Genital Discharge Syndrome Research Articles

High Prevalence of Sexually Transmitted and Reproductive Tract Infections (STI/RTIs) among Patients Attending STI/Outpatient Department Clinics in Tanzania.

The patients were consecutively recruited, and the data collection was conducted in eight health care facilities from 2014 to 2016. Genital swabs were collected for the detection of the aetiological pathogens of STI/RTIs. A total of 1243 participants were recruited in the study; the majority (1073, 86%) were women. The overall median age was 27.8. The prevalence of Neisseria gonorrhoeae was 25.7% (319/1243), with proportions of 50.9 and 21.5% for men and women, respectively, of Chlamydia trachomatis 12.9% (160/1241) and Mycoplasma genitalium 4.7% (53/1134). Unmarried men were more often likely to be infected with gonococcal infections as compared to their women counterparts (57.9 vs. 24.1%) p < 0.001. The majority presented with genital discharge syndrome (GDS) 93.6% (1163/1243), genital ulcer disease (GUD) 13.0% (162/1243) and GDS + GUD 9.6% (119/1243). GDS was more common in the health centres, 96.1% (1195/1243), vs. the regional referral hospitals, 92.2% (1146/1243) (p = 0.01), but those reported to the regional referral hospitals were more likely to be infected with N. gonorrhoeae (OR = 2.5) and C. trachomatis (OR = 2.1) than those from the health centres (p < 0.001). The prevalence of bacterial vaginosis (BV) and vaginal candidiasis (VC) was 24.1 and 10.4%, respectively. Interestingly, unmarried and BV-positive women were less likely to be infected with VC (p = 0.03), though VC was strongly inversely associated with an N. gonorrhoeae infection (p < 0.001). High proportions of N. gonorrhoeae (51.1%) and C. trachomatis (23.3%) were found in the Dodoma and Dar es Salaam regions, respectively. M. genitalium (7.6%) was found to be the highest in Mwanza. We reported a high prevalence of STI/RTIs. The findings suggest that these infections are common and prevalent in STI/OPD clinics in six regions of Tanzania. We recommend surveillance to be conducted regularly to elucidate the true burden of emerging and classical STI/RTIs by employing modern and advanced laboratory techniques for the detection and monitoring of STI/RTIs in low- and high-risk populations, including the community settings.

The Prevalence of Mycoplasma genitalium and Association With Human Immunodeficiency Virus Infection in Symptomatic Patients, Johannesburg, South Africa, 2007-2014.

Mycoplasma genitalium is associated with genital discharge syndrome, but limited prevalence data are available in South Africa. The prevalence rates of M. genitalium infection and human immunodeficiency virus (HIV) coinfection were determined in urogenital specimens collected from male and female patients presenting with genital discharge syndrome to a primary health care center in Johannesburg, South Africa from 2007 through 2014. Genital specimens from 4731 patients were tested by a validated in-house multiplex real-time polymerase chain reaction assay for the detection of Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and M. genitalium. Sera were tested for HIV infection using the Determine HIV 1/2 and Unigold assays. The relative prevalence of M. genitalium in males and females was 8.9% and 10.6%, respectively. The prevalence of HIV infection in those infected with M. genitalium, without other sexually transmitted infections (STIs), was significantly higher than in those without M. genitalium infection (48.9% vs. 40.5%, P = 0.014). This significant difference in HIV seroprevalence was particularly observed among females in the study cohort. The relative prevalence of M. genitalium and its association with prevalent HIV among females with vaginal discharge syndrome (VDS) calls for further research on the potential role of M. genitalium in the transmission and acquisition of HIV.

P007 Effective clinical designs of multiplex point-of-care-tests for genital discharge syndrome management in women: which pathogen combinations and testing protocols deliver the best outcomes?

