Sexually Transmitted Infections in Rural Madagascar at an Early Stage of the HIV Epidemic

Patterns of Rising HIV Positivity in Northern Madagascar: Evidence of an Urgent Public Health Concern

Despite over two decades of progress against HIV/AIDS in adjacent sub-Saharan Africa, HIV rates and deaths due to AIDS are exponentially rising in Madagascar. Furthermore, a growing body of evidence suggests that, due to a scarcity of general-population screening data, even the startling increase demonstrated by official models vastly underestimates the true population prevalence of HIV. We aimed to implement a real-world HIV screening and treatment protocol to serve a general population stemming from across northern Madagascar. In collaboration with the Malagasy Ministry of Health, we provided point-of-care HIV screening and confirmatory testing for over 1000 participants from 73 towns, villages, and cities. We recorded an overall HIV prevalence of 2.94%. Notably, we observed a 13.1% HIV prevalence rate among urban populations and showed that proximity to a major route of travel was significantly associated with HIV risk. We also observed a link between HIV risk and various occupations, including those associated with increased mobility (such as mining). Importantly, all HIV-positive individuals were initiated on antiretroviral therapy in concordance with local health authorities. To our knowledge, this study marks the largest primary test data-based HIV study to date among Madagascar's general population, showing a greatly higher HIV prevalence (2.9%) than previously reported modeling-based figures (0.4%). Our rates aligned with the pattern of higher prevalence demonstrated in smaller general-population screening studies occurring more commonly prior to political strife in the mid-2000s. These findings demonstrate evidence of a growing HIV epidemic in northern Madagascar and underscore the need for future investment into more comprehensive HIV screening and control initiatives in Madagascar.

Anorectal and Urogenital Mycoplasma genitalium in Nigerian Men Who Have Sex With Men and Transgender Women: Prevalence, Incidence, and Association With HIV

Among 413 Nigerian men who have sex with men and transgender women, retrospective testing for Mycoplasma genitalium revealed mostly asymptomatic infections of the anorectum (prevalence, 36.8%; incidence, 18.4 cases/100 person-years) and urogenital tract (12.4%, 4.0 cases/100 person-years). Risk factors included HIV and increasing number of sex partners.

Is Madagascar at the edge of a generalised HIV epidemic? Situational analysis

OBJECTIVES

To describe the epidemiological situation of the HIV/AIDS epidemic and to identify the main drivers for vulnerability in Madagascar.

DESIGN

Literature review, qualitative research and situational analysis.

DATA SOURCES

Search of electronic bibliographic databases, national repositories of documentation from 1998 to 2018. Search keywords included Madagascar, HIV, sexually transmitted infections, men who have sex with men (MSM), sex workers (SWs), transactional sex (TS), injecting drug users (IDUs), vulnerability and sexual behaviour. Qualitative sources were interviews and focus group discussions.

REVIEW METHODS

Studies focused on HIV and/or vulnerability of HIV in Madagascar in general, and key populations (KPs) and HIV/AIDS response were taken into account. National reports from key HIV response actors were included.

RESULTS

Madagascar is characterised by a low HIV/AIDS epidemic profile in the general population (GP) (0.3%) combined with a high prevalence of HIV among KPs (SWs, MSM and IDUs).An increase in HIV prevalence among KP has been observed during recent years. Hospital-based data suggest an increase in HIV prevalence among the GP. The vulnerability traits are inconsistent use of condoms, multipartner relationships and other contextual factors like widespread TS and gender inequality. A high prevalence/incidence of sexually transmitted infections could indicate a high vulnerability to HIV/AIDS. However, there are no reports of HIV prevalence of >1% in antenatal consultation.

CONCLUSION

There is not enough evidence to make a conclusion about the HIV epidemiological situation in Madagascar due to the scarcity of the epidemiological data. However, Madagascar may be closer to a turning point towards a high-prevalence epidemic with severe consequences, particularly when taking into account its socioeconomical fragility and underlying vulnerabilities. More precise epidemiological data and improved HIV/AIDS diagnosis and case management should be a public health priority.

Herpes simplex virus type 1 epidemiology in Africa: Systematic review, meta-analyses, and meta-regressions

OBJECTIVE

To assess herpes simplex virus type 1 (HSV-1) epidemiology in Africa.

METHODS

This systematic review was conducted per the Cochrane Collaboration guidelines. Findings were reported following the PRISMA guidelines. Research questions were addressed using random-effects meta-analyses and meta-regressions.

