women enrolled in HIV prevention clinical trials between 2002 and 2012. STI incidence rates from 7557 South African women enrolled in five HIV prevention trials were geo-mapped using participant household GPS coordinates. Age and period standardised incidence rates were calculated for 43 recruitment areas and Bayesian conditional autoregressive areal spatial regression (CAR) was used to identify significant patterns and spatial patterns of STI infections in recruitment communities. Overall age and period standardised STI incidence rate were estimated as 15 per 100 PY and ranged from 6 to 24 per 100 PY. We identified five significant STI high risk areas with higher-than-expected incidence of STIs located centrally (three-locations) and southern neighbouring areas of Durban (two-locations). Younger age (<25), not married/cohabitating, parity <3 and poor education were all significant correlates of high STI communities. Findings demonstrate sustained STI incidence rates across the greater Durban area. The role of STI incidence in HIV acquisition in high HIV endemic areas need to be revisited as current highly effective PrEP interventions do not protect from STI acquisition. In these settings there is an urgent need for integrative HIV and STI prevention and treatment services.

Variations in sexual network connectivity may explain dramatic variations in sexually transmitted infection prevalence between populations and over time: a selected four-country analysis

Background: The incidence of sexually transmitted infections (STIs) has been noted to vary dramatically between population groups and over time. Here, the hypothesis that changes in network connectivity underpin these changes is explored.

Methods: The incidence/prevalence estimates of HIV, herpes simplex virus-2, syphilis, chlamydia, and gonorrhoea, as well as two markers of sexual network connectivity (partner concurrency and multiple partnering) by ethnic group and sexual orientation in Kenya, South Africa, the United Kingdom (UK) and the United States (USA) were extracted from published studies. Pearson’s correlation was used to test the association between the markers of network connectivity and the incidence/prevalence of these five STIs. A literature review was performed to evaluate the possible causes of the increases and decreases in syphilis incidence over the past 60 years.

Results: In each country, the five STIs were found to cluster in particular ethnic groups and sexual orientations and to be positively associated with the two markers of network connectivity. Syphilis incidence in the UK and USA was found to increase dramatically in the 1960s/1970s, decline in the 1980s and again increase in the late 1990s. These changes took place predominantly in men who have sex with men, and were preceded by corresponding changes in network connectivity. The large decline in antenatal syphilis prevalence in Kenya and South Africa in the 1990s were likewise preceded by declines in network connectivity.

Conclusions: Although other explanatory variables are not controlled for, the present analysis is compatible with the hypothesis that differential network connectivity is a parsimonious explanation for variations in STI incidence over time and between populations.

Differences in Sexual Behavior and Partner Notification for Sexually Transmitted Infections Between the Out of School Youth and University Students in a Peri-Urban District in South Africa-A Cross-Sectional Survey

The increase in sexually transmitted infections (STIs) in young people is a public health concern. Among those in university and out of school, different contextual factors contribute to their risky sexual behavior and increased susceptibility to STIs and HIV. There are limited comparative studies examining risky sexual behavior and partner notification (PN) between these two groups, particularly in South Africa. We investigated sexual behaviors, self-reported STI diagnosis, health seeking behavior, and preferred PN methods of university students and out of school youth. A descriptive cross-sectional survey was used using convenient sampling to select 917 students across five health sciences universities and through periodic sampling 699 out of school youth were selected from two main local shopping centers in South Africa. Descriptive statistics, bivariate and multivariable logistic analysis were performed using Stata IC version 14. More university students (71.7%) than out of school youth were in casual relationships (28.3%), with half of out of school youth being in steady relations (50.2%). Moreover, university students (65.7%) used a condom in the past 6 months compared to their counterparts (34.3%). Of the 124 youth who were diagnosed with STI in the past 12 months, majority (n = 106, 85%) were out of school youth. The probability of notifying a partner about a STI infection was 82% among university students compared to their counterparts (p = >0.05). The odds of notifying a partner was 1.79 times more for those having multiple sexual partners than those who had only one partner. Both groups preferred a face-to-face STI disclosure with partner; however, more university students (67%) preferred SMS notification than PN referral slips as compared to out of school youth (42%). Both the university students and the out of school youth engaged in risky sexual behaviors. Both groups preferred face-to-face and clinic SMS partner notifications, even though university students were in the majority. There is a need for developing health promotion scripts on disclosing STIs to sexual partners to empower the majority of the youth who prefer face-to-face PN over the prescribed methods.

Correlates of bacterial vaginosis among women from North India

Background: Bacterial vaginosis (BV) is the most prevalent cause of abnormal vaginal discharge among pre-menopausal women and associated with adversities of sexual and reproductive health. The present study aimed to identify potential epidemiological and behavioural risk factors and clinical predictors of BV among women in Delhi, India. Methods: A cross-sectional study was conducted to assess 283 non-pregnant women aged 18-45 years for BV using Nugent's scoring criteria. Information on demographics, sexual behaviours, hygiene practices and clinical symptoms was obtained and evaluated for their association with Nugent-BV status. Results: A positive diagnosis for Nugent-BV was made in 69 (24.4%) participants, 55 (19.4%) were intermediate and 159 (65.2%) were negative for Nugent-BV. Infertility (p = .02) and recent unprotected sexual exposure (p = .02) were strongly associated with Nugent-BV. On the other hand, women who reported regular use of condoms during intercourse were more likely to test negative (p = .03). None of the patient complaints, however, had any significant correlation with Nugent-BV diagnosis. Conclusion: Women in their reproductive years share the highest burden of adversities associated with bacterial vaginosis. History of infertility, recent unprotected sexual exposure and frequent use of condoms were correlates having significant associations with Nugent-BV.

Vaginal Microbiota and Mucosal Pharmacokinetics of Tenofovir in Healthy Women Using a 90-Day Tenofovir/Levonorgestrel Vaginal Ring

Background

A relationship between the vaginal microbiota and tenofovir (TFV) concentrations and activity after topical administration has been previously reported.

Objective

CONRAD A15-138 was a randomized, placebo-controlled Phase I study aimed at characterizing the safety, pharmacokinetics (PK), and pharmacodynamics (PD) of TFV and levonorgestrel (LNG) administered through a vaginal ring (IVR) for 90 days. Herein, we describe changes from baseline in the vaginal microbiota with IVR use and the impact of the vaginal microbiota on mucosal TFV PK.

Methods

The study screened 68 participants and randomized 47 (37 TFV/LNG, 10 placebo), assessing the vaginal microbiota by sequencing the V3-V4 regions of 16S rRNA genes prior to IVR insertion and monthly for 3 months. Concentrations of TFV in vaginal fluid (VF), and TFV and TFV-diphosphate (TFV-DP) in vaginal tissue, and modeled PD against HIV-1 in vitro were measured before and after treatment.

Results

There were no clinically significant changes in relative abundance of vaginal bacterial phylotypes from pre-insertion baseline at any month among active and placebo IVR users. There were no significant changes in community state type (CST) with IVR use. Participants with diverse, anaerobic CST IVA/B microbiota had higher in vivo release of TFV from the IVR compared to women with Lactobacillus-dominated (LbD) microbiota, who had expected in vivo TFV release rates. Median VF TFV concentrations were significantly higher among women with CST IVA/B microbiota in months 1 (3,135 ng/mg VF) and 2 (3,800 ng/mg). Women with LbD microbiota had significantly higher median VF TFV concentration (1,423 ng/mg) and median TFV (103 ng/mg) and TFV-DP (5,877 fmol/mg) tissue concentrations versus women with CST IVA/B microbiota at month 3. All women demonstrated a significant increase from pre-insertion baseline of in vitro HIV-1 inhibition by VF (p values <0.05). PD differences in tissue according to CST, however, were not statistically significant.

