Cervical cancer screening strategies using visual inspection or cytology may have suboptimal diagnostic accuracy for detection of precancer in women living with HIV (WLHIV). The optimal screen and ...screen-triage strategy, age to initiate, and frequency of screening for WLHIV remain unclear. This study evaluated the sensitivity, specificity, and positive predictive value of different cervical cancer strategies in WLHIV in Africa.
WLHIV aged 25-50 years attending HIV treatment centres in Burkina Faso (BF) and South Africa (SA) from 5 December 2011 to 30 October 2012 were enrolled in a prospective evaluation study of visual inspection using acetic acid (VIA) or visual inspection using Lugol's iodine (VILI), high-risk human papillomavirus DNA test (Hybrid Capture 2 HC2 or careHPV), and cytology for histology-verified high-grade cervical intraepithelial neoplasia (CIN2+/CIN3+) at baseline and endline, a median 16 months later. Among 1,238 women (BF: 615; SA: 623), median age was 36 and 34 years (p < 0.001), 28.6% and 49.6% ever had prior cervical cancer screening (p < 0.001), and 69.9% and 64.2% were taking ART at enrolment (p = 0.045) in BF and SA, respectively. CIN2+ prevalence was 5.8% and 22.4% in BF and SA (p < 0.001), respectively. VIA had low sensitivity for CIN2+ (44.7%, 95% confidence interval CI 36.9%-52.7%) and CIN3+ (56.1%, 95% CI 43.3%-68.3%) in both countries, with specificity for ≤CIN1 of 78.7% (95% CI 76.0%-81.3%). HC2 had sensitivity of 88.8% (95% CI 82.9%-93.2%) for CIN2+ and 86.4% (95% CI 75.7%-93.6%) for CIN3+. Specificity for ≤CIN1 was 55.4% (95% CI 52.2%-58.6%), and screen positivity was 51.3%. Specificity was higher with a restricted genotype (HPV16/18/31/33/35/45/52/58) approach (73.5%, 95% CI 70.6%-76.2%), with lower screen positivity (33.7%), although there was lower sensitivity for CIN3+ (77.3%, 95% CI 65.3%-86.7%). In BF, HC2 was more sensitive for CIN2+/CIN3+ compared to VIA/VILI (relative sensitivity for CIN2+ = 1.72, 95% CI 1.28-2.32; CIN3+: 1.18, 95% CI 0.94-1.49). Triage of HC2-positive women with VIA/VILI reduced the number of colposcopy referrals, but with loss in sensitivity for CIN2+ (58.1%) but not for CIN3+ (84.6%). In SA, cytology high-grade squamous intraepithelial lesion or greater (HSIL+) had best combination of sensitivity (CIN2+: 70.1%, 95% CI 61.3%-77.9%; CIN3+: 80.8%, 95% CI 67.5%-90.4%) and specificity (81.6%, 95% CI 77.6%-85.1%). HC2 had similar sensitivity for CIN3+ (83.0%, 95% CI 70.2%-91.9%) but lower specificity compared to HSIL+ (42.7%, 95% CI 38.4%-47.1%; relative specificity = 0.57, 95% CI 0.52-0.63), resulting in almost twice as many referrals. Compared to HC2, triage of HC2-positive women with HSIL+ resulted in a 40% reduction in colposcopy referrals but was associated with some loss in sensitivity. CIN2+ incidence over a median 16 months was highest among VIA baseline screen-negative women (2.2%, 95% CI 1.3%-3.7%) and women who were baseline double-negative with HC2 and VIA (2.1%, 95% CI 1.3%-3.5%) and lowest among HC2 baseline screen-negative women (0.5%, 95% CI 0.1%-1.8%). Limitations of our study are that WLHIV included in the study may not reflect a contemporary cohort of WLHIV initiating ART in the universal ART era and that we did not evaluate HPV tests available in study settings today.
In this cohort study among WLHIV in Africa, a human papillomavirus (HPV) test targeting 14 high-risk (HR) types had higher sensitivity to detect CIN2+ compared to visual inspection but had low specificity, although a restricted genotype approach targeting 8 HR types decreased the number of unnecessary colposcopy referrals. Cytology HSIL+ had optimal performance for CIN2+/CIN3+ detection in SA. Triage of HPV-positive women with HSIL+ maintained high specificity but with some loss in sensitivity compared to HC2 alone.
