Epidemiology of Treponema pallidum, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and herpes simplex virus type 2 among female sex workers in the Middle East and North Africa: systematic review and meta-analytics

Prevalence of sexually transmitted infections (STIs), associations with sociodemographic and behavioural factors, and assessment of the syndromic management of vaginal discharge in women with urogenital complaints in Mozambique

In Mozambique, sexually transmitted infections (STIs) are estimated to be prevalent, but diagnosis and treatment of curable STIs rely only on syndromic management. We examined the prevalence of four non-viral STIs and HIV-1/2, based on etiological diagnosis, associations with sociodemographic and behavioural factors, and the STI diagnostic accuracy of the vaginal discharge syndromic management in women with urogenital complaints in Maputo, Mozambique. A cross-sectional study was performed in Maputo, Mozambique, February 2018-January 2019, enrolling 924 women of reproductive age with urogenital complaints. Endocervical/vaginal swabs were sampled and chlamydia, gonorrhoea, trichomoniasis and Mycoplasma genitalium infections were diagnosed using a multiplex real-time PCR (AmpliSens; InterLabServices). Serological testing was performed for HIV-1/2. A structured questionnaire collected metadata. All data were analyzed in STATA/IC 12.1 using descriptive statistics, chi-square tests and logistic regression model. About 40% of the women were less than 24 years old, 50.8% were single, 62.1% had their sexual debut between 12 and 17 years of age, and the main complaint was vaginal discharge syndrome (85%). The prevalence of chlamydia was 15.5%, trichomoniasis 12.1%, gonorrhoea 4.0%, M. genitalium 2.1%, and HIV-1/2 22.3%. The vaginal discharge syndrome flowchart had a sensitivity of 73.0%-82.5% and a specificity of 14%-15% for the detection of any individual non-viral STI in women with urogenital complaints. In total, 19.2% of the symptomatic women with chlamydia, trichomoniasis or gonorrhoea would not be detected and accordingly treated using the vaginal discharge syndromic management (missed treatment) and 70.0% of the women would be treated despite not being infected with any of these three STIs (overtreatment). In conclusion, a high prevalence of especially chlamydia, trichomoniasis, and HIV-1/2 was found in women of childbearing age with urogenital complaints in Maputo, Mozambique. Syndromic management of vaginal discharge revealed low accuracy in the detection of STIs in symptomatic women, especially low specificity, which resulted in under-treatment of STI-positive cases and incorrect or over-treatment of women with urogenital complaints, many of whom were negative for all the non-viral STIs. Etiological diagnosis is imperative for effective management of STIs in symptomatic and asymptomatic women.

Epidemiology of gonorrhoea: systematic review, meta-analyses, and meta-regressions, World Health Organization European Region, 1949 to 2021

BackgroundEpidemiology of Neisseria gonorrhoeae (NG) infection remains inadequately understood.AimWe aimed to characterise NG epidemiology in Europe.MethodsWe used Cochrane and PRISMA guidelines to systematically review, report, synthesise and analyse NG prevalence data from 1949 to 30 September 2021. Random-effects meta-analyses estimated pooled prevalence. Meta-regression analyses investigated associations and sources of heterogeneity.ResultsThe 844 included publications yielded 1,573 prevalence measures. Pooled prevalence of current urogenital infection was 1.0% (95% CI: 0.7-1.2%) among general populations, 3.2% (95% CI: 1.8-4.8%) among female sex workers, 4.9% (95% CI: 4.2-5.6%) among sexually transmitted infection clinic attendees and 12.1% (95% CI: 8.8-15.8%) among symptomatic men. Among men who have sex with men, pooled prevalence was 0.9% (95% CI: 0.5-1.4%), 5.6% (95% CI: 3.6-8.1%), and 3.8% (95% CI: 2.5-5.4%), respectively, for current urogenital, anorectal or oropharyngeal infection. Current urogenital, anorectal or oropharyngeal infection was 1.45-fold (95% CI: 1.19-1.77%), 2.75-fold (95% CI: 1.89-4.02%) and 2.64-fold (95% CI: 1.77-3.93%) higher among men than women. Current urogenital infection declined 0.97-fold (95% CI: 0.96-0.98%) yearly, but anorectal and oropharyngeal infection increased (1.02-fold; 95% CI: 1.01-1.04% and 1.02-fold; 95% CI: 1.00-1.04%), respectively.ConclusionsNeisseria gonorrhoeae epidemiology in Europe has distinct and contrasting epidemiologies for vaginal sex transmission in heterosexual sex networks vs anal and oral sex transmission in MSM sexual networks. Increased transmission may facilitate drug-resistant strain emergence. Europe is far from achieving the World Health Organization target of 90% incidence reduction by 2030.

