Chlamydia and Gonorrhea Infections in HIV-positive Women in Urban Lusaka, Zambia

Self-reported uptake of STI testing services among adolescents and young people aged 15-24 years: Findings from the Yathu Yathu cluster randomized trial in Lusaka, Zambia

There is little evidence regarding community-based delivery of STI testing and treatment for youth aged 15-24 (AYP) in Zambia. In a cluster-randomised trial, we evaluated whether offering syndromic STI screening through community-based, peer-led sexual and reproductive health services (Yathu Yathu) with referral to a local health facility for testing, increased self-reported testing for STIs (other than HIV) among AYP. Two communities in Lusaka were divided into 10 zones each (20 zones in total); by community, zones were randomly allocated (1:1) to Yathu Yathu or control. Monitoring data were used to describe syndromic STI screening through Yathu Yathu and an endline cross-sectional survey used to evaluate the impact of Yathu Yathu on self-reported ever and recent (last 12 months) STI testing. 10,974 AYP accessed Yathu Yathu; 66.6% (females-67.7%; males-64.7%) were screened for STIs, 6.2% reported any STI symptoms. In the endline survey, 23.3% (n = 350/1501) of AYP who ever had sex ever STI tested; 13.5% (n = 174/1498) who had sex in the last 12 months recently STI tested. By trial arm, there was no difference in self-reported ever or recent STI testing among all AYP. Among men aged 20-24, there was evidence that ever STI testing was higher in the Yathu Yathu compared to control arm (24.1% vs 16.1%; adjPR = 1.67 95%CI = 1.02, 2.74; p = 0.04). Among AYP who ever STI tested, 6.6% (n = 23) reported ever being diagnosed with an STI. Syndromic STI management through community-based, peer-led services showed no impact on self-reported STI testing among AYP. Research on community-based delivery of (near) point-of-care diagnostics is needed. Trial registration number(s): NCT04060420 https://clinicaltrials.gov/ct2/show/NCT04060420; and ISRCTN75609016; https://doi.org/10.1186/ISRCTN75609016.

Risk Factors for Infectious Diseases in Urban Environments of Sub-Saharan Africa: A Systematic Review and Critical Appraisal of Evidence

Our world is rapidly urbanizing. According to the United Nations, between 1990 and 2015, the percent of the world's population living in urban areas grew from 43% to 54%. Estimates suggest that this trend will continue and that over 68% of the world's population will call cities home by 2050, with the majority of urbanization occurring in African countries. This urbanization is already having a profound effect on global health and could significantly impact the epidemiology of infectious diseases. A better understanding of infectious disease risk factors specific to urban settings is needed to plan for and mitigate against future urban outbreaks. We conducted a systematic literature review of the Web of Science and PubMed databases to assess the risk factors for infectious diseases in the urban environments of sub-Saharan Africa. A search combining keywords associated with cities, migration, African countries, infectious disease, and risk were used to identify relevant studies. Original research and meta-analyses published between 2004 and 2019 investigating geographical and behavioral risk factors, changing disease distributions, or control programs were included in the study. The search yielded 3610 papers, and 106 met the criteria for inclusion in the analysis. Papers were categorized according to risk factors, geographic area, and study type. The papers covered 31 countries in sub-Saharan Africa with East Africa being the most represented sub-region. Malaria and HIV were the most frequent disease focuses of the studies. The results of this work can inform public health policy as it relates to capacity building and health systems strengthening in rapidly urbanizing areas, as well as highlight knowledge gaps that warrant additional research.

Co- but not Sequential Infection of DCs Boosts Their HIV-Specific CTL-Stimulatory Capacity

