Etiologies of genital inflammation and ulceration in symptomatic Rwandan men and women responding to radio promotions of free screening and treatment services

Prospective Cohort Study of Treatment Outcomes of Vaginal Discharge Syndrome in Women in Windhoek, Namibia

BACKGROUND

Syndromic treatment is the standard of care for vaginal discharge syndrome (VDS) in resource-constrained settings. However, the outcomes of VDS treatment have not been well documented. This study aimed to determine the incidence, risk factors, and microbial etiology of treatment failure in women with VDS.

METHODS

This prospective cohort study of women with VDS was conducted between September 2021 and March 2022 at Katutura Intermediate Hospital in Windhoek, Namibia. Microbiological analyses of sexually transmitted infections (STIs; Chlamydia trachomatis , Neisseria gonorrhoeae , Trichomonas vaginalis , Mycoplasma genitalium ), bacterial vaginosis, and vulvovaginal candidiasis (VVC) were performed. Treatment outcomes were assessed at 7 and 30 days after treatment, followed by microbial investigation in case of treatment failure.

RESULTS

One hundred nine women were enrolled, and 94 (86%) completed the follow-up. At baseline, 58 of 109 women (53%) were diagnosed with STI, 47 of 109 (43%) with bacterial vaginosis, and 45 of 109 (41%) with VVC. Candida albicans (33 of 45; 73%) was the main pathogen in VVC, with fluconazole resistance detected in 8 of 33 isolates (24%); 10 of 12 (80%) of non- albicans Candida species showed resistance. The incidence of treatment failure was 3.6 per 100 person-years at 7 days and 1.0 per 100 person-years at 30 days of follow-up; 17 of 94 women (18%) had recurrent VDS, and 12 of 94 women (13%) had persistent VDS. Vulvovaginal candidiasis (odds ratio, 4.3; 95% confidence interval, 1.7-11; P = 0.002) at baseline was associated with treatment failure.

CONCLUSIONS

Treatment failure after syndromic management of VDS is common in resource-constrained settings. Access to diagnostic testing, including fungal culture and susceptibility testing, is recommended to improve outcomes.

Importance of Candida infection and fluconazole resistance in women with vaginal discharge syndrome in Namibia

BACKGROUND

Vaginal discharge syndrome (VDS) is a common condition. Clinical management targets sexually transmitted infections (STIs) and bacterial vaginosis (BV); there is limited focus on Candida infection as cause of VDS. Lack of Candida treatment coverage and, if present, antifungal resistance may result in VDS treatment failure. This study aimed to determine the prevalence of Candida infection, antifungal resistance, and coinfections in Namibian women with VDS.

METHODS

A cross-sectional study was performed using 253 vaginal swabs from women with VDS in Namibia. Demographic data was collected, and phenotypic and molecular detection of Candida species was performed followed by fluconazole susceptibility testing of Candida isolates. BV was diagnosed using Nugent score microscopy; molecular detection of Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis was performed.

RESULTS

Candida species was detected in 110/253 women (43%). Ninety women (36%) had Candida albicans and 24 (9.5%) had non-albicans Candida species. The non-albicans species detected were 19 (17%) Candida glabrata, 4.0 (3.5%) Candida krusei, and 1.0 (0.9%) Candida parapsilosis. Candida albicans were more frequently isolated in younger (p = 0.004) and pregnant women (p = 0.04) compared to non-albicans Candida species. Almost all (98%) Candida albicans isolates were susceptible to fluconazole while all non-albicans Candida species were fluconazole resistant. STIs were diagnosed in 92 women (36%): 30 (12%) with C. trachomatis, 11 (4.3%) N. gonorrhoeae, and 70 (28%) T. vaginalis; 98 (39%) women had BV. Candida infection alone was diagnosed in 30 women (12%), combined with STIs in 42 women (17%) and was concurrent with BV in 38 women (15%). Candida infection was more often detected in swabs from women without C. trachomatis detected (6.4% vs. 16%; OR 0.30; 95% CI 0.10-0.77, p = 0.006).

CONCLUSIONS

The high prevalence of Candida infection, especially those due to non-albicans Candida species that are resistant to fluconazole, is a great concern in our setting and may lead to poor treatment outcomes. Access to microbiological testing for Candida species in the context of syndromic management is warranted.

Undisclosed HIV Status to Sex Partners and Its Unintended Consequences in the Era of Undetectable = Untransmittable

BACKGROUND

Adherence to antiretroviral therapy (ART) and sustained HIV suppression virtually eliminate HIV transmission, eg, having an undetectable viral load renders HIV untransmittable (U=U). Owing to the greatly reduced likelihood of HIV transmission when viral load is undetectable, we studied one behavioral ramification of adopting a U=U prevention strategy-not disclosing HIV status to sex partners.

SETTING

Cisgender men recruited through community outreach in the state of Georgia, USA.

METHODS

We examined HIV status disclosure to sex partners among 345 young (median age = 29 years) men receiving ART. Data were collected using computerized interviews, daily sexual behavior surveys over 28 days, unannounced pill counts for ART adherence, urine tests for drug use and urogenital health, and blood samples for HIV viral load.

RESULTS

One in 3 participants (34%) engaged in condomless anal/vaginal intercourse with an HIV-negative/unknown HIV status partner over 28 days. Average ART adherence was 76%, and one in 5 men had detectable HIV viral loads. Men who engaged in condomless sex with undisclosed partners demonstrated significantly less HIV disclosure to family and friends and had fewer enacted stigma experiences. Hierarchical regression models showed that endorsing U=U as a personal HIV prevention strategy predicted undisclosed condomless sex over and above substance use, HIV stigma experiences, disclosure to family and friends, ART adherence, and HIV viral load.

CONCLUSIONS

Interventions are needed to improve ART adherence and assist men living with HIV in their decisions to disclose HIV status to sex partners.