Genital infections in women attending a genito-urinary clinic in Harare, Zimbabwe

Prevalence, incidence and risk factors for anogenital warts in Sub Saharan Africa: a systematic review and meta analysis

Introduction

The quadrivalent HPV vaccine is highly effective in primary prevention of anogenital warts (AGWs). However, there is lack of systematic review in the literature of the epidemiology of AGWs in Sub Saharan Africa (SSA).

Objective

To review the prevalence, incidence and risk factors for AGWs in SSA prior to the introduction of HPV vaccination programs.

Methods

PubMed/MEDLINE, Africa Index Medicus and HINARI websites were searched for peer reviewed English language published medical literature on AGWs from January 1, 1984 to June 30, 2012. Relevant additional references cited in published papers were also evaluated for inclusion. For inclusion, the article had to meet the following criteria (1) original studies with estimated prevalence and/or incidence rates among men and/or women (2) detailed description of the study population (3) clinical or self-reported diagnosis of AGWs (4) HPV genotyping of histologically confirmed AGWs. The final analysis included 40 studies. Data across different studies were synthesized using descriptive statistics for various subgroups of females and males by geographical area. A meta - analysis of relative risk was conducted for studies that had data reported by HIV status.

Results

The prevalence rates of clinical AGWs among sex workers and women with sexually transmitted diseases (STDs) or at high risk of sexually transmitted infection (STIs) range from 3.3% - 10.7% in East, 2.4% - 14.0% in Central and South, and 3.5% - 10.5% in West African regions. Among pregnant women, the prevalence rates range from 0.4% - 3.0% in East, 0.2% - 7.3% in Central and South and 2.9% in West African regions. Among men, the prevalence rates range from 3.5% - 4.5% in East, 4.8% - 6.0% in Central and South and 4.1% to 7.0% in West African regions. In all regions, the prevalence rates were significantly higher among HIV+ than HIV- women with an overall summary relative risk of 1.62 (95% CI: 143–1.82).

The incidence rates range from 1.1 – 2.7 per 100 person-years among women and 1.4 per 100 person years among men. Incidence rate was higher among HIV+ (3.0 per 100 person years) and uncircumcised men (1.7 per 100 person-years) than circumcised men (1.3 per 100 person-years).

HIV positivity was a risk factor for AGWs among both men and women. Other risk factors in women include presence of abnormal cervical cytology, co-infection with HPV 52, concurrent bacteria vaginoses and genital ulceration. Among men, other risk factors include cigarette smoking and lack of circumcision.

Conclusions

AGWs are common among selected populations particularly HIV infected men and women. However, there is need for population-based studies that will guide policies on effective prevention, treatment and control of AGWs.

HIV and other sexually transmitted diseases at a rural hospital in Zimbabwe

OBJECTIVE

To define the epidemiological characteristics of STD patients attending an outpatient clinic in rural Zimbabwe, to examine the aetiologic agents causing infection and to determine their relationship with HIV infection.

SUBJECTS

319 men and 146 women, making a sample of about 7% all patients attending an STD clinic during the 3 month study period. Microbiological data were collected from 104 men and 72 women selected randomly from these. Pregnant women were excluded and patients who had received antibiotics within the previous 14 days were excluded from the microbiology sub-sample.

SETTING

An outpatient STD clinic at a District Hospital on a major truck route about 300 km north of the capital, Harare.

METHODS

All new patients attending the clinic during a 3 month period were enrolled for clinical and epidemiological investigations using a standard procedure. Specimens for microbiological investigation were taken from every second patient seen on the first three days of each week.

RESULTS

The typical patient was male (m:f ratio 2.2) aged 20-29 years (68% patients), not married (56% men) and in paid employment (66% men vs. 27% for the district). In men the most common presenting feature was genital ulceration, while in women, discharges were more common. Genital warts were noted frequently in both sexes. In the sub-sample examined microbiologically, H ducreyi was isolated from 46% ulcers clinically diagnosed as chancroid, and motile spirochaetes were detected in 25% painless ulcers. Neither of these were detected in ulcers in women, but HSV antigen was found as frequently in ulcers from men (19%) as from women (17%). In patients with genital discharges, gonococcal infection occurred in 64% men and 17% women, while T vaginalis was isolated from 39% women and only 8% men. Over 60% gonococcal isolates were PPNG, and 18% showed in vitro resistance to tetracycline. Yeasts, mainly C albicans were isolated from 42% women with a discharge and 25% women with ulcers. In men the presence of yeasts was associated with superficial ulceration and itchiness of the glans. Positive HIV-1 serology was found in 64% patients. There was no statistical association with current genital ulcers, though there was an association with previous STD episodes and particularly with serological evidence of syphilis. Apart from yeasts, there was no association between positive HIV-1 serology and the presence of pathogens in the genital tract.

CONCLUSIONS

The high prevalence of HIV-1 antibodies in STD patients in Karoi suggests integration of STD and AIDS control programmes to be a necessity. Since paid employment was a common feature of both STD clinic attendance and HIV-1 seropositivity, these programmes may be effectively directed through the work place.