IntroductionSyndromic management of sexually transmitted infections (STIs) is common practice in sexual health clinics (SHC). Implementation of multi-pathogen point-of-care-tests (POCTs) can improve patient management by providing same day diagnoses and treatment. We assessed the potential impact of five POCT protocols consisting of tests for different combinations ofChlamydia trachomatis(CT),Neisseria gonorrhoeae(NG),Mycoplasma genitalium(MG) andTrichomonas vaginalis(TV) infections, on a standard care pathway (SCP), for 81 symptomatic female patients.Methods5 virtual POCT protocols (assuming 100% sensitivity and specificity) were analysed against diagnoses and laboratory results. Reflex tests (i.e. tests used dependent on the result of another test) were incorporated into protocols to investigate utility of testing for certain pathogens separately. McNemar’s test was used to compare proportions of correct diagnoses from each protocol against each other and establish which is most effective. P values were adjusted using Holm-Bonferroni correction.ResultsProtocol P1 was statistically the most effective at providing the correct diagnosis (p=0.000). P5 was also statistically more effective than the SCP (p=0.001). No significant differences were found between other protocols. Although P4 and P5 diagnosed equal proportions of patients, P5 had better performance (p=0.001) compared with P4 (p=0.0012).Abstract P007 Table 1Point of care test resultsTesting protocolsCorrect diagnoses (%)95% Confidence Interval (%)SCP75.3164.92 to 83.41P1: CT/NG/MG/TV100.0096.96 to 98.30P2: CT/NG + MG reflex92.5986.89 to 98.30P3: NG/MG88.8982.04 to 95.73P4: CT/MG + NG reflex95.0690.34 to 99.78P5: NG/MG + CT/TV reflex95.0690.34 to 99.78DiscussionP1 was more effective than the SCP and all other protocols, however, may not be technically feasible. P5 was not statistically different from P1 and may be a valid alternative. Due to high rates of MG and CT infection in this cohort, a protocol including tests for both pathogens would be desirable for this population.

P09.21 Performance of genexpert®ct/ng in the diagnosis ofneisseria gonorrhoeaeandchlamydia trachomatisamong men and women with genital discharge syndrome in zimbabwe

Background In many countries, patients with genital discharge syndrome (GDS) are treated syndromically with antibiotics that cover both Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT). The syndromic approach leads to both over-treatment (as most patients are not dually infected) and under-treatment (as asymptomatic infections are not detected). We studied the performance of the GeneXpert® nucleic acid amplification test (NAAT) as a testing platform for NG and CT in a study of the aetiology of GDS in Zimbabwe. Materials and methods In an ongoing study, we enrolled 400 patients with GDS in 6 regionally diverse clinics in Zimbabwe serving high numbers of STI cases. Urine (men) and vaginal (women) specimens were taken for testing on 3 NAAT platforms: GeneXpert®, Probetec™ and multiplex polymerase chain reaction (M-PCR), conducted in different laboratories. We analysed overall concordance of results between platforms and assessed the performance of the GeneXpert® test when compared to a gold standard comprised of concordant results on both Probetec™ and M-PCR platforms. Results To date, a total of 197 men and 200 women with GDS have been enrolled. Testing on all 3 platforms is complete for the 136 GDS patients enrolled in Harare. Concordance of positive or negative results for all 3 platforms was 133/136 (97.8%) for NG and 132/136 (97.0%) for CT. Sensitivity of the GeneXpert® platform compared to the Probetec™/M-PCR combined gold standard was 100% for both NG and CT; specificity was 98.8% for NG and 100% for CT. Conclusions Aetiologic diagnosis has long been out of reach for many countries. However, the increasing presence of nucleic acid amplification test (NAAT) devices in many countries, such as GeneXpert®, for the diagnosis of tuberculosis and other infections, opens the possibility to use them for the diagnosis of other pathogens including NG and CT as an alternative or adjunct to syndromic management. Disclosure of interest statement Nothing to declare.