Conclusion

TFV/LNG IVR use did not change the vaginal microbiota nor increase the incidence of CST IVA/B. Vaginal microbiota, and in particular CST IVA/B, possibly through increased vaginal pH, impacted in vivo TFV release and cervicovaginal (CV) PK, but both PK and PD data suggest CV protection against HIV-1.

Clinical Trial Registration

ClinicalTrials.gov (#NCT03279120).

Quantifying geographical diversity in sexually transmitted infections using population attributable risk: results from HIV prevention trials in South Africa

In this study, we investigated spatial diversities of sexually transmitted infections (STIs) and quantified their impacts on the STIs using population attributable risk (PAR%). The study population was 7,557 women who participated in several HIV prevention trials from KwaZulu-Natal, South Africa. Our results provide compelling evidence for substantial geographical diversities on STI incidence rates in the region. Their population-level impacts on the STIs exceeded the combined impacts of the individual risk factors considered in this study (PAR%: 41% (<25 years), 52% (25-34 years) and 34% (35+ years). When all these factors are considered together, PAR% was the highest among younger women (PAR%: 67%, 82% and 50% for <25, 25-34 and 35+ years old respectively). Results from our study will bring greater insight into the previous research by increasing our understanding of the impacts of the sub-geographical level variations of STI prevalence and incidence rates in the region.

The Complex Link between the Female Genital Microbiota, Genital Infections, and Inflammation

The female genital tract microbiota is part of a complex ecosystem influenced by several physiological, genetic, and behavioral factors. It is uniquely linked to a woman's mucosal immunity and plays a critical role in the regulation of genital inflammation. A vaginal microbiota characterized by a high abundance of lactobacilli and low overall bacterial diversity is associated with lower inflammation. On the other hand, a more diverse microbiota is linked to high mucosal inflammation levels, a compromised genital epithelial barrier, and an increased risk of sexually transmitted infections and other conditions. Several bacterial taxa such as Gardnerella spp., Prevotella spp., Sneathia spp., and Atopobium spp. are well known to have adverse effects; however, the definitive cause of this microbial dysbiosis is yet to be fully elucidated. The aim of this review is to discuss the multiple ways in which the microbiota influences the overall genital inflammatory milieu and to explore the causes and consequences of this inflammatory response. While there is abundant evidence linking a diverse genital microbiota to elevated inflammation, understanding the risk factors and mechanisms through which it affects genital health is essential. A robust appreciation of these factors is important for identifying effective prevention and treatment strategies.

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.

Population prevalence of sexually transmitted infections in a high HIV burden district in KwaZulu-Natal, South Africa: Implications for HIV epidemic control

BACKGROUND

Sexually transmitted infections (STIs) and Human immunodeficiency virus (HIV) share a complex bidirectional relationship, however, population prevalence and the association between the presence of STIs and HIV in a high HIV burden district in KwaZulu-Natal, South Africa is not known.

METHODS

A total of 9812 participants aged 15-49 years were enrolled in a cross-sectional population-based household survey. Participants completed a structured questionnaire and provided first-pass urine (males) or self-collected vulvo-vaginal swabs (females) for the detection of STIs.

RESULTS

Prevalence of herpes simplex virus type-2 (HSV-2) was 57.8%, syphilis was 1.6%, Neisseria gonorrhoeae was 2.8%, Chlamydia trachomatis was 7.1%, Trichomonas vaginalis was 9.0%, Mycoplasma genitalium was 5.5% and HIV was 36.3%. HIV positive status was associated with an increased probability of having M. genitalium (aPR = 1.49, 95% CI 1.02-2.19) among males and syphilis (aPR = 2.54, 95% CI 1.32-4.86), N. gonorrhoeae (aPR = 2.39, 95% CI 1.62-3.52), T. vaginalis (aPR = 1.70, 95% CI 1.43-2.01) and M. genitalium (aPR = 1.60, 95% CI 1.15-2.22) among females. HIV viral load ≥400 copies per mL was associated with an increased probability of N. gonorrhoeae (aPR = 1.91, 95% CI 1.36-2.70), C. trachomatis (aPR = 1.52, 95% CI 1.12-2.05) and M. genitalium (aPR = 1.83, 95% CI 1.27-2.63).

CONCLUSIONS

The high prevalence of STIs and the association between STIs and HIV, and HIV viral load underscores the public health implications of sustained transmission risk of STIs and HIV. These findings highlight the urgent need for expanding STI surveillance and implementing interventions to monitor and reduce the STI burden.

Diagnostic evaluation of the BD Affirm VPIII assay as a point-of-care test for the diagnosis of bacterial vaginosis, trichomoniasis and candidiasis

Untreated sexually transmitted infections and bacterial vaginosis (BV) pose a serious health risk to mother and child. Limited data exist on the use of the BD Affirm™ VPIII assay as a point-of-care test (POCT). The performance of the BD Affirm™ VPIII assay was compared with the BD Max™ vaginal assay for the diagnosis of BV, Trichomonas vaginalis (TV) and Candida spp. A total of 273 pregnant women were enrolled in this study and had provided two self-collected vaginal swabs. Sensitivity, specificity, positive predictive value, negative predictive value and prevalence were calculated. The prevalence of BV, candidiasis and trichomoniasis was 49.4, 57.2 and 10.3%, respectively. The BD Affirm™ VPIII assay showed a moderate sensitivity (79.8%) and a moderate specificity (80.3%) for diagnosing BV in all participants. The BD Affirm™ VPIII assay had an excellent specificity for Candida spp. and TV of 97.4 and 100%, respectively; however, the assay exhibited poor sensitivities of 52.9 and 46.4%, respectively. This study was the first to report on the performance of the BD Affirm™ VPIII assay as a POCT in an antenatal population. The assay was found to be unsuitable as a screening test for vaginal infections in pregnancy.

Demographics and health profile on precursors of non-communicable diseases in adults testing for HIV in Soweto, South Africa: a cross-sectional study

OBJECTIVES

This cross-sectional study investigated the burden of HIV-non-communicable disease (NCD) precursor comorbidity by age and sex. Policies stress integrated HIV-NCD screenings; however, NCD screening is poorly implemented in South African HIV testing services (HTS).

SETTING

Walk-in HTS Centre in Soweto, South Africa.

PARTICIPANTS

325 voluntary adults, aged 18+ years, who provided written or verbal informed consent (with impartial witness) for screening procedures were enrolled.

PRIMARY AND SECONDARY OUTCOMES

Data on sociodemographics, tuberculosis and sexually transmitted infection symptoms, blood pressure (BP) (≥140/90=elevated) and body mass index (<18.5 underweight; 18.5-25.0 normal; >25 overweight/obese) were stratified by age-group, sex and HIV status.

RESULTS

Of the 325 participants, the largest proportions were female (51.1%; n=166/325), single (71.5%; n=231/323) and 25-34 years (33.8%; n=110/325). Overall, 20.9% (n=68/325) were HIV infected, 27.5% (n=89/324) had high BP and 33.5% (n=109/325) were overweight/obese. Among HIV-infected participants, 20.6% (14/68) had high BP and 30.9% (21/68) were overweight/obese, as compared with 29.3% (75/256) and 12.1% (31/256) of the HIV-uninfected participants, respectively. Females were more likely HIV-infected compared with males (26.5% (44/166) vs 15.1% (24/159); p=0.012). In both HIV-infected and uninfected groups, high BP was most prevalent in those aged 35-44 years (25% (6/24) vs 36% (25/70); p=0.3353) and >44 years (29% (4/14) vs 48% (26/54); p=0.1886). Males had higher BP than females (32.9% (52/158) vs 22.3% (37/166); p=0.0323); more females were overweight/obese relative to males (45.8% (76/166) vs 20.8% (33/159); p<0.0001). Females were more likely to be HIV infected and overweight/obese.