Seroepidemiological and socioeconomic studies of genital chlamydial infection in Ethiopian women

OBJECTIVE

To measure the prevalence of chlamydial genital infection in Ethiopian women attending gynaecological, obstetric and family planning clinics; to identify the epidemiological, social and economic factors affecting the prevalence of infection in a country where routine laboratory culture and serological tests for chlamydial species are unavailable; to determine the risk factors for genital chlamydial infection in those with serological evidence of other sexually transmitted diseases.

SUBJECTS

1846 Ethiopian women, outpatient attenders at two teaching hospitals and a mother and child health centre in Addis Ababa, Ethiopia.

SETTING

Gynaecological outpatient department, antenatal, postnatal and family planning clinics.

METHODS

Sera were tested for type-specific anti-chlamydial antibodies using purified chlamydial antigens (C. trachomatis A-C (CTA-C), C. trachomatis D-K (CTD-K), Lymphogranuloma venereum (LGV1-3), and C. pneumoniae (CPn)), in a micro-immunofluorescence test. The genital chlamydia seropositivity was analysed against patient's age, clinic attended, ethnic group, religion, origin of residence, age at first marriage and first coitus, income, number of sexual partners, duration of sexual activity, marital status/profession, obstetric and contraceptive history, and seropositivity for other sexually transmitted diseases.

RESULTS

Overall exposure to chlamydia species was found in 84%, genital chlamydial infection in 62%, and titres suggestive of recent or present genital infection in 42% of those studied. Genital chlamydial infection was highest (64%) in family planning and lowest (54%) in antenatal clinic attenders. Exposure to genital chlamydia species was influenced by ethnic group and religion. Those married and sexually active under 13 years of age had greater exposure (69%) to genital chlamydial infection than those first sexually active aged over 18 (46%). Prevalence of infection was highest in those with more than five sexual partners (78%) and in bargirls (84%). The lowest income groups had a higher prevalence (65%) of genital chlamydial infection than the wealthiest (48%). Multivariate analysis showed the most important factors to be age at first coitus, religion, prostitution and present age of the woman in that order. Risk for genital chlamydial infection was increased in those with seropositivity for syphilis, gonorrhoea, HSV-2 but not HBV infection. CONCLUSION/APPLICATION: Chlamydial genital infections are highly prevalent in both symptomatic and asymptomatic Ethiopian women. The high prevalence of infection reported reflects a complexity of socioeconomic factors: very early age at first marriage and first coitus, instability of first marriage, subsequent divorce and remarriage or drift into prostitution, all of which are influenced by ethnic group, religion and poverty--together with transmission from an infected group of prostitutes by promiscuous males to their wives, lack of diagnostic facilities and inadequate treatment of both symptomatic and asymptomatic men and women. The problem of chlamydial disease in Ethiopia needs to be addressed urgently in the context of control of STD.

Seroepidemiological study of gonorrhoea in Ethiopian women. 1. Prevalence and clinical significance

OBJECTIVE

To measure the prevalence of gonorrhoea in Ethiopian women attending gynaecologic, obstetric and family planning clinics: to determine the reliability of patient self history of sexually transmitted disease (STD); to correlate the serological diagnosis of gonorrhoea with clinical evidence of pelvic infection in order to define a reliable clinical diagnosis of gonorrhoea in a country where pelvic inflammatory disease is very common but where routine laboratory culture and serological tests for gonorrhoea are unavailable.

SUBJECTS

1851 Ethiopian women: 50% symptomatic, 50% asymptomatic.

SETTING

Gynaecological outpatient department, antenatal, postnatal and family planning clinics (Ethiopian Family Guidance Association (EFGA)), in two teaching hospitals and a mother and child health centre in Addis Ababa, Ethiopia.

METHODS

The indirect haemagglutination test with gonococcal pilus antigen as an epidemiological tool was used in a cross-section study to screen 1851 sera for evidence of past or current gonococcal infection. The gonococcal antibody test (GAT) seropositivity was correlated with patient's history of STD, age, clinic attended and the clinical evidence of infection in "gonococcal target organs" urethra, salpinges or Bartholin glands.

RESULTS

Fifty nine per cent of the study group were seropositive for the gonococcal antibody test, 22% with titres greater than or equal to 1/320, indicative of current, recent or recurrent infection. Seropositivity indicating past or present gonococcal infection was highest in those who gave a history of having had treated syphilis (85%), in women aged 40-49 (72%), and family planning attenders (EFGA) (66%) of whom 31% had titres greater than or equal to 1/320. Fifty per cent had clinical evidence of past or present infection in the urethra, salpinges or Bartholin glands. Gonococcal antibodies were present in 54% of women with no evidence of clinical infection, compared with 91% of those with pyosalpinx and 86% of those with triple infection of urethra, salpinges and Bartholin glands.

CONCLUSION

The high prevalence of gonococcal antibodies in Ethiopian women, especially in asymptomatic clinic attenders must be of concern for all health workers especially those in gynaecology and obstetrics and the related disciplines of family planning and neonatal paediatrics. While seropositivity was highest in those giving a past history of syphilis, the patient's history of STD was unreliable, as of those who denied having any history of STD, fifty per cent were GAT seropositive. Despite a high correlation between GAT seropositivity with pyosalpinx and clinical evidence of infection in urethra, salpinges and bartholin glands, gonococcal antibodies were present in 54% of women with no clinical evidence of infection. Thus we were unable to define a diagnostic clinical picture of gonorrhoea in Ethiopian women.