P09.22 The aetiology of genital discharge syndromes in zimbabwe

Background In many countries, sexually transmitted infections (STI) are treated syndromically. Thus, male and female patients with genital discharge syndromes (GDS) receive antimicrobials covering Chlamydia trachomatis (CT), Neisseria Gonorrhoeae (NG) and Trichomonas vaginalis (TV) infections and bacterial vaginosis (BV) among women. However, periodic surveys into the aetiology of GDS are necessary to inform treatment guidelines. Methods For this study, we enrolled 400 patients with GDS at 6 regionally diverse clinics in Zimbabwe. To date, test procedures have been completed for patients enrolled at the Harare study sites (N = 137). Sites were visited sequentially by a mobile unit of 3 trained nurses to enrol patients with STI syndromes, including GDS. STI history and risk data were collected by questionnaire and uploaded to a web-based database. Urine and vaginal specimens were taken for testing with a validated multiplex polymerase chain reaction assay (M-PCR, National Institute of Communicable Diseases, Johannesburg) for CT, NG, TV and Mycoplasma genitalium (MG). Smears for Gram stain and subsequent assessment using Nugent criteria for the diagnosis of BV were obtained from all women with vaginal discharge. Results M-PCR testing is complete for all GDS patients enrolled in Harare; 68 men and 69 women. Positivity rates were as follows. Men: NG = 60.3%, CT = 13.2%, TV = 4.4%, MG = 2.9%. Women: NG = 18.8%, CT = 8.7%, TV = 14.5%, MG = 7.3%. Among women, 31.9% met Nugent criteria for BV and 20.0% had yeast infection identified on Gram stain. Conclusions In this preliminary analysis, gonorrhoea was the most common cause of GDS among both men and women, but much more common among men. Chlamydia infections were substantially less common among both men and women and trichomoniasis was more common than chlamydia infections among women. Regardless of investigated microbiologic causes, many women met criteria for BV. M. genitalium infections were uncommon overall. These findings will inform development of future syndromic STI management guidelines.

P09.23 High prevalence of hiv infection among patients with sti syndromes in zimbabwe: implications for prevention

Introduction The occurrence of sexually transmitted infection (STI) syndromes among persons with HIV infection indicates the presence of high-risk behaviours and biological co-factors favouring HIV transmission. We determined HIV prevalence among patients enrolled in a study of the aetiology of STI syndromes in Zimbabwe. Methods In an ongoing study, we enrolled men and women with genital discharge syndrome (GDS) or genital ulcer disease (GUD) at 6 geographically diverse clinics in Zimbabwe. We used Xpert® CT/NG to determine the presence of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) in urethral or vaginal specimens from all study participants. Blood samples were collected for HIV testing by a standard rapid HIV test algorithm (First Response™ followed by Alere HIV 1/2™) and considered positive when reactive on both. Blood samples were also tested for treponemal antibodies (SD Bioline HIV/syphilis DUO™). Results To date we completed laboratory test on 371 patients. Of these, 150 (40.4%) were HIV-infected. HIV rates were as follows. Female GUD: 35/62 (56.5%) vs. female GDS: 46/116 (39.7%, p = 0.05) and male GUD: 32/72 (44.4%) vs. male GDS (37/121 (30.6%, p Conclusion In our study, HIV prevalence was high among patients with STI syndromes and higher among patients with GUD than patients with GDS. The high prevalence of NG infections and evidence for recent syphilis infection among persons with documented HIV infection indicates high risk behaviours related to HIV acquisition and/or ongoing HIV transmission. Clinics serving patients with STI syndromes in Zimbabwe and countries with similar HIV/STI epidemiology are of continued importance in HIV diagnosis and prevention.

006.6 High prevalence of chlamydia and gonorrhoea among patients with genital ulcer disease in zimbabwe: potential implications for syndromic management

Background Syndromic management of genital ulcer disease (GUD) as recommended by the Zimbabwe Ministry of Health and Child Care, includes antibiotics against Treponema pallidum (TP: benzathine penicillin), Haemophilus ducreyi (HD: erythromycin), and herpes simplex virus (HSV: acyclovir). However, these medications are not recommended to treat co-infections with Neisseria gonorrhoeae (NG: ceftriaxone or kanamycin) and Chlamydia trachomatis (CT: doxycycline or azithromycin) and, unless a person with GUD is simultaneously diagnosed with genital discharge syndromes (GDS), NG and CT co-infections will not be treated according to guidelines. Methods In an ongoing study, we enrolled men and women with GDS or GUD syndromes in 6 clinics with high STI prevalence in Zimbabwe. In addition to testing ulcer secretions for TP, HD, and HSV by multiplex polymerase chain reaction (National Institute of Communicable Diseases, Johanneburg), all patients had urine (males) or vaginal swabs (females) tested for NG and CT by nucleic acid amplification (GeneXpert ® ). Results To date, 302 patients have been enrolled for whom testing is complete, including 106 GUD and 196 GDS patients. NG and/or CT infections were present in 19/52 (36.5%) female GUD patients and 13/54 (24.1%) male GUD patients, compared to 26/96 (27.1%) female GDS patients and 68/100 (68.0%) male GDS patients. Of 32 GUD patients infected with NG (N = 24) and/or CT (N = 17), including 9 dual infections, only 4/18 (22%) of women and 4/14 (29%) of men met objective criteria for simultaneous GDS syndromic management. Conclusion In our study, urethral or vaginal GC and/or CT infections were present in 30% of patients with GUD, of whom three quarters would not have been treated according to recommended syndromic treatment guidelines for sexually transmitted infections. Our study methods and findings should be relevant for Zimbabwe and other countries that are using a syndromic approach to STI control.