CONCLUSION

Among HTS clients, NCD precursors rates and co-morbidities were high. Elevated BP occurred more in older participants. Targeted integrated interventions for HIV-infected females and HIV-infected people aged 18-24 and 35-44 years could improve HIV public health outcomes. Additional studies on whether integrated HTS will improve the uptake of NCD treatment and improve health outcomes are required.

Vaginal microbiota and mucosal pharmacokinetics of tenofovir in healthy women using tenofovir and tenofovir/levonorgestrel vaginal rings

Recent data support that the vaginal microbiota may alter mucosal pharmacokinetics (PK) of topically delivered microbicides. Our team developed an intravaginal ring (IVR) that delivers tenofovir (TFV) (8–10 mg/day) alone or with levonorgestrel (LNG) (20 ug/day). We evaluated the effect of IVRs on the vaginal microbiota, and describe how the vaginal microbiota impacts mucosal PK of TFV. CONRAD A13-128 was a randomized, placebo controlled phase I study. We randomized 51 women to TFV, TFV/LNG or placebo IVR. We assessed the vaginal microbiota by sequencing the V3-V4 regions of 16S rRNA genes prior to IVR insertion and after approximately 15 days of use. We measured the concentration of TFV in the cervicovaginal (CV) aspirate, and TFV and TFV-diphosphate (TFV-DP) in vaginal tissue at the end of IVR use. The change in relative or absolute abundance of vaginal bacterial phylotypes was similar among active and placebo IVR users (all q values >0.13). TFV concentrations in CV aspirate and vaginal tissue, and TFV-DP concentrations in vaginal tissue were not significantly different among users with community state type (CST) 4 versus those with Lactobacillus dominated microbiota (all p values >0.07). The proportions of participants with CV aspirate concentrations of TFV >200,000 ng/mL and those with tissue TFV-DP concentrations >1,000 fmol/mg were similar among women with anaerobe versus Lactobacillus dominated microbiota (p = 0.43, 0.95 respectively). There were no significant correlations between the CV aspirate concentration of TFV and the relative abundances of Gardnerella vaginalis or Prevotella species. Tissue concentrations of TFV-DP did not correlate with any the relative abundances of any species, including Gardnerella vaginalis. In conclusion, active IVRs did not differ from the placebo IVR on the effect on the vaginal microbiota. Local TFV and TFV-DP concentrations were high and similar among IVR users with Lactobacillus dominated microbiota versus CST IV vaginal microbiota.

Trial registration: ClinicalTrials.gov NCT02235662.

Exploring the associations between physical and sexual gender-based violence and HIV among women who use substances in South Africa: the role of agency and alcohol

Objective: South Africa has the highest prevalence of HIV among women, the highest prevalence of gender-based violence (GBV), and the highest rates of per capita alcohol consumption in the world. The nuanced associations between GBV, alcohol misuse, and HIV must be explored and protective factors identified. This study examines the associations between physical and sexual GBV and HIV infection and explores how alcohol misuse and sexual agency may mediate the GBV-HIV association. Method: Participants were 361 Black African women (Mean age=28.39, SD = 7.92) who reported using alcohol and/or drugs weekly in the past 3 months, engaging in condomless sex, and having a boyfriend. Women were recruited from disadvantaged communities in Pretoria, South Africa. Individuals who met the eligibility criteria and enrolled in the study consented and completed a computer-assisted personal interview assessing GBV, alcohol misuse, and sexual agency and underwent HIV testing (i.e., blood test). Results: The indirect effect of physical assault on HIV status at enrollment through alcohol misuse was significant (log odds = 0.23, SE = 0.12, 95% CI [0.0151, 0.4998]). Conclusions: HIV prevention efforts focusing on reducing alcohol misuse may be more effective, which might reduce the HIV burden among this group of vulnerable South African women.

Prevalence and associated factors of Chlamydia trachomatis and Neisseria gonorrhoeae among female commercial sex workers in Hawassa City, Southern Ethiopia

Background

Chlamydia trachomatis and Neisseria gonorrhoeae are the most common pathogens causing genital tract infections. Female commercial sex workers (FCSWs) are the key population to be affected by sexually transmitted infections (STIs). In Ethiopia, little is known about C. trachomatis and N. gonorrhoeae infections in most at risk population. Therefore, this study aimed to assess the prevalence of these bacterial STIs among FCSWs.

Methods

A cross-sectional study was conducted at the confidential clinic in Hawassa City, Southern Ethiopia from January to April, 2017. A total of 338 FCSWs were selected using systematic random sampling technique and enrolled in the study. Information about socio-demography and associated factors was collected using structured questionnaires. Endocervical swab samples were also collected from the study participants and tested for C. trachomatis using rapid immunochromatography assay. Samples were also cultured to isolate N. gonorrhoeae according to the standard bacteriological method.

Results

The prevalence of N. gonorrhoeae and C. trachomatis among FCSWs was 3.3% [95% confidence interval (CI): 1.5–5.3] and 6.8% (95% CI: 3.9–9.5), respectively. FCSWs who consistently practiced sex without condom in the last 6 months had 6.3 times (AOR 6.3; 95% CI 1.61–24.86, P = 0.008), and 4.0 times (AOR 4.0; 95% CI 1.06–15.31, p = 0.040) higher odds of acquiring N. gonorrhoeae and C. trachomatis infections, respectively.

Conclusion

The observed rates of C. trachomatis and N. gonorrhoeae infections among FCSWs warrant the need to strengthen intervention efforts. In this regard, screening FCSWs for the specified infections and improving the practice of condom use would be important.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Factors in the HIV risk environment associated with bacterial vaginosis among HIV-negative female sex workers who inject drugs in the Mexico-United States border region

Background

Bacterial vaginosis (BV) is the most common cause of vaginitis among women worldwide and is associated with increased susceptibility to sexually transmitted infections (STIs), including HIV. We aimed to determine the impact of the HIV risk environment on BV among female sex workers who inject drugs (FSW-PWIDs) in Tijuana and Ciudad Juarez, Mexico.

Methods

We performed a cross-sectional analysis utilizing baseline data from a randomized controlled trial evaluating a behavioral HIV prevention intervention. Participants underwent testing for BV using the OSOM BVBlue® Rapid Test (Genzyme Diagnostics, San Diego, CA) and completed a survey eliciting information on the HIV risk environment, sexual risk behaviors, and substance use. We applied logistic regression to identify correlates of BV in the physical, social, economic, and political HIV risk environments stratified by study site (Ciudad Juarez vs. Tijuana).

Results

In total, 584 HIV-negative FSW-PWIDs (300 Ciudad Juarez; 284 Tijuana) were enrolled. The prevalence of BV was 39% (n = 228), which was higher in Ciudad Juarez (56.7%) compared to Tijuana (20.4%). In both cities, micro-level components of the physical HIV risk environment were associated with BV. In Ciudad Juarez, BV was associated with past experiences or threats of physical violence in response to proposed condom use (adjusted odds ratio [aOR] = 3.66, 95% confidence interval [CI]: 1.74–7.69, p = 0.001) and lifetime residence in Ciudad Juarez (aOR = 1.74, 95% CI: 1.05–2.87, p = 0.031). In Tijuana, BV was associated with the number of hours spent on the street daily in the past six months looking for, using, or dealing drugs, engaging in other income generating activities, or sleeping (aOR = 1.05, 95% CI: 1.001–1.097, p = 0.045).

Conclusions

Our findings suggest that FSW-PWIDs’ risk of BV may be shaped by the microphysical HIV risk environment. Addressing components of the physical risk environment, including interventions to reduce gender-based violence, may alleviate the burden of BV and subsequent susceptibility to HIV/STIs among FSW-PWIDs in the Mexico/US border region.

Trial registration

National Institute of Health (NIH) Clinical Trials Identifier NCT00840658, and date of NIH trial registration February 7, 2009.