RESULTS

Forty-three overall (and 69 stratified) HSV-1 seroprevalence measures, and 18 and eight proportions of HSV-1 viral detection in genital ulcer disease (GUD) and in genital herpes, respectively, were extracted from 37 reports. Pooled mean seroprevalence was 67.1% (95% confidence interval (CI): 54.7-78.5%) in children, and 96.2% (95% CI: 95.0-97.3%) in adults. Across age groups, pooled mean was 44.4% (95% CI: 29.9-59.3%) in ≤5 years-old, 85.6% (95% CI: 81.0-89.6%) in 6-15 years-old, 93.3% (95% CI: 89.2-96.6%) in 16-25 years-old, and 93.8% (95% CI: 84.6-99.4%) in >25 years-old. Age explained 78.8% of seroprevalence variation. Pooled mean proportion of HSV-1 detection was 0.4% (95% CI: 0.0-1.5%) in GUD, and 1.2% (95% CI: 0.0-4.0%) in genital herpes.

CONCLUSIONS

HSV-1 is universally prevalent in Africa, at higher levels than other regions, with no evidence for declines in seroprevalence in recent decades. Nearly every person acquires the infection in childhood through oral-to-oral transmission, before sexual debut. Sexual oral-to-genital and genital-to-genital transmission appear very limited.

Prevalence of Mycoplasma genitalium in different population groups: systematic review andmeta-analysis

BACKGROUND

Mycoplasma genitalium is a common cause of non-gonococcal non-chlamydial urethritis and cervicitis. Testing of asymptomatic populations has been proposed, but prevalence in asymptomatic populations is not well established. We aimed to estimate the prevalence of M. genitalium in the general population, pregnant women, men who have sex with men (MSM), commercial sex workers (CSWs) and clinic-based samples, METHODS: We searched Embase, Medline, IndMED, African Index Medicus and LILACS from 1 January 1991 to 12 July 2016 without language restrictions. We included studies with 500 participants or more. Two reviewers independently screened and selected studies and extracted data. We examined forest plots and conducted random-effects meta-analysis to estimate prevalence, if appropriate. Between-study heterogeneity was examined using the I2 statistic and meta-regression.

RESULTS

Of 3316 screened records, 63 were included. In randomly selected samples from the general population, the summary prevalence was 1.3% (95% CI 1.0% to 1.8%, I2 41.5%, three studies, 9091 people) in countries with higher levels of development and 3.9% (95% CI 2.2 to 6.7, I2 89.2%, three studies, 3809 people) in countries with lower levels. Prevalence was similar in women and men (P=0.47). In clinic based samples, prevalence estimates were higher, except in asymptomatic patients (0.8%, 95% CI 0.4 to 1.4, I2 0.0%, three studies, 2889 people). Summary prevalence estimates were, in the following groups: pregnant women 0.9% (95% CI 0.6% to 1.4%, I2 0%, four studies, 3472 people), MSM in the community 3.2% (95% CI 2.1 to 5.1, I2 78.3%, five studies, 3012 people) and female CSWs in the community 15.9% (95% CI 13.5 to 18.9, I2 79.9%, four studies, 4006 people).

DISCUSSION

This systematic review can inform testing guidelines for M. genitalium. The low estimated prevalence of M. genitalium in the general population, pregnant women and asymptomatic attenders at clinics does not support expansion of testing to these groups.

REGISTRATION NUMBERS

PROSPERO: CRD42015020420.

Evaluation of the Xpert MTB/RIF assay for the diagnosis of smear-negative pulmonary and extrapulmonary tuberculosis in Madagascar

OBJECTIVE

To evaluate the feasibility of the implementation of a commercial rapid molecular diagnostic test (Xpert MTB/RIF) for the routine diagnosis of smear-negative or extrapulmonary tuberculosis (TB) and its diagnostic accuracy, and to assess HIV prevalence in a real-life setting in Madagascar. This study was set in a tertiary care hospital in Madagascar.

METHODS

A prospective cohort study was conducted of all consecutive cases with suspected smear-negative and/or extrapulmonary TB over a 2-year period. Cases were classified as proven, probable, or possible TB cases, or as having an alternative diagnosis.

RESULTS

Of the 363 patients included, 183 (50.4%) had suspected smear-negative pulmonary TB and 180 (49.6%) had suspected extrapulmonary TB. For proven cases, the sensitivity, specificity, positive and negative predictive values of Xpert MTB/RIF were 82.4%, 98.8%, 98.3%, and 86.6%, respectively; for proven and probable cases grouped together, these values were 65%, 98.8%, 98.5%, and 64%, respectively. The diagnostic accuracy was slightly lower for extrapulmonary TB compared to smear-negative pulmonary TB. The prevalence of HIV infection was 12.1%, but almost half of these cases did not have TB (alternative diagnosis group).

CONCLUSIONS

The implementation of a rapid diagnosis programme for TB in a resource-poor setting is feasible. The performance of the Xpert-MTB/RIF was remarkable in this difficult-to-diagnose population. HIV prevalence in this study was much higher than the prevalence reported in the general population in Madagascar, in patients with TB and patients with conditions other than TB.

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.