P3.283 Trends and Associations of Neisseria Gonorrhoeae Infection in Men and Women with Genital Discharge Syndromes in Johannesburg, South Africa

BackgroundAnnual STI aetiological surveys undertaken at a primary healthcare facility in Johannesburg, South Africa, each year have determined the prevalence of gonorrhoea amongst men with male urethral discharge syndrome (MUDS)...

P3.298 Trends and Associations of Trichomonas Vaginalis Infection in Men and Women with Genital Discharge Syndromes in Johannesburg, South Africa

ObjectivesTo 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...

P3.291 Associations of Chlamydia Trachomatis Infection in Men and Women with Genital Discharge Syndromes in Johannesburg, South Africa

BackgroundAs part of an on-going STI microbiological surveillance programme, we investigated associations between Chlamydia trachomatis infection and the demographic, clinical, microbiological and behavioural characteristics of patients presenting with either male...

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

ObjectivesTo 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...

Sexually Transmitted Infections and Male Circumcision: A Systematic Review and Meta-Analysis

The claim that circumcision reduces the risk of sexually transmitted infections has been repeated so frequently that many believe it is true. A systematic review and meta-analyses were performed on studies of genital discharge syndrome versus genital ulcerative disease, genital discharge syndrome, nonspecific urethritis, gonorrhea, chlamydia, genital ulcerative disease, chancroid, syphilis, herpes simplex virus, human papillomavirus, and contracting a sexually transmitted infection of any type. Chlamydia, gonorrhea, genital herpes, and human papillomavirus are not significantly impacted by circumcision. Syphilis showed mixed results with studies of prevalence suggesting intact men were at great risk and studies of incidence suggesting the opposite. Intact men appear to be of greater risk for genital ulcerative disease while at lower risk for genital discharge syndrome, nonspecific urethritis, genital warts, and the overall risk of any sexually transmitted infection. In studies of general populations, there is no clear or consistent positive impact of circumcision on the risk of individual sexually transmitted infections. Consequently, the prevention of sexually transmitted infections cannot rationally be interpreted as a benefit of circumcision, and any policy of circumcision for the general population to prevent sexually transmitted infections is not supported by the evidence in the medical literature.

Genital tract infections in women attending sexually transmitted infection clinics in Mwanza, north-west Tanzania

Lack of diagnostic methods to determine a specific aetiology can contribute to an increase in genital tract infections (GTIs) in women. We determined the aetiology of, and risk factors associated with, GTIs in women with genital symptoms. After obtaining informed consent, genital swabs to detect Neisseria gonorrhoeae, Trichomonas vaginalis, vaginal candidiasis, bacterial vaginosis and Chlamydia trachomatis, were collected from women who attended sexually transmitted infection (STI) clinics in Mwanza in 2010. Demographic data were also gathered. A total of 320 women, with a mean age 26.5 ± 6.9 years, were recruited for the study. The percentages of GTIs in women with genital discharge syndromes were 25.9% for bacterial vaginosis, 25.6% for vaginal candidiasis, 14% for C. trachomatis, 8.7% for T. vaginalis and 8.4% for N. gonorrhoeae. Gonococcal infections were detected more by N. gonorrhoeae PCR than by culture methods (p-value 2 infections of bacterial vaginosis, C. trachomatis and N. gonorrhoeae. Women who were reported to have engaged in sexual intercourse before the age of 18 years and those who had > 2 sexual partners were more likely to be infected by C. trachomatis vs. N. gonorrhoeae and T. vaginalis. Following a sensitivity test, 21 out of 27 (77.7%) of gonococcal isolates were quinolone-resistant N. gonorrhoeae. One isolate was resistant to ciprofloxacin, azithromycin and cefixime, but not ceftriaxone. A high prevalence of bacterial vaginosis, gonorrhoea, trichomoniasis, chlamydia and vaginal candidiasis in women who attended the STI clinics in Mwanza was observed. Drug resistance of N. gonorrhoeae to ciprofloxacin is very high. This calls for an immediate review of the guidelines on its use as a first-line treatment for STIs in Tanzania.