Exploring motivation to notify and barriers to partner notification of sexually transmitted infections in South Africa: a qualitative study

Background

This article will review qualitative data from intervention-based counselling sessions to explore barriers to partner notification (PN) for South African men and women who have contracted sexually transmitted infections (STIs). This qualitative study took place in a township where there is high STI and HIV prevalence. In addition to reviewing barriers to PN, the study will also identify participants’ perceptions about effective PN strategies that are presented during the intervention. Ultimately, the study will assess the intervention’s impact on participants’ motivation and skills to notify their partners about their STI status.

Methods

Relying on recorded counselling sessions from an intervention run by a parent study, this sub- study reviewed 30 transcripts from counselling sessions with 15 men and 15 women. The intervention was a 60 min interactive session where STI and HIV education, risk mitigation, and effective PN strategies were discussed. Participants were between 19 and 41 years old (mean age = 28.4) and lived within the catchment area of a South African township. Recordings were chosen based on verbal responsiveness of the participant and were manually coded for analysis. In addition, two programme counsellors were interviewed about their perceptions of the intervention and their experiences with participants to enhance rigour and reduce potential bias.

Results

By the conclusion of the intervention session, both male and female participants were motivated to notify their partners face-to-face about their positive STI status. Despite this, misperceptions about the etiology and transmission of STIs, as well as inadequate support from the clinical level and power imbalances amongst men and women emerged as major barriers for the prevention of future STIs.

Conclusions

While the intervention appears to be successful in facilitating partners’ intentions to notify, the data shows significant social and structural barriers that will create difficulties for the prevention of future STIs. Participants’ persistent concerns about acquiring HIV or their current positive status affect decision-making and therefore, could be a window of opportunity for health-care providers or lay counsellors to discuss STIs in high prevalence areas.

Genital Chlamydia trachomatis and Neisseria gonorrhoeae infections among women in sub-Saharan Africa: A structured review

Chlamydia trachomatis and Neisseria gonorrhoeae constitute major public health problems among women, but the burden of infection in sub-Saharan Africa is poorly documented. We conducted a structured review of the prevalence and incidence of genital, oral and anal C. trachomatis and N. gonorrhoeae infection in women in sub-Saharan Africa. We searched Medline, EMBASE and Web of Science over a 10-year period for studies on epidemiology of genital, oral and anal chlamydial infection and gonorrhoea in women in all countries of sub-Saharan Africa. We assessed geographic and demographic differences in prevalence and incidence of infection; weighted mean prevalence estimates were calculated with a random-effect model. A total of 102 study results were included, with data available for 24/49 of sub-Saharan countries. The weighted prevalence of chlamydial infection was lower among women in community-based studies (3.9%; 95% CI: 2.9-5.1%) than for women recruited at primary healthcare facilities (6.0%; 95% CI: 4.2-8.4%, p < 0.001); the same was observed for gonorrhoea (2.2%; 95% CI: 1.2-4.0% vs. 4.2%; 95% CI: 3.2-5.6%, p < 0.001). Prevalence of Chlamydia among sex workers was 5.5% (95% CI: 4.2-7.3%) and gonorrhoea 7.6% (95% CI: 5.4-11%). Seven studies reported on incidence which varied between 0.75-28 and 2.8-17 per 100 person-years-at-risk for chlamydial infection and gonorrhoea, respectively. Only two studies reported on anal infections and one on oral infection. This overview underscores the considerable incidence and prevalence of genital C. trachomatis and N. gonorrhoeae in women in different settings in sub-Saharan Africa. Better control strategies are warranted to reduce the burden of infection and to prevent long-term complications of these infections.

High human papillomavirus (HPV) prevalence in South African adolescents and young women encourages expanded HPV vaccination campaigns

The objectives of the study were to investigate prevalence of cervical human papillomavirus (HPV) genotypes to inform HPV vaccination strategy in South Africa and to study factors associated with HPV prevalence. Sexually active, HIV-negative women, aged 16-22 years recruited from Soweto (n = 143) and Cape Town (n = 148) were tested for cervical HPV and other genital infections. Overall HPV prevalence was 66.7% (194/291) in young women. Cape Town women were more likely to have multiple HPV infections than the Soweto women (48.0%, 71/148 versus 35.0%, 50/143 respectively, p = 0.033) and probable HR-HPV types (34.5%, 51/148 versus 21.7%, 31/143 respectively, p = 0.022). The most frequently detected HPV types were HPV-16 (11.7%), HPV-58 (10.3%), HPV-51 (8.9%), HPV-66 (8.6%), HPV-18 and HPV-81 (7.6% each). HPV types targeted by the bivalent HPV vaccine (HPV-16/18) were detected in 18.6% (54/291) of women, while those in the quadrivalent vaccine (HPV-6/11/16/18) were detected in 24.7% (72/291) of women; and those in the nonavalent vaccine (HPV-6/11/16/18/31/33/45/52/58) were detected in 38.5% (112/291) of women. In a multivariable analysis, bacterial vaginosis remained significantly associated with HPV infection (OR: 4.0, 95% CI: 1.4-12.6). Women were more likely to be HPV positive if they had received treatment for STI during the past 6-months (OR: 3.4, 95% CI: 1.1-12.4) or if they had ever been pregnant (OR: 2.3, 95% CI: 1.1-5.5). Compared to women who reported only one sexual partner, those with increased number of lifetime sex partners were more likely to have HPV (4-10 partners: OR: 2.9, 95% CI: 1.1-8.0). The high prevalence of HPV types targeted by the nonavalent HPV vaccine encourages the introduction of this vaccine and catch-up HPV vaccination campaigns in South Africa. The high burden of BV and concurrent STIs also highlights the need to improve the prevention and appropriate management of sexually-acquired and other genital tract infections in South African youth.

Demographic and behavioural risk factors associated with Trichomonas vaginalis among South African HIV-positive men with genital ulcer disease: a cross-sectional study

OBJECTIVES

Demographic and risky sexual behaviours may increase the risk for Trichomonas vaginalis (TV) infection and, thus, enhance HIV transmission to uninfected partners. We assessed the demographic and behavioural risk factors associated with TV among South African HIV-positive men with genital ulcer disease.

METHODS

We conducted a cross-sectional study with data from a randomised controlled trial conducted by the Centers for Disease Control and Prevention and the London School of Hygiene and Tropical Medicine. The data were obtained from three primary healthcare clinics in South Africa. At baseline (n=387), participants reported on demographics, sexual behaviour, history of sexually transmitted infections and clinical ulcers. The outcome TV was measured using real-time multiplex PCR assays and a Rotor-gene 3000 platform from the first and past urine samples of all participants. Logistic regression model estimated ORs and 95% CIs adjusted for demographics, sexual risk behaviours and ulcer conditions.

RESULTS

An estimated 11.4% of TV was detected among the men. The odds of TV infection were significantly associated with high blister counts (OR 4.0, 95% CI 1.6 to 28, p=0.01), ulcer pain (OR 0.4, 95% CI 0.2 to 0.7, p=0.003), number of days with ulcers (OR 0.4, 95% CI 0.2 to 0.8, p=0.006), sought treatment before coming into clinics (OR 0.07, 95% CI 0.002 to 0.7, p=0.005) and being unqualified worker (OR 2.5, 95% CI 0.9 to 6.7 p=0.05). Multivariate analyses revealed that increased days with ulcers (OR 0.1, 95% CI 0.04 to 0.5, p=0.002) and ulcer pain intensity (OR 0.08, 95% CI 0.007 to 1.1, p=0.05) remained significantly associated with decreased odds of TV infection. Men from the Sotho ethnic group were eight times more likely to have TV infection (OR 8.6, 95% CI 1.3 to 55.7, p<0.02) than men from the other ethnic groups.