Determinants of sexually transmitted infections among female sex workers in Ethiopia: a count regression model approach

Background

Sexually transmitted infections (STIs) remain a major public health problem worldwide, with the burden of these infections being high among female sex workers (FSWs), who are often not aware of their infection status. This study aimed to determine the factors that are associated with the number of STIs among FSWs in Ethiopia.

Methods

A cross-sectional bio-behavioral study involving respondent-driven sampling (RDS) was conducted among 6,085 FSWs in 16 towns in Ethiopia. The hurdle Poisson regression model was fitted using STATA Version 16.2. The incident rate ratio and adjusted odds ratio with a 95% confidence interval were employed to show the strength and direction of the association. A p-value of ≤0.05 was used as a threshold for statistical significance.

Results

At least one STI was identified in 1,444 (23.64%) of the FSWs. Age group 35-49 years [IRR = 2.32; 95% CI (1.43, 3.74)], forced first sex [IRR = 1.32; 95% CI (1.01, 1.74)], condom breakage [IRR = 1.32; 95% CI (1.01, 1.74)], and a history of depression [IRR = 1.55; 95% CI (1.12, 2.18)] increase the number of STIs. FSWs aged 25-34 years [AOR = 2.99; % CI (2.54, 3.52)] and 35 = 59 years [AOR = 8.05; % CI (6.54, 9.91)], who were selling sex for 5-10 years [AOR = 1.30; 95% CI (1.1, 1.55)], and above 11 years [AOR = 1.21; 95% CI (1.03, 1.43)] were more likely to get STIs.

Conclusion

STIs are common in Ethiopia. The covariates age, educational status, monthly income, condom failure, age at the first sexual encounter, and long duration of sexual practice are significant predictors of STIs. Health interventions among FSWs need to include awareness generation about the prevention and control of STIs and address the determinants identified in this analysis.

Sexually Transmitted Diseases among Saudi Women: Knowledge and Misconceptions

The rate of sexually transmitted diseases is increasing globally. Thus, this study aimed to examine the Al akami female community's knowledge about the nature of sexually transmitted diseases and their associated factors. The STDs-Knowledge Questionnaire (STDs-KQ) was utilized to collect data from the female community (355) in Jeddah, Saudi Arabia. The data were analyzed using JMP Statistics for Windows, version 15. The significance level was set at 0.05. The study reported that participants had a relatively low understanding of STDs in acquisition, protection, prevention, and clinical signs and symptoms; only 33 (9%) had high knowledge scores (10-18), while 70% thought one virus caused all forms of STDs. Also, only 15% of the respondents knew the clinical features of the Chlamydia infection, and 18% identified the correct mode of its transmission. Also, older participants with clinical exposure had a higher knowledge score than young and single females, p < 0.05. A positive correlation between age and knowledge score was reported, r (354) = 0.339, p < 0.0001. The low knowledge scores were associated with marital status, age, and clinical exposure. Practical strategies to minimize literacy toward sexual education and increase the quality of sexual life must be promoted by educators and the academic curriculum.

A Pay-It-Forward Approach to Improve Chlamydia and Gonorrhea Testing Uptake Among Female Sex Workers in China: Venue-Based Superiority Cluster Randomized Controlled Trial

BACKGROUND

Regular chlamydia and gonorrhea testing are essential for key populations, such as female sex workers (FSWs). However, testing cost, stigma, and lack of access prevent FSWs in low- and middle-income countries from receiving chlamydia and gonorrhea testing. A social innovation to address these problems is "pay it forward," where an individual receives a gift (free testing) and then asks whether they would like to give a gift to another person in the community.