Pathogenic bacteria and their microbial products activate dendritic cells (DCs) at mucosal surfaces during sexually transmitted infections (STIs) and therefore might also differently shape DC functions during co-infection with HIV-1. We recently illustrated that complement (C) coating of HIV-1 (HIV-C), as primarily found during the acute phase of infection before appearance of HIV-specific antibodies, by-passed SAMHD1-mediated restriction in DCs and therefore mediated an increased DC activation and antiviral capacity. To determine whether the superior antiviral effects of HIV-C-exposed DCs also apply during STIs, we developed a co-infection model in which DCs were infected with Chlamydia spp. simultaneously (HIV-C/Chlam-DCs or HIV/Chlam-DCs) or a sequential infection model, where DCs were exposed to Chlamydia for 3 or 24 h (Chlam-DCs) followed by HIV-1 infection. Co-infection of DCs with HIV-1 and Chlamydia significantly boosted the CTL-stimulatory capacity compared to HIV-1-loaded iDCs and this boost was independent on the opsonization pattern. This effect was lost in the sequential infection model, when opsonized HIV-1 was added delayed to Chlamydia-loaded DCs. The reduction in the CTL-stimulatory capacity of Chlam-DCs was not due to lower HIV-1 binding or infection compared to iDCs or HIV-C/Chlam-DCs, but due to altered fusion and internalization mechanisms within DCs. The CTL-stimulatory capacity of HIV-C in Chlam-DCs correlated with significantly reduced viral fusion compared to iDCs and HIV-C/Chlam-DCs and illustrated considerably increased numbers of HIV-C-containing vacuoles than iDCs. The data indicate that Chlamydia co-infection of DCs mediates a transient boost of their HIV-specific CTL-stimulatory and antiviral capacity, while in the sequential infection model this is reversed and associated with hazard to the host.

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.

Prevalence of Chlamydia trachomatis and Neisseria gonorrhea and associated factors among women living with Human Immunodeficiency Virus in Brazil: a multicenter study

Background

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) cause infections in the female genital tract, increasing susceptibility to and infectiousness of HIV. The objectives of the present study were to determine the prevalence and associated factors of CT and GC infection among HIV-infected women in Brazil.

Methods

Cross-sectional study conducted from March to December 2015, including HIV-infected women attending referral centers in nine states of Brazil, aged 18–49 years, nonpregnant. An interview was conducted including socio-demographic, epidemiological and clinical characteristics. After the interview, gynecological examination was conducted to collect cervical cytology and vaginal secretion to C. trachomatis and N. gonorrhoeae tests through molecular biology.

Results

A total of 802 (89.1%) women participated. The prevalence of CT was 2.1% (17/802) and CG was 0.9% (7/802). The prevalence of a positive test for both CT and/or GC was 2.7%. The factors associated with positive CT/GC test in the multivariate logistic regression analysis were abnormal Papanicolau smear (OR 4.1; 95% CI: 1.54–11.09) and the presence of abnormal cervical discharge (OR 2.6; 95% CI: 1.02–6.71). Among 377 women who reported previous STI 245 (65.0%) reported using condom more frequently after being diagnosed. 62 (16.4%) discovered the STI after the partner told he was infected; 157 (41.6%) had STI symptoms and looked for care, and 158 (41.9%) discovered it in a routine consultation for another reason.

Conclusions

The control of STI represents a unique opportunity to improve reproductive health of women living with HIV. STI diagnosis can change their behavior and reduce the sexual transmission of HIV and bacterial STI.

A cross-sectional study of bacterial vaginosis, intravaginal practices and HIV genital shedding; implications for HIV transmission and women's health

OBJECTIVES

Bacterial vaginosis (BV) is associated with an increased risk of HIV transmission, and intravaginal practices (IVP) are an important risk factor for developing BV. The relationship between IVP, BV and HIV lower genital shedding, responsible for HIV transmission, has not been examined in women receiving antiretrovirals in Zambia.

DESIGN

Cross-sectional study.

SETTING

Community Health Center in Lusaka, Zambia.

PARTICIPANTS AND METHODS

Participants were HIV-infected women receiving antiretroviral therapy and engaging in IVP (n=128). Participants completed audio computer-administered self-interviews to assess IVP and underwent a vaginal examination. BV was diagnosed using Nugent criteria. HIV-1 lower genital shedding was assessed by measuring HIV-1 RNA in cervicovaginal lavages.

RESULTS

Most women engaged in IVP daily (114, 89.0%) and 81 (63.3%) of the participants had BV. HIV-1 genital shedding was detected in 18 (14.2%) participants. BV was associated with daily use of IVP (prevalence ratio, PR=4.58, CI 1.26 to 16.64, p=0.02) and weekly use of traditional medicines for IVP (PR=1.33, CI 1.05 to 1.68, p=0.02). The only factor associated with HIV-1 lower genital shedding was plasma viraemia (PR=4.61, CI 2.02 to 10.54, p<0.001). Neither IVP nor BV were associated with HIV shedding.

