BACKGROUND
The global epidemic of Mycoplasma genitalium (MG) is marked by its widespread prevalence, varied resistance patterns, and significant impact on sexual health. This study aimed to understand the prevalence and interaction of MG infections with other sexually transmitted infections (STIs) in a low-resource setting, as well as the implications for routine STIs care.
METHODS
This nested cross-sectional study was conducted from July 2022 to April 2023 across six outpatient care sites in Shiselweni, Eswatini. Participants completed a self-questionnaire, underwent syndromic case management, and provided urine samples for parallel molecular-based testing using the Cepheid GeneXpert® platform for MG, Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV). The proportion of MG mono-infection and coinfections were calculated. Multivariable logistic regression models identified predictors of symptomatic MG mono-infections, which could be used to streamline at-risk patients for MG testing.
RESULTS
Among 735 participants, the median age was 27 (interquartile range 23—34) years, 65.9% were women, and 9.5% were HIV-positive. MG infection was detected in 10.5% (n = 77) of clients, with 45.5% (n = 35) coinfected with any of CT/NG/TV, and one case (0.1%) showing macrolide resistance. Among women with vaginal discharge syndrome (28.1%, n = 136), 0.7% (n = 1) had MG mono-infection, and 10.3% (n = 14) had MG and CT/NG/TV coinfections. Among men with male urethral syndrome (31.9%, n = 80), 3.8% (n = 3) had MG mono-infection, and 2.5% (n = 2) had MG and CT/NG/TV coinfections. Most MG-positive cases (66.2%, n = 51) did not receive antibiotic therapy, despite 68.6% (n = 35) reporting symptoms of STIs. Of treated cases, 26.0% (n = 20) received azithromycin monotherapy, 6.5% (n = 5) doxycycline monotherapy, and 1.3% (n = 1) both drugs. Of 305 individuals reporting STIs symptoms but tested negative for CT/NG/TV, 23 (7.5%) had symptomatic MG mono-infections. Unemployment and never having been tested for HIV were identified as risk factors. Streamlining 108/305 (35.4%) at-risk individuals for molecular-based MG testing would identify 14.8% (16/108) as positive, capturing 69.6% (16/23) of all symptomatic MG mono-infections.
CONCLUSIONS
MG was common among outpatients and frequently co-occurred with CT, NG, and TV infections. Syndromic case management often misclassified MG infections, leading to ineffective treatment. Expanding molecular-based MG testing could enhance antibiotic stewardship, crucial for preventing the spread of drug-resistant strains.
The HPV-Automated Visual Evaluation (PAVE) Consortium is validating a cervical screening strategy enabling accurate cervical screening in resource-limited settings. A rapid, low-cost HPV assay permits sensitive HPV testing of self-collected vaginal specimens; HPV-negative women are reassured. Triage of positives combines HPV genotyping (four groups in order of cancer risk) and visual inspection assisted by automated cervical visual evaluation (AVE) that classifies cervical appearance as severe, indeterminate, or normal. Together, the combination predicts which women have precancer, permitting targeted management to those most needing treatment.
We analyzed CIN3+ yield for each PAVE risk level (HPV genotype crossed by AVE classification) from nine clinical sites (Brazil, Cambodia, Dominican Republic, El Salvador, Eswatini, Honduras, Malawi, Nigeria, and Tanzania). Data from 1832 HPV-positive participants confirmed that HPV genotype and AVE classification each strongly and independently predict risk of histologic CIN3+. The combination of these low-cost tests provided excellent risk stratification, warranting pre-implementation demonstration projects.
In 2018, the World Health Organization commenced a multi-country validation study of the Cepheid GeneXpert for a range of molecular-based point-of-care (POC) tests in primary care settings. One study arm focused on the evaluation of POC tests for screening ‘women at risk’ for chlamydia (CT), gonorrhoea (NG) and trichomonas (TV) in four countries – Australia, Guatemala, Morocco and South Africa.
METHODS
Study participants completed a pre-test questionnaire which included demographics, clinical information and general questions on POC testing (POCT). Two vaginal swab samples (either self-collected or clinician collected) from each patient were tested on the GeneXpert at the POC and at a reference laboratory using quality-assured nucleic acid amplification tests (NAATs).
RESULTS
One thousand three hundred and eighty-three women were enrolled: 58.6% from South Africa, 29.2% from Morocco, 6.2% from Guatemala, and 6.0% from Australia. 1,296 samples for CT/NG and 1,380 samples for TV were tested by the GeneXpert and the reference NAAT. The rate of unsuccessful tests on the GeneXpert was 1.9% for CT, 1.5% for NG and 0.96% for TV. The prevalence of CT, NG and TV was 31%, 13% and 23%, respectively. 1.5% of samples were positive for all three infections; 7.8% were positive for CT and NG; 2.4% were positive for NG and TV; and 7.3% were positive for CT and TV. Compared to reference NAATs, pooled estimates of sensitivity for the GeneXpert tests were 83.7% (95% confidence intervals 69.2-92.1) for CT, 90.5% (85.1-94.1) for NG and 64.7% (58.1-70.7) for TV (although estimates varied considerably between countries). Estimates for specificity were ≥96% for all three tests both within- and between-countries. Pooled positive and negative likelihood ratios were: 32.7 ([CI] 21.2-50.5) and 0.17 (0.08-0.33) for CT; 95.3 (36.9-245.7) and 0.10 (0.06-0.15) for NG; and 56.5 (31.6-101.1) and 0.35 (0.27-0.47) for TV.
CONCLUSION
This multi-country evaluation is the first of its kind world-wide. Positive likelihood ratios, as well as specificity estimates, indicate the GeneXpert POC test results for CT, NG and TV were clinically acceptable for ruling in the presence of disease. However, negative likelihood ratios and variable sensitivity estimates from this study were poorer than expected for ruling out these infections, particularly for TV.