OBJECTIVE

This cluster randomized controlled trial examined the effectiveness and cost of the pay-it-forward strategy in increasing access to chlamydia and gonorrhea testing among FSWs in China.

METHODS

This trial integrated a pay-it-forward approach into a community-based HIV outreach service. FSWs (aged 18 years or older) were invited by an outreach team from 4 Chinese cities (clusters) to receive free HIV testing. The 4 clusters were randomized into 2 study arms in a 1:1 ratio: a pay-it-forward arm (offered chlamydia and gonorrhea testing as a gift) and a standard-of-care arm (out-of-pocket cost for testing: US $11). The primary outcome was chlamydia and gonorrhea test uptake, as ascertained by administrative records. We conducted an economic evaluation using a microcosting approach from a health provider perspective, reporting our results in US dollars (at 2021 exchange rates).

RESULTS

Overall, 480 FSWs were recruited from 4 cities (120 per city). Most FSWs were aged ≥30 years (313/480, 65.2%), were married (283/480, 59%), had an annual income

CONCLUSIONS

The pay-it-forward strategy has the potential to enhance chlamydia and gonorrhea testing for Chinese FSWs and may be useful for scaling up preventive services. Further implementation research is needed to inform the transition of pay-it-forward research into practice.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2000037653; https://www.chictr.org.cn/showprojen.aspx?proj=57233.

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Key Words

• China
• HIV
• STD
• care
• chlamydia
• community
• cost
• female sex workers
• gonorrhea
• implementation
• pay-it-forward
• prevention
• research
• stigma
• testing
• women

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MESH Headings

• Humans
• Female
• Sex Workers
• Sex Work
• Gonorrhea/diagnosis
• Gonorrhea/epidemiology
• China/epidemiology
• Chlamydia

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Grants

• 001 World Health Organization
• K24 AI143471 NIAID NIH HHS
• R01 AI158826 NIAID NIH HHS
• R34 MH119963 NIMH NIH HHS

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Affiliation(s)

Weiming Tang Dermatology Hospital of Southern Medical University, Guangzhou, China Southern Medical University Institute for Global Health, Guangzhou, China University of North Carolina at Chapel Hill Project-China, Guangzhou, China
Yewei Xie University of North Carolina at Chapel Hill Project-China, Guangzhou, China Health Service & System Research programme, Duke-NUS Medical School, Singapore, Singapore
Mingzhou Xiong Dermatology Hospital of Southern Medical University, Guangzhou, China Southern Medical University Institute for Global Health, Guangzhou, China
Dan Wu University of North Carolina at Chapel Hill Project-China, Guangzhou, China Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom West China School of Public Health, Sichuan University, Chengdu, China
Jason J Ong Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom Central Clinical School, Faculty of Medicine, Monash University, Melbourne, Australia
Teodora Elvira Wi Department of Global HIV, Hepatitis and STI Programmes, World Health Organization Headquarters, Geneva, Switzerland
Bin Yang Dermatology Hospital of Southern Medical University, Guangzhou, China Southern Medical University Institute for Global Health, Guangzhou, China
Joseph D Tucker University of North Carolina at Chapel Hill Project-China, Guangzhou, China Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
Cheng Wang Dermatology Hospital of Southern Medical University, Guangzhou, China Southern Medical University Institute for Global Health, Guangzhou, China

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Global prevalence of Neisseria gonorrhoeae infection in pregnant women: a systematic review and meta-analysis

BACKGROUND

Neisseria gonorrhoeae infection (gonorrhoea) is associated with several pregnancy complications, including preterm labour, spontaneous abortion, stillbirth, miscarriage, growth retardation, and intrauterine death.

OBJECTIVES

We performed a systematic review and meta-analysis to estimate the global and regional prevalence of gonorrhoea in pregnant women as a scientific basis for further studies.

DATA SOURCES

We systematically searched PubMed/MEDLINE, Web of Science, Embase, Scopus, and SciELO databases from inception to 10 July 2022.

STUDY ELIGIBILITY CRITERIA

We included cross-sectional, cohort, and case-control studies that reported the prevalence of gonorrhoea in pregnant women. In addition, we included baseline data for randomized controlled trials.