Comparing the awareness of and beliefs in sexually transmitted infections among university students in Madagascar and the United States of America

Young adults have a higher risk of contracting sexually transmitted infections (STIs) than other age groups. This risk may be mediated by their social and cultural setting which can impact young adults’ awareness of, beliefs in, and risk of contracting STIs (including HIV/AIDS). In order to understand how these factors vary among young adults of different cultures, it is important to study these issues on a cross-cultural scale. This study aimed to increase understanding of the relationship between the culture of a place of study and: (1) STI awareness; (2) belief in STIs; and (3) self-reported STI prevalence in the study population. Survey data were collected from university students in Madagascar (n = 242 surveys in 2013) and the United States of America (n = 199 surveys in 2015). Compared to students at the American university, students at the Malagasy university: (1) did not appear to have a conclusively lower awareness of STIs; (2) did not differ in rates of belief in the existence of gonorrhea and syphilis, but had higher rates of disbelief in HIV/AIDS; and (3) were more likely to report having been infected with syphilis and gonorrhea, but not with HIV/AIDS. Students at the Malagasy university also listed different reasons than the students at the American university for why they believed in the existence of STIs. These findings highlight the need for further cross-cultural research to better adapt intervention strategies to different cultural settings.

High Burden of Human Papillomavirus Infection in Madagascar: Comparison With Other Sexually Transmitted Infections

Background:

In Madagascar, human papillomavirus (HPV), human immunodeficiency virus (HIV), and hepatitis B virus (HBV) infection, as well as syphilis share common risk factors but seem to differ in their prevalence. We measured and compared their prevalence in the country.

Methods:

The data used in this study came from the Saint Damien Health Centre in Ambanja, Madagascar. The tests used for disease detection were the Alere Determine, Virucheck, rapid plasma reagin, and S-DRY self-HPV samples for HIV infection, HBV infection, syphilis, and HPV infection, respectively.

Results:

In men and women, respectively, the prevalence was 0.6% and 0.4% for HIV infection, 2.2% and 2.0% for HBV infection, and 0.6% and 0.3% for syphilis. The HPV infection prevalence was 39.3%.

Conclusions:

Despite common risk factors, the prevalence of HPV infection was high, in contrast to a much lower prevalence of other sexually transmitted infections (STIs) in the same geographical area. Further investigations are required to clarify the status of STIs in the Malagasy population.

Perceptions and attitudes regarding sexually transmitted infection and family planning among adolescents in Northern Madagascar

The prevalence of sexually transmitted infections (STIs) and early pregnancy are high among adolescents in Madagascar. We applied a qualitative descriptive approach to evaluate perceptions, attitudes, and misconceptions regarding STIs and contraception among female and male adolescents ages 15-19 years (n = 43) in Northern Madagascar in 2014 using focus group discussions with open-ended questions. Data were coded and analyzed for major themes. Participants were in grades 6 to 12 in school; 53% were female. Despite high levels of awareness, significant stigma against and misconceptions about STIs, condom use, and sexual practices existed. Many participants did not know how to use condoms and felt uncomfortable suggesting condoms with regular partners, despite acknowledging infidelity as a frequent problem. Male participants were more willing to use condoms as contraception for unwanted pregnancy than for prevention of STIs. Most participants held misconceptions about side effects of contraceptives, including infertility, cancer, and preventing bad blood from leaving the woman's body. Systematic and community-wide health education and formal reproductive health curricula in schools may improve attitudes and stigma regarding STIs and family planning. These strategies need to be developed and employed via collaboration among faith-based, community, and non-governmental organizations, schools, and governmental health and social service agencies.

Implementation and evaluation of a curriculum to teach reproductive health to adolescents in northern Madagascar

BACKGROUND

In Madagascar, prevalence of sexually transmitted infections (STIs) and unplanned pregnancies are high among adolescents. Limited reproductive health education is available.

METHODS

In northern Madagascar, in 2014, we assessed the baseline knowledge, attitudes and self-efficacy regarding STIs/HIV and family planning among 155 adolescents, and designed and implemented a 6-week reproductive health curriculum for adolescents using complementary teaching methods. We evaluated the curriculum through pre- and post-curriculum surveys of adolescents using paired t-tests.

RESULTS

Pre-test survey revealed a general lack of knowledge regarding different types of STIs. Post-curriculum, there was a significant improvement in the following educational domains: general knowledge of HIV/AIDS, other STIs and family planning (49%±17% to 65%±15%) (p<0.001), self-efficacy and use of contraceptives (57%±26% to 70%±26%) (p<0.01), and the overall combined scores of knowledge, attitude and self-efficacy (53%±14% to 68%±14%) (p<0.001). Open-ended questions revealed significant misconceptions and stigma regarding oral and anal sex and usage of condoms.