This study was undertaken to establish the etiology of the male urethral discharge (MUDS) and vaginal discharge (VDS) syndromes, to determine the prevalence of other sexually transmitted infections ...(STI) and human immunodeficiency virus (HIV) coinfections, and to examine associations between STIs and HIV serostatus among STI patients in South Africa.
A total of 507 MUDS and 300 VDS patients were recruited in Cape Town (CPT) and Johannesburg (JHB). A multiplex polymerase chain reaction assay detected Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and Mycoplasma genitalium infections. Bacterial vaginosis and candidiasis were detected by microscopy. Sera were screened for syphilis, HSV-2, and HIV antibodies.
Etiological diagnoses were made for 92% of MUDS patients and 85% of VDS patients. Gonorrhoea accounted for 85% (CPT) and 71% (JHB) of MUDS presentations. Chlamydia was the second most frequently detected MUDS pathogen (CPT, 13%; JHB, 24%). Among VDS patients, bacterial vaginosis was the most common cause (CPT, 46%; JHB, 36%) and trichomoniasis the most frequently detected STI pathogen (CPT, 19%; JHB, 34%). Few patients (4%) had serological evidence of syphilis. The HSV-2 and HIV seroprevalence were higher in Johannesburg compared to Cape Town and among women compared to men. HIV infection was statistically significantly associated with HSV-2 seropositivity at both sites and with the presence of N. gonorrhoeae and absence of C. trachomatis in Cape Town MUDS patients.
Gonorrhoea and bacterial vaginosis were confirmed as the most frequent causes of MUDS and VDS. The high HIV seroprevalence in STI patients emphasizes the need to address HIV testing among this population.
Abstract
This prospective cohort study of 622 women living with human immunodeficiency virus (HIV) from Johannesburg (2012) detected Mycoplasma genitalium in 7.4% (95% confidence interval CI: ...5.5–9.7, 46/622), with detection more likely with lower CD4 counts(adjusted odds ratio AOR 1.02 per 10 cells/μL decrease, 95% CI: 1.00–1.03) and higher plasma HIV-1 RNA (AOR 1.15 per log copies/mL increase, 95% CI: 1.03–1.27). No mutations for macrolide/quinolone resistance was detected.
ABSTRACTWe report the clinical symptoms and examination findings of Mycoplasma genitalium (MG) in women living with HIV (WLHIV) in South Africa. If we relied on syndromic management alone to treat ...MG, only 15/46 of MG-infected women would have received appropriate treatmentsensitivity 32.6% (95%CI19.5-48.0) and specificity 67.4% (95%CI63.4-71.2).
ABSTRACTWe report the clinical symptoms and examination findings of Mycoplasma genitalium (MG) in women living with human immunodeficiency virus in South Africa. If we relied on syndromic management ...alone to treat MG, only 15 of 46 MG-infected women would have received. appropriate treatmentsensitivity of 32.6% (95% confidence interval, 19.5–48.0) and specificity of 67.4% (95% confidence interval, 63.4–71.2).
Background: This study was undertaken to establish the etiology of the male urethral discharge (MUDS) and vaginal discharge (VDS) syndromes, to determine the prevalence of other sexually transmitted ...infections (STI) and human immunodeficiency virus (HIV) coinfections, and to examine associations between STIs and HIV serostatus among STI patients in South Africa. Methods: A total of 507 MUDS and 300 VDS patients were recruited in Cape Town (CPT) and Johannesburg (JHB). A multiplex polymerase chain reaction assay detected Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and Mycoplasma genitalium infections. Bacterial vaginosis and candidiasis were detected by microscopy. Sera were screened for syphilis, HSV-2, and HIV antibodies. Results: Etiological diagnoses were made for 92% of MUDS patients and 85% of VDS patients. Gonorrhoea accounted for 85% (CPT) and 71 % (JHB) of MUDS presentations. Chlamydia was the second most frequently detected MUDS pathogen (CPT, 13%; JHB, 24%). Among VDS patients, bacterial vaginosis was the most common cause (CPT, 46%; JHB, 36%) and trichomoniasis the most frequently detected STI pathogen (CPT, 19%; JHB, 34%). Few patients (4%) had serological evidence of syphilis. The HSV-2 and HIV seroprevalence were higher in Johannesburg compared to Cape Town and among women compared to men. HIV infection was statistically significantly associated with HSV-2 seropositivity at both sites and with the presence of N. gonorrhoeae and absence of C. trachomatis in Cape Town MUDS patients. Conclusions: Gonorrhoea and bacterial vaginosis were confirmed as the most frequent causes of MUDS and VDS. The high HIV seroprevalence in STI patients emphasizes the need to address HIV testing among this population.