PARTICIPANTS

Pregnant women who were tested for gonorrhoea.

METHODS

Pooled prevalence estimates at 95% CIs were calculated using a random-effects meta-analysis model. We stratified countries according to WHO-defined regions and socio-economic factors. Moreover, sub-group-, meta-regression, and sensitivity analyses were conducted to investigate the effects of pre-determined factors on prevalence estimates and heterogeneity.

RESULTS

We identified 235 studies (249 datasets) on 19 104 175 pregnant women from 71 countries. The worldwide pooled prevalence of gonorrhoea in pregnant women was estimated at 1.85% (95% CI 1.73-1.97%), with the highest rate in the African region (3.53%) (2.84-4.29%) and the lowest rate in the European region (0.52%) (0.27-0.84%). Overall, the prevalence estimates were high among low-income countries (3.03%), pregnant women with HIV (2.81%), and pregnant women <20 years old (8.06%). A significant decreasing trend in prevalence was observed over time (β = -0.0008, 95% CI -0.0012 to -0.0004, p 0.001).

DISCUSSION

Our findings indicate that a substantial number of pregnant women have been infected with gonorrhoea globally, which calls for immediate public health measures to reduce the potential risk of infection. The study highlights the inadequacy or lack of data for many countries, emphasizing the need to expand systematic data collection efforts at national and regional levels.

HIV, sexual violence, and termination of pregnancy among adolescent and adult female sex workers in Malawi: A respondent-driven sampling study

Female Sex Workers (FSWs) are a hard-to-reach and understudied population, especially those who begin selling sex at a young age. In one of the most economically disadvantaged regions in Malawi, a large population of women is engaged in sex work surrounding predominantly male work sites and transport routes. A cross-sectional study in February and April 2019 in Nsanje district used respondent driven sampling (RDS) to recruit women ≥13 years who had sexual intercourse (with someone other than their main partner) in exchange for money or goods in the last 30 days. A standardized questionnaire was filled in; HIV, syphilis, gonorrhea, and chlamydia tests were performed. CD4 count and viral load (VL) testing occurred for persons living with HIV (PLHIV). Among 363 study participants, one-quarter were adolescents 13-19 years (25.9%; n = 85). HIV prevalence was 52.6% [47.3-57.6] and increased with age: from 14.7% (13-19 years) to 87.9% (≥35 years). HIV status awareness was 95.2% [91.3-97.4], ART coverage was 98.8% [95.3-99.7], and VL suppression 83.2% [77.1-88.0], though adolescent FSWs were less likely to be virally suppressed than adults (62.8% vs. 84.4%). Overall syphilis prevalence was 29.7% [25.3-43.5], gonorrhea 9.5% [6.9-12.9], and chlamydia 12.5% [9.3-16.6]. 72.4% had at least one unwanted pregnancy, 17.9% had at least one abortion (40.1% of which were unsafe). Half of participants reported experiencing sexual violence (SV) (47.6% [42.5-52.7]) and more than one-tenth (14.2%) of all respondents experienced SV perpetrated by a police officer. Our findings show high levels of PLHIV-FSWs engaged in all stages of the HIV cascade of care. The prevalence of HIV, other STIs, unwanted pregnancy, unsafe abortion, and sexual violence remains extremely high. Peer-led approaches contributed to levels of ART coverage and HIV status awareness similar to those found in the general district population, despite the challenges and risks faced by FSWs.

Status of the HIV epidemic in key populations in the Middle East and north Africa: knowns and unknowns

The Middle East and north Africa is one of only two world regions where HIV incidence is on the rise, with most infections occurring among key populations: people who inject drugs, men who have sex with men, and female sex workers. In this Review, we show a trend of increasing HIV prevalence among the three key populations in the Middle East and north Africa. Although the epidemic continues at a low level in some countries or localities within a country, there is evidence for concentrated epidemics, with sustained transmission at considerable HIV prevalence among people who inject drugs and men who have sex with men in over half of countries in the region with data, and among female sex workers in several countries. Most epidemics emerged around 2003 or thereafter. The status of the epidemic among key populations remains unknown in several countries due to persistent data gaps. The HIV response in Middle East and north Africa remains far below global targets for prevention, testing, and treatment. It is hindered by underfunding, poor surveillance, and stigma, all of which are compounded by widespread conflict and humanitarian crises, and most recently, the advent of COVID-19. Investment is needed to put the region on track towards the target of eliminating HIV/AIDS as a global health threat by 2030. Reaching this target will not be possible without tailoring the response to the needs of key populations, while addressing, to the extent possible, the complex structural and operational barriers to success.