Sexually transmitted infections (STIs) can impact individuals of any demographic. The most common pathogens causing STIs are Chlamydia trachomatis, Neisseria gonorrhea and Trichomonas vaginalis; these can be treated with specific antibiotics.
OBJECTIVE
To compare the GeneXpert CT/NG test-and-treat algorithm to the syndromic approach algorithm and their impact on antibiotic prescription for gonorrhoea and chlamydia STIs.
DESIGN
A retrospective observational study on women aged ≥18 years who accessed the Médecins Sans Frontières Day Care Centre in Athens with complaints related to urogenital infections between January 2021 and March 2022. Women with abnormal vaginal discharge, excluding clinically diagnosed candidiasis, were eligible for Xpert CT/NG testing.
RESULTS
Of the 450 women who accessed care, 84 were eligible for Xpert CT/NG testing, and only one was positive for chlamydia, therefore resulting in saving 81 doses of ceftriaxone and azithromycin, and 19 doses of metronidazole. The cost of Xpert CT/NG testing, including treatment was €4,606.37, while full antibiotic treatment would have costed €536.76.
CONCLUSION
The overall cost of the Xpert CT/NG test-and-treat algorithm was higher than the syndromic approach. However, quality of care should be weighed against the potential benefits of testing and syndromic treatment to determine the best option for each patient; we therefore advocate for decreasing the costs.
We estimated changes in the HIV incidence from 2013 to 2018 in Eshowe/Mbongolwane, KwaZulu Natal, South Africa where Médecins Sans Frontières is engaged in providing HIV testing and care since 2011.
METHODS
Using data from two cross-sectional household-based surveys conducted in 2013 and 2018, with consenting participants aged 15-59 years, we applied the incidence estimation frameworks of Mahiane et al and Kassanjee et al.
RESULTS
In total 5599 (62.4% women) and 3276 (65.9% women) individuals were included in 2013 and 2018 respectively. We found a mean incidence in women 20-29 years of 2.71 cases per 100 person-years (95% CI: 1.23; 4.19) in 2013 and 0.4 cases per 100 person-years (95% CI: 0.0; 1.5) in 2018. The incidence in men 20-29 years was 1.91 cases per 100 person years (95% CI: 0.87; 2.93) in 2013 and 0.53 cases per 100 person-years (95% CI: 0.0; 1.4) s in 2018. The incidence decline among women aged 15-19 was -0.34 cases per 100 person-years (95% CI: -1.31;0.64).
CONCLUSIONS
The lack of evidence of incidence decline among adolescent girls is noteworthy and disconcerting our findings suggest that large scale surveys should seriously consider focusing their resources on the core group of women aged 15-19.
Sexually transmitted infections (STI’s) are a public health threat. Syndromic approaches based on clinical symptoms have been suggested as having poor diagnostic performance, particularly in the type of settings where MSF is operational. We assessed the burden of STI’s and the diagnostic performance of a syndromic approach within an MSF-supported HIV/STI project in Eswatini.
METHODS
We conducted a cross-sectional study, enrolling adults accessing routine HIV testing and antiretroviral care services in six clinics in Shiselweni, from July 2022 to January 2023. HIV testing counselors performed HIV testing and nurses assessed patients for STI’s. Laboratory investigations included antibody-based rapid diagnostic tests (RDT’s) for Treponema pallidum (TP), hepatitis B (HBV) and hepatitis C (HBC). The molecular platform Xpert was used to test urine samples for Chlamydia trachomatis (CT), Neisseria gonorrhoea (NG), Trichomonas vaginalis (TV), Mycoplasma genitalium (MG), vaginal/anal swabs for human papillomavirus (HPV), and plasma for HIV viraemia to test for acute HIV infection (HIV). We calculated the prevalence of STI’s, and assessed diagnostic performance of a syndromic approach to diagnose male urethritis (MUS) and vaginal discharge (VDS) syndromes, versus laboratory-based testing.
ETHICS
This study was approved by the Eswatini Health and Human Research Review Board and by the MSF Ethics Review Board.
RESULTS
Of 1,041 study participants, 682 were women (65.5%), and the median age was 30 (interquartile range, IQR, 24-38) years. Overall, 280 (26.9%) were known HIV-positive and of 755 with unknown HIV status, 30 (4.0%) were newly diagnosed with HIV, of whom seven (23.3%) had AHI. 308 (29.6%) patients had at least one of the following three pathogens identified: NG 121 (11.6%); CT 155 (14.9%); TV 109 (10.5%). MG was detected in 33/330 participants (10.0%). In addition, 105 (10.1%) had antibodies against TP, 49 (4.7%) against HBV, and three (0.3%) against HCV. HPV prevalence was higher in tested women (104/196; 53.1%) versus men (5/27; 18.5%; p=0.001). Prevalence of NG/CT/TP was highest in newly-diagnosed HIV cases (48.2%) versus known HIV-positive cases (26.8%, p=0.019). Based on the syndromic approach, 188/634 (29.7%) had a VDS, and 97/334 (29.0%) a MUS. Diagnostic performance of the syndromic approach was better in men (MUS: sensitivity: 66.7%, specificity 87.5%; positive predictive value, PPV, 70.1%, negative predictive value, NPV, 85.7%), versus women (VDS: sensitivity 35.9%, specificity 72.9%; PPV 35.1%, NPV 73.5%).
CONCLUSION
A high burden of STI’s in Eswatini and poor diagnostic ability of the syndromic approach in this setting, calls for new approaches for STI care in MSF-supported sexual and reproductive health programmes in resource-poor settings.
CONFLICTS OF INTEREST
None declared