The Zimbabwe STI Etiology Study

This project has been supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through Cooperative Agreement between the Centers for Disease Control and Prevention and the University of Zimbabwe Department of Community Medicine SEAM Project under the terms of Cooperative Agreement Number:  1U2GGH000315-01

This project was approved by the Medical Research Council of Zimbabwe (MRCZ), the Research Council of Zimbabwe (RCZ), the Joint Research Ethical Commission (JREC) and the Institutional Review Board of the U.S. Centers for Disease Control and Prevention (CDC)

Collaborators Department of Community Medicine, University of Zimbabwe School of Medicine Prof. Mufuta Tshimanga, Principal Investigator Dr. Gerald Shambira Zimbabwe Ministry of Health and Child Care Dr. Owen Mugurungi Dr. More Mungati Dr. Mutsa Manghara Ms. Anna Machiha

Collaborators U.S. Centers for Disease Control and Prevention – Zimbabwe Office Dr. Peter Kilmarx Elizabeth Gonese, MPH Amy Herman-Roloff, MPH Zimbabwe Community Health Intervention Research (ZiCHIRe) Vitalis Kupera, RN: Field Supervisor Luanne Rodgers, BA: Laboratory Supervisor

Collaborators National Institute of Communicable Diseases Prof. David Lewis Rietmeijer Consulting Prof. Kees Rietmeijer

Background In many countries sexually transmitted infections (STIs) are treated syndromically with combinations of antibiotics that cover the most prevalence causative infectious agents Periodic surveys are necessary to determine current etiologic patterns of most common STI syndromes

Primary Aims To assess the microbiological etiology of the following sexually transmitted infection (STI) syndromes: Vaginal discharge in women Urethral discharge in men Genital ulcer disease in men and women

Secondary Aims To assess the association between HIV infection and STI syndromes To assess the prevalence of gonorrhea and chlamydia among men and women with genital ulcer disease To assess the performance of novel diagnostic platforms, including: GeneXpert for diagnosis of gonorrhea and chlamydia Standard Diagnostics Bioline DUO for the simultaneous rapid test diagnosis of HIV and syphilis

Study Population A total of 600 patients: 200 women with vaginal discharge 200 men with urethral discharge 200 men and women with genital ulcer disease 6 regionally diverse clinics were selected based on high numbers of reported STI Harare: Mbare (H1) and Budiriro clinics (H2) Bulawayo: Nkulumane (B1) and Khami Road (B2) Clinics Beitbridge: Dulibadzimu Clinic (D1) Gutu: Gutu Road Clinic (G1)

Methods - 1 A specially trained study team of 3 nurses was deployed sequentially to each of the participating clinics Study participants were recruited and consented on the basis of their symptoms Data were collected using a paper-based standardized questionnaire and entered into an online database after completion of the visit All forms and samples shipped overnight to research laboratory in Harare

Data Collection Demographics Clinical history Sexual history Type and duration of symptoms STI history and HIV status Sexual history Number of partners Condom use Commercial Sex

Specimens Collected Blood (all patients) Men with urethral discharge Urethral smears for Gram stain Urine for NAAT Women with vaginal discharge Vaginal smears for Gram stain Vaginal swabs for NAAT Women and men with genital ulcer disease Ulcer swabs for NAAT

Laboratory Methods Genital Discharge Syndromes Nucleic Acid Amplification Tests (NAAT) Gold Standard: Multiplex polymerase chain reaction (M-PCR, NICD*) C. trachomatis N. Gonorrhoeae T. vaginalis M. genitalium Probetec (Becton Dickinson) C. trachomatis and N. gonorrhoeae Xpert CT/NG (Cepheid) *NICD: National Institute for Communicable Diseases, Johannesburg, South Africa

Laboratory Methods Genital Ulcer Disease Nucleic Acid Amplification Tests (NAAT) M-PCR (NICD*) T. pallidum H. ducreyi Herpes simplex virus (HSV) C. trachomatis (LGV strains Probetec (Becton Dickinson) C. trachomatis and N. gonorrhoeae Xpert CT/NG (Cepheid) *NICD: National Institute for Communicable Diseases, Johannesburg, South Africa

Laboratory Methods HIV Serology Determine (screening) First Response (confirmatory) ChemBio (tie-breaker) Syphilis Serology Treponemal TPHA SD Bioline Non-treponemal: RPR