Aetiology of sexually transmitted infections in Maputo, Mozambique

The study sought to ascertain the prevalence of the aetiological agents of genital discharge and genital ulcer diseases in Maputo, Mozambique. Consecutive consenting patients presenting to the Centro de Saúde do Porto in Maputo between March and April 2005 with genital discharge syndrome and/or genital ulcer diseases were recruited. Specimens were collected for the identification of STI pathogens. Of 346 recruited patients, 164 were male and 182 female. The prevalence of confirmed single aetiological agents for male urethritis was as follows: N. gonorrhoeae, 35%; C. trachomatis, 10%; and M. genitalium 4%. For vaginal discharge, N. gonorrhoeae was found in 11% of the women tested, followed by C. trachomatis (6.5%), bacterial vaginosis (34%), and T. vaginalis (2%). The prevalence of genital ulcers was as follows: Herpes simplex virus type 2, 62%; H. ducreyi 4 %; and C. trachomatis biovar LGV, 4%. Five percent of patients with genital ulcers had a positive syphilis serology (RPR ≥ 1:8 and confirmed by TPHA) and 35% of all tested patients were HIV-1/2 infected. Cases of mixed infections were present in 5%, 11% and 3% of patients with male urethritis, vaginal discharge, and genital ulcers respectively. The classic sexually transmitted infection aetiologies are still prevalent in Maputo. The study highlights the need for a periodic surveillance to inform syndromic management protocols.

Pattern of sexually transmitted infections and performance of syndromic management against etiological diagnosis in patients attending the sexually transmitted infection clinic of a tertiary care hospital.

The availability of baseline information on the epidemiology of sexually transmitted infections (STIs) and other associated risk behaviors is essential for designing, implementing, and monitoring successful targeted interventions. Also, continuous analysis of risk assessment and prevalence-based screening studies are necessary to evaluate and monitor the performance of syndromic management. The aim of the present study was to document the pattern of common STIs and to evaluate the performance of syndromic case management against their laboratory diagnoses. Three hundred consecutive patients who attended the STI clinic of a tertiary care hospital at Delhi, with one or more of the complaints as enunciated by WHO in its syndromic approach for the diagnosis of STIs, were included as subjects. Detailed history, demographical data, and clinical features were recorded and screened for common STIs by standard microbiological methods. The mean age was 24 years and most of the male patients were promiscuous and had contact with commercial sex workers (CSWs 63.9%). Majority came with the complaint of genital discharge (63 males; 54 females) followed by genital ulcer (61 males; 30 females). Genital herpes accounted for the maximum number of STI (86/300) followed by syphilis (71/300). The sensitivity of genital discharge syndrome (GDS) was high for Neisseria gonorrhoeae and Chlamydia trachomatis (96% and 91%, respectively) while specificity was low (76% and 72%, respectively). The sensitivity of genital ulcer syndrome for herpes simplex virus-2 (HSV-2) and Treponema pallidum was 82.65% and 81.2%, respectively, while specificity reached 99% approximately. Viral STIs constitute the major burden of the STI clinic and enhance the susceptibility of an individual to acquire or transmit HIV through sexual contact. Syndromic algorithms have some shortcomings, and they need to be periodically reviewed and adapted to the epidemiological patterns of STI in a given setting.