CONCLUSION

HIV-positive men with severe ulceration should be screened and treated for TV to minimise HIV transmission to uninfected partners.

Patterns of prevalent HPV and STI co-infections and associated factors among HIV-negative young Western Cape, South African women: the EVRI trial

OBJECTIVE

To estimate the prevalence and describe the patterns of concurrent human papillomavirus (HPV) and STIs and associated factors among HIV-negative young Western Cape, South African women participating in the Efficacy of HPV Vaccine to Reduce HIV Infection (EVRI) trial.

METHODS

HIV-negative women aged 16-24 years old were enrolled in the EVRI trial (NCT01489527) and randomised to receive the licensed four-valent HPV vaccine or placebo. At study entry, participants were clinically evaluated for five STIs: herpes simplex virus type 2 (HSV-2), chlamydia, gonorrhoea, syphilis and disease-causing HPV genotypes (6/11/16/18/31/33/35/39/45/51/52/56/58/59/68). Demographic and sexual history characteristics were compared among women with STI co-infections, single infection and no infection using Pearson χ² and Mann-Whitney tests. ORs were calculated to evaluate factors associated with STI co-infection prevalence.

RESULTS

Among 388 young women, STI co-infection prevalence was high: 47% had ≥2 concurrent STIs, 36% had a single STI and 17% had none of the five evaluated STIs. HPV/HSV-2 (26%) was the most prevalent co-infection detected followed by HPV/HSV-2/Chlamydia trachomatis (CT) (17%) and HPV/CT (15%). Co-infection prevalence was independently associated with alcohol use (adjusted OR=2.01, 95% CI 1.00 to 4.06) and having a sexual partner with an STI (adjusted OR=6.96, 95% CI 1.53 to 30.08).

CONCLUSIONS

Among high-risk young women from underserved communities such as in Southern Africa, a multicomponent prevention strategy that integrates medical and behavioural interventions targeting both men and women is essential to prevent acquisition of concurrent STI infections and consequent disease.

TRIAL REGISTRATION NUMBER

NCT01489527; Post-results.

A national evaluation using standardised patient actors to assess STI services in public sector clinical sentinel surveillance facilities in South Africa

OBJECTIVES

Quality concerns in STI service delivery and missed opportunities for integration with HIV testing and prevention services in South Africa have been well documented. This national evaluation aimed to evaluate current utilisation and adherence to national STI guidelines, including partner notification and integration with HIV services, for diagnosis and management of STIs.

METHODS

Facility surveys assessed infrastructure and resource availability, and standardised patient (SP) assessments evaluated quality of STI care in 50 public clinics in nine provinces in South Africa. The primary outcome was the proportion of SPs receiving essential STI care, defined as: offered an HIV test, condoms, partner notification counselling and correct syndromic treatment. Weighted proportions were generated, and SP findings were compared by gender using χ² tests with Rao-Scott correction.

RESULTS

More than 80% of facilities reported medications in stock, with the exceptions of oral cefixime (48.3%), oral erythromycin (75.1%) and paediatric syrups. Among 195 SP encounters, 18.7% (95% CI 10.7% to 30.5%) received all hypothesised essential STI services: offered HIV test (67.1%), offered condoms (31.4%), partner notification counselling (70.2%) and recommended syndromic treatment (60.7%). Men were more likely than women to be offered all services (25.1% vs 12.3%, p=0.023), recommended treatment (70.7% vs 50.9%, p=0.013) and partner notification counselling (79.9% vs 60.6%, p=0.020). Only 6.3% of providers discussed male circumcision with male SPs, and 26.3% discussed family planning with female SPs.

CONCLUSIONS

This evaluation of STI services across South Africa found gaps in the availability of medications, adherence to STI guidelines, condom provision and prevention messaging. Limited integration with HIV services for this high-risk population was a missed opportunity. Quality of STI care should continue to be monitored, and interventions to improve quality should be prioritised as part of national strategic HIV and primary healthcare agendas.

Surveillance systems for sexually transmitted infections: a global review

PURPOSE OF REVIEW

Sexually transmitted infections (STIs) continue to exert a substantial public health burden globally but surveillance remains a challenge, especially in the developing world. We reviewed STI surveillance systems in various regions globally and used available data to provide an overview of recent trends in STI epidemiology.

RECENT FINDINGS

STI surveillance systems in the developing world are often limited and restricted to ad hoc cross-sectional surveys; however, available data suggest that these areas are disproportionately affected by STIs, with a higher burden in marginalized groups such as sex workers. Developed countries typically have established surveillance systems. Recent reports suggest many of these countries are experiencing rising diagnoses of STIs in men who have sex with men (MSM) and an increasing contribution of HIV-positive MSM to STI epidemics.

SUMMARY

There is considerable variability in the surveillance for STIs globally, ranging from active or passive, to sentinel, laboratory or clinic-based systems. Given different levels of resources and patterns of healthcare provision, it is difficult to compare surveillance data across regions; however, available data suggest that considerable inequality in STI burden exists. In resource-limited settings, syndromic surveillance with periodic laboratory assessments is recommended to monitor trends in STIs.

Systems Mapping of Sexually Transmitted Infection Services at Three Clinical Sentinel Surveillance Sites in South Africa: Opportunities for Integrated Care

Sexually transmitted infection (STI) service delivery in the context of integrated care and the South African HIV epidemic is complex. We aimed to document STI care and HIV testing processes in public health clinics in South Africa, revealing bottlenecks to patient flow and identifying opportunities for improvement. Clinic mapping, with semi-structured interviews and clinic observation, was conducted with facility representatives at three clinical sentinel surveillance sites. Facility surveys assessed patient volume and staffing. Identified challenges were associated with staffing allocations, and disruptions in patient flow resulted from poor clinic layout, inadequate lighting, and limited allocation of space for HIV testing and physical examination. Recommendations include staffing adjustments, reorganization of space to allow for designated service and waiting areas, sufficient supplies, and improved lighting. The facility reorganization component of South Africa's Ideal Clinic initiative provides a key opportunity for enacting many of these recommendations.

Evaluation of syndromic management guidelines for treatment of sexually transmitted infections in South African women

OBJECTIVE

To evaluate the performance of three different guidelines for the management of vaginal discharge syndrome (VDS) for women living in a rural setting in South Africa.

METHODS

We conducted a secondary analysis of data from a cross-sectional study in Mopani District, South Africa. The 2015 and 2008 guidelines of the South African Department of Health (DoH) and the most recent WHO guidelines were evaluated for adequate treatment of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium and Trichomonas vaginalis infection.

RESULTS

Of the 489 women included in this analysis, 35% presented with VDS according to the DoH and 30% per WHO definition of VDS. Fifty-six per cent of the women with VDS would be treated adequately for these STI when using the 2015 DoH guideline, whereas 76% (P = 0.01) and 64% (P = 0.35) would receive adequate treatment with the 2008 DoH and WHO guidelines, respectively. Of the symptomatic women who tested negative for all four STI, STI treatment would have been indicated for 36% as per 2015 DoH guideline vs. 69% (P < 0.001) per 2008 DoH and 67% (P < 0.001) per WHO guidelines.

CONCLUSION

A considerable proportion of symptomatic women infected with these common curable STI would receive adequate treatment when using a syndromic management approach, and significant differences exist between the three guidelines. Many symptomatic women without these STI receive broad-spectrum antibiotics, so new approaches are needed to improve syndromic STI control.

Sexual behaviour and risk of sexually transmitted infections in young female healthcare students in Spain

Background. Several authors have examined the risk for sexually transmitted infections (STI), but no study has yet analyzed it solely in relation with sexual behaviour in women. We analyzed the association of sexual behaviour with STI risk in female university students of healthcare sciences. Methods. We designed a cross-sectional study assessing over three months vaginal intercourse with a man. The study involved 175 female university students, without a stable partner, studying healthcare sciences in Spain.