Results

STI Surveillance in Zimbabwe

Recruitment (N=600) Source: Zimbabwe STI Aetiology Study, 2015

Recruitment by Site and STI Syndrome (N=600) Source: Zimbabwe STI Aetiology Study, 2015

Demographics by Site (N=600) Age Mean: 28.6 Median: 27 Women: Mean: 27.6 Median: 26 Men: Mean: 29.5 Median: 29 (p<0.01)

Demographics by Site (N=600) Age Mean: 28.6 Median: 27 Women: Mean: 27.6 Median: 26 Men: Mean: 29.5 Median: 29 (p<0.01)

Sexual Behavior Reporting >1 Partner in Past 3 Months Source: Zimbabwe STI Aetiology Study, 2015

Condom Use Last Sexual Encounter Casual Partner Source: Zimbabwe STI Aetiology Study, 2015

Condom Use Last Sexual Encounter Main Partner Source: Zimbabwe STI Aetiology Study, 2015

Sexual Behavior Reporting Commercial Sex in Past 3 Months Source: Zimbabwe STI Aetiology Study, 2015

Perceived HIV Status (N=600) Source: Zimbabwe STI Aetiology Study, 2015

HIV Status Actual (N=489) Source: Zimbabwe STI Aetiology Study, 2015

Urethral Discharge Syndrome (UDS) Men

Gram Stain Results - Men N = 200 (Gram Negative Intracellular Diplococci) Men with Urethral Discharge Syndrome: Gonorrhea: 137 (68%) >10 WBC/HPF: 12 (6%) 1-9 WBC/ HPF: 16 (8%) Negative: 35 (18%) Source: Zimbabwe STI Aetiology Study, 2015

Aetiology of Male Urethral Discharge Syndrome by Multiplex PCR (N=200) % Aetiology of Male Urethral Discharge Syndrome by Multiplex PCR (N=200) Source: Zimbabwe STI Aetiology Study, 2015

Urethral Discharge Syndrome – Men Single vs. Multiple Infections Single infection: 121 (60.5%) NG 106 CT 9 TV 2 MG 4 Dual infections: 40 (20%) NG+CT: 34 NG+TV: 4 NG+MG: 1 TV+MG: 1 3 infections: 2 (1%) NG+CT+TV:1 NG+CT+MG: 1 4 infections: None No infection: 37 (18.5%) 36/43 (84%) CT infections were co-infections 41/147 (28%) GC infections were co-infections Source: Zimbabwe STI Aetiology Study, 2015

CT, TV, and MG infections were more common among men with <10 WBC/HPF (12/24; 50%) compared to men with >10 WBC/HPF (3/97; 4 %) p<0.001 (chi square) Male UDS Aetiology in Relation to Gram Stain Results (Single Infections; N=121) N=24 N=97 Source: Zimbabwe STI Aetiology Study, 2015

Variations in the Aetiology of Urethral Discharge by Clinic (N=200) Source: Zimbabwe STI Aetiology Study, 2015

HIV and Syphilis Co-infections No significant associations with any of the urethritis pathogens

Vaginal Discharge Syndrome Women

Gram Stain Results – Women N 200 (Gram Negative Intracellular Diplococci) Women with Vaginal Discharge Syndrome: Gonorrhea: 18 (9%) BV: 49 (25%) Yeast: 41 (21%) Normal: 82 (45%) Source: Zimbabwe STI Aetiology Study, 2015

Aetiology of Vaginal Discharge Source: Zimbabwe STI Aetiology Study - 2016

Aetiology of Vaginal Discharge syndrome by Multiplex PCR (N=200) Source: Zimbabwe STI Aetiology Study, 2015

Vaginal Discharge Syndrome – Women Single vs. Multiple Infections Single infection: 62 (31%) NG: 24 CT: 9 TV : 21 MG : 8 Dual infections: 18 (9%) NG +CT: 7 NG+TV: 6 CT+MG: 3 NG+MG: 1 TV+MG: 1 3 infections: 10 (5%) NG+CT+TV: 9 NG+MG+TV: 1 4 infections: None No infection: 110 (55%) Number of Infections

HIV and Syphilis Co-infections No significant associations with any of the discharge-associated pathogens