Pattern of sexually transmitted infections and performance of syndromic management against etiological diagnosis in patients attending the sexually transmitted infection clinic of a tertiary care hospital

Background and Objectives:The availability of baseline information on the epidemiology of sexually transmitted infections (STIs) and other associated risk behaviors is essential for designing, implementing, and monitoring successful targeted interventions. Also, continuous analysis of risk assessment and prevalence-based screening studies are necessary to evaluate and monitor the performance of syndromic management. The aim of the present study was to document the pattern of common STIs and to evaluate the performance of syndromic case management against their laboratory diagnoses.Materials and Methods:Three hundred consecutive patients who attended the STI clinic of a tertiary care hospital at Delhi, with one or more of the complaints as enunciated by WHO in its syndromic approach for the diagnosis of STIs, were included as subjects. Detailed history, demographical data, and clinical features were recorded and screened for common STIs by standard microbiological methods.Results:The mean age was 24 years and most of the male patients were promiscuous and had contact with commercial sex workers (CSWs 63.9%). Majority came with the complaint of genital discharge (63 males; 54 females) followed by genital ulcer (61 males; 30 females). Genital herpes accounted for the maximum number of STI (86/300) followed by syphilis (71/300). The sensitivity of genital discharge syndrome (GDS) was high for Neisseria gonorrhoeae and Chlamydia trachomatis (96% and 91%, respectively) while specificity was low (76% and 72%, respectively). The sensitivity of genital ulcer syndrome for herpes simplex virus-2 (HSV-2) and Treponema pallidum was 82.65% and 81.2%, respectively, while specificity reached 99% approximately.Conclusions:Viral STIs constitute the major burden of the STI clinic and enhance the susceptibility of an individual to acquire or transmit HIV through sexual contact. Syndromic algorithms have some shortcomings, and they need to be periodically reviewed and adapted to the epidemiological patterns of STI in a given setting.

Antimicrobial Susceptibility Profile of Neisseria gonorrhoeae Isolated From Patients Attending a STD Facility in Maputo, Mozambique

To ascertain the effectiveness of kanamycin for the treatment of gonorrhoea in Maputo, Mozambique. A cross-sectional study design was employed. Urethral and cervical specimens were collected for the isolation of Neisseria gonorrhoeae from patients attending Centro de Saúde do Porto. Antimicrobial susceptibilities were determined for kanamycin, spectinomycin, ciprofloxacin, ceftriaxone, cefixime, tetracycline and penicillin. Twenty-two (40%) Neisseria gonorrhoeae isolates were intermediate and 4(7%) were resistant to kanamycin; 42(77%) displayed high level resistance to tetracycline (MIC > or = 16 mg/L); 34 (65%) were penicillinase producers, and 52 (95%) had spectinomycin MICs of 64 mg/L. All isolates were susceptible to ciprofloxacin (MIC < or = 0.06 mg/L), ceftriaxone (MIC < or = 0.015 mg/L) and cefixime (MIC < or = 0.015 mg/L). The observations underscore the need for broader susceptibility surveillance studies to elucidate the pattern and extent of drug resistance in Mozambique. A review of the current treatment guidelines for genital discharge syndrome is warranted.

Genital ulcerative disease and sexually transmitted urethritis and circumcision: a meta-analysis

The objective of the study was to determine the relationship of circumcision status to the risk for genital ulcerative disease (GUD) and sexually transmitted urethritis. A MEDLINE search and a review of references in published articles identified studies addressing the risk of sexually transmitted urethritis or GUD based on circumcision status. Meta-analyses, sensitivity analysis, and exploration for publication bias were performed. Thirty articles fulfilled the inclusion criteria. The data from one study were published twice. GUD showed a trend towards being more common in genitally intact men (random-effects summary odds ratio [OR] = 1.34, 95% confidence interval [CI] = 0.98-1.82). When comparing men with GUD to men with 'genital discharge syndrome' (GDS), genitally intact men were more likely to have GUD (OR = 2.31, 95% CI = 1.70-3.15). There was no difference in the risk for chancroid based on circumcision status (OR = 0.91, 95% CI = 0.40-2.05), gonorrhoea (OR = 1.03, 95% CI = 0.82-1.29), or Chlamydia trachomatis infections (OR = 0.62, 95% CI = 0.32-1.19). Genitally intact men were less likely to be diagnosed with 'GDS' (OR = 0.83, 95% CI = 0.67-1.01) or non-specific urethritis (OR = 0.80, 95% CI = 0.64-1.01). Adjustment for publication bias in the literature that applies to chlamydial infections gave a summary OR of 0.46 (95% CI = 0.22-0.97). Significant between-study heterogeneity was a consistent finding. In conclusion, genitally intact men may be at greater risk for GUD, whereas circumcised men may be at greater risk for acquiring sexually transmitted urethritis in general, but there is no statistically significant difference in risk of gonococcal infection. Significant between-study heterogeneity and evidence of publication bias exclude the possibility of reaching a definitive conclusion regarding the association of circumcision status and these sexually transmitted infections.