Trichomonas vaginalis infection in Ethiopia: A systematic review and meta-analysis

BACKGROUND

An estimated 30 million new cases of Trichomonas vaginalis are recorded annually in sub-Saharan Africa. In Ethiopia, there is no study that systematically compiled the burden of T. vaginalis. Therefore, this study aimed to estimate the pooled prevalence of T. vaginalis in Ethiopia.

METHODS

Electronic databases such as PubMed/Medline, EMBASE, Science Direct, Scopus, HINARI, Google Scholar, and Cochrane Library were systematically searched, and studies with high-quality Newcastle Ottawa Scale scores were included. Analyses were performed using STATA version 14 software, and heterogeneity of studies was assessed using the Cochrane's Q test statistics and I² test statistics. Sub-group, sensitivity analysis, and publication bias were performed.

RESULTS

Ten eligible studies consisting of 2979 study participants were included. The overall pooled prevalence of T. vaginalis infections in Ethiopia was 9.62%. Sub-group analysis showed that the overall pooled prevalence of T. vaginalis infections in pregnant women and other study groups was 6.68% and 12.86%, respectively. Publication bias was detected by funnel plots and Egger's tests.

CONCLUSIONS

This study showed that the overall pooled prevalence of T. vaginalis infections was relatively high. This study should trigger policy makers, governmental and non-governmental organizations, and healthcare providers to give attention for prevention and control of T. vaginalis infection.

Chlamydia trachomatis and Neisseria gonorrhoeae PCR detection in women treated for ectopic pregnancy

The aim of this study was to determine the presence of Chlamydia trachomatis (ChT) and Neisseria gonorrhoae (NG) in the genital tract of women with ectopic pregnancy and to compare the positive results with patients' self-reported history of PID. Overall 40 women were eligible for the study. The samples for the ChT and NG Polymerase Chain-reaction (PCR) detection were obtained from the cervix, endometrium and fallopian tube. The results of testing for NG at all sites were negative as were the results from cervical testing for ChT. The prevalence of ChT in the upper genital tract was 12.5%. No statistically significant correlation was found between the positive cases and the previous signs of PID and laparoscopic findings. We found statistically significant relationship between signs of pelvic inflammation in a pacients' history and histopathological findings of tubal inflammation. 12.5% prevalence of ChT confirms the ascending genital infection. There was no association between the positive PCR result and clinical history of pelvic inflammation.IMPACT STATEMENTWhat is already known on this subject? Pelvic inflammatory disease, Chlamydia trachomatis and Neisseria gonorrhoae infections are the main risks for ectopic pregnancy. Clinical history of PID and perioperative adhesions may suggest prior upper genital infection.What do the results of this study add? Chlamydia trachomatis positive PCR result can be found in the upper genital tract without the positivity of cervical smear in women with ectopic pregnancy. Our study is unique in assessing the endometrial biopsy for the presence of Chlamydia trachomatis and Neisseria gonorrhoae.What are the implications of these findings for future clinical practice and/or future clinical research? There is no statistically significant association between positive PCR result and clinical history of PID or pelvic adhesions found during laparoscopy for tubal pregnancy. Therefore there is no need for the preventive antibiotic treatment in patients with these findings.