Genital Ulcer Disease Men and Women

Genital Ulcer Disease - Multiplex PCR Results GRA22HSV: Genital Ulcer Disease - Multiplex PCR Results Of those with pathogens detected (n=102) HSV: 66.6% T. pallidum: 22.5% Both: 9% C. trachomatis (LGV): 1.9% 200 Men and 200 Women with GUD HSV: 68 (34%) Type 1: 1 (0.5%) T. pallidum (Tp): 23 (11.5%) Both HSV and Tp: 9 (4.5%) C. trachomatis (LGV): 2 (1%) 1 co-infected with Tp H. ducreyi: 0 None: 98 (49%) Of those with pathogens detected (n=102) HSV: 66.6% T. pallidum: 22.5% C. trachomatis (LGV): 1.9% Source: Zimbabwe STI Aetiology Study, 2015

M-PCR Results by Clinic Multiplex PCR results varied significantly (p<0.05) by recruitment clinic with lower rates of HSV at the Harare clinics Source: Zimbabwe STI Aetiology Study, 2015

M-PCR Results by HIV Status Multiplex PCR results varied significantly (p<0.01) by HIV status. HSV rates were 51.6% for persons with HIV infection compared to 25.6% for those uninfected with HIV Source: Zimbabwe STI Aetiology Study, 2015

Predictors of HSV Infection – Multivariate Analysis AOR: Adjusted Odds Ratio 95% C.I.: 95% Confidence Intervals

Chlamydia and Gonorrhea Positivity by STI Syndrome Source: Zimbabwe STI Aetiology Study, 2015

Treponemal/Non-treponemal Positivity by Syndrome Source: Zimbabwe STI Aetiology Study, 2015

Gonococcal and chlamydia infections present in 26% of GUD cases. 69% did not have comcomittant genital discharge and thus would not have been treated using syndromic approach In conclusion Urethral or vaginal GC and or CT infections were present in 52 (26%) of participants with genital ulcer disease. Of these 36 (69%) would not have been treated according to the current syndromic management guidelines These results raise concerns about the appropriateness of syndromic management, particularly among patients with genital ulcer disease

HIV Positivity by STI Syndrome Source: Zimbabwe STI Aetiology Study, 2015

Summary Urethral discharge among men was mostly caused by gonorrhea single infections followed by gonorrhea/chlamydia dual infections In men with less inflammatory response, chlamydia was significantly more common

Summary Gonorrhea, although less common among women with vaginal discharge, was the most common pathogen identified, followed by trichomoniasis and chlamydia Almost 50% of vaginal discharge was associated with BV or yeast infections

Summary Mycoplasma genitalium was uncommonly identified among both men and women with genital discharge

Summary Among women and men with genital ulcer disease, HSV infections were the most commonly identified, followed by primary syphilis HSV infections were highly associated with concurrent HIV infection No cases of H. ducreyi infections identified

Summary Gonorrhea and chlamydia prevalence was high among men and women with genital ulcer disease Among these, close to 70% would not have been treated using syndromic approach

Conclusions Source:

Conclusions Current syndromic management appears to adequately cover the most common pathogens associated with genital discharge syndromes or genital ulcer disease in Zimbabwe. However, the prevalence of gonorrhea and chlamydia is high among persons with GUD and, unless simultaneously diagnosed with genital discharge, inadequately covered by syndromic management for GUD alone.

Conclusions The relatively high prevalence of primary syphilis among persons with genital ulcer disease as well as the high prevalence of syphilis serological markers among all persons with STI in this study, warrants further investigations into the current epidemiology of syphilis in Zimbabwe, especially among pregnant women.

Conclusions There was an overall very high (~40%) prevalence of HIV infection among patients with all STI syndromes These results are difficult to interpret in a cross-sectional study and require further investigations, including asymptomatic STIs among HIV-infected persons Regardless, the concurrence of HIV infections and STIs promulgate HIV transmission, especially from persons that are not virally suppressed

Conclusions Prevention efforts among persons with STI syndromes continue to be a high public health priority

Limitations Results from 6 clinics not generalizable Patients with STI syndromes are not representative of all persons with STI infections Persons with chlamydia are less likely to symptomatic and therefore less likely to present to STI clinics Co-location of HIV and STI clinic may bias towards higher HIV prevalence among those with STI syndromes in our study

Thank You!! Source:

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