MAIN OUTCOME VARIABLE

STI risk (not always using male condoms). Secondary variables: sexual behaviour, method of orgasm, desire to increase the frequency of sexual relations, desire to have more variety in sexual relations, frequency of sexual intercourse with the partner, and age. The information was collected with an original questionnaire. A logistic regression model was used to estimate the adjusted odds ratios (ORs) in order to analyze the association between the STI risk and the study variables. Results. Of the 175 women, 52 were positive for STI risk (29.7%, 95% CI [22.9-36.5%]). Factors significantly associated with STI risk (p < 0.05) included: orgasm (not having orgasms →OR = 7.01, 95% CI [1.49-33.00]; several methods →OR = 0.77, 95% CI [0.31-1.90]; one single method →OR = 1; p = 0.008) and desiring an increased frequency of sexual activities (OR = 0.27, 95% CI [0.13-0.59], p < 0.001). Conclusions. Women's desire for sexual activities and their sexual function were significant predictors of their risk for STI. Information about sexual function is an intrinsic aspect of sexual behaviour and should be taken into consideration when seeking approaches to reduce risks for STI.

Bacterial Vaginosis and Subclinical Markers of Genital Tract Inflammation and Mucosal Immunity

Bacterial vaginosis (BV) has been linked to an increased risk of human immunodeficiency virus (HIV) acquisition and transmission in observational studies, but the underlying biological mechanisms are unknown. We measured biomarkers of subclinical vaginal inflammation, endogenous antimicrobial activity, and vaginal flora in women with BV and repeated sampling 1 week and 1 month after completion of metronidazole therapy. We also compared this cohort of women with BV to a healthy control cohort without BV. A longitudinal, open label study of 33 women with a Nugent score of 4 or higher was conducted. All women had genital swabs, cervicovaginal lavage (CVL) fluid, and cervicovaginal biopsies obtained at enrollment and received 7 days of metronidazole treatment. Repeat sampling was performed approximately 1 week and 1 month after completion of therapy. Participant's baseline samples were compared to a healthy, racially matched control group (n=13) without BV. The CVL from women with resolved BV (Nugent 0-3) had significantly higher anti-HIV activity, secretory leukocyte protease inhibitor (SLPI), and growth-related oncogene alpha (GRO-α) levels and their ectocervical tissues had significantly more CD8 cells in the epithelium. Women with persistent BV after treatment had significantly higher levels of interleukin-1β, tumor necrosis factor alpha (TNF-α), and intercellular adhesion molecule 1 (ICAM-1) in the CVL. At study entry, participants had significantly greater numbers of CCR5(+) immune cells and a higher CD4/CD8 ratio in ectocervical tissues prior to metronidazole treatment, compared to a racially matched cohort of women with a Nugent score of 0-3. These data indicate that BV is associated with changes in select soluble immune mediators, an increase in HIV target cells, and a reduction in endogenous antimicrobial activity, which may contribute to the increased risk of HIV acquisition.

Cross-sectional study of genital, rectal, and pharyngeal Chlamydia and gonorrhea in women in rural South Africa

BACKGROUND

Epidemiological data of genital chlamydia and gonorrhea, required to inform design and implementation of control programs, are limited for rural Africa. There are no data on the prevalence of rectal or pharyngeal infections among African women.

METHODS

A cross-sectional study of 604 adult women visiting 25 primary health care facilities in rural South Africa was conducted. Vaginal, anorectal, and oropharyngeal swabs were tested for Chlamydia trachomatis and Neisseria gonorrhoeae.

RESULTS

Prevalence of genital chlamydia was 16% and that of gonorrhea was 10%; rectal chlamydial infection was diagnosed in 7.1% and gonococcal in 2.5% of women. One woman had pharyngeal chlamydia. Most women with genital chlamydia (61%) and gonorrhea (57%) were asymptomatic. Independent risk factors for genital chlamydia were younger age (adjusted odds ratio [aOR], 0.96 per year; 95% confidence interval [CI], 0.93-0.98), hormonal contraceptive use (aOR, 2.2; 95% CI, 1.3-3.7), pregnancy (aOR, 2.4; 95% CI, 1.3-4.4), and intravaginal cleansing (aOR, 1.7; 95% CI, 1.04-2.8). Intravaginal cleansing was associated with genital gonorrhea (aOR, 1.9; 95% CI, 1.1-3.3).

CONCLUSIONS

Genital and rectal, but not pharyngeal, chlamydia and gonorrhea are highly prevalent and frequently asymptomatic in women in rural South Africa. Young women attending health care facilities for antenatal care or family planning should be prioritized in control efforts.

High-resolution multilocus sequence typing reveals novel urogenital Chlamydia trachomatis strains in women in Mopani district, South Africa

OBJECTIVES

Recently, we reported a high prevalence (16%) of urogenital Chlamydia trachomatis infections among women in a rural setting in South Africa. Molecular epidemiological studies on C. trachomatis infections could provide insights into the characteristics of this epidemic, yet such data are not available. The objective of this study was therefore to assess the distribution of C. trachomatis strains among women from a South African rural community, the Mopani district, and to compare it with strains from Amsterdam, the Netherlands.

METHODS

High-resolution multilocus sequence typing (hr-MLST) was used to study urogenital C. trachomatis infections in women visiting primary healthcare facilities across rural Mopani District in Limpopo Province, South Africa. Sequence types (STs) were compared with 100 strains from women visiting the sexually transmitted infection clinic in Amsterdam, the Netherlands.

RESULTS

Full hr-MLST data were obtained for C. trachomatis infection in 43 women from Mopani district. Using the complete hr-MLST profile of all 43 women from Mopani district, 26 STs could be identified, of which 18 (69%) were novel to the hr-MLST database. The remaining STs clustered together with strains from Amsterdam.

CONCLUSIONS

Hr-MLST data revealed a diverse molecular epidemiology with novel STs and a specific cluster for the Mopani district. Also C. trachomatis types that occur worldwide were detected.

What underpins the decline in syphilis in Southern and Eastern Africa? An exploratory ecological analysis

BACKGROUND

AIDS mortality played an important role in the decline in syphilis prevalence in the USA, but its effect on the dramatic reduction in syphilis prevalence in Southern and Eastern Africa has not been explored. In this ecological study, we investigated the extent to which the relationship between syphilis and HIV prevalence at a population level varied between the early and late periods of the HIV epidemic.

METHODS

We performed linear regression analysis to measure the association between the national prevalence of syphilis and the peak-HIV prevalence in the early and late phases of the HIV epidemic in 11 countries of Southern and Eastern Africa.

RESULTS

Our analysis showed a strong positive association between peak-HIV prevalence and syphilis prevalence early in the HIV epidemic (R(2)=0.59; p=0.006). Although only of borderline statistical significance, this linear relationship between HIV prevalence and syphilis prevalence switched to a negative direction late in the HIV epidemic (R(2)=0.32; p=0.07).

CONCLUSIONS

AIDS mortality may have played an important role in the decline in syphilis in this region. Consequently, with AIDS deaths declining in Sub-Saharan Africa, vigilant surveillance of syphilis prevalence will be necessary to detect a potential re-emergence, as has occurred in high-income countries, and to render a timely public health response.

High prevalence and incidence of sexually transmitted infections among women living in Kwazulu-Natal, South Africa

BACKGROUND AND OBJECTIVES

Sexually transmitted infections (STIs) contribute largely to the burden of health in South Africa and are recognized as major contributors to the human immunodeficiency virus (HIV) epidemic. Young women are particularly vulnerable to STIs. The purpose of this secondary analysis was to examine the risk factors associated with prevalent and incident STIs among women who had participated in three clinical trials.