Trichomonas vaginalis follow-up and persistence in Colombian women

Trichomonas vaginalis (TV), the most common non-viral sexually-transmitted infection is considered a neglected infection and its epidemiology is not well known. This study determined TV-infection dynamics in a retrospective cohort of Colombian women and evaluated associations between risk factors and TV-outcome. TV was identified by PCR. Cox proportional risk models were used for evaluating the relationship between TV-outcome (infection, clearance and persistence) and risk factors (sexually-transmitted infections and sociodemographic characteristics). Two hundred and sixty-four women were included in the study; 26.1% had TV at the start of the study, 40.9% suffered at least one episode of infection and 13.0% suffered more than one episode of TV during the study. Women suffering HPV had a greater risk of TV-infection (aHR 1.59), high viral-load (> 10²) for HPV-16 being related to a greater risk of persistent parasite infection; a high viral load (> 10²) for HPV-18 and -33 was related to a lower probability of TV-clearance. Ethnicity (afrodescendent/indigenous people: aHR 5.11) and having had more than two sexual partners (aHR 1.94) were related to greater risk of infection, contrasting with women having a background of abortions and lower probability of having TV (aHR 0.50). Women aged 35- to 49-years-old (aHR 2.08), increased years of sexual activity (aHR 1.10), multiple sexual partners (aHR 8.86) and multiparous women (aHR 3.85) led to a greater probability of persistence. Women whose cervical findings worsened had a 9.99 greater probability of TV-persistence. TV distribution was high in the study population; its coexistence with HPV and other risk factors influenced parasite infection dynamics. The results suggested that routine TV detection should be considered regarding populations at risk of infection.

Syndromic surveillance of female sexually transmitted infections in primary care: a descriptive study in Monastir, Tunisia, 2007─2017

BACKGROUND

Sexually Transmitted Infections (STIs) are a public health problem, especially for reproductive-age women. The aim of this study was to determine the incidence and trend of STIs during 11 years in Tunisia (2007-17).

METHODS

We conducted a descriptive study including all women with curable STIs (chlamydia, gonorrhea, syphilis and trichomoniasis) diagnosed with the syndromic approach in all basic health care centers of the Governorate of Monastir (Tunisia) from 2007 to 2017. Syndromes included, Pelvic Pain (PP), Vaginal Discharge (VD) and Genital Ulceration (GU).

RESULTS

We analyzed 40,388 episodes of curable STIs with a crude incidence rate and age standardized incidence rate of 1393 (95% Confidence Interval (CI); 1348-1438) / 100,000 Person Year (PY) and 1328 (95%CI; 1284-1372) /100,000 PY respectively. The incidence rate showed a positive trend over 11 years for all age groups and syndromes. VD was the most common syndrome with a crude incidence rate of 1170/100,000 PY. For all syndromes, women aged 20 to 39 were the most affected age group (p < 0.001).

CONCLUSION

In conclusion, the incidence rate of STIs episodes among women diagnosed with the syndromic approach was high, consistent with the global evidence. Focusing on reviewing STIs surveillance system in low and middle-income countries could allow the achievement of the ending of STIs epidemics by 2030.

HSV-2 as a biomarker of HIV epidemic potential in female sex workers: meta-analysis, global epidemiology and implications

This study investigated herpes simplex virus type 2 (HSV-2) seroprevalence utility as a predictor of HIV epidemic potential among female sex workers (FSWs) globally. We updated and analyzed a systematically-assembled database for paired HSV-2 and HIV seroprevalence measures among FSWs. The study identified 231 paired HSV-2/HIV prevalence measures from 40 countries. The pooled mean HIV prevalence using meta-analysis increased from 3.7% (95% CI 0.3-9.9%) among populations of FSWs with HSV-2 prevalence < 25% to 18.7% (95% CI 14.1-23.8%) among those with HSV-2 prevalence 75-100%. HIV prevalence was negligible in FSWs with HSV-2 prevalence ≤ 20% suggesting a threshold effect. Multivariable meta-regressions explained > 65% of HIV prevalence variation, and identified a strong positive HSV-2/HIV association. Compared to populations of FSWs with HSV-2 prevalence < 25%, adjusted odds ratios (AORs) of HIV infection increased from 2.8 (95% CI 1.2-6.3) in those with HSV-2 prevalence 25-49%, to 13.4 (95% CI 6.1-29.9) in those with HSV-2 prevalence 75-100%. HSV-2 is a strong predictor of HIV epidemic potential among FSWs. HSV-2 prevalence of 25-49% indicates potential for intermediate-intensity HIV epidemics, with higher levels indicative of large epidemics. HSV-2 surveillance could inform HIV preparedness in countries where HIV prevalence among FSWs is still limited or at zero-level.