CONCLUSIONS

Despite the frequency of IVP and high prevalence of BV, plasma viraemia was the primary factor associated with HIV lower genital shedding. These findings support early initiation of antiretrovirals as an HIV prevention tool. Given adverse health outcomes associated with BV, the association between frequent IVP and BV, and the powerful local norms and traditions encouraging IVP, there is a need for studies assessing culturally tailored interventions to decrease BV in high-prevalence settings.

Risk reduction among HIV-seroconcordant and -discordant couples: the Zambia NOW2 intervention

Heterosexual HIV transmission remains the leading cause of HIV incidence in adult men and women in sub-Saharan Africa. This study assessed whether an HIV risk-reduction intervention would be more likely to increase sexual barrier acceptability and decrease risk behavior when delivered to couples in gender concordant groups or in an individual format. This study also examined the mutual impact of couple members as a source of influence on acceptability, and assessed whether product acceptability, intimate partner violence (IPV), and/or partner communication predicted sexual barrier use. HIV seroconcordant and serodiscordant couples (n=216) were recruited in Lusaka, Zambia, and randomized to a four session gender-concordant intervention. Participants were assessed at baseline, 6, and 12 months. Willingness to use barriers (p=0.012), acceptability (p<0.001), and barrier use (p<0.001) increased over time in both conditions, and were influenced by gender preferences. IPV decreased (p=0.040) and positive communication increased (p<0.001) in both conditions. Individual and gender concordant group sessions achieved similar increases in sexual barrier use following the intervention. Results highlight the influence of partners as well as product acceptability as predictors of sexual barrier use among couples in sub-Saharan Africa. Future prevention studies should consider both product acceptability and partner influence to achieve optimal sexual risk behavior outcomes.

Alcohol use and sexual risk behaviors among individuals infected with HIV: a systematic review and meta-analysis 2012 to early 2013

The purpose of this meta-analytic study is to summarize the current science concerning the (a) prevalence of alcohol use, (b) prevalence of sexual risk behaviors, and (c) association between alcohol use and sexual risk behaviors among people livingwithHIV/AIDS (PLWHA). Studies were included if they sampled PLWHA, evaluated both alcohol use and sexual risk behavior (e.g., condom use, multiple partners), and were published between January 1, 2012, and April 1, 2013. Comprehensive electronic database searches located 728 published studies with relevant keywords; 17 studies (k =19 reports) were included. Findings indicate that a substantial proportion of PLWHA use alcohol and engage in sexual risk behaviors. Among PLWHA, alcohol use was significantly associated with unprotected sex (d +=0.23, 95 % CI=0.05, 0.40; k =5). Secondary prevention programs for PLWHA that address alcohol use in the context of sexual behavior are needed.

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

Background

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

Methods

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

Results

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

Conclusions

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

Chlamydia trachomatis infection in HIV-infected women: need for screening by a sensitive and specific test

Reproductive tract infection (RTIs)/sexually transmitted infections (STIs) are recognized as a major public health problem, particularly due to their relationship with HIV infection. Early detection and treatment of Chlamydia trachomatis infection (CTI) among HIV-infected and HIV-uninfected women may impact heterosexual HIV transmission. A total of 120 participants were enrolled: 30 HIV seropositive women with symptoms of RTIs, 30 HIV seropositive women without symptoms of RTIs, 30 HIV seronegative women with symptoms of RTIs, and 30 HIV seronegative women without symptoms of RTIs. One endocervical swab was collected from all participants and CTI was detected by real-time PCR (COBAS TaqMan CT Test, v2.0). CTI was detected in 4 (6.67%) HIV-infected women and in 1 (1.67%) HIV-uninfected woman (OR 4.214; 95% CI 0.457–38.865). Vaginal discharge was present in almost half of HIV-infected and HIV-uninfected women; lower abdominal pain was present in 11 (18.3%) of HIV-infected and in 9 (15%) of HIV-uninfected women. This study showed that CTI is more prevalent among HIV-infected females as compared to HIV-uninfected females. As the use of real-time PCR is not feasible in most hospitals, efforts should be made to develop a simple, sensitive, and specific test to identify women with CTI for prevention of sequelae and HIV transmission.