MSc (Med), Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwaterstrand
Emergence and spread of resistance to ciprofloxacin among Neisseria;
gonorrhoeae ...strains has reduced the options of effective treatment for;
gonococcal infections and has become a concern worldwide. Up until 2008,;
ciprofloxacin was recommended first-line therapy for treatment of presumptive N.;
gonorrhoeae infections in South Africa. At the time this MSc project was;
conceived, ciprofloxacin was still used as first-line therapy for presumptive;
gonococcal infections.;
A real-time polymerase chain reaction (PCR) assay was used to detect;
ciprofloxacin-resistant N. gonorrhoeae in DNA extracted from non-invasive urine;
samples collected as part of the national microbiological surveillance (NMS);
programme during 2006-2007. The molecular epidemiology of ciprofloxacinresistant;
Neisseria gonorrhoeae was investigated by sequencing the quinolone;
resistance determining regions (QRDR) of the gyrA and parC genes of N.;
gonorrhoeae and performing N. gonorrhoeae multi-antigen sequence typing (NGMAST).;
As part of the NMS program for sexually transmitted infections (STIs) urine and;
urethral swabs were collected from men presenting with urethral discharge at;
primary health care clinics in Johannesburg (Gauteng), Cape Town (Western;
Cape) and Kimberley (Northern Cape). Urine samples and cultured N.;
gonorrhoeae isolates from 2006-2007 were stored at -700C and available for this;
study. Gonococci, previously isolated from urethral swabs, were subcultured;
directly onto New York City media. Isolate identity was re-confirmed by typical;
colony morphology and biochemical tests. Urine samples from Johannesburg;
were tested in order to develop the real-time PCR protocol. Subsequently,;
paired urethral swab DNA and N. gonorrhoeae cultures were tested from NMS;
patients recruited in Kimberley and Cape Town. Where possible, the PCR assay;
results were compared with paired antibiotic susceptibility data for ciprofloxacin.;
Quinolone resistance determining regions (QRDR) for gyrA and parC were screened for known point mutations associated with resistance to ciprofloxacin.;
Detection of mutations by the real-time PCR assay generally agreed with the;
phenotype of either decreased susceptibility or resistance to ciprofloxacin. All;
ciprofloxacin resistant gonococcal isolates had the same gyrA and parC;
mutations, which initially suggested that quinolone resistant N. gonorrhoeae;
(QRNG) in Kimberley, Cape Town and Johannesburg, may be attributed to the;
spread of a single clone. The use of a more discriminatory typing scheme,;
Neisseria gonorrhoeae Multi-Antigen Sequence Typing (NG-MAST) genotyping,;
revealed that ciprofloxacin resistant gonococcal isolates in Johannesburg and;
Cape Town were heterogeneous, with sequence type (ST) 217 being most;
prevalent in both cities (5/16, Johannesburg; 7/11, Cape Town). In contrast, all;
eight QRNG isolates from Kimberley were typed as ST 533.;
The use of molecular methods allowed ciprofloxacin antimicrobial susceptibility;
determination by PCR in non-invasive specimens. This is useful in situations;
where bacterial cultures are unavailable or die before antimicrobial susceptibility;
testing can be performed. Molecular assays to detect ciprofloxacin resistance;
may guide physicians as to the most ideal antimicrobial combinations for;
individual patient treatment.;
As a result of emerging widespread resistance gonococci to ciprofloxacin, in;
2008, the Department of Health recommended that ciprofloxacin be removed as;
a first line therapy in the South African national sexually transmitted infections;
treatment guidelines for treatment of urethritis, cervicitis and their complications.;
Although ciprofloxacin is no longer used as a first-line therapy to treat;
gonorrhoea within our country, it may still be used in cases of severe penicillin;
allergy or as part of multi-drug therapy for gonococcal infections in the future.;
The ability to detect ciprofloxacin resistance by real-time PCR will be a useful;
technique in such situations.
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