METHODS

A total of 5,748 women were screened and 2293 sexually active, HIV negative, non-pregnant women were enrolled in three clinical trials in Kwazulu-Natal, South Africa. The prevalence of individual STIs Chlamydia trachomatis (CT), Neisseria gonorrhea (NG), syphilis, and Trichomonas vaginalis (TV) was assessed at screening; and incident infections were evaluated over a 24 month period.

RESULTS

Overall, the combined study population of all three trials had a median age of 28 years (inter-quartile range (IQR):22-37), and a median duration of follow-up of 12 months. Prevalence of STIs (CT, NG, TV, or syphilis) was 13% at screening. The STI incidence was estimated to be 20/100 women years. Younger women (<25 years, p < 0.001), women who were unmarried (p < 0.001) and non-cohabiting women (p < 0.001) were shown to be at highest risk for incident STIs.

CONCLUSIONS

These results confirm the extremely high prevalence and incidence of STIs among women living in rural and urban communities of KwaZulu-Natal, South Africa, where the HIV epidemic is also particularly severe. These findings strongly suggest an urgent need to allocate resources for STI and HIV prevention that mainly target younger women.

TRIAL REGISTRATION

Clinical Trials.gov, NCT00121459.

The changing relationship between bacterial STIs and HIV prevalence in South Africa - an ecological study

Prevalence estimates of various bacterial sexually transmitted infections in South Africa have declined considerably since the mid-1990s. Syphilis among pregnant women, for example, declined from 10.8% in 1998 to 2.8% in 2001. We used Pearson's correlation coefficients to estimate the association between the prevalence of syphilis/male urethral discharge/male genital ulcers and the peak HIV prevalence at a district and provincial level in the early and late phases of the HIV epidemic in South Africa. Prevalence estimates of syphilis, male urethral discharge and male genital ulcers during the period preceding the peak HIV prevalence were all positively correlated with the peak HIV prevalence at a provincial level (Pearson's correlation coefficient [r] = 0.83, p = 0.006; r = 0.66, p = 0.052; r = 0.79, 0.011, respectively). These relationships all switched to a negative association later in the HIV epidemic at a provincial level (r = -0.53, p = 0.14; r = -0.73, p = 0.130; r = -0.54, p = 0.027, respectively). AIDS mortality may have played an important role in the decline of bacterial sexually transmitted infections such as syphilis in this region. Consequently, the relatively recent scale-up of antiretroviral therapy may result in a resurgence of syphilis and other sexually transmitted infections as observed in high-income countries.

Efficacy of enhanced HIV counseling for risk reduction during pregnancy and in the postpartum period: a randomized controlled trial

INTRODUCTION

Pregnancy and the postpartum period present important intervention opportunities. Counseling can leverage the motivation women have during this time to change behaviors that may negatively affect their health and the heath of their infants.

METHODS

Pregnant women attending an antenatal clinic in South Africa were randomly allocated to treatment (n=733) and control arms (n=747). Treatment arm participants received enhanced HIV pre- and post-test counseling, legal support and access to support groups at baseline, which occurred at the first antenatal visit, and then six and ten weeks postpartum. Control arm participants received standard HIV testing and counseling (HTC) and two postpartum attention control sessions. Outcomes were incidence of sexually transmitted infection (STI) by 14 weeks postpartum and past 30-day inconsistent condom use at 14 weeks and 9 months postpartum.

RESULTS

There were no intervention effects on incident STIs for either HIV-negative (adjusted risk ratio (aRR) 1.01, 95% CI 0.71-1.44) or HIV-positive participants (aRR 0.86, 95% CI 0.61-1.23). The intervention was associated with a 28% decrease in risk of past 30-day inconsistent condom use at nine-months among HIV-negative women (aRR 0.72,95% CI 0.59-0.88), but did not affect inconsistent condom use among HIV-positive women (aRR1.08; 95% CI 0.67-1.75).

DISCUSSION

An enhanced counseling intervention during pregnancy and the postpartum period can lead to reductions in inconsistent condom use among HIV-negative women. Results underscore the importance of the counseling that accompanies HIV HTC. More work is needed to understand how to promote and sustain risk reduction among HIV-positive women.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01683461.

Pregnancy incidence and correlates in a clinical trial preparedness study, North West Province South Africa

Introduction

Women in HIV prevention trials often must typically agree to avoid pregnancy. Regardless, some become pregnant. Screening tools predicting pregnancy risk could maximize trial safety and efficiency.

Objectives

We assessed incidence and correlates of pregnancy among women at high HIV risk.

Methods

We enrolled sexually-active, HIV-negative women into an observational cohort (2008–2011). At enrolment demographic, contraceptive, reproductive, pregnancy intention and behavioural data were collected. Women reported if one or both partners wanted or intended for the couple to become pregnant. We measured gender role beliefs using a locally validated eight-point index. We tested HIV and pregnancy, and inquired about sexually transmitted infection symptoms (STIs) at enrollment and monthly. HIV testing included behavioural counselling and condom provision, but did not specifically counsel women to avoid pregnancy. Cox proportional hazard modelling evaluated the associations with pregnancy. The multivariate model included the following variables “Recent pregnancy attempts”, “Gender Roles Beliefs”, ”Self-reported STIs” and “Age”.

Results

We screened 1068 women and excluded (24.6%, 263/1068) who did not report risk behaviour. Non-pregnant, non-sterilized women aged 18–35 (median = 21 years) enrolled (n = 438). Most women reported one partner (74.7%) and a prior live birth (84.6%). Median follow-up time was 6 months (range 0.7–15.5). Pregnancy incidence was 25.1 per 100 women-years (n = 57 pregnancies). Conservative beliefs on gender roles (Adjusted Hazard Ratio (aHR) 1.8; 95% confidence interval [CI] 1.1–2.9), recent pregnancy attempts (aHR 1.9; 95% CI 1.1–3.4) and baseline self-reported STI (aHR 2.5; 95% CI 1.4–4.4) were associated with increased incident pregnancy. Report of no pregnancy intention was associated with lowered pregnancy risk (aHR 0.3; 95% CI 0.1–0.7).

Conclusions

We identified new and confirmed existing factors that can facilitate screening for pregnancy risk.

Cost-effectiveness of tenofovir gel in urban South Africa: model projections of HIV impact and threshold product prices

BACKGROUND

There is urgent need for effective HIV prevention methods that women can initiate. The CAPRISA 004 trial showed that a tenofovir-based vaginal microbicide had significant impact on HIV incidence among women. This study uses the trial findings to estimate the population-level impact of the gel on HIV and HSV-2 transmission, and price thresholds at which widespread product introduction would be as cost-effective as male circumcision in urban South Africa.

METHODS

The estimated 'per sex-act' HIV and HSV-2 efficacies were imputed from CAPRISA 004. A dynamic HIV/STI transmission model, parameterised and fitted to Gauteng (HIV prevalence of 16.9% in 2008), South Africa, was used to estimate the impact of gel use over 15 years. Uptake was assumed to increase linearly to 30% over 10 years, with gel use in 72% of sex-acts. Full economic programme and averted HIV treatment costs were modelled. Cost per DALY averted is estimated and a microbicide price that equalises its cost-effectiveness to that of male circumcision is estimated.

RESULTS

Using plausible assumptions about product introduction, we predict that tenofovir gel use could lead to a 12.5% and 4.9% reduction in HIV and HSV-2 incidence respectively, by year 15. Microbicide introduction is predicted to be highly cost-effective (under $300 per DALY averted), though the dose price would need to be just $0.12 to be equally cost-effective as male circumcision. A single dose or highly effective (83% HIV efficacy per sex-act) regimen would allow for more realistic threshold prices ($0.25 and $0.33 per dose, respectively).

CONCLUSIONS

These findings show that an effective coitally-dependent microbicide could reduce HIV incidence by 12.5% in this setting, if current condom use is maintained. For microbicides to be in the range of the most cost-effective HIV prevention interventions, product costs will need to decrease substantially.