The impact of syndromic treatment of sexually transmitted diseases on genital shedding of HIV-1

To examine the impact of sexually transmitted diseases (STD) syndromic treatment on genital shedding of HIV and the impact among women in whom STD treatment was not successful. Seventy-one HIV-infected women were included; 60 had symptomatic STD [72% with genital discharge syndrome (GDS) and 28% with genital ulcer syndrome (GUS)] and 11 controls did not have symptomatic STD. Cervical HIV load in 94% women was measured at baseline and after STD treatment. Cervical HIV load at entry was significantly higher in women with symptomatic STD than in controls [median, 3.15; interquartile range (IQR), 1.90-3.34 versus median, 1.90; IQR, 1.90-2.19 log10 RNA copies/swab, respectively; P = 0.024]. Women with STD were also more likely to have detectable cervical HIV RNA (68% versus 27%; P = 0.016). Cervical HIV load was significantly higher in women with GUS than in those with GDS (median 3.46; IQR, 2.84-4.18 versus median, 2.83; IQR, 1.90-3.31 log10 copies/swab; P = 0.019). There was no significant reduction in genital HIV shedding after syndromic treatment of GDS or GUS. However, significant decreases were limited to only those with clinical improvement (median, 2.91; IQR, 1.90-3.45 versus median, 2.25; IQR, 1.90-3.08 log10 RNA copies/swab, respectively; P = 0.006). GUS was significantly associated with treatment failure, independent of plasma HIV RNA load and CD4 T-cell count (odds ratio, 4.79; 95% confidence interval, 1.32-17.46). The fact that STD syndromic treatment impacts very little in reducing genital HIV shedding underscores the need for appropriate validation of STD syndromic diagnosis and management to control heterosexual transmission of HIV.

How many patients with a sexually transmitted infection are cured by health services? A study from Mwanza region, Tanzania.

To estimate the proportion of symptomatic patients with a bacterial sexually transmitted infection (STI) cured by primary health care services in Mwanza Region, Tanzania, and to compare the cure rate achieved by health centres before and after the introduction of improved STI treatment services. A model was used that describes the different hurdles patients with an STI take before they can be considered cured by the health services. The values for the input parameters for the model were taken from different studies. Data from an intervention trial as well as from a population-based study on male urethritis were used to estimate the proportion of symptomatic patients with an STI who seek care from a health centre. An observational study in four health centres where improved STI treatment services had been introduced provided estimates of the proportions of patients with an STI correctly diagnosed and treated. Patients who returned to the health centres after 1 week were interviewed about compliance. An estimate of the efficacy of treatments prescribed for STIs in health centres before the introduction of improved STI services was obtained from a study on prescription patterns for genital discharge syndrome (GDS) and genital ulcer disease (GUD). It was estimated that in the catchment area of health centres offering improved STI services, 51-72% of patients with STI symptoms sought care from those health centres. About 76-85% of cases were correctly diagnosed, and of these 69-80% received efficacious treatment. Compliance with full treatment was estimated at 84%. The estimated overall cure rate achieved by the health centres offering improved STI services ranged between 23 and 41%. The proportion of symptomatic STI patients who attended a health centre before improved STI services were introduced was estimated at 39%. The estimated efficacy of the treatments prescribed was 28%. The overall cure rate achieved by these health centres was less than 10%. When assessing the performance of STI case detection and management all steps have to be taken into account that are taken by patients with an STI before they can be considered cured by the health services. The intervention to improve STI services in Mwanza Region has resulted in an improvement of the cure rate of STIs achieved by primary health care centres.