CONCLUSIONS

Important misconceptions and knowledge gaps regarding reproductive health exist among adolescents. The comprehensive reproductive health curriculum with complementary teaching methods was feasible, well-received and effective, and could be considered for integration into the schools' curricula.

Can churches play a role in combating the HIV/AIDS epidemic? A study of the attitudes of christian religious leaders in Madagascar

Introduction

Churches occupy an important social and cultural position in Madagascar. The sexual transmission of HIV raises controversies about the role that Churches can play in preventing HIV/AIDS. This cross-sectional survey investigated recommendations by religious leaders for condom use and other preventive strategies in the context of international guidelines.

Methods

A questionnaire was self-administered to a random sample of religious leaders. The questions related to preventive methods against HIV/AIDS such as: condom use, marital fidelity, sexual abstinence before marriage, and HIV-testing. Associations with recommendations for condom use were evaluated using univariate and multivariate logistic regression analyses.

Results

Of 231 religious leaders, 215 (93.1%) were willing to share their knowledge of HIV/AIDS with their congregations. The majority received their information from the media (N = 136, 58.9%), a minority from their church (N = 9, 3.9%), and 38 (16.4%) had received prior training on HIV. Nearly all (N = 212, 91.8%) knew that HIV could be sexually transmitted though only a few (N = 39, 16.9%) were aware of mother-to-child transmission or unsafe injections (N = 56, 24.2%). A total of 91 (39.4%) were willing to, or had recommended (N = 64, 27.7%), condom use, while 50 (21.6%) had undergone HIV testing. Only nine (3.9%) had ever cared for a person living with HIV/AIDS (PLHIV). Multivariable logistic regression shows that condom use recommendations by religious leaders were negatively associated with tertiary level education (OR: 0.3, 95% CI 0.1–0.7), and positively associated with knowing a person at risk (OR: 16.2, 95% CI 3.2–80.2), knowing of an ART center (OR: 2.6, 95% CI 1.4–4.8), and receiving information about HIV at school (OR: 2.6, 95% CI 1.2–5.6).

Conclusions

Malagasy church leaders could potentially become key players in HIV/AIDS prevention if they improved their knowledge of the illness, their commitment to international recommendations, and extended their interaction with people most at risk.

Semen quality in Schistosoma haematobium infected men in Madagascar

The seminal vesicles and the prostate are frequently affected by egg-induced inflammation in Schistosoma haematobium infected men. The objective of this study was to assess the semen quality in men with male genital schistosomiasis (MGS). The examination of the semen samples was performed in men aged 15 to 49 years living an S. haematobium endemic area in Madagascar prior to anti-schistosoma treatment with praziquantel and five months later. Men from the high endemic Sirama sugarcane plantation with positive egg excretion in the urine and circulating anodic antigen (CAA) present in serum (n=85) were compared to men (without egg excretion and no CAA) from the neighbouring low-endemic Mataipako village (n=57). The proportion of men with egg excretion in semen was significantly higher in Sirama than in Mataipako (53% versus 4%), whereas the median ejaculate volume was significantly lower in Sirama (1.8 ml versus 2.4 ml). There was no statistical difference in median spermatocyte counts and in the proportions of men detected with azoospermia. The mean apoptotic rate was 7.8% in a subgroup of 30 men from Sirama. A positive correlation was found between apoptotic rate and seminal eosinophil cationic protein (ECP) level (rho=0.560; P<0.001). At follow up, egg excretion and ECP level in semen declined significantly and were paralleled by a significant reduction in the apoptotic rate. The study suggests that S. haematobium infection is associated with sperm apoptosis and a reduced production of seminal fluid. Egg induced inflammation in the seminal vesicles and the prostate could be underlying mechanism for both observations.

Global epidemiology and control of Trichomonas vaginalis

PURPOSE OF REVIEW

Trichomonas vaginalis is the most common curable sexually transmitted infection. Despite a number of serious health consequences including facilitation of HIV transmission, pelvic inflammatory disease and adverse outcomes of pregnancy it remains an under-recognized condition. This review aims to update the reader on the global epidemiology and control of T. vaginalis.

RECENT FINDINGS

The burden of T. vaginalis infection is found in resource-limited settings and high-risk groups in industrialized settings. Utilization of polymerase chain reaction-based diagnostics has enhanced our understanding of the epidemiology of T. vaginalis both at the population level and in sexual partners. High rates of asymptomatic infection in male partners of infected females and subsequent re-infection have significant implications for control programmes. Further studies investigating the role of T. vaginalis in facilitating HIV transmission has highlighted its significance and the need to develop and implement control interventions.

SUMMARY

Future research to develop cheap, point-of-care diagnostic tests will allow a greater understanding of T. vaginalis epidemiology. In addition, the effect of treatment on outcome of pregnancy and HIV acquisition requires further study. This will in turn facilitate operational studies evaluating optimal control strategies and their impact on the complications of T. vaginalis.