Genital donovanosis with malignant transformation: An interesting case report

Donovanosis is a chronic indolent sexually transmitted granulomatous ulceration of genito-inguinal region, caused by Calymmatobacterium granulomatis. It became uncommon due to indiscriminate use of broad spectrum antibiotics. In recent years, much interest is being focused on this condition because genital ulcers facilitate HIV infection. We report an interesting episode of genital donovanosis complicated with squamous cell carcinoma in a middle aged female for its rarity and clinical interest.

Distinct cytokine patterns in semen influence local HIV shedding and HIV target cell activation

BACKGROUND

Semen is the main vector for human immunodeficiency virus (HIV) transmission from men to women. We investigated the influence of cytokines in semen on local HIV burden and activated T cells.

METHODS

Blood and semen were collected from 42 HIV-negative and 38 HIV-positive men. Concentrations of 20 cytokines were measured by Luminex, and frequencies of activated T cells were measured by flow cytometry.

RESULTS

Semen contained higher concentrations of proinflammatory (monocyte chemotactic protein-1, interleukin [IL]-8, IL-6, Fractalkine, macrophage inflammatory protein (MIP)-1β, granulocyte macrophage colony-stimulating factor) and adaptive cytokines (IL-7 and IL-15) and higher frequencies of activated T cells compared to blood. Plasma IL-2, eotaxin, MIP-1β, and IL-15 and semen eotaxin and granulocyte colony-stimulating factor (G-CSF) concentrations were associated with T-cell activation. Cytokines in semen were highly coregulated in HIV-negative men; however, this network was disrupted during HIV infection. Several cytokines in semen correlated with HIV shedding (G-CSF, tumor necrosis factor-alpha [TNF-α], interferon-gamma [IFN-γ], IL-10).

CONCLUSION

Higher levels of inflammation and T-cell activation were observed in semen compared with blood. Seminal G-CSF, which influences neutrophil survival, T-cell function, and dendritic cell activation, was associated with T-cell activation and HIV shedding and may be an important target for reducing HIV shedding or risk.

Sexually Transmitted Infections in Women Participating in a Biomedical Intervention Trial in Durban: Prevalence, Coinfections, and Risk Factors

Background. Sexually transmitted infections (STIs) continue to be a significant public health problem especially among women of reproductive age in Africa. Methods. A total of 2236 women that had enrolled in the MDP301 vaginal microbicide trial were tested for the presence of Chlamydia trachomatis (CT), Neisseria gonorrhea (NG), Treponema pallidum, and Trichomonas vaginalis (TV). Results. CT was identified as the most prevalent STI (11%) followed by TV (10%), NG, and Syphilis (3%). The highest prevalence of coinfection was reported between T. pallidum and TV (19.67%, P = 0.004), followed by CT and TV (13.52%, P ≤ 0.001). Risk factors that were significantly associated with STI acquisition were women of 23 years of age or younger (HR: 1.50, 95% CI 1.17, 1.93), baseline STI with CT (HR: 1.77, 95% CI 1.32, 2.35), TV (HR: 1.58, 95% CI, 1.20, 2.10), and T. pallidum (HR: 5.13, 95% CI 3.65, 7.22), and a low education level (HR: 1.30, 95% CI 1.02, 1.66). Conclusion. Young women with lower education and a history of STIs are at high risk of multiple STIs. Prevention programs should consider target approach to STI prevention among young women. This trial is registered with ISRCTN64716212.

Behavioural and medical predictors of bacterial vaginosis recurrence among female sex workers: longitudinal analysis from a randomized controlled trial

Background

Data on risk factors of recurrent bacterial vaginosis (RBV) are still scarce. We used data from female sex workers (FSW) participating in a randomized controlled microbicide trial to examine predictors of BV recurrence.

Methods

Trial’s participants with at least an episode of BV which was treated and/or followed by a negative BV result and at least one subsequent visit offering BV testing were included in the analysis. Behavioural and medical data were collected monthly while laboratory testing for STI and genital tract infections were performed quarterly. The Andersen-Gill proportional hazards model was used to determine predictors of BV recurrence both in bivariate and multivariate analyses.

Results

440 women were included and the incidence rate for RBV was 20.8 recurrences/100 person-months (95% confidence interval (CI) =18.1–23.4). In the multivariate analysis controlling for the study site, recent vaginal cleansing as reported at baseline with adjusted hazard-ratio (aHR)=1.30, 95% CI = 1.02-1.64 increased the risk of BV recurrence, whereas consistent condom use (CCU) with the primary partner (aHR=0.68, 95% CI=0.49-0.93) and vaginal candidiasis (aHR=0.70, 95% CI=0.53-0.93), both treated as time-dependent variables, were associated with decreased risk of RBV.

Conclusion

This study confirms the importance of counselling high-risk women with RBV about the adverse effects of vaginal cleansing and the protective effects of condom use with all types of partners for the prevention of sexually transmitted infections, including BV. More prospective studies on risk factors of BV recurrence are warranted.

Trial registration

Trial registration: NCT00153777

Trends and associations of Trichomonas vaginalis infection in men and women with genital discharge syndromes in Johannesburg, South Africa

OBJECTIVES

To better understand the epidemiology of Trichomonas vaginalis infection, we investigated the association between T vaginalis and demographic, clinical, microbiological and behavioural characteristics of patients presenting with genital discharges to a primary healthcare clinic in Johannesburg, South Africa.

METHODS

During six annual surveys (2007-2012), 1218 cases of male urethral discharge syndrome and 1232 cases of vaginal discharge syndrome were consecutively recruited. Diagnostic methods included nucleic acid amplification (Neisseria gonorrhoeae, Chlamydia trachomatis, T vaginalis and Mycoplasma genitalium), microscopy (bacterial vaginosis and Candida) and serology (Treponema pallidum, herpes simplex virus type 2 (HSV-2) and HIV). Logistic regression analyses and χ2 tests were used to identify predictors of T vaginalis infection.

RESULTS

The prevalence of T vaginalis decreased from 2007 to 2012 (men from 13.4% to 4.8%; women from 33.8 to 23.1%). Overall, 74 (6.1%) men and 291 (23.6%) women were T vaginalis positive, with the highest prevalence in those aged ≥40 years (men 13.6%; women 30.9%). T vaginalis infection occurred more often in pregnant women (adjusted OR (aOR) 2.67; 95% CI 1.29 to 5.54) and in women with serological evidence of T pallidum (aOR 1.63; 95% CI 1.08 to 2.45) or HSV-2 infections (aOR 1.75; 95% CI 1.16 to 2.64). T vaginalis infection occurred less often in men with coexistent gonorrhoea (aOR 0.35; 95% CI 0.21 to 0.57) and in women with either bacterial vaginosis (aOR 0.60; 95% CI 0.44 to 0.82) or Candida morphotypes (OR 0.61; 95% CI 0.43 to 0.86).

CONCLUSIONS

Although the prevalence of T vaginalis infection has decreased over time, it remains an important cause of genital discharge in South Africa, particularly in older patients and pregnant women.

Herpes simplex virus type 2 infection as a biomarker for sexual debut among young people in sub-Saharan Africa: a literature review

Biological markers are needed in order to provide objective measures to validate self-reported sexual behaviour and interpret prevention trial data. In this review, we evaluated herpes simplex type 2 virus (HSV-2), one of the most prevalent sexually transmitted infections in sub-Saharan Africa as a biological marker of sexual debut. Based on our findings, we do not recommend using HSV-2 as a biomarker for sexual debut due to its low transmission probabilities and the fact that HSV-2 prevalence is not 100% among potential sexual partners. We recommend that the validation of alternative biological measures should be prioritized, and included in future studies and trials of interventions to reduce sexual health risk.